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The provider system for children's mental health: Workforce capacity and effective treatment
Abstract
This issue brief examines two issues that are key to meeting children's unmet needs for mental health care: ensuring that the provider supply is adequate and that the care delivered is effective. It describes the shortage of qualified providers to address children's mental disorders, as well its possible causes; it describes how managed care, to a certain extent, drives practice patterns; and it discusses the gray areas in deciding which providers are most qualified to deliver what care. In addition, this paper introduces what is known about evidence-based care in children's mental health, the extent to which it is being taught and practiced, the extent to which health plans are adopting such practices, and the effect such strategies may have on the makeup of the children's mental health provider field.
... Currently, a key component of the care of children and adolescents with mental disorders is the prescription of psychotropic medications. During the 1990s, the development of new medications such as selective serotonin reuptake inhibitors for the treatment of mental illness triggered significant growth in the rate of psychotropic prescriptions for children and adolescents, with prescription rates tripling between 1987 and 1996 (Koppelman, 2004). ...
... Many steps have been taken in an effort to support NPs, as well as pediatricians and psychologists, to provide children's psychiatric care. There has been a shift in pediatric training in which residency programs are increasing behavioral and developmental requirements and a subspecialty in developmental and behavioral pediatrics has been created ( Koppelman, 2004). Another shift is a recent increase in the number of advanced practice nursing programs available and the creation of psychiatric specialties in advanced practice nursing (Delaney, 2008). ...
... Prescribing rights have been granted to nonphysicians such as psychologists who complete specialized training in certain states, and NPs and other advanced practice nurses also have prescribing rights, including for psychotropic medications, in 50 states and the District of Columbia (National Alliance on Mental Illness, 2002). However, it is estimated that pediatricians and family physicians prescribe 85% of all psychotropic medications taken by children (Koppelman, 2004), and fewer than two thirds of advanced practice psychiatric nurses with prescribing authority were using that authority to prescribe (Campbell et al., 1998). ...
The high prevalence of child and adolescent mental health disorders coupled with shortages in age-appropriate mental health services pose a significant problem likely to be exacerbated over time. A survey was designed to identify the current status of and need for child and adolescent psychiatrists (CAPs) and mental health services, as well as strategies and recommendations to address identified needs in the state of New York. Key informants from each county and New York City were surveyed by telephone (N = 58). Most respondents identified a shortage of child and adolescent psychiatry services and reported that when CAPs are unavailable, nurse practitioners (NPs) are currently among the top four professional groups who prescribe and/or monitor psychotropic medication. Almost half of the respondents (48%) identified employing NPs with advanced certification in child and adolescent psychiatry as a promising strategy to improve access to care. Addressing the shortage of CAPs can provide an opportunity for the nursing profession to advance its role in the provision of mental health services to youth.
... Currently, a key component of the care of children and adolescents with mental disorders is the prescription of psychotropic medications. During the 1990s, the development of new medications such as selective serotonin reuptake inhibitors for the treatment of mental illness triggered significant growth in the rate of psychotropic prescriptions for children and adolescents, with prescription rates tripling between 1987 and 1996 (Koppelman, 2004). ...
... Many steps have been taken in an effort to support NPs, as well as pediatricians and psychologists, to provide children's psychiatric care. There has been a shift in pediatric training in which residency programs are increasing behavioral and developmental requirements and a subspecialty in developmental and behavioral pediatrics has been created ( Koppelman, 2004). Another shift is a recent increase in the number of advanced practice nursing programs available and the creation of psychiatric specialties in advanced practice nursing (Delaney, 2008). ...
... Prescribing rights have been granted to nonphysicians such as psychologists who complete specialized training in certain states, and NPs and other advanced practice nurses also have prescribing rights, including for psychotropic medications, in 50 states and the District of Columbia (National Alliance on Mental Illness, 2002). However, it is estimated that pediatricians and family physicians prescribe 85% of all psychotropic medications taken by children (Koppelman, 2004), and fewer than two thirds of advanced practice psychiatric nurses with prescribing authority were using that authority to prescribe (Campbell et al., 1998). ...
The high prevalence of child and adolescent mental health disorders coupled with shortages in age-appropriate mental health services pose a significant problem likely to be exacerbated over time. A survey was designed to identify the current status of and need for child and adolescent psychiatrists (CAPs) and mental health services, as well as strategies and recommendations to address identified needs in the state of New York. Key informants from each county and New York City were surveyed by telephone (N = 58). Most respondents identified a shortage of child and adolescent psychiatry services and reported that when CAPs are unavailable, nurse practitioners (NPs) are currently among the top four professional groups who prescribe and/or monitor psychotropic medication. Almost half of the respondents (48%) identified employing NPs with advanced certification in child and adolescent psychiatry as a promising strategy to improve access to care. Addressing the shortage of CAPs can provide an opportunity for the nursing profession to advance its role in the provision of mental health services to youth.
... Department of Health and Human Services, 1999, President_s New Freedom Commission on Mental Health, 2003). It could be argued that the shortage of child and adolescent psychiatrists may be addressed in part through the increased numbers of related mental health and primary care practitioners (Koppelman, 2004). Even the role of prescribing psychotropic medication is shared with pediatricians. ...
