Children’s mental health problems are among global health advocates’ highest priorities. Nearly three-quarters of adult disorders have their onset or origins during childhood, becoming progressively harder to treat over time. Integrating mental health with primary care and other more widely available health services has the potential to increase treatment access during childhood, but requires re-design of currently-available evidence-based practices to fit the context of primary care and place a greater emphasis on promoting positive mental health. While some of this re-design has yet to be accomplished, several components are currently well-defined and show promise of effectiveness and practicality.
Key points
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Mental health problems in children and adolescents are common and begin early in life.
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Mental health promotion and early intervention during childhood are global public health priorities.
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Primary care can help meet this need through collaboration with specialists and by recognizing the centrality of mental health to physical health.
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Mental health interventions can be re-designed to fit the work flow and staffing of primary care sites.
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Taking on mental health promotion and care is a “whole office” task that includes families in its design and execution.
Unmet need for child mental health services
Children’s mental health problems are among global health advocates’ highest priorities because they are among the leading causes of disability for children and youth and often go untreated for years, significantly disrupting healthy development. In addition, advocates increasingly see mental health promotion in childhood as the only viable short-term path to reducing the burden of adult mental disorders. Nearly three-quarters of adult disorders have their onset or origins during childhood, becoming harder to treat and incurring ever-greater social, educational, and economic consequences over time. In contrast, there is good evidence that commonly occurring problems such as anxiety and depression can be prevented or ameliorated through intervention in childhood and adolescence.
Designing an expanded program to address mental health in childhood presents many challenges. Even in the most highly resourced countries, child mental health professionals are in short supply and their optimal use is hampered by fragmented systems and competition for limited public funding. In much of the world, specialized care is virtually unavailable except to the most privileged. In the United States, the 2003 National Health Interview Survey found that 56% of children aged 4 to 17 years with definite or severe functional difficulties attributable to mental health problems had not seen a mental health professional in the past year. A decade later, a study in Massachusetts, after the start of mandatory child mental health screening in primary care, found that 40% of screen-positive children had no previous history of mental health service use.
Unmet need for child mental health services
Children’s mental health problems are among global health advocates’ highest priorities because they are among the leading causes of disability for children and youth and often go untreated for years, significantly disrupting healthy development. In addition, advocates increasingly see mental health promotion in childhood as the only viable short-term path to reducing the burden of adult mental disorders. Nearly three-quarters of adult disorders have their onset or origins during childhood, becoming harder to treat and incurring ever-greater social, educational, and economic consequences over time. In contrast, there is good evidence that commonly occurring problems such as anxiety and depression can be prevented or ameliorated through intervention in childhood and adolescence.
Designing an expanded program to address mental health in childhood presents many challenges. Even in the most highly resourced countries, child mental health professionals are in short supply and their optimal use is hampered by fragmented systems and competition for limited public funding. In much of the world, specialized care is virtually unavailable except to the most privileged. In the United States, the 2003 National Health Interview Survey found that 56% of children aged 4 to 17 years with definite or severe functional difficulties attributable to mental health problems had not seen a mental health professional in the past year. A decade later, a study in Massachusetts, after the start of mandatory child mental health screening in primary care, found that 40% of screen-positive children had no previous history of mental health service use.
A role for primary care
Strategies for improving children’s access to mental health care focus largely on increasing the number and kinds of providers who can deliver preventive and treatment services. This includes engaging family members, improving the mental health promotion and treatment capacity of schools and community programs, and increasing the capacity of primary care.
Around the world, primary care is delivered in many different ways and by professionals and paraprofessionals with differing skill sets. The extent to which child mental health care integrates with primary care thus varies, and also depends on opportunities to expand services in schools and from community-based organizations. For example, in the United States, primary care providers (family physicians, primary care pediatricians, nurse practitioners, physicians’ assistants, and the others who work with them) are tasked with a variety of health maintenance and monitoring functions that, in other systems, are carried out by public health workers. Thus, integration efforts in the United States focus mostly on primary care sites themselves, whereas in other countries (such as the United Kingdom) they involve work with a combination of primary care, school-based, and public health services.
