The Integration of Behavioral Health Interventions in Children's Health Care: Services, Science, and Suggestions

Because the integration of mental or behavioral health services in pediatric primary care is a national priority, a description and evaluation of the interventions applied in the healthcare setting is warranted. This article examines several intervention research studies based on alternative models for delivering behavioral health care in conjunction with comprehensive pediatric care. This review describes the diverse methods applied to different clinical problems, such as brief mental health skills, clinical guidelines, and evidence-based practices, and the empirical outcomes of this research literature. Next, several key treatment considerations are discussed to maximize the efficiency and effectiveness of these interventions. Some practical suggestions for overcoming key service barriers are provided to enhance the capacity of the practice to deliver behavioral health care. There is moderate empirical support for the feasibility, acceptability, and clinical utility of these interventions for treating internalizing and externalizing behavior problems. Practical strategies to extend this work and address methodological limitations are provided that draw upon recent frameworks designed to simplify the treatment enterprise (e.g., common elements). Pediatric primary care has become an important venue for providing mental health services to children and adolescents due, in part, to its many desirable features (e.g., no stigma, local setting, familiar providers). Further adaptation of existing delivery models may promote the delivery of effective integrated interventions with primary care providers as partners designed to address mental health problems in pediatric healthcare.

[1]  Thomas L. Campbell,et al.  Family-Oriented Primary Care , 2019, Springer New York.

[2]  B. Sarvet National Network of Child Psychiatry Access Programs , 2014 .

[3]  A. Kilbourne,et al.  Collaborative Care Outcomes for Pediatric Behavioral Health Problems: A Cluster Randomized Trial , 2014, Pediatrics.

[4]  M. Tisminetzky,et al.  A Collaborative Care Model to Improve Access to Pediatric Mental Health Services , 2013, Administration and Policy in Mental Health and Mental Health Services Research.

[5]  P. Kendall,et al.  Brief Cognitive-Behavioral Therapy for Anxious Youth: Feasibility and Initial Outcomes. , 2013, Cognitive and behavioral practice.

[6]  Jonathan D. Brown,et al.  Rethinking the Mental Health Treatment Skills of Primary Care Staff: A Framework for Training and Research , 2012, Administration and Policy in Mental Health and Mental Health Services Research.

[7]  E. Perrin,et al.  The Preschool Pediatric Symptom Checklist (PPSC): development and initial validation of a new social/emotional screening instrument. , 2012, Academic pediatrics.

[8]  A. Kilbourne,et al.  Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. , 2012, The American journal of psychiatry.

[9]  E. Perrin,et al.  Pediatricians’ Perceptions of an Off-Site Collaboration With Child Psychiatry , 2012, Clinical pediatrics.

[10]  A. Kilbourne,et al.  Doctor-office collaborative care for pediatric behavioral problems: a preliminary clinical trial. , 2012, Archives of pediatrics & adolescent medicine.

[11]  E. Perrin,et al.  The challenge of mental health care in pediatrics. , 2012, Archives of pediatrics & adolescent medicine.

[12]  J. Campo,et al.  Anxiety, Depression, and Somatic Distress: Developing a Transdiagnostic Internalizing Toolbox for Pediatric Practice. , 2012, Cognitive and behavioral practice.

[13]  B. Chorpita,et al.  Empirically guided coordination of multiple evidence-based treatments: an illustration of relevance mapping in children's mental health services. , 2011, Journal of consulting and clinical psychology.

[14]  J. Weisz,et al.  Youth Top Problems: using idiographic, consumer-guided assessment to identify treatment needs and to track change during psychotherapy. , 2011, Journal of consulting and clinical psychology.

[15]  Bethany R. Lee,et al.  Evidence-Based Practice at a Crossroads , 2011 .

[16]  Y. Cheng,et al.  Moderators and predictors of clinical outcome in a randomized trial for behavior problems in pediatric primary care. , 2011, Journal of pediatric psychology.

[17]  Anne-Marie R. Iselin,et al.  Evaluation of the sustainability and clinical outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in a child protection center. , 2011, Child abuse & neglect.

[18]  B. Sarvet,et al.  Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project , 2010, Pediatrics.

[19]  M. Rosenthal,et al.  Improving timely childhood immunizations through pay for performance in Medicaid-managed care. , 2010, Health services research.

