The Pediatrician as Gatekeeper to Mental Health Care for Children: Do Parents' Concerns Open the Gate? M INA K. DULC AN , M .D ., ELIZABETH J. CO ST ELLO , PH.D . , AN T HON Y J . COS T ELLO , M .D . , CRAIG EDELBROCK , PH.D . , DAVID BR ENT , M .D . , AN D SUSA N JANI SZEWSKI , B.S .
Abstract. Data from a study of ch ildren seen for pediatric care in a Health Maintenance Organization arc use d to exa mine fac tors whieh int1ucncc the likel ihood that a pedi atri cian will ide ntify a psychia tric prob lem and refer an ident ified child to a ment al health spec ia list for furthe r evaluat ion and treatm ent. Parent a l le ve l of distress , family psychiatri c history , and discussion of pare ntal co ncerns with the pedia trician we re found to be impor tant. Char acteristics of the service del ivery sys tem which may impede appro priate iden tification and refe rral arc disc ussed . Impli cat ions for participati on of child and adolescent psychi atrists in the trai ning of pedi atr ic ians arc present ed . .I . Am . Acad , Child Ado lesc, Psychiat r y, 1990 , 29 , 3:453--458 . Key Wo r ds : pediatrician , diagn osis , screening. At a time when increasing num bers of children are enrolled in managed care settings, the primary care physician has a key role as the gatekee per to mental hea lth services for children (Costello et al ., 1988a). T his is a significant ehange from the traditional pattern of identification and referral for psychiatric se rvices by multiple sources , inclu ding schools , socia l service agencies, and parents , as well as pedia tricians . This paper will focus on so me or the factors that may influen ce the likelihood that a pedi atri cian will iden tify a psychiatri c pro blem and re fer an identified child to a mental health spec ialist for further evaluation and/or treatment. Espeeiall y of interest is how the conce rns of the parent may influenc e the pediatrician . Ment al health services available to children in a Health Mai ntenance Organization (HMO) and their rates of use have been described elsewhere (Go ldensohn et a l. , 197 1; Co le man et al . , 1977 ; Jacobson et a1., 1980 ; Starf ield et al . , 1980; Bennett and Gaval ya, 1982) but without cons ider atio n of va riables related to pedi atri cian iden tification and re ferral.
An HMO was ch osen as the site for the study to pro vide a defined pop ulation and to minimize econo mic factor s in service utilizati on . The HMO is a large and rapid ly gro wing one, serving some 72, 000 peo ple at six sites in the Pittsburgh metrop ol itan area. Two sites wer e used for the study : an urban loca tion, close to two large uni ver siti es and to an areas, inha bited mai nly by a poo r, blac k co mmun ity , and a sub urban site , serving a wide geo graphic area , includ ing primar ily white blue co llar and white co llar fami lies. The HMO pro vides a limited number of outpatient individ ual psychi atr ic visits , or famil y , or gro up sess ions per calenda r year for brief assessment and crisis inter ventio n. Thi rty days per year of inpati ent brief treatm ent of acute conditions, or 60 days per year of partial hospital treatment are offere d . Staff includes a half-time child psy chiatrist, chil d psycholog ists , and master's leve l child therapists. For the most part, spec ialist menta l health se rvices requ ire a form al referral from the prim ary care pro vider. T here are month ly meetings between pedi atric and men ta l hea lth staff to discuss problem cases . A child psychiatri st is readi ly avai lab le to consult informally on cases and 10 car ry out initi al screening (cf. Garber, 1973; Bennett and Gavalya , 1982).
Method The samp le and meth ods arc des cribed in detail elsewhere (Costello and Edclbrock , 1985; Co stell o et al., 1988a ,b ,c). Accep ted JUlie 13 . / 989. li t the time thi s stu dy ll'as conducted, al l auth ors ll'ere with W est ern Psychiatric Ins titute and Cl inic, University of Pitt sbu rgh Schoo l of Medicine , Department of Psy chiatry, Dr . Dul can is I/O ll' with EIIIOI )' Univers ity Scho ol (!f" M edi cine , A tlanta, Georgia . Dr. Eli zabeth J . Co stello is with Dti ke University School of M edicine, D urham , North Ca ro lina. Drs . A ntho ny C ostello and Cra ig E delbro ck ar e with University of" Mas sach usetts Sc hool of Medi cine, Wo rces ter. Ma ssachusells . Th is resear ch wa s su pn o rteil b v NIM H Con tract No . 278 -83· {){){)(' (Dlt] a n d Cl inical Research C enter Grant M H 30 Y/5/i'OIn the N at ional Institute of M ent al H ealth , Elizabeth J . Cost ell o . Ph .D . , Princip al In vestigat or. Th e auth ors wo uld like to than k the staff and patient s of Hcalth/vmeri ca Inc . , Pittsburgh , PA , f or th eir tim e and cooperatio n, An ea rlier vers ion of this paper was presente d 11/ the A nnual Me eting of the Am erica n A cademy of Ch ild Psy chiatr y, Oct ober, / 986, L os Angeles, CA . Reprints are not a vailable . Inquiries may be addre ssed (() M ina K . Dulcan, M .D . , EIIIOI )' Uni versi ty School of M edicine, D epa rtment of Psy chi atry, P. O . B ox AF , At lanta, GA 30322 . 0890·8567/90/290 3-0453$02 .00/0 © 1990 by the American Acad emy of Chi ld and Ado lesce nt Psychiatry.
453
I nstruments The Child Behavior Check list (CB CL) (Ac henbach and Edel brock, 1983) is a brief questionnai re co mposed of behavior prob lems and socia l co mpete nce item s . A wide ly used instru me nt, it has been standard ized o n large samples of both refer red and nonrcfcrrcd childre n. ages 4 to 16 . and its reliability and validity are well esta blished . At the index visit, the pediatricians co mpleted the Health Practition er Report (HPR) , a short form reco rding reas o n fo r vis it , primary and (if appropriate) secondary dia gn osis, and pre sence of a fami ly psyehiatric history and /or known fam ily stres sol's . T hey also ind icated the presence/ab sence of an "emotional or beha viora l problem " and , if prese nt, its nature , using the ICD-9 categor ies . The Diagnost ic Interview Schedule for Children (DISC) (Coste llo et aI., 1982 ) consists of two paralle l struc tured
DULCAN lIT AL. ~
20
Idont tied by Pe dlat rrcia na
18
16 • 14
12
1
0B
6 4
2
o
Diag nosi s Abs ent _
Par e nt al Conce rn
No Pa rental Con c e r n
I. Pediatrician diagnosis of psyc hiatric disor der by DSM-III disorde r and pare ntal co ncern. F IG.
interviews, one for children and adolescents , ages 6 to 18 years (DISC- C) , and one for paren ts about their child (OISC-P). Parent and child were interviewed separately by master 's degree ment al health professionals, who were specifically trained to administer the DISC. DSM-Ill diagnose s arc generated by co mputer algorithm from the child and/or the parent interview . The reliability and validity have been described (Costello et al. , 1982 , 1984 , 1985; Edelbrock et aI., 1985; Anderson et al. , 1987). The General Health Questionna ire (GHQ) (Go ldberg, 1972) is a widel y used self-report measure of current psychiatric distres s. It was com pleted by each parent about himself or herself at the time of the home interview. The Parental Concern Form (PCF) (see Appendix), which records inform ation about parent s' co ncerns and co nsultations, was developed for this study .
