Synopsis: A recent study finds that about 35 percent of children receiving treatment for mental health issues are being treated only by a primary care physician. This is due in part to a shortage in pediatric mental health care providers as well as a stigma in consulting them. Experts discuss readiness of pediatricians to treat mental illness in children and adolescents and efforts to be sure they’re prepared.

Host: Reed Pence. Guests: Dr. Jeanne Van Cleve, Assistant Professor of Pediatrics, Harvard Medical School and Massachusetts General Hospital for Children; Dr. Douglas Tynan, clinical psychologist, American Psychological Association; Dr. Scott Benson, child & adolescent psychiatrist, Pensacola, FL

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Children’s Mental Health Treatment

Reed Pence: Most of us don’t think of children when we think of mental illnesses. However, many of the disorders most familiar to us often start in adolescence. And others that you might not think of as mental health conditions occur primarily in kids. So as it turns out, there are more mental illnesses in children than psychologists and psychiatrists can handle.

Jeanne Van Cleave: The studies vary somewhat, but in general most people agree that 10-20% of school age children and adolescents have a mental health condition that impairs their functioning on a day-to-day basis.

Pence: That’s Dr. Jeanne Van Cleave, Assistant Professor of Pediatrics at the Harvard Medical School and MassGeneral Hospital for Children.

Van Cleave: The most common mental health conditions that children and adolescence age group have are Attention Deficit Hyperactivity Disorder, depression, and anxiety. ADHD is the one we often hear about, that’s the one more common in school age children, so the 6-12 age group, and then as you get to older age groups, depression starts to become more prevalent.

Pence: It’s important that those illnesses are treated, because they generally only get worse with time. But often treatment doesn’t happen at all, according to Dr. Douglas Tynan, a clinical psychologist with the American Psychological Association.

Dr. Douglas Tynan:  We know that in any given year the majority of children who need mental health services don’t receive those services. That has been essentially unchanged for decades. Frequently pediatricians and family practice doctors will try to treat and try to counsel the parents, refer to services within school systems, refer to services in the community, but more often than not, kids don’t receive the services.

Pence:  The reasons children don’t see a mental health professional are many. One is insurance. Sometimes it doesn’t cover mental health services adequately. There’s also a severe shortage of child psychologists and psychiatrists. Often only larger communities have any at all. Dr. Scott Benson is a child and adolescent psychiatrist in Pensacola, Florida.

Benson: You drive an hour and there’s nobody; there’s nothing. In those situations you might have a primary care physician, but they would have a real hard time finding a mental health professional in that community. So, for many families they have to drive a long time. Many communities have a shortage of child psychiatrists or other mental health professionals who could do an adequate evaluation. That’s a real problem.       

Pence: Benson and Tynan say another major problem is the stigma of seeking help from a psychologist or psychiatrist.

Tynan: Half of all referrals from pediatricians and family practice physicians and nurse practitioners, half the time when they refer parents to a mental health agency or a mental health practice, the parents do not follow through on that.

Benson: Some families take to that, some families feel very threatened by that because the stigma of having a mental illness is more than they can stomach. Years ago I had a parent – I was evaluating a child in a hospital who had lots of chronic headaches. To my evaluation there were psychiatric issues that were contributing. The father looked at me and said, “I would rather my child have a brain tumor than any kind of psychiatric problem.” And I thought, I wouldn’t wish that on my child or anyone.

Pence: As a result of those reasons and more, about 35% of children with mental health issues get treatment for them only from their primary care physician. That’s usually a pediatrician, according to Van Cleave’s study in the journal Pediatrics.

Van Cleave: There just aren’t enough child psychiatrists to treat everybody. So, in that sense primary care is a good place to bolster efforts for treatment for children with mild to moderate conditions. As a pediatrician I am always interested in how my patients are doing psychologically, how they’re doing in school, how they’re functioning with their friends, how they’re families are functioning. Mental health conditions affect all of that, so it’s perfectly naturally for me to ask about it and want to do something about it.

Benson: I think that’s pretty standard. When we look at prescriptions of psychiatric medicines in the adult populations, 80% of those prescriptions are written in primary care settings, either internal medicine, family physicians, pediatricians. And as a psychiatrist I’m certainly comfortable with that because so many of the conditions that are so prevalent a physicians with a busy practice is going to meet many people who have these condition. Just in the same way we would expect a pediatrician to have good skills with treating bladder infections or a thyroid problem, we certainly hope that they’ve had sufficient training so that they can treat attention problems, they can treat a lot of the anxiety problems that are successfully treated in primary care setting. Some children with depression can be treated in that setting as well.

Pence: Some people might question whether pediatricians are qualified to treat mental health conditions, and wonder if a psychologist or psychiatrist is required. But Van Cleave says for primary care doctors, mental health isn’t really any different than any other health issue.

Van Cleave: Pediatricians are, in general, qualified to provide mental health care, but with the caveat that there has to be support for improving the quality of mental health care and primary care and also access to mental health specialists for advice, and access to therapists for treatment so that they can get their patients seen in a timely fashion. With any condition, primary care is a great source for standard common conditions. As the case gets more complex then you need the help of a specialist.

Pence: However, that’s the way it is with any health issue. A primary care doctor’s decision to refer to a specialist isn’t unique to mental health. The decision will vary from one doctor to another.

