MENTAL HEALTH COMMUNICATIONTRAINING FOR PEDIATRIC PRIMARY CARE

PROVIDERS: IMPACT ON DISPARITIES

Presentation for A System of Care for Children’sMental Health, Tampa, FL

February 26, 2008

Jonathan D. Brown, PhD, MHSMathematica Policy Research, Inc. and Johns

Hopkins School of Public Health

Lawrence S. Wissow, MD, MPHJohns Hopkins School of Public Health

Why Primary Care is Important in theSystem of Care

10-20% prevalence of mental disorder inprimary care

PCPs are among first professionals toidentify and provide treatment

Most children have an annual primary carevisit

PCPs see children over time

Parents have positive attitudes about theirchild receiving mental health care from PCP

Barriers to Identification and Treatment ofMental Health Problems in Primary Care

Inadequate training & lack of confidence

Lack of time & burden

Limited collaboration with mental healthspecialists

Low reimbursement

Patients have low expectations that mentalhealth services can help

Limitations of Current Primary CareMental Health Quality Improvement Efforts Most target specific disorders based on a

chronic care model

Difficult to accurately diagnose child mentalhealth disorders, especially in primary care

Children have functional impairments but donot meet diagnostic categories

One-third of children with one diagnosis alsohave another diagnosis – complicatesadherence to clinical guidelines

What Mental Health Treatment SkillsDo Primary Care Providers Need

Skills that can be applied to a broad spectrumof mental disorders or symptoms clusters

Skills that can address both child and parentmental health problems

Skills that are adaptable to treatmentpreferences and culture

Skills that help identify when disorder specifictreatment is warranted

Skills that build on existing knowledge

The Training ProgramCombines skills from:

Motivational enhancement

Family therapy

Solution-focused cognitive therapy

Training Domain 1: Elicit Parent andChild Mental Health Concerns

Use techniques from family therapyto promote turn-taking

Engage both child and parentin discussion

Elicit full range of concerns, listen,respond with empathy and interest

Demonstrate to family aninterest in mental healthrelated topics

Manage rambling and set prioritiesReduce provider fears oflosing control of time

See parallels between medical andmental health diagnosis and treat-ment process; apply knowledge ofpediatric development to behavioraladvice

Improve provider feelings ofcompetency

Specific SkillTraining Goal

Training Domain 2: Partner with Familiesto Find Acceptable Forms of Treatment

Ask about readiness to hearprovider’s assessment andrecommendations; use motivationalinterviewing techniques to askabout barriers

Address barriers to treatingmental health problems

Offer choices and ask for feedback;use techniques from motivationalinterviewing to anticipate & respondto ambivalence & resistance

Develop acceptable plan fortreatment or further diagnosis

Specific SkillTraining Goal

Training Domain 3: Increase Expectationsthat Treatment will be Helpful

Use techniques from solution-focused cognitive therapy toidentify practical goals, first steps,and sources of self-esteem;manage negative affect betweenparent and child during visit

Respond to hopelessness,anger, and frustration

Specific SkillTraining Goal

Training Delivery 3 cycles spaced 3 weeks apart

Structured and active learning

Small group discussion led by psychiatrist

Each cycle immediately followed with 10minute standardized patient visit

Videotapes of patient visit given to providerfor self-assessment

Total of 4 hours of training

Evaluation Design Cluster randomized clinical trial

Compared outcomes of families who visited trainedprovider versus those who visited control provider

Providers randomized within clinic

Examined changes in parent emotional distress andchild mental health symptoms and impairment for 6month duration

Clinics

16 in rural New York, suburban and urbanBaltimore, and Washington, DC

All served patients with mix of insurance

Served children age infant to 18 years

None had formal collaborative relationshipswith mental health specialists

Providers

85%84%> 1 year in study site4%10%Child development

15.3 years13.7 yearsTime since receiving degreePhysician Belief Scale

17.117.1 Burden subscale15.013.6 Belief and feelings subscale

19%23%Child behavior training56%65%Pediatrics41%35%Family practice52%65%Female

Control = 27Trained = 31Characteristic

Recruitment of Families

Eligible if child pain less than 4 on 1-10 scale

Screened using Strengths and DifficultiesQuestionnaire (SDQ): those with “possible”or “probable” meeting of DSM criteriaenrolled into follow-up

