Do Pediatricians Think They Are Responsible for Identification and Management of Child Mental Health Problems? Results of the AAP Periodic Survey
Department of Pediatrics, Albert Einstein College of Medicine/Children's Hospital at Montefiore, Bronx 10467, NY, USA. Ambulatory Pediatrics
(Impact Factor: 2.49).
01/2008; 8(1):11-7. DOI: 10.1016/j.ambp.2007.10.006
Childhood psychosocial problems have profound effects on development, functioning, and long-term mental health. The pediatrician is often the only health professional who regularly comes in contact with young children, and it is recommended that health care supervision should include care of behavioral and emotional issues. However, it is unknown whether pediatricians believe they should be responsible for this aspect of care. Our objective was to report the proportion of physicians who agree that pediatricians should be responsible for identifying, treating/managing, and referring a range of behavioral issues in their practices, and to examine the personal physician and practice characteristics associated with agreeing that pediatricians should be responsible for treating/managing 7 behavioral issues.
The 59th Periodic Survey of members of the American Academy of Pediatrics was sent to a random sample of 1600 members. The data that are presented are based on the responses of 659 members in current practice and no longer in training who completed the attitude questions.
More than 80% of respondents agreed that pediatricians should be responsible for identification, especially for attention-deficit/hyperactivity disorder (ADHD), eating disorders, child depression, child substance abuse, and behavior problems. In contrast, only 59% agreed that pediatricians were responsible for identifying learning problems. Seventy percent thought that pediatricians should treat/manage ADHD; but for other conditions, most thought that their responsibility should be to refer. Few factors were consistently associated with higher odds of agreement that pediatricians should be responsible for treating/managing these problems, except for not spending their professional time exclusively in general pediatrics.
These data suggest that pediatricians think that they should identify patients for mental health issues, but less than one-third agreed that it is their responsibility to treat/manage such problems, except for children with ADHD. Those not working exclusively in general pediatrics were more likely to agree that pediatricians should be responsible for treating and managing children's mental health problems.
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- "As an example, knowing that managing depression is seen as significantly more work than routine care suggests that recent calls for the expansion of depression screeningmay need to be paired with additional support or payment, at least initially. Pediatricians may feel that their current skill-set does not include depression-specific skills, and they may worry about self-harm, even when patients do not report those thoughts. Two results suggest opportunities for promoting integration of mental health into primary care. "
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ABSTRACT: Background: To further efforts to integrate mental health and primary care, this study develops a novel approach to quantifying the amount and sources of work involved in shifting care for common mental health problems to pediatric primary care providers. Methods: Email/web-based survey of a convenience sample (n = 58) of Maryland pediatricians (77 % female, 58 % at their site 10 or more years; 44 % in private practice, 52 % urban, 48 % practicing with a co-located mental health provider). Participants were asked to review 11 vignettes, which described primary care management of child/youth mental health problems, and rate them on an integer-based ordinal scale for the overall amount of work involved compared to a 12th reference vignette describing an uncomplicated case of ADHD. Respondents were also asked to indicate factors (time, effort, stress) accounting for their ratings. Vignettes presented combinations of three diagnoses (ADHD, anxiety, and depression) and three factors (medical co-morbidity, psychiatric co-morbidity, and difficult families) reported to complicate mental health care. The reference case was pre-assigned a work value of 2. Estimates of the relationship of diagnosis and complicating factors with workload were obtained using linear regression, with random effects at the respondent level. Results: The 58 pediatricians gave 593 vignette responses. Depression was associated with a 1.09 unit (about 50 %) increase in work (95 % CL .94, 1.25), while anxiety did not differ significantly from the reference case of uncomplicated ADHD (p = .28). Although all three complicating factors increased work ratings compared with the reference case, family complexity and psychiatric co-morbidity did so the most (.87 and 1.07 units, respectively, P < .001) while medical co-morbidity increased it the least (.44 units, p < .001). Factors most strongly associated with increased overall work were physician time, physician mental effort, and stress; those least strongly associated were staff time, physician physical effort, and malpractice risk. Pediatricians working with co-located mental health providers gave higher work ratings than did those without co-located staff. Conclusions: Both diagnosis and cross-diagnosis complicating factors contribute to the work involved in providing mental health services in primary care. Vignette studies may facilitate understanding which mental health services can be most readily incorporated into primary care as it is presently structured and help guide the design of training programs and other implementation strategies.
