Barriers to the Identification and Management of Psychosocial Issues in Children and Maternal Depression
CONTEXT. Child psychosocial issues and maternal depression are underidentified and undertreated, but we know surprisingly little about the barriers to identification and treatment of these problems by primary care pediatricians.
OBJECTIVES. The purpose of this work was to determine whether (1) perceived barriers to care for children's psychosocial issues and maternal depression aggregate into patient, physician, and organizational domains, (2) barrier domains are distinct for mothers and children, and (3) physician, patient, and practice/organizational characteristics are associated with different barrier domains for children and mothers.
METHODS. We conducted a cross-sectional survey of the 50818 US nonretired members of the American Academy of Pediatrics. Of a random sample of 1600 members, 832 (745 nontrainee members) responded. This was a mailed 8-page survey with no patients and no intervention. We measured physician assessment of barriers to providing psychosocial care for children's psychosocial problems and maternal depression.
RESULTS. Pediatricians frequently endorse the lack of time to treat mental health problems (77.0%) and long waiting periods to see mental health providers (74.0%) as the most important barriers to the identification and treatment of children's psychosocial problems. For maternal depression, pediatricians most often endorsed lack of training in treatment (74.5%) and lack of time to treat (64.3%) as important barriers. Pediatricians' reports of barriers clustered into physician and organizational domains. Physician domains were distinct for children and mothers, but organizational domains were not. Several physician and practice characteristics are significantly associated with the 4 barrier scales, and different characteristics (eg, sociodemographic, attitudinal, and practice features) were related to each barrier area.
CONCLUSIONS. Pediatricians endorse a wide range of barriers with respect to the diagnosis and treatment of children's mental health problems and maternal depression. The specificity of factors relating to various barrier areas suggests that overcoming barriers to the identification and treatment of child mental health problems and maternal depression in primary care pediatrics is likely to require a multifaceted approach that spans organizational, physician, and patient issues. In addition, comprehensive interventions will likely require social marketing approaches designed to engage diverse audiences of clinicians and their patients to participate.
Pediatricians are identifying more children with psychosocial problems than they did in 1979 (6.8%–18.7%).1 However, despite some indication of increases in identification and the continued attention to psychosocial issues by pediatric practitioners,2–6 the vast majority of children with emotional or behavioral problems still go undiagnosed and untreated.7–10
A similar problem exists with respect to identifying family psychosocial issues, including those problems with serious implications for children's development, such as maternal depression.11 Depressed women with young children are unlikely to be identified and treated, perhaps because of their limited use of health services.12 However, given that almost all children in the United States routinely interact with primary care pediatricians, and most young children visit their pediatricians multiple times a year, pediatricians are in a unique position to identify and treat or refer depressed mothers. The unique potential of pediatricians to intervene in family health and mental health issues has received attention in the professional literature,13,14 and work by Kahn et al15 suggests that mothers who visit pediatricians “would not mind” or “would welcome” screening and referral services from their child's pediatrician for their own health issues.
Given the prevalence of child psychosocial problems and maternal depression, as well as their importance for children's health, the continued underidentification and minimal management of child psychosocial problems and maternal depression is puzzling. Although much attention has been paid to the treatment of adult depression in primary care, and a model for barriers to treatment has been suggested,16 much less information exists about the barriers to identification or management for child mental health problems or maternal depression in primary care pediatrics. The adult literature suggests that barriers may fall into 3 areas: patient, physician, and organizational domains and that different characteristics may be related to the different barrier domains.16
Much of what is known about barriers to identification and treatment of child psychosocial problems comes from studies of the diagnosis and management of children's psychosocial issues in pediatric primary care,17–23 secondary analyses of large national databases,24 or studies specifically examining barriers to the identification and management of these issues.25–27 These studies suggest that provider characteristics, such as training or confidence,20,25–27 knowledge of the child,17,21 physician specialty,19,24 and, to a small extent, physician beliefs,22 may facilitate or impede access to mental health services. Similarly, family and child characteristics, such as severity of the problem, family use of mental health services, and sociodemographic characteristics,19,23 are also barriers. However, only the organizational issues, such as lack of time or lack of available mental health services, seem to affect recognition and management.25–27
Two studies that examined barriers to identification and treatment of psychosocial issues specifically for children and maternal depression used national samples. One study by Olson and colleagues28,29 used a national sample of pediatricians drawn from the American Academy of Pediatrics (AAP) current member lists and asked about barriers to care for maternal and child/adolescent depression. Pediatricians received 1 of 2 questionnaires, so no comparisons of perceptions of barriers across maternal and child issues were possible. Furthermore, although this work used the Williams et al16 domains, no formal examination of the domains was reported, and no characteristics associated with the barrier domains were examined. For child/adolescent and maternal depression, Olson and colleagues27,28 identified few patient barriers, training, and knowledge as physician barriers and time as the chief organizational issue.
