Interactions Between Parents and Pediatric Primary Care Physicians About Children’s Mental Health William T. Garrison, Ph.D. Edward N. Bailey, M.D. Jane Garb, M.A. Bruce Ecker, Ph.D. Peter Spencer, Ph.D. David Sigelman, M.D. Interaction patterns between parents and pediatricians were examined during 1,378 well-child visits to four public and private podiatric dinics. During 327 visits, parents listed at least one psychosocial concern related to their child’s mentalhealtb. At 37 percent ofthese visits, parents saidthey did not wish to discuss the concern with the physician. Physicians failed to address concerns during approximately 35 percent ofvisits at which parents were willing to discuss them. Successful parent-physician interactions were three times more frequent in private practices than in a public dinic; they were more likely when fewer concerns were stated and less likely when bebaviorproblems were the concern. Parents concerned about the parentinfant relationship were four times more likely to be referred to outside mental health services, although these cases were relatively rare. Older children and families receiving Medicaid were also more likely to be referred to such services.
Dr. Garrison
is affiliated
with the
department of psychology Children’s National Medical ter, 1 1 1 Michigan Avenue, Washington, D.C. 20010.
other authors the departments psychiatry Center
at the
are
affiliated
at the CenN.W., The with
of pediatrics Baystate
in Springfield,
and Medical
Massachu-
setts.
Hospital
and
Community
Psychiatry
In recent years several articles and editorials have supported pediatnicians’ attempts to become more active in the broad area of children’s mental health. Primary came pediatnicians
do
appear
to
be
uniquely
situated to provide systematic case screening and detection (1) and early intervention (2,3) as well as to implement briefer mental health themapies, such as behavior modification training (4,5) or short-term individual and family counseling (6,7). Despite this optimistic perspective, many factors may limit attempts by pediatricians to become more involved in the mental health area. Shortcomings in the educational preparation ofpediatnicians, the entrenchment of traditional practice and insurance reimbursement pattemns in primary care, and the multiplicity and complexity of child and family mental-health-related problems are three formidable obstacles (8). Studies oflarge pediatric populations in primary health care settings indicated that a significant proportion ofdiagnosable psychiatric disorden in children and adolescents goes undetected and untreated (9,10). Data suggest that in the primary care setting, parents frequently express concerns related to their children’s mental health (1 1 , 1 2) and that diagnosable psychiatric disorders are common (13,14). However, much less is known about pediatricians’ actual case management patterns or their responsiveness to parental concerns and children’s mental health problems (15,16). Psychosocial problems and concemns ofchildren and families in pnimary care settings are a potentially important area for the mental health professions. Linked services offered by pediatricians and child psychia-
May
1992
Vol.
43
No.
5
trists are becoming more common, as are systematic screening and referral networks. To date, however, much of the attention to mental health issues in primary care has been limited to the pediatric research literature. Psychiatrists and psychologists who seek to broaden the scope of their work to include early intervention and prevention of children’s psychological and developmental problems recognize the unique opportunities in primary care health settings. This paper describes results from a survey ofparents and providers in both private and public pediatric primary care settings. The goals of the study were to investigate factors hypothesized to influence parentphysician interactions about childnen’s mental health in public and private settings and to examine pediatnicians’ responsiveness and case management practices pertinent to these concerns. The starting point for this survey was parental concerns and motivation to seek help in the primary care setting. We were most interested in describing interactions between parents and pediatricians within a cooperative model of service deliverythat is, a model of interaction in which both parents and providers are presumed to have some level of interest in addressing children’s mental health problems. We did not examine children with clinically significant mental health problems whose parents reported no concern due to a lack ofawareness, misrepmesentation, on active denial. We mecognize that these children represent an important clinical subgroup in need of professional attention in primary care, but they were not the focus of this initial survey.
