Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth

Public health and health care systems face many challenges as indicators of acuity and demand for child mental health services increase.1McMartin SE Kingsbury M Dykxhoorn J et al.Time trends in symptoms of mental illness in children and adolescents in Canada.CMAJ. 2014; 186: E672-E678Crossref PubMed Scopus (36) Google Scholar, 2Kalb LG Stapp EK Ballard ED et al.Trends in psychiatric emergency department visits among youth and young adults in the US.Pediatrics. 2019; 143e2018292Crossref Scopus (124) Google Scholar, 3Ruch DA Sheftall AH Schlagbaum P et al.Trends in suicide among youth aged 10 to 19 years in the United States, 1975 to 2016.JAMA Netw Open. 2019; 2e193886Crossref PubMed Scopus (143) Google Scholar These systems have not been designed to detect problems early and intervene with potentially preventive interventions.4Leslie LK. Mehus CJ. Hawkins JD et al.Primary health care: potential home for family-focused preventive interventions.Am J Prev Med. 2016; 17: S106-S108Abstract Full Text Full Text PDF Scopus (118) Google Scholar,5Cuijpers P Van Straten A Smit F Preventing the incidence of new cases of mental disorders: a meta-analytic review.J Nerv Ment Dis. 2005; 193: 119-125Crossref PubMed Scopus (132) Google Scholar In addition, the child mental health workforce lacks sufficient capacity as it is presently configured.6AACAP work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar Integration of mental health services into primary care has been promoted as one answer to these challenges7Unützer J Carlo AD Collins PY Leveraging collaborative care to improve access to mental health care on a global scale.World Psychiatry. 2020; 19: 36-37Crossref PubMed Scopus (23) Google Scholar and is endorsed by national and international organizations.8Foy JM Green CM Earls MF Mental health competencies for pediatric practice.Pediatrics. 2019; 144: e20192757https://doi.org/10.1542/peds.2019-2757Crossref PubMed Scopus (55) Google Scholar,9World Health Organization (WHO)Caring for Children and Adolescents With Mental Disorders: Setting WHO Directions. World Health Organization, Geneva2003Google Scholar Nearly all children have primary care visits,10Bloom B Cohen RA Freeman G Summary health statistics for U.S. children: national health interview survey, 2010. National Center for Health Statistics.Vital Health Stat. 2011; 10Google Scholar and the philosophy of pediatric primary care in the United States is oriented toward universal prevention, surveillance, and early intervention.11Jellinek M Patel BP Froehle MC Bright Futures in Practice: Mental Health – Volume I, Practice Guide. National Center for Education in Maternal and Child Health, Arlington, Va2002Google Scholar Primary care providers are seen as credible sources of psychosocial information and guidance,12Moseley KL Freed GL Goold SD Which sources of child health advice do parents follow?.Clin Pediatr (Phila). 2011; 50: 50-56Crossref PubMed Scopus (47) Google Scholar and many families express a preference for getting psychosocial care in a primary care rather than a mental health setting.13Herman PM Ingram M Rimas H et al.Patient preferences of a low-income Hispanic population for mental health services in primary care.Adm Policy Ment Health. 2016; 43: 740-749Crossref PubMed Scopus (8) Google Scholar Some of this preference comes from primary care being a more familiar and potentially less stigmatizing place to receive mental health care,14Pingitore D Snowden L Sansone RA et al.Persons with depressive symptoms and the treatments they receive: a comparison of primary care physicians and psychiatrists.Int J Psychiatry Med. 2001; 31: 41-60Crossref PubMed Scopus (56) Google Scholar a factor that may be especially salient to patients who already experience racial or ethnic stigma.15Interian A Lewis-Fernández R Dixon LB Improving treatment engagement of underserved U.S. racial-ethnic groups: a review of recent interventions.Psychiatr Serv. 2013; 64: 212-222Crossref PubMed Scopus (70) Google Scholar Incorporating mental health as part of “routine” medical care also sends a message that emotional well-being is an essential part of one's overall wellness.16McEwen B. The untapped power of allostasis promoted by healthy lifestyles.World Psychiatry. 2020; 19: 57-58Crossref PubMed Scopus (18) Google Scholar Prior to the beginning of this century, very few pediatricians worked in close coordination with mental health professionals. Despite evidence that child/youth integrated care can be effective and practical,17Asarnow JR Rozenman M Wiblin J et al.Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis.JAMA Pediatr. 2015; 169: 929-937Crossref PubMed Scopus (344) Google Scholar,18Platt RE Spencer AE Burkey MD et al.What's known about implementing co-located paediatric integrated care: a scoping review.Int Rev Psychiatry. 