... In this case and others, the role of child and adolescent psychiatrists as part of the mental health care system for youth remains essential. The calls for increased recruitment efforts and policies that support and provide incentives for child mental health professionals are certainly warranted (Kim, 2003; Koppelman, 2004), but the trends found in the present study indicate that they are insufficient in reducing the shortage of child and adolescent psychiatrists for the foreseeable future. Efforts to date also have not addressed the basic disparities for children living in rural or impoverished areas in access to child and adolescent psychiatric care. ...
The national shortage of child and adolescent psychiatrists has prompted efforts to improve recruitment. It is uncertain whether these efforts will be sufficient to address this shortage and its impact on youth mental health services.
Data were compared from 1990 to 2001 by state, county characteristics, number of youths, and percentage of youths living in poverty to determine any changes in the number and distribution of child and adolescent psychiatrists. Trends in the number of residents and age distribution of child and adolescent psychiatrists were also analyzed.
The number of child and adolescent psychiatrists has increased, but it still falls below estimates projected to adequately serve youth mental health needs. Disparities in child and adolescent psychiatrist distribution persist, with significantly fewer in rural counties or counties with a high percentage of children living in poverty. The age of child and adolescent psychiatrists has shifted, with fewer below age 35. The number of residents in training has not changed significantly since 1995.
The shortage of child and adolescent psychiatrists remains and is still accentuated for those living in rural areas or in poverty. Despite the increased number of child and adolescent psychiatrists, the number of residents and changes in workforce age indicate that the shortage will continue.
... Despite a recognized shortage of child and adolescent psychiatrists (CAPs), the number of residents in psychiatry choosing the subspecialty has not changed significantly since 1995 [1]. According to the American Medical Association, there were approximately 8,000 child and adolescent psychiatrists in the United States in 2013. ...
Objective
Since 2002, the Klingenstein Third Generation Foundation (KTGF) has supported a network of medical student mentorship programs (MSMPs) across the USA with the explicit aim of enhancing interest in, and eventual recruitment into the field of child and adolescent psychiatry (CAP). The authors conducted a multisite, retrospective cohort analysis to examine the impact of the program on career selection, as reflected by graduation match rates into psychiatry or pediatrics.Methods
The authors collected graduating match information (2008–2019) from fourteen participating medical schools (Exposed) and thirteen non-participating schools (Control). Control schools were selected based on region, comparable student body and faculty size, national standing, and rank in NIH funding. Match rates into psychiatry and pediatrics were compared between Exposed and Control groups.ResultsExposed schools had significantly higher match rates into psychiatry as compared to unexposed schools (6.1% and 4.8%, respectively; OR [95%CI] = 1.29 [1.18, 1.40]; X2 = 32.036, p < 0.001). In contrast, during the same time period, exposed schools had significantly lower match rates into pediatrics than unexposed ones (11.6 and 10.5%, respectively; OR [95%CI] = 0.89 (0.83, 0.95); X2 = 12.127, p < 0.001). These findings persisted even after adjustment for secular trends in match rates.Conclusions
Seventeen years after its inception, the KTGF medical student mentorship program network has had a positive impact on match rates into general psychiatry. Future studies will address whether these results translate to trainees’ eventual selection of careers in CAP.
... The asymmetry created by separate service systems (i.e., pediatric and mental health clinics) responsible for providing care to children with mental health needs creates difficult challenges for caregivers seeking services for their children. This includes lengthy waitlists delaying service initiation (Koppelman, 2004;McKay & Bannon, 2004), poorly coordinated care (Heflinger, 1996;Saxe, Cross, & Silverman, 1988), a poorly trained workforce providing ineffective services (Huang, Macbeth, Dodge, & Jacobstein, 2004;Weissman et al., 2006), piecemeal service plans (Vernberg, E. M., Roberts, M. C., & Nyre, J. E., 2002), and other significant barriers to access and continuity (Kataoka, Zhang, & Wells, 2002). ...
Disruptive behavior disorders (DBDs) are chronic, impairing, and costly behavioral health conditions that are four times more prevalent among children of color living in impoverished communities as compared to the general population. This disparity is largely due to the increased exposure to stressors related to low socioeconomic status including community violence, unstable housing, under supported schools, substance abuse, and limited support systems. However, despite high rates and greater need, there is a considerably lower rate of mental health service utilization among these youth. Accordingly, the current study aims to describe a unique model of integrated health care for ethnically diverse youth living in a New York City borough. With an emphasis on addressing possible barriers to implementation, integrated models for children have the potential to prevent ongoing mental health problems through early detection and intervention.
... Given their tremendous potential, it is problematic that beyond the boundaries of the nursing community, there are significant gaps in the awareness of the capabilities of the APPN workforce. Nursing is often left out of federal mental health policy statements (Delaney, 2008) and holds a weak presence in mental health workforce development and planning dialogue at the national level (Koppelman, 2004;Scheffler & Kirby, 2003). There are several potential reasons for this oversight. ...