Whether in primary care predominantly, or in a combination of primary care and public health, the philosophy of promoting and tracking children’s healthy development creates the benefit of integration, forming a natural base from which to promote mental health and detect emerging problems. Mental health care can then be delivered in the context of care for co-occurring medical conditions, and with a focus on periods of individual and family vulnerability. Ongoing relationships can build willingness to share sensitive information and trust in the appropriateness of diagnosis and treatment.
Developing primary care as a resource for mental health has involved 2 strategies (collaborative care and task shifting), which in fact are inseparable. Collaborative care emphasizes effective partnerships between primary and specialty care, allowing patients to receive treatments that take advantage of specialty expertise, while benefiting from the comprehensiveness and longitudinal aspects of primary care. However, collaborative care cannot function without some degree of task shifting, the delivery of some specialized services by primary care providers themselves. Task shifting is needed for several reasons: early detection and intervention (as well as efforts at health promotion) may identify situations that do not qualify for specialty care; waiting times for specialty care may be too long; many patients may prefer to be treated in primary care and opt for no care at all rather than accepting a referral. Task shifting may be the only alternative in settings where specialty care is available only at great expense or in extraordinary circumstances.
Barriers to task shifting
The biggest barrier to task shifting, and even to the co-location of mental health providers in primary care offices, is that most current mental health treatment does not fit with how primary care is practiced by clinicians or used by families. Primary care practice is characterized by the need to conduct many visits in a short time and accommodate unscheduled visits for acute illness. In contrast, mental health treatments are usually delivered in sessions lasting from 30 to 60 minutes. Primary care continuity is defined as longitudinal access and monitoring over an indefinite time frame, while mental health treatments are delivered in a series of closely spaced visits, often for a finite time. These differences may apply both to primary care providers themselves and to co-located practitioners. Business models supporting co-located providers may not allow for extended visits, and families may find it just as hard to return for serial visits to a primary care site as they do for mental health service sites.
Other difficulties with currently available treatments lie in their therapeutic targets. A recent analysis of child-youth treatments supported by randomized trials found that, even if a full set of those targets recommended by the Substance Abuse and Mental Health Services Administration were to be available, nearly 50% of youth in need of services would technically not be considered appropriate candidates because their age, gender, or disorder did not match the characteristics of children among whom the intervention had been studied. The situation in primary care is even worse: up to 20% to 30% of children seen in primary care have behavioral or emotional problems that impair their function but do not meet criteria for any disorder; thus, the range of available evidence-based treatments is even smaller.
Many evidence-based treatments fail to take an ecologic perspective. Children’s problems may stem from difficulties within their family or community and include parental mental health problems, food and housing insecurity, or exposure to dangerous neighborhoods or challenging schools. The child may be the “identified patient” in these situations, but intervention may be more effectively directed to the underlying issues rather than the child’s resulting behavioral or emotional state. The links between these so-called social determinants and mental health are becoming increasingly clear. In the United States, an estimated 7% of infants and young children live with severely depressed mothers, a recognized and treatable cause of child mental health problems. The prevalence increases to 11% for children living in poverty, and to 41% and 55% for all children and those in poverty, respectively, if mild and moderate depression are included. Poverty itself affects parental functioning in ways that have an impact on children’s mood and behavior; the daily hassles of poverty, even when not experienced as stress, reduce cognitive “bandwidth,” making it harder for parents to reason through problems and sustain goal-directed attention.
Another shortcoming of current mental health services is that they are separate from or lacking interventions that promote mental wellness. The “dual continuum model” posits that mental illness and mental wellness are 2 separate although related concepts. Both mental illness and mental wellness predict lifetime medical problems and mortality, with mental illness markedly reducing lifespan and mental wellness increasing it. Importantly, promoting wellness can prevent illness, but treating illness may not necessarily promote wellness. Promoting mental wellness has long been an aspiration of primary care in the United States, but there are no widely disseminated practical interventions beyond infancy and toddlerhood. The “Triple P” program shows promise as a primary care and community-based approach based on parenting training, but evidence for its effectiveness remains limited.
