Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community

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Enhancing Pediatric Mental Health Care: Strategies

for Preparing a Community

Pediatricians and other primary care clinicians* caring for children tradi-tionally have focused their attention on meeting the health care needs of individual children they see in their ofﬁces and clinics. However, effective care of the growing number of children and families who are experiencing chronic medical and mental disorders will also require a “population” health perspective. Many policy statements from the American Academy of Pediatrics (AAP) have pointed to the importance of the population perspec-tive in providing and improving pediatric health services.1–10_{From this} perspective, all members of a community are affected by the health of its individual members. For children, mental health resides not solely within the child but within the web of interactions that connect the child, the family and school, health and other child service systems, and the neigh-borhood and community in which the child lives.11_{This is not to deny} that biology is a determinant of mental health and mental illness; rather, biological factors interact with the psychosocial environ-ment to result in environ-mental health, environ-mental illness, and recovery from mental illness.

Primary care clinicians who are interested in enhancing mental† health services in their community will need to form partnerships. Key partners for a community mental health advocacy effort include other primary care clinicians, developmental-behavioral pediatricians, ado-lescent health specialists, the local public mental health agency, rep-resentatives of the mental health care provider community (eg, psychi-atrists, psychologists, social workers, substance abuse counselors, psychiatric nurse practitioners), community mental health activ-ists including parents and youth, school system representatives, early childhood educators, Early-Intervention (EI) system represen-tatives, representatives of the child protective and juvenile justice systems, and the local department of public health.

*Throughout this document, the term “primary care clinicians” is intended to encompass pediatricians, family physicians, nurse practitioners, and physician assistants who provide primary care to infants, children, and adolescents.

†Throughout this statement, the term “mental” is intended to encompass “behavioral,” “neu-rodevelopmental,” “psychiatric,” “psychological,” “social-emotional,” and “substance abuse,” as well as adjustment to stressors such as child abuse and neglect, foster care, separation or divorce of parents, domestic violence, parental or family mental health issues, natural disasters, school crises, military deployment of children’s loved ones, and the grief and loss accompanying any of these issues or the illness or death of family members. It also encom-passes somatic manifestations of mental health issues, such as fatigue, headaches, eating disorders, and functional gastrointestinal symptoms. This is not to suggest that the full range or severity of all mental health problems is primarily managed by pediatric primary care clinicians but, rather, that children and adolescents may suffer from the full range and severity of mental health conditions and psychosocial stressors. As such, children with mental health needs, just as children with special physical and developmental needs, are children for whom pediatricians, family physicians, nurse practitioners, and physician assis-tants provide a medical home.

AUTHORS:Jane Meschan Foy, MDa_{and James Perrin,}

MDb_{, for the American Academy of Pediatrics Task Force}

on Mental Health

a_{Department of Pediatrics, Wake Forest University School of}

Medicine, Winston-Salem, North Carolina;b_{Center for Child and}

Adolescent Health Policy, Division of General Pediatrics, MassGeneral Hospital for Children, Boston, Massachusetts

ABBREVIATIONS

AAP—American Academy of Pediatrics EI— early intervention

NAMI—National Alliance on Mental Illness

FFCMH—Federation of Families for Children’s Mental Health SOC—system of care

www.pediatrics.org/cgi/doi/10.1542/peds.2010-0788D doi:10.1542/peds.2010-0788D

Accepted for publication Mar 24, 2010

Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy@wfubmc.edu

FINANCIAL DISCLOSURE:The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose.

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Primary care clinicians cannot feasibly pursue the strategies that follow in the absence of such partnerships. In every region of the United States, there is a public agency formally charged with managing and/or providing mental health services; this same agency may be charged with managing and/or pro-viding EI services, or another agency may be charged with this responsibility. Some state public mental health agen-cies (eg, California, North Carolina) lectively serve only individuals with se-verely impairing conditions (severe emotional disorders). Whatever their target population, these agencies typi-cally organize advisory groups of family members who have been affected by these disabilities (“consumers” or “cli-ents” in the vocabulary of the mental health specialty system) and providers of EI, mental health, and/or substance abuse services. These groups often omit primary care clinicians from their mem-bership but usually welcome primary care clinician involvement if it is offered. Consumer and advocacy groups such as the National Alliance on Mental Illness (NAMI), the Federation of Families for Children’s Mental Health (FFCMH), and the local Mental Health Association also welcome primary care clinicians’ inter-est and involvement in their activities. In-creasingly, the public health community has come to view mental health as a pub-lic health issue, mirroring the clinical movement toward “reconnecting” the mind and the body. The Association of Maternal and Child Health Programs, in fact, devoted its 2004 national confer-ence to reframing mental health as a public health issue.

