A pediatric office–based intervention for assessing and treating children’s mental health problems significantly reduced oppositional behavior, inattention, hyperactivity, and functional impairment in a study of 78 children reported online Nov. 7 in the Archives of Pediatrics and Adolescent Medicine.
The availability of mental health services at a pediatrician’s office greatly increased the number of patients who initiated treatment and the number who completed treatment, consistent with previous reports that parents and children are more accepting of visits to a pediatric setting than to a mental health setting, said David J. Kolko, Ph.D., and his associates.
The authors reported the results of a 2-year pilot study comparing this doctor-office collaborative care (DOCC) program with "enhanced" usual care in four large community-based pediatric practices affiliated with the Children’s Hospital of Pittsburgh. A total of 29 pediatricians participated.
In the DOCC intervention, three master’s-degree–level staff members (a social worker, a counselor, and a nurse) served as case managers and worked under the supervision of a senior clinician who had input from a child and adolescent psychiatrist. The case managers provided on-site and telephone services to patients and parents: they conducted psychological assessments, explained diagnoses and treatment recommendations, provided education on behavioral disorders, gave parents and children skills training in cognitive behavior treatment, provided peer and school consultation as needed, and coordinated any necessary medical care such as drug therapy.
"Most parent skills-training content targeted the management of family stressors and child behavior, whereas child skills training primarily targeted affect regulation and social skills," noted Dr. Kolko of Western Psychiatric Institute and Clinic, Oakland, Pa., and the departments of psychiatry, psychology, and pediatrics at the University of Pittsburgh, and his colleagues.
The case managers met with the pediatricians and the entire care team weekly to review the cases. Their sessions with patients and families were videotaped so that they could be reviewed by supervising clinicians as well as the participating pediatricians.
An "enhanced usual care" intervention was provided for comparison (control group). In it, the case managers provided education about the child’s mental or behavioral disorder(s), explained clinical recommendations, and gave up to three referral options for a mental health provider tailored to the child’s needs, geographic location, and insurance. They also made a single follow-up phone call 2 weeks later to check on the patient’s progress.
The pediatricians referred to the study any children aged 5-12 years who seemed appropriate for formal screening for mental health problems. A total of 78 patients met study inclusion criteria (rated at or above the 75th percentile on the externalizing problems subscale of the Pediatric Symptom Checklist) and agreed to participate. The most common psychiatric diagnoses were anxiety disorder (47% of children), ADHD (45%), and opposition defiance disorder (49%).
The children were randomly assigned to the DOCC program (55 patients) or enhanced usual care (23 patients). After 6 months, their scores on a battery of measures were compared with scores obtained at baseline. In addition to the Pediatric Symptom Checklist, these measures included the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, the Clinical Global Impressions (CGI) Scale, the Vanderbilt ADHD Parent Rating Scale, and the Screen for Child Anxiety Related Emotional Disorders.
All 55 of the children in the DOCC group received some mental health treatment, compared with only 4 of the 23 in the control group. Similarly, 43 children in the DOCC group, compared with none in the usual care group, completed their treatment. The use of recommended ADHD medication was higher in the DOCC group (78% of eligible patients) than in the control group (20%), but that difference was not significant because of the small sample size of the control group.
Children in the DOCC group were more likely to be rated as improved or significantly improved (66%) at the conclusion of the program than were those in the usual care group (8%). In particular, CGI scores showed markedly greater improvement for the DOCC group (62%) than the control group (0%), the investigators said (Arch. Pediatr. Adolesc. Med. 2011 Nov. 7 [doi:10.1001/archpediatrics.2011.201]).
The DOCC intervention was superior to usual care in reducing oppositional behavior, inattention, hyperactivity, and functional impairment. However, there were no differences between the two groups regarding improvement in anxiety or depression.
On average, the case managers spent approximately 2 hours per child conducting screening and assessments, 14 hours providing services, and another 2-3 hours on administrative tasks including consulting with the pediatricians. Pediatricians spent approximately 1 hour per child providing direct services and 18 minutes in consultations with case managers, other staff, and physician supervisors.