... Health pro- fessionals with a doctoral degree may avoid referrals to social workers who lack the PhD because they are unsure of social workers' qualifications to deliver psychotherapy. Rather than focusing on solutions that all the primary mental health professions might offer to address the shortage of children's mental health clinicians, social closure by virtue of educational degree is found in some psychologists' and psychiatrists' discussions of the children's mental health workforce (Black & Nabors, 2004;Blount, DeGirolamo, & Mariani, 2006;Campo, 2004;Koppelman, 2004). Although it is often pre- sumed that professionals with higher degrees would deliver better quality health services, in the case of psychotherapy, the research literature suggests otherwise. ...
While many child mental health issues manifest themselves in primary care, few pediatricians have received mental health training, and their communication with social workers may be limited due to unfamiliarity with mental health professions. The purpose of this study was to use ethnographic interviews to investigate factors affecting communication satisfaction between social workers and pediatricians. The study found that scope of practice issues were a communication barrier. This barrier is significant because health reform may lead social workers and pediatricians to collaborate more frequently in the future.
... Corporate funds are not available to support the dissemination of efficacious psychotherapies. In addition, the public policy failures that have created a dysfunctional child mental health workforce 3 have contributed significantly to the misuse of child and adolescent psychiatrists as full-time psychopharmacologists. ...
... In the three decades since, a number of initiatives have been undertaken to boost the supply of behavioral health providers, but shortages of many specialists, including psychiatrists and psychologists, appear to be growing. 35 These shortages are particularly pronounced for certain population groups such as children and adolescents 36 and for geographic areas, particularly rural areas and inner city areas. 24 While integration has been promoted as one solution to these historic shortages, an adequate supply and distribution of behavioral health specialists is necessary to support the integration of these services. ...
... The regular presence of an MHC in primary care settings increases the physicians' familiarity, knowledge, and competence with mental health concerns. The extension of doctors' knowledge is important because there are not enough child MHCs to meet the demand for mental health services (Koppelman, 2004 ). Consequently , a pediatrician whose mental health knowledge has grown due to collaboration with an MHC may be more likely to implement comprehensive, multimodal treatment for ADHD by working with an MHC, rather than relying on medication alone. ...
As primary care physicians, pediatricians are often called upon to address attention-deficit hyperactivity disorder (ADHD) (Epstein et al., 2007; National Institute of Mental Health, 2010; Shaffer et al., 1996; U.S. Department of Health and Human Services, 1999). Indeed, at least 50% of patients with ADHD are not treated for ADHD by a mental health specialist, but are instead evaluated and managed in primary care settings (Leslie, Stallone, Weckerly, McDaniel, & Monn, 2006; Leslie, Weckerly, Plemmons, Landsverk, &
Eastman, 2004).
... Sufficient ability to treat children and adolescents in need of behavioral health treatment has been highlighted as a concern for some time [22,[30][31][32][33][34]. Although not all practitioners in this MBHO demonstrate this expertise as part of their credentialing application, it is fairly common, with two out of five practitioners expert in treating children and three out of five expert in treating adolescents. ...
Background
Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO.
Methods
Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners.
Results
About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents.
Conclusions
Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce.
... I n California, youths who need mental health treatment face a patchwork of programs and financing structures, which are the result of changes in private insurance coverage, limited community-based services, and reductions in public funding (1)(2)(3)(4). These inadequate systems of mental health care are accompanied by a long-standing shortage of mental health professionals qualified to treat youths (5)(6)(7)(8), as well as an increasing reluctance by primary care physicians to treat pediatric psychiatric disorders (9)(10)(11), particularly amid growing concerns about the safety of psychopharmacologic treatments for youths (12)(13)(14). For youths who are seriously ill with psychiatric conditions, unfavorable reimbursement rates have caused private-sector beds to decline in number. ...
This study examined patient, hospital, and county characteristics associated with hospitalization after emergency department visits for pediatric mental health problems.
Retrospective analysis of emergency department encounters (N=324,997) of youths age five years to 17 years with psychiatric diagnoses was conducted with 2005-2009 California Office of Statewide Health Planning and Development emergency department statewide data.
For youths with any psychiatric diagnosis, 23.4% of emergency department encounters resulted in hospitalization. In these cases, hospitalization largely was predicted by clinical need. Nonclinical factors that decreased the likelihood of hospitalization included demographic characteristics (such as younger age, lack of insurance, and rural residence) and resource characteristics (private hospital ownership, lack of psychiatric consultation in the emergency department, and lack of pediatric psychiatric beds). For youths with a significant psychiatric diagnosis plus a suicide attempt, 53.8% of emergency department encounters resulted in hospitalization. In these presumably more life-threatening cases, nonclinical factors that decreased the likelihood of hospitalization persisted: demographic characteristics (lack of insurance and rural residence) and resource characteristics (public hospital ownership, lack of psychiatric consultation, and lack of pediatric psychiatric beds).
