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Enhancing Pediatric Mental Health Care: Strategies for Preparing a Primary
Care Practice
Jane Meschan Foy, Kelly J. Kelleher, Danielle Laraque and for the American
Academy of Pediatrics Task Force on Mental Health
Pediatrics 2010;125;S87
DOI: 10.1542/peds.2010-0788E
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/125/Supplement_3/S87.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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SUPPLEMENT ARTICLE
Enhancing Pediatric Mental Health Care: Strategies
for Preparing a Primary Care Practice
AUTHORS: Jane Meschan Foy, MD,a Kelly J. Kelleher, MD,
MPH,b and Danielle Laraque, MD,c for the American
Academy of Pediatrics Task Force on Mental Health
aDepartment of Pediatrics, Wake Forest University School of
Medicine, Winston-Salem, North Carolina; bThe Research
Institute, Nationwide Children’s Hospital, Columbus, Ohio;
cDivision of General Pediatrics, Mount Sinai School of Medicine,
New York, New York
ABBREVIATIONS
AAP—American Academy of Pediatrics
EI— early intervention
HIPAA—Health Insurance Portability and Accountability Act
ADHD—attention-deficit/hyperactivity disorder
SOC—system of care
LGBTQ—lesbian, gay, bisexual, transgender, and questioning
EHR— electronic health record
www.pediatrics.org/cgi/doi/10.1542/peds.2010-0788E
doi:10.1542/peds.2010-0788E
Accepted for publication Mar 24, 2010
Address correspondence to Jane Meschan Foy, MD, Department
of Pediatrics, Wake Forest University School of Medicine, Medical
Center Blvd, Winston-Salem, NC 27157. E-mail:
[email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
+
In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with
developing strategies to improve the quality of child and adolescent
mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health
care that pediatricians and other primary care clinicians† provide
to children and adolescents will require systemic interventions at
the national, state, and community levels to improve the financing
of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “Strategies for System Change in Children’s Mental Health: A Chapter
Action Kit” (chapter action kit),1 “Improving Mental Health Services
in Primary Care: Reducing Administrative and Financial Barriers to
Access and Collaboration,”2 and “Enhancing Pediatric Mental Health
Care: Strategies for Preparing a Community.”3
The task force also recognized that enhanced mental health practice
will require competencies not currently achieved by many primary
care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force
collaborated with the AAP Committee on Psychosocial Aspects of Child
and Family Health to outline these competencies and propose strategies for achieving them.
This report offers strategies for preparing the primary care practice
itself for provision of enhanced mental health care services. The task
force proposes incrementally applying chronic care principles to the
care of children with mental health and substance abuse problems as
primary care clinicians apply them to the care of children with chronic
medical conditions such as asthma.
*Throughout this statement, the term “mental” is intended to encompass “behavioral,” “neurodevelopmental,” “psychiatric,” “psychological,” “social-emotional,” and “substance abuse,”
as well as adjustment to stressors such as child abuse and neglect, foster care, separation
or divorce of parents, domestic violence, parental or family mental health issues, natural
disasters, school crises, military deployment of children’s loved ones, and the grief and loss
accompanying any of these issues or the illness or death of family members. It also encompasses somatic manifestations of mental health issues, such as fatigue, headaches, eating
disorders, and functional gastrointestinal symptoms. This is not to suggest that the full range
or severity of all mental health problems is primarily managed by pediatric primary care
clinicians but, rather, that children and adolescents may suffer from the full range and
severity of mental health conditions and psychosocial stressors. As such, children with
mental health needs, just as children with special physical and developmental needs, are
children for whom pediatricians, family physicians, nurse practitioners, and physician
assistants provide a medical home.
†Throughout this document, the term “primary care clinicians” is intended to encompass
pediatricians, family physicians, nurse practitioners, and physician assistants who provide
primary care to infants, children, and adolescents.
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Most primary care clinicians will find
that significant gaps exist between
their current practice and the proposed ideal. The task force offers guidance in this report while recognizing
that priorities for change and the sequence of change will be determined
by the needs of the children and families whom the practice serves and
by the capacity and resources of the
practice.
APPLYING THE CHRONIC CARE
MODEL TO CHILDREN WITH MENTAL
HEALTH PROBLEMS
Children with mental health problems
are children with special health care
needs. Although many people can and
do recover from their mental health
problems, they may chronically experience symptoms and/or some level of
impaired functioning. Although much
of the literature on the chronic care
model focuses on medical rather than
mental health conditions and on adults
rather than children with mental illness,5,6 the task force recognizes the
applicability of chronic care methods
to children with mental health problems and the potential importance of
these methods in creating a “medical
home” for children who experience
mental health problems (Fig 1).
The payoff at the practice level can
be substantial. For example, a majority of studies on depressed adults
managed with chronic care methods
in primary care settings have documented significant improvement in
quality and outcomes. Moreover,
most studies have shown decreases
in the cost of care or reductions in
the use of health services.7
Most practices will not be able to implement quickly all or even most of the
elements of the chronic care model.
Practice change is a slow and incremental process that requires learning
and modification at the practice level.
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AAP TASK FORCE ON MENTAL HEALTH
FIGURE 1
The care model for mental health (adapted from the chronic care model developed by Wagner et al.).5,6
Primary care clinicians and managers
can consider which strategies seem
most feasible and are most consistent
with other aspects of their practice
and gradually plan the enhancements
they choose.
The Mental Health Practice Readiness
Inventory (Appendix S3) can assist primary care clinicians and managers in
assessing the strengths and needs of
the practice and in setting its priorities. The inventory is organized in accordance with key elements in the
chronic care model: (1) community resources; (2) health care financing; (3)
support for children and families; (4)
clinical information systems/delivery
system redesign; and (5) decision support for clinicians. Individual clinicians
and practices may have limited influence over some of these elements, but
there are steps that any practice can
take to improve mental health service
delivery. Appendix S3 was designed to
accompany reading of the following
narrative and to structure practiceimprovement initiatives.
The task force envisions that clinicians
typically will make changes first on behalf of children and adolescents with
recognized mental health disorders in
their practice. Discussions with spe-
cialists‡ about these patients will enhance the collaborative and clinical
skills of primary care clinicians, and experience with scheduling, coding, and
billing will build a business infrastructure for the practice’s mental health services. Clinicians can subsequently apply
the chronic care principles to children
whose mental health problems do not
meet the criteria of a diagnosable disorder but require care and monitoring nevertheless. With chronic care management and business systems in place,
clinicians will be prepared to enhance
their efforts to identify children with occult mental health and substance abuse
problems; these efforts may include routinely screening for mental health and
substance problems at health supervision visits (see discussion in Appendix
S4). Efforts to implement screening
before office systems, collaborative
relationships, and referral supports are
in place are unlikely to achieve
sustainable benefits. Clinicians may
choose to enhance their identification of
children with mental health problems by
focusing a screening effort on a
particular age group or high-risk
population within the practice or
through mental health updates at acute
‡See definition, Appendix S9.
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SUPPLEMENT ARTICLE
care visits (see “Decision Support”
below).
aap.org/mentalhealth,8 www.samhsa.
gov,9 www.schoolpsychiatry.org,10 and
www.aacap.org.11
COMMUNITY RESOURCES
Methods to use in creating or adapting
a resource guide for the practice
are detailed in the chapter action kit1
and “Enhancing Pediatric Mental
Health Care: Strategies for Preparing a
Community.”3 Organizations in the
community (eg, the public mental
health agency; department of public
health; local mental health association; local branches of consumer organizations such as the National Alliance
on Mental Illness or Federation of Families for Children’s Mental Health; support groups for families of children
with specific disabilities such as autism or attention-deficit/hyperactivity
disorder [ADHD]) typically benefit from
such an inventory and are willing to
participate in developing it or in building on one that is already in place.
Building resilience and promoting
mental health in children and youth
will require the participation of
many organizations and individuals
throughout the community. (See “Enhancing Pediatric Mental Health Care:
Strategies for Preparing a Community”3
for a full discussion.) Treatment of children with mental illness will require
strong collaborative relationships between primary care clinicians and the
mental health specialty system. These
collaborations will function in ways that
will make practice better for both
groups and care better for patients.
Create a Resource Guide of
Community Mental Health and
Substance Abuse Resources (and
the Types of Payment Accepted)
This guide might include developmentalbehavioral pediatricians, adolescent
specialists, mental health and substance
abuse specialists, family support
groups, Early-Intervention (EI) services,
human service agencies, child care consultants, parenting education programs,
key school contacts, youth organizations, recreation programs, and others
who are involved in supporting or serving children and families.
The task force has developed a table to
summarize key mental health services
necessary to care for children with
common mental health problems
(Appendix S1). A variety of specialists
may be qualified and reimbursed to offer evidence-based services, depending on state licensing policies and insurers’ credentialing decisions.1 The
selection of service providers depends
on current information about the
safety and efficacy of various treatments for the common childhood mental health disorders. Internet sources
of this information include www.