Effective communication among pri-mary care clinicians, mental health specialists‡, educators, and agency representatives depends on develop-ing an understanddevelop-ing of the different cultures in which they function. For ex-ample, primary care clinicians may

come to a community meeting thinking that their mental health responsibili-ties are prevention, early identification of mental health problems, and care of children who are mildly impaired with mental health disorders—perhaps only those with specific disorders such as attention-deficit/hyperactivity dis-order. Representatives of a chronically underfunded public mental health sys-tem may be focused primarily on chil-dren who are severely impaired with mental health conditions; they may have been able to give little attention to prevention or early identification and to provision of consultative services to primary care clinicians for their less severely impaired patients. School sys-tem representatives may be focused primarily on behavioral problems that interfere with their students’ school attendance, classroom behavior, and academic success; representatives of social service agencies may be fo-cused on the needs of children in fos-ter care; and representatives of the ju-venile justice system may be focused on the unmet mental health needs of adjudicated youth. Each group wants to engage the other’s time and re-sources for its priority activities. Ide-ally, the process of coming together opens primary care clinicians, families, and their community partners to new op-portunities for mutual support and new solutions to common problems.

Moreover, the vocabulary of the men-tal health specialty system differs sig-niﬁcantly from that of primary care cli-nicians. For example, the acronym “PCP” in primary care terminology means a primary care physician, but “PCP” in mental health terminology may mean a person-centered plan. Likewise, the term “screening” may have different meanings in the 2 sys-tems. A glossary of mental health terms and select mental heath re-sources, Supplemental Appendix S9may

be helpful to primary care clinicians in crossing this divide.*

STRATEGY 1: APPLY A

“POPULATION” PERSPECTIVE TO GAIN UNDERSTANDING OF THE MENTAL HEALTH NEEDS OF CHILDREN AND YOUTH IN THE COMMUNITY

Many studies have identiﬁed factors that place children at risk for mental health problems later in life.12–14_There are also well-documented protective factors that reduce risks (Fig 1).11 Other protective factors include good nutrition, physical activity, and sleep.

As indicated by the horizontal arrows in Fig 1, the community, family, and child all contribute to creating the school environment, which can be a potent factor in fostering resilience in its students.

To identify needs and track progress to-ward community goals, primary care cli-nicians and their partners can examine measures of child well-being in their community (eg, child abuse and neglect reports, EI referrals, kindergarten screening results, adolescent suicide and homicide rates, high school dropout and graduation rates, suspension and expulsion rates, and substance abuse and teen pregnancy rates). An additional source for statistics is the Youth Risk Be-havior Surveillance System.15_{Analysis of} data according to school or neighbor-hood may yield additional insights and lead to speciﬁc interventions tailored to a particular school or area in the community.

Primary care clinicians and their part-ners can look at the needs of special populations known to be at higher risk for mental health problems (eg, chil-dren affected by a disaster,16_children with parents deployed in military ser-vice,17 _{children with developmental} disabilities,18,19 _{children who} experi-ence academic difﬁculties,20 _and/or children in foster care).21_{They can also}

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review utilization of local or regional emergency facilities, mental health outpatient and inpatient services, nonproﬁt and private-sector pro-grams, and the school system’s ex-ceptional children’s or special edu-cational services. Findings can assist in developing priorities for school-based initiatives and for ei-ther targeted or community-wide ef-forts to enhance protective factors (see Fig 1) or improve access to needed services.

There are pervasive racial and ethnic disparities in children’s health and ed-ucational outcomes and in their ac-cess to effective mental health ser-vices. These disparities call for attention to accessibility and cultural appropriateness of all the mental health systems that touch children and families.22_{Attention should also be} di-rected to issues such as racism, xeno-phobia, sexism, and homophobia, which may disproportionately affect

the mental health of certain groups within the community by contributing to their stress, isolation, and socioeco-nomic disadvantage.