Mental health service delivery can improve only by addressing nonclinical demographic and resource obstacles that independently decrease the likelihood of hospitalization after an emergency department visit for a mental health issue; this is true even for the most severely ill youths-those with a suicide attempt as well as a serious psychiatric diagnosis. (Psychiatric Services 63:896-905, 2012; doi: 10.1176/appi.ps.201000482).
... This lack of service reflects the long-standing shortage of child and adolescent mental health professionals. After the Surgeon General's report, former President Bush's New Freedom Commission on Mental Health confirmed the inadequate supply of child and adolescent mental health professionals [42]. To illustrate this shortage, in Florida in 2001, there were only 255 child psychiatrists for a child and adolescent population (birth to 17 years of age) of 3.6 million. ...
In pediatric primary care, the term mental health should be taken to include child and family psychosocial needs across a wide spectrum. Mental illness therefore includes developmental, behavioral, emotional, and cognitive dysfunction. Quantifying the number of children with a mental illness can be challenging. Even within a narrow definition limited to psychiatric disorders, there is wide variation in prevalence estimates because of differing methodologies and criteria used (eg, screening or clinical diagnosis, different screening instruments, who makes the diagnoses and whether diagnoses are ascertained by chart review or parent report, and whether diagnoses reflect current symptoms or a prior lifetime diagnosis). A published review of 52 articles found prevalence estimates ranging from 1% to 51%, with a median of 18% [1]. The most frequently cited prevalence rate for child and adolescent psychiatric disorders is 20%, from the Surgeon General’s mental health report (1999) [2]. This figure, derived from a federal survey that only included children and youths 9 to 17 years of age, indicates that at least 8.4 million children have a diagnosable psychiatric condition, including 4.3 million with a disability (ie, a condition that impairs daily functioning at home, school, and community), of whom an estimated 2 million have severe functional impairments [3]. Although this number of children with psychiatric illness is impressive, it does not include diagnosed preschool-age children or young children who
... 171 To compound this problem, critical shortages of child and adolescent psychiatrists have been predicted on the basis of expected increases in demand and projected numbers of psychiatrists who can be trained over the next decade. 173 Thus, pediatric providers, who will undoubtedly be seeing a growing population of patients with both emotional and behavioral health needs in their practices, will also need to provide increasingly the assessment of these children as well as their management. 174 ...
Anxiety disorders are among the most common and functionally impairing mental health disorders to occur in childhood and adolescence. Primary care providers can expect to treat youth who have anxiety disorders frequently, and this article aims to provide the tools necessary to evaluate and manage patients who present with anxiety symptoms during childhood or adolescence. This article discusses the epidemiology of anxiety disorders, including the increased risk of future anxiety disorders and other mental health problems that are associated with having an anxiety disorder in childhood and adolescence. Next, the etiology of anxiety disorders is delineated, including discussion of genetic, cognitive-behavioral, physiological, and ecological explanatory models, and a summary of neurophysiological findings related to childhood and adolescent anxiety. Next, methods and tools are presented for assessment and treatment of anxiety disorders, with a focus on assessment and treatment that can be initiated in a primary care setting. Evidence-based therapy and medication interventions are reviewed. The article includes a focus on developmental differences in symptom presentation, assessment techniques, and treatment strategies, such that a primary care provider will have tools for working with the wide age range in their practices: preschool children through adolescents. We conclude that many effective intervention strategies exist, and their improving availability and ease of use makes it both critical and achievable for children and adolescents with anxiety disorders to be accurately diagnosed and treated with evidence-based medication and therapy.
... Need was considered across the entire adult community, and we took into account the fact that individuals with and without serious mental illness have different levels of need. Children's needs and the mental health workforce to serve those needs have unique challenges (13,14) and are not addressed in this study. Supply was measured for the mental health professional workforce: psychiatrists, psychologists, advanced practice psychiatric nurses, social workers, licensed professional counselors, and marriage and family therapists. ...
This study examined shortages of mental health professionals at the county level across the United States. A goal was to motivate discussion of the data improvements and practice standards required to develop an adequate mental health professional workforce.
Shortage of mental health professionals was conceptualized as the percentage of need for mental health visits that is unmet within a county. County-level need was measured by estimating the prevalence of serious mental illness, then combining separate estimates of provider time needed by individuals with and without serious mental illness derived from National Comorbidity Survey Replication, U.S. Census, and Medical Panel Expenditure Survey data. County-level supply data were compiled from professional associations, state licensure boards, and national certification boards. Shortage was measured for prescribers, nonprescribers, and a combination of both groups in the nation's 3,140 counties. Ordinary least-squares regression identified county characteristics associated with shortage.
Nearly one in five counties (18%) in the nation had unmet need for nonprescribers. Nearly every county (96%) had unmet need for prescribers and therefore some level of unmet need overall. Rural counties and those with low per capita income had higher levels of unmet need.
These findings identified widespread prescriber shortage and poor distribution of nonprescribers. A caveat is that these estimates of need were extrapolated from current provider treatment patterns rather than from a normative standard of how much care should be provided and by whom. Better data would improve these estimates, but future work needs to move beyond simply describing shortages to resolving them.