The recent study by Wiley et al30 examined pediatricians' knowledge and views of postpartum depression (PPD), its diagnosis, and its management. Using a randomly selected sample of pediatricians listed on the American Medical Association Physician master file, a 2-page questionnaire was mailed to 1200 pediatricians with a 32% response rate. This work documented that many pediatricians (49%) had little or no knowledge of PPD, underestimated the incidence of PPD in their practices (80%), and reported a number of barriers to screening for PPD, such as time (69%), few office resources (57%), and lack of referral sources (43%). Again, there was no conceptual formulation of barriers and little examination of correlates of perceived barriers.
Although critical for children's health and development, child psychosocial issues and maternal depression are underidentified and undertreated. We know surprisingly little about the barriers to identification and treatment of children's psychosocial problems or maternal depression by primary care pediatricians. The extant literature lacks a comprehensive examination of barriers across multiple child psychological issues and maternal depression, using a national sample and testing a conceptual model. Therefore, we developed a study to determine whether: (1) perceived barriers to care for children's psychosocial issues and maternal depression aggregate into the previously suggested patient, physician, and organizational domains16; (2) barrier domains are distinct for mothers and children; and (3) physician, patient, and practice/organizational characteristics are associated with different barrier domains for children and mothers.
The study population for this research consisted of the 50818 US nonretired members of the AAP. The AAP estimates that 80% of all board-certified pediatricians in the United States are academy members. The Periodic Survey (PS) has been conducted 3 to 4 times yearly since 1987 and is designed to provide information on current topics to inform policy, develop new initiatives, or evaluate current projects (AAP Web site). Using the AAP PS, academy researchers (Ms O’Connor) selected and mailed the survey to 1600 members beginning in March 2004 with a sixth and final mailing in August 2004. The questionnaire was 8 pages in length, contained largely closed-ended questions, had been pretested, and was approved by the AAP Institutional Review Board before the initial mailing.
Overall, 832 (52.0%) of the members responded with 745 (57.5%) of nontrainee members responding. Of the 745 respondents who were not trainees, 687 are involved in direct patient care. Overall, the sample reflects the AAP membership as described on the AAP Web site (www.aap.org). Bivariate comparisons of responders and nonresponders for all of the members surveyed show that women, fellows, and candidate fellows were significantly more likely to respond. To avoid potential bias created by differential nonresponse and to ensure that the respondents are representative of the population, poststratification sample weights were created by fitting multivariable logistic regression models to estimate the probability of response. Although the bivariate analyses indicated response bias by AAP member status, this was no longer a significant predictor of response after controlling for age and gender. The sample weights were created via a saturated logistic regression model with age group (≥40 vs <40), gender, and the 2-way interaction between age and gender as predictors of response. The sample weights were rescaled such that the mean is unity and the sum is equal to the analytic sample size (men <40 years of age: 1.28; men ≥40 years of age: 1.10; women <40 years of age: 0.93; and women ≥40 years of age: 0.87).
The respondents were asked a broad range of questions about sociodemographic and practice characteristics used in previous PSs. In addition, we asked questions on the prevalence and impact of child psychosocial problems and maternal depression, attitudes toward mental health issues, responsibility for identifying such problems, care activities with respect to mental health problems, and barriers to care activities for these problems. Questions about barriers and attitudes were modeled on the Williams et al16 and Olson and colleagues28,29 studies. Because physicians in the pretest affirmed no child-specific patient barriers (eg, family reluctance to acknowledge that their child may have a mental health problem), these questions were deleted from the questionnaire and, therefore, we could only test 5 of the 6 domains, namely, organizational issues for child psychosocial issues (eg, lack of time to treat child mental health problems) and maternal depression (eg, lack of time to identify maternal depression), physician issues for child psychosocial problems (eg, lack of training in identifying child mental health problems) and maternal depression (eg, unfamiliarity with criteria for identifying maternal depression), and patient issues, specifically mother-specific issues related to maternal depression (eg, fear of losing patients if maternal depression is addressed).
To assess attitudes, questions were adapted from an instrument developed by Park et al.31 The attitudes questions were a subset of those reported by McLennan et al.23 Finally, pediatricians were asked which of a range of strategies they currently use or would like to use to address maternal depression. These were adapted from work by Heneghan et al.32 The full instrument is available through the AAP Office of Research.