Procedures The parent of each chi ld, age s 7 to I I years, visiting the HMO for a scheduled appointme nt was asked for permission to have the HPR filled out and to complete the CBCL. Only one age-app ropriate child in a fam ily was includ ed . All children scori ng above the 90th percentil e for the normative sample (Achenbach and Ede lbrock, 1983) and a random sample of those scoring at or belo w it were recruit ed for further asses sment at a hom e visi t, which included the DISC , the GHQ , the PCF, and other measures not reported here . The rate of refusal to complete the CBCL was 6%, and that for the home visit was 26% . Seven hundred eig hty-nine children were screened, and 300 were interviewed: 126 highscoring children (65 %) and 174 (29%) children scoring in the normal range .
Analyses In this report, psychiatric disorder, diagnosed on the basi s of the DISC-P interview with the parent , was used as the criterion of compar ison for the pediatri cians' jud gment s. In this sample, no parent refused to complete the DISC-P , once begun. Although DISC's arc ava ilab le on all the children, only the DISC-P results are reported here . Since parents
454
decide when to bring their children for pedi atric care, the parental report is more relevant to the questi ons addresse d in this paper. Odds ratios (OR) are reported , as the preferred meas ure in case-control studies (Stein and Susser , 1981) of the increased likelihood of a psychi atric diagnosis in a child with a risk factor (e.g . , a family psychia tric history) co mpared with the likelihood in a child without the risk factor (Lilien feld and Lilienfeld, 1980). Unless specified, ORs are only given if the difference in probability of a disorder is significantly greater in the exposed than in the nonexposcd gro up. Since the outco me variable of interest (the presence of a diagnosis), and man y of the predictive factors are dichotomous, logistic regression analysis was the main analytic procedure used . Thi s meth od of multi variate anal ysis calcul ates the relative odd s of a diagnosis in the group exposed to a risk factor controlling for all other variable s, such as sex and race, in the equ ation.
Results Factors Influencing Pediatricians ' Diagnoses of M ental Health Problems For the 300 children interviewed, pediatricians were highly specific , i.e., 84% of ch ildren who they did not ident ify were not diagnosed on the basis of the DIS C-P . However, they showed low sensitivity, i.e ., they only identi fied 17% of the ch ildren who received a psychi atric diagnosis based on the DISC-P. This means that 83% of the 52 children who recei ved diagnoses, using relatively conserva tive standards, were not ide ntified by the ped iatrician s. T he parent s of 52% of the 300 children expressed a con cern to the DISC-P intervi ewer. In only 44 % of these cases (23 % of the original gro up) did the parent report having discu ssed this concern with HMO pedi atric staff. Figure I shows the relations hip between ped iatricians' ident ification of a psych iatric disorder in childre n with and with out on e or more c ur re nt DSM -Il l d isorders (by DISC-P) and whether the pare nt consulted a pediatrician about the child ' s emotional or beh avioral problems. The effect of consultation on the likeliho od of identi fication was increased if the child actually met DSM-Il/ criteria for a disorder. In these cases the likelihood of identifica tion whe n parents consulted was more than 13 times that when parent s did not co nsult (O R = 13.5 , X2 = 6. 0, p < 0 .05). When no disorder was present , the likel ihood of being identified as disturbed was not significan tly increased by parental co nsultation (OR = 3 .0 , X2 = 2.5 , NS) . Adju sting for the presence of DSM -l/I disorder , the ove rall assoc iation between pare ntal consultation and identi ficati on was significant (corrected chi-square = 9 .6, P < 0.01) . Pediatricians ident ified a disorder in eight of 24 disturb ed children whose parent s had consulted them at some time about the ch ild' s mental health, co mpared with only one out of eig ht disturbed childr en whose parents had not con sulte d them . Thus it appears that the pediatrici ans in this study were much more likely to ident ify a child as disturb ed if a parent had at some time consulted them about the child's emotional or behavioral problems, and that this beha vior was partially mod ified by the actual presence of a diagnosabl e disord er. l. Am .Acad. Child Adolesc .Psychiatry , 29: 3, May 1990
PEDIATRICIAN AS GATE KEEPER TO MENTAL HEALT H CARE T A13LE
I . Factors Increasing the Likelihood of Parental Concern and Consultation About Their Child's Emotional
or Behavoral Problems, Holding All Other Factors Constant Paren ta l Con sult at ion
Pare ntal Con cern Fact ors
Odds Rat io
p
Odds Ra tio
p
DSM-III di sorder (pre sent )
5.1 1.6
< 0 .000 1 0 .05 0.0002
3.3
Family psych iatric histor y (p rese nt) Moth er ' s G HQ sco re (high) Se x (male) Age (younger) Race (black) SES Repeated sc hool grade No fathe r in ho me Chro nic illness Mean clinic visits (h igh) Recent life stress (child) Recent life stress (parent)
0. 0002 O.ll6
NS NS
1.3
2.8 1.2 1. 1
1.0 1.0 1.1 1.1 1.2 1.2 1.5
1.2
1.7 1.6
NS"
NS NS NS NS
NS NS
1.1 1.8 1.1 1.1 1.2 1.8
NS
1.3
NS NS
1.2
NS NS
1.1
NS
NS NS
NS
NS NS
NS
.. NS = not significa nt at fI < O.ll i .
Factors Influ encing Parental Concern and Co nsultati on
Not surprisingly, parent s whose chi ldren met DSM-III criteria for one or more disorders, on the basis of the interview with the paren t, were more likely to express concern to the DISC interviewer about the child' s problem s; 85% of such parents expressed concern, compared with 45% of those with nondisturbcd children (OR = 6.6, p < 0.000 1). Contr ollin g for the presence of a diagnosis , logistic regression analysis was used to examine the effect on parent al concern of soc ioeconom ic status , child 's sex and age , presence of a famil y history of disorder , presence of a father in the family, recent stressful events for pare nts or child , a history of multiple episodes of medical illness , and mother ' s current distress (see Table I). The factors that significantly pred icted whether a parent expressed concern about the child to the DISC-P interviewer , controlling for all other variables, were distress in the mother and a family history of ment al health problems. Moth ers who scored 5 or more on the GHQ (the level usually adopted as the cutoff point for significant psychi atric distress) were 2.8 times as likely to express concern (p < 0 .001 ) . Similarly , when there was a report in the fam ily of .one or more ment al health probl ems , arrests, or outpatient psychiatric treatment , the probab ility of parent al concern was 1.6 times greater than in the absence of such problems (p < 0 .05) . Th e same factors had the greatest effect on the conditional probability that a concerned parent would repo rt having consulted an HMO practitioner about a problem (but at a lower level of statisti cal significance) : The likelih ood was 1.7 times greater in the presen ce of a family psych iatric history (p < 0.06) and 1.6 times grea ter if the mother was significantly distressed (p = 0 .1). A family psych iatric history increased the likelihood of consulting a pediatrician by 44% for children with DSM-III disorders and by 53% for those without. Holding other factors constant, the child's age , sex, social class, and race did not affect the probability of a consultation, nor did the presence or absence of a father l.Am. Acad . Child Adolesc . Psychiatry, 29:3, May 1990
in the home , the amount of stress reported by the parent for self or child , or whether the child had a serious chronic physical illness such as asthma, diabete s, or a seizure disorder. Frequent use of medical services in previous years was also unrel ated to the likelihood of a consultation about a mental health problem. It appears that in this sample , only experience with ment al health problems , expressed in the mother ' s current distress and/or in reports of a fam ily history of psych iatric prob lem s, significantly increased the probability of parent al concern or of consulting the ped iatrician about the child 's emotional or behav ioral probl ems, controlling for the child's own symptoms. Paren tal questionin g was , in turn, an important factor in predictin g whether pediatricians would ident ify psychi atric problem s in childre n. Cases Identified by Pediatricians but no t by Pa rents
There were six children whos e parents were not concerned but who were diagnosed by the pediatrician. On CBCL , two of these had normal scores on all problem subscalcs, and four had scores above the 98th percentil e on one or more subscale. Two had positive parent reports of family history of psyc hiatr ic problems in parents or siblings . Th e father of one child was hospitalized for psychia tric care after burning the house , and a brother was treate d for emotional problems after the parents divorced ; in the other case both mother and father had received psych iatric treatm ent. In another case the DISC interviewe r noted that the mother went to great extr emes to minimi ze the problems . In all six cases the DISC interviewers found indications fro m the child and/or the parent that the child had ADD, opp ositional disorder, conduct disorder , anx iety disorder, and/or depression. For three of the six cases there was at least one diagnosis of which the cli nician was confident from the child andlor parent report , but the sym ptoms were not sufficiently severe to reach the level set by the computer algorith ms. On review of the HMO med ical record , four of the charts had repeated references to psychosocial problem s, includ ing: 455
D UL C A N ET A L.
