Advantages of providing psychological services in primary care pediatrics

Early development of cognitive skills, emotional well-being, social competence, and sound physical and mental health are critical to children's overall health and well-being. But opportunities for promoting children's social and emotional development in primary care settings, where children are most commonly treated, are often missed.

• Children experience mental health problems but few have access to psychological services.
• Children sometimes struggle with their emotions, but these struggles may not develop into a diagnosable mental disorder.
• Nearly 13 percent of all children qualify for an individual education plan in public schools, which can include a range of instructional and therapy services (U.S. Department of Education, 2015).
• Few children have access to resources that promote social and emotional skills or help prevent problems before they start.
• Parents have a range of questions regarding child development that require expert advice.

Treatment for mental health issues in children is increasingly provided by pediatricians and family physicians. In the past 20 years, the rate of psychosocial problems identified by primary care providers has more than doubled — from 7 percent to 19 percent (Kelleher, Campo, & Gardner, 2006).

• Primary care providers have taken on greater roles in children's mental health services but may lack the time and skills to fully address children's social and emotional needs.
• Well-intentioned primary care physicians can disrupt their patient schedules when addressing a child's mental health concerns in an extended visit.
• Referral of children for mental health assessment and treatment may result in frustration due to inadequate communication between providers in primary care and mental health systems.
• When children are referred to an external mental health provider, less than half of their families follow through on the referrals (Kelleher et al., 2006).

Given the complexities of addressing children's mental health by primary care providers, new models for integrating child development and mental health services into primary care have emerged. These models include:

• Training primary care providers in child development issues and mental health disorders.
• Consultation by mental health providers to primary care providers.
• Co-location of pediatric mental health providers within primary care practices (Bower, Garralda, Kramer, Harrington, & Sibbald, 2001).

Studies indicate that high-quality mental health services located in primary care are multidisciplinary, collaborative, and more effective than traditional services (Asarnow, Rozenman, Wiblin, & Zeltzer (2015).

The advantages of co-location of mental health providers in primary care settings include:

• Decreased use of general health care services by children with unidentified and untreated mental health problems, resulting in improved outcomes and reduced costs (Williams, Shore, & Foy, 2006).
• Increased confidence among primary care providers to explore mental health concerns.
• Less stigma for families seeking mental health care.
• Increased likelihood that families will seek timely well-child care.
• Improved parenting practices that promote child development.
• Enhanced communication among mental health and primary care providers.
• Increased exchange of knowledge and skills between mental health and primary care disciplines (Kramer & Garralda, 2000; Minkovitz et al., 2007; Rossman, Perry, & Hepburn, 2005; Steele, Elkin, & Roberts, 2008).
• Improved behavioral health outcomes in children and adolescents when compared with traditional silo models of care (Asarnow et al., 2015).

Psychologists are uniquely equipped to be integrated into pediatric practices. They can

• Administer and interpret screening and/or assessment tools to identify a mental health problem.
• Offer therapy for adolescent substance abuse, unhealthy behaviors, and developmental concerns that arise in a pediatric visit.
• Coordinate medical, therapy and educational services with school psychologists to optimize each child's outcome.

Licensed clinical psychologists are independent mental health professionals who bill for services using health and behavior codes as well as mental health therapy codes for children with a diagnosable mental illness. Pediatric practices interested in integrating psychologists into their care team have less financial risk to absorb.

Asarnow, J. R., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta-analysis. JAMA Pediatrics. Advance online publication. doi:10.1001/jamapediatrics.2015.1141

Bower, P., Garralda, E., Kramer, T., Harrington, R., & Sibbald, B. (2001). The treatment of child and adolescent mental health problems in primary acre: A systematic review. Family Practice, 18 (4), 373–382. doi:10.1093/fampra/18.4.373

Kelleher, K. J., Campo, J. V., & Gardner, W. P. (2006, December). Management of pediatric mental disorders in primary care: Where are we now and where are we going? Current Opinions in Pediatrics, 18 (6), 649–653. doi:10.1097/MOP.0b013e3280106a76

Kramer, T., & Garralda, M. E. (2000). Child and adolescent mental health problems in primary care. Advances in Psychiatric Treatment, 6 (4), 287–294. doi:10.1192/apt.6.4.287

Minkovitz, C. S., Strobino, D., Mistry, K. B., Scarfstein, D. O., Grason, H., Hou, W., . . . Guyer, B. (2007). Healthy steps for young children: Sustained results at 5.5 years. Pediatrics, 120 (3), e658–e668. doi:10.1542/peds.2006-1205

Rossman, E. A., Perry, D. F., & Hepburn, K. S. (2005). The best beginning: Partnerships between primary health care and mental health and substance abuse services for young children and their families. Washington, DC: National Technical Assistance Center for Children's Mental Health.

Steele, R. G., Elkin, T. D., & Roberts, M. (Eds.). (2008). Handbook of evidence-based therapies for children and adolescents: Bridging science and practice. New York, NY: Springer. doi:10.1007/978-0-387-73691-4

U.S. Department of Education, National Center for Education Statistics. (2015). Digest of Education Statistics: 2013 (NCES 2015-011). Retrieved from https://nces.ed.gov/programs/digest/d13/

Williams, J., Shore, S. E., & Foy, J. M. (2006, July). Co-location of mental health professionals in primary care settings: Three North Carolina models. Clinical Pediatrics, 45 (6), 537–543. doi:10.1177/0009922806290608