MODELS OF CARE ENCOMPASSING MENTAL HEALTH IN THE PRIMARY CARE SETTING

Given the many barriers to receiving mental health care, new approaches to identifying concerns and providing mental health professional services have been recently explored.

Usual or typical pediatric care of emotional and behavioral problems is related to the comfort level of the individual pediatric provider and available resources. The efficacy of surveillance in the form of developmentally appropriate anticipatory guidance and counseling is variable; the average time spent on surveillance is 2.5 minutes. However, as stated earlier, the majority of emotional and behavioral problems are not identified in this model of care. In addition, when they are identified, the logistics of referral can be problematic. Although pediatricians often refer to mental health providers, only 50% of families will actually attend an appointment and the average number of appointments attended is only slightly greater than one. Based on level of comfort and training, the primary clinician in this model is more likely to be responsible for psychiatric medications if prescribed.

Among the technological interventions that can enhance identification of problems and target specific symptoms for assessment is the Child Health & Development Interactive System (CHADIS) (http://www.childhealthcare.org). In this system, parents use a computer kiosk to note their level of concern about various behaviors, which triggers algorithmic interviews for each concern based on psychiatric diagnostic criteria. The CHADIS system provides an electronic worksheet of analyzed results, school communication tools, as well as other resources.

Enhanced care is a model of care in which a pediatric developmental or behavioral specialist is embedded in the clinic, thus making for improved referral and communication and management. This “colocation” creates easier access for patients and improved communication with mental health professionals.

Telephonic consultation or telepsychiatry with mental health consultation teams in a stepped care approach allows enhanced access to mental health providers, especially for children in rural communities. The provision of consultation to pediatric care providers also allows pediatric providers ongoing education with the eventual goal of pediatric providers learning to manage these concerns on their own.

Collaborative care provides high-quality, multidisciplinary, and collaborative care through the colocation of educators, consultants, or direct service mental health providers in the clinic. Successful collaborative care results in greater specialist involvement by negating identification and referral and other system-of-care barriers. Successful components include a leadership team, primary clinicians, mental health and developmental specialists, administrators, clinical informatics specialists, and care managers. Collaborative care implies that nearly all visits are done jointly and that mental health professionals are always available for consultation, in contrast to the approach in the enhanced care model, which requires the scheduling of an appointment with a mental health specialist in the practice. These interventions can be accomplished through collaboration among mental health and primary care providers, mental health systems and primary care practices, and in academic settings with interdepartmental collaboration. Typically, philanthropic or other foundation grants are necessary to start a collaborative program so that reimbursement and sustainability concerns can be identified and remedied.

EARLY IDENTIFICATION & PREVENTION OF DEVELOPMENTAL & SOCIOEMOTIONAL PROBLEMS

The role of the primary care pediatrician continues to expand to include public health, mental health, and community concerns. The American Academy of Pediatrics (AAP) policy statement on community pediatrics addresses the fact that today’s children and families live in a period of rapid social change and declining economic circumstances. In addition, the economic organization of the healthcare and social service systems in the United States is undergoing profound changes. For many pediatric providers, efforts to promote the health of children have been directed at attending to the needs of particular children in a practice setting, on an individual basis, and providing them with a medical home. This approach, in combination with pediatricians’ own personal community interests and commitments, has been dramatically successful. Increasingly, however, the major threats to the health of US children—the new morbidity—arise from problems that cannot be adequately addressed by the practice model alone. These problems include unacceptably high infant mortality rates in certain communities, extraordinary levels of intentional and unintentional injuries, chemical dependency, behavioral and developmental consequences of inappropriate care and experience, family dysfunction, sexually transmitted diseases, unplanned pregnancies and out-of-wedlock births, and lack of a medical home. The policy statement concludes, “We must become partners with others, or we will become increasingly irrelevant to the health of children.”

Today’s community pediatrician seeks to provide a far more realistic and complete clinical picture by taking responsibility for all children in a community, providing preventive and curative services, and understanding the determinants and consequences of child health and illness, as well as the effectiveness of services provided.

Bright Futures

Bright Futures is a national health promotion and disease prevention initiative that addresses children’s health needs in the context of family and community. In addition to use in pediatric practice, many states implement Bright Futures principles, guidelines, and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities. The Bright Futures Guidelines, now in its third edition, was developed to provide comprehensive health supervision guidelines, including recommendations on immunizations, routine health screenings, and anticipatory guidance. In addition, Bright Futures for Mental Health provides numerous guidelines, tools, and strategies for improving mental health identification, assessment, initiation, management, and coordination.

