Advertisement

Evolution of Child Mental Health Services in Primary Care

  • Kelly J. Kelleher
    Correspondence
    Address correspondence to Kelly J. Kelleher, MD, MPH, Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, Ohio 43205.
    Affiliations
    Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio (Dr Kelleher and Dr Stevens); and Public Health and Psychiatry, College of Public Health, The Ohio State University, Columbus, Ohio (Dr Kelleher)
    Search for articles by this author
  • Jack Stevens
    Affiliations
    Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio (Dr Kelleher and Dr Stevens); and Public Health and Psychiatry, College of Public Health, The Ohio State University, Columbus, Ohio (Dr Kelleher)
    Search for articles by this author

      Objective

      Although the importance of mental health assessment and treatment in primary care is increasingly recognized, the research that underlies current practices largely stems from a considerable body of non–mental health primary care studies. Our purpose was to describe trends in research over the past 2 decades and to suggest further key items for the research agenda.

      Methods

      We reviewed the literature broadly on health services research in pediatrics, especially studies of changes in primary care practice, and examined recent articles in primary care mental health services.

      Results

      The evolution of primary care mental health services for children has been slow, but the focus of research has changed with the development of clinical improvements. Proposals to deliver more effective services have evolved over the past 40 years in a series of approaches that paralleled initiatives in the broader fields of medicine and pediatrics. Current trends in electronic technology, practice consolidation and coordination, and personalized medicine are likely to increase the pace of change in mental health services for primary care.

      Conclusions

      The evolution of pediatric mental health services in primary care suggests a continuing expansion from a focus initially on provider behavior and quality to a growing attention to patient and systems’ behavior over time and within communities.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Costello E.J.
        • Mustillo S.
        • Erkanli A.
        • et al.
        Prevalence and development of psychiatric disorders in childhood and adolescence.
        Arch Gen Psychiatry. 2003; 60: 837-844
        • Kramer T.
        • Gerralda M.E.
        Psychiatric disorders in adolescents in primary care.
        Br J Psychiatry. 1998; 173: 508-513
        • Roberts R.E.
        • Attkisson C.
        • Rosenblatt A.
        Prevalence of psychopathology among children and adolescents.
        Am J Psychiatry. 1998; 155: 715-725
        • Knapp M.
        • McCrone P.
        • Fombonne E.
        • et al.
        The Maudsley long-term follow-up of child and adolescent depression: 3. Impact of comorbid conduct disorder on service use and costs in adulthood.
        Br J Psychiatry. 2002; 180: 19-23
        • Harpin V.A.
        The effect of ADHD on the life of an individual, their family, and community from preschool to adult life.
        Arch Dis Child. 2005; 90: i2-i7
        • Costello E.J.
        • Copeland W.
        • Cowell A.
        • Keeler G.
        Service costs of caring for adolescents with mental illness in a rural community, 1993–2000.
        Am J Psychiatry. 2007; 164: 36-42
        • Guevara J.
        • Lozano P.
        • Wickizer T.
        • et al.
        Utilization and cost of health care services for children with attention-deficit/hyperactivity disorder.
        Pediatrics. 2001; 108: 71-78
        • Leibson C.L.
        • Katusic S.K.
        • Barbaresi W.J.
        • et al.
        Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder.
        JAMA. 2001; 285: 60-66
      1. CMS/Centers for Medicare and Medicaid Services. The Mental Health Parity Act of 1996 (MHPA). Available at: http://www.cms.hhs.gov/healthinsreformforconsume/04_thementalhealthparityact.asp. Accessed December 5, 2008.

