AAP Task Force Report Offers Guide to Enhance Delivery of Mental Health Services

A report from the American Academy of Pediatrics Task Force on Mental Health offers clinicians a comprehensive blueprint for improving delivery of mental health care services in pediatric settings.

The 135-page document, entitled “Enhancing Pediatric Mental Health Care,” describes “what pediatricians and other primary care physicians can do at the community level, what they can do at the practice level, and how they can integrate the process of providing mental health services into the primary care flow,” Dr. Jane Meschan Foy, chair of the task force, said in an interview.

Four years in the making, the report (Pediatrics 2010; 125[suppl. 3]:S1-135) builds on three key documents previously published by the task force: “Strategies for System Change in Children's Mental Health: A Chapter Action Kit” (available at www.aap.org/mentalhealth/mh2ch.html

The new report contains three main chapters followed by eight appendices and six supplemental appendices. Together with the previous reports, it addresses three main goals set by the task force: Facilitate system changes, build skills, and incrementally change practice.”

“This is really a tour de force,” said Dr. Martin T. Stein, who was not involved in developing the report. “It's an exceptionally comprehensive, well-written, and practical guideline for including psychological/psychosocial/mental health issues in the practice of primary care pediatrics. There are many practical tools such as thinking about your referral patterns, being aware of what's available in the community, and knowing the insurance sources.

“There is also a chapter on how to code for billing for mental health services, which is a critical issue in primary care. In addition, there is a practice readiness inventory, algorithms for early recognition of conditions, and good references to support the recommendations for diagnosis and screening in primary care,” Dr. Stein, professor of pediatrics in the division of child development and community health at the University of California, San Diego, said in an interview.

Dr. Foy, professor of pediatrics at Wake Forest University, Winston-Salem, N.C., called the pediatric primary care setting “a really good place to provide mental health services. It's a place where families are comfortable, a place where they have a trusting long-term relationship with a clinician. If a child has a complex or chronic illness or disability, families know that their pediatrician can help them connect with the specialty services they need and coordinate and monitor their care.”I

In the report's first chapter, “Strategies for Preparing a Community,” the task force outlines ways to gauge the mental health needs of children and youth in the community, and emphasizes the importance of developing or strengthening relationships with mental health advocates, schools, human service agencies, mental health and substance abuse providers, and developmental specialists.

For example, clinicians “might consider initiating previsit data collection from children in foster care,” the report states. “Sharing the responsibility for previsit data collection with the foster care agency increases the likelihood that adults with knowledge of the child's mental health strengths and needs provide critical information. Many states mandate that children placed in foster care receive a mental health assessment within 1 month of placement. Primary care clinicians may participate in providing this assessment.”

In the second chapter, “Strategies for Preparing a Primary Care Practice,” the task force recommends applying principles of the chronic care model to the care of children and youth with mental health problems. One critical element is a wide variety of partnerships to support and coordinate with the services in primary care.

“There are many new models of collaborative practice,” Dr. Foy said. “We are excited about those that integrate a mental health professional into the primary care setting. They show great promise. There are a number of these now around the country.”

Dr. Foy acknowledged that while chronic care model principles have worked well in primary care for medical conditions such as asthma and diabetes, less is known about how these principles will affect the delivery of mental health care to children and youth. “We are intuitively applying this model, knowing that it has been successful, knowing that pediatricians are familiar with it, and knowing that mental health conditions and concerns are often chronic in nature,” she explained.

The third chapter, “Algorithms for Primary Care,” grew out of the work of four separate teams convened by the task force, including youth and families who have had mental health problems.

The chapter proposes a clinical process for promoting mental health, identifying mental health symptoms and concerns, engaging the family as early and effectively as possible to address emerging problems, collaborating with mental health specialists when needed, and monitoring the child's progress toward recovery or further care.

For her part, Dr. Foy said she hopes the report sends a message to pediatricians that they are well positioned to provide a broad range of mental health care services to patients and their families.

