In 2004, the American Academy of Pediatrics (AAP) Board of Directors appointed the Task Force on Mental Health, charging it to assist pediatricians and other primary care clinicians* in enhancing the mental† health care that they provide to children and adolescents.
The board's directive stemmed from its recognition that (1) pediatric primary care clinicians will play an increasingly important role in promoting the social-emotional health of children and providing treatment—or serving as an entry point to specialty treatment—for children and adolescents who have mental health and substance abuse problems and (2) the growth in this role will involve transformational changes in pediatric primary care practice, requiring new knowledge and skills, payment structures, collaborative relationships, office systems, and resources.
The Growing Role of Pediatric Primary Care Clinicians in Mental Health Care
A compelling body of evidence demonstrates the enduring effects of early social and emotional experiences on the brain architecture and development of infants and young children. The evidence demonstrates the effects of these experiences, in turn, on behavior, biological stress reactivity, psychological resilience, and immunologic resistance throughout life.1,–,3 Pediatric primary care clinicians have unique access to the families of young children before and after the birth of a child and, thus, are uniquely situated to foster effective nurturing by their caregivers and positive early experiences for the child. Bright Futures provides a framework for the integration of social-emotional care within the context of routine pediatric health supervision.4 In addition to providing their own guidance, primary care clinicians play an important role in advocating for and linking families to parenting resources and to high-quality child care, preschool, and school programs, all of which may positively influence the social-emotional health of children.5,–,8
Primary care clinicians also encounter many families with concerns about their children's mental health and many children with mental health problems.
In the United States between 9.5% and 14.2% of children from birth to 5 years of age experience social-emotional problems that cause suffering to the child and family and interfere with functioning.9,10
An estimated 21% of children and adolescents in the United States meet diagnostic criteria for a mental health disorder and have evidence of at least minimal impairment11; approximately half of these children have significant functional impairment (severe emotional disturbance).12
An estimated 16.1% of children and adolescents in the United States do not meet criteria for a disorder but have some impairment13 (“problems” in the terminology of the Diagnostic and Statistical Manual for Primary Care [DSM-PC]14).
Fully half of the adults in the United States with a mental health disorder had symptoms by the age of 14 years.15
Within primary care settings in the United States an estimated 13% of school-aged children and 10% of preschool-aged children have parents who present with “concerns” about their children, although their children are functioning reasonably well.16,17
Unidentified mental health conditions such as anxiety and depression, particularly in children with chronic medical conditions, are a significant force that drives utilization of medical services.18
Yet, few of the children who need mental health and substance abuse services receive them—only ∼20% do12,19—despite the fact that many psychosocial and some pharmacologic treatments have been found to be safe and effective for children.20,–,23 Reasons that so few receive needed services include the shortage and inaccessibility of parenting programs and social-emotional interventions for families of children younger than 5 years1,–,3,5,6,9,10,24,–,28; the shortage of specialty mental health services,29 especially in rural areas and for children from low-income families who do not fall within the target population for public/community mental health services; the shortage of school-based mental health programs and services, despite evidence of the effectiveness of many of these programs30,–,32; and the shortage or lack of awareness of emergency mental health services for children and adolescents in crisis, which causes these patients to rely on overcrowded emergency departments for care.33,34 Minority populations suffer disproportionately from lack of access to mental health services.35 Unmet childhood social-emotional, mental health, and substance abuse needs contribute to poor educational, social, and economic outcomes.36,–,38
As a consequence of these unmet needs, the mental health community, which is increasingly focusing its limited resources on the most severely impaired individuals, and families of children with mental health needs are looking to primary care clinicians as a source of mental health care and a gateway to mental health care. The opportunity—and urgency—for primary care clinicians to fulfill these roles was articulated in the President's New Freedom Commission report,39Mental Health: A Report of the Surgeon General,12 and the Future of Pediatric Education II40 study. In multiple resolutions to the AAP Annual Leadership Forum, AAP members expressed their need for assistance in fulfilling these roles.
