enhancing pediatric mental health care: strategies …...or severity of all mental health problems...

Enhancing Pediatric Mental Health Care: Strategiesfor Preparing a Community

Pediatricians and other primary care clinicians* caring for children tradi-tionally have focused their attention on meeting the health care needs ofindividual children they see in their offices and clinics. However, effectivecare of the growing number of children and familieswho are experiencingchronic medical and mental disorders will also require a “population”healthperspective.Manypolicy statements fromtheAmericanAcademyofPediatrics (AAP)havepointed to the importanceof thepopulationperspec-tive in providing and improving pediatric health services.1–10 From thisperspective, all members of a community are affected by the health of itsindividual members. For children, mental health resides not solely withinthe child but within the web of interactions that connect the child, thefamily and school, health and other child service systems, and the neigh-borhood and community in which the child lives.11 This is not to denythat biology is a determinant of mental health and mental illness;rather, biological factors interact with the psychosocial environ-ment to result in mental health, mental illness, and recovery frommental illness.

Primary care clinicians who are interested in enhancing mental†health services in their community will need to form partnerships. Keypartners for a community mental health advocacy effort include otherprimary care clinicians, developmental-behavioral pediatricians, ado-lescent health specialists, the local public mental health agency, rep-resentatives of themental health care provider community (eg, psychi-atrists, psychologists, social workers, substance abuse counselors,psychiatric nurse practitioners), community mental health activ-ists including parents and youth, school system representatives,early childhood educators, Early-Intervention (EI) system represen-tatives, representatives of the child protective and juvenile justicesystems, and the local department of public health.

*Throughout this document, the term “primary care clinicians” is intended to encompasspediatricians, family physicians, nurse practitioners, and physician assistants who provideprimary care to infants, children, and adolescents.†Throughout this statement, the term “mental” is intended to encompass “behavioral,” “neu-rodevelopmental,” “psychiatric,” “psychological,” “social-emotional,” and “substance abuse,”as well as adjustment to stressors such as child abuse and neglect, foster care, separationor divorce of parents, domestic violence, parental or family mental health issues, naturaldisasters, school crises, military deployment of children’s loved ones, and the grief and lossaccompanying any of these issues or the illness or death of family members. It also encom-passes somatic manifestations of mental health issues, such as fatigue, headaches, eatingdisorders, and functional gastrointestinal symptoms. This is not to suggest that the full rangeor severity of all mental health problems is primarily managed by pediatric primary careclinicians but, rather, that children and adolescents may suffer from the full range andseverity of mental health conditions and psychosocial stressors. As such, children withmental health needs, just as children with special physical and developmental needs, arechildren for whom pediatricians, family physicians, nurse practitioners, and physician assis-tants provide a medical home.

AUTHORS: Jane Meschan Foy, MDa and James Perrin,MDb, for the American Academy of Pediatrics Task Forceon Mental HealthaDepartment of Pediatrics, Wake Forest University School ofMedicine, Winston-Salem, North Carolina; bCenter for Child andAdolescent Health Policy, Division of General Pediatrics,MassGeneral Hospital for Children, Boston, Massachusetts

ABBREVIATIONSAAP—American Academy of PediatricsEI—early interventionNAMI—National Alliance on Mental IllnessFFCMH—Federation of Families for Children’s Mental HealthSOC—system of care

www.pediatrics.org/cgi/doi/10.1542/peds.2010-0788D

doi:10.1542/peds.2010-0788D

Accepted for publication Mar 24, 2010

Address correspondence to Jane Meschan Foy, MD, Departmentof 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 haveno financial relationships relevant to this article to disclose.

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Primary care clinicians cannot feasiblypursue the strategies that follow in theabsence of such partnerships. In everyregion of the United States, there is apublic agency formally charged withmanaging and/or providing mentalhealth services; this same agency maybe charged with managing and/or pro-vidingEI services, oranotheragencymaybe charged with this responsibility.Some state public mental health agen-cies (eg, California, North Carolina) se-lectively serve only individuals with se-verely impairing conditions (severeemotional disorders). Whatever theirtarget population, these agencies typi-cally organize advisory groups of familymembers who have been affected bythese disabilities (“consumers” or “cli-ents” in the vocabulary of the mentalhealth specialty system) and providersof EI, mental health, and/or substanceabuse services. These groups often omitprimary care clinicians from their mem-bership but usually welcome primarycare clinician involvement if it is offered.Consumer and advocacy groups such asthe National Alliance on Mental Illness(NAMI), the Federation of Families forChildren’s Mental Health (FFCMH), andthe local Mental Health Association alsowelcome primary care clinicians’ inter-est and involvement in their activities. In-creasingly, the public health communityhas come to viewmental health asapub-lic health issue, mirroring the clinicalmovement toward “reconnecting” themind and the body. The Association ofMaternal and Child Health Programs, infact, devoted its 2004 national confer-ence to reframing mental health as apublic health issue.

