Pediatric Annals

Guest Editorial Free

Collaborative Care in Primary Care Pediatrics

Rachel Ballard, MD; John V. Lavigne, PhD; John T. Walkup, MD

Over 40 years have passed since two seminal articles urged that greater attention be paid to the role of mental health problems in pediatric primary care. In 1978, Regier et al.1 noted that approximately 15% of the United States population experience a mental disorder each year, but only one-fifth received care from a specialty mental health provider.2 More than 50% of Americans use outpatient primary care, which has become the de facto mental health system, for mental health challenges. The second influential text, Haggerty et al.,3 reported that a substantial number of children and adolescents with mental health issues observed in primary care went undetected and the “hidden morbidity” of those challenges was a significant problem that needs attention.

Over the next several decades, there was slow progress toward improving mental health care in primary care settings. Randomized controlled trials were conducted that supported the concept that psychosocial treatments provided in primary care settings were an effective way to deliver mental health care.4 During that time, there was a realization that the shortage of child and adolescent psychiatrists was unlikely to improve substantially, that effective psychopharmacologic treatments could be provided by pediatricians with the proper training and support, and that it was critical for pediatricians to provide such services given the national shortage of mental health service providers. In addition, training programs for pediatricians and programs to provide collaborative care in pediatric settings began to be developed. Gradually, recognition of the importance of collaborative care began to accelerate.

The Affordable Care Act ( https://www.healthcare.gov/where-can-i-read-the-affordable-care-act/), which was passed by the US Congress in 2010, recognized the importance of collaborative primary care and the passage of that act increased our awareness of the need to improve collaboration between health and mental health care service providers. Now, the American Academy of Pediatrics is advocating greater emphasis on identifying and treating pediatric patients with behavioral health problems, psychologists are advocating increased collaboration between health and behavioral health practitioners,5 and psychiatrists are developing models of support for their pediatrician colleagues ranging from state-wide telephone consultation programs to fully integrated collaborative care at the clinical practice level.6

This issue of Pediatric Annals aims to support pediatric clinicians who wish to improve the mental health care provided in their practices through collaboration with mental health service providers, increasing recognition of patients with mental health concerns, and improving their approach to pharmacotherapy for the mental health problems of their patients.

In the first article, “Models of Mental Health Consultation and Collaboration in Primary Care Pediatrics,” Drs. Courtney Romba and Rachel Ballard discuss strategies for pediatric clinicians to access didactic training and continuing consultation or collaboration on the recognition, diagnosis, and treatment of common mental health problems. The article includes a resource list showing where to start looking for training, implementation strategies, and toolkits.

Integrated pediatric primary care provides the opportunity to identify children and adolescents with mental health problems who would not otherwise receive evaluation and treatment. Systematic mental health screening is key to the early identification and treatment of pediatric mental health disorders, resulting in identification of children and adolescents whose symptoms would otherwise be missed.7,8 In the second article, “Screening for Mental Health Problems in Pediatric Primary Care,” Drs. John T. Parkhurst and Susan Friedland describe screening approaches that may maximize the utility of broad-based, universal screening, minimizing false positives, and supporting the diagnostic process.

In the next article, “Developmental Aspects of Pediatric Mental Health,” Drs. Ballard and Marisa Perez-Reisler present a framework that may help the pediatric clinician recognize mental health, like physical health, as arising from familiar aspects of child and adolescent development. Mental health disorders emerge in children and adolescents in a predictable timeframe, which are outlined in the article. The developmental framework facilitates the recognition of mental health disorders, focuses the differential diagnosis for emotional or behavioral symptoms into a developmental frame, and importantly sets up a timely structure of anticipatory guidance.

An increasing number of children and adolescents are prescribed psychotropic medications. These medications reduce suffering and improve functioning and can be prescribed safely, but they can have adverse effects. In the fourth article, “Management of Adverse Effects of Psychotropic Medications,” Drs. Courtney Romba and Perez-Reisler review the potential adverse effects of the major classes of psychotropic medications used in pediatric patients and discuss the role of the pediatrician in monitoring for and managing them.

Finally, for the oft-occurring comorbidity of attention-deficit/hyperactivity disorder (ADHD) and anxiety in pediatric primary care, in the article, “Diagnosis and Management of Comorbid Anxiety and ADHD in Pediatric Primary Care,” Drs. Daniel Janiczak, Perez-Reisler, and Ballard provide a bit of “Psychopharmacology 202” for pediatric clinicians who have some level of comfort in the diagnosis and treatment of straightforward ADHD and mild to moderate anxiety. They discuss the ways in which the symptoms of these two common pediatric mental health disorders overlap, potentially confounding the diagnosis of one or the other, and how the treatment of one may impact the treatment of the other.

Our hope is that this collection of articles offers our pediatric colleagues current, evidence-based, practical guidance to address the substantial mental health burden in children and adolescents. We believe that collaborative care speeds the early identification and treatment of common mental health disorders in the familiar, trusted setting of pediatric primary care, appropriately stages referral to mental health specialists for patients with more severe or chronic disorders, and overall contributes to healthier childhoods.