Twenty-five individual questions assessing barriers to care were asked on a 5-point Likert scale with the following response choices and scoring system: strongly disagree (1 point), disagree (2 points), neutral (3 points), agree (4 points), and strongly agree (5 points). A weighted exploratory factor analysis using casewise deletion was conducted to determine the extent to which the 14 maternal and 11 child barrier questions could be grouped into physician, patient, and organizational barriers. Principal axis factoring was used for factor extraction; promax, an oblique rotation that allows the factors to be correlated, was used to facilitate interpretation. Three methods were used to select the number of factors to retain: the scree test, Glorfeld's extension of Horn's parallel analysis, and Velicer's Minimum Average Partial Test.33,34 Items with a primary loading ≥0.40 and secondary cross-loadings <0.35 in the rotated pattern matrix were retained. Internal consistency reliability was assessed for each factor using Cronbach's α. Barrier scale scores were calculated by summing the individual items, provided that ≥80% of the questions for that barrier scale were completed using the person-mean substitution method for the 1% to 2% of respondents with 1 missing item.35 High scores on any barrier scale reflect greater barrier endorsement.
Means and proportions were used to summarize sample characteristics for continuous and categorical data, respectively. Between-group differences were assessed using 2 sample t tests and correlations for unweighted analyses, and weighted linear regression was used for weighted analyses. Unweighted and weighted linear regressions were used to assess the relationship among physician/practice characteristics, mental health activities, and beliefs, with each of the barrier outcomes using a stepwise procedure. Main effects models were fitted, and predictors were retained if statistically significant (P < .05). Based on the results of the main effects models, 2-way interactions of clinical relevance were evaluated. A step-down Bonferroni procedure was used to adjust for multiple comparisons.36 The results are summarized using adjusted least squares means for categorical variables and slopes for continuous variables, along with their SEs. Factor analyses were performed using SPSS 13.0 (SPSS Inc, Chicago, IL), and weighted analyses were performed using procedures appropriate for survey data in SAS 9.1.3 (SAS Institute, Inc, Cary, NC).37,38
Table 1 displays the weighted physician and practice characteristics for the 687 nontrainee respondents who provide direct patient care. Approximately half were women (52%), and most were ≥40 years of age (63%) and white (72%). The largest group of respondents (44%) practice in an urban setting, in multipediatrician group practices (36%), have ≥100 ambulatory visits weekly (50%), and indicate that their patients are assigned or select a specific pediatrician (70%).
Mental health activities are displayed in Table 2. The majority of physicians report that they provide mental health treatment to children (61%) and/or someone in their practice provides child mental health services (71%). Only 14% report that child mental health services are very available, and only 27% of physicians report fellowship training in child mental health. Many pediatricians report identifying a mother as depressed (74%), but few regularly use screening tools to identify mothers who are depressed (4.5%), and few indicate that they have ever treated a mother for depression (4.3%).
Table 3 shows the respondents' endorsements of barriers for children's psychosocial problems and mothers' depression. Pediatricians endorse most frequently lack of time to treat mental health problems (77%) and long waiting periods to see mental health providers (74%), with lack of training in treatment of these problems (65%), lack of confidence to treat mental health problems with counseling (62%), or medication (59%) and lack of providers to refer children with mental health problems (61%) also commonly endorsed. For maternal depression, pediatricians most often endorsed lack of training in treatment (74%) and lack of time to treat (64%) as important barriers. Concerns about liability (54%), unfamiliarity with screening instruments (60%), lack of time to identify (60%), inadequate time to contact community mental health providers (55%), and too few community mental health resources (54%) were also endorsed as important barriers.
Table 4 contains the results of the exploratory factor analyses of the barrier questions. Pediatricians' report of barriers clustered into physician and organizational domains. A 4-factor solution was identified with each factor containing either 5 or 6 items: factor 1: physician-child barriers; factor 2: organization-systems barriers (liability, Current Procedural Terminology [CPT] codes, and inadequate reimbursement for both children and mothers); factor 3: organization-local services barriers (too few community resources and long waiting periods, etc, for children and mothers); and factor 4: physician-mother barriers. Lack of time to treat maternal depression had the lowest primary loading (0.49 on factor 4: physician-mother barriers), and the highest secondary cross-loading was 0.33 (inadequate time for making contacts with provider cross-loads on the organizational-local services barriers). Two items with primary loadings <0.40 were excluded: fear of losing patients if maternal depression is addressed and lack of time to treat child/adolescent mental health problems.39 Internal consistency reliability was high, ranging from 0.81 to 0.87 (Table 4). The interfactor correlations are shown in Table 5. The correlation between the 2 organizational barriers was the largest (r = 0.51), and the physician-mother barriers scale was moderately correlated with the other 3 barrier scales (r values range from 0.33 to 0.41).