Effective communication among pri-mary care clinicians, mental healthspecialists‡, educators, and agencyrepresentatives depends on develop-ing an understanding of the differentcultures in which they function. For ex-ample, primary care clinicians may

come to a community meeting thinkingthat their mental health responsibili-ties are prevention, early identificationof mental health problems, and care ofchildren who are mildly impaired withmental health disorders—perhapsonly thosewith specific disorders suchas attention-deficit/hyperactivity dis-order. Representatives of a chronicallyunderfunded public mental health sys-tem may be focused primarily on chil-dren who are severely impaired withmental health conditions; they mayhave been able to give little attention toprevention or early identification andto provision of consultative services toprimary care clinicians for their lessseverely impaired patients. School sys-tem representatives may be focusedprimarily on behavioral problems thatinterfere with their students’ schoolattendance, classroom behavior, andacademic success; representatives ofsocial service agencies may be fo-cused on the needs of children in fos-ter care; and representatives of the ju-venile justice system may be focusedon the unmet mental health needs ofadjudicated youth. Each group wantsto engage the other’s time and re-sources for its priority activities. Ide-ally, the process of coming togetheropens primary care clinicians, families,and their communitypartners tonewop-portunities for mutual support and newsolutions to common problems.

Moreover, the vocabulary of the men-tal health specialty system differs sig-nificantly from that of primary care cli-nicians. For example, the acronym“PCP” in primary care terminologymeans a primary care physician, but“PCP” in mental health terminologymay mean a person-centered plan.Likewise, the term “screening” mayhave different meanings in the 2 sys-tems. A glossary of mental healthterms and select mental heath re-sources, Supplemental Appendix S9may

be helpful to primary care clinicians incrossing this divide.*

STRATEGY 1: APPLY A“POPULATION” PERSPECTIVE TOGAIN UNDERSTANDING OF THEMENTAL HEALTH NEEDS OFCHILDREN AND YOUTH IN THECOMMUNITY

Many studies have identified factorsthat place children at risk for mentalhealth problems later in life.12–14 Thereare also well-documented protectivefactors that reduce risks (Fig 1).11

Other protective factors include goodnutrition, physical activity, and sleep.

As indicated by the horizontal arrowsin Fig 1, the community, family, andchild all contribute to creating theschool environment, which can be apotent factor in fostering resilience inits students.

To identify needs and track progress to-ward community goals, primary care cli-nicians and their partners can examinemeasures of child well-being in theircommunity (eg, child abuse and neglectreports, EI referrals, kindergartenscreening results, adolescent suicideand homicide rates, high school dropoutand graduation rates, suspension andexpulsion rates, and substance abuseand teen pregnancy rates). An additionalsource for statistics is the Youth Risk Be-havior Surveillance System.15 Analysis ofdata according to school or neighbor-hood may yield additional insights andlead to specific interventions tailored toa particular school or area in thecommunity.

Primary care clinicians and their part-ners can look at the needs of specialpopulations known to be at higher riskfor mental health problems (eg, chil-dren affected by a disaster,16 childrenwith parents deployed in military ser-vice,17 children with developmentaldisabilities,18,19 children who experi-ence academic difficulties,20 and/orchildren in foster care).21 They can also‡See definition, Appendix S9.

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review utilization of local or regionalemergency facilities, mental healthoutpatient and inpatient services,nonprofit and private-sector pro-grams, and the school system’s ex-ceptional children’s or special edu-cational services. Findings canassist in developing priorities forschool-based initiatives and for ei-ther targeted or community-wide ef-forts to enhance protective factors(see Fig 1) or improve access toneeded services.

There are pervasive racial and ethnicdisparities in children’s health and ed-ucational outcomes and in their ac-cess to effective mental health ser-vices. These disparities call forattention to accessibility and culturalappropriateness of all the mentalhealth systems that touch children andfamilies.22 Attention should also be di-rected to issues such as racism, xeno-phobia, sexism, and homophobia,which may disproportionately affect

the mental health of certain groupswithin the community by contributingto their stress, isolation, and socioeco-nomic disadvantage.

Just as the public health perspectiveenlightens a discussion of mentalhealth, the mental health perspectivecan enlighten discussions of issuestraditionally in the domain of publichealth (eg, physical inactivity, poordiet, environmental toxins [eg, lead,mercury], neighborhood violence, un-intended pregnancy, and injuries).Each of these issues has mental healthcauses and/or effects; and each hasimplications for the mental, as well asphysical, health of children in the com-munity. Partnership across disciplinescan result in fresh approaches.