2018; 30: 242-271Crossref PubMed Scopus (25) Google Scholar still only about half of US pediatricians consider that they work in practices co-located with a behavioral health professional.19Richman EL Lombardi BM Zerden LDS Where Is Behavioral Health Integration Occurring? Mapping National Co-Location Trends Using National Provider Identifier Data. UMSPH, University of Michigan Behavioral Health Workforce Research Center. Ann Arbor, Mich2018Google Scholar Integration continues to face significant barriers, including lack of consensus on how primary care and co-located mental health professionals should share roles, the need for substantial transformation in how practices operate if they are to provide mental health care,20Sarvet B. The need for practice transformation in children's mental health care.JAACAP. 2017; 56: 460-461Google Scholar financing schemes that do not incentivize treatment in primary care or collaboration with mental health providers,21American Academy of Child and Adolescent Psychiatry Committee on Healthcare Access and Economics, American Academy of Pediatrics Task Force on Mental HealthImproving mental health services in primary care. Reducing administrative and financial barriers to access and collaboration.Pediatrics. 2009; 123: 1248-1251Crossref PubMed Scopus (175) Google Scholar and a lack of mental health practitioners trained to work in primary care settings (especially in linguistically and culturally diverse communities).22Hails K Brill CD Chang T et al.Cross-cultural aspects of depression management in primary care.Curr Psychiatry Rep. 2012; 14: 336-344Crossref PubMed Scopus (9) Google Scholar,23Burkey MD Kaye DL Frosch E Training in integrated mental health-primary care models: a national survey of child psychiatry program directors.Acad Psychiatry. 2014; 38: 485-488Crossref PubMed Scopus (15) Google Scholar To these structural barriers, however, additional dilemmas have emerged as the field of integrated care has evolved. First, there is the realization that conceptualizing integrated care as a binary partnership between mental health and primary care does not address the high level of co-occurrence of mental health, developmental, and psychosocial problems that limit the effectiveness of mental health treatments when they are applied in isolation.24Spencer AE Baul TD Sikov J et al.The relationship between social risks and the mental health of school-age children in primary care.Acad Pediatr. 2020; 20: 208-215Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar As the United States and much of the world enter into an era of unprecedented social and economic challenge related to the novel coronavirus, which has disproportionately impacted populations already experiencing limited access to mental health services, the need to expand the scope of integration will only become greater.25Yoshikawa H Aber JL Beardslee WR The effects of poverty on the mental, emotional, and behavioral health of children and youth: implications for prevention.Am Psychol. 2012; 67: 272-284Crossref PubMed Scopus (589) Google Scholar Second, there is the difficulty of translating the most widely known models of integrated care, developed in adult medicine, into pediatrics.26Katon W Unützer J Collaborative care models for depression: time to move from evidence to practice.Arch Intern Med. 2006; 166: 2304-2306Crossref PubMed Scopus (105) Google Scholar Compared to adult integrated care, child mental health integration must contend with presentations that vary significantly with age, which complicates screening and other forms of case-finding.27Costello EJ Mustillo S Erkanli A et al.Prevalence and development of psychiatric disorders in childhood and adolescence.Arch Gen Psychiatry. 2003; 60: 837-844Crossref PubMed Scopus (2805) Google Scholar Child mental health treatment relies more on brief, practical psychosocial interventions compared to easier-to-deliver medication titration.28Locher C Koechlin H Zion SR et al.Efficacy and safety of selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents: a systematic review and meta-analysis.JAMA Psychiatry. 2017; 74: 1011-1020Crossref PubMed Scopus (199) Google Scholar,29Marchette LK Weisz JR Practitioner review: empirical evolution of youth psychotherapy toward transdiagnostic approaches.J Child Psychol Psychiatry. 2017; 58: 970-984Crossref PubMed Scopus (76) Google Scholar In addition, while nearly everyone's mental health is related to that of the people they live with, children's mental health outcomes are particularly dependent on their parents’ own mental health,30Eckshtain D Marchette LK Schleider J et al.Parental depressive symptoms as a predictor of outcome in the treatment of child internalizing and externalizing problems.J Abnorm Child Psychol. 