Weighted linear regression was used to examine the physician and practice characteristics associated with each barrier scale. Physician-child barriers (Table 6) are associated with physician-specific characteristics, such as lack of fellowship training in a psychosocial area, not having attended a lecture/conference on child mental health, and younger physician age, as are perceptions of unavailability of mental health services and not providing mental health services to children. Finally, physicians who are full-time in general pediatric practice and those whose patient populations are <75% white have higher physician-specific barrier scores for child psychosocial problems.
Correlates of endorsing organizational-systems barriers (Table 6) include type of practice. Physicians who practice in a medical school/parent university settings report significantly lower mean organizational-systems arriers scores compared with those in 1–2 physician practices (P = .0002), those in pediatric group practices (P = .0054), and those in multispecialty group practices (P = .0035). Physicians practicing in “other” settings (including health maintenance organizations, government, etc) report significantly lower mean organizational-systems barriers compared with physicians working alone or with 1 other physician (P = .0005). Physicians in practice for <5 years, physicians who use ≥2 methods to address maternal depression, and male physicians have lower organizational-systems barriers scores, whereas physicians who are very interested in further education in managing/treating child mental health problems have higher organizational-system barrier scores on average.
Correlates of endorsing organizational-local services barriers have some overlapping correlates with organizational-systems barriers; physicians who use ≥2 methods to address maternal depression have lower scores, whereas physicians who are very interested in further education in managing/treating child mental health problems have greater endorsement of this barrier. Physicians who use <2 methods to address maternal depression did not attend a lecture or conference on maternal depression in the past 2 years, practice in a suburban or rural setting, and see predominantly nonwhite patients reported greater endorsement of this barrier. Physicians who report that <80% of their patients have private insurance and physicians who do not know their patients' insurance show greater endorsement of organizational-local services barriers (P = .0011 and P = .0087, respectively). Interestingly, physicians who attended a lecture/conference on children's mental health in the past 2 years and physicians who are very interested in further education in managing/treating child mental health problems had greater endorsement of this barrier (Table 6).
For physician-mother barriers (Table 6), higher scores are associated with many of the same characteristics that are related to physician-child barriers, including lack of training in adult mental health issues, no continuing education in maternal depression, and lack of availability of mental health services. In addition, physicians who use <2 methods to address maternal depression, have some or no interest in further education in managing/treating maternal depression, and have ≥100 ambulatory visits per week had greater endorsement of this barrier.
The results generated from the AAP PS of Fellows point to the complexity of barriers contributing to the identification and treatment of children's psychosocial problems and mothers' depression as perceived by pediatricians involved in direct patient care. The barriers identified by pediatricians clustered into physician and organizational domains, but only physician-specific barriers were capable of being measured using separate scales for children and their mothers. Furthermore, different characteristics were related to each barrier area.
Pediatricians who believe that organizational issues involving broad systems issues, such as lack of reimbursement and liability, are barriers to the identification and treatment of both children's psychosocial issues and maternal depression are interested in further education in children's mental health issues, have few strategies to address maternal depression, work in solo or 2-physician groups, are more often women, and have been in practice ≥5 years. These factors suggest that those who are interested in treating children's psychosocial issues and, indeed, probably treat them given that they are not in large pediatric or multispecialty groups where there might be experts in developmental and behavioral problems, see these issues as barriers perhaps because they are consistently confronted by the lack of reimbursement for the mental health services that they deliver and are concerned about their liability.
Organizational barriers with respect to local services was likewise a barrier that was not capable of being measured separately for maternal depression and child psychosocial issues. Physicians who scored high on this barrier scale have a curious inconsistency. They use fewer methods to address maternal depression and report not having attended any educational offering on maternal depression, suggesting a lack of interest in maternal depression. Perhaps these individuals see local services as barriers because they believe depressed women should have services other than their child's pediatric services available. Conversely, pediatricians who report local services as a barrier are also more likely to have attended a conference on children's mental health, have more interest in this area, and are more likely themselves to provide mental health services for children. Why these physicians see local services as a problem seems clear: they treat mental health problems and are probably confronted frequently with constrained service options. It is also sensible that physicians whose patients may not have insurance see local services as a barrier because it is difficult to obtain mental health services without the ability to pay for such services.