STRATEGY 2: INVENTORY THECOMMUNITY’S MENTAL HEALTHRESOURCES

Primary care clinicians cite lack of re-ferral sources as a major barrier to

their identifying and meeting the men-tal health needs of children and theirfamilies.23 In some cases, primary careclinicians are unaware of existing EIand mental health specialty resourcesin their community. Ideally, the com-munity would have a directory of men-tal health and substance abuse ser-vices available. The local communitymental health agency, emergency de-partment, EI provider, community re-source line (accessed in some commu-nities by dialing 211 or 311), family andconsumer advocacy groups (such asthe NAMI, Mental Health America, theFFCMH, Children and Adults With Atten-tion Deficit/Hyperactivity Disorder[CHADD]), or health department mayhave directories that can provide astarting point. A community can seekfunding for this process from non-profit or governmental sources; fre-quently, the public mental healthagency will fund and staff its continua-tion. Distribution of a paper version of

FIGURE 1Protective, or buffering, factors that promote resilience. The underlined factors apply especially to young children; italicized factors apply especially toadolescents. (Adapted from Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Promotion and Prevention inMental Health: Strengthening Parenting and Enhancing Child Resilience. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2007.DHHS publication No. CMHS-SVP-0175. Available at: http://download.ncadi.samhsa.gov/ken/pdf/SVP-0186.pdf.) Sources: Masten AS, Coatsworth JD. AmPsychol. 1998;53(2):205–220; Hawkins JD. Promoting successful youth development. Paper presented at: White House Conference on Helping America’sYouth; October 27, 2005; Washington, DC; andMrazek PJ, Haggerty RJ, eds. Reducing Risks for Mental Health Disorders: Frontiers for Prevention InterventionResearch. Washington, DC: National Academy Press; 1994.

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the directory as a first step may serveto publicize it and guide primary careclinicians toward a Web site.24 Forguidance in developing a directory, seeStrategies for System Change in Chil-dren’s Mental Health: A Chapter ActionKit.25

STRATEGY 3: DEVELOP ORSTRENGTHEN RELATIONSHIPS WITHMENTAL HEALTH ADVOCATES,SCHOOLS, HUMAN SERVICEAGENCIES, MENTAL HEALTH ANDSUBSTANCE ABUSE PROVIDERS,AND DEVELOPMENTAL SPECIALISTSBY COLLABORATING ON SYSTEM-FOCUSED INITIATIVES SUCH ASWORKING TO FILL GAPS IN NEEDEDSERVICES AND CARE-COORDINATION MECHANISMS

After identifying community mentalhealth and substance abuse profes-sionals and other mental health–related resources, primary careclinicians can form or join a multidis-ciplinary community group to addresssystemic issues such as gaps inneeded services (including preventiveprograms), management of psychiat-ric emergencies (see Strategy 4), ex-change of information between pri-mary care clinicians andmental healthprofessionals, and access to mentalhealth/substance abuse services forthe uninsured. Professionals who pro-vide mental health services may func-tion in separate “silos” from thosewhoprovide developmental-disabilitiesservices; efforts to combine and coor-dinate their efforts may be fruitful.

Enhancing communication among dis-ciplines is an important priority. Al-though relationships between primarycare clinicians and medical subspe-cialists typically are built throughthe care of mutual patients, privacyconcerns and perceived confidentialitybarriers keep many mental health/substance abuse professionals fromcommunicating with primary care cli-

nicians. In fact, the Health InsurancePortability and Accountability Act(HIPAA) allows health care providerswho are involved in the treatment ofmutual patients to exchange informa-tion, excepting psychotherapy notesand information about substance use/abuse, even without the consent of pa-tients.26 Dialogue with local mentalhealth agencies, emergency depart-ments, and others who provide mentalhealth and substance abuse servicescan raise awareness about the impor-tance of communication with primarycare clinicians. Ideally, routine intakeprocedures of emergency depart-ments andmental health specialty pro-viders would prompt mental healthprofessionals to seek families’ consentfor exchange of information with pri-mary care clinicians, and routine pro-cedures in primary care clinicians’offices would prompt staff to seek in-formation about other sources ofhealth care and request consent forexchange of information. Such routineprocedures can become a goal ofcommunity-level problem-solving.

