Receiving advice about child mental health from a primary care provider: African American and Hispanic parent attitudes

Treatment for Anxiety Disorders in the Pediatric Primary Care Setting

Anxiety disorders are among the most diagnosed mental health problems in children and adolescents. Without intervention, anxiety disorders in youth are chronic, debilitating, and amplify risk of negative sequelae. Youth with anxiety present to primary care frequently and often families choose to first discuss mental health concerns with their pediatricians. Both behavioral and pharmacologic interventions can be effectively implemented in primary care, and research demonstrates the effectiveness of both approaches.

Hispanic mothers' accounts of vaccinating their adolescent children against HPV: features of the clinic visit

ABSTRACTObjective: Despite the widespread availability of the human papillomavirus (HPV) vaccine in the US, rates of vaccination among Hispanic adolescents lag behind those of other recommended vaccines. Understanding what happens during the HPV vaccination visit should provide important insight into communication between health care providers and Hispanic mothers and identifies areas where communication can be improved. As such, this qualitative study explored Hispanic mothers' experiences during their adolescent child's HPV vaccination visit.Design: Fifty-one participants completed individual interviews. Transcripts were analyzed using a conventional content analysis approach to identify emergent categories or themes.Results: We identified three features of the HPV vaccination visit including: the primary reason for the visit, the type of counseling the mother received about the vaccine and the type of HPV vaccine recommendation received. Most mothers reported that their child was vaccinated against HPV at a routine well-child visit. Some mothers reported that they received in-depth counseling about the vaccine, while others received brief or no counseling from the provider. Mothers also reported receiving either a strong recommendation to vaccinate, a recommendation to vaccinate that emphasized her choice, or no recommendation to vaccinate.Conclusion: Most Hispanic mothers report that they received counseling and a recommendation from their adolescent child's health care provider before vaccinating. However, most of the mothers first heard about the HPV vaccine at the vaccination visit. Mothers who had previously heard about the vaccine outside of the clinic, reported making an appointment specifically for their child to be vaccinated against HPV. Together, these findings indicate a need to raise awareness of the vaccine and to promote HPV vaccination more strongly in this population. Education efforts should target mothers in community settings, in addition to clinic settings in order to increase awareness and vaccination in this population.

Racial/ethnic differences in the treatment of adolescent major depressive disorders (MDD) across healthcare providers participating in the medicaid program

BACKGROUND

To examine whether racial/ethnic differences in receipt of MDD treatment could be explained by the specialty of provider diagnosing the adolescent.

METHOD

Adolescents (10-20 years-old) with ≥2 MDD diagnoses were identified using 2005-2007 Medicaid data from Texas. Patients were categorized based on the types of provider who gave the initial MDD diagnosis (psychiatrist (PSY-I), social worker/psychologist (SWP-I), and primary care physician (PCP-I)). Within the sub-cohorts identified by each type of provider, patients were further divided by racial/ethnic groups.

RESULTS

Of the 13,234-new pediatric MDD cases diagnosed, 61% were SWP-I, 33% PSY-I and 6% PCP-I. Results of the analysis using general linear multi-level model showed that being first diagnosed by a psychiatrist was associated with higher chance of receiving MDD related treatment (PCP-I vs. PSY-I (OR: 0.54, 95%CI: 0.4-0.7) and SWP-I vs. PSY-I (OR: 0.17, 95%CI: 0.1-0.2)). Specifically, regarding the receipt of pharmacotherapy, an interaction effect was detected between types of identifying providers and patients' race/ethnicity. The analysis stratified by race/ethnicity found Whites received comparable treatment regardless being PCP-Is or PSY-Is, while for Hispanics, being first identified by a PCP was associated with lower likelihood of receiving treatment as compared to being first identified by a psychiatrist. Further analysis stratified by provider types showed that a significant racial/ethnic variation in medication utilization was observed in PCP-Is, but not in PSY-Is.

CONCLUSION

For adolescents with MDD, being first diagnosed by a psychiatrist was associated with higher treatment rate and reduced racial/ethnic variation in the utilization of pharmacotherapy.

Stepped Care Interpersonal Psychotherapy Treatment for Depressed Adolescents: A Pilot Study in Pediatric Clinics

Adolescents with depression are at risk for negative long-term consequences and recurrence of depression. Many do not receive nor access treatment, especially Latino youth. New treatment approaches are needed. This study examined the feasibility and acceptability of a stepped collaborative care treatment model (SCIPT-A) for adolescents with depression utilizing interpersonal psychotherapy for adolescents (IPT-A) and antidepressant medication (if needed) compared to Enhanced Treatment as Usual (E-TAU) in urban pediatric primary care clinics serving primarily Latino youth. Results suggest the SCIPT-A model is feasible, acceptable and potentially beneficial for urban Latino adolescents. Clinicians delivered the SCIPT-A model with fidelity using supervision successfully implemented in a community setting.