Physician-specific barriers related to the identification and treatment of children's psychosocial issues are endorsed by pediatricians who are less likely to treat child mental health problems, have had no fellowship training in any child psychosocial area (eg, developmental/behavioral pediatrics, child psychiatry, etc) or continuing medical education in the area but who spend all of their time in general in pediatric practice, or are younger and perceive that mental health services are not readily available in their communities. This suggests that those pediatricians without specialized training but who care for general pediatric patients and are confronted with mental health problems on a daily basis identify physician issues as barriers. Furthermore, physicians who are younger and may not have the experience in treating these issues endorse physician-related barriers. This is particularly concerning given that younger physicians have had ≥4 weeks of developmental and behavioral pediatrics. This finding suggests that a single rotation in developmental and behavioral pediatrics may be insufficient to prepare pediatricians for the psychosocial issues that they are confronted with in general pediatric practice.
When we move to physician-specific barriers for maternal depression, we find that using fewer strategies to address maternal depression, lack of residency or fellowship training in adult mental health techniques or continuing education in the area, having less interest in further education on managing maternal depression, and perceiving low availability of adult mental health services are related to high barrier scores. Lack of training/interest in maternal depression coupled with likely exposure to depressed mothers given ≥100 ambulatory visits per week seem to be driving endorsement of the physician-mother barriers scale. Unfortunately, pediatricians who acknowledge that their own skills and confidence in diagnosing and managing maternal depression are lacking are the very physicians least interested in seeking education to improve their skills in this area.
These findings must be evaluated in light of their limitations. This survey, like others of physicians, has a suboptimal, although solid, response rate.40,41 Although a detailed analysis of response rates in AAP surveys shows little nonresponse bias,42 we weighted for nonresponse. Even with the weighting, it is unlikely that we corrected for all of the nonresponse bias. Furthermore, given that those pediatricians who are most interested in this topic are most likely to respond, the results must be viewed with this fact in mind.43 Given that the correlates of interest and the barriers were measured at the same time, these results represent associations and in no way imply causality. Finally, given the possibility of response biases for socially desirable behaviors, it may be that respondents overestimated some of the behaviors or actions listed on the survey.
Pediatricians report a wide range of barriers with respect to the diagnosis and treatment of children's mental health problems and maternal depression. Physician barriers are capable of being measured using separate scales for children and mothers, although organizational barriers seem to be measured as unified scales for mothers and children. Furthermore, these barrier domains are associated with different sociodemographic, practice-related, and physician-training factors. Interestingly, perception of local services as barriers seems to be driven by very different attitudes toward maternal depression and child psychosocial problems. Our findings suggest that pediatricians with the least interest in treating maternal depression rate local services barriers as high, whereas those physicians who may be most interested in and attentive to child psychosocial issues are more likely to report local services barriers as high. This may be attributable, in part, to the way pediatricians perceive their responsibilities toward children versus their responsibilities toward mothers. This curious dichotomy bears further investigation. The specificity of factors relating to various barrier areas suggests that overcoming barriers to the identification and treatment of child mental health problems and maternal depression in primary care pediatrics is likely to require separate multifaceted approaches that span organizational, physician, and patient problems. In addition, comprehensive interventions will likely require social marketing approaches designed to engage and educate diverse audiences of clinicians and their patients.
This study was supported by the AAP. This research was funded by the Anne E. Casey Foundation.
- Accepted July 11, 2006.
- Address correspondence to Sarah McCue Horwitz, Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Room W-G 72, 10900 Euclid Ave, Cleveland, Ohio 44106-4945. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
The findings and conclusions presented in this article are those of the authors alone and do not necessarily reflect the opinions of the Anne E. Casey Foundation.
An earlier version of the results was presented at the annual meeting of the Pediatric Academic Societies, May 14–17, 2005; Washington, DC.
Drs Horwitz, Kelleher, Hoagwood, and Stein and Ms O'Connor created the study concept and design; Ms O'Connor acquired the data; Dr Horwitz, Ms Storfer-Isser, and Dr Youngstrom conducted analysis and interpretation of data; Dr Horwitz drafted the article; Drs Horwitz, Kelleher, Stein, Park, Heneghan, Jensen, and Hoagwood, Ms Storfer-Isser, and Ms O'Connor made critical revision of the article for important intellectual content; Ms Storfer-Isser and Dr Youngstrom provided statistical expertise; Drs Hoagwood, Horwitz, and Kelleher obtained funding; and Drs Horwitz, Hoagwood, and Kelleher supervised the project.
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