Mental illness affects between 14% and 20% of children and adolescents.

The prevalence is higher for those juveniles

liv- ing in poor socioeconomic circumstances. Unfortunately, the shortage of mental health providers, stigma attached
to receiv- ing mental health services, chronic underfunding, institutional barriers of the public mental health system,
and disparate insurance benefits have contributed to the fact that only 2% of these children are actually seen by
mental health specialists. About 75% of children with psychiatric disturbances are seen in primary care settings, and
half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. Parents and children often
prefer discussing these issues with someone they already know and trust. As a result, pediatric primary care
providers are compelled to play an important role in the prevention, identification, initiation, management, and
coordination of mental health care in children and adolescents.

Despite being strategically positioned as the gatekeeper for identifying these concerns, primary care providers iden-
tify fewer than 20% of children with emotional and behav- ioral problems during health supervision visits when
these concerns are also present. In addition, these problems are not identified when they begin (and are more readily
amenable to treatment). This gatekeeper role has become more important over the past decade as advances in
mental health awareness and treatment have improved opportunities for early identi- fication and intervention. This
role is especially critical since child psychiatry remains an underserved medical specialty, with only 7400 board-
certified child and adolescent psychia- trists in the United States. In contrast, the more than 50,000 board-certified
pediatricians and innumerable midlevel pedi- atric providers in the United States are in a unique position to identify
issues affecting the emotional health of children and to initiate treatment or referrals to other providers.

Mental illness affects between 14% and 20% of children and adolescents. The prevalence is higher for those juveniles
liv- ing in poor socioeconomic circumstances. Unfortunately, the shortage of mental health providers, stigma attached
to receiv- ing mental health services, chronic underfunding, institutional barriers of the public mental health system,
and disparate insurance benefits have contributed to the fact that only 2% of these children are actually seen by
mental health specialists. About 75% of children with psychiatric disturbances are seen in primary care settings, and
half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. Parents and children often
prefer discussing these issues with someone they already know and trust. As a result, pediatric primary care
providers are compelled to play an important role in the prevention, identification, initiation, management, and
coordination of mental health care in children and adolescents.

Despite being strategically positioned as the gatekeeper for identifying these concerns, primary care providers iden-
tify fewer than 20% of children with emotional and behav- ioral problems during health supervision visits when
these concerns are also present. In addition, these problems are not identified when they begin (and are more readily
amenable to treatment). This gatekeeper role has become more important over the past decade as advances in
mental health awareness and treatment have improved opportunities for early identi- fication and intervention. This
role is especially critical since child psychiatry remains an underserved medical specialty, with only 7400 board-
certified child and adolescent psychia- trists in the United States. In contrast, the more than 50,000 board-certified
pediatricians and innumerable midlevel pedi- atric providers in the United States are in a unique position to identify
issues affecting the emotional health of children and to initiate treatment or referrals to other providers.

Emotional problems that develop during childhood and adolescence can have a significant impact on develop- ment
and may continue into adulthood; in fact, most “adult” psychiatric disorders have their onset during childhood. Most

disorders do not present as an “all-or-none” phenomenon; rather, they progress from adjustment concerns to
perturba- tions in functioning to significant disturbances and severe disorders. Pediatricians have the capacity to
manage emotional problems and behavioral conditions early on, when improve- ment can be achieved with less
intensive interventions. If pedia- tricians and schools do not appropriately identify mental health problems, provide
education about the benefits of intervention, and encourage and initiate intervention, childhood-onset dis- orders are
more likely to persist, cause worsening impairment, and lead to a downward spiral of school and social difficulties,
poor employment opportunities, and poverty in adulthood, as well as increased health care utilization and costs as
adults.

Pediatricians and other pediatric care providers may be the first or sometimes only medical professional in a position
to identify a mental health problem. This chapter reviews prevention, surveillance, and screening for mental illness;
situations that may arise in the context of such assessments; illnesses that are often diagnosed during childhood or
ado- lescence; current recommendations for interventions and use of psychotropic medications; and indications for
referral to mental health professionals.

Belfer ML: Child and adolescent mental disorders: the magnitude of the problem across the globe. J Child Psychol Psychiatry
2008;49(3):226–236 [PMID: 18221350].

Costello EJ, Egger H, Angold A: 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I.
Methods and public health burden. J Am Acad Child Adolesc Psychiatry 2005;44:972–986 [PMID: 16175102].
Costello EJ, Foley DL, Angold A: 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: II.
Developmental epidemiology. J Am Acad Child Adolesc Psychiatry 2006;45(1):8–25 [PMID: 16327577].

