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Commentary: Caring for the Psychosocial Needs of Children: From Advocacy to Structural Change

  • Michael S. Jellinek
    Correspondence
    Address correspondence to Michael S. Jellinek, MD, Bulfinch 351, Massachusetts General Hospital, Department of Psychiatry, Boston, Massachusetts 02114.
    Affiliations
    From the Department of Psychiatry, Massachusetts General Hospital, Boston, Mass
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      The work of Stein and colleagues
      • Stein R.E.K.
      • Horwitz S.M.
      • Storfer-Isser A.
      • et al.
      Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP Periodic Survey.
      based on an analysis of the 59th American Academy of Pediatrics (AAP) Periodic Survey suggests that approximately 90% of pediatricians accept the professional responsibility of identifying children with 7 conditions: attention-deficit/hyperactivity disorder (ADHD), eating disorders, child and adolescent depression, substance abuse, behavior problems, anxiety, and learning disabilities. The demographic mix of the sample of physicians answering the survey seemed reasonable, with possibly an over-representation of those who had some additional specialized mental health training experiences. Although 70% felt they should treat/manage ADHD, only approximately 25% felt they should treat/manage any of the other quite common diagnoses, instead indicating they would choose to refer. These results suggest 3 key questions:
      • 1.
        If 90% believe they should identify and refer, why is the rate of identification within pediatric primary care approximately 20%?
        • Borowsky I.W.
        • Mozayeny S.
        • Ireland M.
        Brief psychosocial screening at health supervision and acute care visits.
        • Costello E.J.
        Primary care pediatrics and child psychopathology: a review of diagnosis, treatment, and referral practices.
        • Costello E.J.
        • Edelbrock C.
        • Costello A.J.
        Psychopathology in pediatric primary care: the new hidden morbidity.
        • Horwitz S.M.
        • Leaf P.
        • Leventhal J.
        • Forsyth B.
        • Speechley K.N.
        Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices.
        • Lavigne J.
        • Binns H.
        • Christoffel K.
        • et al.
        Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians' recognition.
        Part of the answer is that pediatricians have not adopted an approach to psychosocial screening that parallels the measurement methods applied to height, weight, and other office screening procedures. A number of screening questionnaires exist—from the brief Pediatric Symptom Checklist

        Jellinek MS, Murphy M. The pediatric symptom checklist. Available at: http://psc.partners.org. Accessed November 9, 2007.

        to the longer, more thorough Child Behavior Checklist.

        Achenbach TM. Achenbach system for empirically based assessment. 2007. Available at: http://aseba.org/index.html. Accessed November 9, 2007.

        For young children, there are also well-validated screening tests for autism,

        Autism spectrum disorders (pervasive developmental disorders). National Institute of Mental Health Web site. Available at: http://nimh.nih.gov/health/publications/autism/complete-publication.shtml. Accessed November 9, 2007.

        and for adolescents, tests to recognize depression
        and substance abuse.

        Screening for alcohol use and alcohol related problems. CAGE questionnaire. National Institute on Alcohol Abuse and Alcoholism. Available at: http://pubs.niaaa.nih.gov/publications/aa65/AA65.htm. Accessed November 9, 2007.

        In most primary care settings, pediatricians recognize psychosocial issues based on observation, 1 or 2 questions, or parental complaint. The result is a level of recognition that is low, unsystematic, and often delayed. The 2 major obstacles to a system of screening are a lack of reimbursement and concern about finding places to refer for services. We pay for what we value, and some would say that if the marketplace does not bid on an item (a house) or pay for a service (a pediatrician's professional time), it is de facto worthless. Further, the mental health services that would follow positive screening, including pediatric management, are poorly reimbursed, if at all. We would not accept the current identification and referral rate for any other “real” illness. Imagine if the same results reported by Stein and colleagues
        • Stein R.E.K.
        • Horwitz S.M.
        • Storfer-Isser A.
        • et al.
        Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP Periodic Survey.
        applied to children with diabetes or asthma: low recognition, reluctance to treat, and a 1 in 5 recognition rate. Rather than complacency, we would launch an urgent national effort based on quality and safety.
      • 2.
        If approximately 80% of pediatricians said they should refer identified children, why is the referral rate from pediatric primary care to mental health services so low?