It is important to note the type(s) of
third-party payment that each specialist or resource accepts and the types
of assessment and/or therapies they
provide. EI services are critical for
young children who are experiencing socioemotional or developmental problems.3 As federally mandated services,
they are universally available in the
United States but variable in quality and
accessibility. Details about EI referral criteria and intake procedures are important to include in the inventory.
The burgeoning body of knowledge
about early brain development calls
attention to the critical importance
of parenting, attachment, and highquality child care on the emotional, social, and cognitive development of young
children.12 Many communities have begun offering such services as nurse visits to pregnant and parenting women
who are at high-risk, parenting programs, child care consultation, and therapeutic child care settings. These resources should be included in the
inventory, along with resources to help
parents and teachers who are dealing
with anxiety, depression, substance
abuse, mental illness, or other personal
challenges that affect the quality or continuity of their relationships with young
children.
Schools are key partners in providing
mental health services to children and in
collecting data about children’s academic and social functioning. In rural areas of the country they may, in fact, be
the major provider of mental health services to children.13 Guidance counselors
are typically the initial contact for clinicians seeking to establish a connection
with the child’s school; counselors,
school nurses, or other school-based
personnel may be helpful in making
classroom observations, gathering behavior scales from teachers, assisting
with implementation of classroom interventions, and pursuing testing for special educational services. They may also
assist the primary care clinician in monitoring a child’s progress and providing
support and education to the family. A
school psychologist can provide psychological testing; a school social worker
can often provide counseling and linkage
to other school and community resources;
and the school system’s special education officer can assist in determining a
child’s eligibility for special educational services or respond to questions
about those services. School-based
health centers may house additional
professionals, including mental health
specialists; when collaborative relationships exist between school-based
health centers and primary care clinicians, these centers augment, rather
than fragment, care.
Involvement in extracurricular
school activities enhances a child’s
attachment to school and improves
his or her resilience.14,15 Involvement
in community service and involvement in a faith community are also
protective for youth.14–17 Recreation
programs, youth groups, and family
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support groups may all play significant roles in providing children and
adolescents with positive experiences and social skills; for this reason, all are relevant to child mental
health and warrant inclusion in the
practice’s resource directory.
Become Knowledgeable About the
Available Community Resources
Most clinicians are understandably reluctant to refer to sources that are unknown to them. The authors of “Enhancing Pediatric Mental Health Care:
Strategies for Preparing a Community”3
suggest some strategies for getting to
know mental health specialists and
other child advocates through participation in efforts to address community
mental health issues and gaps in services. In a policy statement on mental
health competencies, the AAP suggests
ideas for joint educational efforts, which
may serve the additional purpose of fostering interpersonal relationships.4
Referred families are also an invaluable source of information about
community resources. Primary care
practices can annotate their resource directory with the feedback
received from children and families.
This information will assist clinicians in creating matches between
families and service providers or
community programs.
Develop Collaborative
Relationships With Providers of
Key Services
Previous understanding about respective roles of primary care clinicians
and key mental health service providers can create efficiencies and improve coordination of care. For example, school-based personnel and
primary care clinicians can meet to determine how they will collaboratively
assess and monitor the progress of
children with learning and behavior
problems that affect school perfor-
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AAP TASK FORCE ON MENTAL HEALTH
mance. Together, they can decide what
circumstances or symptoms will trigger an evaluation at the school; what
tools will be used to measure children’s cognitive ability, academic
achievement, and classroom behavior;
who will gather the information and
relay it to the primary care clinician;
and what mechanisms will be used to
convey the primary care clinician’s
assessment and care plan back to
the school and monitor the child’s
progress in the classroom.18 Similarly,
previous understanding with community agencies, such as child protective
services or the juvenile justice system,
about collecting a psychosocial and
medical history from the biological
parents before the child’s placement
in foster care or a juvenile detention
facility can greatly improve continuity
of care and assessment of the child’s
mental health needs. See the chapter
action kit1 and “Enhancing Pediatric
Mental Health Care: Strategies for
Preparing a Community”3 for additional ideas about strengthening these
relationships.
Ultimately, collaborative clinical relationships are built through jointly caring for children and families. Personal
contact and conversation are the
starting point; yet, these can be challenging for the busy primary care clinician and a mental health professional. Mental health professionals
often lack “front-office” personnel and
instead function with little support and
use voice mail to capture messages
while they are in therapy sessions.
They are also extremely protective of
their patients’ confidentiality, often exceeding standards of the Health Insurance Portability and Accountability Act
(HIPAA). The primary care practice can
develop office procedures to support
collaboration (eg, routinely requesting
families to sign a consent for exchange
of information at the time of a referral;
developing a previous understanding
with mental health colleagues about a
convenient time to chat; providing
mental health colleagues with the primary care clinician’s direct line; or
hosting “lunch and learn” sessions for
primary care clinicians and mental
health professionals to exchange information, review cases, and coordinate care). Section “Prepare for Participation in the Full Range of
Collaborative Models” provides more
detail about the types of collaborative
relationships that clinicians can nurture, and section “Put Office Systems in
Place to Support Screening, Assessment, and Collaboration” elaborates
on office procedures to support
collaboration.
HEALTH CARE FINANCING
To sustain innovations that improve
care, primary care clinicians will require substantial enhancements in
payment for their mental health
services.
Provide a Realistic Business
Framework for Mental Health
Services
The task force recognizes that many
primary care clinicians in the United
States are not adequately paid for the
mental health care they provide. In
some cases, this inadequate payment
is because primary care clinicians are
not aware of coding mechanisms that
lead to payment. In other cases, it is
because insurers do not pay for the
mental health services that primary
care clinicians provide (screening, assessment, early intervention to address emerging problems that do not
rise to the level of disorders, interaction with schools and agencies, consultation with mental health specialty
providers, care coordination, patient
and family education, and family conferences). Furthermore, many insurers do not allow primary care clini-
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SUPPLEMENT ARTICLE
cians to serve as mental health providers; instead, their insurance plans
have mental health “carve-outs”—separate mental health provider networks
with separate “gate-keeping” or intake
procedures—that exclude primary care
clinicians from participation and disallow payment of primary care clinicians
for the mental health treatment services
they provide to children with mental
health diagnoses. For clinicians who
function in this type of environment,
preparation for enhancements in mental health practice will require advocacy
efforts aimed at insurers of their patients and major purchasers of their patients’ insurance plans. Strategies applicable to these efforts are detailed in the
chapter action kit.1 A white paper developed jointly by the task force and the
American Academy of Child and Adolescent Psychiatry addressing the administrative and financial barriers to providing collaborative mental health care was
published in Pediatrics in April 2009.2
Gain Access to Mental
Health/Substance Abuse Provider
Lists and Authorization
Procedures of Major Public and
Private Health Insurers
Because mental health benefits and formularies are quite variable and often
poorly understood by patients and families, many offices struggle to find out
what resources are appropriate for referral or prescribing and what the patient cost-sharing for such services is
likely to be. Increasingly, large insurers
are providing online resources for rapid
access. In addition, some creative vendors (eg, Rachel Systems19) provide such
services for all insured patients in a region through a common Web portal so
that office staff and clinicians can
quickly identify appropriate resources
and medications for any insured patients. Where such systems are not available, clinicians in a region (or perhaps
AAP chapter or district) can collaborate
or work through AAP chapter pediatric
councils to acquire or develop such portals. Chapter pediatric councils are forums whereby pediatricians meet with
health plan medical directors to discuss
carrier policies and administrative
practices that affect access to, quality
of, coverage of, and payment for pediatric services.20
Prepare the Practice to Code and
Bill Effectively to Ensure Payment
for Mental Health Services
The chapter action kit1 and “Enhancing
Pediatric Health Care: Algorithms for
Primary Care”21 (referred to throughout this article as “Algorithms for Primary Care”) provide tools to assist
practices with coding and billing for
mental health services. Informed by
these tools and assisted by their practice manager and other staff members, primary care practices can create encounter forms to capture
necessary documentation and ensure
that the mental health services provided are billed for appropriately and
efficiently. Supplemental Appendix S10
provides a listing of sample tools to
assist primary care clinicians with
these preparations.
SUPPORT FOR CHILDREN AND
FAMILIES
Pediatric primary care practices are
typically child- and family-friendly
places and can readily take additional
steps to normalize and destigmatize
mental health concerns. Engagement
of children and their families in their
own care is one of the best correlates
of successful outcomes. Such efforts
may focus on child and family motivation, education, skill-building, or emotional support. When mental health
specialty care is needed, children and
families need support in the referral
process.
