A Collaborative Care Model to Improve Access to Pediatric Mental Health Services

  • O. Aupont
  • L. Doerfler
  • D. F. Connor
  • C. Stille
  • M. Tisminetzky
  • T. J. McLaughlin
Original Article

Abstract

To examine if an innovative collaborative care model known as Targeted Child Psychiatric Services designed for primary care pediatricians (PCPs) and child psychiatrists (1) was associated with improved access to child psychiatry services, (2) had the potential to identify optimal care settings for pediatric mental health care and (3) examined if pediatricians appeared as likely to accept children back into their practices at discharge from TCPS depending upon diagnostic category, controlling for severity of illness and function. The diagnostic classes examined were ADHD (39%), depression (31%) and anxiety (13%). This prospective cohort design study collected medical records of 329 children referred to TCPS by 139 PCPs. To detect the likelihood of return to referring pediatricians for follow-up care at discharge from TCPS, we employed logistic regression models. Mean age was 12.3 (SD = 4.0); 43% were female. Ninety-three percent of parents complied with pediatricians’ recommendations to have their child assessed by a child psychiatrist. A total of 28.0% of referrals returned to PCPs for follow-up care; the remainder were followed in mental health. Regression findings indicated that children with major depression (OR = 7.5) or anxiety disorders (OR = 5.1) were less likely to return to PCPs compared to ADHD even though severity of psychiatric illness and functional levels did not differ across diagnostic groups. Families widely accepted pediatricians’ recommendations for referral to child psychiatrists. Depression and anxiety were strong correlates of retention in mental health settings at discharge from TCPS though children with these disorders appeared to be no more severely ill or functionally limited than peers with ADHD. These children possibly could be managed in a less intensive and expensive primary care treatment setting that could access mental health specialty services as needed in a collaborative model of care. TCPS is contrasted with the well-known collaborative model for adult depression in primary care. TCPS could serve as a feasible model of care that addresses the daunting barriers in accessing pediatric mental health services.