References

  1. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry. 1978;35(6):685–693. doi:10.1001/archpsyc.1978.01770300027002 [CrossRef] PMID:306803
  2. Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32–45. doi:10.1016/j.jaac.2010.10.006 [CrossRef] PMID:21156268
  3. Haggerty RJ, Roghmann KJ, Pless IB. Child Health and the Community. John Wiley & Sons; 1975.
  4. Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis. JAMA Pediatr. 2015;169(10):929–937. doi:10.1001/jamapediatrics.2015.1141 [CrossRef] PMID:26259143
  5. Asarnow JR, Kolko DJ, Miranda J, Kazak AE. The pediatric patient-centered medical home: innovative models for improving behavioral health. Am Psychol. 2017;72(1):13–27. doi:10.1037/a0040411 [CrossRef] PMID:28068135
  6. Dillon-Naftolin E, Margret CP, Russell D, French WP, Hilt RJ, Sarvet B. Implementing integrated care in pediatric mental health: principles, current models, and future directions. Focus Am Psychiatr Publ. 2017;15(3):249–256. doi:10.1176/appi.focus.20170013 [CrossRef] PMID:31975854
  7. Foy JM, Kelleher KJ, Laraque DAmerican Academy of Pediatrics Task Force on Mental Health. Enhancing pediatric mental health care: strategies for preparing a primary care practice. Pediatrics. 2010;125(suppl 3):S87–S108. doi:10.1542/peds.2010-0788E [CrossRef] PMID:20519566
  8. Weitzman C, Wegner LSection on Developmental and Behavioral PediatricsCommittee on Psychosocial Aspects of Child and Family HealthCouncil on Early Childhood; Society for Developmental and Behavioral PediatricsAmerican Academy of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems. Pediatrics. 2015;135(2):384–395. doi:10.1542/peds.2014-3716 [CrossRef] PMID:25624375
Authors

Rachel Ballard, MD
John V. Lavigne, PhD
John T. Walkup, MD

About the Guest Editors

Rachel Ballard, MD, is an Attending Psychiatrist at Ann & Robert H. Lurie Children's Hospital of Chicago and an Assistant Professor of Child and Adolescent Psychiatry and of Pediatrics at Northwestern University Feinberg School of Medicine. She completed medical school at the University of Texas Health Science Center in San Antonio (UTHSCSA), did a primary care track residency in pediatrics at the Children's National Medical Center in Washington, DC, and practiced outpatient pediatrics for 5 years before training in psychiatry and child and adolescent psychiatry at UTHSCSA. She practiced community pediatrics and child psychiatry simultaneously for 5 years before joining the faculty at Ann & Robert H. Lurie Children's Hospital of Chicago, where she is Director of Collaborative Care.

Address correspondence to Rachel Ballard, MD, via email at rballard@luriechildrens.org.

John V. Lavigne, PhD, is Chief Psychologist at Ann & Robert H. Lurie Children's Hospital of Chicago and Professor of Psychiatry and Behavioral Sciences and of Pediatrics at Northwestern University Feinberg School of Medicine. He completed a doctorate in clinical psychology at the University of Texas at Austin in 1974 and an internship at Duke University Medical School. After working for a year at Duke, he began working at Children's Memorial Hospital (now Ann & Robert H. Lurie Children's Hospital of Chicago) in 1975.

He has authored over 90 reports in respected journals as well as more than 20 book chapters, books, editorials, and reviews. His research interests have centered on the developmental psychopathology of preschooler's behavior problems, psychological aspects of chronic illness in children, and contributing to the research base underlying pediatric collaborative care. The latter work includes serving as principal investigator on National Institute of Mental Health-funded studies of the pediatrician's ability to identify preschooler's behavior problems, and the treatment of oppositional defiant disorder and attention-deficit/hyperactivity disorder in primary care settings.

Address correspondence to John V. Lavigne, PhD, via email at jlavigne@luriechildrens.org.

John T. Walkup, MD, is the Head of the Pritzker Department of Psychiatry and Behavioral Health at Ann & Robert H. Lurie Children's Hospital of Chicago and the Margaret C. Osterman Professor of Psychiatry and Behavioral Science. He also serves as Director of the Division of Child and Adolescent Psychiatry in the Department of Psychiatry and Behavioral Sciences at Northwestern University Feinberg School of Medicine.

His scholarly activity covers three main areas of investigation. His work with movement disorders, specifically Tourette syndrome and the other tic disorders, uniquely spans psychiatry, child psychiatry, and neurology. His expertise in child and adolescent psychiatry clinical trials focuses on the development and evaluation of psychopharmacological and psychosocial treatments, and lastly he has been involved in developing and evaluating interventions to reduce the large mental health disparities facing Native American youth, specifically drug use and suicide prevention.

For his work, he has been awarded three United States achievement awards for child and adolescent psychiatry, the Norbert and Charlotte Rieger Award for Academic Achievement in 2009 from the American Academy of Child and Adolescent Psychiatry, the Blanche F. Ittleson Award for Research in Child Psychiatry in 2011 from the American Psychiatric Association, and the Schonfeld Award from the American Society of Adolescent Psychiatry in 2016.

Address correspondence to John T. Walkup, MD, via email at JWalkup@luriechildrens.org.

Disclosure: John T. Walkup receives royalties from Oxford Press, Guilford Press, and Wolters Kluwer; is an advisor to the Anxiety and Depression Association of America and the Trichotillomania Learning Center; and is a member of the Board of Directors of the Tourette Association of America. The remaining authors have no relevant financial relationships to disclose.

10.3928/19382359-20200921-03

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