[20]  N. Halfon,et al.  Factors associated with discipline counseling for parents of infants and young children. , 2010, Academic pediatrics.

[21]  L. Wissow,et al.  Training clinicians in mental health communication skills: impact on primary care utilization. , 2010, Academic pediatrics.

[22]  K. Wells,et al.  Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. , 2010, General hospital psychiatry.

[23]  S. Eyberg,et al.  Early identification and intervention for behavior problems in primary care: a comparison of two abbreviated versions of parent-child interaction therapy. , 2010, Behavior therapy.

[24]  M. Cabana,et al.  The family-centered medical home: specific considerations for child health research and policy. , 2010, Academic pediatrics.

[25]  Yu Cheng,et al.  Improving Access to Care and Clinical Outcome for Pediatric Behavioral Problems: A Randomized Trial of a Nurse-Administered Intervention in Primary Care , 2010, Journal of developmental and behavioral pediatrics : JDBP.

[26]  J. Keller,et al.  Predictors and correlates of completing behavioral parent training for the treatment of oppositional defiant disorder in pediatric primary care. , 2010, Behavior therapy.

[27]  E. Perrin,et al.  Practice Parameters and Financial Factors Impacting Developmental-Behavioral Pediatrics , 2010, Journal of developmental and behavioral pediatrics : JDBP.

[28]  K. Kelleher,et al.  Enhancing Pediatric Mental Health Care: Strategies for Preparing a Primary Care Practice , 2010, Pediatrics.

[29]  Oliver Lindhiem,et al.  Trajectories of Symptom Reduction and Engagement During Treatment for Childhood Behavior Disorders: Differences Across Settings , 2010, Journal of abnormal child psychology.

[30]  Joshua M. Langberg,et al.  Attention-deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings. , 2010, Archives of pediatrics & adolescent medicine.

[31]  E. Perrin,et al.  Medical Home Services for Children With Behavioral Health Conditions , 2010, Journal of developmental and behavioral pediatrics : JDBP.

[32]  Bruce E. Wampold,et al.  The Heart & Soul of Change: Delivering What Works in Therapy , 2009 .

[33]  N. Duan,et al.  Long-term benefits of short-term quality improvement interventions for depressed youths in primary care. , 2009, The American journal of psychiatry.

[34]  J. Lowery,et al.  Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science , 2009, Implementation science : IS.

[35]  B. Duncan,et al.  Using client feedback to improve couple therapy outcomes: a randomized clinical trial in a naturalistic setting. , 2009, Journal of consulting and clinical psychology.

[36]  K. Kelleher,et al.  The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care , 2009, Pediatrics.

[37]  B. Chorpita,et al.  Mapping evidence-based treatments for children and adolescents: application of the distillation and matching model to 615 treatments from 322 randomized trials. , 2009, Journal of consulting and clinical psychology.

[38]  B. Sarvet Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration , 2009, Pediatrics.

[39]  A. Goodman,et al.  Strengths and difficulties questionnaire as a dimensional measure of child mental health. , 2009, Journal of the American Academy of Child and Adolescent Psychiatry.

[40]  D. Shera,et al.  Survey of mental health consultation and referral among primary care pediatricians. , 2009, Academic pediatrics.

[41]  P. Shekelle,et al.  Determining Key Features of Effective Depression Interventions , 2009 .

[42]  D. Pardini,et al.  Community vs. Clinic-Based Modular Treatment of Children with Early-Onset ODD or CD: A Clinical Trial with 3-Year Follow-Up , 2009, Journal of abnormal child psychology.

[43]  Joshua Fogel,et al.  Randomized Clinical Trial of an Internet-Based Depression Prevention Program for Adolescents (Project CATCH-IT) in Primary Care: 12-Week Outcomes , 2009, Journal of developmental and behavioral pediatrics : JDBP.

[44]  H. Pincus,et al.  Pay for performance in behavioral health. , 2008, Psychiatric services.

[45]  Joshua M. Langberg,et al.  Community-wide Intervention to Improve the Attention-Deficit/Hyperactivity Disorder Assessment and Treatment Practices of Community Physicians , 2008, Pediatrics.

[46]  Golda S. Ginsburg,et al.  A Common Factors Approach to Improving the Mental Health Capacity of Pediatric Primary Care , 2008, Administration and Policy in Mental Health and Mental Health Services Research.