2019; 47: 459-474Crossref PubMed Scopus (17) Google Scholar and thus treatment often must include plans to address parents’ treatment needs and parent-child interactions.31Shonkoff JP Fisher PA Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy.Dev Psychopathol. 2013; 25: 1635-1653Crossref PubMed Scopus (193) Google Scholar The American Academy of Pediatrics has issued a policy statement outlining what it sees as pediatric providers’ responsibilities to address parental mental health,32Earls MF Yogman MW Mattson G et al.Committee on psychosocial aspects of child and family health. Incorporating recognition and management of perinatal depression into pediatric practice.Pediatrics. 2019; 143: e20183259https://doi.org/10.1542/peds.2018-3259Crossref PubMed Scopus (114) Google Scholar but there remains little precedent for mental health in pediatric primary care, effects on H A et mental health care in a pediatric primary care a of Pediatr. 2019; 19: Full Text Full Text PDF PubMed Scopus (11) Google Scholar To integrated care has from and to With however, as the for and and by the American of Pediatrics and the American Academy of JM Green CM Earls MF Mental health competencies for pediatric practice.Pediatrics. 2019; 144: e20192757https://doi.org/10.1542/peds.2019-2757Crossref PubMed Scopus (55) Google for and for Available Accessed M AE future pediatricians to the behavioral and mental health needs of 2020; PubMed Google Scholar there has been a on with care for for Healthcare Research and The Behavioral Health Primary Available Accessed Scholar policy have how health systems as a including with integrated care can child and family well-being in C S E for to Child and Using and to and of Health. Scholar The more on mental health into pediatric primary care. The are as a to health and and they address on the are to the and effectiveness of pediatric integrated pediatric practice to address family psychosocial needs and must in the scope of pediatric primary care that it can address psychosocial for care Pediatr. 2018; Full Text Full Text PDF PubMed Scopus Google Scholar social and emotional needs to be as an part of pediatric care and these aspects of health need to be and by pediatricians in collaboration with services that address social of JP Fisher PA Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy.Dev Psychopathol. 2013; 25: 1635-1653Crossref PubMed Scopus (193) Google M KL the early parent-child of for parents and Pediatr Health 2011; PubMed Scopus (8) Google Scholar and programs have the to these financial and providers and health care need the and of how to about their practices and the they will need to provide integrated care. health care systems to mental will and to for implementing or of Health and Mental Health Available Accessed March 6, 2020.Google Academy of for children: medical Available Accessed March 6, 2020.Google Scholar models that are for integrated care. States can these models by practices additional if they for financing be to the of integrated care to address in mental health services and as as to coordination of child/youth and adult mental health expand policy the and treatment of parental mental health problems as part of pediatric primary for and A for in the of and of Health and Scholar include that to parental mental health for depression in the perinatal as as the of including mental health information in the medical These with for pediatricians in the and of parental health to include to parental mental health as the scope of pediatric and Mental Health the Health and Health and or programs that provide practices or health systems with the to pediatric integrated care, as Collaborative of Center. Collaborative Available Accessed March 6, 2020.Google L J D et mental and health services a Pediatr Health 2016; PubMed Scopus (15) Google Scholar the a national on pediatric integrated care information related to the Center for and for and for Available Accessed Scholar or of the and Mental Health integrated care for Behavioral Health. Center of for Healthcare Available Accessed March 6, 2020.Google Scholar to of that have integrated care all they have population and policy as as models that work in with of mental health and expand and that all have psychiatry access that collaboration and mental health in the pediatric primary M child psychiatry access a in child psychiatry access program 2017; Full Text Full Text PDF PubMed Scopus (11) Google A et national of child psychiatric on children's mental health care Child Psychiatry. 2019; 58: Full Text Full Text PDF PubMed Scopus (15) Google Scholar These programs provide mental health to primary care providers and many have primary care and practice transformation which be to include integrated behavioral health providers in and evidence-based interventions or when with these health care and additional mental health for primary care of the to provide and for practice RA J et of the for health outcomes as applied to primary care for a Pediatr. 