The Transformation of Primary Care Practice
The forces described above will transform pediatric primary care practice. The Task Force on the Vision of Pediatrics 2020 estimates that by the year 2020, mental health care will constitute a significant part of general pediatric practice. Primary care clinicians’ role in mental health care will differ substantively from that of mental health specialists, many of whom may be unfamiliar with problems as they present in primary care. Children and families who seek care from a mental health specialist do so because they have recognized a mental health need or because some crisis has compelled them. Children and families seeking care at primary care offices often have not framed the visit as related to “mental health.” They may be seeking routine health supervision, acute care for a physical complaint, help with a challenging behavior, or simply reassurance. Ideally, primary care clinicians would elicit psychosocial and mental health concerns from children and families in each of these situations. They would find ways to support and help families that are resistant to seeking psychosocial intervention or mental health care and to recognize those emergent situations that compel an immediate intervention. If and when a family is ready to address a problem, primary care clinicians may choose to assess and manage the child themselves—in roles similar to those of mental health specialists—or they may choose to guide the family toward appropriate referral sources. Whether providing mental health services alone or collaboratively, primary care clinicians would ideally monitor the child and family's functioning and progress in care, applying chronic care principles as they do to other children and youth with special health care needs. Primary care clinicians would ideally be able to provide these mental health services within the constraints of a busy practice without compromising the efficiency and financial viability of the practice.
Unique Strengths of Primary Care Clinicians
The AAP recognizes the unique strengths of primary care clinicians and the opportunities inherent in the pediatric primary care setting (“the primary care advantage”41):
a longitudinal, trusting, and empowering therapeutic relationship with children and family members;
unique opportunities to prevent future mental health problems through promoting healthy lifestyles, reinforcing strengths in the child and family, recognizing adverse childhood experiences and stressors associated with social-emotional problems, offering anticipatory guidance, and providing timely intervention for common behavioral, emotional, and social problems encountered in the typical course of infancy, childhood, and adolescence (as described in Bright Futures)4,50,51;
an understanding of common social, emotional, and educational problems in the context of a child's development and environment4;
experience working with specialists in the care of children with special health care needs and serving as coordinator and care manager through the medical home; and
familiarity with chronic care principles and practice-improvement methods.
Barriers to Primary Care Change
Primary care clinicians experience many barriers to providing mental health services, including discomfort with their knowledge and skills, time constraints, poor payment, limited access to mental health consultation and referral resources, and administrative barriers in insurance plans.52,53
WORK OF THE TASK FORCE ON MENTAL HEALTH
The task force set 3 goals toward its purpose of assisting primary care clinicians in enhancing their provision of mental health care.
Goal 1: Facilitate System Changes
Improving children's mental health requires primary care clinicians and their respective professional organizations to adopt a population perspective, to work collaboratively with other stakeholders, and to understand and participate in changing system characteristics such as financing, availability of mental health specialty care, communication mechanisms, and stigma.
Recognizing that financing is a central issue in improving mental health care, the task force worked with committees and staff within the AAP to incorporate mental health issues into an advocacy agenda that targets federal government policy makers, major private insurers, and major insurance purchasers. The AAP played an active role in influencing the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. This law requires parity of mental health and physical health benefits in group health plans that provide mental health or substance abuse benefits and insure 50 or more employees, regardless of whether the plans are self-funded (regulated under the Employee Retirement Income Security Act) or fully insured (regulated under state law). Together with a number of partner organizations, the AAP also addressed problems such as policies that prevent primary care clinicians, developmental-behavioral pediatricians, and adolescent specialists from serving as mental health providers in insurance plans; absent or insufficient payment to primary care clinicians for mental health screening and assessment, treatment of children with emerging problems or impairing mental health problems that do not rise to the level of a diagnosis, and, in many plans, even for treatment of children with mental health diagnoses; lack of payment to primary care clinicians (and other mental health providers) for time spent with parents or teachers and for the many non–face-to-face aspects of mental health care and consultation; lack of pediatric expertise among mental health providers in insurance plans; and the absence of policies that require communication from mental health providers to primary care clinicians about children in their mutual care. The task force worked with colleagues from the American Academy of Child and Adolescent Psychiatry to develop an article that was published in Pediatrics in April 2009.53 It provided recommendations to insurance purchasers, payers, and managed behavioral health organizations and addressed a set of key impediments that primary care and specialty clinicians encounter when providing mental health services to children and adolescents. This article was disseminated to public and private health plan carriers and employer groups. The AAP also continues to advocate to payers for coverage and appropriate payment for developmental screening as recommended in Bright Futures.