... In the United States, MH professionals are in short supply, and their distribution is inversely proportional to rurality and socioeconomic status (SES), both markers of need. 3,4 In Latin America, children's access to MH services is even more limited. 5,6 Brazil, for example, has about 300 child psychiatrists for a population of over 130 million. ...
Primary care offers opportunities to expand children's access to mental health (MH) services, but a given practice's community context and staff attitudes may influence which integration models are feasible. The aim of this study was to explore the possibility of using community-based primary care to increase access to MH services in low-income communities in Brazil.
A qualitative study was undertaken using focus groups with adolescents aged 11 to 16 (n = 46), parents (n = 40), and primary care clinicians and staff (n = 52) from public-sector health centers in 6 low-income Brazilian communities chosen for their geographic diversity.
Parents felt they had little support in parenting and attributed much of their children's behavior and mood problems to life in violent, poor communities. Parents thought that primary care could potentially be a source of MH care, but that clinicians often seemed rushed or uninterested. Clinicians classified many child problems as issues with parenting rather than MH. Nonprofessional staff was more likely to be a source of support to parents, except at one center that had a truly integrated MH service. Adolescents reported little need for MH services.
Expanding the role of primary care in child MH may require close attention to how parents, adolescents, and clinicians define their problems and on the causes to which they attribute them. These factors interact with differences in how centers organize MH care, and the extent to which they take advantage of patient interactions with nonprofessional staff.
Introduction
The financial crisis of the last decade has increased the number of people living in extreme poverty in Greece. Despite this fact, little evidence exists on their profile and psychosocial needs.
Method
The current study explored the socioeconomic circumstances and psychosocial profile of 798 people confronted with severe poverty. This article further reports on brief interventions introduced at individual-, group-, and community level to address the psychosocial burden of these people.
Results
A huge health and mental health burden was found among the participants. People also experienced long periods of unemployment, bad housing and living conditions, and absence of a supportive social/family network. Brief interventions increased people’s self-awareness, self-expression, and self-esteem and improved their problem-solving and coping skills.
Conclusions
Integrated and family-focused care seems necessary. Mapping the biopsychosocial needs of these people is important for health care and social welfare planning.
More beginning graduate students and new mental health professionals are seeing children and families in their therapeutic work, creating a growing need for play therapy-specific training and supervision. Training students and professionals in the art of play therapy is critical to the wellbeing of children, families, and the future profession. A university-based approved center of play therapy education aims to fulfill this growing need while undertaking a momentous amount of responsibility. Training skilled play therapists is a complex endeavor requiring a combination of foundational knowledge, advanced clinical and conceptual skills, and supervision that surpasses classroom coursework requirements. The authors describe the evolution of Georgia State University's Center of Play Therapy Education and Play Therapy Training Institute to provide readers with a comprehensive model for play therapy training and supervision.
More beginning graduate students and new mental health professionals are seeing children and families in their therapeutic work, creating a growing need for play therapy-specific training and supervision. Training students and professionals in the art of play therapy is critical to the wellbeing of children, families, and the future profession. A university-based approved center of play therapy education aims to fulfill this growing need while undertaking a momentous amount of responsibility. Training skilled play therapists is a complex endeavor requiring a combination of foundational knowledge, advanced clinical and conceptual skills, and supervision that surpasses classroom coursework requirements. The authors describe the evolution of Georgia State University's Center of Play Therapy Education and Play Therapy Training Institute to provide readers with a comprehensive model for play therapy training and supervision.
The medical home was proposed by the American Academy of Pediatrics in 1967 as a model of care for children with special health-care needs-children with chronic health conditions who required care from pediatric subspecialists and mental health and child development professionals. In the medical home model, the primary care provider (PCP) is responsible for coordination of services from within the health care system and from community-based agencies including schools, to ensure that the child’s complex needs are comprehensively met. As the medical home model evolved, there was an increasing focus on primary care management of chronic health conditions like diabetes, cardiovascular disease, and asthma. The emphasis remained on providing care that is comprehensive, coordinated, continuous, and patient centered. In pediatrics, this means care that meets the needs of the child and family. Because services from diverse providers are integral to the model, it has also become known as the health home or health care home. Variations have been developed, including a mental health home in which the mental health professional is the care coordinator for individuals with a primary psychiatric diagnosis.