Ensure That Children and Families
With Mental Health Concerns Have
a Positive First Contact With the
Practice
Clinical staff, receptionists, and administrative staff may figure importantly in a child’s and family’s engagement or continuation in mental
health care. McKay et al22 have developed a 1-day training that assists
staff of outpatient mental health facilities in developing “first-contact
skills” (including telephone engagement skills) and in identifying key
barriers to seeking mental health
care. Evaluation of sites that have implemented engagement strategies
suggests that they have significantly
higher appointment-keeping rates
than sites that have not implemented
these strategies. Although not developed specifically for primary care
settings, the application of evidencebased engagement principles is
likely to be beneficial to staff in primary care settings that provide mental health services.
Address Stigma
Creating an environment supportive of
children and families facing mental
health challenges requires that primary care practices address stigma.
Clinicians can reflect with their staff
members on the important role they
can all play in making children and
families comfortable to share and address mental health concerns. Staff
members can examine their own
knowledge and attitudes. They can affirm that mental illnesses are treatable; that children and adults living
with these illnesses can achieve recovery and lead full and productive lives;
and that mental illness is not a character flaw, a sign of moral weakness, or
anyone’s fault. They can eliminate language that contributes to stigma
through defining people by their condition (eg, referring to someone as “a
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schizophrenic” or saying “he is bipolar,” instead of a person with schizophrenia or bipolar disorder). (See
also “Enhancing Pediatric Mental
Health Care: Strategies for Preparing a
Community.”3)
address concerns in primary care
encounters, developing a contingency or crisis plan for urgent mental health problems, closing a visit in
a supportive and efficient manner,
and facilitating coding and billing
that are specific to mental health).4,31
Promote the Concept of Mental
Health as Integral to the Care of
Children in the Medical Home
Adverse childhood experiences may affect a person’s mental health for a lifetime.12,32,33 Examples include trauma
such as abuse or neglect, placement in
foster care, death of a loved one, a
move, separation and divorce of parents, military deployment of parent(s)
or a sibling, incarceration of a parent
or sibling, breakup of a relationship,
and exposure to violence or a natural
disaster. The clinician will need to view
all future physical and mental health
issues in the family through the prism
of the traumatic experience(s).
Separation of mental health services
from medical care contributes to
stigma, poor coordination of care, and
increased costs.23 The office environment can speak to the importance of
mental health and substance abuse issues (eg, posters that invite mental
health and substance abuse questions, educational materials about
common mental health problems, brochures for crisis lines and support
groups, and meeting places for evening
support and treatment groups). By implementing Bright Futures guidelines,24 primary care clinicians can
normalize mental health care and incorporate conversation about psychosocial issues into every routine health
supervision visit. When given the opportunity during a well-child visit, most
parents will express some concern
about a behavioral or developmental
issue.25
Many primary care practices have concerns about the time and expertise required to address mental health concerns and about poor payment for the
mental health services they provide.26
The use of previsit questionnaires
and electronic tools to gather information from youth and families in advance of an office visit can allow clinicians to redirect their time from
gathering data to addressing concerns.27–30 The practice can host educational sessions to assist clinicians
in acquiring new skills (eg, improving diagnostic skills, gaining knowledge of treatment strategies, applying “common-factors” techniques to
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AAP TASK FORCE ON MENTAL HEALTH
and sending them a note on the anniversary of the loved one’s death can
communicate support; it will also keep
the door open to further conversations
about the reactions of family members
to trauma and loss and their effects on
children.34
Assure Children and Families
About Confidentiality
Children vary widely in their reactions to these events depending on
their developmental level, temperament, previous state of mental
health, coping mechanisms, parental
responses, and support system.
Practices should establish office systems that routinely collect information about such stressful experiences in the child’s life and flag them
in the health record of the child and
siblings to signal clinicians’ interest
and support, monitor the child(ren)’s adjustment over time, and
make appropriate referrals if the
child’s functioning is impaired. Conversely, overlooking such experiences and failing to follow-up on the
child’s and family’s progress after a
traumatic event are lost opportunities to connect with the child and
family around important mental
health issues.
People with mental health and substance abuse concerns are usually
deeply concerned about confidentiality. Office procedures should ensure
that all interactions between staff and
children/families are private,24,35 including sign-in procedures, discussion
of the reason for the visit or “chief
complaint,” and each phase of the clinical process, including any referrals
made to mental health or substance
abuse specialists. In accordance with
the HIPAA, the practice should post information about its privacy rules and
offer families written information
about them. Staff members can reinforce their commitment to maintaining confidentiality at the time they
request consent for exchange of information with other health care providers and schools. All faxes should have
cover sheets that label the information
as confidential. When faxing information to schools or agencies that may
have fax machines used by multiple
staff members, previous arrangements may be necessary to ensure
that the intended recipient is awaiting
the fax and protects its confidentiality.
Certain mental health information (eg,
psychotherapy notes and any information related to substance abuse issues) is protected by federal statues
that supersede the HIPAA.
The anniversary date of a traumatic
event or loss can also be recorded on
the office calendar. Such practices as
remembering a deceased loved one
through use of his or her name during
contacts with the child(ren) and family
In states where minors are allowed to
consent for their own mental health
and substance abuse services, there
should be a clear understanding with
both youth and parents/guardians
about “conditional confidentiality,”
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SUPPLEMENT ARTICLE
which is the clinician’s right and responsibility to break confidentiality if
he or she judges the youth or others
to be in danger. Office procedures
must ensure that youth treated for a
mental health or substance abuse
problem without their parent/guardian’s knowledge express their preferences in relation to messages left on
telephones and mailing of communications such as billing statements, laboratory results, and explanations of
benefits. Further guidance for the protection of confidentiality of mental
health and substance abuse information can be found in the chapter action
kit under “Strategies to Collaborate
With Mental Health Professionals,”1
and the AAP Policy Web site (www.
aappolicy.org).
should take into account the need to
speak with both the adolescent and the
parent/guardian privately. Both conversations are important, because
parents and guardians may not be fully
aware of their adolescents’ activities
or feelings, because the adolescents
may be reluctant to share some concerns with their parents/guardians,
and because youth and parents often
differ in their ability to report on various mental health conditions (see “Algorithms for Primary Care”21). Further
guidance on meeting the health care
needs of adolescents is available in
Bright Futures24 and from the Adolescent Health Working group.36
Prepare to Address the Mental
Health and Substance Abuse Needs
of Adolescents
At the time a primary care clinician
identifies a child with a mental health
problem, the child and family may be
resistant to taking action to address
the problem, perhaps because of the
stigma of mental illness, conflict within
the family, lack of resources, distraction
by other family priorities, anger, denial,
or a sense of hopelessness, possibly
rooted in unsuccessful past efforts.
Behavior-change science has demonstrated that people are in various stages
of readiness to address a health problem: some are not even contemplating
action, some are contemplating action
but are ambivalent, some are ready to
act, and some are already acting to create change.37 Rather than using a prescriptive approach, primary care clinicians are more effective if they assess a
family’s readiness to address a problem
and then help them to move to the next
stage of readiness at their own pace.4,21,38
Children gradually assume responsibility for their own health care. The
timing and pace will depend on the
child’s maturity and cognitive abilities.
By the time they reach adolescence,
most of them will want an opportunity
to air concerns directly with their
health care providers and, at times, receive care without knowledge of their
parents/guardians. The laws governing the confidentiality of minors’
health care in relation to their parents/guardians vary from state to
state. Keeping these factors in mind, a
primary care practice may choose to
mark the occasion of a patient’s upcoming adolescent health supervision
visit or 12th birthday by sending a letter to the adolescent and parents describing expectations for the adolescent’s increasing independence in
seeking and receiving health care and
their practices in relation to privacy. At
every visit with an adolescent, clinicians should reinforce the conditional
confidentiality of their relationship. Appointment scheduling for adolescents
Focus Effort on Engagement of the
Child and Family in Help-Seeking
The practice can collaborate with a
mental health professional to train clinicians in these techniques. Application of these techniques is quite manageable within the pace of a busy
primary care practice, particularly if
the primary care clinician is prepared
with skills to bring a visit to an efficient
and supportive close and to reschedule the family for additional brief sessions, if necessary.39 However, such
primary care interventions are typically briefer than usual mental health
outpatient services and different in
content. Practice preparations to ensure appropriate scheduling, Current
Procedural Terminology (CPT) coding,
and billing for these sessions will help to
make these activities sustainable. Guidance is available in the chapter action
kit1 and in Supplemental Appendix S10.