I. Qu estionable school rea diness, anxiety, low self esteem , enco presis , and recommendations for therapy; 2. Sexua lly abu sed , father set fire to family hom e , in thera py ; 3. Father incarcerated , child angry and aggressive , unread y for kindergarten , parental disagreeme nt concerning child's care; 4 . Fights at school, mo ther offered ment al heal th referral but refu sed . From this small group it appears that if the pract itioner makes a diagnosis , even if the parent does not express a co ncern , mental healt h screening , at a minimum , is likely to be warranted .
Discus sion The Role or Parents in l dentifying Children' s Mental Health Problems Parent s emerged from these analyses as cruc ial inform ants abo ut their children's emotiona l and behavioral probl em s, alerting pediatricians to psychop athology that wo uld otherwise go und etected . T hus , although pedi atr ician s failed to identi fy psychia tric d isorder in 83 % of disturbed children, the propo rtion missed fell to 67 % in children whose parent s had consu lted them about such probl em s, and rose to 87 % in those who had not. It is par ticularly interesting that parent s suffering from greater personal distress (here assessed by the GHQ) or with a fam ily histor y of psych iatr ic d isorder were mor e likely to co nsult the ped iatricians about their children's prob lems. T his has been fou nd in other stud ies (Tes sler and Mechan ic , 197R; Wo lkind , 1985). T he importance of the data present ed here , how ever, is to dem on strate that without these " d isturbed" paren ts' concern and co nsultation, man y childre n with signifi cant mental health problems would probabl y have gone unidentified by their pedia tricia ns. Although causa lity cannot be established in a cross-sectional study of this type , the hypothesis needs to be ex plored that disturbed parent s ' complaints about their children serve to bring to light pathology that would oth erwise go unn oticed .
Pediat ricians and " the New Morbidity " Emotional, behavior al , and learning problems seen in ped iatr ic primary care have been called " the new morbidity" (Haggerty et aI. , 1975; Coste llo and Pant ino , (987), and ped iatricians are urged by their senior colleagues to invo lve them selves in their dia gno sis and treatmen t (Gree n, 1983; Haggerty , 1988). Ped iatricians' ambivalenc e to wards parents' concerns abo ut their children's emotiona l and behavioral pro blems is reflected in other studies , as well as ours. For example , fellow s in amb ulatory pediatrics have bee n found to docum ent a resp onse to 78% of parent s ' somatic conce rns about their children , but to only 42% of behavioral co mplaints (Starfield and Borkow f, 1969). In another study, the main concern of 70% of the moth ers see king care from a group of private ped iatricians in Tennessee was beha vioral , emo tional, or developm ental , rather than medical. Onl y 28 % of the mo thers discussed these
456
issues with their ped iatr icians , due to a lack of awareness that the pediatricians might be able to help with this type of probl em or to questioning of his/her ability or interest (Hickson et aI. , 1983). Starfield and Borkowf ( 1969) listed five possible reason s for the relative fa ilure of pediatric ph ysicians to attend to behavioral complaints: I. T he physician may not th ink that the probl em is w ithin the purview of his/her med ica l practice. 2. T he physician may feel inadequate handl ing beh avior pro blems because of speci fic de ficienci es in his/her training . 3. The managem ent of a behav ior problem m ay be an unrewarding task for a physician accustomed to experiencing relatively rapid results from a specific therapy. 4 . Previous unsatisfactory ex perience with the manageme nt of behavior probl ems. 5. Anticipation of excessiv e time necessary for the manage ment of a beh avioral problem . It is commonly found that primary care physicians identify fewer children as disturbed than do paren ts (Cos tello, 1986; Garralda and Bailey , 1986a ,b). In addition, psych iatric diagnose s made by pediatricians differ conside rably from those made by chec klists or by struc tured interviews (Cos tello et al ., 1988b ,e). In prev ious studies , ped iatri cians have been found to diagnose psychopathology in 4 to 7% of the patients they see , co mpared to a preval en ce of at least 17% to 20% esti ma ted fro m co mmunity samples (Costello et al . , 1988b). Thi s has not been found to vary as a function of whether the ca re is fee-for-ser viee or in a prepaid program . Ment al health services available to children in an HMO and their rate of use have been described (Go ldenso hn et al., 1971 ), but wit hout a co nsi deration of variables related to pediatrician ident ification and referral. Hankin and Starfield ( 1986) note that fewer than half of the children identified by pediatricians see mental health specialists . The important question, which remains to be addressed , is whether this figure represents appropriate care , with the remainder bein g cared for satisfactorily by ped iatricians , or whether there is a substantial number of children who should be receiving ment al health ca re who do not. It is ofte n difficult to tease out the relati on ship between identifica tion and referral for men tal healt h ca re. Alth ough generally identification must precede referral, earli er studies rarely specify the amo unt of psychosocial treatm en t performed by primary care phy sicians . In one sam ple of pri mary care practices in Monroe County , NY (Goldberg et al., 1984 ; Costello and Janiszewski , 1988) , the pedi atr icians repo rted that they provided some treatm ent for four- fifths of the children whom they ident ified as disturbed . Most of this treatm ent co nsisted of counse lling; psych otropic medication for hyperact ivity was the next most co mmo n modality . The Mon roe County study (Goldberg et aI. , 1979) asked pediatrician s about their reasons fo r not referring an ide ntified patient. By far the most co mmon was the feeling th at l.Am.Acad. Child Adolesc , Psychiatry, 29:3, M ay 1990
PEDIA TRICI A N A S GATEKEEPER T O MENTA L H EALTH CARE
the pediatrician coul d han dle the problem alone . For a few patients the reason reported was the patient's dislike of psychiat ric referral, or the ped iatrician ' s reluctan ce to label the patient as a " mcntal casc, " or to share responsibilit y for the patient. Lack of access to or ava ilability of psychi atric services or cos t to the patient were not end orsed as barriers to referral . Kamerow et al. ( 1986) summarized potential barriers to better recognition and treatment of substance abuse and mental disorders in primary care . These included: inadequate training in med ical schools and in primary ca re residenc ies, physician attitudes about substance abuse and mental disorders , negative pat ient attitudes , with reluctance to discuss these problems with the prim ary care physician added to their own denial, the stigma of mental health treat ment, and finally the present system of third-p arty rei mbursement , in which third part y payo rs reward procedures rather than talkin g , and which docs not pro vide sufficient mental health benefits in prepaid health plan s.