[47]  Jennifer Duffy,et al.  Bridging the Gap Between Prevention Research and Practice: The Interactive Systems Framework for Dissemination and Implementation , 2008, American journal of community psychology.

[48]  C. Cicchetti,et al.  Predictor and moderator effects in the treatment of oppositional defiant disorder in pediatric primary care. , 2008, Journal of pediatric psychology.

[49]  J. Campo,et al.  Brief Behavioral Therapy for Pediatric Anxiety and Depression: Piloting an Integrated Treatment Approach. , 2008 .

[50]  Cynthia Suveg,et al.  Cognitive-behavioral therapy for anxiety disordered youth: a randomized clinical trial evaluating child and family modalities. , 2008, Journal of consulting and clinical psychology.

[51]  D. Kamat,et al.  American Academy of Pediatrics Textbook of Pediatric Care , 2008 .

[52]  D. Roter,et al.  Improving Child and Parent Mental Health in Primary Care: A Cluster-Randomized Trial of Communication Skills Training , 2008, Pediatrics.

[53]  A. Riley,et al.  Physician and Patient Characteristics Associated With Discussion of Psychosocial Health During Pediatric Primary Care Visits , 2007, Clinical pediatrics.

[54]  C. Cicchetti,et al.  Treating oppositional defiant disorder in primary care: a comparison of three models. , 2007, Journal of pediatric psychology.

[55]  C. Bell,et al.  Development and process evaluation of a primary care internet-based intervention to prevent depression in emerging adults. , 2007, Primary care companion to the Journal of clinical psychiatry.

[56]  Martin P Charns,et al.  Transformational change in health care systems: An organizational model , 2007, Health care management review.

[57]  S. Scholer,et al.  Parents View a Brief Violence Prevention Program in Clinic , 2007, Clinical pediatrics.

[58]  A. Erkanli,et al.  Improving attention-deficit/hyperactivity disorder treatment outcomes through use of a collaborative consultation treatment service by community-based pediatricians: a cluster randomized trial. , 2007, Archives of pediatrics & adolescent medicine.

[59]  Renee Turchi,et al.  Children and youth with special healthcare needs: there is no place like (a medical) home , 2007, Current opinion in pediatrics.

[60]  L. Solberg Improving Medical Practice: A Conceptual Framework , 2007, The Annals of Family Medicine.

[61]  Bruce F Chorpita,et al.  Understanding the common elements of evidence-based practice: misconceptions and clinical examples. , 2007, Journal of the American Academy of Child and Adolescent Psychiatry.

[62]  W. Gardner,et al.  Comparison of the PSC-17 and alternative mental health screens in an at-risk primary care sample. , 2007, Journal of the American Academy of Child and Adolescent Psychiatry.

[63]  Ken P Kleinman,et al.  The response of physician groups to P4P incentives. , 2007, The American journal of managed care.

[64]  J. Mathai,et al.  Comparison of mental health symptoms between children attending developmental/behavioural paediatric clinics and child and adolescent mental health service , 2007, Journal of paediatrics and child health.

[65]  A. Riley,et al.  Identification of Youth Psychosocial Problems During Pediatric Primary Care Visits , 2007, Administration and Policy in Mental Health and Mental Health Services Research.

[66]  W. Gardner,et al.  Management of pediatric mental disorders in primary care: where are we now and where are we going? , 2006, Current opinion in pediatrics.

[67]  S. Scholer,et al.  A Multimedia Program Helps Parents Manage Childhood Aggression , 2006, Clinical pediatrics.

[68]  W. Livingood,et al.  A Model for Training Pediatricians to Expand Mental Health Services in the Community Practice Setting , 2006, Clinical pediatrics.

[69]  W. O'brien,et al.  Targeted Child Psychiatric Services: A New Model of Pediatric Primary Clinician—Child Psychiatry Collaborative Care , 2006, Clinical pediatrics.

[70]  M. Sanders,et al.  Help when it's needed first: a controlled evaluation of brief, preventive behavioral family intervention in a primary care setting. , 2006, Behavior therapy.

[71]  Harold Alan Pincus,et al.  From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. , 2006, Health affairs.

[72]  M. Rosenthal,et al.  What Is the Empirical Basis for Paying for Quality in Health Care? , 2006, Medical care research and review : MCRR.

[73]  J. Campo,et al.  Pediatric Behavioral Health in Primary Care: A Collaborative Approach , 2005 .