Finally, despite the demand and need for mental health services, current treatments are far from widely embraced by families. In 1 US study, more than half of parents with emotional, behavioral, or developmental concerns about their children did not discuss them with their child’s doctor, and even in highly integrated health care systems anywhere from a significant minority to a majority of referrals from primary care to mental health are never completed. Patient preferences are important; in 1 primary care study of medication for adult depression, treatment was highly cost-effective for patients with favorable attitudes toward medication but showed no advantage over usual care for patients with negative attitudes. In pediatrics, parents vary considerably in their attitudes toward therapeutic options for common childhood mental health problems.
Designing mental health interventions for primary care
In this article, we focus on what types of mental health treatment and promotion interventions might be practical, engaging to families, and effective for use by primary care providers and primary care–based mental health professionals. The goals of providing these services include
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Being an effective gateway to specialty services
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Being part of a safety net: identifying and helping families who fall out of the specialized mental health system for one reason or another
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Providing early intervention: catching things before they get worse
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Promoting positive mental health: the attributes that help children “flourish”
We divide the remaining sections of the paper into 3 groups: what primary care providers might do, how they might be supported to learn how to do it, and what could make it sustainable and become part of routine.
What might providers do?
A Holistic Framework for Care
Much of the reasoning in this section flows from the concept that the brain is the principle organ of human adaptation. The brain’s processing of, and responses to, the environment determine both mental and physical health. Appraisal of the environment drives autonomic, endocrine, and immunologic responses, with long-term implications for health; emotional responses to the environment drive behaviors that have profound implications for physical health as well as social connectedness, cognitive development, and ultimately reproductive success. Thus, thinking about mental health is integral to good medical care; it is not an add-on. If mental health care is then integral to all of pediatric care, it needs to begin with interventions that permeate all care but are particularly put into play when working with families in which a child may have a mental health problem.
There are several possibilities for universal interventions that mesh seamlessly with day-to-day medical practice ( Table 1 ). First, the “common factors” literature from psychotherapy demonstrates that there are aspects of the client-therapist interaction predicting outcomes across conditions and treatments. This parallels observations of how patient-provider interactions and organizational culture influence outcomes in medical and agency-based services. Second, studies of “single session” psychotherapy demonstrate the effectiveness of providing problem (rather than diagnostic) targeted treatment in brief pulses across extended periods, similar to patterns of medical care. Third, “stepped care” models suggest that generalists can provide first-contact mental health treatment based on brief problem-oriented assessments if they follow patients to ascertain need for further diagnosis or intervention.
| Community and General Medical Settings | Parallels in Mental Health Services |
|---|---|
| Emphasis on patient-centered care and joint decision making building trust and activation | “Common factors” in psychotherapeutic processes promoting engagement, optimism, alliance |
| Treatment delivered in pulses with follow-up for monitoring or as needed | “Single session” treatment models |
| Initial treatment often presumptive or relatively nonspecific | Stepped care models with increasing specificity of diagnosis and intensity of treatment |
| Treatment based on brief counseling focused on patient-identified problems | “Common elements” |
| Links with community services, advice addressing family and social determinants | Peer/family navigators |
Targeted Brief Interventions
The major gap in our ability to provide mental health services in primary care is the need for brief interventions more specifically targeting particular common problems. To reach a large number of children, these interventions need to be relatively few in number (crossing current diagnostic categories), easy to implement, and broadly address early intervention, family and social influences, and wellness promotion.
These brief interventions can be developed from more complex evidence-based treatments. In 2004, Hawaii’s Evidence Based Services Committee pioneered the technique of identifying ‘‘practice elements’’ used repeatedly across multiple evidence-based therapies for specific conditions. Since then, the process of identifying elements has been refined, and trials in outpatient child mental health programs have found that using treatment where problems are matched to elements (as opposed to diagnoses being matched to evidence-based interventions) was effective and well received by families.