Just as the public health perspective enlightens a discussion of mental health, the mental health perspective can enlighten discussions of issues traditionally in the domain of public health (eg, physical inactivity, poor diet, environmental toxins [eg, lead, mercury], neighborhood violence, un-intended pregnancy, and injuries). Each of these issues has mental health causes and/or effects; and each has implications for the mental, as well as physical, health of children in the com-munity. Partnership across disciplines can result in fresh approaches.

STRATEGY 2: INVENTORY THE COMMUNITY’S MENTAL HEALTH RESOURCES

Primary care clinicians cite lack of re-ferral sources as a major barrier to

their identifying and meeting the men-tal health needs of children and their families.23_{In some cases, primary care} clinicians are unaware of existing EI and mental health specialty resources in their community. Ideally, the com-munity would have a directory of men-tal health and substance abuse ser-vices available. The local community mental health agency, emergency de-partment, EI provider, community re-source line (accessed in some commu-nities by dialing 211 or 311), family and consumer advocacy groups (such as the NAMI, Mental Health America, the FFCMH, Children and Adults With Atten-tion Deﬁcit/Hyperactivity Disorder [CHADD]), or health department may have directories that can provide a starting point. A community can seek funding for this process from non-proﬁt or governmental sources; fre-quently, the public mental health agency will fund and staff its continua-tion. Distribution of a paper version of

FIGURE 1

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the directory as a ﬁrst step may serve to publicize it and guide primary care clinicians toward a Web site.24 _For guidance in developing a directory, see Strategies for System Change in Chil-dren’s Mental Health: A Chapter Action Kit.25

STRATEGY 3: DEVELOP OR

STRENGTHEN RELATIONSHIPS WITH MENTAL HEALTH ADVOCATES, SCHOOLS, HUMAN SERVICE AGENCIES, MENTAL HEALTH AND SUBSTANCE ABUSE PROVIDERS, AND DEVELOPMENTAL SPECIALISTS BY COLLABORATING ON SYSTEM-FOCUSED INITIATIVES SUCH AS WORKING TO FILL GAPS IN NEEDED SERVICES AND

CARE-COORDINATION MECHANISMS

After identifying community mental health and substance abuse profes-sionals and other mental health– related resources, primary care clinicians can form or join a multidis-ciplinary community group to address systemic issues such as gaps in needed services (including preventive programs), management of psychiat-ric emergencies (see Strategy 4), ex-change of information between pri-mary care clinicians and mental health professionals, and access to mental health/substance abuse services for the uninsured. Professionals who pro-vide mental health services may func-tion in separate “silos” from those who provide developmental-disabilities services; efforts to combine and coor-dinate their efforts may be fruitful.

Enhancing communication among dis-ciplines is an important priority. Al-though relationships between primary care clinicians and medical subspe-cialists typically are built through the care of mutual patients, privacy concerns and perceived conﬁdentiality barriers keep many mental health/ substance abuse professionals from communicating with primary care

cli-nicians. In fact, the Health Insurance Portability and Accountability Act (HIPAA) allows health care providers who are involved in the treatment of mutual patients to exchange informa-tion, excepting psychotherapy notes and information about substance use/ abuse, even without the consent of pa-tients.26 _{Dialogue with local mental} health agencies, emergency depart-ments, and others who provide mental health and substance abuse services can raise awareness about the impor-tance of communication with primary care clinicians. Ideally, routine intake procedures of emergency depart-ments and mental health specialty pro-viders would prompt mental health professionals to seek families’ consent for exchange of information with pri-mary care clinicians, and routine pro-cedures in primary care clinicians’ ofﬁces would prompt staff to seek in-formation about other sources of health care and request consent for exchange of information. Such routine procedures can become a goal of community-level problem-solving.