Implications fo r Train ing Since the early 1970' s , in so me un iversities , there has been increased interest in training pediatric resid ents in developmental and beh avioral aspects of evaluatin g and treating children . In 1978 , the Report of the Ta sk Force on Pediatric Education identified the maj or deficiency in res-
idency tra ining to be in the psychosocia l area. Simultaneously , the W . T . Grant Foundation began awarding grants to departments of pediatrics to strengthen teach ing in behavioral pedia trics (Friedman et 'II. , 1983). Th ere is evi dence that both programs which received grants and those which did not were able to impro ve the knowled ge and attitud es of their resident s , as long as experience in beh avioral pediatrics was mandatory (Ph illips et aI., 1985). Unfortun ately, some programs have not bee n will ing to require attenti on to the psycho social aspects of pediatrics or to deplo y the necessary resources in facult y and residen t time . In additi on, studies have not been done of the outcome of such training: Docs edu cating the prim ary care physician result in more accurate diagnosi s , more appropriate treatment, and improved pat ient outcome'? Unfortunately , the continuing pressure to fund residency education from doll ars earned fro m the care of hospitalized patients and behavioral pediatri cs' lack of acade mic prestige places this trainin g and its evaluation at high risk for eve n more attentuation . Thi s study suggests that teachin g pedi atricians to enco urage par ents to voice their conce rns about thei r childrcu ' s emotions and behavior and to respond to these parental concerns would be a potenti ally fruitful aren a for collaboration betwe en child and adolescent psychiatry and pediatrics. If children and adole scents are to receiv e appropriate ment al health care, the gatekee per must know when to o pen the gate .
Appendix Par ent' s Conc erns and Consultations Interviewer Code I.
2.
_
We have talk ed about a lot of different problem s that childre n can have . Are there any of these problems that have especially concerned you in the past year as far as _ _ _ _ _ _ _ _ is conce rned? If no , exit. If yes, can you tell me about that. (Descr ibe) _
Have you consulted anyo ne at about this? If no , can you tell me what made you decide not to consult them '? (Describe)
HMOlD
_
o
2
o
2
o
2
If yes , whom did you talk to?
If yes, what happened '?
If yes, arc you sati sfied with how the probl em was treated?
./. Am .Acad. Child Adolesc. Psychiatry, 29:3, May 1990
457
References Ache nbac h, T . M . & Edc lbrock , C. S . ( 1 9 ~3), Manu alfor the Child Bclurvior Checklist and Rev ised C hild Beha vior Profile . Bu rlington, VT : Uni versity Assoc iates in Psychiatry . Am erican Aca de my or Pedi at rics Task For ce o n Pediatric Ed ucat ion . ( 1 97~), The Future o{ Pediatric s . Evansto n , IL. Anderson, J . C , Will iams, S . , McGee , R. & S ilva , P . A . ( 1 9~7) , IJSM -1I1 d iso rde rs in pread o lesce nt c hi ldre n. A rch . Ge n . Psychiatry, 44, 69- ~O . B en nett , M . S. & Ga va lya , A . S . (l9~2), Pre pa id co mp rehe ns ive mental hea lth serv ice s for chil dr en. J . Am . A cad. C hild P sych iatry , 21 , 4 ~ 6--49 1 . Co lem a n , J . V., Pat rick , D. L. & Ba ke r , S , M . (1977) , Th e menta l hea lth of ch ildre n in a n H MO pro gram . J . Pedia tr. , 9 1, 105- 15 3. Co ste llo , A. J . , Ede lhro ek , C . S . , Dulcan, M . K., Ka las , R . & Klaric, S. A . ( 1 9~ 4), Tes ting of the N IMH Dia gnostic interview Sc hedule [o r Childre n (DISC ) ill a C lini ca l Pop ulation : Final Rep ort . (C ontract No . R I' P - f) B - ~ 1. 0( 27 ). Rockvi lle , MD : Center for Epidemiological Stud ies, Nat ional Institute of Me nta l Health . .- Ka las, R ., Kessle r , M . K . & Klaric , S . A . (19 82 ) , N ational Insti tute (!( M enta l Health D iag nosti c Intervi ew S chedule [o r Childrcn . Beth esd a , MJ) : Nat ion a l Institute or Men ta l Hea lth . Coste llo , E. J . ( 1 9~ 6) , Primary care ped iatrics a nd c hild psychop athology : A revie w o r d iagnost ic , treatm ent. and re ferra l pract ices . Pediatrics, 78, 1044- 105 1. - - Janiszewsk i, S. M . (l9 ~~), Analysis (if a data set Oil pediatric mental health ca re ( # ~ 7 M 020 2 9 3 3 0 I D ). Bethesd a , M D: Na tiona l Institute o r Me ntal Hea lth . --- - Pantino . T . ( 1 9~7), T he ne w mo rbid ity: Who sho uld treat it'! .I . Del'. Bchav. Ped iat r., s, 2 8 ~-29 1. ---- - - Edcl broc k , C. ( 19 ~ 5 ) , De tec tion of psy ch iatric di sord ers in pediatric primary ca re : A preliminary rep ort. J. 11m. /vcad , Child Psychiatry , 24, 771 - 77 4. ~---- Bu rn s , B. J . , C ostell o , A . J. , Ed clbro ck , C. , Dulcan , M . K . & Bre nt , D. ( 1 9 8 ~ a ), Se rvice uti lizati on a nd psyc hiatr ic d iag nosis in pediatric primary care: Th e role of the gatekee per. Pediatrics, ~ 2:43 5· 441. - - Co stel lo, A . J . , Ede lbro ek , C . ; Burn s , B. J . , D ub IO , M . K. , Brent , D . & Jan isze wsk i. S . ( 1 9 ~ ~ b), Psych iatric d isorders in pedia tric prim ary ca re: Prevalence and r isk factors . A rch . Gen . Psychiurry. 45 , 1 10 7
ru «.
