The Challenge of Mental Health Care in Pediatrics

Rising rates of identification of attention-deficit/hyperactivity disorder¹ and other mental health disorders,² and increasing recognition of their long-term morbidity,^{3 - 5} have underscored the importance of creating efficient and effective mechanisms of providing access to high-quality mental health care for all children. The primary care setting should be an appropriate setting for recognition of and early intervention in these issues because virtually all children see a primary care pediatrician frequently in their first 3 years of life and at least once per year thereafter.⁶ Unfortunately, this potential is rarely met due to inconsistencies in pediatricians' training and skills; the enormous requirements for identification, care, prevention, and documentation of the myriad child health problems that pediatricians are called on to manage⁷ ; and a fiscal environment that demands ever-shorter visits and ever-more documentation. For many physicians, identifying appropriate mental health referrals is a difficult and increasingly time-consuming task,⁸ underscoring the motivation to develop new models of care.⁹

A diverse range of solutions to improve access to quality mental health services in pediatric settings has been proposed. Training programs, some intrinsic to pediatric residency programs¹⁰ and others directed at pediatricians already in practice,¹¹ are designed to increase the ability of pediatricians to identify and treat mental health disorders in children and adolescents. A different model designed to address the same problem is the Massachusetts Child Psychiatry Access Project (MCPAP),¹² in which child and adolescent psychiatrists consult with pediatricians via telephone and e-mail.

In addition, enterprising pediatricians have devised a variety of unique mechanisms to meet the need for better access and care for their patients. Models include the location of a mental health department as part of a multispecialty group practice, rental of office space to 1 or more mental health clinicians, and partnership of a mental health clinician as part of the primary care office staff. Co-located and collaborative care models emerged initially in family medicine^{13 - 14} and internal medicine, largely in recognition of the comorbidity between medical and mental health disorders in adults.^{15 - 16} Similar models have been launched more recently in pediatrics, but these have undergone even less systematic research.^{17 - 18} The potential advantages of co-located services include earlier recognition of treatable conditions, improved and more comfortable access to and improved adherence with mental health treatment,¹⁹ and improved coordination between pharmacologic and nonpharmacologic treatments.²⁰ Unfortunately, there has been little systematic research documenting the various models that have been developed, the barriers to their implementation, or their successes.^{21 - 22}

The terms co-location, integration, and collaboration are often used synonymously to describe these new practice models, but these models do not necessarily coexist. As we have conceptualized these terms, co-location refers to the pediatrician and the mental health clinician sharing space and having at least somewhat overlapping hours. The mental health clinician may be employed by the practice, may rent space, or may be offered free use of office space. In an integrated practice, there are linkages in systems of care: the mental health clinician and physician share charts, go to the same meetings, share the office staff for scheduling and billing, and record their work in the same medical charts, and there is a clear system for referrals back and forth. Collaborative practice goes a giant step further, including ongoing interpersonal interactions, shared decision making, and truly shared care of the same patients. While co-location may facilitate integrated and/or collaborative practice models, it is neither necessary nor sufficient for such models to exist.

Recent findings about the prevalence of innovative practice models are intriguing. In a national survey of pediatricians,²³ 17% reported having an on-site mental health clinician in their practice setting. Those who had such a clinician on site reported that they were more likely to consult or refer patients for mental health treatment than did pediatricians who did not have such a colleague readily available. Care is required in interpreting these cross-sectional data because it is unclear whether on-site care facilitated more referrals or an increased number of referrals created the need for on-site care—or perhaps there was interplay between both factors.

In a recent survey of Massachusetts pediatricians, 80% reported that finding adequate mental health services for their patients was a serious problem.²⁴ In this study, 33% reported having a mental health and/or developmental specialist present in the same practice location. Physicians, nurses, social workers, and psychologists were the professionals typically noted to perform this role. Their responsibilities included performing developmental and mental health assessments, administering child and parent counseling and/or short-term therapy, managing a systematic screening program, initiating and monitoring medications, and facilitating referrals.

The article by Kolko et al²⁵ in this issue of the Archives reports on an important experimental intervention that documents, using a systematic randomized controlled design, some of the benefits of having a mental health clinician located in the primary care office setting. The article describes careful training, supervision, and documentation on the part of the care managers and the supervising staff. More children began and continued treatment protocols in the experimental group than among controls, and outcome measures documented greater improvements in symptoms, especially among children with externalizing behaviors.

Because this was a pilot study, the “reach” of the intervention was only modest. The study involved only 4 pediatric practices sharing 2 case managers. Only 78 children participated, and the trial was limited to children aged between 5 and 12 years. On the other hand, the range of conditions is reflective of that seen in typical pediatric practice, and improved utilization and benefits of care are amply documented (see, eg, Figure 1 in Kolko et al²⁵ ), as were participating pediatricians' and parents' appreciation of this innovative model.

The co-located collaborative model described by Kolko et al²⁵ is an important step to improving prompt and appropriate intervention for mental health disorders among children. By increasing access, reducing stigma and discomfort, and increasing ongoing problem-solving and communication between pediatricians and their mental health colleagues, the co-located collaborative practice greatly increases the chances that parents and children will have better access to high-quality mental health care and overall be better served.

Future research efforts should pick up where Kolko et al²⁵ left off. Surprisingly, few children were referred to the office-based Care Manager; one wonders whether a systematic behavioral screening program would have increased the referral rate. It would be interesting to know, as well, how the type and number of concerns would change if parents had direct access to the care manager rather than requiring a referral from the pediatrician. Furthermore, issues of cost are not addressed. Are collaborative care arrangements affordable in primary care, and if not, what types of reforms in practice systems and/or payment mechanisms would be required to make them so? In the future, greater attention to the training of pediatricians and mental health clinicians in collaboration and the effects of collaborative care on access for all children to mental health services—in addition to their quality—is clearly needed.