        • Qinghong L.
        • Manteuffel B.
        • Paulic C.
        • Sondheimer D.
        Describing the population of adolescents served in systems of care.
        J Emot Behav Disord. 2001; 9: 13-29
        • Pescosolido B.A.
        • Jensen P.S.
        • Martin J.K.
        • et al.
        Public knowledge and assessment of child mental health problems: findings from the National Stigma Study-Children.
        J Am Acad Child Adolesc Psychiatry. 2008; 47: 339-349
        • Azrin S.T.
        • Huskamp H.A.
        • Azzone V.
        • et al.
        Impact of full mental health and substance abuse parity for children in the Federal Employees Health Benefits Program.
        Pediatrics. 2007; 119: e452-e459
        • Buckley P.F.
        • Madaan V.
        Leadership and professional workforce development.
        Psychiatr Clin North Am. 2008; 31: 105-122
        • Horwitz S.M.
        • Kelleher K.J.
        • Stein R.E.K.
        • et al.
        Barriers to the identification and management of psychosocial issues in children and maternal depression.
        Pediatrics. 2007; 119: e208-e218
        • Olson A.L.
        • Kelleher K.J.
        • Kemper K.J.
        • et al.
        Primary care pediatrician's roles and perceived responsibilities in the management of depression in children and adolescents.
        Ambul Pediatr. 2001; 1: 91-98
        • Lavigne J.V.
        • Binns H.J.
        • Kaufer K.
        • et al.
        Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians’ recognition.
        Pediatrics. 1993; 91: 649-655
        • Jensen P.
        • Hinshaw S.
        • Swanson J.
        • et al.
        Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers.
        J Dev Behav Pediatr. 2001; 22: 60-73
        • Gau S.S.
        • Shen H.Y.
        • Chou M.C.
        • et al.
        Determinants of adherence on methylphenidate and the impact of poor adherence on maternal and family measures.
        J Child Adolesc Psychopharmacol. 2006; 16: 286-297
        • Gardner W.
        • Kelleher K.J.
        • Pajer K.
        • Campo J.V.
        Follow-up care of children identified with ADHD by primary care clinicians: a prospective cohort study.
        J Pediatr. 2004; 145: 767-771
        • Rushton J.
        • Bruckman D.
        • Kelleher K.
        Primary care referral of children with psychosocial problems.
        Arch Pediatr Adolesc Med. 2002; 156: 592-598
        • Marhefka S.L.
        • Koenig L.J.
        • Allison S.
        • et al.
        Family experiences with pediatric antiretroviral therapy: responsibilities, barriers, and strategies for remembering medications.
        AIDS Patient Care STDS. 2008; 22: 637-647
        • Shemesh E.
        • Annunziato R.A.
        • Shneider B.L.
        • et al.
        Improving adherence to medications in pediatric liver transplant recipients.
        Pediatr Transplant. 2008; 12: 316-323
        • Charach A.
        • Skyba A.
        • Cook L.
        • Antle B.J.
        Using stimulant medication for children with ADHD: what do parents say? A brief report.
        J Can Acad Child Adolesc Psychiatry. 2006; 15: 75-83
        • dosReis S.
        • Myers M.A.
        Parental attitudes and involvement in psychopharmacological treatment for ADHD: a conceptual model.
        Int Rev Psychiatry. 2008; 20: 135-141
        • Hoagwood K.
        (quoted by the National Academies Adolescent Health Care Committee Workshop)National Research Council and Institute of Medicine of the National Academies. Challenges in Adolescent Health Care: Workshop Report. National Academies Press, Washington, DCJanuary 22, 2007
        • Lipkin M.
        • Quill T.E.
        • Napadano R.J.
        The medical interview: a core curriculum for residencies in internal medicine.
        Ann Intern Med. 1984; 100: 277-284
        • Evans B.J.
        • Stanley R.O.
        • Mestrovic R.
        • Rose L.
        Effects of communication skills training on students’ diagnostic efficiency.
        Med Educ. 1991; 25: 517-526
        • Weisman C.S.
        Communication between women and their health care providers: research findings and unanswered questions.
        Public Health Rep. 1987; 102: 147-151
        • Wasserman R.C.
        • Inui T.S.
        • Barriatua R.D.
        • et al.
        Pediatric clinicians’ support for parents makes a difference: an outcome-based analysis of clinician-parent interaction.
        Pediatrics. 1984; 74: 1047-1053
        • Street R.L.
        Communicative styles and adaptations in physician-parent consultations.
        Soc Sci Med. 1992; 34: 1155-1163
        • Regier D.A.
        • Goldberg I.D.
        • Taube C.A.
        The de facto US mental health services system: a public health perspective.