- ..-. - .- - - - Du lcan , M . K . , Bu rns , B. J . & Bre nt , D . ( 1988c), Th e new h idde n morbidit y: Psyc hopatho logy in pedi at ric pr ima ry car e . Pediatrics . 82 :4 15 -42 4. _.- Edclbrock , C & Cos te llo , A. J. (1985) , Vali d ity o r the NIM H Diagn ostic Interview Sc he dule for Ch ildre n: A comparison be twee n psych iatric an d ped iatric refe rrals . .I. /sbno rm , Child P sychol . , 13 , 57 9-5 95 . Edc lbrock , C . S. , Co ste llo , A . J . , Du lcan , M . K . , Kal as , R . & Co nov e r , N . C. ( 198 5) , Age difference s in the re liability o f the psyc hia tr ic interv iew of the ch ild . Child Dev . , 56 ,265-275 . Friedman , S . B. . Phi llips . S . & Parrish , J . M . ( 1983 ), C urre nt status of be havioral pediatric traini ng for ge ne ra l pedi atric residents : A study o f I I fund ed pro gra ms. Pediatrics , 7 1, 904-908 . Ga rber , N . ( 1973) , Pedi a tric-ch ild psych iatry co llabo ration in a Hea lth
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Ma inte na nce Organ iza tio n . 11 m . J. Psychia try, 136 , 392-39 6 . Ga rra lda , M. E. & Ba ile y , D . (l 9 86a ), C h ild re n 'with psyc hiatric disorder s in primar y care . J . Chi ld Psy chol . and Psy chiatry , 27 , 6 11- 624 . - - -----..-- ( 198 6b), Psycho logica l de via nce in ch ildren attendi ng ge neral pra ctice . Psy chol . Me d . , 16, 4 23- 429 . Goldb erg , D . P. ( 1972 ) , M anua l of the Ge ne ra l Health Qu estio nnaire . Lon don: Na tio nal f ou nd atio n for Educati on . Goldb e rg , I. D . , Reg ier , D . A ., Mci ne rny , T . K . , Ple ss , I. B . & Roghmann , K . J . ( 1979) , T he ro le of the pediatrician in the de livery of me nta l health se rvices to ch ild re n . Pediatrics , 6 3 , 898- 909 . - - Roghmann , K . J . , Mc in er ny , T . K . , c t a l. (19 84 ) , Me nta l health prob le ms among childre n see n in pedi at ric pr actice : P revalen ce and manage ment. Pedi atrics , 73 , 278- 2 93 . Gold cnsohn, S . S . , fink , R . & S hapi ro , S . ( 197 1), T he de livery of menta l health se rv ices to c hild re n in a prep a id med ica l ca re pro gra m . Alii. J . Psychiatry, 127 , 135 7-1 362 . Gree n, M , (1 9~3) , C o m ing o f age in ge nera l pe diatrics . Ped iatrics . 72: 275- 282 . Ha ggert y , R.J. (19 88) , Be hav iora l ped iatrics: a tim e for rese arch . Pediat rics, 8 I: 179- 185 . - - Ro gh m ann , K . J . & Pl ess , I. 13 . cds. (1975) , Chi ld H eal th and the Comm unity, New York : W iley . Hankin, J . R . & Starficld , B. H. (19 86 ) , Epide m io log ic perspec tives o n psych osoci al problem s in chi ldre n . In: C hild H ea lth Beha vior : A Beha viora l Pediatrics Persp ecti ve . eds. N . A . Kr asncgor , J . D . Arascth , & M . F. Ca tal do. Ncw Y ork: W iley 7G- 93 . Hick so n , G . B . , A ltme ier , W . A . & O ' Con nor , S . (19 83) , Co ncerns o r mother s see king care in pr ivate pediatric offices . Ped iatrics , 72 , 6 19 . Jaco bso n, A. M. , Go ldb erg, I. G . , Burn s , 13 . J . , Hoep er, E. W . , Han kin , .T . R . & He wit t. K. ( 198 0) , Diagnosed m ental d isor de r in childre n and usc o f health ser vices in four organized heal th care sett ing s . A m . .I . Psychiatry. 137 , 559- 565 . Kam crow , D . B. , Pincu s , H . A. & Macdonald , D . I. (19 86) , A lc ohol abuse , ot he r drug abuse , a nd me nta l d isorde rs in med ica l practi ce : Pre vale nce , co sts, recog nition, and treatm e nts . .lAMA , 255 , 20 54205 7 . Lilicnfc ld , A . M . & Lilicnfcld , D . E . ( 198 0) , Fou ndation s of Epidemiology. New York : O xford Un ive rs ity Press . Ph illi ps , S ., Fr iedm an , S . B. & Ze bal , B. 1-1 . (19 85) , T he impact of (ra ini ng in beha v io ral ped ia tri cs: A study of 24 reside ncy pr og ra m s.
.I . Del'. Behav, Pediatr., 6, 15- 21. Starfi c ld , B . & Borkowf', S . ( 1969) , Ph ysi c ians ' recog nition o f co mpla ints made by pare nts a bo ut the ir c h ild ren' s hea lth . Ped iat rics , 4 3 , 168- 172. - - Gros s , E., W ood , M ., et al. (19 80 ) , Ps yc hosoci al and psychosoma tic di agnos es in primary care of ch ildren . Pediatrics , 66 , 159167 . Stei n, Z. & S usse r , S . ( 198 1), Method s in e pide m iology. J . llm . Acad. Child Psychiatry , 20:444-46 1. Tessler, R . & Me c ha nic, D . (19 78) , Fact ors affecti ng ch ildre n 's usc of physici an services in a prepai d gro up pract ice . M ed . Ca re, 16 , 33- 46 . W olk ind , S . (198 5), Mot hers ' de pr ess io n and their child re n 's atte ndance at med ical faci lit ies . J . Psych osom . Res . , 29 , 57 9-582 .
l.Am . A ca d. C h ild Adolesc, Psy chiatry , 29 :3, May 1990
Abstract. Data from a study of ch ildren seen for pediatric care in a Health Maintenance Organization arc use d to exa mine fac tors whieh int1ucncc the likel ihood that a pedi atri cian will ide ntify a psychia tric prob lem and refer an ident ified child to a ment al health spec ia list for furthe r evaluat ion and treatm ent. Parent a l le ve l of distress , family psychiatri c history , and discussion of pare ntal co ncerns with the pedia trician we re found to be impor tant. Char acteristics of the service del ivery sys tem which may impede appro priate iden tification and refe rral arc disc ussed . Impli cat ions for participati on of child and adolescent psychi atrists in the trai ning of pedi atr ic ians arc present ed . .I . Am . Acad , Child Ado lesc, Psychiat r y, 1990 , 29 , 3:453--458 . Key Wo r ds : pediatrician , diagn osis , screening. At a time when increasing num bers of children are enrolled in managed care settings, the primary care physician has a key role as the gatekee per to mental hea lth services for children (Costello et al ., 1988a). T his is a significant ehange from the traditional pattern of identification and referral for psychiatric se rvices by multiple sources , inclu ding schools , socia l service agencies, and parents , as well as pedia tricians . This paper will focus on so me or the factors that may influen ce the likelihood that a pedi atri cian will iden tify a psychiatri c pro blem and re fer an identified child to a mental health spec ialist for further evaluation and/or treatment. Espeeiall y of interest is how the conce rns of the parent may influenc e the pediatrician . Ment al health services available to children in a Health Mai ntenance Organization (HMO) and their rates of use have been described elsewhere (Go ldensohn et a l. , 197 1; Co le man et al . , 1977 ; Jacobson et a1., 1980 ; Starf ield et al . , 1980; Bennett and Gaval ya, 1982) but without cons ider atio n of va riables related to pedi atri cian iden tification and re ferral.