Service gaps will often dominate dis-cussions among child mental healthadvocates. For children and adoles-cents, mental health specialty re-sources of all types are insufficient vir-tually everywhere.27 Infants and youngchildren often are not even within the“target” population for public mentalhealth program funding. There is aneed for Medicaid and other insurersto incorporate the DC 0-3R (DiagnosticClassification of Mental Health and De-velopmental Disorders of Infancy andEarly Childhood),28 which recognizesthat some diagnoses may be transientin this age group and that childrenwith significant problems may not fitDiagnostic and Statistical Manual ofMental Disorders, Text Revision (DSM-IV-TR)29 criteria. There is also a needfor public and private insurers to rec-ognize that children and adolescents

suffer impairment from mental healthsymptoms thatmay not rise to the levelof a disorder. The classification systemoutlined in the Diagnostic and Statisti-cal Manual for Primary Care (DSM-PC)30 reflects the full spectrum of be-havioral issues that require the timelyattention of primary care clinicians.Professional associations of primarycare clinicians can partner with men-tal health specialty organizations andfamily and consumer advocacy groupsto advocate for mental health and sub-stance abuse services needed by chil-dren of all ages and public funding ofmental health programs generally.

A list of key mental health and sub-stance abuse services for childrenis included as Appendix S1. Efforts tofill gaps or expand capacity shouldbuild on available evidence about ef-fective programs and services. TheSubstance Abuse and Mental HealthServices Administration (SAMHSA) Na-tional Registry of Evidence-BasedPrograms and Practices31 is an excel-lent resource for primary care clini-cians to use in partnership with localhuman service agencies, school sys-tems, and nonprofit organizations todevelop strategies that address com-munity needs12; this registry providesa database of current interventionsfor the prevention and treatment ofmental and substance use disorders.Attached as Appendix S2 is a tablewhich summarizes evidence-basedchild and adolescent psychosocial in-terventions32; this resource for pri-mary care clinicians is updated bien-nially. Essential services include thoseinterventions that meet criteria forbest support (levels 1 and 2 in the tableof psychosocial interventions).

Care-coordination mechanisms arecritically important to child and familywell-being. Perrin et al defined a sys-tem of services for children and youthwith special health care needs, includ-ing those with mental health prob-




lems, as “a family-centered network ofcommunity-based services designedto promote the healthy developmentand well-being of these children andtheir families”33 (see Fig 2).

Roberts et al34 delineated 6 centralcharacteristics of such a system: (1)responsive to family challenges, prior-ities, and strengths; (2) developed inpartnership with constituents; (3) re-flective and respectful of the culturalnorms and practices of the participat-ing families; (4) accessible to every-one; (5) affordable to those who needassistance; and (6) organized and co-ordinated through collaboration sothat resources are equitably distrib-uted in an efficient and effective man-ner. To these characteristics Perrin etal added that such a system recog-nizes and addresses the specific devel-opmental needs of infants, children,and adolescents and their importantdevelopmental transitions and is orga-nized to promote the cost-effectiveprovision of services.33 In the mentalhealth specialty world, such a systemis called a system of care (SOC). Stud-

ies have revealed that involvement in aSOC improves coordination of care andeducational outcomes for children andyouth with mental illness and otherpsychosocial challenges.35 In commu-nities where such a system is underdevelopment, primary care clinicianscan be valuable partners in its design.A primary care clinician’s involvementin an individual child’s SOC planning isan invaluable opportunity for buildingprofessional relationships while en-hancing the child’s care.

The Early Childhood ComprehensiveServices (ECCS) initiative, funded bythe Maternal and Child Health Bu-reau (MCHB) to implement the MCHBstrategic plan for early childhoodhealth, has allowed 49 states to de-velop plans for building a compre-hensive system of health care foryoung children. The ECCS Web site36

provides resource information ongovernance; community-level sys-tems building, finance, indicators,and outcomes; and plans for improv-ing developmental services.

Primary care clinicians can success-fully partner with others all along thecontinuum of prevention, early inter-vention, treatment, and coordinationservices, as discussed below.

School-Based Services

It is important to include schools in acommunitymental health SOC. Schoolsare the largest de facto provider ofmental health services,37 and school-based mental health personnel (guid-ance counselors, social workers,psychologists) typically function inparallel with themental health system.Although their focus is often on atten-dance, testing, and, in high schools,course selection and college prepara-tion, these school-based mental healthprofessionals may play an importantrole in children’s comprehensivemental health care, especially whenthey have an effective connection withcommunity mental health systems.School social workers are more likelythan other school personnel to pro-vide direct mental health services andcommunity referrals for children andfamilies; however, many school socialworkers have unreasonably high caseloads and sometimes travel to mul-tiple schools. School-based healthcenters in many areas of the countryprovide students with enhanced ac-cess to an array of health servicesincludingmental health and substanceabuse care; such programs are espe-cially effective when linked to a stu-dent’s primary care medical homeand to the SOC in the community. Advo-cacy for enhanced school-based men-tal health services requires partner-ship with the local school boardand/or school health advisory council,as well as mental health specialtypartners, other community health andservices agencies, youth, parents, andteachers.

