The responsibility for the identification and management of mental health disorders has historically resided within the specialty mental health disciplines of social work, psychology, and psychiatry. In the past few decades, a number of factors have shifted the care of and responsibility for children with mental health disorders to other child service sectors such as child welfare, education, juvenile justice, and most importantly, general health care settings such as primary care clinician offices.
This shift in care can present several challenges to providers in these nontraditional service sectors. Clinicians from various disciplines may be faced with the question of how to best provide care for patients with disorders about which they may have received little formal training. In many settings, mental health treatment is not seen as the primary task of the sector; rather, mental health disorders are seen as disruptive to the mission of the organization. The stigmatizing nature of mental health disorders has often suppressed organized efforts to address these prevalent and impairing conditions. To further complicate the delivery of care, the world of mental health is very different from traditional medical care, and clinicians may find the assessment, treatment, and referral processes difficult to navigate.
The purpose of this chapter is to highlight the role of nonmental health specialists generally and primary care clinicians specifically in the management of these disorders. Because the literature is more extensive on primary care settings as compared to juvenile justice or child welfare, the majority of this chapter will focus on primary care clinicians and their practices. However, many of the lessons are relevant for other child service sectors. Throughout the chapter we will emphasize resources that can help facilitate efficient and high-quality evaluation and treatment for targeted mental health problems within primary care settings. A separate section will be devoted to office preparedness in order to assist clinicians by anticipating potential pitfalls and offering practical suggestions to address them.
The most appropriate management of many mental health disorders continues to reside within the specialty of mental health services. Primary care clinicians are encouraged to define the types of problems that they can safely manage alone or in close collaboration with a specialist, and when they should refer.
The Care of Mental Health Disorders in General Health and Other Settings
As the initial point of contact into the health care system, primary care clinicians are often asked by families to evaluate behavioral and developmental problems. In fact, as many as 20% of children and adolescents in primary care have a significant psychosocial problem that requires
attention. Mental health disorders are associated with increased use of general health care services and can be among the greatest frustrations for primary care clinicians.
The Value of Primary Care—Centered Approaches
A number of important factors unique to primary care make it an ideal location for the management of patients with psychosocial concerns. Mental health disorders may be conceptualized like other chronic health conditions that benefit from the care and coordination provided by the child’s medical home. As defined by the American Academy of Pediatrics (AAP), the ideal medical home is accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. The medical home model suggests that children receive the highest quality care when service delivery is coordinated and located in a central, accessible location rather than within fragmented systems of care. Benefits of this type of care model include the provision of a single, often familiar, clinician to oversee the patient’s care, coordination of multiple types of information from diverse settings, longitudinal monitoring and communication, and the ability to keep comprehensive records in a single location.
The stigma associated with mental health disorders is commonplace, and feelings of shame or embarrassment often translate into barriers for accessing care. The pre-existing relationship of the primary care clinician with families can mitigate some of these feelings for patients and families alike. Through the delivery of services within the primary care setting, patients and families can feel more comfortable discussing their concerns in an environment with which they are already familiar. Primary care relationships in the home community through schools and social service agencies may also provide a stable foundation upon which to manage complex psychosocial problems and often lead to interaction with diverse agencies and professionals.
The Challenges of Care Delivery Within the Primary Care Sector
Many clinicians are committed to the provision of care for children with mental health disorders within their practices. Yet despite these potential strengths, primary care clinicians may not adequately address concerns raised by families due to several barriers within the primary care service sector. Primary care clinicians are called upon to address a wide variety of psychosocial problems that may be difficult to anticipate within a busy primary care practice. Patients and parents may suppress concerns because of the stigma accompanying mental health disorders. Parents of children with mental health disorders are often affected by similar conditions themselves, compounding the processes of assessment and management. Clinicians are also responsible for the management of psychosocial problems with a wide range of severity. While some problems may represent a normal developmental process, they may still be of concern for families and require attention on the part of the clinician. In other cases, symptoms may be significant enough to warrant the diagnosis of a mental health disorder.