Role of the general practitioner in providing early intervention for youth mental health: a mixed methods investigation

INTRODUCTION

Youth suicide in Ireland is now the second highest in the European Union. General practitioners (GPs), as the health-care professional most often consulted by young people, have a central role in early detection of youth mental health problems. However, evidence regarding the perspectives of young people and health-care workers towards screening and treatment for such issues in primary care in Ireland is lacking.

AIM

This study aimed to examine the role of GP in providing early intervention and treatment for youth mental health problems.

METHODS

A mixed methods study that involved qualitative interviews with health-care workers from primary care, secondary care and community agencies (n = 37) and young people (n = 20) in two of Ireland's most socioeconomically disadvantaged areas and a national cross-sectional survey of GPs (n = 175) were carried out.

RESULTS

GP satisfaction rates were low in regard to postgraduate training received in child and adolescent mental health (17%) and substance use (21%). Key barriers to treatment included the attitude of patients/families, lack of specialist staff, poor service availability and time. Access to services (66%), knowing which interventions can be initiated in primary care (44%), having appropriate time and space (47%) and access to a youth worker (42%) were the interventions most commonly identified that would facilitate screening and treatment.

CONCLUSION

The research outlined potential implications for clinical practice, research and education such as promoting awareness of mental health and the role of the GP in helping these issues, education of practitioners and improving access to psychological treatments.

Addressing the Mental Health Needs of Latino Children in Immigrant Families

Latino children in the United States, whether immigrants themselves or children in immigrant families, are at high risk for mental health disorders stemming from poverty, exposure to trauma, assimilation stressors, and discrimination. The timely identification and treatment of mental health disorders in Latino children are compromised by limited healthcare access and quality as well as the lack of routine mental health screening in pediatric primary care. Here we review Spanish-language validity and implementation studies of Bright Futures previsit mental health screening tools and models of care. We identify strengths and weaknesses in the literature and suggest tools for use in mental health care assessment, management, and treatment for Latino children in pediatric primary care. Pediatricians can improve care of Latino children through awareness of risk factors for mental health disorders, integration of evidence-based screening tools, and advocacy for culturally tailored mental health resources.

Acculturation differences in communicating information about child mental health between Latino parents and primary care providers

Significant Latino-white disparities in youth mental health care access and quality exist yet little is known about Latino parents' communication with providers about youth mental health and the role of acculturation in influencing this communication. We estimated regression models to assess the association between time in the US and the number of psychosocial issues discussed with the medical assistant (MA) and doctor, adjusting for child and parent mental health and sociodemographics. Other proxies of acculturation were also investigated including measures of Spanish and English language proficiency and nativity. Parent's length of time in the US was positively associated with their communication of: their child's psychosocial problems with their child's MA, stress in their own life with their child's MA, and their child's school problems with their child's doctor. These differences were especially apparent for parents living in the US for >10 years. Parent-child language discordance, parent and child nativity were also significantly associated with communication of psychosocial problems. Greater provider and MA awareness of variation in resistance to communicating psychosocial issues could improve communication, and improve the prevention, diagnosis and treatment of youth mental illness.

Ethnicity, socioeconomic position and severity of problems as predictors of mental health care use in 5- to 8-year-old children with problem behaviour

BACKGROUND

Empirical research on mental health care use and its determinants in young school-aged children is still scarce. In this study, we investigated the role of ethnicity, socioeconomic position (SEP) and perceived severity by both parents and teachers on mental health care use in 5- to 8-year old children with emotional and/or behavioural problems.

METHODS

Data from 1,269 children with a high score([P90) on the Strengths and Difficulties Questionnaire (SDQ) in the school year 2008–2009 were linked to psychiatric case register data over the years 2010–2011. Cox proportional hazards models were used to predict mental health care use from ethnicity, SEP and perceived severity of the child's problems.

RESULTS

During the follow-up period, 117 children with high SDQ scores (9.2 %) had used mental health care for the first time. Ethnic minority children were less likely to receive care than Dutch children (HR Moroccan/Turkish:0.26; 95 % CI 0.13-0.54, HR other ethnicity: 0.26; 95 %CI 0.12-0.58). No socioeconomic differences were found.After correction for previous care use, ethnicity and parental perceived severity, impact score as reported by teachers was significantly associated with mental healthcare use (HR 1.58; 95 % CI 1.01–2.46).