        Arch Gen Psychiatry. 1978; 35: 685-693
        • Jacobs J.W.
        • Bernhard M.R.
        • Delgado A.
        • Strain J.J.
        Screening for organic mental syndromes in the medically ill.
        Ann Intern Med. 1977; 86: 40-46
        • Strain J.J.
        Models for teaching communication and attitudes.
        Cancer. 1982; 50: 1974-1978
        • Strain J.J.
        • Pincus H.A.
        • Houpt J.L.
        • et al.
        Models of mental health training for primary care physicians.
        Psychosom Med. 1985; 47: 95-110
        • Jones L.R.
        • Badger L.W.
        • Ficken R.P.
        • et al.
        Mental health training of primary care physicians: an outcome study.
        Int J Psychiatry Med. 1988; 18: 107-121
        • Kelleher K.J.
        • McInerny T.K.
        • Gardner W.P.
        • et al.
        Increasing identification of psychosocial problems: 1979–1996.
        Pediatrics. 2000; 105: 1313-1321
        • Wissow L.S.
        • Wilson M.E.H.
        • Roter D.L.
        Pediatrician interview style and mothers’ disclosure of psychosocial issues.
        Pediatrics. 1994; 93: 289-295
        • Cegala D.J.
        • Post D.M.
        On addressing racial and ethnic health disparities: the potential role of patient communication skills interventions.
        Am Behav Sci. 2006; 49: 853-867
        • Wissow L.S.
        • Roter D.
        • Bauman L.J.
        • et al.
        Patient-provider communication during the emergency department care of children with asthma.
        Med Care. 1998; 36: 1439-1450
        • Brown J.D.
        • Riley A.W.
        • Wissow L.S.
        Identification of youth psychosocial problems during pediatric primary care visits.
        Adm Policy Ment Health. 2007; 34: 269-281
        • Brown J.D.
        • Wissow L.S.
        • Zachary C.
        • Cook B.L.
        Receiving advice about child mental health from a primary care provider: African American and Hispanic parent attitudes.
        Med Care. 2007; 45: 1076-1082
        • Erickson S.J.
        • Gerstle M.
        • Feldstein S.W.
        Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: a review.
        Arch Pediatr Adolesc Med. 2005; 159: 1173-1180
        • Lewis C.C.
        • Pantell R.H.
        • Sharp L.
        Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention.
        Pediatrics. 1991; 88: 351-358
        • Roter D.L.
        • Larson S.
        • Shinitzky H.
        • et al.
        Use of an innovative video feedback technique to enhance communication skills training.
        Med Educ. 2004; 38: 145-157
        • Mangione-Smith R.
        • DeCristofaro A.H.
        • Setodji C.M.
        • et al.
        The quality of ambulatory care delivered to children in the United States.
        N Engl J Med. 2007; 357: 1515-1523
        • McGlynn E.A.
        • Asch S.M.
        • Adams J.
        • et al.
        The quality of health care delivered to adults in the United States.
        N Engl J Med. 2003; 348: 2635-2645
        • Osborne C.E.
        • Thompson H.C.
        Criteria for evaluation of ambulatory health care by chart audit: development and testing of a methology. Final Report of the Joint Committee on Quality Assurance of Ambulatory Health Care for Children and Youth.
        Pediatrics. 1975; 56: 625-692
        • Spivak H.R.
        • Levy J.C.
        • Bonanno R.A.
        • Cracknell M.
        Patient and provider factors associated with selected measures of quality of care.
        Pediatrics. 1980; 65: 307-313
        • Gardner W.
        • Kelleher K.J.
        • Pajer K.A.
        • Campo J.V.
        Primary care clinicians’ use of standardized tools to assess child psychosocial problems.
        Ambul Pediatr. 2003; 3: 191-195
        • Zuckerbrot R.A.
        • Jensen P.S.
        Improving recognition of adolescent depression in primary care.
        Arch Pediatr Adolesc Med. 2006; 16: 200-210
        • Rushton J.L.
        • Fant K.E.
        • Clark S.J.
        Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder.
        Pediatrics. 2004; 114: e23-e28
        • Stein M.T.
        • Perrin J.M.
        Diagosis and treatment of ADHD in school-age children in primary care settings.
        Pediatr Rev. 2003; 24: 92-98
        • Zuckerbrot R.A.
        • Cheung A.H.
        • Jensen P.S.
        • et al.
        • GLAD-PC Steering Group
        Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management.
        Pediatrics. 2007; 120: e1299-e1312
      2. US Preventive Services Task Force. Screening for depression. US Department of Health and Human Services and Agency for Healthcare Research and Quality Online. Released May 2002. http://www.ahrq.gov/clinic/uspstf/uspsdepr.htm. Accessed December 5, 2008.