An HMO was ch osen as the site for the study to pro vide a defined pop ulation and to minimize econo mic factor s in service utilizati on . The HMO is a large and rapid ly gro wing one, serving some 72, 000 peo ple at six sites in the Pittsburgh metrop ol itan area. Two sites wer e used for the study : an urban loca tion, close to two large uni ver siti es and to an areas, inha bited mai nly by a poo r, blac k co mmun ity , and a sub urban site , serving a wide geo graphic area , includ ing primar ily white blue co llar and white co llar fami lies. The HMO pro vides a limited number of outpatient individ ual psychi atr ic visits , or famil y , or gro up sess ions per calenda r year for brief assessment and crisis inter ventio n. Thi rty days per year of inpati ent brief treatm ent of acute conditions, or 60 days per year of partial hospital treatment are offere d . Staff includes a half-time child psy chiatrist, chil d psycholog ists , and master's leve l child therapists. For the most part, spec ialist menta l health se rvices requ ire a form al referral from the prim ary care pro vider. T here are month ly meetings between pedi atric and men ta l hea lth staff to discuss problem cases . A child psychiatri st is readi ly avai lab le to consult informally on cases and 10 car ry out initi al screening (cf. Garber, 1973; Bennett and Gavalya , 1982).
Method The samp le and meth ods arc des cribed in detail elsewhere (Costello and Edclbrock , 1985; Co stell o et al., 1988a ,b ,c). Accep ted JUlie 13 . / 989. li t the time thi s stu dy ll'as conducted, al l auth ors ll'ere with W est ern Psychiatric Ins titute and Cl inic, University of Pitt sbu rgh Schoo l of Medicine , Department of Psy chiatry, Dr . Dul can is I/O ll' with EIIIOI )' Univers ity Scho ol (!f" M edi cine , A tlanta, Georgia . Dr. Eli zabeth J . Co stello is with Dti ke University School of M edicine, D urham , North Ca ro lina. Drs . A ntho ny C ostello and Cra ig E delbro ck ar e with University of" Mas sach usetts Sc hool of Medi cine, Wo rces ter. Ma ssachusells . Th is resear ch wa s su pn o rteil b v NIM H Con tract No . 278 -83· {){){)(' (Dlt] a n d Cl inical Research C enter Grant M H 30 Y/5/i'OIn the N at ional Institute of M ent al H ealth , Elizabeth J . Cost ell o . Ph .D . , Princip al In vestigat or. Th e auth ors wo uld like to than k the staff and patient s of Hcalth/vmeri ca Inc . , Pittsburgh , PA , f or th eir tim e and cooperatio n, An ea rlier vers ion of this paper was presente d 11/ the A nnual Me eting of the Am erica n A cademy of Ch ild Psy chiatr y, Oct ober, / 986, L os Angeles, CA . Reprints are not a vailable . Inquiries may be addre ssed (() M ina K . Dulcan, M .D . , EIIIOI )' Uni versi ty School of M edicine, D epa rtment of Psy chi atry, P. O . B ox AF , At lanta, GA 30322 . 0890·8567/90/290 3-0453$02 .00/0 © 1990 by the American Acad emy of Chi ld and Ado lesce nt Psychiatry.
453
I nstruments The Child Behavior Check list (CB CL) (Ac henbach and Edel brock, 1983) is a brief questionnai re co mposed of behavior prob lems and socia l co mpete nce item s . A wide ly used instru me nt, it has been standard ized o n large samples of both refer red and nonrcfcrrcd childre n. ages 4 to 16 . and its reliability and validity are well esta blished . At the index visit, the pediatricians co mpleted the Health Practition er Report (HPR) , a short form reco rding reas o n fo r vis it , primary and (if appropriate) secondary dia gn osis, and pre sence of a fami ly psyehiatric history and /or known fam ily stres sol's . T hey also ind icated the presence/ab sence of an "emotional or beha viora l problem " and , if prese nt, its nature , using the ICD-9 categor ies . The Diagnost ic Interview Schedule for Children (DISC) (Coste llo et aI., 1982 ) consists of two paralle l struc tured
DULCAN lIT AL. ~
20
Idont tied by Pe dlat rrcia na
18
16 • 14
12
1
0B
6 4
2
o
Diag nosi s Abs ent _
Par e nt al Conce rn
No Pa rental Con c e r n
I. Pediatrician diagnosis of psyc hiatric disor der by DSM-III disorde r and pare ntal co ncern. F IG.
interviews, one for children and adolescents , ages 6 to 18 years (DISC- C) , and one for paren ts about their child (OISC-P). Parent and child were interviewed separately by master 's degree ment al health professionals, who were specifically trained to administer the DISC. DSM-Ill diagnose s arc generated by co mputer algorithm from the child and/or the parent interview . The reliability and validity have been described (Costello et al. , 1982 , 1984 , 1985; Edelbrock et aI., 1985; Anderson et al. , 1987). The General Health Questionna ire (GHQ) (Go ldberg, 1972) is a widel y used self-report measure of current psychiatric distres s. It was com pleted by each parent about himself or herself at the time of the home interview. The Parental Concern Form (PCF) (see Appendix), which records inform ation about parent s' co ncerns and co nsultations, was developed for this study .
Procedures The parent of each chi ld, age s 7 to I I years, visiting the HMO for a scheduled appointme nt was asked for permission to have the HPR filled out and to complete the CBCL. Only one age-app ropriate child in a fam ily was includ ed . All children scori ng above the 90th percentil e for the normative sample (Achenbach and Ede lbrock, 1983) and a random sample of those scoring at or belo w it were recruit ed for further asses sment at a hom e visi t, which included the DISC , the GHQ , the PCF, and other measures not reported here . The rate of refusal to complete the CBCL was 6%, and that for the home visit was 26% . Seven hundred eig hty-nine children were screened, and 300 were interviewed: 126 highscoring children (65 %) and 174 (29%) children scoring in the normal range .
Analyses In this report, psychiatric disorder, diagnosed on the basi s of the DISC-P interview with the parent , was used as the criterion of compar ison for the pediatri cians' jud gment s. In this sample, no parent refused to complete the DISC-P , once begun. Although DISC's arc ava ilab le on all the children, only the DISC-P results are reported here . Since parents
454
decide when to bring their children for pedi atric care, the parental report is more relevant to the questi ons addresse d in this paper. Odds ratios (OR) are reported , as the preferred meas ure in case-control studies (Stein and Susser , 1981) of the increased likelihood of a psychi atric diagnosis in a child with a risk factor (e.g . , a family psychia tric history) co mpared with the likelihood in a child without the risk factor (Lilien feld and Lilienfeld, 1980). Unless specified, ORs are only given if the difference in probability of a disorder is significantly greater in the exposed than in the nonexposcd gro up. Since the outco me variable of interest (the presence of a diagnosis), and man y of the predictive factors are dichotomous, logistic regression analysis was the main analytic procedure used . Thi s meth od of multi variate anal ysis calcul ates the relative odd s of a diagnosis in the group exposed to a risk factor controlling for all other variable s, such as sex and race, in the equ ation.