To facilitate chapter- and state-level efforts to effect systemic changes, the task force disseminated the Strategies for System Change in Children's Mental Health: A Chapter Action Kit54 (also available at www.aap.org/mentalhealth) to AAP chapter leaders in September 2007.
In the first article of this supplement,55 the task force proposes strategies that primary care clinicians can use with their partners at the community level, collectively, to foster resilience in children, to address factors that increase children's risk of developing mental health problems, to enhance or expand services, and to facilitate systemic changes that foster collaboration between primary care clinicians and others who are important to children's mental health and care.
Goal 2: Build Skills
Enhancing mental health practice in primary care settings will depend on primary care clinicians’ and their staff's acquiring not the same skill set of mental health professionals but, rather, complementary skills, built on primary care clinicians’ unique strengths, role, opportunities, and setting. To coordinate efforts toward this goal, the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to identify the competencies requisite to providing mental health services in the primary care setting. A policy statement that outlines the recommended competencies was published in Pediatrics in July 2009.56 By highlighting these mental health competencies, the task force hopes, over the long-term, to provide educational goals for residency training and recertification; in the near term, the task force has developed a number of educational programs keyed to the competencies (eg, educational sessions for the AAP National Conference and Exhibition and a PediaLink module).
Goal 3: Incrementally Change Practice
The task force envisions that primary care clinicians, by achieving changes in community systems and acquiring (or honing) skills, will gain the capacity to make practice enhancements necessary for effective mental health care. These enhancements are described in the second article of this supplement.57 They involve, first and foremost, the application of “medical home” or chronic care principles to the care of children with identified psychosocial problems and mental health disorders, as they would to the care of children with other special health care needs such as asthma or diabetes. Mechanisms include support for self-management and family management; registries of children with mental health conditions; office protocols to guide decision-making, care, and monitoring of these children; and effective, appropriate use of validated functional assessment and mental health screening tools.
With practice enhancements in place, primary care clinicians can implement a process for mental health care that builds on their unique opportunities to assist families in building strength and resilience in their children; to recognize psychosocial stressors and emerging social-emotional and mental health problems; to provide mental health services in the medical home; to serve as an entry point for youth and families seeking, or in need of, parent training, social-emotional support, early intervention services, or specialty care; and to coordinate care for those children with chronic mental health conditions, as they would for other children with special health care needs. This process, represented in algorithms annotated with the procedure codes applicable to each step, is the subject of the final article in this supplement.58
In addition to its publications, the task force maintains a Web site at www.aap.org/mentalhealth. Through this site, readers will find descriptions of innovative primary care practices that incorporate mental health services, educational and funding opportunities relevant to mental health, up-to-date clinical guidance for the primary care practice of common mental health and substance abuse conditions, information about the clinical toolkit created to complement the task force publications, and other resources.
The task force acknowledges with gratitude the involvement of a number of other organizations in developing and disseminating its products: American Academy of Child and Adolescent Psychiatry, American Psychological Association, Centers for Disease Control and Prevention, Child Neurology Society, Health Resources and Services Administration's Maternal and Child Health Bureau, National Alliance on Mental Illness, National Association of Pediatric Nurse Practitioners, National Association of Social Workers, National Medical Association, Society for Adolescent Medicine, Society for Developmental-Behavioral Pediatrics, and Substance Abuse and Mental Health Services Administration.
The 2005–2009 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, Penelope K. Knapp, MD, Danielle Laraque, MD, 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.
- Accepted March 24, 2010.
- Address correspondence to Joy Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail:
* 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.
† 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.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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