Integrating mental health services in pediatric practices feasible, effective, study finds

March 24, 2014
This diagram explains how in-office pediatric behavioral health services delivered using the adapted collaborative care model work to provide the best possible results for the child and their caregiver. Credit: UPMC

Brief behavioral and mental health programs for children can be effectively provided within pediatric practices as an alternative to being referred to a community specialist, University of Pittsburgh Schools of the Health Sciences researchers found in a National Institutes of Health-funded randomized trial.

Behavioral health treatment provided in the 's office resulted in improved access to care, greater participation by both the child and their caregiver in treatment programs, and higher rates of treatment completion, without burdening the pediatric practice, researchers report in the April issue of the journal Pediatrics.

"Treating both physical and behavioral health in the office of the child's pediatrician is an achievable goal that provides many benefits to the child, caregiver and pediatrician" said lead author David Kolko, Ph.D., professor of psychiatry, psychology, pediatrics, and clinical and translational science in Pitt's School of Medicine. "When the behavioral health treatment was provided in the pediatrician's office, participants were more than six times as likely to complete the program, as they were when it was provided at a specialty care clinic outside the pediatrician's office."

Dr. Kolko and his colleagues recruited more than 300 children and their caregivers at eight community affiliated with Children's Hospital of Pittsburgh of UPMC who had been referred for treatment of behavioral problems, though many also had attention-deficit/hyperactivity disorder (ADHD) or anxiety. This study is the third one completed by Services for Kids in Primary-Care (SKIP), a program that integrates behavioral health services into primary pediatric and family medicine practices (more information available at http://www.skipproject.org).

In this trial, half the children received "doctor office collaborative care," where a trained behavioral health clinician, known as a care manager, collaborated with the child's pediatrician to deliver mental health services in the pediatrician's office. The other half received "enhanced usual care," where the patients received educational materials and were referred to a local mental health specialist outside the pediatrician's office who accepted the child's health insurance.

The participants averaged 8 years old and two-thirds were boys. Most had a primary diagnosis of ADHD, followed by disruptive behavior disorder and anxiety disorder. Only 10 percent previously had received ADHD medication.

In the program at the pediatrician's office, the child and their caregiver participated in six to 12 individual or family sessions within six months where the mental health clinician worked on individualized goals to address the behavioral health issue and reviewed educational materials to help achieve those goals. The clinician communicated with the pediatrician in regular meetings and through progress notes.

In both the in-office and outside specialist programs, the pediatrician was updated on the patient's care and could prescribe medication for the child when necessary.

Of the participants assigned to the care manager at the pediatrician's office, 99.4 percent began treatment programs and 76.6 percent completed them. Of those assigned to a specialist outside the office, 54.2 percent began treatment and 11.6 percent completed it.

The program in the pediatrician's office also was associated with higher rates of improvement in behavioral and hyperactivity problems, lowered parental stress, better treatment response and consumer satisfaction.

Beyond the child and their caregiver, pediatricians whose offices received the in-office program reported greater efficacy and more confidence in their skills to treat ADHD, compared with the outside specialist program.

"In fact, the participating pediatric practices in this clinical trial later hired their own clinicians to continue delivering on-site services, after the trial had ended," said Dr. Kolko. "Still more research is needed to understand how pediatric practices adapt clinical and financial strategies to make an in-office provider a sustainable resource. Perhaps pediatricians who observe the program in operation may be willing to find a way to support these resources and make that service work."

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