Many clinicians express concern that they did not receive comprehensive training in mental health issues. Recent updated guidelines in many different primary care fields have emphasized the importance of training and ongoing continuing education for mental health disorders. Some providers may feel as though there is “little they can do” in the office setting and may choose not to elicit concerns or to avoid them when they arise. Many clinicians are understandably cautious to initiate management because limited specialty resources are accessible in many communities for ongoing support and backup. Thankfully, a number of practical and easy-touse resources have been developed and are readily available for use in the primary care setting. These resources will be discussed in more detail later in the chapter.
Lastly, primary care clinicians who bill for assessment and treatment services often find that care is inadequately reimbursed by insurance companies. The longer visit time required to adequately address complex problems may be difficult to fit into a busy primary care practice. In some instances, third-party payers may challenge payment under the assumption that
services fall under the realm of mental health carveouts. Recent statewide and national initiatives to reform the insurance system and treat mental health disorders with the same respect as medical diagnoses may begin to offer a solution to these issues. Continued advocacy from both primary care and mental health specialists is vital for enhancing insurance coverage for mental health disorders.
In summary, primary care clinicians are often called upon to address mental health concerns within their practices, but the presence of certain barriers can present challenges to the delivery of care. By anticipating the difficulties that families and clinicians alike may face, the evaluation and treatment process can proceed more smoothly when psychosocial concerns arise or are elicited. The following sections will highlight the management of mental health disorders with the primary care setting, from the classification of symptoms to the processes of assessment, treatment, referral, emergency care, and prevention.
Consider the scenario of Brittany Clark and her pediatrician Dr. King. Their story will continue throughout the chapter, highlighting key points in the assessment and management of mental health concerns within the primary care setting.
Classification of Mental Health Problems
The clustering of signs and symptoms into a diagnostic classification system can be useful for many reasons. It can serve as a way for parents and professionals to conceptualize their concerns and to better communicate with each other. Accurate diagnosis can allow for conversations about treatment and, in some cases, a discussion about the child’s future. The unique demands of primary care call for different approaches to diagnostic assessment than those traditionally employed in mental health settings.
The DSM Approach
For clinicians in the fields of mental health, the classification system detailed in the Diagnostic and Statistical Manual of Mental Disorders (DSM)
is most widely used. With a fifth revision in preparation, DSM-IV
provides information on symptom clusters, epidemiology, and clinical course, plus detailed information regarding diagnostic criteria for mental health disorders. For many disorders listed in the DSM-IV,
diagnosis requires not only the presence of symptoms but also the occurrence of distress or impairment associated with those symptoms. A section in the DSM-IV
entitled “Disorders Usually First Diagnosed in Childhood” describes conditions commonly diagnosed within the childhood and adolescent years. These include
attention-deficit hyperactivity disorder (ADHD), autism spectrum disorders, oppositional defiant disorder, and disorders of sleep, feeding, and elimination. For other conditions such as anxiety and mood disorders, the clinician relies on adult criteria as detailed in DSM-IV.
The diagnostic criteria set forth by DSM-IV have been endorsed by a number of professional organizations as guidelines to follow in the primary care setting. For example, the AAP recommends that all clinicians, primary care clinicians and specialists alike, utilize the DSM-IV criteria for the diagnosis of ADHD. Similar recommendations have been made for the diagnosis of autism spectrum disorders and depression.
Aspects of Classification Unique to Primary Care
While the DSM framework offers salient diagnostic guidelines for primary care, certain aspects of management in the office setting cannot be fully addressed using the DSM system. Mental health clinicians, for whom the DSM system was designed, focus their practice on individuals with manifest mental health disorders. In contrast, primary care clinicians spend more time with families whose concerns exist along a continuum that may range from typical development to an overt mental health disorder. Challenges regarding coding and reimbursement for symptoms that do not meet the threshold for a mental health diagnosis can further complicate the process of addressing these concerns in the office setting.