Schools may also play an importantrole in prevention of mental health

FIGURE 2Family-centered community-based system of services for children and youth with special needs.33

(p934) CYSHCN indicates children and youth with special health care needs.

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problems. As an example, with theGood Behavior Game, a 1-year inter-vention for elementary school class-rooms, participants have manifestedreduced aggressive and disruptive be-haviors during the first grade and,over the long-term, reduced risk of al-cohol and drug abuse and suicideattempts.38 Information regardingevidence-based interventions is inref. 39.

Preventive Services

A growing body of evidence has shownthat there is a window of opportunityfor prevention of mental health disor-ders that will otherwise emerge laterin adolescence or adulthood. A num-ber of interventions have been showneffective in at-risk groups (eg, theClarke Cognitive-Behavioral Preven-tion Intervention for adolescents atrisk of depression).38 Community part-ners can collaborate to identify chil-dren at risk and implement programsthat match needs with resources.

Recent scientific developments to-ward understanding the brain devel-opment of infants and young childrenhave highlighted the critical influenceof parenting, attachment, and earlychildhood education on the emotional,social, and cognitive development ofyoung children40,41 and the role of at-tachment disturbances in many childand adult disorders.41–44 Many com-munities have responded to this newscience by offering such services asnurse visits to pregnant and parent-ing women at high risk, parentingprograms, child care consultation,and therapeutic child care settings.Appendix S7 provides resources to as-sist in determining which programsthat target young children are mostpromising. Ideally, communities wouldalso have resources to help parentsand teachers dealing with depression,substance abuse, mental illness, orother challenges that affect the quality

or continuity of their relationshipswith young children.45

EI Services

In the United States, EI services targetchildren, from birth to 36 months ofage, with delayed development or acondition associated with develop-mental delay. The EI program, Part C ofthe Individuals With Disabilities Educa-tion Act (IDEA), is federally mandatedto include such services as special in-struction and, usually, interventionssuch as speech/language, occupa-tional and physical therapy; nutrition;and audiologic and psychological ser-vices.46 In some states, it also providesintervention services to children atrisk for poor developmental out-comes.46 Its funding, resources, andprocedures vary from state to stateand, at times, from community to com-munity47; however, it serves as a door-way to early identification of develop-mental disabilities and to a variety ofservices for infants and toddlers andtheir families.

A key variation from state to state isthe agency responsible for EI pro-grams; it may be the public health sys-tem, the public school system, themental health system, or some com-bination of these systems. When EI isa public school responsibility, it oftenincludes limited or no medical in-volvement. Eligibility also varies; somestates offer services to children atrisk for developmental problems, aswell as those with identified prob-lems, but others are more restrictive.States and communities also vary inthe expertise and availability of EI pro-viders. If the EI program does not offermedical services, such as consultationby developmental-behavioral pediatri-cians or child psychiatrists with ex-pertise in infant mental health, pri-mary care clinicians will need otherreferral sourceswith special expertisein this age group. For families in which

maternal depression and attachmentare concerns, it is important to identifysources of treatment for the mother-infant dyad as well as for the motherherself.

Child Psychiatry Services

Although many communities do nothave child psychiatrists, several re-gions of the country have used creativestrategies to gain access to child psy-chiatry consultation for primary careclinicians. In Massachusetts, a state-wide psychiatry telephone consulta-tion service was established to assistprimary care clinicians in assessingand managing the mental health prob-lems of children and adolescents. Re-sults of an initial evaluation of this pro-gram suggested high rates of use andsatisfaction among participating pri-mary care clinicians.48 Several statesare using telepsychiatry clinics to pro-vide access to consultation for chil-dren remote from child psychiatrists.The AAP’s mental health Web site49 pro-vides examples of consultation mod-els. In many rural areas, consultationis provided by general psychiatristswhose training in child psychiatry maybe limited; in such areas, educationalprograms to enhance the psychia-trists’ pediatric skills and their accessto child psychiatrists for consultationmay be useful adjuncts.

