Child Mental Health Treatment Shifts from Specialists to Pediatricians, and So Does Concern

Workshop on collaboration among providers to ensure mental health care for children

In November 1998, the University of Pennsylvania School of Medicine held a one-day conference on children's mental health care issues and produced a monograph including a literature review, conference proceedings and recommendations.

Shifts in the role of primary care physicians have limited the option of referral to child psychiatrists and other specialists, leaving pediatricians and family physicians increasingly responsible for diagnosing and treating the mental health problems of children and adolescents.

This and other challenges in pediatric mental health care were the focus of the conference.

Key Results

  • The conference took place on November 10, 1998, at the University of Pennsylvania in Philadelphia with approximately 125 invited attendees representing the fields of child psychiatry, pediatrics, family medicine, public health, nursing, social work, and school health as well as family mental health advocates. Presenters and panelists addressed these topics:
    • Children's Mental Health: Where Are We and Where Are We Going?
    • Screening and Diagnosis in Primary Care: What Works?
    • Establishing Criteria for Interaction from Frontline to Specialty Care
    • Measuring Outcomes: What Do We Need to Know?
    • The Managed Care Perspective: Resource Allocation Models/Evidence-Based Practice
    • Practice, Research, and Policy Recommendations for Children's Mental Health Care
  • A 79-page monograph — Children's Mental Health: The Changing Interface Between Primary and Specialty Care — explored the conference issues and directed a set of recommendations each to policy-makers, consumers, managers, practitioners and researchers.

Recommendations

The monograph directed the following recommendations to various stakeholders:

Policymakers

  • There is a need for universal coverage, including health benefits.
  • Behavioral health care that serve Medicaid beneficiaries should be required to demonstrate coordination and a system of care.
  • Efforts should be hastened to create a uniform approach for gathering information concerning quality indicators, including some tracking and outcome of children's mental health problems.
  • Health services research using the resources of public agencies, foundations, and managed care organizations should be part of the evaluation and contracting processes.

Consumers

  • Public education campaigns should be developed to educate consumers, destigmatize mental health problems, and stimulate patient activation.
  • Stronger family support initiatives should include family representation in all aspects of children's mental health, including policy, research, and training.

Managers

  • The multiple stakeholders involved in children's mental service need to agree on outcomes and quality indicators.
  • An evidence-based approach to children's mental health problems is needed and must address the complexity of working with several levels of primary care providers as well as specialists.

Practitioners

  • Psychosocial dysfunction and psychiatric disorders are harmful to children. Health care providers who assume medical responsibility must provide the best care based on what is presently known so that children can fulfill their potential.
  • Children need to be evaluated in the context of their families, ethnicity, communities, and environments.
  • Specialty care practitioners need to feed back clinically relevant information on diagnosis and management of children with mental health disorders to their primary care practitioners.
  • A consolidated system of care is needed, whereby involved agencies work together and interdisciplinary communication, training, and treatment planning occur on a regular basis.

Researchers

  • Research in children's mental health services should be the shared responsibility of health care, managed care, and academia.
  • The limited evidence about the efficacy of psychotropic interventions for children is hindering development of an evidence-based approach to children's mental health. More efficacy trials including children are needed.
  • The limited evidence about the effectiveness of primary versus specialty care for children's mental health services will lead to further variation in the provision of these services and uncertain outcomes. The study of "usual care" and mediators in real life settings is essential in assisting the translation of research into practice.
  • Specific and timely means of disseminating the results of efficacy trials and effectiveness studies to primary care and specialty care providers is necessary in order to address the gap between research and practice for both primary and specialty care providers.
  • Research should be interdisciplinary and collaborative, incorporating medical disciplines (including pediatric primary care providers, family physicians, psychiatrists, and psychologists) and the extension of those medical disciplines into the community, including families, schools, and the community as a whole.
  • Measures of function, outcome, quality, readiness for change, parental and familial function, medical cost offset, and systems coordination need to be developed in order to capture the complexity of the multiple factors that contribute to child mental health.
  • Research needs to move beyond short-term assessments, such as those used in typical efficacy trials, to demonstrating the impact of early identification, prevention, and intervention services in the primary care.

Communications

  • Conference organizers distributed some 500 copies of the monograph to experts in the fields it addressed.
  • Conclusions cited in the monograph were the subject of a news article in the Journal of the American Medical Association in July 2000.
  • Conference organizers also made presentations about conclusions reached in the monograph to professional organizations, including the American Public Health Association and the American Academy of Child and Adolescent Psychiatry. (See the Bibliography.) The AHRQ printed and distributed additional copies of the monograph.
  • The project team also wrote an Issue Brief, Children's Mental Health: Recommendations for Research, Practice and Policy, published by the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

Funding


The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $50,000. The U.S. Agency for Healthcare Research and Quality (AHRQ) provided cofunding ($45,702).

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