As an example, she offered the case of an anxious child who resists going to school, with a family that is not willing to seek help from a mental health specialist. A technique to try in such a case is the common factors approach, which is described in the report. “It's a way to find out how the family perceives the problem; to express sympathy, support, and empathy for them; to address any barriers that they may experience in taking action-for example, conflict within the family or stigma about seeking mental health services-and then to agree on an incremental first step that they feel comfortable with and capable of taking.”

Dr. Foy noted that pediatricians and other primary care clinicians who care for children are “in a widely varied state of readiness to follow” the recommendations contained in the report. “Some are just beginning to think about expanding their mental health practice,” she said. “Others have very sophisticated multidisciplinary approaches to mental health practice, and the majority is in between. I do think that most primary care clinicians will be able to find some action steps in the wide variety of recommendations that we have made. That is our hope, that there will be something for everybody.”

The report's appendices even include appropriate billing codes.

The report was supported by the AAP, the AAP Friends of Children Fund, and the Substance Abuse and Mental Health Services Administration. ok Dr. Foy and Dr. Stein said they had no financial conflicts of interest.

“Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit” is intended to help clinicians implement action steps from the supplement and is expected to be available for purchase soon. For more information, visit http://tinyurl.aap.org/pub112382

Nurse practitoner Beth Spangle (left), teen patient Garrett Locklear, and Dr. Jane Meschan Foy, chair of the AAP Task Force on Mental Health, confer.

Source Courtesy Wake Forest University Baptist Medical Center Photography

My Take

'Brilliant and Timely'

I'm excited to see this. If it had come out in 2004 it would have been really brilliant, but before its time. In 2010 it's extremely brilliant and timely. It really points out the ongoing change in the nature of primary care of children and families. There are behavioral concerns and mental health concerns, and the state of Massachusetts has mandated that there be mental health screening at every well-child visit.

There's not a lot in the report that surprises me, but I think that when it goes to most physicians in practice, they're going to have some “Aha!” moments, and that's a good thing. This will need to be updated over time. As we learn more, we're going to learn to identify mental health problems better, we're going to learn how to treat patients better, and we're going to learn how to collaborate better with mental health professionals.

When I talk to colleagues about this issue, one of the things I always say is, 'If you have a mental health question, ask it.' For example, I always ask about divorce adjustment. Or if I think a child looks sad, I will screen him or her for depression.

The strength of this report is that it's going to encourage people to ask those kinds of questions and do that kind of screening, because now we've given them something to do with the findings. There are algorithms, and there are ways to talk about building collaborations with mental health practitioners. I think this is a real state-of-the-art good start.

JOSEPH F. HAGAN JR., M.D., is a pediatrician in private practice in Burlington, Vt. He was one of the coeditors of the AAP's “Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 3rd ed. Dr. Hagan said that he had no conflicts of interest relevant to this topic.

A report from the American Academy of Pediatrics Task Force on Mental Health offers clinicians a comprehensive blueprint for improving delivery of mental health care services in pediatric settings.

The 135-page document, entitled “Enhancing Pediatric Mental Health Care,” describes “what pediatricians and other primary care physicians can do at the community level, what they can do at the practice level, and how they can integrate the process of providing mental health services into the primary care flow,” Dr. Jane Meschan Foy, chair of the task force, said in an interview.

Four years in the making, the report (Pediatrics 2010; 125[suppl. 3]:S1-135) builds on three key documents previously published by the task force: “Strategies for System Change in Children's Mental Health: A Chapter Action Kit” (available at www.aap.org/mentalhealth/mh2ch.html

The new report contains three main chapters followed by eight appendices and six supplemental appendices. Together with the previous reports, it addresses three main goals set by the task force: Facilitate system changes, build skills, and incrementally change practice.”

“This is really a tour de force,” said Dr. Martin T. Stein, who was not involved in developing the report. “It's an exceptionally comprehensive, well-written, and practical guideline for including psychological/psychosocial/mental health issues in the practice of primary care pediatrics. There are many practical tools such as thinking about your referral patterns, being aware of what's available in the community, and knowing the insurance sources.