Overview of Chapter Integrating Psychiatric and Physical Assessment Approaches Who Initially Assesses the Child? Elements of an Assessment Observation of the Child, Adolescent, and Family Impact of the Problem or Disorder Eliciting Information Areas of Psychiatric Assessment of Children and Adolescents Use of Assessment Tools Ethnic Differences Using Behavioral Rating Scales Review of Specific Evaluation Tools for Use in Primary Care Identifying Risk and Protective Factors Teaching Needs Communicating Findings to Children, Adolescents, and Families Establishing Trust with the Child or Adolescent and Family Implications for Nursing Practice, Research, and Education Case Exemplar Resources for Primary Care Providers and Families References
Appointment wait times are a neglected dimension of children's access to psychiatry. We systematically examined how long an adolescent waits for a new patient appointment with a psychiatrist for routine medication management. From state directories, we identified 578 providers of adolescent psychiatric care in Ohio. Researchers posing as parents telephoned randomly selected offices, seeking care for a hypothetical 14-year-old patient under different scenarios. Overall, we measured 498 wait times at 140 unique offices. The median wait time was 50 days (interquartile range = 29-81 days). In adjusted models, adolescents with Medicaid waited longer than those with private insurance, especially during the spring (geometric mean = 50.9 vs. 41.9 days; p = 0.02). Wait times also varied markedly by region, with geometric means ranging from 22.4 to 75.1 days (p < 0.01). This study demonstrates that adolescents often experience lengthy wait times for routine care. This methodology represents a useful approach to real-time monitoring of psychiatric services.
Counselors encounter the needs of youth (3–17 years) in a variety of settings; however, outside of school counseling, the profession faces a lack of preparation, professional development, and research focused on mental health practice with youth. Using the Delphi method, 12 counselor educators and 15 practicing counselors were polled regarding research priorities for mental health counseling with youth. Research that considers how varying developmental stages and systems (e.g., families, schools, communities) affect the mental health of youth was identified as a priority. Implications for counselor preparation, professional development, and research are offered on the basis of these results.
Long and frequent deployments, with short dwell times in between, have placed stresses on Army children and families already challenged by frequent moves and parental absences. These stresses may present in the form of social, emotional, or behavioral problems among children at home and at school. With a better understanding of the issues that children face when a parent or guardian deploys, services for military families and children can be more effectively targeted to address those needs. RAND Arroyo Center was asked by the Army to conduct an analysis of the effects of soldiers' frequent and extended deployments on their children's academic performance as well as their emotional and behavioral outcomes in the school setting. This research included the following objectives: * To assess academic effects and behavioral health challenges associated with parental deployment; * To examine programs to support children's academic and school-related behavior during parental deployment and identify the gaps that currently exist; * To examine the current systems of behavioral health support for these children; and * Where indicated, make recommendations to support programs to ensure that children's academic and emotional needs are met. There are three interrelated research components to this study. For all research elements, we examine school-age children of soldiers in the Active force, Army Reserve, and Army National Guard, of all ranks.
Psychiatric Nurse Practitioners are quickly becoming sought after employees, especially in public mental health systems where a shrinking number of psychiatrists necessitate alternate access to prescribers. In addition, new guidelines necessitate greater attention to the follow up and monitoring of the medical problems of psychiatric patients. These events are occurring in the midst of declining reimbursement and rising litigation concerns in psychiatry. At the same time there is an increased focus on a recovery orientation to psychiatry alongside the primacy of psychotropic medicine as the most cost effective treatment, which can become competing aims for practitioners. It is important for psychiatric nurses and psychiatric nurse practitioners to consider how these opportunities might also have a negative impact on the core foundation of psychiatric nursing.
In the past few decades, the treatment of psychological disorders has changed. While psychotherapy was once regarded as the
treatment of choice for most psychological disorders, the use of psychotropic medications has now become commonplace. Although
psychological research literature continues to suggest that some psychotherapeutic treatments are at least equally as effective
as medications (for example, see Hollon, Thase, & Markowitz, 2002), many factors (for example, economic) propel the continued
growth of the use of medications.
In the United States, pediatricians prescribe the majority of medications used to treat children with psychological disorders,
such as ADHD. However, because pediatricians have limited background in psychology or psychiatry, opportunities exist for
properly trained clinical child psychologists to assist pediatricians in assessing and treating youngsters with psychological
disorders. Psychologists with additional training in psychopharmacology can make even greater contributions by helping pediatricians
select and monitor appropriate medications. This paper reviews models of consultation that are especially relevant to psychologists
who seek to expand their practice by consulting with pediatricians. Consultant-centered models seem most appropriate in private
practice settings, but institutionally employed psychologists have opportunities to also utilize some system-centered approaches.
Examples of methods in which pediatric clinical psychologists and child psychologists with psychopharmacology training can
assist pediatricians in treating a child with ADHD are discussed.
This qualitative study examined the roles that practice setting, education level, and gender may play in social workers' communication satisfaction with pediatricians. Taking an ethnographic approach, the researcher interviewed social workers and pediatricians who worked together to provide mental health services in primary care. The results suggested that gender at the health system level may be an issue and that gendered work culture in primary care was a factor in communication. In particular, reimbursement, an aspect of the gendered work culture, was a substantial communication barrier, and the implications for Medicaid billing are discussed.
Psychiatric Mental Health (PMH) Advanced Practice Nurses (APNs) provide mental health services to the poorest in at least 20 states, the proportion of APNs working in rural health settings. The mental health workforce is counted in terms of eight clinical professions, including the four core professions such as psychiatry, psychology, nursing, and social work. Government agencies such as SAMHSA continue to shape the vision of a transformed mental health care system. Many of the goals of the transformed system easily correspond with the contribution of the PMH APN workforce, including an integrated mind-body recovery-centered approach, training in multiple fields of science. Workforce data of the eight clinical mental health professions have been organized for the biannual publications of Mental Health, United States since 1990. All PMH faculties must assure that data are accurately reported to AACN for their yearly publication of enrollments and graduation.
