Integrating Mental Health Services in Pediatric Practices Is Feasible and Effective, Study Says

Treating a child’s mental and physical health care needs in a pediatrician’s office—instead of referring the child to an outside mental-health specialist—can result in improved access to behavioral-health care, greater participation by both the child and caregiver in treatment programs, and higher rates of treatment completion, according to a study by University of Pittsburgh Schools of the Health Sciences researchers. The results of the National Institutes of Health randomized trial are reported in the April issue of Pediatrics.

“Treating both physical and behavioral health in the office of the child’s pediatrician is an achievable goal that provides many benefits to the child, caregiver, and pediatrician” said lead author David Kolko, a Pitt professor of psychiatry, psychology, pediatrics, and clinical and translational science. “When the behavioral health treatment was provided in the pediatrician’s office, participants were more than six times as likely to complete the program as they were when it was provided at a specialty care clinic outside the pediatrician’s office.”

Kolko and his colleagues recruited more than 300 children and their caregivers at eight community pediatric practices affiliated with Children’s Hospital of Pittsburgh of UPMC. The children had been referred to their doctors for treatment of behavioral problems, though many also had attention-deficit/hyperactivity disorder or anxiety.

In this trial, half of the children received “doctor-office collaborative care,” where a trained behavioral health clinician, known as a care manager, collaborated with the child’s pediatrician to deliver mental health services in the pediatrician’s office. The other half of the children received “enhanced usual care,” which included educational materials and referrals to a local mental health specialist outside the pediatrician’s office.

The participants averaged 8 years old and two-thirds were boys. Most had a primary diagnosis of attention-deficit/hyperactivity disorder, followed by disruptive behavior disorder and anxiety disorder. Only 10 percent previously had received medication to treat attention-deficit/hyperactivity disorder.

In the program at the pediatrician’s office, the child and his or her caregiver participated in six to 12 individual or family sessions within six months. The in-office mental health clinician devised individualized goals to address the child’s behavioral health issues and reviewed educational materials to help achieve those goals. The clinician communicated with the pediatrician in regular meetings and through progress notes. In both the in-office and outside-specialist programs, the pediatrician was updated on the patient’s care and could prescribe medication for the child when necessary.

Of the participants assigned to an in-office care manager, 99.4 percent began treatment programs and 76.6 percent completed them. Of those assigned to a specialist outside the office, 54.2 percent began treatment and 11.6 percent completed it.

The program in the pediatrician’s office also was associated with higher rates of improvement in behavioral and hyperactivity problems, lowered parental stress, and better treatment response and consumer satisfaction.

In addition, pediatricians whose offices received the in-office support from a care manager reported greater efficacy and more confidence in their skills to treat attention-deficit/hyperactivity disorder compared with the outside specialist program.

“In fact, the participating pediatric practices in this clinical trial later hired their own mental health clinicians to continue delivering on-site services, after the trial had ended,” Kolko said. “Still more research is needed to understand how pediatric practices adapt clinical and financial strategies to make an in-office behavioral health provider a sustainable resource. Perhaps pediatricians who observe the program in operation may be willing to find a way to support these resources and make that service work.”

Additional Pitt study coauthors were Stephen Wisniewski, Graduate School of Public Health; Jonathan Hart, Western Psychiatric Institute and Clinic of UPMC; and Dara Sakolsky, School of Medicine.