“There is also a chapter on how to code for billing for mental health services, which is a critical issue in primary care. In addition, there is a practice readiness inventory, algorithms for early recognition of conditions, and good references to support the recommendations for diagnosis and screening in primary care,” Dr. Stein, professor of pediatrics in the division of child development and community health at the University of California, San Diego, said in an interview.

Dr. Foy, professor of pediatrics at Wake Forest University, Winston-Salem, N.C., called the pediatric primary care setting “a really good place to provide mental health services. It's a place where families are comfortable, a place where they have a trusting long-term relationship with a clinician. If a child has a complex or chronic illness or disability, families know that their pediatrician can help them connect with the specialty services they need and coordinate and monitor their care.”I

In the report's first chapter, “Strategies for Preparing a Community,” the task force outlines ways to gauge the mental health needs of children and youth in the community, and emphasizes the importance of developing or strengthening relationships with mental health advocates, schools, human service agencies, mental health and substance abuse providers, and developmental specialists.

For example, clinicians “might consider initiating previsit data collection from children in foster care,” the report states. “Sharing the responsibility for previsit data collection with the foster care agency increases the likelihood that adults with knowledge of the child's mental health strengths and needs provide critical information. Many states mandate that children placed in foster care receive a mental health assessment within 1 month of placement. Primary care clinicians may participate in providing this assessment.”

In the second chapter, “Strategies for Preparing a Primary Care Practice,” the task force recommends applying principles of the chronic care model to the care of children and youth with mental health problems. One critical element is a wide variety of partnerships to support and coordinate with the services in primary care.

“There are many new models of collaborative practice,” Dr. Foy said. “We are excited about those that integrate a mental health professional into the primary care setting. They show great promise. There are a number of these now around the country.”

Dr. Foy acknowledged that while chronic care model principles have worked well in primary care for medical conditions such as asthma and diabetes, less is known about how these principles will affect the delivery of mental health care to children and youth. “We are intuitively applying this model, knowing that it has been successful, knowing that pediatricians are familiar with it, and knowing that mental health conditions and concerns are often chronic in nature,” she explained.

The third chapter, “Algorithms for Primary Care,” grew out of the work of four separate teams convened by the task force, including youth and families who have had mental health problems.

The chapter proposes a clinical process for promoting mental health, identifying mental health symptoms and concerns, engaging the family as early and effectively as possible to address emerging problems, collaborating with mental health specialists when needed, and monitoring the child's progress toward recovery or further care.

For her part, Dr. Foy said she hopes the report sends a message to pediatricians that they are well positioned to provide a broad range of mental health care services to patients and their families.

As an example, she offered the case of an anxious child who resists going to school, with a family that is not willing to seek help from a mental health specialist. A technique to try in such a case is the common factors approach, which is described in the report. “It's a way to find out how the family perceives the problem; to express sympathy, support, and empathy for them; to address any barriers that they may experience in taking action-for example, conflict within the family or stigma about seeking mental health services-and then to agree on an incremental first step that they feel comfortable with and capable of taking.”

Dr. Foy noted that pediatricians and other primary care clinicians who care for children are “in a widely varied state of readiness to follow” the recommendations contained in the report. “Some are just beginning to think about expanding their mental health practice,” she said. “Others have very sophisticated multidisciplinary approaches to mental health practice, and the majority is in between. I do think that most primary care clinicians will be able to find some action steps in the wide variety of recommendations that we have made. That is our hope, that there will be something for everybody.”

The report's appendices even include appropriate billing codes.

The report was supported by the AAP, the AAP Friends of Children Fund, and the Substance Abuse and Mental Health Services Administration. ok Dr. Foy and Dr. Stein said they had no financial conflicts of interest.

“Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit” is intended to help clinicians implement action steps from the supplement and is expected to be available for purchase soon. For more information, visit http://tinyurl.aap.org/pub112382

Nurse practitoner Beth Spangle (left), teen patient Garrett Locklear, and Dr. Jane Meschan Foy, chair of the AAP Task Force on Mental Health, confer.

