Progress in integrating psychology services within pediatric primary care
By Elizabeth S. Molzon, MS, and Erin E. Brannon, MS
As medical primary care physicians are often the first source for parents or caregivers regarding medical, behavioral and/or mental health questions related to their child, the integration of psychologists within primary care settings is critical (Lavigne et al., 1999). Wright (1967) argued for this integration and emphasized a need to define the specific role of the psychologist within the primary care clinic. He suggested that the psychologist should be integrated within the clinic and work alongside the pediatricians to intervene with parents and children before the issues got to the "disordered" stage (Wright, 1967). The second component to integrating child psychology into the primary care clinic would be the development of curriculum within the psychologist’s training (e.g., internship, postdoctoral fellowships). Lastly, it was recommended to demonstrate the financial utility and successful outcomes of this level of integration through systematic research (Wright, 1967).
Training of the Primary Care Psychologist
The recommendations for training psychologists working within primary care clinics have continued to be refined over the last several decades. It is recommended that primary care psychologists have experiences regarding the conceptualization of family, individual, adult and child therapy cases and be comfortable with assessing such needs (McDaniel, Belar, Schroeder, Hargrove & Freeman, 2002). Additionally, primary care psychologists should also have an understanding of health psychology and the integration of the biological, psychological and social aspects that contribute to symptoms reported, as well as experience working on multidisciplinary teams. (Dobmeyer, Rowan, Etherage & Wilson, 2003; Engel, 1977). Primary care psychologists have the opportunity to play a major role in the assessment and treatment of presenting concerns within a primary care clinic through their knowledge of pediatric and child literature.
In order to facilitate this integration, psychologists will need to develop the skills necessary to maneuver through the healthcare environment. Wright (1967) recommended that psychologists should gain skills through formal training during internship and post-doctoral training as opposed to experiential learning. Additionally, training as described by Spirito and colleagues (2003) could begin during graduate school with an emphasis of the biopsychosocial model, education of medical terminology and experiences working within a medical setting. Thus, students who have specific interests can work to facilitate their own training during graduate school if they are not able to have specific practicum experiences within a primary care setting.
An additional area of training that Rozensky & Janicke (2012) emphasize is that with the overhaul of the healthcare system, psychologists need to be involved in the health care decisions at a federal level to help define the role they have within the primary care setting. For example, in our current billing system psychologists are not able to be reimbursed for intensive behavioral therapy for obesity; yet this treatment can be reimbursed to physicians, physician assistants and nurse practitioners ("Decision memo for intensive behavioral therapy for obesity," 2011). This is just one example of the importance of having psychologists integrated within clinics, but also advocating for the role psychologists can play in the medical arena.
Role of the Primary Care Psychologist
Some of the most common presenting problems in the primary care clinic outside well-child checks are abdominal pain, toileting and feeding issues, management of oppositional and disruptive behavior, and sleep problems (Pace, Chaney, Mullins & Olsen, 1995; Rozensky & Janicke, 2012). All of which are target problems potentially well managed by a psychologist who has the requisite training to intervene. The role of a primary care psychologist is to act as a consultant to the physician by communicating with them about extraneous factors that need to be taken into consideration (e.g., Pace et al., 1995), and educating the physician on the presentation of psychological disorders that may mimic medical complications (Roberts & Wright, 1982). As many consultations are for sub-threshold or unhealthy lifestyle behaviors, psychologists can assist physicians in making recommendations for appropriate empirically-supported treatments rather than services as usual, lending to better treatment outcomes and ultimately saving health care dollars (Nash, McKay, Vogel, & Masters, 2012). Consultation services can also extend to educating physicians regarding child mental health concerns, communicating in clear language with limited vernacular and helping to promote the assessment of behavioral health concerns (Nash et al., 2012). There are several different models for integrating psychologists within a primary care clinic; for more information please see Roberts and Wright (1982).
Expansion of research and knowledge in Primary Care Psychology
As the integration of psychologists within primary care clinics increases, our expansion of research must also increase. Research in the field has just now started to document the effectiveness and utility of housing a psychologist within a primary care clinic. Sobel and colleagues (2001) specifically tested the impact of the brief interventions delivered by primary care psychologists. Their research found that the child’s presenting behavioral problem was significantly decreased with the brief therapy sessions that were completed in the primary care clinic. Additionally, Bower and colleagues (2001) completed a systematic review of interventions within primary care clinics, finding preliminary support for the effectiveness of mental health specialists within the primary care setting. Interestingly, Dempster and colleagues (2012) attempted to identify pertinent patient and parent behaviors that would prompt pediatricians to provide a behavioral health referral, and found that authoritarian parents had lower referral rates than other parenting styles. Although these studies demonstrate some benefits for having a psychologist integrated within a primary care clinic, additional research should replicate these results. Additional research should also examine the rate of follow-up of referral information for outpatient mental health services, and determine cost-effectiveness of having a psychologist integrated within a primary care clinic.
Since Wright’s seminal article in 1967, the field of pediatric psychology has expanded and progressed in both training and integration; however, more research is warranted to highlight the importance of integrating child psychology in the primary care setting. It is important to demonstrate the utility of this service and ensure the role primary care psychologists have within the expanding and changing healthcare system.
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Liz Molzon, MS, is a doctoral candidate in clinical psychology at Oklahoma State University, working primary under the mentorship of Larry L. Mullins, PhD. Molzon's research interests are best conceptualized as a desire to understand the complex interrelationship between parent and child psychosocial functioning within pediatric chronic illness populations. Molzon is currently a member of the Society for Pediatric Psychology Student Advisory Board.
Erin Brannon, MS, is a doctoral candidate in clinical psychology at Oklahoma State University, under the mentorship of Christopher Cushing, PhD. Brannon's research interests are understanding the mechanisms of health behavior change to improve outcomes for parents and children. A second interest is developing and disseminating intervention materials to consumers and the healthcare community through the use of technology.