Surgeon General’s National Action Plan

The Office of the Surgeon General (OSG) also recommends that pediatrics continue to evolve and include lifestyle, health system, and other psychosocial areas. The OSG’s National Action Agenda on Mental Health includes several calls to primary care pediatricians, including the following: engage other professional organizations in educating new frontline providers in various systems (eg, teachers, physicians, nurses, hospital emergency personnel, day care providers, probation officers, and other child healthcare providers) in child development; equip them with skills to address and enhance children’s mental health; and train them to recognize early symptoms of emotional or behavioral problems for proactive intervention. Such training must focus on developmental and cultural differences in cognitive, social, emotional, and behavioral functioning, and understanding these issues in familial and ecological context.

Partnership Access Line

In this chapter, various clinical tools from the Partnership Access Line (PAL) Washington website (www.palforkids.org) are used to assist the primary care provider in diagnosis and treatment of the more common psychiatric conditions. The PAL algorithms are useful for treatment of specific diagnoses, considering alternative diagnoses in the differential, and reviewing medication treatment tables for specific information regarding psychopharmacologic treatments.

Summary of the Pediatrician’s Role

Given these calls for a new pediatric role as the gatekeeper for socioemotional health, the expanding role of the primary care pediatric provider encompasses the following broad categories: prevention, identification, assessment, initiation, management, coordination, and collaboration (Table 7–1).

IDENTIFICATION & ASSESSMENT DURING HEALTH MAINTENANCE VISITS

Most families seek help from their primary care providers when they are concerned about a child’s health, growth, or development. Historically, the most efficient indicator in eliciting psychosocial problems is the history provided by parents or guardians and interview and observation of the child. The possible approaches to identification of problems include surveillance, screening, and assessment.

Surveillance consists of the following elements: checking in, eliciting concerns, asking open-ended questions, watching and waiting, listening for red flags, identifying risk factors, and monitoring closely over time. Like vital signs, which represent an essential component of the physical evaluation, the essential components of the primary care surveillance for mental health concerns should generally include a review of the youth’s general functioning in different aspects of their life. Five questions forming the mnemonic PSYCH can be addressed to parents and youth as a surveillance means of uncovering areas of concern.

    1. Parent-child interaction: How are things going with you and your parents? Or you and your infant (or toddler)?

    2. School: How are things going in school (or child care; academically, behaviorally, and socially)?

    3. Youth: How are things going with peer relationships/friendships (how does child get along with same-aged peers)?

    4. Casa: How are things going at home (including siblings, family stresses, and relationship with parents)?

    5. Happiness: How would you describe your mood? How would you describe your child’s mood?

Many pediatric practices are hampered by lack of continuity and not enough time for in-depth surveillance. In addition, surveillance is notoriously tied to office and provider characteristics. Given current time constraints for current pediatric visits, and the fact that only 18% of parents reporting elevated behavior problems in children actually told their providers about it, surveillance is currently considered nonoptimal. Although part of the clinical interview with families, surveillance is not a separate and billable service under current Medicaid and insurance reimbursement plans, whereas formal screening is.

Screening is the process of using standardized instruments to identify areas of risk, delay, or concern. Newborn hearing, vision, and developmental screenings are common in today’s pediatric practice. However, the morbidity associated with developmental, emotional, and psychosocial problems requires that socioemotional screening also be performed to identify the presence of symptoms of emotional, behavioral, or relationship disorders. Screening tools are brief, easy to use, and can be administered as a questionnaire or using an interview format. A positive screen warrants a more complete assessment. The use of screening tools can also lead to early identification and interrupt the adjustment-perturbation-disturbance-disorder pathway. Newer methods of eliciting socioemotional and behavior concerns have been developed (see section below on Tools). Helpful information can also be obtained from broad screening checklists and symptom-specific questionnaires (such as depression or anxiety self-report inventories). Questions can be incorporated into the general pediatric office screening forms, or specific questionnaires can be used.

Tools for Mental Health Screening in the Office Setting

Given the low rates of identification of psychosocial problems by pediatric surveillance, the use of standardized screening tools has become standard practice. Typically, broad screeners that elicit information regarding multiple domains are employed first and are followed by targeted screens to address symptomatology, severity, impairment, and context of specific psychosocial problems.

A. General or Broad Screening Tools

1. Strengths and Difficulties Questionnaires (SDQs)—The SDQs are brief behavioral screening questionnaires targeting patients 3–16 years old with parent, teacher, and child self-report versions available. Several versions are available and can readily be used by researchers, clinicians, and educators. They have been well validated and are available on the Internet without cost. The SDQs are available in over 40 languages. The domains assessed include: emotional problems, conduct problems, hyperactivity/inattention, peer-relationship problems, and prosocial behaviors. For further information, refer to the following web site: http://www.sdqinfo.org.