      3. US Preventive Services Task Force. Screening for alcohol misuse. US Department of Health and Human Services and Agency for Healthcare Research and Quality Online. Released April 2004. http://www.ahrq.gov/clinic/uspstf/uspsdrin.htm. Accessed December 5, 2008.

        • Valenstein M.
        • Vijan S.
        • Zeber J.E.
        • et al.
        The cost-utility of screening for depression in primary care.
        Ann Intern Med. 2001; 134: 418-420
        • Mellow M.M.
        Policing Medicaid and Medicare managed care: the role of courts and administrative agencies.
        J Health Polit Policy Law. 2002; 27: 465-466
      4. Kenny HA. Implementing the Rosie D. Remedy: the opportunities and challenges of restructuring a system of care for children's mental health in Massachusetts. Massachusetts Medicaid Policy Institute. Issue brief, September 2007. Available at: http://www.massmedicaid.org/pdfs/2007-10-12_rosie-d.pdf. Accessed December 5, 2008.

        • Ferris T.G.
        • Dougherty D.
        • Blumenthal D.
        • Perrin J.M.
        A report card on quality improvement for children's health care.
        Pediatrics. 2001; 107: 143-155
        • Szilagyi P.G.
        • Schaffer S.
        • Shone L.
        • et al.
        Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices.
        Pediatrics. 2002; 110: e58
        • Shafer M.A.
        • Tebb K.P.
        • Pantell R.H.
        • et al.
        Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls.
        JAMA. 2002; 288: 2846-2852
        • Wells K.B.
        • Sherbourne C.
        • Schoenbaum M.
        • et al.
        Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial.
        JAMA. 2000; 283: 212-220
        • Asarnow J.R.
        • Jaycox L.H.
        • Duan N.
        • et al.
        Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial.
        JAMA. 2005; 293: 311-319
        • Leslie L.K.
        • Weckerly J.
        • Plemmons D.
        • et al.
        Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings.
        Pediatrics. 2004; 114: 129-140
        • Bernal P.
        • Estroff D.B.
        • Aboudarham J.F.
        • et al.
        Psychosocial morbidity. the economic burden in a pediatric health maintenance organization sample.
        Arch Pediatr Adolesc Med. 2000; 154: 261-266
        • Navon M.
        • Nelson D.
        • Pagano M.
        • Murphy M.
        Use of the pediatric symptom checklist in strategies to improve preventive behavioral health care.
        Psychiatr Serv. 2001; 52: 800-804
        • Iezzoni I.
        Assessing quality using administrative data.
        Ann Intern Med. 1997; 127: 666-674
        • Leslie L.K.
        • Wolraich M.L.
        ADHD service use patterns in youth.
        J Pediatr Psychol. 2007; 32: 695-710
        • Richardson L.P.
        • Lewis C.W.
        • Casey-Goldstein M.
        • et al.
        Pediatric primary care providers and adolescent depression: a qualitative study of barriers to treatment and the effect of the black box warning.
        J Adolesc Health. 2007; 40: 433-439
        • Kelleher K.J.
        • Campo J.V.
        • Gardner W.P.
        Management of pediatric mental disorders in primary care: where are we now and where are we going?.
        Curr Opin Pediatr. 2006; 18: 649-653
        • Von Korff M.
        • Gruman J.
        • Schaefer J.
        • et al.
        Collaborative management of chronic illness.
        Ann Intern Med. 1997; 127: 1097-1102
        • American Academy of Pediatrics
        The medical home: Medical Home Initiatives for Children With Special Needs Project Advisory Committee.
        Pediatrics. 2002; 110: 184-186
        • Wagner E.H.
        • Austin B.T.
        • Von Korff M.
        Organizing care for patients with chronic illness.
        Milbank Q. 1996; 74: 511-544
        • Weinreb L.
        • Nicholson J.
        • Williams V.
        • Anthes F.
        Integrating behavioral health services for homeless mothers and children in primary care.
        Am J Orthopsychiatry. 2007; 77: 142-152
        • Rothman J.
        • Rudnick D.
        • Slifer M.
        • et al.
        Co-located substance use treatment and HIV prevention and primary care services, New York State, 1990–2002: a model for effective service delivery to a high-risk population.
        J Urban Health. 2007; 84: 226-242
        • Menachemi N.
        Barriers to ambulatory HER: who are “imminent adopters” and how do they differ from other physicians?.
        Inform Prim Care. 2006; 14: 101-108
        • Basch P.
        Electronic health records and the National Health Information Network: affordable, adoptable, and ready for prime time?.
        Ann Intern Med. 2005; 143: 227-228
        • Katz S.J.
        • Moyer C.A.
        The emerging role of online communication between patients and their providers.
        J Gen Internal Med. 2004; 19: 973-983
        • Stevens J.
        • Kelleher K.J.
        • Gardner W.
        • et al.
        Trial of computerized screening for adolescent behavioral concerns.
        Pediatrics. 2008; 121: 1099-1105
        • Cook K.F.
        • O'Malley K.J.
        • Roddey T.S.
        Dynamic assessement of health outcomes: time to let the CAT out of the bag?.
        Health Serv Res. 2005; 40: 1694-1711
        • Gardner W.
        • Kelleher K.J.
        • Pajer K.
        Computerized adaptive measurement of depression: a simulation study.
        Med Care. 2002; 40: 812-823
        • Gerstle R.S.
        Task Force on Medical Informatics. E-mail communication between pediatricians and their patients.
        Pediatrics. 2004; 114: 317-321
      5. Gardner W. Pharmacy Safety Tracking (PhaST): Using IVR to Monitor Pediatric Outpatients Taking Antidepressants. American Academy of Pediatrics' Second National Ambulatory Primary Care Patient Safety and Health Information Technology (HIT) Conference. Washington, DC; 2008.

