The primary goal of mental health integration in pediatrics is prevention and early intervention. Mental health integration in pediatric primary care is increasingly recognized as a key approach to support children’s healthy social and emotional development and intervene early to prevent more serious problems from developing later. Mental health conditions are common in pediatric populations (about 20%) yet are often unidentified and untreated (Perou et al., 2013). Over time, untreated mental health disorders are associated with impaired functioning, troubled family and peer relationships, substance use, and school failure (National Academy of Sciences, 2009). The pediatric practice is an accessible, non-stigmatizing setting for mental health screening and integration of mental health services because children have regular well-child visits during which parents/caregivers expect developmental guidance and expertise from pediatricians and form trusting relationships with them over the long-term (SAMHSA-HRSA CIHS, 2013).
Successful integration of mental health into pediatrics should include screening and promotion of healthy development, addressing risk factors, assessing how social-emotional and other developmental domains are intertwined, and working with parents/caregivers.
Developmental and Behavioral Screening
One important goal of integrating mental health into pediatrics is to identify children with behavioral health challenges. Screening during routine well-child visits provides an opportunity to ensure that children with mental health challenges are identified as early as possible when intervention is most effective and cost-efficient (American Academy of Pediatrics, Committee on Children with Disabilities, 2011). While it is standard practice for pediatric care providers to ask about developmental and behavioral concerns at every well-child visit (referred to as surveillance), few use a formal screening instrument. Without a validated screening instrument, however, providers in one systematic review were only able to correctly identify 14% to 54% of children with a developmental-behavioral problem (Sheldrick, Merchant, & Perrin, 2011). A screening tool completed by a parent prior to a pediatric visit improves early recognition by identifying far more children with developmental and social emotional needs than surveillance alone, even performed by a seasoned clinician (Guevara et al., 2013). The American Academy of Pediatrics (AAP) recommends use of standardized valid developmental and behavioral screens as an integral component to well-child care (AAP Committee on Psychosocial Aspects of Child and Family Health, 2009), and the American Academy of Child and Adolescent Psychiatry (AACAP) supports the integration of mental health in pediatric primary care (AACAP Committee on Health Care Access and Economics, 2009).
Models of Mental Health Integration in Pediatric Practices
Successful integration of mental health in pediatric care practices depends on a number of factors. A Substance Abuse and Mental Health Services Administration (SAMHSA) framework describes a continuum of integration with increasing degrees of collaboration, co-location of services, and medical record and system integration (Heath et al., 2013). For integrated teams to work effectively, team members need skills and competencies in interpersonal communication, care planning, collaborative teamwork, and informatics, among others. On-site mental health clinicians are available to address developmental and behavioral concerns, and can function as a consultant or even as a primary therapist. These clinicians need to have flexible schedules so that they can be available for same-day consultations, brief follow-up interventions, supervision of screening, and informal consultations (Stancin & Perrin, 2014).
One evidence-based model for integrating physical and behavioral health services within adult primary care is the collaborative care model; it has been found to improve health and mental health outcomes while reducing health care costs (Unutzer, Harbin, Schoenbaum, & Druss, 2013). The key clinical activities are care coordination, monitoring patient progress to treatment targets, and “step up” of treatment to specialty care, using a care manager and consulting psychiatrist as part of the integrated team. The collaborative care model is increasingly used in pediatric community clinics to target Attention Deficit Hyperactivity Disorder and anxiety disorders. Studies show the model reduced child behavioral and anxiety symptoms as well as parental stress, and was well accepted by parents (Kolko et al., 2014, and Myers et al., 2010).
The NYC Department of Health and Mental Hygiene (DOHMH), through a SAMHSA grant, Project LAUNCH, funds a model that co-locates an early childhood mental health psychologist and a primary care assistant within pediatric clinics at a Federally Qualified Health Center and a municipal hospital. This model includes conducting routine social-emotional (mental health) screening, and providing assessment, short-term treatment, referral and follow-up when needed. The mental health clinician works with the child and caregiver together during assessment and treatment. Several other NYC programs provide mental health consultation to young children and their families through city and state funding mechanisms so that mental health clinicians from behavioral health agencies are co-located in various pediatric clinics that serve high-needs children.
To better understand models, and successes and challenges of mental health integration in NYC pediatric clinics, in 2013 DOHMH conducted interviews with medical and behavioral health directors of 16 NYC pediatric clinics practicing elements of integrated care. The telephone interviews included questions about mental health screening and services for children and parents/caregivers; integration (e.g. staffing, referral sources, linkages to outside services); communication (between mental health and primary care providers, with children and families); and financing and reimbursement.
Common characteristics across the sites are that mental health clinicians are typically onsite, yet when offsite they are readily available to the pediatric site. Informal consultation between medical and mental health providers is a frequent method of communication, rather than integrated treatment plans or joint case conferences. Almost all of these sites use integrated electronic medical records for pediatric and mental health providers. Developmental surveillance with clinician generated questions from the American Academy of Pediatrics’ Bright Futures guidelines is commonly used. Routine use of formal screening tools is less common, although some sites will formally screen young children when the mental health clinician is onsite.
Perceived benefits of co-location include improved communication between medical and mental health providers, a ‘warm handoff’ of families to mental health staff, as well as quicker appointments and reduced stigma for families who receive their mental health care in the familiar primary care setting. Overall, integration was thought to lead to improved effectiveness of the primary care practice, child health and mental health outcomes, and experiences for families.
Perceived challenges to integration include the need for various combinations of sources of payment and funding to cover costs because insurance collections alone are not sufficient to support the services. Agencies generally require a combination of sources to cover costs, including revenue from Medicaid (most patients are insured by Medicaid in these interview sites) and private insurers, grant-funding, and the agency’s internal operating budgets. Financing limitations make it harder to recruit and maintain adequate numbers of mental health professionals as these positions are not fully supported by insurance reimbursement, and therefore additional resources are required. Further reported challenges include merging professional cultures within medical and mental health teams, and the need for additional resources such as administrative staff time and clinical office space.
This exploratory study points to the importance of adequate payment and funding, infrastructure support, and strong, integrated medical and mental health teams to achieve sustainable mental health integration.
Current federal and state health care reform initiatives present an opportunity to promote mental health integration and closely monitor results and successes. Implementing and sustaining mental health integration in primary care is a challenging endeavor but critically important given the prevalence and potential long-term impacts of childhood mental health conditions. Pediatric primary care providers have an essential role in identifying these conditions, intervening early, and improving the health, mental health and developmental outcomes of children.
Myla Harrison, MD, MPH, is Medical Director; Jessica Auerbach, MPH, is the Young Child Wellness Coordinator; Shirley Berger, MPH, is a Research Associate; and Marilyn Sinkewicz, PhD, is Director of Research and Evaluation; Bureau of Children, Youth, & Families; New York City Department of Health and Mental Hygiene.