2. Pediatric Symptoms Checklist (PSC)—The PSC is a one-page questionnaire listing a broad range of children’s emotional and behavioral problems that reflects parents’ impressions of their children’s psychosocial functioning. An adolescent self-report version is also available for children ages 11 and older. The PSC was developed initially for children older than age 5, but cutoff scores for preschool and school-aged children indicating clinical levels of dysfunction have been empirically derived. The questionnaire is easy to score, is free of charge, and is available in English and Spanish from the following web sites: http://www.brightfutures.org/mentalhealth/pdf/professionals/ped _sympton_chklst.pdf.

3. Parents’ Evaluation of Developmental Status (PEDS)—The PEDS is a validated screener for socioemotional, developmental, and behavioral concerns in children aged 1 month to 8 years. Parents answer yes/no about their concerns in various areas of their child’s development. Scoring the PEDS is more labor intensive than other general screeners and the instrument must be purchased. Its benefits include extensive validity data and useful pathways for level of concern and referral. It is available in English, Vietnamese, and Spanish. For further information, see the following web site: http://www.pedstest.com.

4. Ages and Stages, Socioemotional (ASQ: SE)—The Ages and Stages, SE is a companion to the Ages and Stages Developmental Screen. It is an easy-to-use tool with a deep, exclusive focus on infant, toddlers, and younger children’s social and emotional behavior. After a one-time cost, the instrument is reproducible, making it cost-effective. It is culturally sensitive for use across diverse pediatric populations. Screens are available for the 6-, 12-, 18-, 24-, 36-, 48-, and 60-month visits, and in English, French, Spanish, and Korean.

5. Family Psychosocial Screen—Pediatric Intake Form, Bright Futures, Retrieved November 19, 2013, from http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf. Form adapted, with permission, from Kemper KJ, Kelleher KJ: Family psychosocial screening: Instruments and techniques. Ambulatory Child Health 1996;1:325–339.

6. WE CARE—Available in appendix of article. (Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR: Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project. Pediatrics 2007;120(3):547–558 [PMID: 17766528].)

Assessment of Behavioral & Emotional Signs & Symptoms

When an emotional problem or mental illness is mentioned by the patient or parents, elicited by an interview, or identified by a screening instrument, a thorough evaluation is indicated. At least 30 minutes should be scheduled, and additional appointments may be necessary to gather information or perform tests to determine a mental health diagnosis. Examples of more thorough questions and observation are given in Table 7–2. Targeted assessment screening tools are also useful in determining severity, comorbidity, and context of impairment.

It is useful to see both parents and the child first together, then the parents alone, and then the child alone (for school-aged children and adolescents). This sequence enables the provider to observe interactions among family members, allows the child to feel more comfortable with the provider, and offers the parents and the child an opportunity to talk confidentially about their concerns. Parents and children often feel shame and guilt about some personal inadequacy they perceive to be causing the problem. The provider can facilitate the assessment by acknowledging that the family is trying to cope and that the ultimate task of assessment is to seek solutions and not to assign blame. An attitude of nonjudgmental inquiry can be communicated with supportive statements such as, “Let’s see if we can figure out what might be happening here and find some ways to make things better.”

A. History of the Presenting Problem

First, obtain a detailed description of the problem.

• When did it start?

• Where and with whom does it occur?

• Were there unusual stresses, changes, or life events at that time?

• How is the child’s life and the family’s functioning affected?

• What does the child say about the problem?

• What attempts have been made to alleviate the problem?

• Do the parents have any opinions about the cause of the problem?

B. Techniques for Interviewing Children and Adolescents

1. Interviewing the preschool child—Preschool children should be interviewed with their parents. As the parents discuss their concerns, the provider can observe the child’s behavior, including their activity level and any unusual behaviors or symptoms. It is helpful to have toy human figures, animals, or puppets, and crayons and paper available that the child can use to express him- or herself. After hearing the history from the parents and observing and talking with the child, the provider can begin to develop an impression about the problem and formulate a treatment plan to discuss with the family.

