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March 9, 2020

Promotion of Mental Health as a Key Element of Pediatric Care

Author Affiliations
  • 1Division of Developmental-Behavioral Pediatrics, Center for Children With Special Needs, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
JAMA Pediatr. Published online March 9, 2020. doi:10.1001/jamapediatrics.2020.0020

Numerous national surveys, cohort studies, and meta-analyses have documented the etiologic and experiential connections between childhood abuse, physical illness, and mental health disorders1,2 spanning from childhood to adulthood. Yet pediatric training and practice typically focus primarily on the identification and treatment of physical health conditions. The recent advent of enthusiasm for integrated care is a welcome nod to the marked comorbidities that have been amply reported.

Approximately 20% of children and adolescents have a diagnosed mental health or behavioral disorder that threatens their development and well-being3 and often foretells adult mental health disorders.4 In addition, many children have symptoms of mental health or behavioral disorders that do not meet diagnostic criteria but nevertheless carry significant risk of impaired adult functioning. Children who have had adverse experiences of various types are at greater risk of developing both physical and mental health or behavioral problems during childhood, adolescence, and adulthood.

In the face of this immense, important, and growing need, there is a severe shortage of qualified mental health clinicians across the country—a deficiency that is especially acute for (but not limited to) children younger than 13 years and children of nonwhite racial/ethnic backgrounds or limited financial means. Access to and use of mental health services by parents and children is limited by stigma, geography, financial constraints, and the paucity of qualified clinicians. The lack of access to behavioral health services has been called a national emergency, especially highlighted by the striking increase in the number of adolescents with serious depression and suicide, which is now the second leading cause of death among individuals aged 10 to 34 years. The urgency of addressing mental health and behavioral disorders in childhood is highlighted by the fact that most such disorders diagnosed among adults had their origin and early symptoms in childhood.

Furthermore, children with chronic physical health conditions have a heightened risk of mental health symptoms and disorders,5 and children with mental health and behavioral disorders are at an increased risk of diabetes, heart disease, and inflammatory diseases.6,7 Nevertheless, the service systems remain remarkably separate.

Pediatricians in primary care practices and across specialties are increasingly called upon to develop mechanisms to promote well-being, prevent mental health disorders, identify children at risk as early as possible through regular screening, and provide a mechanism to ameliorate at least the most common mental health and behavioral disorders. These responsibilities are too important and too complex to be successfully accomplished by pediatricians alone. Primary care and subspecialty pediatricians are increasingly creating teams to supplement their activities. These teams may include a case worker who helps families to address social determinants of health, a nurse to supervise the care of children with a chronic physical illness, and a mental health clinician to focus on the critical tasks necessary to promote the resilience and mental health of their patients.

In the accompanying article,8 the authors summarize some common features of the 11 randomized controlled clinical trials they identified as describing a behavioral health treatment program housed in a pediatric primary care office. The 3 common elements were a focus on population-based care, a commitment to measurement of outcomes, and delivery of evidence-based services. The 11 programs included 3 studies of youth with depression, 3 studies of youth with attention-deficit/hyperactivity disorder, and 5 studies of youth with externalizing symptoms or disorders. The studies varied in their target ages, the methodologies of their interventions and evaluations, and their outcomes. Overall, approximately two-thirds of the programs (8 of 11) reported improvement in the participants’ primary symptoms.

The title of the article is a little misleading because the level of integration (rated as level 1 through 5) varied considerably across the 11 studies. Five programs had a low degree of integration (level 1 or 2) while 6 were substantially integrated within the pediatric practice (level 4 or 5). The success of the outcomes did not differ by level of integration, suggesting that age, diagnostic groups addressed, or some other factor may have been important to their success.

Collaborations between pediatricians and mental health clinicians take many forms, ranging from established patterns of community referrals to telephone consultation services to colocation in the same office space to truly integrated shared-care arrangements. In-office collaborations between mental health clinicians and primary care physicians, which are increasingly referred to as integrated practice arrangements, were initially introduced in family medicine9 and have recently gained popularity in the field of pediatrics.