Recreational Resources andVolunteer Service

Children also benefit from resourcesto enhance their social experiencesand promote physical activity. Boys’and girls’ clubs, summer camps andenrichment programs, and sports andrecreational activities may providechildren and adolescents with struc-ture and opportunities to develop so-cial skills and confidence. Volunteerservice activities have been shown tobe beneficial to young people’s socialand emotional development.50 Involve-



ment in extracurricular school activi-ties and/or youth religious organiza-tions has a protective effect on adoles-cent mental health.50,51 Although thechildren at highest risk in a communitymay not currently be involved in theseactivities, an understanding of barri-ers to their participation (eg, trans-portation, preparticipation physicals)can inform efforts to engage them.

Transition Services

As adolescents with mental illness ageout of pediatric care, insurance plans,and community resources that sup-ported them during their childhood,they must find new providers of theirprimary and specialty health care andface the stresses experienced by otheryoung adults with special needs. Theymay have limited educational, voca-tional, or social opportunities; finan-cial hardships; difficulty finding hous-ing; and inadequate services to assistthem in overcoming or coping withthese problems and in achieving theirhealth, educational, vocational, and so-cial goals. Primary care clinicians canpartner with the mental health com-munity to address deficiencies in tran-sition services for young people whoare living with mental illness. Pro-grams in several areas of the countrymay serve as models.52,53

STRATEGY 4: DEVELOP ACOMMUNITY PROTOCOL FORMANAGING PSYCHIATRICEMERGENCIES

Deaths attributable to homicide, sui-cide, and child abuse are tragicallycommon.54,55 Life-threatening mentalhealth problems, including acute intox-ication, delirium, psychosis, mania, se-vere family dysfunction or acute stressresponses, domestic violence, severemood disorders, and medical crisesassociated with eating disorders, alsooccur frequently. Primary care clini-cians may be the only source fromwhom a child and family are comfort-

able seeking help. Primary care clini-cians have a role in preventing crisesby identifying children with mentalhealth/substance abuse problemsearly in their course, developing a re-lationship when the child is not in cri-sis, and collaborating with the familyto develop a crisis plan in advance. Pri-mary care clinicians also have a role inapplying a management strategy to acrisis situation, which involves assess-ing the level of urgency of the child’sneed for care, identifying interven-tion options, and using appropriateresources.

A natural disaster, act of violence, war,or industrial accident may inflicttrauma and loss on many children andfamilies simultaneously—those di-rectly exposed and those emotionallyexposed through death or injury ofloved ones—and may pose evengreater threats to children with preex-isting mental health issues. Primarycare clinicians have a role in planningwith their community partners to dealwith both the short-term and long-term aftermath of these crises.56,57

Emergency departments in many com-munities are not well equipped to ad-dress psychiatric emergencies in chil-dren and adolescents.58,59 Throughovercrowding, exposure to stressfulsights and sounds, and long delays,they may inadvertently increase thedistress and trauma experienced bychildren and their families.60 Boardingof child and adolescent psychiatricpatients in nonpsychiatric settingsshould be avoided as much as possi-ble. When such boarding is unavoid-able, every attempt should be made toensure that such patients are hospital-ized in the least restrictive setting pos-sible and transferred to a psychiatricfacility as expeditiously as possible.When optimal services are unavail-able, primary care clinicians can par-ticipate in community and regional ef-forts to fund and develop them.

In some communities, specific psychi-atric emergency services are avail-able (eg, mobile crisis units that canbe deployed to a physician’s office orschool; mental health screening, tri-age, and referral centers; mentalhealth/ substance abuse intake facili-ties; intensive outpatient treatmentprograms)61–63; however, primary careclinicians (as well as school andagency personnel with whom primarycare clinicians collaborate) may beunaware of them. As part of their in-ventory of mental health resources,pediatric primary care clinicians canidentify and prepare to use the emer-gency mental health services that aremost appropriate for children and ad-olescents, often in the mental healthsystem rather than an emergency de-partment. The primary care clinicianscan negotiate with providers of emer-gencymental health services to secureready access for their patients in cri-sis and/or “urgent” assessment slots.In addition, primary care clinicianscanworkwith thesemental health pro-viders to ensure that primary care cli-nicians are informed about childrenserved in their system and that ar-rangements are made for their contin-ued monitoring and care after dis-charge from hospital or residentialfacilities.

