Doctors and parents of children may be in the examining room together,
but they disagree on whether mental health counseling took place.
Has the “Rashomon” effect come to the doctor's
Parents in a recent study said they did not receive counseling for their
children's mental health problems in 75 percent of the visits with primary
care providers in which the primary care providers said they had delivered
Psychiatrists and pediatricians have been experimenting with ways to
improve mental health diagnosis and care at the primary care level, either by
making referral simpler or quicker or by deepening the knowledge of primary
The new study suggests that process may also involve a complex set of
factors attributable to both providers and parents, wrote Jonathan Brown,
Ph.D., M.H.S., of Mathematica Policy Research in Washington, D.C., and
Lawrence Wissow, M.D., M.P.H., a professor of health, behavior, and society at
the Johns Hopkins Bloomberg School of Public Health in Baltimore. Their report
appeared in the December 2008 Pediatrics.
Their analysis was based on data drawn from a study of how nonspecific“
common factors”—helping providers engage and involve
children and parents, addressing hopelessness and anger, the therapeutic
alliance, decreasing barriers to care, increasing patient
motivation—often result in better outcomes than more specific
treatments, said Wissow in an interview.
In this study, Brown and Wissow documented the results of 749 visits to 54
pediatric primary care providers at 16 practices in Baltimore, Washington,
D.C., and a rural area in upstate New York. Forty-four of the providers were
physicians, nine were nurse practitioners, and one was a physician assistant.
Patients were aged 5 to 16, and 27 percent had high levels of mental health
Immediately after the patient visit, the providers and parents answered one
yes-or-no question each about mental health counseling in the encounter.
Parents were asked whether the provider counseled them about the child's mood,
behavior, ability to get along with others, parental stresses, or family
problems. Providers were asked if they had given counseling for a psychosocial
problem requiring clinical attention.FIG1
The providers said they gave mental health counseling to parents of their
young patients at 239 visits (32 percent), yet parents reported such
counseling at just 179 visits (11 percent). (Curiously, parents did
report counseling at 26 of the 510 visits in which the providers said they had
not provided it. See chart.)
The odds of parents' reporting no counseling rose if they also said the
visit was for mental health reasons, there was any discussion of mental
health, or if a provider was more burdened by delivering mental health
“Burden is a combination of things, but mainly the anxiety of having
to deal with mental health issues,” he said. “Providers worry that
if they bring up these issues, the patient will emote, the doctor won't know
what to do and will fall further behind in the day's work, and nobody will be
The two parties' definition of counseling seemed to be the same, but
parents' expectations may have something to do with the results.
“When you say 'mental health care,' people still think of medications
or psychotherapy, not a reframing of the problems they came in with,”
said Wissow. So even if a family walks out with a sense that their concerns
have been heard, that their problems are common enough with children that age,
or that it may help to talk to the school counselor, they may think that the
provider has not specifically helped them with a mental health issue.
“Providers may not be good enough at framing what they are doing as
mental health care,” said Wissow.
“[They] may require [more] skills to communicate efficiently and
effectively with families about mental health when faced with competing
demands and fewer resources,” wrote Brown and Wissow. “Such skills
should help [primary care providers] overcome language or cultural barriers,
clarify what the parent and youth hope to gain from the visit, and investigate
whether their expectations have been met.”
The providers may be doing better over the longer term than they are right
after the visit. Brown and Wissow are still analyzing follow-up data, but
Wissow said that both clinical outcomes and parental views seem improved six
months after the visit recorded in the study.
An abstract of “Disagreement in Parent and Primary Care
Provider Reports of Mental Health Counseling” is posted at<http://pediatrics.aappublications.org/cgi/content/abstract/122/6/1204>.▪