During my training as a child and adolescent psychiatry fellow, I “lived” down the hall from 10 other people just like me who had similar offices and training. Our pace was tailored to pediatric psychiatry. Appointments were 30 minutes or more. Our goal was to provide the most comprehensive mental health care for the families whom we grew to know and love.
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The impetus to create an integrated mental health care approach has been well elucidated by the American Academy of Child and Adolescent Psychiatry (AACAP) in its report, Collaborative mental health care in pediatric primary care. It is based on some telling statistics: Fifty percent of all cases of mental illness begin before age 14 years and 75% begin by age 24. Half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. The American Academy of Pediatrics’ Task Force on Mental Health similarly has stated that primary care clinicians can and should be able to provide mental health services to children and adolescents in a primary care setting.
Integrative psychiatry and primary care treatment comes in three forms: classic consultation, in which a specialist sees a patient and refers back to the PCP with recommendations; colocation, in which mental health specialists practice in the same office but essentially are “ships crossing in the night” with PCPs; and the most-lauded form, collaborative/integrative care, in which back-and-forth consultation and discussions of a case occur between mental health specialists and PCPs, with in-person follow-up as needed.
Several institutions offer programs to address the AACAP and AAP imperatives, most prominently the University of Washington, Seattle, and the University of Massachusetts, Worcester. Both offer resources on how to create an integrated care model (University of Washington AIMS Resource Center; The University of Massachusetts Center for Integrated Care).
What can one do in a busy pediatric primary care practice to address mental health imperatives on the individual provider level? Often PCPs can, as I do, offer families some resources by having a set of mental health handouts and resources. I have gathered useful handouts for families throughout my residency to use as shortcuts and visual aids to promote mental health. I use the AACAP Facts for Families for handouts on mental health diagnoses and topics. I use the National Sleep Foundation for its sleep hygiene tips. I also offer some low-cost mindfulness resources to help kids and parents with their anxiety, such as the Calm app and Headspace app. If parents have difficulty with access to parent management training (the first-line treatment to manage aggression in children), I often recommend “The Defiant Child: A Parent’s Guide to Oppositional Defiant Disorder” (Lanham, Md.: Taylor Trade Publishing, 1997), which shows how to create a rewards system in the home to promote positive behavior. “How to Talk So Kids Will Listen & Listen So Kids Will Talk” (New York: Scribner, 2012 ) is a beloved book for parents (and there is a teenager version) that I recommend when parents launch into questions about how to talk to kids and teens about difficult topics so that, ultimately, they can improve their relationship.
Dr. Sara Pawlowski
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. Email her at pdnews@frontlinemedcom.com.