2. Interviewing the school-aged child—Most school-aged children have mastered separation anxiety sufficiently to tolerate at least a brief interview alone with the provider. In addition, they may have important information to share about their own worries. The child should be told beforehand by the parents or provider (or both) that the doctor will want to talk to the child about his or her feelings. School-aged children understand and even appreciate parental concern about unhappiness, worries, and difficulty in getting along with people. At the outset, it is useful to explore the child’s thoughts about certain issues raised by the parents and ask whether the child thinks that a problem exists (eg, unhappiness, anxiety, or sleep disturbance) and any other concerns the child may have. The provider should ask the child to describe the problem in his or her own words and ask what he or she thinks is causing the problem. It is important to ask the child how the problem affects the child and the family. At the end of the interview with the child, it is important to share or reiterate the central points derived from the interview and to state that the next step is to talk with the parents about ways to make things better for the child. At that time, it is good to discuss any concerns or misgivings the child might have about sharing information with parents so that the child’s right to privacy is not arbitrarily violated. Most children want to make things better and thus will allow the provider to share appropriate concerns with the parents.

3. Interviewing the adolescent—The provider usually begins by meeting briefly with the parents and adolescent together to define the concerns. Because the central developmental task of adolescence is to create an identity separate from that of the parents, the provider must show respect for the teen’s point of view. The provider should then meet alone with the adolescent or, at least, give the teen the option. After the provider has interviewed the adolescent and talked further with the parents, he or she should formulate thoughts and recommendations. Whenever possible, it is helpful to discuss these with the adolescent before presenting them to the parents and teen together. The issue of confidentiality must be discussed early in the interview: “What we talk about today is between you and me unless we decide together that someone should know or unless it appears to me that you might be in a potentially dangerous situation.”

The interview with the adolescent alone might start with a restatement of the parents’ concerns. The teen should be encouraged to describe the situation in his or her own words and say what he or she would like to be different. The provider should ask questions about the adolescent’s primary concerns, predominant mood state, relationships with family members, level of satisfaction with school and peer relationships, plans for the future, drug and alcohol use, and sexual activity.

In concluding the interview, the provider should summarize his or her thoughts and develop a plan with the teenager to present to the parents. If teenagers participate in the solution, they are more likely to work with the family to improve the situation. This should include a plan either for further investigation or for ways of dealing with the problem and arranging subsequent appointments with the provider or an appropriate referral to a mental healthcare provider.

C. Targeted Screening Tools and Assessment Measures

As with broad screening tools, targeted screening tools or assessment instruments can be very valuable in the clinic since they are standardized and allow for the assessment of current symptoms and severity. They can also be useful for following or reassessing a patient’s progress after initiation of treatment.

1. Vanderbilt Assessment Scales for Attention-Deficit/Hyperactivity Disorder—These scales are included in the American Academy of Pediatrics/National Initiative for Children’s Health Quality (AAP/NICHQ) Attention-Deficit/Hyperactivity Disorder Practitioner’s Toolkit, available at: http://www.nichq.org/toolkits_publications/toolkits _landingpage.html. http://www.schoolpsychiatry.org.

2. Center for Epidemiologic Studies Depression Scale for Children (CESD-C)—Available at: http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf.

3. Self-Report for Childhood Anxiety-Related Emotional Disorders (SCARED)—Available at: http://www.wpic.pitt.edu/research/.

4. Patient Health Questionnaire-9 Modified for Teens (PHQ-Modified)—Available at: http://www.lfmp.com/Portals/8/PHQ-9%20(Depression%20Screener%20for%20Adolescents%2012-18).pdf.

5. Other Tools

A. BRIGHT FUTURES—The Bright Futures Tool Kit has numerous guidelines, tools, and other resources for identifying mental health concerns. Available at: http://www.brightfutures.org/mentalhealth/pdf/tools.html.

B. CHADIS—See earlier discussion of models of health care.

C. DISORDER-SPECIFIC SCREENING TOOLS—Useful tools for evaluating other mental health concerns, such as obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and pervasive developmental disorder (PDD), can be found at the following websites: http://www.schoolpsychiatry.org and http://www.mcpap.com/.

The Mental Status Examination

The mental status examination (MSE) is a tool equivalent to the physical examination. It includes some standard aspects to help evaluate an individual including observation of an individual’s overall cognitive, emotional, and behavioral presentation. Through observations, interaction, and questions, the MSE identifies current behavioral presentation and areas of clinical concern (eg, suicidal thinking, hallucinations). A well-documented MSE details the patient’s behavioral and clinical presentation. Please refer to standard elements of MSE (Table 7–3).

Diagnostic Formulation & Interpretation of Findings

Diagnosis, the final product of the assessment, starts with a description of the presenting problem, which is then evaluated within the context of the child’s age, developmental needs, the stresses and strains on the child and the family, and the functioning of the family system.