Service gaps will often dominate dis-cussions among child mental health advocates. For children and adoles-cents, mental health specialty re-sources of all types are insufficient vir-tually everywhere.27_{Infants and young} children often are not even within the “target” population for public mental health program funding. There is a need for Medicaid and other insurers to incorporate the DC 0-3R (Diagnostic Classification of Mental Health and De-velopmental Disorders of Infancy and Early Childhood),28 _{which recognizes} that some diagnoses may be transient in this age group and that children with significant problems may not fit Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR)29_{criteria. There is also a need} for public and private insurers to rec-ognize that children and adolescents

suffer impairment from mental health symptoms that may not rise to the level of a disorder. The classiﬁcation system outlined in theDiagnostic and Statisti-cal Manual for Primary Care (DSM-PC)30_{reﬂects the full spectrum of} be-havioral issues that require the timely attention of primary care clinicians. Professional associations of primary care clinicians can partner with men-tal health specialty organizations and family and consumer advocacy groups to advocate for mental health and sub-stance abuse services needed by chil-dren of all ages and public funding of mental health programs generally.

A list of key mental health and sub-stance abuse services for children is included as Appendix S1. Efforts to ﬁll gaps or expand capacity should build on available evidence about ef-fective programs and services. The Substance Abuse and Mental Health Services Administration (SAMHSA) Na-tional Registry of Evidence-Based Programs and Practices31_{is an}

excel-lent resource for primary care clini-cians to use in partnership with local human service agencies, school sys-tems, and nonproﬁt organizations to develop strategies that address com-munity needs12_{; this registry provides}

a database of current interventions for the prevention and treatment of mental and substance use disorders. Attached as Appendix S2 is a table which summarizes evidence-based child and adolescent psychosocial in-terventions32_{; this resource for}

pri-mary care clinicians is updated bien-nially. Essential services include those interventions that meet criteria for best support (levels 1 and 2 in the table of psychosocial interventions).

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prob-lems, as “a family-centered network of community-based services designed to promote the healthy development and well-being of these children and their families”33_{(see Fig 2).}

Roberts et al34 _{delineated 6 central} characteristics of such a system: (1) responsive to family challenges, prior-ities, and strengths; (2) developed in partnership with constituents; (3) re-flective and respectful of the cultural norms and practices of the participat-ing families; (4) accessible to every-one; (5) affordable to those who need assistance; and (6) organized and co-ordinated through collaboration so that resources are equitably distrib-uted in an efficient and effective man-ner. To these characteristics Perrin et al added that such a system recog-nizes and addresses the specific devel-opmental needs of infants, children, and adolescents and their important developmental transitions and is orga-nized to promote the cost-effective provision of services.33_{In the mental} health specialty world, such a system is called a system of care (SOC).

Stud-ies have revealed that involvement in a SOC improves coordination of care and educational outcomes for children and youth with mental illness and other psychosocial challenges.35_In commu-nities where such a system is under development, primary care clinicians can be valuable partners in its design. A primary care clinician’s involvement in an individual child’s SOC planning is an invaluable opportunity for building professional relationships while en-hancing the child’s care.

The Early Childhood Comprehensive Services (ECCS) initiative, funded by the Maternal and Child Health Bu-reau (MCHB) to implement the MCHB strategic plan for early childhood health, has allowed 49 states to de-velop plans for building a compre-hensive system of health care for young children. The ECCS Web site36 provides resource information on governance; community-level sys-tems building, ﬁnance, indicators, and outcomes; and plans for improv-ing developmental services.

Primary care clinicians can success-fully partner with others all along the continuum of prevention, early inter-vention, treatment, and coordination services, as discussed below.

School-Based Services

It is important to include schools in a community mental health SOC. Schools are the largest de facto provider of mental health services,37_and school-based mental health personnel (guid-ance counselors, social workers, psychologists) typically function in parallel with the mental health system. Although their focus is often on atten-dance, testing, and, in high schools, course selection and college prepara-tion, these school-based mental health professionals may play an important role in children’s comprehensive mental health care, especially when they have an effective connection with community mental health systems. School social workers are more likely than other school personnel to pro-vide direct mental health services and community referrals for children and families; however, many school social workers have unreasonably high case loads and sometimes travel to mul-tiple schools. School-based health centers in many areas of the country provide students with enhanced ac-cess to an array of health services including mental health and substance abuse care; such programs are espe-cially effective when linked to a stu-dent’s primary care medical home and to the SOC in the community. Advo-cacy for enhanced school-based men-tal health services requires partner-ship with the local school board and/or school health advisory council, as well as mental health specialty partners, other community health and services agencies, youth, parents, and teachers.