Keywords

Pediatrics Mental health Collaborative care System enhancement 

References

  1. American Academy of Pediatrics. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158–1170.CrossRefGoogle Scholar
  2. American Academy of Pediatrics. (2001). Clinical practice guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics, 108(4), 1033–1044.CrossRefGoogle Scholar
  3. APA. (1994). Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Press.Google Scholar
  4. Bernal, P. (2003). Hidden morbidity in pediatric primary care. Pediatric Annals, 32(6), 413–418. 421–412.PubMedGoogle Scholar
  5. Bernal, P., Estroff, D. B., et al. (2000). Psychosocial morbidity: The economic burden in a pediatric health maintenance organization sample. Archives of Pediatrics and Adolescent Medicine, 154(3), 261–266.PubMedGoogle Scholar
  6. Biederman, J., Newcorn, J., et al. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 148(5), 564–577.PubMedGoogle Scholar
  7. Blau, G. M., Huang, L. N., et al. (2010). Advancing efforts to improve children’s mental health in America: A commentary. Administration and Policy in Mental Health, 37(1–2), 140–144.PubMedGoogle Scholar
  8. Cheung, A. H., Zuckerbrot, R. A., et al. (2007). Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics, 120(5), e1313–e1326.PubMedCrossRefGoogle Scholar
  9. Conners, C. K. (1990). Conner’s rating scale. Toronto: Multihealth System.Google Scholar
  10. Connor, D. F., McLaughlin, T. J., et al. (2006). Targeted child psychiatric services: A new model of pediatric primary clinician–child psychiatry collaborative care. Clinical Pediatrics (Philadelphia), 45(5), 423–434.CrossRefGoogle Scholar
  11. Costello, E. J. (1989). Child psychiatric disorders and their correlates: A primary care pediatric sample. Journal of the American Academy of Child and Adolescent Psychiatry, 28(6), 851–855.PubMedCrossRefGoogle Scholar
  12. Costello, E. J., Mustillo, S., et al. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60(8), 837–844.PubMedCrossRefGoogle Scholar
  13. Guy, W. (1976). Assessment Manual for Psychopharmacology. Department of Health, Education, and Welfare, Washington, DC.Google Scholar
  14. Hill, A. B. (1965). The environment and disease: Association or causation? Proceedings of the Royal Society Medicine, 58, 295–300.Google Scholar
  15. Jellinek, M. S., Murphy, J. M., et al. (1986). Brief psychosocial screening in outpatient pediatric practice. The Journal of Pediatrics, 109(2), 371–378.PubMedCrossRefGoogle Scholar
  16. Jellinek, M. S., Murphy, J. M., et al. (1988). Pediatric symptom checklist: Screening school-age children for psychosocial dysfunction. The Journal of Pediatrics, 112(2), 201–209.PubMedCrossRefGoogle Scholar
  17. Jellinek, M. S., Murphy, M., et al. (1999). Use of the pediatric symptom checklist to screen for psychosocial problems in pediatric primary care. Archives of Pediatrics and Adolescent Medicine, 153, 254–260.PubMedGoogle Scholar
  18. Khan, A., Khan, S., et al. (2003). Suicide rates in clinical trials of SSRIs, other antidepressants, and placebo: Analysis of FDA reports. American Journal of Psychiatry, 160(4), 790–792.PubMedCrossRefGoogle Scholar
  19. Kim, W. J. (2003). Child and adolescent psychiatry workforce: A critical shortage and national challenge. Academic Psychiatry, 27(4), 277–282.PubMedCrossRefGoogle Scholar
  20. Lavigne, J. V., Gibbons, R. D., et al. (1996). Prevalence rates and correlates of psychiatric disorders among preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35(2), 204–214.PubMedCrossRefGoogle Scholar
  21. Liang, Y., & Zeger, S. (1986). Longitudinal data analysis using generalized linear models. Biometrika, 73(1), 13–22.CrossRefGoogle Scholar
  22. Mann, J.J., (2004). A clinical perspective on safety and efficacy of ssris in depressed children and adolescents. From http://www.fda.gov/ohrms/dockets/ac/04/slides/2004-4065OPH1_07_Mann.ppt.
  23. March, J., Silva, S., et al. (2009). The treatment for adolescents with depression study (TADS): Outcomes over 1 year of naturalistic follow-up. American Journal of Psychiatry, 166(10), 1141–1149.PubMedCrossRefGoogle Scholar
  24. McCarthy, M., Abenojar, J., et al. (2009). Child and adolescent psychiatry for the future: Challenges and opportunities. Psychiatric Clinics of North America, 32(1), 213–226.PubMedCrossRefGoogle Scholar
  25. Merikangas, K. R., He, J. P., et al. (2010a). Prevalence and treatment of mental disorders among US children in the 2001–2004 NHANES. Pediatrics, 125(1), 75–81.PubMedCrossRefGoogle Scholar
  26. Merikangas, K. R., He, J. P., et al. (2010b). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child Adolescent Psychiatry, 49(10), 980–989.CrossRefGoogle Scholar
  27. Muratori, F., Picchi, L., Bruni, G., Patarnello, M., & Romagnoli, G. (2003). A two-year follow-up of psychodynamic psychotherapy for internalizing disorders in children. Journal of the American Academy of Child Adolescent Psychiatry, 42(3), 331–339.CrossRefGoogle Scholar
  28. Olfson, M., Marcus, S. C., et al. (2008). Effects of Food and Drug Administration warnings on antidepressant use in a national sample. Archives of General Psychiatry, 65(1), 94–101.PubMedCrossRefGoogle Scholar
  29. Richardson, L., McCauley, E., et al. (2009). Collaborative care for adolescent depression: A pilot study. General Hospital Psychiatry, 31(1), 36–45.PubMedCrossRefGoogle Scholar
  30. Rosack, J. (2004). FDA poised to intensify suicide warnings on SSRIs. Psychiatry News, 39(5), 1–63.Google Scholar
  31. Schonwald, A., & Lechner, E. (2006). Attention deficit/hyperactivity disorder: Complexities and controversies. Current Opinion in Pediatrics, 18(2), 189–195.PubMedCrossRefGoogle Scholar
  32. Shaffer, D., Gould, M. S., et al. (1983). A children’s global assessment scale (CGAS). Archives of General Psychiatry, 40(11), 1228–1231.PubMedCrossRefGoogle Scholar
  33. Simon, G. E., & Vonkorff, M. (1995). Recognition, management, and outcomes of depression in primary care. Archives of Family Medicine, 4(2), 99–105.PubMedCrossRefGoogle Scholar
  34. Spirito, A., & Esposito-Smythers, C. (2006). Attempted and completed suicide in adolescence. Annual Review of Clinical Psychology, 2(1), 237–266. doi:10.1146/annurev.clinpsy.2.022305.095323.PubMedCrossRefGoogle Scholar
  35. Spirito, A., Valeri, S., et al. (2003). Predictors of continued suicidal behavior in adolescents following a suicide attempt. Journal of Clinical Child and Adolescent Psychology, 32(2), 284–289.PubMedCrossRefGoogle Scholar
  36. Stiffman, A. R., Stelk, W., et al. (2010). A public health approach to children’s mental health services: Possible solutions to current service inadequacies. Administration and Policy in Mental Health, 37(1–2), 120–124.PubMedGoogle Scholar
  37. Thomas, C. R. (1999). National distribution of child and adolescent psychaitrists. Journal of the American Academey of Child and Adolescent Psychiatry, 38(1), 9–17.CrossRefGoogle Scholar
  38. U.S. Department of Health and Human Services (1999). Mental health: a report of the Surgeon General. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, Rockville.Google Scholar
  39. Valuck, R. J., Libby, A. M., et al. (2004). Antidepressant treatment and risk of suicide attempt by adolescents with major depressive disorder: A propensity-adjusted retrospective cohort study. CNS Drugs, 18(15), 1119–1132.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • O. Aupont
    • 3
  • L. Doerfler
    • 2
    • 4
  • D. F. Connor
    • 5
  • C. Stille
    • 3
  • M. Tisminetzky
    • 6
  • T. J. McLaughlin
    • 1
  1. 1.Department of Pediatrics, Psychiatry & Quantitative Health SciencesUniversity of Massachusetts Medical SchoolShrewsburyUSA
  2. 2.Department of PsychiatryUniversity of Massachusetts Medical SchoolWorcesterUSA
  3. 3.Department of PediatricsUniversity of Massachusetts Medical SchoolShrewsburyUSA
  4. 4.Department of PsychologyAssumption CollegeWorcesterUSA
  5. 5.Department of PsychiatryUniversity of Connecticut Medical SchoolFarmingtonUSA
  6. 6.Department of Pediatrics & Quantitative Health SciencesUniversity of Massachusetts Medical SchoolShrewsburyUSA

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