Children with potentially severe health conditions such as cerebral palsy (CP) are at risk for unmet health care needs. We sought to determine whether children with CP had significantly greater unmet health care needs than children with other special health care needs (SHCN), and whether conditions associated with CP increased the odds of unmet health care needs. We analyzed data from the National Survey of Children with Special Health Care Needs, 2005-2006, using multivariate logistic regression to calculate the adjusted odds of children with CP having one or more unmet health care needs compared to children with other SHCN. We also determined the association of CP-related conditions with unmet health care needs in children with CP. After weighting to national averages, our sample represented 178,536 children with CP (1.9%), and 9,236,794 with children with other SHCN (98.1%). Although having CP increased the odds that children had unmet health care needs (OR = 1.46, 95% CI [1.07-1.99]), the presence of a "severe" health condition weakened the association. Gastrointestinal problems and emotional problems increased the odds that children with CP would have unmet health care needs above that of children without the associated conditions (p ≤ .01). Children with CP are similar to children with other SHCN and may benefit from collaborative programs targeting severe chronic conditions. However, children with CP and associated conditions have increased odds of unmet health care needs in comparison to children without those problems.
In the last decade the US federal government proposed a transformation vision of mental health service delivery; patient-centered, evidence-based and recovery oriented treatment models. Health care reform brings additional expectations for innovation in mental/substance use service delivery, particularly the idea of creating systems where physical health, mental health and substance use treatment is fully integrated. Psychiatric nurses, as one of the four core US mental health professions, have the potential to play a significant role in the both the transformation initiative and health care reform vision. However, psychiatric nurses, particularly advanced practice psychiatric nurses, are an untapped resource due in part to significant state regulatory barriers that limit their scope of practice in many states. The purpose of this paper is to document what is currently known about advanced practice psychiatric nurses and discuss policy implications for tapping into the strengths of this workforce. Strategies for facilitating utilization of advanced practice psychiatric nurses discussed.
The authors examined characteristics and predictors of response to placebo in all available reports of short-term randomized controlled trials of antidepressants for pediatric major depressive disorder.
Response, defined as a score <or=2 on the improvement item of the Clinical Global Impression scale, and potential predictors were extracted from 12 published and unpublished randomized controlled trials of second-generation antidepressants in participants 6-18 years of age with major depression.
The single best predictor of the proportion of patients taking placebo who responded to treatment was the number of study sites. Baseline severity of illness also emerged as a significant inverse predictor of placebo response, although the strength of this relationship was diminished when number of sites was controlled for. After one large fluoxetine trial was excluded, younger participants showed a higher placebo response rate than older adolescents. Higher placebo response rates in more recent studies were explained by an increasing trend toward large multisite trials and by publication delays and failures to publish some negative trials.
The recent shift toward large multisite trials of antidepressant medications for pediatric major depression may be contributing to an increasing incidence of response to placebo. Pharmacotherapy studies of pediatric depression that carefully recruit patients with at least moderately severe depression may be more informative and efficient than many trials conducted to date. Such studies should have sufficient power to determine whether age moderates medication and placebo response.
This article presents a DVD-based educational program intended to help pediatric residents and practicing pediatricians recognize and respond to adolescent depression in busy primary care settings.
Representatives from pediatrics and adolescent medicine, child and adolescent psychiatry and psychology, and experts in the creation of educational mental health programs met to design a multimedia approach to improving the mental health diagnostic skills among pediatric residents. The authors chose depression as the initial topic because of its relatively high prevalence among children and adolescents, and evidence suggesting that pediatricians may have difficulty diagnosing this disorder in the primary care setting. The authors created a 30-minute DVD program featuring depressed adolescents and experts in child psychiatry and adolescent medicine. After viewing the DVD, residents in the training program, as well as practicing pediatricians, completed a standardized survey to assess the usefulness and attractiveness of this approach to pediatric education.
The survey results support the potential value of this type of material and the feasibility of similar programs in addressing an array of mental health concerns in pediatric residencies. Participants found the program useful and indicated interest in receiving more educational programs in this format.
The authors suggest that the relative ease with which initiatives such as this media-based approach can be implemented make this educational technique appropriate and feasible on a large scale for programs throughout the nation and for a variety of mental health concerns.
Good mental health provides an essential foundation for normal growth and development through adolescence and into adulthood. Many adolescents, however, experience mental health problems that significantly impede the attainment of their full potential. The majority of these adolescents do not receive needed mental health services, in part because of financial obstacles to care. This article reviews the magnitude and impact of mental health problems during adolescence and highlights the importance of insurance coverage in assuring access to mental health services for adolescents. Significant limitations in private health insurance coverage of mental health services are outlined. Recent federal and state efforts to move toward parity in private insurance coverage between mental and physical health services are discussed, including an explanation of the role of Medicaid and the State Children's Health Insurance Program (SCHIP) in providing access to mental health services for adolescents. Finally, other elements that would facilitate financial access to essential mental health services for adolescents are presented.