The provider’s first task is to decide whether a problem exists. For example, how hyperactive must a 5-year-old child be before he or she is too hyperactive? When a child’s functioning is impaired in major domains of life, such as learning, peer relationships, family relationships, authority relationships, and recreation, or when a substantial deviation from the trajectory of normal developmental tasks occurs, a differential diagnosis should be sought based on the symptom profile. The provider then develops an etiologic hypothesis based on the information gathered:

    1. The behavior falls within the range of normal given the child’s developmental level.

    2. The behavior is a temperamental variation.

    3. The behavior is related to central nervous system impairment (eg, prematurity, exposure to toxins in utero, seizure disorder, or genetic disorders).

    4. The behavior is a normal reaction to stressful circumstances (eg, medical illness, change in family structure, or loss of a loved one).

    5. The problem is primarily a reflection of family dysfunction (eg, the child is the symptom bearer, scapegoat, or the identified patient for the family).

    6. The problem indicates a possible psychiatric disorder.

    7. The problem is complicated by an underlying medical condition.

    8. Some combination of the above.

Sharing of the diagnosis is also the beginning of initiating treatment. The provider’s interpretation of the complaint and diagnosis is then presented to the family. The interpretive process includes the following components:

    1. Psychoeducation: An explanation of how the presenting problem or symptom is a reflection of a suspected cause and typical outcomes both with and without intervention.

    2. A discussion of possible interventions, including the following options:

      a. Close monitoring

      b. Counseling provided by the primary care provider

      c. Referral to a mental health professional

      d. Initiation of medication

      e. Some combination of the above

    3. A discussion of the parent’s and adolescent’s response to the diagnosis and potential interventions.

A joint plan involving the provider, parents, and child is then negotiated to address the child’s symptoms and developmental needs in light of the family structure and stresses. If an appropriate plan cannot be developed, or if the provider feels that further diagnostic assessment is required, referral to a mental health practitioner should be recommended.

Situations Requiring Emergent or More Extensive Psychiatric Assessment

If there is any concern about the child’s safety, the provider must also evaluate the risk of danger to self (suicidal attempts or ideation), danger to others (assault, aggression, or homicidal ideation), and screen for other factors that could heighten the risk of danger to self or others, such as physical or sexual abuse or illicit substance use or abuse. The presence of drug or alcohol abuse in adolescent patients may require referral to community resources specializing in the treatment of these addictive disorders.

The following questions should be asked of the youth. The parents should be asked similar questions about what they have observed. Specific details about the circumstances should be asked if any question below is answered with “yes.”

    1. Have you ever been sad for more than a few days at a time such that it affected your sleep or appetite?

    2. Have you ever been so sad that you wished you weren’t alive?

    3. Have you ever thought of ways of killing yourself or made a suicide attempt?

    4. Have you ever thought about killing someone else, or tried to kill someone?

    5. Has anyone ever hit you and left marks? (If yes, ask who, when, and under what circumstances, and if it was reported.)

    6. Has anyone ever touched your private areas when they weren’t supposed to, or in a way that made you feel uncomfortable? (If yes, ask who, when, and under what circumstances, and if it was reported.)

    7. Do you use alcohol, tobacco, or illicit drugs? (If yes, ask what, when, with whom, and how much.)

A. Civil Commitment and Involuntary Mental Health “Holds”

If further assessment indicates a need for inpatient hospitalization, it is optimal if the patient and guardian give consent for this care. In a situation in which the guardian is unwilling or unable to give consent for emergency department (ED)–based assessment or inpatient hospitalization of a child or adolescent, an involuntary mental health “hold” may become necessary.

The term involuntary mental health “hold” refers to a legal process that can be initiated by providers, police officers, and certified mental health professionals, which allows the individual to be prevented from leaving the ED or hospital for up to 72 hours. This allows the provider to establish a safe environment and prevent the individual from harming themselves or others, and allows sufficient time to determine if the individual is a risk to him- or herself or others due to mental illness. Each state has laws specifying rules and regulations that must be followed as part of this process. A specific form must be completed and the patient and family informed of their rights. As this involves revoking the civil rights of a patient or their guardian, it is critical to implement the procedure correctly. All providers should be familiar with their state laws regulating this process.

Although the precise wording and conditions of involuntary mental health holds may vary slightly from state to state, they are generally quite similar. A 72-hour involuntary mental health hold is obtained for the purpose of acute evaluation and determination of the patient’s safety when the evaluator elicits sufficient information to confirm a significant risk exists of danger to self or others. Additional criteria for involuntary psychiatric admission include a determination that the patient is “gravely disabled” by virtue of impaired judgment, which renders the patient unable to provide food, clothing, or shelter for him- or herself, or in the case of a child or adolescent, that he or she is unable to eat and perform normal activities of daily living. In addition, patients that have a medical condition(s) requiring urgent or emergent treatment do not require a mental health hold. In this case, the primary team/provider should conduct a capacity evaluation.

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