Enrollment and Follow-up

248 Entered Follow-up

507 Patients of TreatmentGroup Assessed for Eligibility

875 Approached

220 Analyzed at 6 months(88%)

340 Patients of ControlsAssessed for Eligibility

170 Entered Follow-up

147 Analyzed at 6 months(86%)

Participating Youth

6%4%Other

61%49%White

45%47%Private health insurance

52%47%Mental health services in 6months before recruitment

14%10%Latino

19%37%African American

9.910.7Age39%51%Female

Visited ControlProvider = 170

Visited TrainedProvider = 248

Characteristic

Participating Parents

37.636.8Age

73%75%High school graduate

89%92%Female

Visited ControlProvider = 170

Visited TrainedProvider = 248Characteristic

6 Month Outcome Measures

Parent completed GeneralHealth Questionnaire

Parent EmotionalDistress

Parent completed Strengths andDifficulties Questionnaire

Youth MentalHealth Symptomsand Impairment

Statistical Analysis

Multivariate linear regression that accountedclustering of patients within provider andcontrolled for geography, use of other mentalhealth services, age, gender

Interaction terms to test differential impact oftraining according to patient race andethnicity

Unadjusted 6 Month Change in ChildMental Health Impairment

Unadjusted Change in ChildImpairment

-1.52.6 Visited control-.892.8 Visited trained

Caucasian (n = 233).14.70 Visited control-.851.6 Visited trained

Latino (n = 48).162.3 Visited control-.762.0 Visited trained

African American (n = 125)-.832.2All visited control-.882.4All visited trained

6 Month ChangeSDQ At BaselineSample

Summary of Child Results

Minority children visiting trained providerhad a mean improvement in impairment of.91 points more (CI: -1.8 to –0.05) thanCaucasian children

Training improved impairment amongminority youth but not Caucasian youth

Unadjusted 6 Month Change inParent Emotional Distress

Unadjusted Change in Parent EmotionalDistress

-1.33.8 Visited control-1.24.2 Visited trained

Caucasian (n = 233)2.41.0 Visited control.692.2 Visited trained

Latino (n = 48)3.02.9 Visited control.772.5 Visited trained

African American (n = 119)-.0063.2All visited control-.413.3All visited trained

Change at 6Months

GHQ atEnrollmentSample

Summary of Parent Results Visiting trained provider was associated with

1.7 GHQ points (CI: -3.2 to –0.11) lessworsening of symptoms compared withcontrols

Training improved the worsening ofemotional distress among minority parents

Why Would Training Impact MinorityFamilies

Providers may have learned to agree onacceptable form of treatment

May have improved minorities’ expectationsthat treatment would help

May have gained skills to increase trustamong minorities

Implications for the System of Care

Training may provide PCPs with skills that canbe used to improve identification and treatment

May complement disorder specificinterventions

Collaboration with specialists needed

Similar training may be useful to othertreatment settings

Collaborators and Further Reading National Institute of Mental Health R01MH62469

Wissow et al. (2008). Improving child and parent mental healthin primary care: A cluster-randomized trial of communicationskills training. Pediatrics, 121, 266-275.

Anne Gadmoski, Bassett Healthcare, New York

Johns Hopkins: Debra Roter, Susan Larson, Xianghua Luo,Mei-Cheng Wang, Edward Bartlett, Ciara Zachary

Ivor Horn, Children’s National Medical Center

Mary’s Center for Maternal and Child Care, DC

Johns Hopkins Community Physicians, Baltimore

ReferencesBriggs-Gowan, M. J., Horwitz, S. M., Schwab-Stone, M. E., Leventhal,

J. M., & Leaf, P. J. (2000). Mental health in pediatric settings:Distribution of disorders and factors related to service use. Journalof the American Academy of Child and Adolescent Psychiatry,39(7), 841-849.

Brown, J. D., Riley, A. W., & Wissow, L. S. (2007). Identification ofyouth psychosocial problems during pediatric primary care visits.Administration and Policy in Mental Health, 34(3), 269-281.

Brown, J. D., Wissow, L. S., Zachary, C., & Cook, B. L. (2007).Receiving advice about child mental health from a primary careprovider: African american and hispanic parent attitudes. Medicalcare, 45(11), 1076-1082.

Goldberg, D. P., & Hillier, V. F. (1979). A scaled version of the generalhealth questionnaire. Psychological medicine, 9(1), 139-145.

References (continued)Goodman, R. (1999). The extended version of the strengths and

difficulties questionnaire as a guide to child psychiatric casenessand consequent burden. Journal of child psychology andpsychiatry, and allied disciplines, 40(5), 791-799.

Horwitz, S. M., Kelleher, K. J., Stein, R. E., Storfer-Isser, A.,Youngstrom, E. A., Park, E. R., et al. (2007). Barriers to theidentification and management of psychosocial issues in childrenand maternal depression. Pediatrics, 119(1), e208-18.

Olson, A. L., Kelleher, K. J., Kemper, K. J., Zuckerman, B. S.,Hammond, C. S., & Dietrich, A. J. (2001). Primary care pediatricians'roles and perceived responsibilities in the identification andmanagement of depression in children and adolescents.Ambul.Pediatr., 1(2), 91-98.