Barriers to the Identification and Management of Psychosocial Problems: Changes From 2004 to 2013

Published:August 26, 2015DOI:



      Pediatricians report many barriers to caring for children with mental health (MH) problems. The American Academy of Pediatrics (AAP) has focused attention on MH problems, but the impact on perceived barriers is unknown. We examined whether perceived barriers and their correlates changed from 2004 to 2013.


      In 2004, 832 (52%) of 1600 and in 2013, 594 (36.7%) of 1617 of randomly selected AAP members surveyed responded to periodic surveys, answering questions about sociodemographics, practice characteristics, and 7 barriers to identifying, treating/managing, and referring child/adolescent MH problems. To reduce nonresponse bias, weighted descriptive and logistic regression analyses were conducted.


      Lack of training in treatment of child MH problems (∼66%) and lack of confidence treating children with counseling (∼60%) did not differ across surveys. Five barriers (lack of training in identifying MH problems, lack of confidence diagnosing, lack of confidence treating with medications, inadequate reimbursement, and lack of time) were less frequently endorsed in 2013 (all P < .01), although lack of time was still endorsed by 70% in 2013. In 2004, 34% of pediatricians endorsed 6 or 7 barriers compared to 26% in 2013 (P < .005). Practicing general pediatrics exclusively was associated with endorsing 6 or 7 barriers in both years (P < .001).


      Although fewer barriers were endorsed in 2013, most pediatricians believe that they have inadequate training in treating child MH problems, a lack of confidence to counsel children, and limited time for these problems. These findings suggest significant barriers still exist, highlighting the need for improved developmental and behavioral pediatrics training.


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


        • US Department of Health and Human Services
        • US Department of Education
        • US Department of Justice
        Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda.
        US Department of Health and Human Services, Washington, DC2000
        • Ringeisen H.
        • Oliver K.A.
        • Menvielle E.
        Recognition and treatment of mental disorders in children.
        Pediatr Drugs. 2002; 4: 697-703
        • Kelleher K.J.
        • McInerny T.K.
        • Gardner W.P.
        • et al.
        Increasing identification of psychosocial problems: 1979–1996.
        Pediatrics. 2000; 105: 1313-1321
        • Horwitz S.M.
        • Kelleher K.J.
        • Stein R.E.
        • et al.
        Barriers to the identification and management of psychosocial issues in children and maternal depression.
        Pediatrics. 2007; 119: e208-e218
        • Hogan M.F.
        New Freedom Commission report. The president's New Freedom Commission: recommendations to transform mental health care in America.
        Psychiatr Serv. 2003; 54: 1467-1474
        • 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
        • Shaw K.
        • Mitchell G.
        • Wagner I.
        • et al.
        Attitudes and practices of general practitioners in the diagnosis and management of attention-deficit/hyperactivity disorder.
        J Paediatr Child Health. 2002; 38: 481-486
        • Williams J.
        • Klinepeter K.
        • Palmes G.
        • et al.
        Diagnosis and treatment of behavioral health disorders in pediatric practice.
        Pediatrics. 2004; 114: 601-606
        • Glied S.
        Too little time? The recognition and treatment of mental health problems in primary care.
        Health Serv Res. 1998; 33: 891
        • Kelleher K.J.
        • Childs G.E.
        • Wasserman R.C.
        • et al.
        Insurance status and recognition of psychosocial problems: a report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks.
        Arch Pediatr Adolesc Med. 1997; 151: 1109-1115
        • Rushton J.
        • Bruckman D.
        • Kelleher K.
        Primary care referral of children with psychosocial problems.
        Arch Pediatr Adolesc Med. 2002; 156: 592-598
        • Stein R.E.
        • 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
        • Horwitz S.M.
        • Caspary G.
        • Storfer-Isser A.
        • et al.
        Is developmental and behavioral pediatrics training related to perceived responsibility for treating mental health problems?.
        Acad Pediatr. 2010; 10: 252-259
        • Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health
        Policy statement—The future of pediatrics: mental health competencies for pediatric primary care.
        Pediatrics. 2009; 124: 410-421
        • American Academy of Pediatrics
        Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit.
        American Academy of Pediatrics, Elk Grove Village, Ill2010
      1. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. Available at: Accessed December 22, 2014.

        • Wolraich M.
        • Felice M.E.
        • Drotar D.
        The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version.
        American Academy of Pediatrics, Elk Grove Village, Ill1996
        • Olson A.L.
        • Kelleher K.J.
        • Kemper K.J.
        • et al.
        Primary care pediatricians' roles and perceived responsibilities in the identification and management of depression in children and adolescents.
        Ambul Pediatr. 2001; 1: 91-98
        • Williams Jr., J.W.
        • Rost K.
        • Dietrich A.J.
        • et al.
        Primary care physicians' approach to depressive disorders: effects of physician specialty and practice structure.
        Arch Fam Med. 1999; 8: 58
      2. American Academy of Pediatrics. Pediatricians' practice and personal characteristics: US only, 2013. Available at: Accessed June 8, 2015.

        • Berk M.L.
        • Schur C.L.
        Access to care: how much difference does Medicaid make?.
        Health Aff. 1998; 17: 169-180
        • Kataoka S.H.
        • Zhang L.
        • Wells K.B.
        Unmet need for mental health care among US children: variation by ethnicity and insurance status.
        Am J Psychiatry. 2002; 159: 1548-1555
        • Newacheck P.W.
        • Hughes D.C.
        • Stoddard J.J.
        Children's access to primary care: differences by race, income, and insurance status.
        Pediatrics. 1996; 97: 26-32
        • Newacheck P.W.
        • Pearl M.
        • Hughes D.C.
        • et al.
        The role of Medicaid in ensuring children's access to care.
        JAMA. 1998; 280: 1789-1793
        • Starfield B.
        • Shi L.
        The medical home, access to care, and insurance: a review of evidence.
        Pediatrics. 2004; 113: 1493-1498
        • Asch D.A.
        • Jedrziewski M.K.
        • Christakis N.A.
        Response rates to mail surveys published in medical journals.
        J Clin Epidemiol. 1997; 50: 1129-1136
        • Cummings S.M.
        • Savitz L.A.
        • Konrad T.R.
        Reported response rates to mailed physician questionnaires.
        Health Serv Res. 2001; 35: 1347
        • Cull W.L.
        • O'Connor K.G.
        • Sharp S.
        • et al.
        Response rates and response bias for 50 surveys of pediatricians.
        Health Serv Res. 2005; 40: 213-226
        • Groves R.M.
        • Presser S.
        • Dipko S.
        The role of topic interest in survey participation decisions.
        Public Opin Q. 2004; 68: 2-31
        • Keeter S.
        • Kennedy C.
        • Dimock M.
        • et al.
        Gauging the impact of growing nonresponse on estimates from a national RDD telephone survey.
        Public Opin Q. 2006; 70: 759-779
        • Lepkowski J.M.
        • Tucker C.
        • Brick J.M.
        • et al.
        The causes and consequences of response rates in surveys by the news media and government contractor survey research firms.
        in: Holbrook A. Krosnick J. Pfent A. Advances in Telephone Survey Methodology. Wiley, Hoboken, NJ2007: 499-528
        • Kerker B.D.
        • Hoagwood K.E.
        • Radigan M.
        • et al.
        Detection and treatment of mental health issues by pediatric PCPs in New York State: an evaluation of Project TEACH.
        Psychiatr Serv. 2015; 66: 430-433