An additional diagnostic challenge for the primary care clinician involves the substantial amount of comorbidity that exists among children with behavioral disorders. Nearly one third of children with ADHD may also meet the diagnostic criteria for oppositional defiant disorder, and learning disorders, anxiety, and mood disorders are more common than in the general population. Among children with autism spectrum disorders, there is a relatively high prevalence of ADHD and/or anxiety symptoms. Diagnostic uncertainty may exist for young children in whom symptoms can be difficult to categorize. For example, early-onset bipolar disorder can be difficult to distinguish from ADHD and disruptive behaviors disorder in younger children. Added to the behavioral comorbidity is the extensive medical comorbidity present among many children seen in health care settings. Children with chronic medical conditions are at risk for mental health disorders, but psychosocial concerns may be difficult to identify in the midst of significant medical illness.
Primary Care-Oriented Diagnostic Approaches
Primary care—based diagnostic frameworks have been developed to assist nonmental health clinicians in the office setting. These resources help clinicians classify symptoms to begin to provide or access care in the setting of subthreshold symptoms, environmental challenges, and the reality of greater diagnostic uncertainty.
The Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version was designed by experts in the fields of child psychiatry, psychology, and pediatrics. The purpose of the DSM-PC is to assist primary care clinicians in describing and identifying behavioral conditions in the office setting. Codes for billing were also proposed to begin to allow for improved reimbursement for the management of behavioral concerns from primary care offices. The DSM-PC was designed to be compatible with the classification of mental disorders described in DSM-IV but also to better capture the diagnostic challenges faced by primary care clinicians.
manual is divided into two main sections. The situations section
describes environmental concerns that can affect child development. Subsections include challenges to the primary support group (domestic violence and divorce), changes in care giving (foster care and physical or mental illness in a parent), housing and education challenges (illiteracy and discord with peers or teachers), and community or social challenges (discrimination and
religious concerns). This section also highlights risk and protective factors to help clinicians consider how the effect of certain stressors may be amplified or attenuated by environmental factors. The child manifestations section
groups presenting symptoms into behavioral clusters that help the clinician determine a differential diagnosis. Examples of child manifestation clusters include impulsive/hyperactive or inattentive behaviors, emotions and moods, and negative/antisocial behaviors. Common presentations that take into account the child’s age and development are provided, and common comorbid conditions are also listed.
Based on the premise that symptoms vary along a continuum, symptoms are presented in the DSM-PC framework under three different categories:
Developmental variations: symptoms that fall within the range of typical development but that can result in stress or concern for parents. A teenager whose parents are concerned about occasional moodiness is an example of a developmental variation. While the behavior is within the range of typical development, it may still cause substantial stress for the family.
Problems: symptoms that cause disruption of the child’s functioning but are not sufficiently severe or impairing to the degree that a mental disorder should be diagnosed. A preschooler whose parents present with concerns about high energy level without other symptoms of ADHD is an example in this category. While the child may have behavior problems in preschool, his or her symptoms do not meet criteria for the diagnosis of a disorder.
Disorders: symptoms that are significantly severe and impairing to warrant the diagnosis of a disorder, as detailed in DSM-IV. A school-aged child who presents with classic obsessive and compulsive symptoms and a resulting inability to do schoolwork is an example in this category. Obsessive—compulsive disorder is diagnosed when the DSM-IV criteria are met and the symptoms cause marked difficulty for the child.
Bright Futures in Practice: Mental Health
Another primary care—oriented approach was created as part of the Bright Futures program. Bright Futures in Practice: Mental Health seeks to define mental health in the context of the developing child and to promote healthy outcomes for children and adolescents. It serves as an extension ofBright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, which outlines preventive care strategies for pediatric health supervision visits. In Bright Futures in Practice: Mental Health, a major emphasis is placed on the early identification of psychosocial problems and mental health disorders. Collaborative care between families, professionals, and communities is emphasized.