Roberts RE, Roberts CR, Xing Y: Prevalence of youth-reported DSM-IV psychiatric disorders among African, European, and Mexican
American adolescents. J Am Acad Child Adolesc Psychiatry 2006;45(11):1329–1337 [PMID: 17075355].

185

MODELS OF CARE ENCOMPASSING MENTAL HEALTH IN THE PRIMARY CARE SETTING

Given the many barriers to receiving mental health care, new approaches to identifying concerns and providing
mental health professional services have been recently explored.

Usual or typical pediatric care of emotional and behav- ioral problems is related to the comfort level of the individ-
ual pediatric provider and available resources. The efficacy of surveillance in the form of developmentally
appropriate anticipatory guidance and counseling is variable; the aver- age time spent on surveillance is 2.5 minutes.
However, as stated earlier, the majority of emotional and behavioral problems are not identified in this model of care.
In addi- tion, when they are identified, the logistics of referral can be problematic. Although pediatricians often refer
to mental health providers, only 50% of families will actually attend an appointment and the average number of
appointments attended is only slightly greater than one. Based on level of comfort and training, the primary clinician
in this model is more likely to be responsible for psychiatric medications if prescribed.

Among the technological interventions that can enhance identification of problems and target specific symptoms for
assessment is the Child Health & Development Interactive System (CHADIS) (http://www.childhealthcare.org). In
this system, parents use a computer kiosk to note their level of concern about various behaviors, which triggers
algorithmic interviews for each concern based on psychiatric diagnostic criteria. The CHADIS system provides an
electronic work- sheet of analyzed results, school communication tools, as well as other resources.

Enhanced care is a model of care in which a pediatric developmental or behavioral specialist is embedded in the
clinic, thus making for improved referral and communi- cation and management. This “colocation” creates easier
access for patients and improved communication with men- tal health professionals.

Telephonic consultation or telepsychiatry with mental health consultation teams in a stepped care approach
allows enhanced access to mental health providers, especially for children in rural communities. The provision of
consulta- tion to pediatric care providers also allows pediatric provid- ers ongoing education with the eventual goal
of pediatric providers learning to manage these concerns on their own.

Collaborative care provides high-quality, multidisci- plinary, and collaborative care through the colocation of
educators, consultants, or direct service mental health pro- viders in the clinic. Successful collaborative care results in
greater specialist involvement by negating identification and referral and other system-of-care barriers. Successful
compo- nents include a leadership team, primary clinicians, mental health and developmental specialists,
administrators, clinical informatics specialists, and care managers. Collaborative care
implies that nearly all visits are done jointly and that mental health professionals are always available for
consultation, in contrast to the approach in the enhanced care model, which requires the scheduling of an
appointment with a mental health specialist in the practice. These interventions can be accomplished through
collaboration among mental health and primary care providers, mental health systems and primary care practices,
and in academic settings with interdepartmental collaboration. Typically, philanthropic or other foundation grants
are necessary to start a collaborative program so that reimbursement and sustainability concerns can be identified
and remedied.

Brito A et al: Bridging mental health and medical care in under- served pediatric populations: three integrative models. Adv Pediatr
2010;57(1):295–313 [PMID: 21056744].

Chenven M: Community systems of care for children’s mental health. Child Adolesc Psychiatr Clin N Am 2010;19(1):163–174 [PMID:
19951815].

Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health: Policy statement—the future of
pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009;124(1):410–421 [PMID: 19564328].

Connor DF et al: Targeted child psychiatric services: a new model of pediatric primary clinician—child psychiatry collaborative care.
Clin Pediatr 2005;45:423–434 [PMID: 16891275].

Foy J et al: Improving mental health services in primary care: reducing administrative and financial barriers to access and
collaboration. Pediatrics 2009;123(4):1248–1251

Most

disorders do not present as an “all-or-none” phenomenon; rather, they progress from adjustment concerns to
perturba- tions in functioning to significant disturbances and severe disorders. Pediatricians have the capacity to
manage emotional problems and behavioral conditions early on, when improve- ment can be achieved with less
intensive interventions. If pedia- tricians and schools do not appropriately identify mental health problems, provide
education about the benefits of intervention, and encourage and initiate intervention, childhood-onset dis- orders are
more likely to persist, cause worsening impairment, and lead to a downward spiral of school and social difficulties,
poor employment opportunities, and poverty in adulthood, as well as increased health care utilization and costs as
adults.