Offer Self-help Interventions
Although not a substitute for specialty
care, interactive support services that
assist patients and their families in
managing, tracking, and working on
their symptoms seem to be effective in
extending the reach and success of
mental health care. Results of randomized trials support the efficacy of
ADHD-support Web sites, online depression management, telephone case
management, motivational interviewing services, text-messaging reminders for medication adherence, and related services.40–50 In addition, primary
care practices can have available a
range of written materials and Web resources aimed at promoting mental
health, educating the child and family
about particular behavioral challenges, and providing guidance in selfmanagement and family management
of problems. Whatever resources are
offered, the primary care practice
plays a critical role in monitoring to
determine the child’s and family’s
progress in managing problems.
Support Families in the Referral
Process
Communication techniques, such as
motivational interviewing, are helpful in
preparing a family for referral to mental
health specialty services, which is otherwise completed by a family less than 50%
of the time.51,52 Primary care clinicians
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can also increase the likelihood that families complete referrals and successfully
navigate the mental health system by
providing referral support services, including telephone or personal contact by
staff members, case workers, family advocates, or paid providers of peer support services.53–57 Written materials for
families that describe the referral process and the types of mental health specialty resources available in the community will reinforce information shared
verbally. It is critical to implement a
tracking mechanism for children who
are referred for mental health specialty
care.
Identify Children Involved in the
Mental Health System and Provide
Them With a Medical Home
The practice will need to work systematically to identify children who have
not shared information with their primary care clinician about their existing mental health condition(s). Some
of them may be children with severe
mental illness, known to the mental
health specialty system but not to the
primary care clinician. This situation
may arise because the family selfreferred into the mental health system
or entered the mental health or juvenile justice system after a crisis such
as a suicide attempt, group-home
placement, arrest, or incarceration.
Even families who have warm relationships with their child’s primary
care clinician may feel embarrassed
by their child’s problems and reluctant to share this information with
the primary care clinician, not recognizing the primary care clinician’s potential role in coordinating services or
the potential risk of keeping the primary care clinician unaware of psychiatric care, particularly pharmacologic
treatment.
Primary care practices interested in
folding these children into the medical home will need to scrutinize their
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AAP TASK FORCE ON MENTAL HEALTH
intake forms and processes to ensure
that they include queries about mental
health specialty care. They will also
need to take general steps to communicate their interest in mental health
and substance abuse issues through
integration of these topics into health
supervision and acute care visits and
through posters and brochures in the
waiting room. The primary care clinician or practice manager may also advocate with local agencies and with
contracted insurance plans to request
notification of the primary care practice when a child seeks services from
mental health professionals or prepares for discharge from a hospital or
group home.
(SOC) around the child and family. The
SOC philosophy, developed in the
1990s, reflects the influence of “consumers” (preferred term in the mental
health advocacy community for people
with mental illness) on mental health
specialty care and has as its core
principles58:
As these children are identified, they
may be added to a registry and incorporated into chronic care protocols,
as described below. The primary care
practice will need to make a special
effort to reassure the families of its
support and willingness to partner
with them and their child’s mental
health specialty provider(s). Families
of children with mental health disorders have a range of experiences in
mental health specialty and primary
care and will likely become important
sources of education for the primary
care clinician about community resources and supportive primary care
practices. They are also potential fellow advocates in the quest for improved insurance benefits and payment rates.
family, built around the family’s
needs and preferences, and articulating the therapeutic goals and
roles of all service providers.
Children with severely impairing mental illness often qualify for and/or receive services of a mental health case
manager. This person is responsible
for coordinating the agencies involved
in the child’s care and for overseeing
development and implementation of a
“person-centered plan” (abbreviated
PCP, which often confuses primary
care providers, who are also known as
PCPs) or “family-centered plan,” intended to create a system of care
● focus on strengths rather than
problems;
● “nothing about us without us”;
● commitment to recovery as a goal;
● consumer choice among treatment
options;
● services provided in the least re-
strictive environment; and
● a plan of care, developed with the
Primary care clinicians are often not
engaged with specialty mental health
systems of care for these children, and
the primary care needs of these children may be overlooked. There may be
a number of possible explanations: primary care clinicians may not feel that
they have the expertise to participate
in a mental health SOC; primary care
clinicians may be unaware of community efforts toward building a SOC;
mental health professionals and agencies may not recognize primary care
clinicians’ potential to contribute to
the child’s and family’s care; families
may resist involvement of primary
care clinicians because of stigma; and
families and mental health professionals may be overwhelmed with the
child’s mental illness to the neglect of
any primary care concerns. Whatever
the reasons, an expression of interest
on the part of a primary care clinician
is very likely to be appreciated and valued by families and mental health professionals. A natural entry point for the
primary care clinician into a community’s mental health SOC efforts is the
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SUPPLEMENT ARTICLE
mutual care of a child. However, to be
effective, primary care clinicians and
professional organizations that represent them must participate in systemic
planning at the regional and state
levels.
Increasingly, the essential role of primary care in SOC-planning efforts is
being recognized.59 People with severe
mental illness experience dramatically
higher rates of morbidity and mortality from medical illnesses than do
others.60 Incorporating primary care
into the plan of care for all children
with mental illness may establish a
pattern that has lifelong benefits.
As adolescents with mental illness approach adulthood, they face transition
to new primary care and specialty providers, as well as developmental tasks
for which they may be inadequately
prepared: completing high school or
an equivalent course of study, attaining higher education, living independently, building social supports, finding employment and housing, and
adhering to their treatment regimen.
Although transition services for youth
with mental illnesses are absent or insufficient in many communities, primary care clinicians can apply medical
home principles, as they do for other
youth with special health care needs:
they can ensure that their practice
provides education to young people
and their families about transition issues and anticipates the health, educational, social, and vocational needs
they may encounter.61 In communities
without adequate transition resources
for young people with mental illness,
clinicians can partner with others to
address deficiencies.3,62,63
Prepare to Address the Mental
Health and Substance Abuse Needs
of Special Populations Within the
Practice
Every day, children witness, hear
about, or directly experience trau-
matic events (eg, plane crash, tornado,
war, crime, flood). Feelings Need
Check Ups Too is a set of resources to
help primary care clinicians address
the needs of traumatized children.64
The US Task Force on Community Preventive Services recently conducted a
systematic review of interventions for
reducing psychological harm to youth
after exposure to a traumatic event.
Just 2 interventions met this task
force’s criteria for evidence of effectiveness in helping traumatized children: trauma-focused individual cognitive behavioral therapy and traumafocused group cognitive behavioral
therapy.65,66 Ideally, these services
would be available in every community
and accessible to children in the practice.
● MilitaryHOMEFRONT
Virtually all children in foster care
have mental health needs. The authors
of “Enhancing Pediatric Mental Health
Care: Strategies for Preparing a Community”3 suggest strategies for collaborating with the community’s child
protective services agency to address
the needs of these children and their
families. The AAP has created a task
force to address the needs of children
in foster care and provided Web resources at www.aap.org/fostercare.
● offer respect to youth;
Children whose parents are serving in
the military or are active members of
the National Guard and Reserve are
subject to stress, separation, and loss;
resources for addressing the needs of
these families can be found at:
● AAP Section on Uniformed Ser-
vices
(www.aap.org/sections/
unifserv/deployment/index.htm)67
● National Military Family Association–
Operation Purple camps (www.
nmfa.org)68
● Military
One Source (www.
militaryonesource.com)69
● Military Family Research Institute
(www.mfri.purdue.edu)70
(www.
militaryhomefront.dod.mil)71
● Tragedy Assistance Program for
Survivors (www.taps.org)72
● Military Child Education Coalition
(www.militarychild.org)73
Lesbian, gay, bisexual, transgender,
and questioning (LGBTQ) youth are at
higher risk than their heterosexual
peers for substance use, depression,
suicide, and harassment or violence in
the community or school.74,75 The AAP
has published a policy statement that
underscores and draws providers’ attention to the health needs of LGBTQ
youth.76 In addition, surveys of LGBTQ
youth75,77 have provided insights into
what they need from their health care
providers:
● maintain privacy;
● be well educated;
● do not “talk down” to patients;
● be a good listener;
● hold a nonjudgmental stance about
LGBTQ persons;
● do not assume that every LGBTQ
youth has HIV;
● provide guidance for talking with
family about sexual orientation (especially true for younger teenagers,
which possibly reflects the fact that
many LGBTQ youth are “coming out”
earlier while still living at home with
their parents); and
● facilitate access to mental health
services.
There may be other groups within the
community, such as alternative school
populations, pregnant and parenting
adolescents, incarcerated youth, or
immigrant groups, that have particular needs for mental health and substance abuse services and social support. Through partnership with other
health care and human service providers, primary care clinicians can determine how the medical home can best
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serve the mental health needs of
these children and coordinate services with the other providers. Primary
care practices would benefit from a
previous shared understanding about
respective responsibilities for collecting a psychosocial history, administering and scoring mental health and
substance abuse screening tools, enlisting support from nonprofit or volunteer agencies, and identifying culturally appropriate and accessible
assessment and treatment services.