Source Courtesy Wake Forest University Baptist Medical Center Photography

My Take

'Brilliant and Timely'

I'm excited to see this. If it had come out in 2004 it would have been really brilliant, but before its time. In 2010 it's extremely brilliant and timely. It really points out the ongoing change in the nature of primary care of children and families. There are behavioral concerns and mental health concerns, and the state of Massachusetts has mandated that there be mental health screening at every well-child visit.

There's not a lot in the report that surprises me, but I think that when it goes to most physicians in practice, they're going to have some “Aha!” moments, and that's a good thing. This will need to be updated over time. As we learn more, we're going to learn to identify mental health problems better, we're going to learn how to treat patients better, and we're going to learn how to collaborate better with mental health professionals.

When I talk to colleagues about this issue, one of the things I always say is, 'If you have a mental health question, ask it.' For example, I always ask about divorce adjustment. Or if I think a child looks sad, I will screen him or her for depression.

The strength of this report is that it's going to encourage people to ask those kinds of questions and do that kind of screening, because now we've given them something to do with the findings. There are algorithms, and there are ways to talk about building collaborations with mental health practitioners. I think this is a real state-of-the-art good start.

JOSEPH F. HAGAN JR., M.D., is a pediatrician in private practice in Burlington, Vt. He was one of the coeditors of the AAP's “Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 3rd ed. Dr. Hagan said that he had no conflicts of interest relevant to this topic.

A report from the American Academy of Pediatrics Task Force on Mental Health offers clinicians a comprehensive blueprint for improving delivery of mental health care services in pediatric settings.

The 135-page document, entitled “Enhancing Pediatric Mental Health Care,” describes “what pediatricians and other primary care physicians can do at the community level, what they can do at the practice level, and how they can integrate the process of providing mental health services into the primary care flow,” Dr. Jane Meschan Foy, chair of the task force, said in an interview.

Four years in the making, the report (Pediatrics 2010; 125[suppl. 3]:S1-135) builds on three key documents previously published by the task force: “Strategies for System Change in Children's Mental Health: A Chapter Action Kit” (available at www.aap.org/mentalhealth/mh2ch.html

The new report contains three main chapters followed by eight appendices and six supplemental appendices. Together with the previous reports, it addresses three main goals set by the task force: Facilitate system changes, build skills, and incrementally change practice.”

“This is really a tour de force,” said Dr. Martin T. Stein, who was not involved in developing the report. “It's an exceptionally comprehensive, well-written, and practical guideline for including psychological/psychosocial/mental health issues in the practice of primary care pediatrics. There are many practical tools such as thinking about your referral patterns, being aware of what's available in the community, and knowing the insurance sources.

“There is also a chapter on how to code for billing for mental health services, which is a critical issue in primary care. In addition, there is a practice readiness inventory, algorithms for early recognition of conditions, and good references to support the recommendations for diagnosis and screening in primary care,” Dr. Stein, professor of pediatrics in the division of child development and community health at the University of California, San Diego, said in an interview.

Dr. Foy, professor of pediatrics at Wake Forest University, Winston-Salem, N.C., called the pediatric primary care setting “a really good place to provide mental health services. It's a place where families are comfortable, a place where they have a trusting long-term relationship with a clinician. If a child has a complex or chronic illness or disability, families know that their pediatrician can help them connect with the specialty services they need and coordinate and monitor their care.”I

In the report's first chapter, “Strategies for Preparing a Community,” the task force outlines ways to gauge the mental health needs of children and youth in the community, and emphasizes the importance of developing or strengthening relationships with mental health advocates, schools, human service agencies, mental health and substance abuse providers, and developmental specialists.

For example, clinicians “might consider initiating previsit data collection from children in foster care,” the report states. “Sharing the responsibility for previsit data collection with the foster care agency increases the likelihood that adults with knowledge of the child's mental health strengths and needs provide critical information. Many states mandate that children placed in foster care receive a mental health assessment within 1 month of placement. Primary care clinicians may participate in providing this assessment.”