The Bright Futures in Practice: Mental Health is divided into two volumes. Volume I, a practice guide, includes developmental chapters that highlight problems that can arise during the developmental stages of infancy, early childhood, middle childhood, and adolescence. The bridges section seeks to assist clinicians with the continuum of care from the identification of conditions to the management of common behavioral and mental disorders in primary care. Criteria for diagnosis are based on the DSM-IV and DSM-PC frameworks. Volume II is a mental health toolkit that contains hands-on resources for screening, education, and management. As a key resource for clinicians, the mental health tool kit will be discussed in more detail later in the chapter.
Common Factor Approach
Traditional management strategies have focused on the importance of accurate diagnosis to ensure specific, evidence-based treatments. As discussed earlier in the text, several factors unique to primary care can render this approach difficult. The common factor approach is
based on the theory that communication interventions, termed “practice elements,” can be utilized early in the course of symptoms to help groups of individuals with similar types of undifferentiated concerns rather than a specific diagnosis. In short, communication strategies for undifferentiated concerns can help improve both early symptoms and subsequent diagnostic strategies. Common factors that are important for determining the treatment process include characteristics of the patients and clinicians, their interactions, and the expertise of the clinician to foster behavior change.
A common factor approach that enhances communication between clinician and family can be successfully integrated into the traditional model of assessment and treatment for mental health in primary care. Using this model, early interventions can begin at the onset of the assessment process and be fine-tuned during the diagnostic process. Initial treatments such as parent education, reassurance, behavior plans, or communication strategies can be pursued for children who do not meet diagnostic criteria for a specific disorder but whose concerns warrant intervention and are causing distress. When problems are more differentiated or focused, interventions specific to certain types of disorders may be offered, even if the diagnosis is uncertain or symptoms are subthreshold. Examples of these types of interventions, or “practice elements,” include limit setting, rewards, and time out for disruptive and noncompliant behaviors. For disorders in which diagnosis implies specific treatments, such as stimulant medication for ADHD, the diagnostic framework of the DSM-PC and DSM-IV is suggested, although the communication strategies, involvement of families, and ongoing counseling of the common factor approach can still be engaged. Throughout the process, it is important to remember that more severe symptoms necessitate a faster progression toward formal diagnosis, specific evidence-based treatments or practice elements, and possibly specialty care. A potential difficulty with the use of the common factor approach by primary care clinicians is the current emphasis by third-party payers on formal diagnosis and mental health credentialing in order for behavioral services to be reimbursed.
The Assessment Process
The fast pace of the primary care setting can make it a challenging place to address psychosocial concerns. In response, screening and assessment tools have been designed to allow families and clinicians to begin a dialogue about symptoms, elicit symptoms that are not apparent, and better define diagnoses. In many cases, consensus on the use of a specific type of tool does not yet exist, although there is growing support for the use of formal instruments to assess psychosocial health during routine well-child visits.
TABLE 24-1 The Essentials of Assessment in Primary Care Settings
In addition to a careful history, assessment tools provide essential information as follows:
Identify symptoms that warrant further evaluation
Are administered to a general population
Example: Pediatric Symptom Checklist-17 (PSC-17)
Quantify and group symptoms into a recognizable pattern
Are administered when clinical concerns arise
Example: Center for Epidemiologic Studies—Depression Scale for Children (CES-DC), Vanderbilt Rating Scales for attention-deficit hyperactivity disorder, parent and teacher versions (VADPRS and VADTRS), Screen for Children’s Anxiety and Related Emotional Disorders (SCARED)
Allow clinicians to track symptoms in response to treatment
Are administered after diagnosis is confirmed
Example: VADPRS and VADTRS Follow-Up Scales
Screening and Assessment Tools
Defining terms and the specific uses of formal instruments is important when considering how to best elicit psychosocial concerns in the primary care setting. Universal screening tools are given to broad groups of children to identify the need for more targeted evaluation and elicit undisclosed symptoms (Table 24-1
). This may include all children or all children presenting for well visits in general health care settings. In contrast, specific assessment tools are used to validate diagnoses and define the degree of impairment once concerns have been elicited either by history or through a screening tool. Some can also be used as a monitoring tool to evaluate the patient’s response to treatment over time, although most assessment tools have not been tested for this purpose. It is important to remember that each type of questionnaire was developed for a specific purpose, and the characteristics of the instrument will be valid only when the questionnaire is used for the purpose for which it was designed. Questionnaires can also be helpful to obtain information from other sources such as teachers or care providers. While questionnaires provide a useful supplement to clinical information, the results of questionnaires must be combined with historical information and the clinician’s impressions before a diagnosis is determined. The results of questionnaires alone are not sufficient to establish a diagnosis.
