What is children's mental health care?

 Patricia Wen's front page story Children's Access to Mental Health Care is Growing, in which she describes the "co-location" of mental health care services in pediatric practices, brought me back to the summer of 2011 when I attended a meeting of a working group of the Massachusetts Chapter of the American Academy of 
Pediatrics (MCAAP.) The task of this working group, a subgroup of the MCAAP task force on mental health care in pediatrics, was to address the need for collaboration between pediatricians and mental health professionals in caring for children. At the meeting individuals described different models.



One pediatrician, a man who has been in practice for over 30 years in a large group with 15 pediatricians and 10 nurse practitioners, was invited to present his model, held up as an example of an innovative and workable model. This is what he said. 



First, clinicians went in groups of 4 to attend conferences run by a prominent MGH child psychiatrist. Then another child psychiatrist started bi-weekly phone consultation with the group as a whole. 



Now, this pediatrician said with pride, the clinicians in his practice are comfortable " treating 80% of ADHD, anxiety and depression." They were hiring a social worker, whose job it would be not to do therapy, but rather to "make sure patients are taking their medications and refilling prescriptions." 



In other words, mental health care, at least for this doctor and his large group, is equivalent to prescribing psychiatric medication.



This practice is paid by Blue Cross Blue Shield under the model of AQC(alternative quality care) global budget. If the practice overspends they pay the insurance company and if they underspend they split the profit. In addition, if they practice "quality care" as defined by the insurance company, they receive more money. One measure of quality is follow up every four month for ADHD and compliance with psychiatric medication.



Another pediatrician offered an alternative model of collaborative care. She described a close personal relationship with a psychologist, who was also at the meeting. She described how, through confidential voicemail and email, they spoke frequently about their most challenging patients, working closely to provide care, and in doing so keeping a number of patients out of the hospital.



 In a sense the people who presented these two models were speaking completely different languages, one in which mental health care equals medication and another in which mental health care equals providing a "holding environment" through relationships. Unfortunately the second model is at risk of being overpowered, under the influence of the pharmaceutical and health insurance industries, by the first model. 

Our best hope for fighting this trend, I believe, lies in maintaining a focus on prevention- on promotion of healthy social-emotional development in early childhood through relationship-based interventions. 

In the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital I collaborate closely with pediatricians who refer infants, toddlers and preschoolers. I work with children with a range of issues including, but not limited to colic, sleep problems, separation anxiety and explosive behavior. I work with parents and child together. Another program, Project Climb at Colorado Children's Hospital, described in the article  Providing Perinatal Mental Health Care in Pediatric Primary Care integrates infant mental health services in to primary care.

This is a role that primary care clinicians can and should embrace. In a previous post I wrote about a proposed model of including a professional who is experienced with working with parents and infants together in every primary care practice. This person could work with parent-infant pairs when parents are struggling with postpartum depression or anxiety, and/or an infant is fussy/colicky, or in other ways "dysregulated."   

 Research at the interface of developmental psychology, neuroscience and genetics offers extensive evidence that supporting early parent-child relationships is an essential part of promoting healthy  emotional development.

This important aspect of children's mental health care was not mentioned in Wen's article. Instead, the focus was on treatment of "ADHD" and other DSM diagnoses in collaboration with MCPAP- the Massachusetts Child Psychiatry Access Project- whose role Wen describes: 

The Massachusetts Child Psychiatry Access Project provides a hotline for pediatricians to call for consultations with psychiatrists, especially for help with the complexities of prescribing psychotropic drugs. 

The co-location model described in Wen's article is an excellent one. Pediatricians have relationships with children and families that are invaluable. They are important collaborators with mental health professionals.  Parents and young children can be found frequently in a primary care office.  However, any conversation about "co-location" of children's mental health care is lopsided and incomplete without a discussion of preventive care focused on infancy and early childhood.