Children prefer mental health care at office of pediatrician

Study finds families seek familiarity

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Integrated care -- the decades-old but slow-to-catch-on concept of providing mental- and physical-health care in one place -- gets a big boost today with publication of a University of Pittsburgh study in the journal Pediatrics.

The five-year, federally funded study found children treated for mental-health disorders at their pediatricians' offices were nearly seven times more likely to complete a program of care, with better results, than those referred to outside specialists.

Lead researcher David Kolko said the results suggest families view the pediatrician as a convenient, trusted and discreet source for effective treatment of certain behavioral disorders.

"They came back to a setting where they've been for years and feel comfortable," said Mr. Kolko, a clinical psychologist and professor of psychiatry, psychology, pediatrics and clinical and translational science at Pitt's School of Medicine.

Robert Rutkowski, a pediatrician who took part in the study, said children's acceptance of mental-health care at his office makes sense because "they come to us for all sorts of other things."

Dr. Rutkowski, of Children's Community Pediatrics in Moon, South Fayette and Pine, said his practice is so pleased with the results it plans to continue offering mental-health services.

The findings didn't surprise Gregory Fritz, president-elect of the American Academy of Child and Adolescent Psychiatry, who said integrated care will be one of his leadership priorities. He said he soon will meet with representatives of the American Academy of Pediatrics -- the group publishing the Pitt study in its journal -- to plan joint initiatives on the subject.

The study focused on 321 children, 160 of whom received treatment at their pediatricians and 161 of whom were referred to regular mental-health providers. The children had attention deficit hyperactivity disorder, anxiety disorders or other behavioral disorders diagnosed by Mr. Kolko's team.

The participating pediatricians were in eight practices affiliated with Children's Hospital of Pittsburgh of UPMC. Researchers arranged for social workers to counsel the children and consult with their doctors, who prescribed any necessary medications. The patients and family members were asked to attend six to 12 consultations within six months.

Of the children assigned to receive care at their doctor's office, 99.4 percent initiated treatment and 76.6 percent completed their programs. Of those referred to specialists outside the office, 54.2 percent began treatment and 11.6 percent completed it.

While children's issues with behavior and hyperactivity generally improved regardless of where they received care, those treated in the pediatrician's office made more progress, according to caregiver and researcher assessments. Also, during the study period, parents of those treated at the pediatrician's office reported less stress than parents of children treated by other providers.

Researchers did some screening of outside providers before referring study participants to them but don't know exactly what care they provided, what patients and their families liked or didn't like about the care or whether insurance or waiting times affected participant follow-through, Mr. Kolko said.

A South Fayette mother whose son was one of those treated at pediatric practices echoed Mr. Kolko's assertion that a long-term relationship with a primary-care doctor can make all the difference.

She said her son previously refused to see a mental-health professional about his behavioral disorders but agreed to take part in the study because of rapport with his pediatrician. She said her son, now 15, made "vast improvements" during the study, and she said she liked the convenience of having his records and appointments all in one place.

"I would highly advise it as an option," she said.

Mr. Kolko said integrated care -- he had a fellowship on the topic in the 1980s -- has been slow to catch on because the physical- and mental-health care systems have developed independently.

"They don't easily merge," he said.

Yet his study comes amid growing support for the concept, partly because of a growing awareness of the symbiosis of mind and body and partly because a shortage of psychiatrists is pushing the medical community to examine other models of care for adults and children.

"I think that's the direction health care should go," said Patton V. Nickell, chairman of psychiatry for Allegheny Health Network.

In a bill aimed at overhauling parts of the mental-health system, U.S. Rep. Tim Murphy, R-Upper St. Clair, proposed grants for states that develop programs encouraging primary-care doctors to screen patients for mental-health and substance-abuse problems. Dr. Nickell noted Pittsburgh Regional Healthcare Initiative, an arm of the Jewish Healthcare Foundation, already has worked on the screening and management of psychiatric illnesses at primary-care practices.

A push for integrated care may require enhanced training for primary-care physicians.

Whitehall resident Melissa Jones said she asked a pediatrician's advice about her 2-year-old's unusual level of aggressiveness and was disappointed when the doctor told her, "You just need to get control of your daughter. It's bad behavior." Years later, Ms. Jones said, her daughter, Montana, now 10, was diagnosed with bipolar and separation anxiety disorders.

Dr. Fritz, president-elect of the child and adolescent psychiatry academy, said the profession must develop a tiered system in which primary-care doctors treat some mental-health problems, consult psychiatrists on others and refer certain cases to specialists. He said the profession also must work to break down insurance barriers to integrated care.

Joe Smydo: jsmydo@post-gazette.com or 412-263-1548.


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