The activities of integrated mental health partners vary considerably, with some prioritizing being accessible for informal consultations with pediatricians throughout the day, others providing evidence-based treatments for specifically diagnosed disorders (often depression, attention-deficit/hyperactivity disorder, and externalizing disorders), and still others offering short-term counseling for early symptoms of emotional and behavioral disorders. Some integrated mental health clinicians take responsibility for overseeing universal screening and offer programs designed to promote social-emotional well-being (eg, parenting groups)10 and/or to prevent disorders among children at risk, such as children with a chronic health condition or a history of adverse experiences (eg, abuse, adoption, or divorce). Depending on the mental health clinician’s training and experience, he or she may also help with the monitoring of medication management and communication with community consultants. Barriers to creating and sustaining any collaboration include workforce challenges, daunting financial constraints, professional and cultural assumptions and communication, record-keeping, and space.11

A recent meta-analysis of 31 studies of integrated care programs in pediatric primary care settings indicated that programs of various configurations were associated with a significant benefit. The strongest associations were observed among programs that targeted specific mental health diagnoses and that were designed as fully collaborative models.12 Programs designed for the prevention of mental health disorders or substance abuse fared less well. Other reviews have similarly found that integrated models of care were associated with improvements in access and engagement as well as measurable improvements in outcomes.

An example of a program for infants and preschool children with a mental health promotion and prevention focus is Healthy Steps. In this model, a mental health clinician (usually a psychologist or social worker) is based in the primary care office and linked with the pediatricians. The clinician may make home visits, conduct parent training groups, screen parents for depression, join the pediatricians during part or all of the office visit, and be available for questions and to meet parents who bring up concerns in the screening process or in the course of their office visit.13

Financial barriers to creating a truly collaborative pediatric practice are daunting. Mental health clinicians employed by a pediatric office have to complete a lengthy credentialing process for each of the many health insurance providers that each pediatrician accepts, and payments are limited to traditional services based on the child’s DSM diagnosis. Reimbursement rates for mental health services in a pediatric office are generally the same for master’s degree–level social workers and doctoral degree–level psychologists despite large differences in their salary expectations. In addition, a well-functioning collaborative practice requires time available for curbside consultations during the time of a well-child care visit, informal communication about shared patients, supervision of screening and follow-up programs, facilitation of referrals to outside consultants, and counseling for parents and/or children with a chronic illness, none of which is paid by insurers. Universal mental health promotion and prevention activities, such as parenting training and support or attention to parental depression, are not billable because the child does not carry a diagnosis. Innovative practices that have developed integrated teams often fail to cover the additional costs.11 On the other hand, integrated care might allow for more effective prevention and early identification, potentially reducing long-term expenditures.

Adequate space is often another barrier in the pediatric office, especially with regard to areas in which groups of parents and/or children can meet. Documentation is a challenge for several reasons, such as differing professional jargon, concerns about confidentiality, and clarity about what parts of the records are available in case of legal requests. Nevertheless, it is critical for truly shared care that both the medical and mental health clinicians can regularly read and write in the same chart and have access to each other’s observations and plans.

Training of both mental health clinicians and pediatricians for successfully integrated/collaborative and comprehensive behavioral and physical health care is essential. The American Board of Pediatrics has begun to consider including greater understanding of the diagnoses and treatments of mental health and behavioral disorders in the curricula for pediatric residents and fellows.14,15 Some schools of social work and psychology are providing degree tracks in pediatric partnerships, focusing on the process of collaboration as well as knowledge of children’s health needs and challenges and how those factors intersect with their mental health and behavioral needs. There are exciting efforts to create joint training programs for pediatricians and psychologists in collaborative care.16,17 Integrated care models are also beginning to develop in specialty pediatric settings.18

Numerous studies document the value of integrated practice arrangements among primary care pediatricians and mental health clinicians. The accompanying article documents some elements that signal their success.8 Although fiscal, workforce, space, training, and communication constraints limit their implementation, fully integrated and collaborative teams are successful in expanding the scope of pediatric care. It is critical for children’s health, and for the health of the adults they will become, that health care policies and programs, including payment policies, adapt to support pediatricians as they address growing responsibilities for the promotion of mental health, the early identification of risk, and the prevention of mental health and behavioral disorders as well as treatment of common mental health and behavioral conditions.

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Article Information

Corresponding Author: Ellen C. Perrin, MD, Division of Developmental-Behavioral Pediatrics, Center for Children With Special Needs, Floating Hospital for Children, Tufts Medical Center, 800 Washington St, Boston, MA 02111 (eperrin@tuftsmedicalcenter.org).

Published Online: March 9, 2020. doi:10.1001/jamapediatrics.2020.0020

Conflict of Interest Disclosures: None reported.

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