Van Cleave: Some pediatricians and primary care providers have a greater level of comfort with one condition versus others. Certainly the more open you are to working with your patients providing mental health care in primary care, the more experience you get with it. The decision to refer to a specialist, usually we refer complex conditions, conditions where we’re not sure what the diagnosis is; sometimes the referrals are for the psychiatrist to take over treatment and to provide long-term care. Some of the referrals are for a psychiatrist to examine the case and provide advice about where the primary care doctor can go for the next step.

Tynan: Most pediatricians are comfortable with ADHD treatment. There’s a large number who are comfortable with treating with antidepressants. I think when kids have more complex disorders or do not respond well – the initial medication trials, then those pediatricians almost always then refer to a child psychiatrist or sometimes a pediatric neurologist if you live in an area where there are no child psychiatrists. I think over half the counties in the United States do not have a child psychiatrist. There are big swatches of the country where the pediatrician will refer to whatever specialist that are able to manage these more complex medication regimens.

Pence: Pediatrics as a field has recognized that more and more kids’ doctors are being called on to provide mental health care. So they’ve put a considerable amount of money and effort into training pediatricians to do it right.

Van Cleave: There are a lot of resources from the American Academy of Pediatrics for pediatricians. Pediatricians have a tool kit that they can use for mental health problems and for ADHD specifically. There are also guidelines for treatments of depression in primary care for adolescents. Also, in several areas of the country there are programs where pediatricians and other primary care providers can call a psychiatrist and get advice about a patient that they are seeing.

Pence: However, Benson says one problem that gets in the way for many primary care doctors is the lack of time.

Benson: An adequate evaluation for a psychiatric issue takes time. What I hear from so many of my colleagues that are working in primary care settings as pediatricians or family physicians is that somehow their schedules get so jammed up and they feel so rushed and there are so many adolescents that need to be seen, that they they don’t feel like they can carve the time out of their schedule to really spend the time getting enough history from the parents about what’s going on with this child. Part of the evaluation is spending time alone with the child to see what their take on the issue is, or certainly engaging with the child, being sure that they’ve had enough opportunity to talk about what’s going on. With children who have attention problems there has to be some effort to reach out and collaborate with the school.

Pence: Benson says in many cases getting medication adjusted correctly also takes several visits. Increasingly, primary care physicians are seeking to address problems and improve care by collaborating with mental health professionals.

Van Cleave: Care coordination is often vey beneficial for patients because all of their providers can be on the same page with the same treatment goals and be looking out for whether patients are improving or having side effects from a treatment or where a treatment is just not working and you have to take another route. The more care coordination that can happen is usually of benefit. There’s a push now to have greater collaboration with mental health providers in one’s community. There is even a push to get therapists to work in primary care practices to treat the panel of patients that the primary care practice takes care of. Now there’s opportunity for great collaboration because mental health provider and the primary care provider are working side by side.

Pence: Tynan says much of the stigma is also eliminated by having psychologists, psychiatrists, and social workers under the same roof as the primary care doctor.

Tynan:  Since most of my work is in integrative care, and that is where you embed the mental health professional within the primary care office, in that type of situation about 85% of the parents will follow through on an appointment. So there is this stigma and reticence to go to another provider, to another office, park in a different parking lot and meet different front desk staff and tell their story all over again. I think parents are much more likely to follow through if the mental health provider is embedded within the primary care office or if the providers embedded within their school.

Pence: Some people are troubled by another of Van Cleave’s findings – that primary care doctors are more likely than psychiatrists to put kids on mood altering medications. According to the study nearly three-quarters of kids with ADHD were prescribed a medication by a primary care physician. Van Cleave speculates that psychiatrists may prescribe fewer meds because they’re seeing more children who didn’t respond to medication in the first place. Benson says the finding doesn’t bother him. There’s been more research into the safety of ADHD medications than any other drug given to children.

Benson: The one thing that surprised me most was that there were so few children being treated with medicine because medicine is the standard of care. It has the best evidence base for treatment, and if the child truly has ADHD, then medicine has the best evidence base. So then it’s puzzling – hmm, what are we doing with these children? But that’s okay; there are lots of children with presentations that need treatment.

Tynan: A lot of discussion about psychiatry has to do with medication. Medication is just one part of intervening in children’s lives. The critical elements are screening and detecting early, because we know if we treat problems early they don’t get worse, that kids typically do not grow out of these things, they tend to get worse. Secondly, there are a lot of effective child psychotherapies, parenting therapies, parenting approaches that do bring about permanent long-term, positive change. There are also a lot of life style variables, including getting enough sleep, exercise, all the things your grandmother told you that are critically importantly. Medication is important for treating significant psychiatric disorders, but I really need to emphasize that it’s one piece of a more complex puzzle and to work on that puzzle we need input from parents, from teachers, from counselors, from psychologists, from pediatricians, and a consulting psychiatrists. We really have to work as a team.

Pence: Pediatricians are trained to take a whole child approach. That includes mental health. So all of our experts say primary care is a very good first step at getting help for a child or adolescent who appears to be having mental health issues. You can find out more about all of our guests through links on our website, where you can also find archives of our shows. You’ll also find them on iTunes and Stitcher. I’m Reed Pence.


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