Thanks to all of you who responded to my last post about the mental health crisis among American children. Your comments confirm the impression I’ve received from pediatricians I’ve spoken with from around the country – that mental health diagnoses are increasing among our children and we’re not prepared to deal effectively with the crisis.
The big question is, what should we be doing about it?
The “we” here is inclusive – the ABP, general pediatricians, subspecialists and others. Your replies offered descriptions of several innovative models and best practices. I feel it’s worth highlighting a few representative ones.
A thoughtful post from Dr. Ellen Perrin sums up many of your concerns. She is Tufts University professor and director of research at the Center for Children with Special Needs – and incidentally, was the first chair of the ABP’s Developmental and Behavioral Pediatrics subboard. She makes these recommendations (view her entire post for additional details):
- Focus on evidence-based prevention and early intervention,whichwouldincorporate:
- parenting support and education
- routine screening and referral for early evidence of emotional/behavioral difficulties
- systematic liaisons with other professional and non-professional providers
- collaboration with one or more mental health clinicians present in the practice setting
- Support social programs, such as job training, quality childcare, early preschool and nutritional support.
- Encourage off-site psychiatric consultation programs (such as the Massachusetts Child Psychiatry Access Project (MCPAP), replicated in more than 20 states) which can support pediatricians in office-based diagnostic and therapeutic mental health efforts.
- Re-evaluate residency training. (Primary care pediatricians report that they spend more than half their professional time dealing with developmental and mental health issues, and yet 3-year residency programs provide about one month of developmental-behavioral pediatrics.)
- Use the opportunities available through the Affordable Care Act and other incentives to develop better payment arrangements that don’t depend on fee-for-service coding (which offer inadequate support for co-located mental health professionals).
Several discussed networks that are providing education and support to general pediatricians in both rural and urban areas.
Dr. David Kaye wrote about his organization in New York State – Child and Adolescent Psychiatry for Primary Care (CAP PC), funded by the state’s Office of Mental Health, which provides education and consultation through both phone and in-person visits to pediatricians across the state. His program is affiliated with The Reach Institute, mentioned by several of you, which provides a 2.5-day intensive training program, followed by phone conferences over a six-month period, and ongoing support.
“To be clear,” Dr. Kaye writes, “we aim to assist and support pediatrics in addressing mild to moderate mental health problems, with an ultimate goal of preventing more serious deterioration. To have pediatrics face this squarely and take it into mainstream practice is a welcome step in de-stigmatizing mental health problems, promoting access to care, and making the kind of strides we need to make in order to assure treatment for all, and prevent disability and reduce risk.”
I couldn’t agree more.
Insurance is a major issue for all physicians, but especially for pediatricians dealing with mental health issues.
Dr. Linda Cozzens of Southboro, MA, writes: “I currently am reimbursed $350 for ablating a wart, and $25 for a mental health diagnosis. Until the system reimburses pediatricians and mental health professionals adequately for their time and training, we will continue to see an increasing number of mental health providers who accept self-pay patients only, and see a limited number of people choosing child psychiatry or counseling as a career path.”
Dr. Kevin P. Marks, a general pediatrician in Eugene, OR, suggests that the ABP consider offering Maintenance of Certification (MOC) credit for activities like team-based training, learning to better implement evidence-based developmental-behavioral screening tools, or demonstrating the quality improvement value of co-locating with an early childhood developmental specialist – all ideas we will consider.
I’m glad to hear positive feedback, even tinged with criticism, as we got from Dr. Neal Spears of Smithville, TX. He writes of one activity approved for MOC credit: “It was tedious, expensive, and time consuming but it completely changed my approach to ADHD assessment and treatment. Although it was a fairly painful experience, I do feel like it has significantly enhanced the accuracy of my ADHD diagnosis as well as helped identify problems with treatment. I continue to use the program daily to keep track of my patients’ Total Symptom Scores and to keep in touch with teachers during the school year.”
While we hope to take the pain out of MOC activities, I am heartened to hear about benefits. We welcome other suggestions on topics we should pursue, both for self-assessment and for quality improvement activities.
Keep sending your comments. The ABP is committed to staying engaged in this issue with you to improve the lives of children with behavioral and mental health conditions.