Schools may also play an important role in prevention of mental health

FIGURE 2

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problems. As an example, with the Good Behavior Game, a 1-year inter-vention for elementary school class-rooms, participants have manifested reduced aggressive and disruptive be-haviors during the ﬁrst grade and, over the long-term, reduced risk of al-cohol and drug abuse and suicide attempts.38 _Information _regarding evidence-based interventions is in ref. 39.

Preventive Services

A growing body of evidence has shown that there is a window of opportunity for prevention of mental health disor-ders that will otherwise emerge later in adolescence or adulthood. A num-ber of interventions have been shown effective in at-risk groups (eg, the Clarke Cognitive-Behavioral Preven-tion IntervenPreven-tion for adolescents at risk of depression).38_Community part-ners can collaborate to identify chil-dren at risk and implement programs that match needs with resources.

Recent scientiﬁc developments to-ward understanding the brain devel-opment of infants and young children have highlighted the critical inﬂuence of parenting, attachment, and early childhood education on the emotional, social, and cognitive development of young children40,41 _{and the role of} at-tachment disturbances in many child and adult disorders.41–44 _Many com-munities have responded to this new science by offering such services as nurse visits to pregnant and parent-ing women at high risk, parentparent-ing programs, child care consultation, and therapeutic child care settings. Appendix S7provides resources to as-sist in determining which programs that target young children are most promising. Ideally, communities would also have resources to help parents and teachers dealing with depression, substance abuse, mental illness, or other challenges that affect the quality

or continuity of their relationships with young children.45

EI Services

In the United States, EI services target children, from birth to 36 months of age, with delayed development or a condition associated with develop-mental delay. The EI program, Part C of the Individuals With Disabilities Educa-tion Act (IDEA), is federally mandated to include such services as special in-struction and, usually, interventions such as speech/language, occupa-tional and physical therapy; nutrition; and audiologic and psychological ser-vices.46_{In some states, it also provides} intervention services to children at risk for poor developmental out-comes.46 _{Its funding, resources, and} procedures vary from state to state and, at times, from community to com-munity47_{; however, it serves as a} door-way to early identiﬁcation of develop-mental disabilities and to a variety of services for infants and toddlers and their families.

A key variation from state to state is the agency responsible for EI pro-grams; it may be the public health sys-tem, the public school syssys-tem, the mental health system, or some com-bination of these systems. When EI is a public school responsibility, it often includes limited or no medical in-volvement. Eligibility also varies; some states offer services to children at risk for developmental problems, as well as those with identiﬁed prob-lems, but others are more restrictive. States and communities also vary in the expertise and availability of EI pro-viders. If the EI program does not offer medical services, such as consultation by developmental-behavioral pediatri-cians or child psychiatrists with ex-pertise in infant mental health, pri-mary care clinicians will need other referral sources with special expertise in this age group. For families in which

maternal depression and attachment are concerns, it is important to identify sources of treatment for the mother-infant dyad as well as for the mother herself.

Child Psychiatry Services

Although many communities do not have child psychiatrists, several re-gions of the country have used creative strategies to gain access to child psy-chiatry consultation for primary care clinicians. In Massachusetts, a state-wide psychiatry telephone consulta-tion service was established to assist primary care clinicians in assessing and managing the mental health prob-lems of children and adolescents. Re-sults of an initial evaluation of this pro-gram suggested high rates of use and satisfaction among participating pri-mary care clinicians.48_{Several states} are using telepsychiatry clinics to pro-vide access to consultation for chil-dren remote from child psychiatrists. The AAP’s mental health Web site49 pro-vides examples of consultation mod-els. In many rural areas, consultation is provided by general psychiatrists whose training in child psychiatry may be limited; in such areas, educational programs to enhance the psychia-trists’ pediatric skills and their access to child psychiatrists for consultation may be useful adjuncts.