        Usher CT, Caplan JE, Jellinek MJ. Overcoming resistance to psychiatric care referral. Contemp Pediatr. In press.

        There are multiple reasons for the low referral rate, which include: 1) no objective measure that pushes the process (like a high blood sugar), 2) inadequate options for referral, which is the result of the inter-relationship between poor reimbursement and shortages of mental health clinicians, 3) the sense of stigma and loss when accepting a mental health referral, 4) pediatricians feeling inadequately trained to support their decision, 5) the likelihood that the pediatrician does not know the mental health clinician as a colleague, because they have been “carved out” from the circle of the pediatrician's subspecialty colleagues, and 6) the shortage of available referral options. I am sure others will add to this list of reasons for a low referral rate.
      • 3.
        What can be done to change these practice patterns to encourage pediatricians to “own” recognition and manage psychosocial issues paralleling their other screening and prevention efforts for medical disorders? Without a sense of ownership, in the context of overwhelmed schools and shortages of mental health professionals, the psychosocial needs of children will not be met. There is no one else with access and the potential skills to do it.
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      References

        • Stein R.E.K.
        • Horwitz S.M.
        • Storfer-Isser A.
        • et al.
        Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP Periodic Survey.
        Ambul Pediatr. 2008; 8: 11-17
        • Borowsky I.W.
        • Mozayeny S.
        • Ireland M.
        Brief psychosocial screening at health supervision and acute care visits.
        Pediatrics. 2003; 112: 129-133
        • Costello E.J.
        Primary care pediatrics and child psychopathology: a review of diagnosis, treatment, and referral practices.
        Pediatrics. 1986; 78: 1044-1051
        • Costello E.J.
        • Edelbrock C.
        • Costello A.J.
        Psychopathology in pediatric primary care: the new hidden morbidity.
        Pediatrics. 1988; 82: 415-424
        • Horwitz S.M.
        • Leaf P.
        • Leventhal J.
        • Forsyth B.
        • Speechley K.N.
        Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices.
        Pediatrics. 1992; 89: 480-485
        • Lavigne J.
        • Binns H.
        • Christoffel K.
        • et al.
        Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians' recognition.
        Pediatrics. 1993; 91: 649-655
      1. Jellinek M. Patel B.P. Froehle M.C. Bright Futures in Practice: Mental Health–Volume 2, Tool Kit. Pediatric Symptom Checklist. National Center for Education in Maternal and Child Health, Arlington, Va2001
      2. Jellinek MS, Murphy M. The pediatric symptom checklist. Available at: http://psc.partners.org. Accessed November 9, 2007.

      3. Achenbach TM. Achenbach system for empirically based assessment. 2007. Available at: http://aseba.org/index.html. Accessed November 9, 2007.

      4. Autism spectrum disorders (pervasive developmental disorders). National Institute of Mental Health Web site. Available at: http://nimh.nih.gov/health/publications/autism/complete-publication.shtml. Accessed November 9, 2007.

      5. Jellinek M. Patel B.P. Froehle M.C. Bright Futures in Practice: Mental Health–Volume 2, Tool Kit. Edinburgh Depression Scale. National Center for Education in Maternal and Child Health, Arlington, Va2001
      6. Screening for alcohol use and alcohol related problems. CAGE questionnaire. National Institute on Alcohol Abuse and Alcoholism. Available at: http://pubs.niaaa.nih.gov/publications/aa65/AA65.htm. Accessed November 9, 2007.

      7. Usher CT, Caplan JE, Jellinek MJ. Overcoming resistance to psychiatric care referral. Contemp Pediatr. In press.