This paper examines pediatricians' perspectives regarding access to children's mental health care. In response to a question about factors that help or hinder coordination of care 190 respondents voluminously wrote about mental health access barriers. Responses were qualitatively analyzed to understand pediatricians' perspectives. Four thematic areas emerged: Insurance issues; availability of mental health specialty providers; state mental health systems; and pediatricians' attempts to improve access to mental health services. Pediatricians' responses included educating themselves, using telemedicine, and hiring co-located mental health specialists. Recommendations are made to address pediatricians' treatment of children with mental illnesses and their access to treatment resources.
This study measured service satisfaction, perceptions of service quality and general health, and overall quality of care among 787 adult recipients of Medicaid mental health services. Methods included cross-sectional retrospective design and stratified random sampling technique. Respondents were satisfied with consumer-provider relationships and were dissatisfied with functional outcomes resulting from treatment. Satisfaction was positively correlated with ratings of mental health care and the mental health component score of the SF-12. Predictors of satisfaction included ratings of mental health care and overall health. Recommendations include coordination of services that promote patient functioning and measurement of consumer satisfaction as an indicator of quality.
Building on the President's New Freedom Commission on Mental Health, this article highlights the twofold crisis in children's mental health: a critical shortage of practitioners in child‐serving disciplines, and a mismatch between training and preparation and actual practice and service delivery. The authors discuss the challenges of transforming the workforce in the context of changing population demographics, the prevalence of complex childhood disorders, and emerging evidence‐based practices. The authors conclude with recommendations targeted to states, community agencies, universities, professional associations, and advocates.
The authors review the status, strength, and quality of evidence-based practice in child and adolescent mental health services. The definitional criteria that have been applied to the evidence base differ considerably across treatments, and these definitions circumscribe the range, depth, and extensionality of the evidence. The authors describe major dimensions that differentiate evidence-based practices for children from those for adults and summarize the status of the scientific literature on a range of service practices. The readiness of the child and adolescent evidence base for large-scale dissemination should be viewed with healthy skepticism until studies of the fit between empirically based treatments and the context of service delivery have been undertaken. Acceleration of the pace at which evidence-based practices can be more readily disseminated will require new models of development of clinical services that consider the practice setting in which the service is ultimately to be delivered.
The mental health workforce has changed dramatically since the mid-1970s. Nonphysician providers, particularly psychologists and clinical social workers, have become a much larger share of the workforce. While the supply of psychiatrists has been relatively stable, there has been a dramatic increase in the supply of psychologists and social workers. Changes in clinical practice, combined with the continued expansion of managed care into mental health, will largely determine the future composition and supply of the mental health workforce.
This study sought to determine sociodemographic characteristics of treatment of children and adolescents for whom psychotropic medications are prescribed and to describe the clinical management approaches associated with the prescription of each major class of psychotropic medication in office-based medical practices in the United States.
Data for a four-year period (1992-1996) were drawn from the National Ambulatory Medical Care Survey, a nationally representative survey of office-based medical practices, to determine prescribing patterns, patients' sociodemographic characteristics, and clinical management approaches associated with visits during which psychotropic medications were prescribed to patients aged 19 years or under.
Psychotropic medications were prescribed during 2.2 percent of all visits. A majority of the prescriptions for psychotropic medications (84.8 percent) were provided by general practitioners or pediatricians. For the visits during which a psychotropic medication was prescribed, stimulants were the most commonly prescribed (53.9 percent of such visits), but prescription of other classes of medications was not uncommon: antidepressants (30 percent), anxiolytics (7.2 percent), antipsychotics (7.2 percent), and mood stabilizers (12.7 percent). Significant differences were observed in the prescription of each class of medication by sex, race, and payment source.
General practitioners and pediatricians have a role in the office-based treatment of youths with psychotropic medications.
Despite the decades-long projection of an increasing utilization of child and adolescent psychiatry services and an undersupply of child and adolescent psychiatrists, the actual growth and supply of child and adolescent psychiatrists have been very slow. Inadequate support in academic institutions, decreasing graduate medical education (GME) funding, decreasing clinical revenues in the managed care environment, and a devalued image of the profession have made academic child and adolescent psychiatry programs struggle for recruitment of both residents and faculty, although child and adolescent psychiatry has made impressive progress in its scientific knowledge base through research, especially in neuroscience and developmental science. While millions of young people suffer from severe mental illnesses, there are only about 6,300 child and adolescent psychiatrists practicing in the United States. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced. By any method of workforce analysis, it is evident that there will continue to be a shortage of child and adolescent psychiatrists well into the future. Medical/psychiatric educators have a mission to encourage medical students and general psychiatry residents to enter child and adolescent psychiatry and provide crucial mental health care and health care advocacy for our country's youngest and most vulnerable citizens. This article stems from the work of the American Academy of Child and Adolescent Psychiatry Task Force on Work Force Needs, which led to its 10-year recruitment initiative.