Ensure the Family Friendliness of
the Practice
The practice can take general steps to
ensure that it is partnering successfully with children and families. The
AAP participated with Family Voices,
the Maternal and Child Health Bureau,
and other partners in developing tools
to assess the family-centeredness of
the care a practice provides.78 These
tools, along with a guide that enables
users to apply findings to practice improvements, are available at www.
familyvoices.org.
Periodically Assess the Quality of
Care the Practice Provides to
Children With Mental Health
Problems and Take Action to
Improve Care
A number of resources are available to
help primary care clinicians with their
quality-improvement efforts, including
AAP Practice Management Online
(http://practice.aap.org), eQIPP (Education in Quality Improvement for Pediatric Practice [www.eqipp.org]), and
the Improving Chronic Illness Care
Web site (www.improvingchroniccare.
org). Specific AAP projects also provide resources on particular topics
(eg, “Bright Futures Training Intervention and Practicing Safety: Child Abuse
and Neglect Prevention”).79 Clinicians
may monitor their psychosocial care
in maintenance of certification by using such quality-improvement pro-
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AAP TASK FORCE ON MENTAL HEALTH
grams as eQIPP and developing relevant pay-for-performance and quality
indicators for health plans.
charge, can be customized to meet
the tracking and registry needs of a
given practice.
CLINICAL INFORMATION SYSTEMS
AND DELIVERY SYSTEM REDESIGN
Use Monitoring, Prescribing, and
Tracking Systems for Psychosocial
Therapy and Psychotropic Drugs
Clinical information systems ensure
continuity of patient information
across settings and time and facilitate
collaboration between primary care
clinicians and mental health professionals. Collaboration is particularly
important in the care of children with
comorbidities. Local resources and
clinical circumstance will dictate the
specific model(s) of collaboration and
the design of delivery systems that are
necessary to support them.
Create Registries of Children With
Mental Health Problems
Preparing the practice to care for
children with identified mental
health conditions is similar to preparing the practice to care for children with chronic medical conditions such as diabetes or asthma. It
depends on registries of children
with mental health problems (including those who are not yet ready to
address their problems). Although
this step is greatly facilitated by an
electronic health record (EHR), registries can be developed in the absence of an EHR through the use of
claims data and other approaches.
As examples, the AAP toolkit for
ADHD80 contains tracking procedures
for patients with ADHD; the Institute
for Healthcare Improvement and the
National Initiative for Children’s
Healthcare Quality have frequently
used condition-specific registries
(which do not depend on EHRs) in
their quality-improvement initiatives; a program called the Chronic
Disease Electronic Management System (CDEMS),81 which incorporates
an Access (Microsoft, Redmond, WA)
database and is available free of
Some children have mental health
problems that resolve quickly; some
children have mental health disorders
that require treatment to be administered over extended periods of time
and monitored for initial remission
and symptoms of recurrence; and
some children recover from mental
health disorders or return to normal
functioning. Primary care systems
cannot act as a medical home for children with mental health problems
without the capacity to monitor receipt
and outcomes of treatment. Monitoring systems can be set up in a variety
of ways that ensure that information
will be shared among the family, EI specialist, school (or preschool), and
health care providers and between primary care clinicians and specialists. At
the core of such a system are a registry of children with a certain condition
(see above) and an established protocol that assigns responsibility for communication to a certain team member
who will assist in the monitoring process (see below). Although “tickler”
systems—the use of manual reminders entered onto a staff member’s calendar or a “record review” entered
onto a provider’s clinic schedule—
can be used for this purpose, electronic systems that are capable of extracting information from records and
producing notices, reports, and/or appointments are especially useful.
Put Into Place a Plan for Managing
Psychiatric and Social
Emergencies
Primary care clinicians need access to
emergency services for children and
adolescents with suicidal thoughts
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SUPPLEMENT ARTICLE
and other psychiatric emergencies.
Virtually all communities in the United
States have some resource and process identified for handling psychiatric emergencies, although capacity
varies widely and, in many areas, depends on law enforcement agencies
and emergency departments. Some
communities have 24-hour, 7-days/
week emergency psychiatric facilities
and/or mobile response units staffed
by experienced personnel. Primary
care practices need to be aware of
these services, participate in community dialogue about management of
psychiatric and social emergencies,
and establish office protocols that link
youth and families immediately to appropriate services. (See the chapter
action kit1 and “Enhancing Pediatric
Mental Health Care: Strategies for Preparing a Community”3 for further discussion of this strategy.)
Put Office Systems in Place to
Support Screening, Assessment,
and Collaboration
Office procedures to ensure exchange
of information between the primary
care practice and mental health specialists are critical for effective care
and coordination. Although the HIPAA
actually allows mental health professionals and primary care clinicians
involved in the care of the same patient to exchange information (other
than psychotherapy notes and substance abuse records) without the
patient’s and family’s consent, the
mental health culture is very protective of privacy, even from referring
physicians. Primary care clinicians
may need to educate mental health
professionals about the concept of
the medical home for children with
special health care needs, the primary care clinician’s role and interest in the care of children with mental illness, and the primary care
clinician’s need for information
about their patients’ mental health
treatment, especially as it may affect
other elements of a child’s care (including medication interactions).
Many children and families will readily agree to the exchange of information between their mental health
professional and primary care clinician, if asked. Routine use of forms
that document consent for exchange
of information will facilitate communication. Use of fax-back forms (see
Supplemental Appendix S11 for an example) or other methods to facilitate
exchange has been helpful in some
communities.82,83 Telephone calls may
be less convenient for mental health
professionals, who are typically scheduled with back-to-back 45- to 60-minute
appointments and have little administrative support; however, previous understanding about convenient times to
talk may be beneficial. E-mail is often
convenient, but as with other uses of
e-mail in health care settings, secure
communication must be in place
and confidentiality must be carefully
considered.
Whatever methods are used, primary
care practices can demonstrate their
commitment to bidirectional communication with mental health specialists. Office procedures can ensure that
specialists receive, for example, a
summary of the presenting concern,
the family’s level of engagement in the
process, results from tools used to
measure symptoms and/or functioning, and the primary care clinician’s
capacity and preferences in relation
to comanagement. The primary care
practice can create the expectation
that, in return, it will receive from the
mental health specialist a summary of
diagnostic findings, treatment recommendations, and clarification of respective roles in ongoing comanagement of the identified problem.
Collaboratively Develop Care Plans
Chronic care principles suggest that
optimal outcomes are achieved when
the family, primary care clinician, and
specialists involved in assessment and
treatment collaboratively develop a
comprehensive plan of care. Key elements of collaborative care plans include identification of family concerns,
education of the family about the condition and self-management strategies, listing of all professionals involved in the care of the child, listing of
the strengths and resources available
to the family and child, a comprehensive account of diagnoses and therapies, therapeutic goals, and a specific
plan for monitoring progress toward
these goals, including periodic functional assessment. Care-plan development is discussed in more depth in
“Algorithms for Primary Care.”21 Sample paper-based care plans for chronic
conditions in pediatric settings are
available at the AAP Web site under the
medical home toolkit section.84
Prepare for Participation in the
Full Range of Collaborative Models
Previous strategies have addressed
the need for a resource directory and
for relationships with providers of key
mental health services. The model of
collaboration between a primary care
practice and mental health specialist(s) in a particular clinical situation
depends on the needs of the child,
child and family preferences, availability of the needed resources, and the
primary care clinician’s comfort with
the child’s condition(s) and its severity. A child may move between models
as the mental health condition
changes in severity or the child
achieves recovery. In regions where
mental health specialty services are
inaccessible or insufficient, including
most rural areas of the country, primary care practices may need to plan
for collaboration by telephone, Inter-
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net, or video with off-site mental health
specialists. Innovative systems in several regions of the country have been
developed to provide decision support
for primary care clinicians.1,8,85–88 Social workers or referral coordinators
can help patients navigate public and
private mental health specialty systems. In all collaborative models, a system of communication among providers is critically important to prevent
clinicians from relying on family members as conduits of clinical information.
Primary Care Only
In this model, the child can be assessed and managed appropriately
and successfully in the primary care
practice. The child’s mental health
needs are clear and, typically, uncomplicated by comorbidities, and the
child responds positively to primary
care interventions. For example, the
child with ADHD who requires medication and behavioral management but
does not have coexisting conditions
may be managed in primary care. The
practice is prepared to work directly
with the child and family in developing,
implementing, and monitoring the
child’s plan of care.