Recreational Resources and Volunteer Service

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Involve-ment in extracurricular school activi-ties and/or youth religious organiza-tions has a protective effect on adoles-cent mental health.50,51 _{Although the} children at highest risk in a community may not currently be involved in these activities, an understanding of barri-ers to their participation (eg, trans-portation, preparticipation physicals) can inform efforts to engage them.

Transition Services

As adolescents with mental illness age out of pediatric care, insurance plans, and community resources that sup-ported them during their childhood, they must find new providers of their primary and specialty health care and face the stresses experienced by other young adults with special needs. They may have limited educational, voca-tional, or social opportunities; finan-cial hardships; difficulty finding hous-ing; and inadequate services to assist them in overcoming or coping with these problems and in achieving their health, educational, vocational, and so-cial goals. Primary care clinicians can partner with the mental health com-munity to address deficiencies in tran-sition services for young people who are living with mental illness. Pro-grams in several areas of the country may serve as models.52,53

STRATEGY 4: DEVELOP A COMMUNITY PROTOCOL FOR MANAGING PSYCHIATRIC EMERGENCIES

Deaths attributable to homicide, sui-cide, and child abuse are tragically common.54,55 _{Life-threatening mental} health problems, including acute intox-ication, delirium, psychosis, mania, se-vere family dysfunction or acute stress responses, domestic violence, severe mood disorders, and medical crises associated with eating disorders, also occur frequently. Primary care clini-cians may be the only source from whom a child and family are

comfort-able seeking help. Primary care clini-cians have a role in preventing crises by identifying children with mental health/substance abuse problems early in their course, developing a re-lationship when the child is not in cri-sis, and collaborating with the family to develop a crisis plan in advance. Pri-mary care clinicians also have a role in applying a management strategy to a crisis situation, which involves assess-ing the level of urgency of the child’s need for care, identifying interven-tion opinterven-tions, and using appropriate resources.

A natural disaster, act of violence, war, or industrial accident may inﬂict trauma and loss on many children and families simultaneously—those di-rectly exposed and those emotionally exposed through death or injury of loved ones—and may pose even greater threats to children with preex-isting mental health issues. Primary care clinicians have a role in planning with their community partners to deal with both the short-term and long-term aflong-termath of these crises.56,57 Emergency departments in many com-munities are not well equipped to ad-dress psychiatric emergencies in chil-dren and adolescents.58,59 _Through overcrowding, exposure to stressful sights and sounds, and long delays, they may inadvertently increase the distress and trauma experienced by children and their families.60_Boarding of child and adolescent psychiatric patients in nonpsychiatric settings should be avoided as much as possi-ble. When such boarding is unavoid-able, every attempt should be made to ensure that such patients are hospital-ized in the least restrictive setting pos-sible and transferred to a psychiatric facility as expeditiously as possible. When optimal services are unavail-able, primary care clinicians can par-ticipate in community and regional ef-forts to fund and develop them.

In some communities, speciﬁc psychi-atric emergency services are avail-able (eg, mobile crisis units that can be deployed to a physician’s ofﬁce or school; mental health screening, tri-age, and referral centers; mental health/ substance abuse intake facili-ties; intensive outpatient treatment programs)61–63_{; however, primary care} clinicians (as well as school and agency personnel with whom primary care clinicians collaborate) may be unaware of them. As part of their in-ventory of mental health resources, pediatric primary care clinicians can identify and prepare to use the emer-gency mental health services that are most appropriate for children and ad-olescents, often in the mental health system rather than an emergency de-partment. The primary care clinicians can negotiate with providers of emer-gency mental health services to secure ready access for their patients in cri-sis and/or “urgent” assessment slots. In addition, primary care clinicians can work with these mental health pro-viders to ensure that primary care cli-nicians are informed about children served in their system and that ar-rangements are made for their contin-ued monitoring and care after dis-charge from hospital or residential facilities.