STRATEGY 5: ALIGN WITHCOMMUNITY PARTNERS INADDRESSING THE MENTAL HEALTHNEEDS OF CHILDREN WITHIN THEPRIMARY CARE PRACTICE

Depending on community priorities,the clinicianmay choose initially to tar-get the practice’s mental health ser-vices to those of a particular agegroup, such as adolescents; a high-need groupwithin the population, suchas children in foster care; children af-fected by a disaster; children with par-ents deployed in military service; orchildren in a certain neighborhood or

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school associated with poor healthor educational outcomes. In some set-tings, the clinician can seek the coop-eration of school nurses, school-basedhealth centers, or community agencies(eg, public health, social services, juve-nile justice) to administer and collectmental health history and screeningtools needed by the primary care clini-cian and provide them in advance ofthe primary care visit.64

As an example, clinicians might con-sider initiating previsit data collectionfrom children in foster care. Sharingthe responsibility for previsit data col-lection with the foster care agency in-creases the likelihood that adults withknowledge of the child’s mental healthstrengths and needs provide criticalinformation. Many statesmandate thatchildren placed in foster care receive amental health assessment within 1month of placement. Primary care cli-nicians may participate in providingthis assessment. There may also besome mechanism to assess for acutemental health needs (suicidality, homi-cidality, severe aggression, ongoingpsychotropic medication needs, or therisk of withdrawal symptoms in asubstance-addicted adolescent cut offfrom his or her supply) within 1 or 2days of foster placement. Again, theprimary care clinician may incorpo-rate this assessment into a primarycare visit.

As a second example, clinicians canwork with their local school system(s)to develop a community protocol forassessing and managing school-agedchildren who experience problemswith attention, behavior, or learning.With parental permission, school per-sonnel are usually willing to collectand share information with the pri-mary care clinician. This informationcould include behavior scales, such asthe Vanderbilt ADHD Scales and theStrengths and Difficulties Question-naire, Teacher Version; grades and

end-of-grade test results; and psycho-educational evaluations, including for-mal cognitive testing, individually ad-ministered educational achievementtesting, or other standardized assess-ments, such as neuropsychologicaltesting. A clear description of thechild’s academic program, includingany special services provided infor-mally or through an individualized ed-ucation plan or 504 plan also should beprovided before the medical evalua-tion. In turn, the primary care cliniciancan provide the school with clinicalfindings, a description of treatmentprovided, and follow-up plans (includ-ing a mechanism to monitor medica-tion effects) as needed and withproper permission from parents. In aNorth Carolina community, such a pro-tocol, which streamlines primary careclinicians’ assessment of children whoare experiencing school difficultiesand facilitates communication abouttheir ongoing care, has been in placefor�15 years.64

STRATEGY 6: PARTICIPATE IN AAPCHAPTER EFFORTS TO ADDRESSPAYMENT AND BROADER SYSTEMISSUES

Primary care clinicians require ade-quate payment for the mental healthservices they provide and a policy en-vironment that supports primary careclinicians’ involvement in mentalhealth care. These issues require un-derstanding of the additional time andeffort needed to address mentalhealth issues in primary care practice.There are a growing number of suc-cessful AAP chapter advocacy effortsthat have achieved significant policychanges in private (employer-based)health insurance, state Medicaid pro-grams, and the State Children’s HealthInsurance Program.65 Examples of sys-tem features that support and fostermental health practice in primary caresettings are:

● payment of primary care cliniciansfor their mental health services;

● payment for multiple mental healthvisits to the primary care clinicianbefore the establishment of a diag-nosis (ie, for problem-level condi-tions and/or conditions for whichthe clinician is not ready to assign adiagnostic code);

● authorization of mental health re-ferrals by primary care clinicians;

● notification of the primary care cli-nician when a child enters the men-tal health specialty system;

● payment structure that supportsmental health professionals colo-cated or integrated within the pri-mary care setting;

● independent enrollment of Medic-aid mental health providers, whichmakes it possible for primary careclinicians to refer directly to a men-tal health professional (rather thanthrough an agency’s cumbersomeintake process) and develop a col-laborative relationship with thatprofessional in the mutual care ofthe child;

● payment to primary care cliniciansfor the services of their employedmental health professionals; and

● an electronic system to access fam-ilies’ mental health benefits andprovider panels.

In many areas of the country, managedcare “carve-outs” (separate insuranceplans that deliver mental health/sub-stance abuse benefits) provide theirinsured customers with a limitedpanel of mental health professionalswho may or may not have expertise inworkingwith children and adolescentsand may or may not provide evidence-based interventions; furthermore, theprimary care clinician may have no ac-cess to the list of mental health profes-sionals on an insurance plan’s mentalhealth panel. Typically, families mustaccess these services directly. In these


situations, it will be necessary for pri-mary care clinicians to partner withregional or state groups of primarycare clinicians and to focus advocacyefforts on regional directors of theseambulatory managed care plans andon insured families and their employ-ers tomake themmore knowledgeableof pediatric needs. For AAP chaptersthat have established managed care“pediatric councils” (groups of pedia-tricians who meet periodically withmedical directors of the region’s ma-jor managed care plans and otherinsurers), mental health/substanceabuse advocacy issues can becomeagenda items (eg, notification of theprimary care clinician when a familyaccesses mental health services, rou-tine exchange of information betweenmental health providers and primarycare clinicians, and expansion of men-tal health panels to include pediatricspecialists). The recently adopted fed-eral law that mandates parity of men-tal health and physical health insur-ance benefits should provide incentivefor such efforts.