Primary Care With Consultation
This model is applicable to children
with chronic medical conditions accompanied by impairing mental health
comorbidities, such as anxiety or depression, and to children with mental
health disorders that are beyond the
comfort or capacity of primary care
clinicians. The primary care practice
serves as the source of primary care
and coordination of school and specialty services, fostering relationships
that enable the primary care clinician
to consult with:
1. A psychologist or other nonphysician mental health therapist (eg,
licensed clinical social worker,
licensed marriage and family ther-
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AAP TASK FORCE ON MENTAL HEALTH
apist, licensed professional counselor). The primary care clinician
typically provides the initial assessment and asks the mental health
professional to help clarify the diagnosis; to provide information about
types of psychosocial treatment approaches that may be beneficial; to
guide the primary care clinician’s
management; and/or to review or
address complicating developments such as new behavior problems, family conflicts, and high-risk
behaviors. The primary care clinician manages the prescription and
monitoring of medication, if it is a
part of the treatment plan. This type
of mental health consultation may
involve the child’s face-to-face visit(s) with the mental health specialist and/or intermittent conversations between the specialist and the
primary care clinician. It may occur
with or without consultation with a
physician specialist, as described
below.
2. A physician specialist, such as a
child and adolescent psychiatrist,
developmental-behavioral pediatrician, neurodevelopmental pediatrician, pediatric neurologist, or adolescent specialist. The primary
care clinician (or collaborating
mental health specialist, as described above) may pose specific
questions about diagnosis or management strategies, including medication issues (eg, choice of agent,
potential interactions, adverse effects, dosage adjustments), coexisting conditions, and suicide risk
or other safety concerns. The consulting physician may provide an
initial evaluation with the intention
that the child will return to the primary care clinician (and mental
health specialist) for ongoing care.
The consultant may also offer advice intermittently when new behavior problems, medication questions,
family conflicts, or high-risk behaviors occur.
Shared Care
In this model, the primary care practice fosters relationships that enable
its clinicians to “share” the mental
health care of the child with 1 or more
mental health specialists; that is, both
(or all) are jointly responsible for monitoring mental health symptoms, response to therapy, and effects of medication, if prescribed. In this model,
ongoing communication about the
child among the providers is particularly critical.
1. The primary care clinician may
share the care of the child with a:
●
child and adolescent psychiatrist, who provides not only an initial evaluation but also ongoing
treatment; and/or
●
mental health specialist such as
a psychologist or social worker,
who provides individual, group,
or family psychosocial therapy;
and/or
●
multidisciplinary team, which
may include the child’s mental
health case manager, an agency
representative from the Department of Social Services or Juvenile Justice system, a mental
health therapist, and school representative(s) such as a social
worker, school counselor, and/or
special education individual education plan (IEP) case manager;
in situations that involve children
with higher levels of complexity,
additional multidisciplinary team
members may participate (eg,
teams that care for children with
mental health disorders who require partial hospitalization or
day treatment may include representatives of the mental
health specialty facility); children with chronic medical conditions, such as cancer or
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SUPPLEMENT ARTICLE
chronic pulmonary disease,
may include the child’s medical
subspecialist or specialty clinic
coordinator.
2. Key features of shared-care models
include:
●
central role of the child and family in developing the plan of care;
●
mutual understanding of the
roles of family members, school
or child care personnel, and providers, including frequency of
and responsibility for follow-up,
with mental health specialists assuming relatively more responsibility for children with safety concerns and those whose mental
health conditions are of high severity or acuity;
●
general health supervision by the
primary care clinician, including
care of medical illnesses, immunizations and other preventive
services, and coordination of
specialty and educational services; and
●
a communication protocol, including parental consent for exchange of information, clear
understanding of respective responsibilities and mechanisms
for monitoring progress toward
therapeutic goals, mechanisms
for sharing information among
providers, and contact persons
in each provider’s practice and
child’s school or child care
setting.
Specialty Care
In this model, the mental health specialty system assumes responsibility
for the child’s care because of the level
of severity and complexity of the
child’s problems, higher levels of concern regarding safety, and/or the coexistence of other complicating mental
health or social conditions. The primary care practice ideally receives
regular communication about progress
and any changes in the level of care
such as hospitalization or group-home
placement and makes recommendations concerning the child’s ongoing
primary medical care and coordination of medical specialty services. Examples include a child with psychosis
or major depressive disorder.
Consider Co-locating a Mental
Health Specialist
A growing number of practices across
the country have successfully integrated 1 or more mental health specialists into the primary care setting.
Primary care clinicians who have a colocated mental health professional
have reported a greater likelihood of
consultation and referral than those
who do not have a co-located mental
health professional.89 Although studies
have focused primarily on adults with
depression, integrated care programs
have also been tested for anxiety, alcohol use, and ADHD in primary care settings. Although it is not possible to
distinguish the effects of increased attention to mental health problems
from the effects of specific integration
strategies, case reports have suggested the benefits of integrated models compared with usual care.90 Examples include improved Healthcare
Effectiveness Data and Information Set
(HEDIS) indicators for depression91;
lower utilization of mental health specialty services, lower overall costs per
patient, lower emergency department
utilization, and lower hospital admissions92; cost-neutrality; lower psychiatric inpatient admissions and length of
stay; and lower medical inpatient
length of stay.93 The events of September 11, 2001, Hurricane Katrina, and
other disasters have emphasized the
particular need for primary care practices to integrate mental health services in times of disasters. Evidence
points to families’ preference for these
services within primary care settings,
as compared with traditional mental
health settings.94
Role of Mental Health Specialist in
Primary Care
The role of a co-located mental health
professional is ideally developed in response to the needs of the practice
and the population it serves. Collaboration with primary care clinicians
may fall within any or all of the collaborative models described above. In areas that suffer from a shortage of child
psychiatrists or developmentalbehavioral pediatricians, a co-located
mental health specialist, such as a licensed clinical social worker or psychologist, enhances the level of assessment that is shared in advance
with consulting physicians, which increases the efficiency and appropriateness of the consultative process,
and facilitates implementation of a
treatment plan and follow-up afterward.95 This type of arrangement also
enriches the involved primary care clinicians and specialists through informal consultation and shared problemsolving around children and families in
their mutual care.
The co-located mental health specialist
may function in a number of ways, depending on practice preferences and
business realities. He or she may function similarly to his or her role in a
mental health specialty site, offering
traditional mental health assessment
and treatment services in 30- to 60minute blocks, or the mental health
specialist may provide services more
closely integrated with the primary
care clinician’s services: he or she may
“off-load” certain activities from the
primary care clinician, such as collecting an interval history, scoring mental
health screening tools, and/or providing supportive services such as parent
education. The co-located mental
health specialist can collaborate with
the primary care clinician to assess
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children with identified problems,
communicate with school personnel
or other mental health providers, provide mental health interventions, address barriers to care, monitor
progress in care, provide periodic contact and support to the family, and/or
link the child and family to referral
sources. He or she may work from a
specific chronic care protocol or generally in response to the needs that
present to the practice. In one model, a
mental health case manager supported by the practice provided many
of the nonreimbursed mental health
services such as data collection and
care coordination; this case manager
created efficiencies and increased primary care clinicians’ productivity,
more than compensating for the cost
of supporting this position.96 In all
models, primary care clinicians and
their patients benefit from the crossfertilization of multidisciplinary practice. In fully integrated mental health
models, the collaboration with a mental health specialist in primary care is
a seamless part of all encounters.
Business Arrangements for
Co-location Models
Choice of business arrangements depends importantly on the mental
health benefit structure and reimbursement rates of regional public
and private insurers, their requirements for authorizing services, and
their requirements for credentialing
mental health specialists to participate in their plans. Practices that are
contemplating co-location should develop a business plan based on their
unique needs, resources, payer mix,
and rates of payment. The simplest financial arrangement is one in which
the primary care practice rents office space to an independent mental
health provider who performs his or
her own billing and collecting of fees;
however, this model may limit the
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AAP TASK FORCE ON MENTAL HEALTH
extent to which real integration can
occur. Other business models include a mental health specialist employed by the primary care practice
and a mental health specialist employed by a mental health agency or
hospital and “out-stationed” in the
primary care practice.91,95 Some
states support integrated models by
allowing payment of mental health
specialists in Article 28 facilities (eg,
hospital, primary care settings,
school-based health centers). Practices with a high concentration of
Medicaid beneficiaries should pay
particular attention to their state’s
Medicaid “incident to” rules; these
rules may allow mental health specialists employed by a physician or
by the same entity that employs the
physician to bill in a physician’s
name, “incident to” that physician’s
on-site supervision. This arrangement, if available, may allow a higher
payment rate, more flexibility, and
more genuine integration of the mental health professional into the practice than arrangements in which the
mental health specialist bills directly
for his or her services, adhering to
traditional mental health codes and
billing processes. Further discussion of this issue is included in the
chapter action kit.1
A number of successful co-location
models have been sustained with
grant dollars during the implementation phase, until reimbursements became sufficient to support the mental
health specialist. In several regions of
the country, co-location models are
sustained through third-party reimbursement.97 The task force is collecting the experiences of primary care
practices that have co-located or integrated a mental health specialist.8 The
task force places high priority on research to identify best practices in implementing, sustaining, and evaluating
these models.