2020; PubMed Scopus (23) Google as with programs that of medical have programs of outcome and the to in a with social program Is for Health and Policy JM et barriers to children's mental health: an systems health Ment Health 2016; Scopus Google Scholar These include additional for systems as that of L PA of the in a of Child Psychol. 2020; Scopus (23) Google L S et health in early the of for pediatric Pediatr Psychol. 2020; PubMed Scopus Google Scholar and development of programs that between primary care and providers as and and programs that economic D B et Health A to Health in Primary and create programs that their to for the of child/youth mental health care. that and care and statistics on child behavioral health by age, and psychiatric These statistics can be a for the of a mental health and the to which they are by are the of care in statistics on the of these as a for the of integrated care and potentially access and early additional that the of mental health screening in primary care can primary care is as an effective for child/youth mental health et health services of screening in 2014; PubMed Scopus (18) Google pediatric integrated care Second, must pediatric integrated care for practices and health especially a time when on overall social and health care may the of mental health care by services that have a M D E to of Health in Health, Scholar integrated care does not the potentially from adult integrated care, and interventions for families with children are more to than for models must into the in time it providers to with families (especially who have or with and other and a population of children and youth with psychosocial from to and among practices with that create more the and can to health financing of which of integrated care can be for and Health or as part of care J A et and Health Primary A for Leveraging and to Center for the of Behavioral Health Integration in Primary and for and Scholar care to that have integrated care provide or for preventive services, have to services the social of health, parental and child mental health care, or for as a for implementing integrated can to barriers to for integrated mental health services Academy of Child and Adolescent Psychiatry Committee on Healthcare Access and Economics, American Academy of Pediatrics Task Force on Mental HealthImproving mental health services in primary care. Reducing administrative and financial barriers to access and collaboration.Pediatrics. 2009; 123: 1248-1251Crossref PubMed Scopus (175) Google M D E to of Health in Health, Scholar, J A et and Health Primary A for Leveraging and to Center for the of Scholar, Behavioral Health Integration in Primary and for and it to mental health providers who work in primary care it to primary care as also mental health primary care providers to to co-located or mental health providers the need for mental health treatment by co-located or mental health providers of all as part of medical additional a mental health for an of mental health for mental health care on the as a primary care can expand the of that collaborative work that primary care and psychiatric providers can be for and coordination of for children and Health Collaborative Available Accessed March 6, 2020.Google Scholar As part of for collaborative care, can also for the services of health or who can families to services and mental health treatments in and for for services that also have potential for on the for and A for in the of and of Health and a and more diverse integrated care workforce need to development of the workforce that integrated care can be work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar only is there a lack of child mental health workforce in most of the there is an lack of providers trained to work the of medicine, mental health, and work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar,23Burkey MD Kaye DL Frosch E Training in integrated mental health-primary care models: a national survey of child psychiatry program directors.Acad Psychiatry. 2014; 38: 485-488Crossref PubMed Scopus (15) Google M R et al.Integrated pediatric behavioral health: implications for and Psychol 2016; 47: Scopus (18) Google Scholar In diverse this workforce has to and be of care to families from and mental health for health who be from diverse and services be or management J A et and Health Primary A for Leveraging and to Center for the of M K health for patients with medical and behavioral health and 2016; PubMed Scopus Google Scholar to or health care providers be to the and of the workforce and for who in these but Mental Health Available Accessed March 6, 2020.Google of Health Available Accessed March 6, 2020.Google additional in family and child psychiatry that on integrated to integrated care and in mental health for that the especially physicians who will into primary MD Kaye DL Frosch E Training in integrated mental health-primary care models: a national survey of child psychiatry program directors.Acad Psychiatry. 