[74]  L. Bickman,et al.  Intervening to Improve Communication Between Parents, Teachers, and Primary Care Providers of Children With ADHD or at High Risk for ADHD , 2005, Journal of attention disorders.

[75]  John R Knight,et al.  Attention-Deficit/Hyperactivity Disorder Among Adolescents: A Review of the Diagnosis, Treatment, and Clinical Implications , 2005, Pediatrics.

[76]  S. Iliffe,et al.  Training general practitioners in the identification and management of adolescent depression within the consultation: a feasibility study. , 2003, Journal of adolescence.

[77]  H. Pincus,et al.  Emerging models of depression care: multi‐level (‘6 P’) strategies , 2003, International journal of methods in psychiatric research.

[78]  A. Garwick,et al.  Children with Special Health Care Needs , 2002 .

[79]  Subcommittee on Attention-Deficit,et al.  Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. , 2001, Pediatrics.

[80]  J. Knutson,et al.  Disciplinary history, adult disciplinary attitudes, and risk for abusive parenting. , 2001 .

[81]  E. Perrin,et al.  Commentary: collaboration in pediatric primary care: a pediatrician's view. , 1999, Journal of pediatric psychology.

[82]  K. Kelleher,et al.  Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study. , 1999, Archives of pediatrics & adolescent medicine.

[83]  M. Macias,et al.  Use of the pediatric symptom checklist in the pediatric neurology population. , 1999, Pediatric neurology.

[84]  J. Schaefer,et al.  Collaborative Management of Chronic Illness , 1997, Annals of Internal Medicine.

[85]  Brian T. Austin,et al.  Organizing care for patients with chronic illness. , 1996, The Milbank quarterly.

[86]  D L Newman,et al.  Behavioral observations at age 3 years predict adult psychiatric disorders. Longitudinal evidence from a birth cohort. , 1996, Archives of general psychiatry.

[87]  W. Katon,et al.  Collaborative management to achieve treatment guidelines. Impact on depression in primary care. , 1995, JAMA.

[88]  E. Costello Child psychiatric disorders and their correlates: a primary care pediatric sample. , 1989, Journal of the American Academy of Child and Adolescent Psychiatry.

[89]  E. Perrin,et al.  Improving parenting skills for families of young children in pediatric settings: a randomized clinical trial. , 2014, JAMA pediatrics.

[90]  S. Mohrman,et al.  It's a Great Time to Be A Physician: Building a Healthcare System that Works , 2013 .

[91]  E. Perrin,et al.  The baby pediatric symptom checklist: development and initial validation of a new social/emotional screening instrument for very young children. , 2013, Academic pediatrics.

[92]  A. Mack Testing Standard and Modular Designs for Psychotherapy Treating Depression, Anxiety, and Conduct Problems in Youth: A Randomized Effectiveness Trial , 2013 .

[93]  T. Welbourne,et al.  AFFORDABLE CARE ACT , 2012 .

[94]  B. Sarvet A guide to building collaborative mental health care partnerships in pediatric primary care , 2010 .

[95]  Bruce E. Wampold,et al.  The heart and soul of change: Delivering what works in therapy, 2nd ed. , 2010 .

[96]  K. Kelleher,et al.  Evolution of child mental health services in primary care. , 2009, Academic pediatrics.

[97]  W. Katon,et al.  Collaborative care for adolescent depression: a pilot study. , 2009, General hospital psychiatry.

[98]  L. Rubenstein Determining Key Features of Effective Depression Interventions Investigators , 2009 .

[99]  Jonathan D. Brown,et al.  Discussion of sensitive health topics with youth during primary care visits: relationship to youth perceptions of care. , 2009, The Journal of adolescent health : official publication of the Society for Adolescent Medicine.

[100]  D. Shaw,et al.  What we have Learned about Early Childhood and the Development of Delinquency , 2008 .

[101]  Shelagh A. Mulvaney,et al.  Large-Scale Evaluations of Children’s Mental Health Services , 2005 .

[102]  J. Squires,et al.  The ASQ:SE user's guide: For the Ages & Stages Questionnaires: Social-emotional. , 2002 .

[103]  A. Soni The Five Most Costly Children's Conditions, 2011: Estimates for U.S. Civilian Noninstitutionalized Children, Ages 0-17 , 2001 .

[104]  S. McDaniel,et al.  Training health professionals to collaborate. , 1997 .