Pediatricians and other pediatric care providers may be the first or sometimes only medical professional in a position
to identify a mental health problem. This chapter reviews prevention, surveillance, and screening for mental illness;
situations that may arise in the context of such assessments; illnesses that are often diagnosed during childhood or
ado- lescence; current recommendations for interventions and use of psychotropic medications; and indications for
referral to mental health professionals.

Belfer ML: Child and adolescent mental disorders: the magnitude of the problem across the globe. J Child Psychol Psychiatry
2008;49(3):226–236 [PMID: 18221350].

Costello EJ, Egger H, Angold A: 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I.
Methods and public health burden. J Am Acad Child Adolesc Psychiatry 2005;44:972–986 [PMID: 16175102].

Costello EJ, Foley DL, Angold A: 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: II.
Developmental epidemiology. J Am Acad Child Adolesc Psychiatry 2006;45(1):8–25 [PMID: 16327577].

Roberts RE, Roberts CR, Xing Y: Prevalence of youth-reported DSM-IV psychiatric disorders among African, European, and Mexican
American adolescents. J Am Acad Child Adolesc Psychiatry 2006;45(11):1329–1337 [PMID: 17075355].
185

MODELS OF CARE ENCOMPASSING MENTAL HEALTH IN THE PRIMARY CARE SETTING

Given the many barriers to receiving mental health care, new approaches to identifying concerns and providing
mental health professional services have been recently explored.

Usual or typical pediatric care of emotional and behav- ioral problems is related to the comfort level of the individ-
ual pediatric provider and available resources. The efficacy of surveillance in the form of developmentally
appropriate anticipatory guidance and counseling is variable; the aver- age time spent on surveillance is 2.5 minutes.
However, as stated earlier, the majority of emotional and behavioral problems are not identified in this model of care.
In addi- tion, when they are identified, the logistics of referral can be problematic. Although pediatricians often refer
to mental health providers, only 50% of families will actually attend an appointment and the average number of
appointments attended is only slightly greater than one. Based on level of comfort and training, the primary clinician
in this model is more likely to be responsible for psychiatric medications if prescribed.

Among the technological interventions that can enhance identification of problems and target specific symptoms for
assessment is the Child Health & Development Interactive System (CHADIS) (http://www.childhealthcare.org). In
this system, parents use a computer kiosk to note their level of concern about various behaviors, which triggers
algorithmic interviews for each concern based on psychiatric diagnostic criteria. The CHADIS system provides an
electronic work- sheet of analyzed results, school communication tools, as well as other resources.

Enhanced care is a model of care in which a pediatric developmental or behavioral specialist is embedded in the
clinic, thus making for improved referral and communi- cation and management. This “colocation” creates easier
access for patients and improved communication with men- tal health professionals.

Telephonic consultation or telepsychiatry with mental health consultation teams in a stepped care approach
allows enhanced access to mental health providers, especially for children in rural communities. The provision of
consulta- tion to pediatric care providers also allows pediatric provid- ers ongoing education with the eventual goal
of pediatric providers learning to manage these concerns on their own.

Collaborative care provides high-quality, multidisci- plinary, and collaborative care through the colocation of
educators, consultants, or direct service mental health pro- viders in the clinic. Successful collaborative care results in
greater specialist involvement by negating identification and referral and other system-of-care barriers. Successful
compo- nents include a leadership team, primary clinicians, mental health and developmental specialists,
administrators, clinical informatics specialists, and care managers. Collaborative care

implies that nearly all visits are done jointly and that mental health professionals are always available for
consultation, in contrast to the approach in the enhanced care model, which requires the scheduling of an
appointment with a mental health specialist in the practice. These interventions can be accomplished through
collaboration among mental health and primary care providers, mental health systems and primary care practices,
and in academic settings with interdepartmental collaboration. Typically, philanthropic or other foundation grants
are necessary to start a collaborative program so that reimbursement and sustainability concerns can be identified
and remedied.
Brito A et al: Bridging mental health and medical care in under- served pediatric populations: three integrative models. Adv Pediatr
2010;57(1):295–313 [PMID: 21056744].

Chenven M: Community systems of care for children’s mental health. Child Adolesc Psychiatr Clin N Am 2010;19(1):163–174 [PMID:
19951815].

Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health: Policy statement—the future of
pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009;124(1):410–421 [PMID: 19564328].

Connor DF et al: Targeted child psychiatric services: a new model of pediatric primary clinician—child psychiatry collaborative care.
Clin Pediatr 2005;45:423–434 [PMID: 16891275].

Foy J et al: Improving mental health services in primary care: reducing administrative and financial barriers to access and
collaboration. Pediatrics 2009;123(4):1248–1251