2014; 38: 485-488Crossref PubMed Scopus (15) Google Scholar States have more if medical and mental health in programs for all primary care including physicians and M AE future pediatricians to the behavioral and mental health needs of 2020; PubMed Google or in social and programs that work in co-located or of of Behavioral Health Workforce Integration and Education Available Accessed March 6, 2020.Google of of and Primary Health Available Accessed March 6, 2020.Google program the for pediatric integrated care are to the and interventions that will pediatric integrated care to development of screening that with families about their psychosocial and and and to LK Weisz JR Practitioner review: empirical evolution of youth psychotherapy toward transdiagnostic approaches.J Child Psychol Psychiatry. 2017; 58: 970-984Crossref PubMed Scopus (76) Google H A Mental illness and an Psychiatry. 2019; PubMed Scopus Google Scholar more and interventions for primary care that address parent-child H A et mental health care in a pediatric primary care a of Pediatr. 2019; 19: Full Text Full Text PDF PubMed Scopus (11) Google JM et for families of young children in pediatric a Pediatr. 2014; PubMed Scopus Google Scholar and for practices and these In the of global mental health, the US National of Mental Health, the and the for have in on integrated mental health care for adults and J Carlo AD Collins PY Leveraging collaborative care to improve access to mental health care on a global scale.World Psychiatry. 2020; 19: 36-37Crossref PubMed Scopus (23) Google C M M et a to the treatment for mental disorders in and Med. 2012; PubMed Scopus Google Scholar A a which and of brief, that can be by with and mental health and that can be to families in a of LK Weisz JR Practitioner review: empirical evolution of youth psychotherapy toward transdiagnostic approaches.J Child Psychol Psychiatry. 2017; 58: 970-984Crossref PubMed Scopus (76) Google J Weisz J A for adolescent and depression: outcomes of a Child Psychol Psychiatry. 2018; PubMed Scopus (124) Google of and parent-child interventions for primary care, in early childhood and the pediatric LK. 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Hawkins JD et al.Primary health care: potential home for family-focused preventive interventions.Am J Prev Med. 2016; 17: S106-S108Abstract Full Text Full Text PDF Scopus (118) Google A S et and in primary care: of the Pediatr. 2018; Full Text Full Text PDF PubMed Scopus Google of models of care as that the care for the mental health and psychosocial needs of for care Pediatr. 2018; Full Text Full Text PDF PubMed Scopus Google C et care practice for low-income 2014; PubMed Scopus Google of novel of for integrated care services, including of the of and other to the of mental health and the integration of treatments for parents and other into services in L L et in pediatric primary care: a 2019; 143: PubMed Scopus Google W et depression in primary Med. 2011; PubMed Scopus Google of and programs for health and who can the mental health workforce and capacity for care in diverse and from diverse S P et of a mental health for children: in the and health in Psychiatry. 2019; PubMed Scopus Google A A et in a global Psychiatry. 2020; 19: PubMed Scopus (36) Google related to practice transformation and PA et practices to medical from the National 2011; 30: PubMed Scopus Google Scholar with on for including diverse families in the and of D D an to and among young children and their families in a barriers and J Public Health. 2019; Scopus Google Scholar and for and to practices and systems as they and integrated D K et in outcomes a in practices that are to a collaborative care a 2019; PubMed Scopus (11) Google Scholar care is to be one of the most for in the of child and youth mental health the to and early into an of child health and as as to create a of child and youth mental health care can be of pediatric integrated care continues to face barriers into the that pediatric primary care is and need to in the scope of pediatric primary care, as as financing that these A and more diverse mental health workforce will be to an of pediatric integrated care. Training programs for primary care providers and a of and potential mental health providers must provide with the they need to and families in the primary care there remains much to be about interventions that pediatric integrated care more and to there are on which to address all of these it should be to in these and move pediatric integrated care a time when it is particularly

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