        • Marcin J.P.
        • Ellis J.
        • Mawis R.
        • et al.
        Using telemedicine to provide pediatric subspecialty care to children with special health care needs in an underserved rural community.
        Pediatrics. 2004; 113: 130
        • Young T.L.
        • Ireson C.
        Effectiveness of school-based telehealth care in urban and rural elementary schools.
        Pediatrics. 2003; 112: 1088-1094
        • Simon G.E.
        • Von Korff M.
        • Rutter C.
        • Wagner E.
        Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care.
        Br Med J. 2000; 320: 550-554
        • Simon G.E.
        • Ludman E.J.
        • Tutty S.
        • et al.
        Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial.
        JAMA. 2004; 292: 935-942
        • Neufeld J.D.
        • Yellowlees P.M.
        • Hilty D.M.
        • et al.
        The e-Mental Health Consultation Service: providing enhanced primary-care mental health services through telemedicine.
        Psychosomatics. 2007; 48: 135-141
      6. Colliers CRE Group. GP practices face consolidation and closure, says Colliers CRE Primary Healthcare Review, UK. Medical News Today Online. Available at: http://www.medicalnewstoday.com/articles/114194.php. Accessed December 5, 2008.

      7. The primary care problem: consolidation, unplugging, and concierge care. Piercing the Veil, April 4, 2008. Available at: http://blogs.law.harvard.edu/jancer/2008/04/04/the-primary-care-problem-consolidation-unplugging-and-concierge-car/. Accessed December 5, 2008.

        • Sloane P.D.
        • Slatt L.M.
        • Ebell M.H.
        • et al.
        Principles of Family Medicine. Essentials of Family Medicine.
        5th ed. Lippincott Williams & Wilkins, Baltimore, Md2007
        • Bartels S.J.
        • Coakley E.H.
        • Zubritsky C.
        • et al.
        Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use.
        Am J Psychiatry. 2004; 161: 1455-1462
        • Gallo J.J.
        • Zubritsky C.
        • Maxwell J.
        • et al.
        Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-E).
        Clin Pediatr. 2004; 2: 305-309
        • Williams J.
        • Shore S.
        • Foy J.M.
        Co-location of mental health professionals in primary care settings: three North Carolina models.
        Clin Pediatr. 2006; 45: 537-543
        • Williams J.
        • Palmes G.
        • Klinepeter K.
        • et al.
        Referral by pediatricians of children with behavioral health disorders.
        Clin Pediatr. 2005; 44: 343-349
        • Williams J.
        • Klinepeter K.
        • Palmes G.
        • et al.
        Diagnosis and treatment of behavioral health disorders in pediatric practice.
        Pediatrics. 2004; 114: 601-606
        • Connor D.F.
        • McLaughlin T.J.
        • Jeffers-Terry M.
        • et al.
        Targeted child psychiatric services: a new model of pediatric primary clinician–child psychiatry collaborative care.
        Clin Pediatr. 2006; 45: 423-434
        • Connor D.F.
        Targeted child psychiatric services: a new model of pediatric primary clinician–child psychiatry collaborative care.
        Clin Pediatr. 2006; 45: 423-434
      8. de Leon J. The future (or lack of future) of personalized prescription in psychiatry. Pharmacol Res. 2008 [Epub ahead of print]. Available at: http://www.sciencedirect.com/science?_ob=Mlmg&_imagekey=B6WP9-4TPHRR7-3-1&_cdi=6985&_user=3366836&_orig=search&_coverDate=10%2F17%2F2008&_sk=999999999&view=c&wchp=dGLzVzz-zSkzk&_valck=1&md5=7511065e4585e6d87c5ea2057ec07563&ie=/sdarticle.pdf. Accessed December 16, 2008.

        • de Leon J.
        Test: personalized medicine has arrived in psychiatry.
        Expert Rev Mol Diagn. 2006; 6: 277-286
        • Cascorbi I.
        Pharmacogenetics of cytochrome P4502D6: genetic background and clinical implication.
        Eur J Clin Invest. 2003; 33: 17-22