Some practices have also incorporated a child psychiatrist (usually employed by a separate entity such as a
mental health agency or academic institution) who provides periodic consultation on site or through telephone
or telemedicine hook-up. The primary
care clinician or the practice’s integrated mental health specialist can
greatly improve the efficiency of psychiatric consultation services by gathering data and performing a psychosocial assessment in advance of the
psychiatrist’s encounter with the child
and family, by posing specific clinical
questions to be answered by the psychiatrist, by spending time with the
child and family after the psychiatric
consultation to provide education
about the psychiatrist’s findings and
recommendations, by identifying and
addressing any barriers to engaging in
further care, and by following up with
the family periodically to monitor
progress.
Figure 2 provides an overview of the
characteristics of an integrated care
system.90
DECISION SUPPORT
Tools that inform diagnosis and management at various stages and for diverse conditions will assist primary
care practices in enhancing their mental health care.
Select Validated Functional
Assessment Tool(s) for Use in
Identifying Mental Health
Problems and in Monitoring a
Child’s and Family’s Progress
Toward Therapeutic Goals
Although primary care clinicians are accustomed to using spirometry for assessing and monitoring children with
asthma and A1C hemoglobin levels in
children with type 1 diabetes, they may
be unfamiliar with tools used for assessing and monitoring the clinical status of
children with mental health conditions.
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SUPPLEMENT ARTICLE
primary care settings. See Supplemental Appendix S12 for a summary of
their characteristics and resources
for further information.
Identify Reliable, Current Sources
of Information Concerning
Diagnostic Classification of Mental
Health Problems and Evidence
About the Safety and Efficacy of
Treatments
FIGURE 2
Characteristics of integration linked to process of care (adapted from ref 90).
In mental health specialty practice, tools
that measure child and family functioning are a routine part of the assessment
and monitoring process. Such tools can
provide clinicians with information
about a child’s areas of strength, as well
as their problem areas. The tools may
also lead to identification of children
who do not meet diagnostic criteria for a
specific mental health disorder but have
some impairment in functioning at
home, at school, or with peers, and/or
they may measure the effects that a
child’s mental health disorder has on the
child, the family, the child’s interpersonal relationships, and the child’s
school performance.
Measuring the global functioning of
children and families offers the following potential benefits to primary care
clinicians98:
● functional
assessments demonstrate better interreporter reliability than symptom-based assessments for a number of mental
health disorders;
● impaired functioning may precede
the recognition of specific mental
health symptoms and may resolve
more slowly than symptoms;
● identifying
areas of functional
strength and challenge can guide
the development and monitoring of
treatment goals; and
● improved functional outcome is a
measure of the efficacy of mental
health services and is important to
children and families.
Although many tools used to assess
mental health functioning are not applicable in primary care settings, a few
have shown promise in assisting primary care clinicians in screening,
assessment, and monitoring of children and adolescents for mental
health problems, and several are
available in the public domain.
Appendix S4 summarizes the task
force’s current recommendations in
relation to these tools.
Select Instruments for the
Assessment of Children Whose
Screening Results or Clinical
Findings Suggest the Presence of a
Mental Health or Substance Abuse
Problem
A number of tools are available to
assist the clinician in further assessment of children with suspected
mental health or substance abuse
problems. The task force has compiled
a table of those with sound psychometric properties and potential for use in
The task force has developed guidance
to assist primary care clinicians in the
assessment and management of children from birth to 5 years of age with
symptoms of social-emotional problems and school-aged children with
problems of inattention/impulsivity,
anxiety, depression, disruptive behavior/
aggression, substance use, and learning difficulties.99 This guidance outlines
the type of assessment indicated by
presenting symptoms or screening results, lists evidence-based psychosocial
interventions, suggests primary care–
appropriate approaches to initiating
care and assisting families with selfmanagement, and lists psychopharmacologic agents approved by the US Food
and Drug Administration for use in children with disorders diagnosed within
each cluster of symptoms. Several resources are available to assist clinicians
in weighing the risks and benefits of
mental health and substance abuse
treatments.8,11,100–102
Primary care clinicians are often faced
with caring for children who have been
prescribed a psychopharmacologic
medication (or multiple medications)
by a mental health specialist, sometimes without access to ongoing consultation with that specialist, which
underscores the importance of the
strategy that follows.
Develop and Implement EvidenceBased Protocols
Development of office protocols and flow
sheets, in accordance with evidence-
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S101
based guidelines or locally developed
standards of care, will “routinize” the
essential elements of the care process. A logical starting point might be
children with ADHD, a mental health
disorder that most pediatricians feel
comfortable assessing and managing
and for which there are established
clinical guidelines103,104 and extensive
experience in quality-improvement efforts.105–107
Implementing mental health management protocols within the practice will
involve a team-building process and
significant participation by nonphysician staff. These staff members may be
charged with, for instance, requesting
information or records from schools,
the child welfare system, and other
care providers when a child on the registry is scheduled for a visit; collecting
and scoring assessment tools in advance of the visit; clarifying insurance
benefit and provider issues; scheduling medication checks (adverse effects, laboratory surveillance, refills);
obtaining height and weight measurements and vital signs; periodically assessing the functioning of the child
and family (see below); checking
progress toward therapeutic goals;
calling the child and/or family for a
structured follow-up or appointment
reminder or recall after a missed visit;
and/or assisting with the referral process. These mechanisms can be enhanced through an EHR system that
improves access to the chart for all
treating clinicians and support staff
(at appropriate levels), improves routing of information to appropriate clinicians, supports jointly developed care
management plans, automates recall
for missed appointments, and embeds
the results of automatically scored behavioral and functional scales. Other
models in development include Webbased portals that allow youth or parents to complete previsit questionnaires and send results to an EHR or
S102
AAP TASK FORCE ON MENTAL HEALTH
other electronic tool, which then links
the clinician to sources of information
about the child’s presenting difficulties.27–29 Regardless of the specific
tools, primary care clinicians must
consider both the content of particular
instruments or tools and how such
tools will be administered, recorded,
and monitored.
Examples of protocols and tools for ongoing management of chronic medical
conditions can be found on the
AAP medical home Web site (www.
medicalhomeinfo.org). Specific protocols for tracking and monitoring mental health conditions are available for
ADHD80 and adolescent depression.108
The mass introduction of EHRs will
eventually automate the use of
evidence-based physician order sets,
flow sheets, and tracking reports to
assist in improving the quality of care
for persons with chronic conditions.
Electronic reminders, quality reports,
and standardized order sets have already been shown to reduce medical
errors, improve patient satisfaction,
increase guideline-compliant care by
physicians, and assist in identifying
unmet health care needs.109–113 Although few of these studies to date
have focused on pediatric mental
health and electronic records, the improvements in care are likely to be
substantial.
Establish a Relationship With a
Psychiatrist Who Has Expertise
With Children and Adolescents
This strategy is a significant challenge
in many communities. In a number of
areas of the country, primary care clinicians have collaborated with academic institutions to develop models
of telepsychiatry, regional consultation, or co-location within the practice.
Evaluation of several programs has
demonstrated their value in enhancing
the self-efficacy of primary care clinicians and decreasing their use of
polypharmacy for pediatric mental
health disorders.85,86,114 A more complete discussion of these strategies is
included in the chapter action kit1 and
“Enhancing Pediatric Mental Health
Care: Strategies for Preparing a
Community.”3
Routinely Screen for Mental Health
and Substance Abuse Problems in
the Child and Family
Many children with mental health
problems or difficulty in their parentchild relationships, families experiencing psychosocial stresses, and
parents with mental illness are not
identified as needing mental health or
social services, although they may frequent primary care settings.115 This is
particularly true for children with
special health care needs.116 Furthermore, their unrecognized mental
health problems may drive their utilization (and their parents’ utilization)
of medical services.117 Although an exhaustive review of the literature on
mental health screening was beyond
the scope of the task force, the task
force reviewed the literature for answers to several important questions
related to screening in primary care
settings. From this review and guidance of experts in the field of general
pediatrics, developmental-behavioral
pediatrics, adolescent medicine, and
child psychiatry, the task force concluded that the many unmet mental
health needs of children, adolescents,
and their families warrant enhanced
primary care efforts to identify children with occult mental health problems and families in need of mental
health or social assistance.
Bright Futures24 affirmed the importance of using all routine health supervision visits for surveillance of a child’s
and family’s psychosocial well-being.