Results Factors Influencing Pediatricians ' Diagnoses of M ental Health Problems For the 300 children interviewed, pediatricians were highly specific , i.e., 84% of ch ildren who they did not ident ify were not diagnosed on the basis of the DIS C-P . However, they showed low sensitivity, i.e ., they only identi fied 17% of the ch ildren who received a psychi atric diagnosis based on the DISC-P. This means that 83% of the 52 children who recei ved diagnoses, using relatively conserva tive standards, were not ide ntified by the ped iatrician s. T he parent s of 52% of the 300 children expressed a con cern to the DISC-P intervi ewer. In only 44 % of these cases (23 % of the original gro up) did the parent report having discu ssed this concern with HMO pedi atric staff. Figure I shows the relations hip between ped iatricians' ident ification of a psych iatric disorder in childre n with and with out on e or more c ur re nt DSM -Il l d isorders (by DISC-P) and whether the pare nt consulted a pediatrician about the child ' s emotional or beh avioral problems. The effect of consultation on the likeliho od of identi fication was increased if the child actually met DSM-Il/ criteria for a disorder. In these cases the likelihood of identifica tion whe n parents consulted was more than 13 times that when parent s did not co nsult (O R = 13.5 , X2 = 6. 0, p < 0 .05). When no disorder was present , the likel ihood of being identified as disturbed was not significan tly increased by parental co nsultation (OR = 3 .0 , X2 = 2.5 , NS) . Adju sting for the presence of DSM -l/I disorder , the ove rall assoc iation between pare ntal consultation and identi ficati on was significant (corrected chi-square = 9 .6, P < 0.01) . Pediatricians ident ified a disorder in eight of 24 disturb ed children whose parent s had consulted them at some time about the ch ild' s mental health, co mpared with only one out of eig ht disturbed childr en whose parents had not con sulte d them . Thus it appears that the pediatrici ans in this study were much more likely to ident ify a child as disturb ed if a parent had at some time consulted them about the child's emotional or behavioral problems, and that this beha vior was partially mod ified by the actual presence of a diagnosabl e disord er. l. Am .Acad. Child Adolesc .Psychiatry , 29: 3, May 1990
PEDIATRICIAN AS GATE KEEPER TO MENTAL HEALT H CARE T A13LE
I . Factors Increasing the Likelihood of Parental Concern and Consultation About Their Child's Emotional
or Behavoral Problems, Holding All Other Factors Constant Paren ta l Con sult at ion
Pare ntal Con cern Fact ors
Odds Rat io
p
Odds Ra tio
p
DSM-III di sorder (pre sent )
5.1 1.6
< 0 .000 1 0 .05 0.0002
3.3
Family psych iatric histor y (p rese nt) Moth er ' s G HQ sco re (high) Se x (male) Age (younger) Race (black) SES Repeated sc hool grade No fathe r in ho me Chro nic illness Mean clinic visits (h igh) Recent life stress (child) Recent life stress (parent)
0. 0002 O.ll6
NS NS
1.3
2.8 1.2 1. 1
1.0 1.0 1.1 1.1 1.2 1.2 1.5
1.2
1.7 1.6
NS"
NS NS NS NS
NS NS
1.1 1.8 1.1 1.1 1.2 1.8
NS
1.3
NS NS
1.2
NS NS
1.1
NS
NS NS
NS
NS NS
NS
.. NS = not significa nt at fI < O.ll i .
Factors Influ encing Parental Concern and Co nsultati on
Not surprisingly, parent s whose chi ldren met DSM-III criteria for one or more disorders, on the basis of the interview with the paren t, were more likely to express concern to the DISC interviewer about the child' s problem s; 85% of such parents expressed concern, compared with 45% of those with nondisturbcd children (OR = 6.6, p < 0.000 1). Contr ollin g for the presence of a diagnosis , logistic regression analysis was used to examine the effect on parent al concern of soc ioeconom ic status , child 's sex and age , presence of a famil y history of disorder , presence of a father in the family, recent stressful events for pare nts or child , a history of multiple episodes of medical illness , and mother ' s current distress (see Table I). The factors that significantly pred icted whether a parent expressed concern about the child to the DISC-P interviewer , controlling for all other variables, were distress in the mother and a family history of ment al health problems. Moth ers who scored 5 or more on the GHQ (the level usually adopted as the cutoff point for significant psychi atric distress) were 2.8 times as likely to express concern (p < 0 .001 ) . Similarly , when there was a report in the fam ily of .one or more ment al health probl ems , arrests, or outpatient psychiatric treatment , the probab ility of parent al concern was 1.6 times greater than in the absence of such problems (p < 0 .05) . Th e same factors had the greatest effect on the conditional probability that a concerned parent would repo rt having consulted an HMO practitioner about a problem (but at a lower level of statisti cal significance) : The likelih ood was 1.7 times greater in the presen ce of a family psych iatric history (p < 0.06) and 1.6 times grea ter if the mother was significantly distressed (p = 0 .1). A family psych iatric history increased the likelihood of consulting a pediatrician by 44% for children with DSM-III disorders and by 53% for those without. Holding other factors constant, the child's age , sex, social class, and race did not affect the probability of a consultation, nor did the presence or absence of a father l.Am. Acad . Child Adolesc . Psychiatry, 29:3, May 1990
in the home , the amount of stress reported by the parent for self or child , or whether the child had a serious chronic physical illness such as asthma, diabete s, or a seizure disorder. Frequent use of medical services in previous years was also unrel ated to the likelihood of a consultation about a mental health problem. It appears that in this sample , only experience with ment al health problems , expressed in the mother ' s current distress and/or in reports of a fam ily history of psych iatric prob lem s, significantly increased the probability of parent al concern or of consulting the ped iatrician about the child 's emotional or behav ioral probl ems, controlling for the child's own symptoms. Paren tal questionin g was , in turn, an important factor in predictin g whether pediatricians would ident ify psychi atric problem s in childre n. Cases Identified by Pediatricians but no t by Pa rents
There were six children whos e parents were not concerned but who were diagnosed by the pediatrician. On CBCL , two of these had normal scores on all problem subscalcs, and four had scores above the 98th percentil e on one or more subscale. Two had positive parent reports of family history of psyc hiatr ic problems in parents or siblings . Th e father of one child was hospitalized for psychia tric care after burning the house , and a brother was treate d for emotional problems after the parents divorced ; in the other case both mother and father had received psych iatric treatm ent. In another case the DISC interviewe r noted that the mother went to great extr emes to minimi ze the problems . In all six cases the DISC interviewers found indications fro m the child and/or the parent that the child had ADD, opp ositional disorder, conduct disorder , anx iety disorder, and/or depression. For three of the six cases there was at least one diagnosis of which the cli nician was confident from the child andlor parent report , but the sym ptoms were not sufficiently severe to reach the level set by the computer algorith ms. On review of the HMO med ical record , four of the charts had repeated references to psychosocial problem s, includ ing: 455
D UL C A N ET A L.
I. Qu estionable school rea diness, anxiety, low self esteem , enco presis , and recommendations for therapy; 2. Sexua lly abu sed , father set fire to family hom e , in thera py ; 3. Father incarcerated , child angry and aggressive , unread y for kindergarten , parental disagreeme nt concerning child's care; 4 . Fights at school, mo ther offered ment al heal th referral but refu sed . From this small group it appears that if the pract itioner makes a diagnosis , even if the parent does not express a co ncern , mental healt h screening , at a minimum , is likely to be warranted .
Discus sion The Role or Parents in l dentifying Children' s Mental Health Problems Parent s emerged from these analyses as cruc ial inform ants abo ut their children's emotiona l and behavioral probl em s, alerting pediatricians to psychop athology that wo uld otherwise go und etected . T hus , although pedi atr ician s failed to identi fy psychia tric d isorder in 83 % of disturbed children, the propo rtion missed fell to 67 % in children whose parent s had consu lted them about such probl em s, and rose to 87 % in those who had not. It is par ticularly interesting that parent s suffering from greater personal distress (here assessed by the GHQ) or with a fam ily histor y of psych iatr ic d isorder were mor e likely to co nsult the ped iatricians about their children's prob lems. T his has been fou nd in other stud ies (Tes sler and Mechan ic , 197R; Wo lkind , 1985). T he importance of the data present ed here , how ever, is to dem on strate that without these " d isturbed" paren ts' concern and co nsultation, man y childre n with signifi cant mental health problems would probabl y have gone unidentified by their pedia tricia ns. Although causa lity cannot be established in a cross-sectional study of this type , the hypothesis needs to be ex plored that disturbed parent s ' complaints about their children serve to bring to light pathology that would oth erwise go unn oticed .