CONCLUSIONS

Ethnicity is an important predictor of mental health care use in young children. Already in the youngest school-aged children, ethnic differences in the use of mental health care are present.A distinct predictor of care use in this age group is severity of emotional and behavioural problems as perceived by teachers. Therefore, teachers may be especially helpful in the process of identifying young children who need specialist mental health care.

Child problem recognition and help-seeking intentions among black and white parents

Parents play a central role in utilization of mental health services by their children. This study explored the relationship between parents' recognition of child mental health problems and their decisions to seek help. Participants included 251 parents (49% Black, 51% White; 49% fathers, 51% mothers) recruited from community settings. Parents ranged in age from 20 to 66 years old with at least one child between ages 2 and 21. Parents read three vignettes that described a child with an anxiety disorder, ADHD, and no clinically significant diagnosis. Parents completed measures of problem recognition, perception of need, willingness to seek help, and beliefs about causes of mental illness. Findings from Generalized Estimating Equations revealed that parents were more likely to report intentions to seek help when they recognized a problem (odds ratio [OR] = 41.35, p < .001), 95% confidence interval (CI) [14.81, 115.49]; when it was an externalizing problem (OR = 1.85, p < .05), 95% CI [1.14, 3.02]; and when parents were older (OR = 1.04, p < .05), 95% CI [1.01, 1.08]. Predictors of parental problem recognition included perceived need, prior experience with mental illness, and belief in trauma as a cause of mental illness. Predictors of help-seeking intentions included problem recognition, perceived need, externalizing problem type, and being female. Given the relationship between parental problem recognition and willingness to seek help, findings suggest that efforts to address disparities in mental health utilization could focus on problem-specific, gender-sensitive, mutable factors such as helping parents value help-seeking for internalizing as well as externalizing problems.

Mental health communications skills training for medical assistants in pediatric primary care

Paraprofessional medical assistants (MAs) could help to promote pediatric primary care as a source of mental health services, particularly among patient populations who receive disparate mental health care. This project piloted a brief training to enhance the ability of MAs to have therapeutic encounters with Latino families who have mental health concerns in pediatric primary care. The evaluation of the pilot found that MAs were able to master most of the skills taught during the training, which improved their ability to have patient-centered encounters with families during standardized patient visits coded with the Roter Interaction Analysis System. Parents interviewed 1 and 6 months following the training were more than twice as willing as parents interviewed 1 month before the training to discuss mental health concerns with MAs, and they had better perceptions of their interactions with MAs (all p < 0.01) even after controlling for a range of patient and visit characteristics. Before training, 10.2% of parents discussed a mental health concern with the MA but not the physician; this never happened 6 months after training. This pilot provides preliminary evidence that training MAs holds potential to supplement other educational and organizational interventions aimed at improving mental health services in pediatric primary care, but further research is necessary to test this type of training in other settings and among different patient populations.

Rethinking the mental health treatment skills of primary care staff: a framework for training and research

Health care reforms may offer several opportunities to build the mental health treatment capacity of primary care. Capitalizing on these opportunities requires identifying the types of clinical skills that the primary care team requires to deliver mental health care. This paper proposes a framework that describes mental health skills for primary care receptionists, medical assistants, nurses, nurse practitioners, and physicians. These skills are organized on three levels: cross-cutting skills to build therapeutic alliance; broad-based, brief interventions for major clusters of mental health symptoms; and evidence-based interventions for diagnosis specific disorders. This framework is intended to help inform future mental health training in primary care and catalyze research that examines the impact of such training.

Can general practice help address youth mental health? A retrospective cross-sectional study in Dublin's south inner city

AIMS

With general practice potentially having an important role in early intervention of mental and substance use disorders among young people, we aim to explore this issue by determining the prevalence of psychological problems and general practice/health service utilization among young people attending general practice.

METHODS

A retrospective cross-sectional study of patients attending three general practices in Dublin city.

RESULTS

Among a sample of young people (mostly women, 44% general medical services (GMS) eligible), we observed considerable contact with general practice, both lifetime and for the 2 years of the study. The mean consultation rate was 3.9 consultations in 2 years and psychosocial issues (most commonly stress/anxiety and depression) were documented in 35% of cases. Identification of psychosocial issues was associated with GMS eligibility, three or more doctor consultations, and documentation of smoking and drinking status.

CONCLUSIONS

Psychosocial issues are common among young people attending general practice and more work on their epidemiology and further identification in general practice are advocated.