In the second chapter, “Strategies for Preparing a Primary Care Practice,” the task force recommends applying principles of the chronic care model to the care of children and youth with mental health problems. One critical element is a wide variety of partnerships to support and coordinate with the services in primary care.

“There are many new models of collaborative practice,” Dr. Foy said. “We are excited about those that integrate a mental health professional into the primary care setting. They show great promise. There are a number of these now around the country.”

Dr. Foy acknowledged that while chronic care model principles have worked well in primary care for medical conditions such as asthma and diabetes, less is known about how these principles will affect the delivery of mental health care to children and youth. “We are intuitively applying this model, knowing that it has been successful, knowing that pediatricians are familiar with it, and knowing that mental health conditions and concerns are often chronic in nature,” she explained.

The third chapter, “Algorithms for Primary Care,” grew out of the work of four separate teams convened by the task force, including youth and families who have had mental health problems.

The chapter proposes a clinical process for promoting mental health, identifying mental health symptoms and concerns, engaging the family as early and effectively as possible to address emerging problems, collaborating with mental health specialists when needed, and monitoring the child's progress toward recovery or further care.

For her part, Dr. Foy said she hopes the report sends a message to pediatricians that they are well positioned to provide a broad range of mental health care services to patients and their families.

As an example, she offered the case of an anxious child who resists going to school, with a family that is not willing to seek help from a mental health specialist. A technique to try in such a case is the common factors approach, which is described in the report. “It's a way to find out how the family perceives the problem; to express sympathy, support, and empathy for them; to address any barriers that they may experience in taking action-for example, conflict within the family or stigma about seeking mental health services-and then to agree on an incremental first step that they feel comfortable with and capable of taking.”

Dr. Foy noted that pediatricians and other primary care clinicians who care for children are “in a widely varied state of readiness to follow” the recommendations contained in the report. “Some are just beginning to think about expanding their mental health practice,” she said. “Others have very sophisticated multidisciplinary approaches to mental health practice, and the majority is in between. I do think that most primary care clinicians will be able to find some action steps in the wide variety of recommendations that we have made. That is our hope, that there will be something for everybody.”

The report's appendices even include appropriate billing codes.

The report was supported by the AAP, the AAP Friends of Children Fund, and the Substance Abuse and Mental Health Services Administration. ok Dr. Foy and Dr. Stein said they had no financial conflicts of interest.

“Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit” is intended to help clinicians implement action steps from the supplement and is expected to be available for purchase soon. For more information, visit http://tinyurl.aap.org/pub112382

Nurse practitoner Beth Spangle (left), teen patient Garrett Locklear, and Dr. Jane Meschan Foy, chair of the AAP Task Force on Mental Health, confer.

Source Courtesy Wake Forest University Baptist Medical Center Photography

My Take

'Brilliant and Timely'

I'm excited to see this. If it had come out in 2004 it would have been really brilliant, but before its time. In 2010 it's extremely brilliant and timely. It really points out the ongoing change in the nature of primary care of children and families. There are behavioral concerns and mental health concerns, and the state of Massachusetts has mandated that there be mental health screening at every well-child visit.

There's not a lot in the report that surprises me, but I think that when it goes to most physicians in practice, they're going to have some “Aha!” moments, and that's a good thing. This will need to be updated over time. As we learn more, we're going to learn to identify mental health problems better, we're going to learn how to treat patients better, and we're going to learn how to collaborate better with mental health professionals.

When I talk to colleagues about this issue, one of the things I always say is, 'If you have a mental health question, ask it.' For example, I always ask about divorce adjustment. Or if I think a child looks sad, I will screen him or her for depression.

The strength of this report is that it's going to encourage people to ask those kinds of questions and do that kind of screening, because now we've given them something to do with the findings. There are algorithms, and there are ways to talk about building collaborations with mental health practitioners. I think this is a real state-of-the-art good start.

JOSEPH F. HAGAN JR., M.D., is a pediatrician in private practice in Burlington, Vt. He was one of the coeditors of the AAP's “Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 3rd ed. Dr. Hagan said that he had no conflicts of interest relevant to this topic.