Although there have yet to be similar trials in primary care, a pilot study that trained pediatricians to use an elements-based approach for children with anxiety found evidence of effectiveness and feasibility within the structure of primary care practice. Table 2 shows elements extracted from evidence-based treatments by the Hawaii Evidence Based Services Committee for 4 major child behavioral and emotional problems encountered by pediatricians. There are a relatively small number of discrete interventions, most of which are already suggested for use in primary care.
| Presenting Problem Area | Most Common Elements of Related Evidence-Based Practices |
|---|---|
| Anxiety | Graded exposure, modeling |
| ADHD and oppositional problems | Tangible rewards, praise for child and parent, help with monitoring, time out, effective commands and limit setting, response cost |
| Low mood | Cognitive/coping methods, problem-solving strategies, activity scheduling, behavioral rehearsal, social skills building |
Beyond Diagnosis to Promoting Core Components of Mental Health
Whereas the conditions in Table 2 are readily recognizable, they still are “problems” rather than qualities related to positive mental health. Ideally, we want to be able to address issues that are at the root of healthy functioning, and we want to be able to acknowledge that children’s behavior and emotional problems are closely linked to developmental, family, school, and community issues that might be important primary or simultaneous targets of intervention.
Over the last several years, the US National Institute of Mental Health has developed what it calls the Research Domain Criteria (RDoC) framework as a way identifying core brain circuits identified with mental illness and wellness independently of current diagnostic categories. Although not suggesting that there is a neurologic correlate to all behaviors and mental states, RDoC follows a line of inquiry in developmental psychology that tries to identify processes underlying the frequently comorbid and variable conditions seen in children’s mental health problems. Multidisciplinary panels identified 5 major domains: negative and positive valence systems, cognitive systems, social processes, and arousal systems. Within each domain, particular constructs represent feelings and behaviors associated with both successful adaptation and difficulty functioning. Although the domains have evidence for their independent existence and functioning, they clearly work together to promote positive mental health or influence states of emotional distress or behavioral dysfunction.
Although the RDoC framework is new, it has shown promise as a clinical as well as a research tool, helping clinicians consider patients’ strengths and difficulties in ways that open additional avenues for treatment. It offers the promise of grouping treatments in ways that are more intuitive to clinicians, using fewer categories than current schemes, thus increasing ease of dissemination.
Table 3 maps key circuits identified by RDoC with mental states associated with positive mental health and then with a tentative selection of interventions for promoting mental health or intervening early with potential difficulties. The entries in the intervention columns of the table can be thought of as involving treatments aimed at children or parent-child dyads. Interventions in the bottom row of the table target the family overall or a parent in particular.
| RDoC Domain/Construct | States Related to Positive Mental Health | Promotion/Prevention | Early Intervention |
|---|---|---|---|
|
Reasonable ability to sustain attention, engage in problem solving | Parent-child joint attention activities, play involving concentration and memory, learning to structure work Whole-school interventions | Task monitoring, organizational support, rewards for sustained attention |
| Positive valence systems | Reasonable ability to derive satisfaction from constructive social and intellectual activity | Early cognitive and social stimulation, early exposure to role models intellectually stimulating peer activities | Identification and intervention for learning disorders and other impediments to school success |
| Negative valence, low mood | Reasonable ability to regulate emotions and moderate responses to perceived threats | Contingent responsiveness, parental warmth, cognitive coping skills, promotion of self-esteem, self-efficacy (via social processes domain), skills and activities that build social capital | Behavioral activation, solution-focused problem solving |
|
Differentiation of sustained vs acute or potential fears: cognitive coping, behavioral rehearsal, modeling, graded exposure | ||
| Tolerance of negative valence states | Relaxation, distraction, mindfulness, controlled avoidance | ||
|
Positive sense of self, ability to form bonds with others, ability to read and express emotions | Parenting guidance Whole-classroom programs Community-based group activities for children | Social skills groups Parent-child bibliotherapy |
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Evolving ability to match sleep needs with cultural norms | Monitoring of electronic activities, sufficient physical activity, limiting intake of substances interfering with sleep and arousal | Sleep hygiene, problem solving around schedules, substance intake, increasing physical activity |
| Parent/family interventions | Support for parent to maintain these interactions over time, promotion of parental self-efficacy, mentalization, developmental knowledge | Support from across formal and informal community agencies to provide these interventions; treatment of parental mental health problems | |
| Support for the family in the community: social support of various kinds, promotion of financial stability; attention to mental health promotion and prevention across the lifespan | |||
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