Stimulant adherence and academic performance in urban youth with attention-deficit/hyperactivity disorder

OBJECTIVE

This analysis assessed whether stimulant adherence was associated with improvement in academic grade point average (GPA) among children diagnosed with and treated for attention-deficit/hyperactivity disorder (ADHD).

METHOD

Medicaid claims were merged with academic records from Philadelphia public schools of Medicaid-eligible children in first through eighth grades who were diagnosed with ADHD and who had filled one or more stimulant prescription. Students diagnosed with mental retardation, autism, or speech, hearing, visual, or language impairments were excluded. Marking periods were scored for GPA (range: 0-4.0) based on English, mathematics, social studies, and science grades and for stimulant adherence (medication possession ratio ≥ 0.70). Random and fixed-effects models estimated the effects of stimulant adherence on GPA, between all adherent and nonadherent marking periods in aggregate and within individual student's marking periods, respectively.

RESULTS

A total of 3,543 students contributed 29,992 marking periods, of which 18.6% were adherent. Mean GPA was significantly higher during stimulant-adherent (2.18) than stimulant-nonadherent (1.99) marking periods in aggregate (p < .0001). The regression coefficient representing within-student association between stimulant adherence and GPA over time was 0.108 (p < .0001), indicating that adherence was associated with a 0.108 increase in GPA. In stratified analyses, analogous coefficients were 0.106 for boys, 0.111 for girls, 0.078 for elementary students, and 0.118 for middle school students (all p < .0001). The association was stronger among students with (0.139) than without (0.088) comorbid disruptive behavior disorders (both p < .0001).

CONCLUSIONS

Stimulant adherence, although found to be low among urban elementary and middle school students diagnosed with ADHD, was associated with a marginal improvement in GPA.

Stigma in child and adolescent mental health services research: understanding professional and institutional stigmatization of youth with mental health problems and their families

To understand the low utilization rates of child and adolescent mental health services, it is necessary to recognize the kinds of professional and institutional stigma that may produce barriers to care. We address the large literature on the stigmatization of mental illness, linkages between such literature and children's mental health services use, and the kinds of professional and institutional attitudes and practices that communicate shame and low expectations to youth and their families. It will take recognition of such stigmatizing practices-including overcoming resistance to the messages presented herein-to make real progress in the effort to increase utilization of evidence-based practices. Multi-faceted, multi-level, and multi-disciplinary approaches to both research and intervention are recommended.

Screening to identify mental health problems in pediatric primary care: considerations for practice

OBJECTIVE

Few pediatric primary care providers routinely use mental health screening tools, in part because they may have concerns about whether screening is useful and how it will affect their practice. This study examined the extent to which screening in primary care would increase the identification of mental health problems among a diverse population of children and youth.

METHODS

Prior to the visit, the parents of 767 patients age 5 to 16 completed the Strengths and Difficulties Questionnaire to report their child's mental health symptoms and impairment. Without viewing the screening results, each child's provider (N = 53) completed a questionnaire to report whether the child or youth demonstrated a mental health problem.

RESULTS

Compared with providers, the screen identified twice as many patients with moderate symptoms and nearly 28% more patients with high symptoms. Among patients with high symptoms, providers failed to identify a problem among 78% of those who were Latino/Other and 55% of those who were African American compared with 27% of Caucasian patients (p < 0.001). Providers were not more likely to identify patients with externalizing versus internalizing symptoms but were more likely to identify patients who demonstrated symptoms across multiple domains of functioning.

CONCLUSIONS

Screening substantially increased the number of children and youth who would be identified as possibly having a mental health problem. Screening may have the most potential to increase the identification of problems among patients who have moderate mental health symptoms and those who are African American or Latino.

Pediatric primary care as a component of systems of care

Systems of care should be defined in a manner that includes primary care. The current definition of systems of care shares several attributes with the definition of primary care: both are defined as community-based services that are accessible, accountable, comprehensive, coordinated, culturally competent, and family focused. However, systems of care is defined as serving only children and youth with serious emotional disturbance and their families and does not fully embrace the concept of primary prevention. Although similarities in the definitions of primary care and systems of care may provide a theoretical foundation for including primary care within the systems of care framework, a definition of systems of care that incorporates the idea of prevention and takes into account the broad population served in primary care would provide communities with a definition that can be used to further the work of integrating primary care into systems of care.

