A report from the American Academy of Pediatrics Task Force on Mental Health offers clinicians a comprehensive blueprint for improving delivery of mental health care services in pediatric settings.
The 135-page document, entitled “Enhancing Pediatric Mental Health Care,” describes “what pediatricians and other primary care physicians can do at the community level, what they can do at the practice level, and how they can integrate the process of providing mental health services into the primary care flow,” Dr. Jane Meschan Foy, chair of the task force, said in an interview.
Four years in the making, the report (Pediatrics 2010; 125[suppl. 3]:S1-135) builds on three key documents previously published by the task force: “Strategies for System Change in Children's Mental Health: A Chapter Action Kit” (available at www.aap.org/mentalhealth/mh2ch.html
The new report contains three main chapters followed by eight appendices and six supplemental appendices. Together with the previous reports, it addresses three main goals set by the task force: Facilitate system changes, build skills, and incrementally change practice.”
“This is really a tour de force,” said Dr. Martin T. Stein, who was not involved in developing the report. “It's an exceptionally comprehensive, well-written, and practical guideline for including psychological/psychosocial/mental health issues in the practice of primary care pediatrics. There are many practical tools such as thinking about your referral patterns, being aware of what's available in the community, and knowing the insurance sources.
“There is also a chapter on how to code for billing for mental health services, which is a critical issue in primary care. In addition, there is a practice readiness inventory, algorithms for early recognition of conditions, and good references to support the recommendations for diagnosis and screening in primary care,” Dr. Stein, professor of pediatrics in the division of child development and community health at the University of California, San Diego, said in an interview.
Dr. Foy, professor of pediatrics at Wake Forest University, Winston-Salem, N.C., called the pediatric primary care setting “a really good place to provide mental health services. It's a place where families are comfortable, a place where they have a trusting long-term relationship with a clinician. If a child has a complex or chronic illness or disability, families know that their pediatrician can help them connect with the specialty services they need and coordinate and monitor their care.”I
In the report's first chapter, “Strategies for Preparing a Community,” the task force outlines ways to gauge the mental health needs of children and youth in the community, and emphasizes the importance of developing or strengthening relationships with mental health advocates, schools, human service agencies, mental health and substance abuse providers, and developmental specialists.
For example, clinicians “might consider initiating previsit data collection from children in foster care,” the report states. “Sharing the responsibility for previsit data collection with the foster care agency increases the likelihood that adults with knowledge of the child's mental health strengths and needs provide critical information. Many states mandate that children placed in foster care receive a mental health assessment within 1 month of placement. Primary care clinicians may participate in providing this assessment.”
In the second chapter, “Strategies for Preparing a Primary Care Practice,” the task force recommends applying principles of the chronic care model to the care of children and youth with mental health problems. One critical element is a wide variety of partnerships to support and coordinate with the services in primary care.
“There are many new models of collaborative practice,” Dr. Foy said. “We are excited about those that integrate a mental health professional into the primary care setting. They show great promise. There are a number of these now around the country.”
Dr. Foy acknowledged that while chronic care model principles have worked well in primary care for medical conditions such as asthma and diabetes, less is known about how these principles will affect the delivery of mental health care to children and youth. “We are intuitively applying this model, knowing that it has been successful, knowing that pediatricians are familiar with it, and knowing that mental health conditions and concerns are often chronic in nature,” she explained.
The third chapter, “Algorithms for Primary Care,” grew out of the work of four separate teams convened by the task force, including youth and families who have had mental health problems.
The chapter proposes a clinical process for promoting mental health, identifying mental health symptoms and concerns, engaging the family as early and effectively as possible to address emerging problems, collaborating with mental health specialists when needed, and monitoring the child's progress toward recovery or further care.