Pediatrics Academy Urges More Screening for MH Problems

Developmental screening is a regular part of comprehensive pediatric care, but physicians should routinely expand on that model to include the mental health of their young patients, according to a new clinical report issued by the American Academy of Pediatrics.

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“Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the U.S. health system,” wrote Carol Weitzman, M.D., a professor of pediatrics and director of the Developmental-Behavioral Pediatrics Program at the Yale School of Medicine, and Lynn Wegner, M.D., an assistant professor at the University of North Carolina School of Medicine, in the February Pediatrics.

Developmental and behavioral problems often overlap to some extent, they noted: “Studies have revealed that children with cognitive, language, and social impairments and developmental disabilities, in general, are far more likely to manifest behavioral and emotional problems.”

Identifying those symptoms is critical for pediatricians, given that more than 1 in 3 children will be diagnosed with an impulse-control, behavioral, anxiety, or mood disorder by age 16, they added. At the same time, “fewer than 1 in 8 children with identified mental health problems receives treatment.”

However, despite a widespread understanding among pediatricians of the value and need for screening, many do not feel confident in managing children’s mental health problems. They often say they don’t have the time or they are concerned about barriers to referral, such as long wait times and too few providers.

“Pediatricians don’t go into pediatrics to be mental health professionals,” said Gregory Fritz, M.D., a professor and director of the Division of Child and Adolescent Psychiatry at the Warren Alpert Medical School of Brown University. “They are not trained to do this work, but two years out of residency, once they see it in their practices, they say they wish they’d had more didactics on mental health diagnosis and treatment.”

Mental health screening is not as systematic as it should be, especially when pediatricians get busy or a child’s problems are ones they are less familiar with, said Fritz, who was not involved with the clinical report.

However, better training and increased use of available standardized screening instruments might help, suggested Weitzman and Wegner.

So could collaborative models of care, they suggested. Such approaches might include placing mental health practitioners in the same clinic or using paradigms like the Massachusetts Child Psychiatry Access Project, which offers near-real-time phone consults to pediatricians. That program has been adapted in at least 30 other states, building the capacity of pediatricians, said Fritz.

Much of the work the report proposes—such as following up on referrals and consulting with psychiatrists or counselors—takes up physician or staff time, only some of which is covered by CPT codes.

“The question is, how do pediatricians find time to screen and interpret results, and how do they get reimbursed for it?” said Fritz, president-elect of the American Academy of Child and Adolescent Psychiatry (AACAP). “Adding an unremunerated service is not an incentive, given the challenging economics of pediatrics.”

AACAP and APA are also working to remove financial barriers to getting children into care, such as rules against patients’ seeing two doctors on one day, requirements for face-to-face contacts, or not reimbursing for non-DSM-level conditions.

“I’ve been working at the boundaries of pediatrics and child psychiatry for 30 years, and this is a very exciting time,” said Fritz. “I’ve never been so encouraged about the spirit of cooperation and the recognition and interest within primary care of the importance of children’s mental health problems.” ■