Obstacles to mental health care in pediatric epilepsy: insight from parents

This exploratory study compared the responses of 20 Caucasian and 20 Hispanic mothers of children with epilepsy about possible obstacles to mental health care (MHC) for their children before and after they read a brochure on the neurobehavioral comorbidities of epilepsy. The intervention significantly increased the mothers' knowledge of the behavior and cognitive comorbidities of pediatric epilepsy and their treatment. Baseline differences in the attitude toward MHC and the stigma of epilepsy between Hispanic and Caucasian mothers were no longer apparent after the intervention. Irrespective of ethnicity, the mothers also became significantly more aware that their children did not want to have epilepsy-related behavior and learning difficulties. Efficient use of time spent in doctors' waiting rooms to educate parents about the neurobehavioral comorbidities of epilepsy can address the lack-of-knowledge barrier to MHC. However, the study's findings suggested a need to determine if there are specific obstacles to MHC in pediatric epilepsy.

Evolution of child mental health services in primary care

OBJECTIVE

Although the importance of mental health assessment and treatment in primary care is increasingly recognized, the research that underlies current practices largely stems from a considerable body of non-mental health primary care studies. Our purpose was to describe trends in research over the past 2 decades and to suggest further key items for the research agenda.

METHODS

We reviewed the literature broadly on health services research in pediatrics, especially studies of changes in primary care practice, and examined recent articles in primary care mental health services.

RESULTS

The evolution of primary care mental health services for children has been slow, but the focus of research has changed with the development of clinical improvements. Proposals to deliver more effective services have evolved over the past 40 years in a series of approaches that paralleled initiatives in the broader fields of medicine and pediatrics. Current trends in electronic technology, practice consolidation and coordination, and personalized medicine are likely to increase the pace of change in mental health services for primary care.

CONCLUSIONS

The evolution of pediatric mental health services in primary care suggests a continuing expansion from a focus initially on provider behavior and quality to a growing attention to patient and systems' behavior over time and within communities.

Disagreement in parent and primary care provider reports of mental health counseling

OBJECTIVES

The goals were to examine disagreement in primary care provider and parent reports of mental health counseling and to determine whether disagreement was associated with provider, parent, youth, and visit characteristics.

METHODS

Directly after 749 visits to 54 pediatric primary care providers in 16 practices, the parents of youths 5 to 16 years of age and the providers independently reported whether mental health counseling was provided. The parent also reported child mental health symptoms, the reason for the visit, and his or her attitudes about receiving treatment for child mental health problems in primary care. The provider reported confidence in his or her mental health treatment skills, burden and beliefs associated with treating mental health problems, and the accessibility of mental health specialists.

RESULTS

Providers reported delivering counseling during 31.9% of visits (n=239), whereas parents reported receiving counseling during only 11.4% of visits (n=86). Parents did not report receiving counseling during 74.8% of the visits in which the provider reported delivering counseling; this was more common when the parent was seeking help for a mental health problem, when the provider reported greater burden associated with treating mental health problems, and when the youth had more mental health symptoms or was of other race/Hispanic. Provider report of counseling in the absence of parent report of counseling was less common when the provider had greater access to mental health specialists.

CONCLUSIONS

Parents often did not report that the counseling delivered in primary care was mental health treatment. Counseling that is not perceived as mental health treatment may fail to meet parent expectations for care or fail to help parents identify mental health problems.

Discussion of maternal stress during pediatric primary care visits

OBJECTIVE

To determine whether the discussion of maternal stress in pediatric primary care is associated with the mother's satisfaction with her child's provider.

METHODS

Children ages 5-16 and their mothers (N=747) were recruited from the waiting rooms of 13 geographically diverse pediatric primary care sites from 2002 to 2005. Directly after the visit, the mother reported her satisfaction with the attention that the provider gave to her and her child's problems and also reported whether the provider understood the problems that she wanted to discuss during the visit. The mother also reported whether the visit included discussion of her "stresses and strains" and the discussion of child mood or behavior.

RESULTS

Thirty-five percent of mothers discussed their stresses and strains with their child's provider. The mother was more likely to be "completely" satisfied with the attention that she and her child received from the provider (odds ratio [OR] 2.43, 95% confidence interval [95% CI], 1.43-4.11) and to agree "strongly" that the provider understood the problems she wanted to discuss (OR 1.95, 95% CI, 1.32-2.93) when the visit included the discussion of maternal stress after controlling for the reason for the visit, number of previous visits, provider specialty (family practice or pediatrics), youth mental health status, whether the visit included the discussion of child mood or behavior, and maternal distress measured with a standard screening tool.

CONCLUSIONS

The mother was more satisfied with her child's primary care provider when maternal stress was discussed during the visit. This finding should somewhat alleviate fears that mothers will react negatively to discussion of their stress during pediatric visits.

A common factors approach to improving the mental health capacity of pediatric primary care

To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that "common factors" contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.

A common factors approach to improving the mental health capacity of pediatric primary care

To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that "common factors" contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.