Available from: Stacy Sterling
- "Providers also may not feel that behavioral health problems, particularly AOD problems, fall within their purview. A recent survey of pediatricians found that, while the majority (88%) felt that they should be responsible for identifying substance abuse among their patients, very few (21%) felt that they should be responsible for the treatment and management of those problems, preferring instead to refer such patients to other providers for treatment (90%) . This is in spite of the fact that many primary care providers also express skepticism about the effectiveness of specialty AOD treatment. "
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This paper used data from a study of pediatric primary care provider (PCP) screening practices to examine barriers to and facilitators of adolescent alcohol and other drug (AOD) screening in pediatric primary care.
A web-based survey (N = 437) was used to examine the influence of PCP factors (attitudes and knowledge, training, self-efficacy, comfort with alcohol and drug issues); patient characteristics (age, gender, ethnicity, comorbidities and risk factors); and organizational factors (screening barriers, staffing resources, confidentiality issues) on AOD screening practices. Self-reported and electronic medical record (EMR)-recorded screening rates were also assessed.
More PCPs felt unprepared to diagnose alcohol abuse (42%) and other drug abuse (56%) than depression (29%) (p < 0.001). Overall, PCPs were more likely to screen boys than girls, and male PCPs were even more likely than female PCPs to screen boys (23% versus 6%, p < 0.0001). Having more time and having other staff screen and review results were identified as potential screening facilitators. Self-reported screening rates were significantly higher than actual (EMR-recorded) rates for all substances. Feeling prepared to diagnose AOD problems predicted higher self-reported screening rates (OR = 1.02, p <0.001), and identifying time constraints as a barrier to screening predicted lower self-reported screening rates (OR = 0.91, p < 0.001). Higher average panel age was a significant predictor of increased EMR-recorded screening rates (OR = 1.11, p < 0.001).
Organizational factors, lack of training, and discomfort with AOD screening may impact adolescent substance-abuse screening and intervention, but organizational approaches (e.g., EMR tools and workflow) may matter more than PCP or patient factors in determining screening.
Available from: Gerd Schulte-Körne
- "Given the serious consequences, early recognition of major as well as minor depression is of great importance. Since the majority of depressive patients experience somatic symptoms, general practitioners and pediatricians are often the first to be consulted by a young person . Hence, they can play a key role in the course of the illness  . "
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ABSTRACT: This study investigated the criterion validity of the WHO-Five Well-Being Index (WHO-5) in screening for depression in pediatric care.
A total of 446 children aged 9 to 12 and 324 adolescents aged 13 to 16, recruited from pediatric hospitals, completed the WHO-5 and a structured diagnostic interview serving as the gold standard. Diagnoses of depressive disorder included major depression and minor depression. Criterion validity was analyzed using the area under the receiver operating curve (AUC). Sensitivity and specificity were computed for optimal cutoffs. Additionally, unaided clinical diagnoses of depression made by the attending pediatricians were assessed.
Diagnoses of depressive disorder were established for 3.6% of children and 11.7% of adolescents. AUCs were .88 for the child and .87 for the adolescent sample. A cutoff score of 10 for children maximized sensitivity (.75) and specificity (.92). For the adolescent sample, decreasing the cutoff score to 9 yielded optimal sensitivity (.74) and specificity (.89). Sensitivity of the unaided clinical diagnosis of depression was .09, while specificity was .96.
The WHO-5 demonstrated good diagnostic accuracy for both age groups. Further evidence is needed to support the feasibility of the WHO-5 as a depression screening instrument used in pediatric care.
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