STRATEGY 5: ALIGN WITH COMMUNITY PARTNERS IN ADDRESSING THE MENTAL HEALTH NEEDS OF CHILDREN WITHIN THE PRIMARY CARE PRACTICE

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school associated with poor health or educational outcomes. In some set-tings, the clinician can seek the coop-eration of school nurses, school-based health centers, or community agencies (eg, public health, social services, juve-nile justice) to administer and collect mental health history and screening tools needed by the primary care clini-cian and provide them in advance of the primary care visit.64

As an example, clinicians might con-sider initiating previsit data collection from children in foster care. Sharing the responsibility for previsit data col-lection with the foster care agency in-creases 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 cli-nicians may participate in providing this assessment. There may also be some mechanism to assess for acute mental health needs (suicidality, homi-cidality, severe aggression, ongoing psychotropic medication needs, or the risk of withdrawal symptoms in a substance-addicted adolescent cut off from his or her supply) within 1 or 2 days of foster placement. Again, the primary care clinician may incorpo-rate this assessment into a primary care visit.

As a second example, clinicians can work with their local school system(s) to develop a community protocol for assessing and managing school-aged children who experience problems with attention, behavior, or learning. With parental permission, school per-sonnel are usually willing to collect and share information with the pri-mary care clinician. This information could include behavior scales, such as the Vanderbilt ADHD Scales and the Strengths and Difﬁculties Question-naire, Teacher Version; grades and

end-of-grade test results; and psycho-educational evaluations, including for-mal cognitive testing, individually ad-ministered educational achievement testing, or other standardized assess-ments, such as neuropsychological testing. A clear description of the child’s academic program, including any special services provided infor-mally or through an individualized ed-ucation plan or 504 plan also should be provided before the medical evalua-tion. In turn, the primary care clinician can provide the school with clinical ﬁndings, a description of treatment provided, and follow-up plans (includ-ing a mechanism to monitor medica-tion effects) as needed and with proper permission from parents. In a North Carolina community, such a pro-tocol, which streamlines primary care clinicians’ assessment of children who are experiencing school difﬁculties and facilitates communication about their ongoing care, has been in place for⬎15 years.64

STRATEGY 6: PARTICIPATE IN AAP CHAPTER EFFORTS TO ADDRESS PAYMENT AND BROADER SYSTEM ISSUES

Primary care clinicians require ade-quate payment for the mental health services they provide and a policy en-vironment that supports primary care clinicians’ involvement in mental health care. These issues require un-derstanding of the additional time and effort needed to address mental health issues in primary care practice. There are a growing number of suc-cessful AAP chapter advocacy efforts that have achieved signiﬁcant policy changes in private (employer-based) health insurance, state Medicaid pro-grams, and the State Children’s Health Insurance Program.65_{Examples of} sys-tem features that support and foster mental health practice in primary care settings are:

● payment of primary care clinicians for their mental health services;

● payment for multiple mental health visits to the primary care clinician before the establishment of a diag-nosis (ie, for problem-level condi-tions and/or condicondi-tions for which the clinician is not ready to assign a diagnostic code);

● authorization of mental health re-ferrals by primary care clinicians;

● notiﬁcation of the primary care cli-nician when a child enters the men-tal health specialty system;

● payment structure that supports mental health professionals colo-cated or integrated within the pri-mary care setting;

● independent enrollment of Medic-aid mental health providers, which makes it possible for primary care clinicians to refer directly to a men-tal health professional (rather than through an agency’s cumbersome intake process) and develop a col-laborative relationship with that professional in the mutual care of the child;

● payment to primary care clinicians for the services of their employed mental health professionals; and

● an electronic system to access fam-ilies’ mental health beneﬁts and provider panels.

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situations, it will be necessary for pri-mary care clinicians to partner with regional or state groups of primary care clinicians and to focus advocacy efforts on regional directors of these ambulatory managed care plans and on insured families and their employ-ers to make them more knowledgeable of pediatric needs. For AAP chapters that have established managed care “pediatric councils” (groups of pedia-tricians who meet periodically with medical directors of the region’s ma-jor managed care plans and other insurers), mental health/substance abuse advocacy issues can become agenda items (eg, notiﬁcation of the primary care clinician when a family accesses mental health services, rou-tine exchange of information between mental health providers and primary care clinicians, and expansion of men-tal health panels to include pediatric specialists). The recently adopted fed-eral law that mandates parity of men-tal health and physical health insur-ance beneﬁts should provide incentive for such efforts.