Pediat ricians and " the New Morbidity " Emotional, behavior al , and learning problems seen in ped iatr ic primary care have been called " the new morbidity" (Haggerty et aI. , 1975; Coste llo and Pant ino , (987), and ped iatricians are urged by their senior colleagues to invo lve them selves in their dia gno sis and treatmen t (Gree n, 1983; Haggerty , 1988). Ped iatricians' ambivalenc e to wards parents' concerns abo ut their children's emotiona l and behavioral pro blems is reflected in other studies , as well as ours. For example , fellow s in amb ulatory pediatrics have bee n found to docum ent a resp onse to 78% of parent s ' somatic conce rns about their children , but to only 42% of behavioral co mplaints (Starfield and Borkow f, 1969). In another study, the main concern of 70% of the moth ers see king care from a group of private ped iatricians in Tennessee was beha vioral , emo tional, or developm ental , rather than medical. Onl y 28 % of the mo thers discussed these
456
issues with their ped iatr icians , due to a lack of awareness that the pediatricians might be able to help with this type of probl em or to questioning of his/her ability or interest (Hickson et aI. , 1983). Starfield and Borkowf ( 1969) listed five possible reason s for the relative fa ilure of pediatric ph ysicians to attend to behavioral complaints: I. T he physician may not th ink that the probl em is w ithin the purview of his/her med ica l practice. 2. T he physician may feel inadequate handl ing beh avior pro blems because of speci fic de ficienci es in his/her training . 3. The managem ent of a behav ior problem m ay be an unrewarding task for a physician accustomed to experiencing relatively rapid results from a specific therapy. 4 . Previous unsatisfactory ex perience with the manageme nt of behavior probl ems. 5. Anticipation of excessiv e time necessary for the manage ment of a beh avioral problem . It is commonly found that primary care physicians identify fewer children as disturbed than do paren ts (Cos tello, 1986; Garralda and Bailey , 1986a ,b). In addition, psych iatric diagnose s made by pediatricians differ conside rably from those made by chec klists or by struc tured interviews (Cos tello et al ., 1988b ,e). In prev ious studies , ped iatri cians have been found to diagnose psychopathology in 4 to 7% of the patients they see , co mpared to a preval en ce of at least 17% to 20% esti ma ted fro m co mmunity samples (Costello et al . , 1988b). Thi s has not been found to vary as a function of whether the ca re is fee-for-ser viee or in a prepaid program . Ment al health services available to children in an HMO and their rate of use have been described (Go ldenso hn et al., 1971 ), but wit hout a co nsi deration of variables related to pediatrician ident ification and referral. Hankin and Starfield ( 1986) note that fewer than half of the children identified by pediatricians see mental health specialists . The important question, which remains to be addressed , is whether this figure represents appropriate care , with the remainder bein g cared for satisfactorily by ped iatricians , or whether there is a substantial number of children who should be receiving ment al health ca re who do not. It is ofte n difficult to tease out the relati on ship between identifica tion and referral for men tal healt h ca re. Alth ough generally identification must precede referral, earli er studies rarely specify the amo unt of psychosocial treatm en t performed by primary care phy sicians . In one sam ple of pri mary care practices in Monroe County , NY (Goldberg et al., 1984 ; Costello and Janiszewski , 1988) , the pedi atr icians repo rted that they provided some treatm ent for four- fifths of the children whom they ident ified as disturbed . Most of this treatm ent co nsisted of counse lling; psych otropic medication for hyperact ivity was the next most co mmo n modality . The Mon roe County study (Goldberg et aI. , 1979) asked pediatrician s about their reasons fo r not referring an ide ntified patient. By far the most co mmon was the feeling th at l.Am.Acad. Child Adolesc , Psychiatry, 29:3, M ay 1990
PEDIA TRICI A N A S GATEKEEPER T O MENTA L H EALTH CARE
the pediatrician coul d han dle the problem alone . For a few patients the reason reported was the patient's dislike of psychiat ric referral, or the ped iatrician ' s reluctan ce to label the patient as a " mcntal casc, " or to share responsibilit y for the patient. Lack of access to or ava ilability of psychi atric services or cos t to the patient were not end orsed as barriers to referral . Kamerow et al. ( 1986) summarized potential barriers to better recognition and treatment of substance abuse and mental disorders in primary care . These included: inadequate training in med ical schools and in primary ca re residenc ies, physician attitudes about substance abuse and mental disorders , negative pat ient attitudes , with reluctance to discuss these problems with the prim ary care physician added to their own denial, the stigma of mental health treat ment, and finally the present system of third-p arty rei mbursement , in which third part y payo rs reward procedures rather than talkin g , and which docs not pro vide sufficient mental health benefits in prepaid health plan s.
Implications fo r Train ing Since the early 1970' s , in so me un iversities , there has been increased interest in training pediatric resid ents in developmental and beh avioral aspects of evaluatin g and treating children . In 1978 , the Report of the Ta sk Force on Pediatric Education identified the maj or deficiency in res-
idency tra ining to be in the psychosocia l area. Simultaneously , the W . T . Grant Foundation began awarding grants to departments of pediatrics to strengthen teach ing in behavioral pedia trics (Friedman et 'II. , 1983). Th ere is evi dence that both programs which received grants and those which did not were able to impro ve the knowled ge and attitud es of their resident s , as long as experience in beh avioral pediatrics was mandatory (Ph illips et aI., 1985). Unfortun ately, some programs have not bee n will ing to require attenti on to the psycho social aspects of pediatrics or to deplo y the necessary resources in facult y and residen t time . In additi on, studies have not been done of the outcome of such training: Docs edu cating the prim ary care physician result in more accurate diagnosi s , more appropriate treatment, and improved pat ient outcome'? Unfortunately , the continuing pressure to fund residency education from doll ars earned fro m the care of hospitalized patients and behavioral pediatri cs' lack of acade mic prestige places this trainin g and its evaluation at high risk for eve n more attentuation . Thi s study suggests that teachin g pedi atricians to enco urage par ents to voice their conce rns about thei r childrcu ' s emotions and behavior and to respond to these parental concerns would be a potenti ally fruitful aren a for collaboration betwe en child and adolescent psychiatry and pediatrics. If children and adole scents are to receiv e appropriate ment al health care, the gatekee per must know when to o pen the gate .
Appendix Par ent' s Conc erns and Consultations Interviewer Code I.
2.
_
We have talk ed about a lot of different problem s that childre n can have . Are there any of these problems that have especially concerned you in the past year as far as _ _ _ _ _ _ _ _ is conce rned? If no , exit. If yes, can you tell me about that. (Descr ibe) _
Have you consulted anyo ne at about this? If no , can you tell me what made you decide not to consult them '? (Describe)
HMOlD
_
o
2
o
2
o
2
If yes , whom did you talk to?
If yes, what happened '?
If yes, arc you sati sfied with how the probl em was treated?
./. Am .Acad. Child Adolesc. Psychiatry, 29:3, May 1990
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