Universal Screening Questionnaires
Universal screening questionnaires may be useful for clinicians to use routinely at health supervision visits or when they have general concerns about the presence of a disorder. Clinicians are cautioned to first develop a plan to effectively manage clinically significant universal screening results before general screens are administered to groups of children. Practical issues to consider before using general screening tools include determining methods to address clinically significant findings and the specific linkages with specialists that must be made before initiating any program to identify children. More information on these issues is provided in the section entitled “Office Preparedness” at the end of this chapter.
An example of a universal screening questionnaire is the Pediatric Symptom Checklist (PSC). It is a 35-item questionnaire completed by parents that focuses on cognitive, emotional, and behavioral concerns in children. The accompanying PSC-Youth Report (Y-PSC) can be
completed by children 11 years or older. Respondents rate the presence of symptoms from “never,” to “sometimes,” to often.” Higher scores suggest that further assessment is warranted, and cutoff ranges have been determined based on the child’s age. The checklists and scoring system can be found in Bright Futures in Practice: Mental Health.
An abbreviated 17-item version of the PSC has also been developed (PSC-17).
Specific Assessment Tools
A specific assessment tool can be used when concerns steer the provider toward the consideration of a particular diagnosis. Specific assessment tools can be used to validate conditions commonly seen in primary care including ADHD and depression. The Vanderbilt ADHD Diagnostic Rating Scales, designed for both parents and teachers to complete, can be used by primary care clinicians in the evaluation of children for ADHD. Respondents rate the presence of symptoms from “never,” to “occasionally,” to “often,” to “very often.” Behaviors are divided into the following categories: inattention, hyperactivity/impulsivity, oppositional defiant disorder and conduct disorder, and anxiety or depression symptoms. A brief “performance” section is included to assess the degree of impairment associated with symptoms. Rating scales are available for initial diagnosis and for follow-up, such as for symptom monitoring once medication has been initiated. The rating scales and scoring information are available in the public domain through the National Association for Children’s Healthcare Quality or through the AAP’s ADHD toolkit.
Several rating scales are available to help providers better define the presence of depressive symptoms. A useful resource for primary care clinicians is the Guidelines for Adolescent Depression in Primary Care (GLAD-PC). These recommendations include information on assessment tools and are summarized in the GLAD-PC toolkit, which is available electronically. The Columbia Depression Scale includes 22 yes/no questions derived from the depression section of the Diagnostic Interview Schedule for Children (DISC), a structured clinical interview designed to aid in the diagnosis of mental health disorders in youth. It is available in teen and parent versions. The 6-item Kutcher Adolescent Depression Scale is a brief version of the complete KADS. It contains six items completed by the adolescent, who rates depressive symptoms from “hardly ever” to “all of the time” on a four-point scale. Information on both of these scales can be accessed through the GLAD-PC toolkit and can be reproduced with permission. The Center for Epidemiological Studies—Depression Scale for Children (CES-DC) is a 20-item self-report scale in the public domain designed to assess for the presence of depressive symptoms. The scale and scoring system can be accessed in Bright Futures in Practice: Mental Health.
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