The task force members believe that
there is a strong case for routine
periodic mental health screening of
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SUPPLEMENT ARTICLE
children and their families by using
validated instruments. This case is
summarized in Appendix S4. Primary
care clinicians also need to weigh the
limitations of screening tools, particularly their use in populations for which
English is a second language and for
which the cultural context of a child’s
behavior and family’s parenting may
differ from that of the populations in
which the screening tools were validated. For practices in which screening is not routine, primary care clinicians need to make special efforts to
enhance their skills in eliciting mental
health concerns.38
Several authors have described steps
necessary to support the integration
of screening.118–121 These steps include
“selling” clinicians and staff on the
benefits of screening (eg, parent engagement, early identification of problems, responsiveness to family needs),
addressing barriers to screening (eg,
insufficient training of physicians, time
pressures, inadequate payment, uncertain referral sources, parental resistance), and preparing the practice
(eg, identifying a physician champion,
mapping practice workflow, training
office staff, identifying community referral sources, developing systems for
bidirectional communication with referral sources, and developing tracking tools including a practice registry
for children with positive screening
results—those whose parents choose
not to take action, as well as those
who do).
While recognizing the need for more
studies in the pediatric population, particularly to determine outcomes of children identified through a screening process, the task force proposes that
primary care practices consider routine
screening to enhance identification of
children with mental health symptoms
or impaired functioning (Table 1) and
identification of risks in the family and
environment (Table 2). When possible, it
TABLE 1 Proposed Mental Health Screening of Children and Adolescents in Primary Care Settings
1
2
3
Use validated instruments to screen for socioemotional problems in children at 0–5 y of age
with abnormal developmental screening test results (typically performed at 9, 18, and 24
or 30 mo) or abnormal autism screening test result (typically performed at 18 and 24
mo); at any time clinician observes poor growth and/or attachment and/or symptoms,
such as excessive crying, clinginess, or fearfulness for developmental stage, or
regression to earlier behavior; and at any time family identifies psychosocial concerns.
Use validated instruments to screen all school-aged children (ages 5 through adolescence)
for symptoms of mental illness and impaired psychosocial functioning at health
maintenance visits; at any time of family disruption, poor school performance, reported
behavioral difficulties, recurrent somatic complaints, or involvement of a social service
or juvenile justice agency; and/or when child or family identifies psychosocial concerns.a
In addition to 2 above, screen all adolescents for substance use (including tobacco) at each
health maintenance visit and whenever circumstances such as an injury, car crash, or
decrease in school performance suggest the possibility of substance abuse.a If
adolescent reports using substance(s), assess for extent of use.
a
For adolescents, screening with paper-and-pencil tools is more likely to elicit concerns than an interview; electronic tools
are more likely to elicit concerns than paper-and-pencil tools122 and may be perceived as more confidential.123
TABLE 2 Proposed Screening and Surveillance of Family and Social Environment for Risk Factors
1
2
Obtain a history of trauma exposure and update child and family’s psychosocial history (eg, parental
distress or discord, domestic violence, parental substance abuse or mental illness, youth and
family social support, grief and loss issues) at each health maintenance visit and as dictated by
clinical need.
Screen for maternal depression in the first year of life of the child and when psychosocial history
indicates. The incidence of postpartum maternal depression peaks when infants are between 2
and 6 mo of age.124
is advantageous to have youth or parents complete screening tools before a
visit, either on paper or electronically,
and to have scoring completed in advance, which enables the primary care
clinicians to use the office visit for building rapport and expanding discussion of
any concerns rather than for rote data
collection.
For many practices, routinely screening
their patients as proposed will require
incremental implementation. Depending
on the population served by the practice and its health risks and strengths,
the clinician may choose to begin with
routine mental health/substance abuse
screening of an age group, such as adolescents, or a high-needs groups within the population, such as children in
foster care or children with parents
who have been deployed in military service. In some settings, the practice may
seek cooperation of school guidance
counselors or nurses, school-based clinics, or community agencies (eg, public
health, social services, juvenile justice)
to collect previsit data at their intake
points and relay the information to the
practice.
Supplemental Appendix S12 contains
examples of mental health screening
tools that have sound psychometric
properties and are accessible to primary care clinicians. In each category,
the task force has noted several tools
that can be most feasibly implemented
in primary care settings. Use of these
or other screening tools does not replace the clinical interview needed to
confirm findings and expand on identified problems.
Characteristics of tools the task force
selected for Supplemental Appendix
S12 include the following:
● User-friendly: not requiring special
training to administer.
● Designed to elicit information from
multiple reporters (ie, versions are
available for completion by youth,
parents, and teachers): multiple
data sources offer additional in-
PEDIATRICS Volume 125, Supplement 3, June 2010
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S103
sights in the course of mental
health assessment.
● Available in multiple platforms: pro-
viding options for youth and families
to complete screens on-line outside
the office or via computer in the waiting room may have advantages; however, some practices will prefer traditional pen-and-paper screenings.
● Relatively brief and easily scored:
the task force suggests that screenings require no longer than 10 to 15
minutes to complete.
● Multilingual: screenings should be
available in the preferred language
of each reporter.
● Available in the public domain.
Use Acute Care Visits to Elicit
Mental Health Concerns
Recognizing that many school-aged
children and adolescents do not seek
routine health supervision, members
of the task force urge that primary
care practices consider using acute
care visits as opportunities for brief
mental health updates, especially for
those children and adolescents who
do not receive routine health supervision services. The task force drew
from the expertise of its professional
members, opinions of its youth and
family participants, and informal
trials in primary care practices to
develop sample questions that primary care clinicians can consider
using during acute care visits. These
sample questions are included as
Appendix S8. Research is necessary
to determine outcomes and best
practices.
Depending on their pace and practice style, primary care clinicians
may choose to try several of these
questions and then gradually implement the routine use of those that
are most comfortable and yield the
most helpful responses. Alternatively, clinicians can use the context
of the acute care visit (eg, an injury)
to lead naturally into mental health
topics (eg, “Had you or your friends
been drinking when this happened?”
or “Has this person [the perpetrator
of the injury] ever threatened you or
injured you before?”).
clinicians can use a mental health
practice-readiness inventory (see Appendix S3) to assess their needs and
establish priorities for enhancing the
practice’s mental health care. The key
elements are:
Because of the association between
sleep difficulties and mental health
conditions, use of questions regarding
sleep is helpful throughout childhood.
“Algorithms for Primary Care”21 provides more specificity about clinical
approaches.
AAP TASK FORCE ON MENTAL
HEALTH
● community resources;
● health care financing;
● support for children and families;
● clinical information systems and de-
livery system redesign; and
● decision support.
Primary care clinicians who are interested in enhancing the mental health
services they provide can look to the
chronic care model for guidance. This
report suggests ways to apply this
model to the care of children and
adolescents who are experiencing
mental health and substance abuse
problems and to prepare a pediatric
practice to function as a medical
home for these children. The returns
are likely to be substantial, enhancing
the early identification of those who
need mental health and substance
abuse services and improving the
quality of care the practice provides to
children with mental health and substance abuse problems. Primary care
The AAP Task Force on Mental Health
included Jane Meschan Foy, MD (chairperson, lead author), Paula Duncan,
MD, Barbara Frankowski, MD, MPH,
Kelly Kelleher, MD, MPH (lead author),
Penelope K. Knapp, MD, Danielle
Laraque, MD (lead author), Gary Peck,
MD, Michael Regalado, MD, Jack Swanson, MD, and Mark Wolraich, MD; the
consultants were Margaret Dolan, MD,
Alain Joffe, MD, MPH, Patricia O’Malley,
MD, James Perrin, MD, Thomas K. McInerny, MD, and Lynn Wegner, MD; the
liaisons were Terry Carmichael, MSW
(National Association of Social Workers), Darcy Gruttadaro, JD (National
Alliance on Mental Illness), Garry Sigman, MD (Society for Adolescent
Medicine), Myrtis Sullivan, MD, MPH
(National Medical Association), and
L. Read Sulik, MD (American Academy
of Child and Adolescent Psychiatry);
and the staff were Linda Paul and
Aldina Hovde.
2. American Academy of Pediatrics, Task
Force on Mental Health; American Academy of Child and Adolescent Psychiatry,
Committee on Health Care Access and Economics. Improving mental health services
in primary care: reducing administrative
and financial barriers to access and collaboration [published correction appears
in Pediatrics. 2009;123(6):1611]. Pediatrics. 2009;123(4):1248 –1251
3. American Academy of Pediatrics, Task Force
on Mental Health. Enhancing pediatric mental health care: strategies for preparing a
community. Pediatrics. 2010;125(3 suppl):
S75–S86
4. American Academy of Pediatrics, Commit-
CONCLUSIONS
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Enhancing Pediatric Mental Health Care: Strategies for Preparing a Primary
Care Practice
Jane Meschan Foy, Kelly J. Kelleher, Danielle Laraque and for the American
Academy of Pediatrics Task Force on Mental Health
Pediatrics 2010;125;S87
DOI: 10.1542/peds.2010-0788E
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