Strategies for System Change in Chil-dren’s Mental Health: A Chapter ActionKit25 and the AAP mental health Website49 offer strategies for AAP chaptersand other primary care professionalassociations to use in their attempts toachieve equity of mental health bene-fits in insurance plans, fair payment ofprimary care clinicians and mentalhealth professionals for the servicesthey provide, policies that support andpromote collaboration, and support ofpublicmental health systems. The TaskForce on Mental Health worked withthe Academy of Child and AdolescentPsychiatry to develop a white paper onadministrative and financial barriersto children’smental health care, whichwas published in Pediatrics in April2009.66 Consumer groups such as theNAMI and the FFCMH are invaluableto primary care clinicians’ advocacy

efforts, as they have been to the taskforce’s work.

STRATEGY 7: ADDRESS STIGMATHROUGH PUBLIC EDUCATION

Stigma prevents many children andfamilies from seeking care for theirmental health and substance abuseconcerns. Primary care clinicians canpartner effectively with mental healthadvocates and mental health profes-sionals to combat stigma at the com-munity level. Such partnerships withlocal NAMI, Children and Adults With At-tention Deficit/Hyperactivity Disorder,and FFCMH organizations, for example,have focused on:

● battling stigma with facts (eg, men-tal illnesses are treatable; childrenand adults who live with these ill-nesses can achieve recovery andlead full and productive lives; chil-dren often have behavioral prob-lems; mental illness is not a charac-ter flaw, a sign of moral weakness,or anyone’s fault);

● establishing support groups andeducation programs for families(combating the social isolation thatso often accompanies mental ill-ness, for both the child and family);and

● eliminating language that contrib-utes to stigma through defining peo-ple by their condition and using“people-first” language (eg, refer-ring to someone as “a person withschizophrenia” rather than “aschizophrenic”).

CONCLUSIONS

Enhancing the mental health of chil-dren requires a population perspec-tive that recognizes collective opportu-nities to promote mental health,reduce the risk of mental illness, andimprove mental health services. Eachclinician will choose strategies in ac-cordance with his or her community’s

specific needs and his or her prac-tice’s priorities. Forming a group ofinterested primary care clinicians,developmental and adolescent special-ists, advocates, educators, agency rep-resentatives, and mental health/sub-stance abuse professionals offers thebenefit of enhancing relationshipswhile ensuring coordination and syn-ergy of effort. The resources availableon the AAP mental health Web site28

can provide assistance. By facilitatingsystem changes at the community level,the primary care clinician can set thestage for enhancements in mentalhealth care at the practice level.

Community-level strategies for en-hancing children’s mental healthinclude:

● apply a “population” perspective togain understanding of the mentalhealth needs of children and youthin the community;

● inventory the community’s mentalhealth resources;

● develop or strengthen relationshipswith mental health advocates,schools, human service agencies,mental health and substance abuseproviders, and developmental spe-cialists by collaborating on system-focused initiatives;

● develop a community protocol formanaging psychiatric emergencies;

● align with community partners inaddressing the mental health needsof children within the primary carepractice;

● participate in AAP chapter efforts toaddress payment and broader sys-tem issues; and

● address stigma through publiceducation.

AAP TASK FORCE ON MENTALHEALTH

The AAP Task Force on Mental Healthincluded JaneMeschan Foy, MD (chair-

SUPPLEMENT ARTICLE


person, lead author), Paula Duncan,MD, Barbara Frankowski, MD, MPH,Kelly Kelleher, MD, MPH, Penelope K.Knapp, MD, Danielle Laraque, MD, GaryPeck, MD, Michael Regalado, MD, JackSwanson, MD, and Mark Wolraich, MD;the consultants were Margaret Dolan,

MD, Alain Joffe, MD, MPH, Patricia J.O’Malley, MD, James Perrin, MD (leadauthor), Thomas K. McInerny, MD, andLynn Wegner, MD; the liaisons wereTerry Carmichael, MSW (National Asso-ciation of Social Workers), Darcy Grut-tadaro, JD (National Alliance onMental

Illness), Garry Sigman, MD (Society forAdolescent Medicine), Myrtis Sullivan,MD, MPH (National Medical Associa-tion), and L. Read Sulik, MD (AmericanAcademy of Child and Adolescent Psy-chiatry); and the staff were Linda Pauland Aldina Hovde.

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