Pediatricians and other primary care physicians (PCPs) are finding themselves as providers of child mental health care more than ever. Whether it be screening toddlers for autism, starting medications for conditions such as ADHD or depression, or dispensing parental advice to manage oppositional children, your PCP is now finding him or herself on the front lines of treating childhood emotional-behavioral problems, like it or not. While there was once the opportunity for PCPs to outsource mental health problems in their patients to therapists and child psychiatrists, national shortages are making this practice a dim memory in many parts of the country. Some pediatricians welcome the challenge, others find it quite uncomfortable, given the lack of specific training most of them receive in medical school and residency.
New initiatives in public health are working towards the idea of the primary care office as the central “medical home” equipped with ever more resources to handle things in house. At the same time, more traditional models in which children with significant emotional-behavioral problems are sent to people like child psychiatrists with the idea that the psychiatrist will simply take over the mental health care for an indefinite period of time are slowly being replaced with more consultative models in which psychiatrists provide advice and recommendations to the PCP, who remains the direct provider of that care.
Are these changes positive and welcome? To get some perspective, I talked to Dr. Joseph Hagan, a pediatrician from Burlington, Vermont. Dr. Hagan has been involved in shaping pediatric mental health care policy for years as the former chair of the American Academy of Pediatrics’ (AAP) Committee on the Psychosocial Aspects of Child and Family Health and current member of the Bright Futures Steering Committee. He is also running this year to be the President-Elect of the AAP nationally.
Q: What do you see as some of the key issues affecting child mental health care?
A: One of the things I haven’t heard a lot about is that there are not enough therapists to see kids. The system has traditionally been based upon procedures and not on time and that’s a problem. Therapists get paid less than the shop rate of your local auto mechanic, and of course, anyone who sees kids has to talk to schools and parents outside of the session. That’s non-billable, and we wonder why nobody will see kids. Mental health is part of health, and the earlier we invest, the bigger the return. Since our practice was certified as a Family Centered Medical Home and now has access to a Community Health Team, my life has changed because we now have services that we didn’t have before. The problem with screening in the past has been “What if you find something?” Now we have so much more to offer.
Q: How much should a pediatrician really be expected to know and do when it comes to child behavioral problems? Is there a floor of knowledge and skills when it comes to mental health that all pediatricians should attain?
A: I think there definitely is. Behavioral and mental health problems can be managed in our offices and everyone ought to be able to manage the majority of kids not only with ADHD, but also with oppositional defiant disorder, anxiety and depression. I mean, there are certain mental health problems that are part of pediatrics. To refer a standard ADHD child is absurd because it really is a day to day problem that needs to be managed in your primary care medical home. Everybody needs to know how to do that and do it well. It is a chronic illness and you need to hang in there with these kids.
Q: Psychiatric medications certainly have become even more controversial lately. What advice do you have for pediatricians when they prescribe them?
A: Tell families the expected effects and potential side effects. If you don’t, Dr. Google will. Start low and go slow, but titrate until desired effect of recovery. Remember if you are 100% anxious and miserable, you’ll look and feel great when your only 50% anxious, but you’re still only halfway better! It’s also important to discuss with your patient when you start meds how long you are going to continue them, lest they feel good and stop prematurely.
Q: There are a lot of efforts these days to extend the education of pediatricians and provide consulting back up while the patient remains directly in the care of the pediatrician. Do you think those efforts are enough or should we be more focused on providing more psychiatrists and other mental health clinicians that pediatricians can refer to?
A: We need to be able to do this (mental health) work. But part of being successful is having someone to consult with and someone to refer to. Just like with cardiac or GI problems, there are cases we can take care of all by ourselves, cases where we will need to reach out to a consultant for help, and cases that need referral. Yes we need more child psychiatrists. Co-located and collaborative care are best-case scenarios.
More information about mental health care can be found from the American Academy of Pediatrics. More information about Dr. Hagan can be found here.
@copyright by David Rettew, MD
David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illnessand a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.
Follow him at @PediPsych and like PediPsych on Facebook.