Strategies for System Change in Chil-dren’s Mental Health: A Chapter Action Kit25 _{and the AAP mental health Web} site49_{offer strategies for AAP chapters} and other primary care professional associations to use in their attempts to achieve equity of mental health bene-ﬁts in insurance plans, fair payment of primary care clinicians and mental health professionals for the services they provide, policies that support and promote collaboration, and support of public mental health systems. The Task Force on Mental Health worked with the Academy of Child and Adolescent Psychiatry to develop a white paper on administrative and ﬁnancial barriers to children’s mental health care, which was published in Pediatrics in April 2009.66_{Consumer groups such as the} NAMI and the FFCMH are invaluable to primary care clinicians’ advocacy

efforts, as they have been to the task force’s work.

STRATEGY 7: ADDRESS STIGMA THROUGH PUBLIC EDUCATION

Stigma prevents many children and families from seeking care for their mental health and substance abuse concerns. Primary care clinicians can partner effectively with mental health advocates and mental health profes-sionals to combat stigma at the com-munity level. Such partnerships with local NAMI, Children and Adults With At-tention Deﬁcit/Hyperactivity Disorder, and FFCMH organizations, for example, have focused on:

● battling stigma with facts (eg, men-tal illnesses are treatable; children and adults who live with these ill-nesses can achieve recovery and lead full and productive lives; chil-dren often have behavioral prob-lems; mental illness is not a charac-ter ﬂaw, a sign of moral weakness, or anyone’s fault);

● establishing support groups and education programs for families (combating the social isolation that so often accompanies mental ill-ness, for both the child and family); and

● eliminating language that contrib-utes to stigma through deﬁning peo-ple by their condition and using “people-ﬁrst” language (eg, refer-ring to someone as “a person with schizophrenia” rather than “a schizophrenic”).

CONCLUSIONS

Enhancing the mental health of chil-dren requires a population perspec-tive that recognizes collecperspec-tive opportu-nities to promote mental health, reduce the risk of mental illness, and improve mental health services. Each clinician will choose strategies in ac-cordance with his or her community’s

speciﬁc needs and his or her prac-tice’s priorities. Forming a group of interested primary care clinicians, developmental and adolescent special-ists, advocates, educators, agency rep-resentatives, and mental health/sub-stance abuse professionals offers the beneﬁt of enhancing relationships while ensuring coordination and syn-ergy of effort. The resources available on the AAP mental health Web site28 can provide assistance. By facilitating system changes at the community level, the primary care clinician can set the stage for enhancements in mental health care at the practice level.

Community-level strategies for en-hancing children’s mental health include:

● apply a “population” perspective to gain understanding of the mental health needs of children and youth in the community;

● inventory the community’s mental health resources;

● develop or strengthen relationships with mental health advocates, schools, human service agencies, mental health and substance abuse providers, and developmental spe-cialists by collaborating on system-focused initiatives;

● develop a community protocol for managing psychiatric emergencies;

● align with community partners in addressing the mental health needs of children within the primary care practice;

● participate in AAP chapter efforts to address payment and broader sys-tem issues; and

● address stigma through public education.

AAP TASK FORCE ON MENTAL HEALTH

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(chair-person, lead author), Paula Duncan, MD, Barbara Frankowski, MD, MPH, Kelly Kelleher, MD, MPH, Penelope K. Knapp, MD, Danielle Laraque, MD, Gary Peck, MD, Michael Regalado, MD, Jack Swanson, MD, and Mark Wolraich, MD; the consultants were Margaret Dolan,

MD, Alain Joffe, MD, MPH, Patricia J. O’Malley, MD, James Perrin, MD (lead author), Thomas K. McInerny, MD, and Lynn Wegner, MD; the liaisons were Terry Carmichael, MSW (National Asso-ciation of Social Workers), Darcy Grut-tadaro, JD (National Alliance on Mental

Illness), Garry Sigman, MD (Society for Adolescent Medicine), Myrtis Sullivan, MD, MPH (National Medical Associa-tion), and L. Read Sulik, MD (American Academy of Child and Adolescent Psy-chiatry); and the staff were Linda Paul and Aldina Hovde.

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DOI: 10.1542/peds.2010-0788D

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Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community