489
In addition, the study focused on parental concerns rather than on diagnosable psychiatric disorders. We chose this approach because of the nature of the population served in primary care pediatrics-namely, younger children-and because of
could confound comparisons between the two setting types. However, the samples reflect the practice settings studied, in terms both of socioeconomic skew and of provider characteristics. Our findings mepresent parent-physician interactions as
the
they
suggestion
in the
epidemiologi-
cal literature that parental concerns are often a useful index to current and future psychiatric problems in children (14). Because we chose to study well-child visits, and because we did not target specifically defined psychiatric disorders, the aim was not to derive prevalence rates for disorders. Rather, the study was an attempt to describe parent-physician interactions and pediatricians’ case management practices related to parents’ psychosocial concerns. Methods Sample. A one-page, bilingual survey in Spanish and English was administered to all parents accompanying children on well-child visits to a large urban ambulatory care center and to three private-practice settings. A total of 1,378 visits were surveyed over a 14-month period. Included were 655 visits to the urban center and 723 visits to the private practices. Initially, the survey completion rate was 95 percent in the urban care center, but the rate gradually decreased
to
around
60
percent
as
repeat patient visits occurred. The completion rate in the pnivate-practice settings averaged 80 percent, based on weekly comparisons between the number of surveys completed and the number of appointments kept at these sites. The urban care center serves pnimanly an indigent, minority patient population, while the private practices serve a primarily white, multiclass patient population. The providems in the urban came center were resident
physicians
and
more
senior,
board-certified pediatric physicians. Providers in the private-practice settings were all board-certified pediatric physicians. It is clear that sharp differences in social class, race, and provider factors, all of which are characteristic of the two-tiered health care delivery system in the United States (17,18),
490
occur
in
two
rather
disparate
primary
care practice types, where it was inherently difficult to separate out effects that may have been due to differences in the populations served rather than to type of setting. Survey. The survey form was completed by the child’s accompanying parent (typically the mother) and then placed in the medical chart for all patients seen in well-child care. Patient-oriented items in the survey asked for the age and gender of the child and the composition of the household, including the number of parents in the home. Other items asked about the family’s insurance status, its racial identification, and the primary language spoken in the home. Parents indicated whether they had concerns in any of four areas listed in the survey: behavior problems at home or school, developmental delays or learning difficulties, parent-infant interaction problems, and family on personal problems that might be affecting the child. These broad categories were thought to touch on the most common mental-health-related concerns ofparents. An additional item asked parents whether they were willing to discuss these concerns with the pediatnician. they were
If they were asked to give
not willing, the reason for
seeking help outside the care setting. After the parent responded first part of the survey, the completed it. Providers whether they were willing the parents’ concerns and how they addressed the during the visit by checking more of five case disposition ses: reassurance or guidance intervention made during cial appointment made plementing intervention, referred out of the clinic, or
primary to the provider indicated to discuss reported concerns one or respongiven, visit, spefor imfamily no action
taken. Data
May
1992
analysis.
Initial
Vol. 43
data
anal-
No.
5
yses focused on the frequencies with which parents expressed any of the four concerns listed in the survey. The rates of providers’ case disposition responses were also measured. Rates were compared by type of setting and across the whole sample. Subsequent analyses sought to model factors associated with two outcome variables of interest: successful parent-provider interactions and out-of-clinic referrals for subspecialty mental health services or evaluations. These models were derived by multiple logistic regression analysis, a technique that can be used for two major purposes. First, it can identify important variables that affect the occurrence of a particular event or outcome. Second, it is used to predict, for an individual or a group ofindividuals, the probability of occurrence of that event. In this study, multiple logistic regression analysis was used for the first punpose, to identify important variables influencing out-of-clinic referrals for psychosocial problems and successful parent-physician interactions. Successful i nteractions were defined as visits in which a parental concern was stated, the parent mdicated a willingness to discuss the concern with the provider, and the provider addressed the concern duning the visit. Unsuccessful intenactions were characterized either by the parent’s indicating unwillingness to discuss the concern on by the provider’s failing to address the concern during the well-child visit. It is important to note that the success or failure of the provider-parent interaction does not reflect on the clinical status ofthe child or on treatment outcome. Rather, success on failure refers only to the final status of the parent-provider interaction relevant to parental concerns.
Results Sample and site characteristics. As was anticipated, significant diffemences
between
the
clinic
types
were
found for race, insurance status, and primary language spoken in the home. A significantly greater proportion of black and Hispanic families were treated in the public clinic (34 and 52 percent, respectively, of the total patients seen) than in the
Hospital
and
Community
Psychiatry
Table
sponse to parental concerns are shown in Table 2. It is noteworthy that significant differences were detected between clinic types in three of the provider responses. Providers in the urban setting tended to
1
Types
ofpsychosocial
visits,
by public
concerns
or private
by parents care setting
during
reported
health
1,378
well-child
pediatric
Setting
Public (N=655)
Psychosocial
concern
N
Behaviorproblem problem
93 52
25
3.8
50
7.6
Total (N=1,378)
rely
%
N
%
12.9
192
13.9
7.2
1 53
11.1
or personal
18
2.5
43
3.1
41
5.7
91
6.6
problem
,
df=
1 , p=.OO2,
180
for comparison
147
27.5
between
clinic
20.3
327
less
frequently
23.7
settings
failed
to meet
statistical private settings (6 and 2 percent, respectively) (X2=622.97, df=1, p< .001). More families receiving Medicaid visited the public clinic than the private practices (83 and 16 percent, respectively; X241313 df= 1 , p< .00 1). Also, more families treated at the public clinic spoke Spanish at home than did families treated in the private settings (25 and 4 percent, respectively; 2 124.36,
df=
1, p
Dr. Garrison
is affiliated
with the
department of psychology Children’s National Medical ter, 1 1 1 Michigan Avenue, Washington, D.C. 20010.
other authors the departments psychiatry Center
at the
are
affiliated
at the CenN.W., The with
of pediatrics Baystate
in Springfield,
and Medical
Massachu-
setts.
Hospital
and
Community
Psychiatry
In recent years several articles and editorials have supported pediatnicians’ attempts to become more active in the broad area of children’s mental health. Primary came pediatnicians
do
appear
to
be
uniquely
situated to provide systematic case screening and detection (1) and early intervention (2,3) as well as to implement briefer mental health themapies, such as behavior modification training (4,5) or short-term individual and family counseling (6,7). Despite this optimistic perspective, many factors may limit attempts by pediatricians to become more involved in the mental health area. Shortcomings in the educational preparation ofpediatnicians, the entrenchment of traditional practice and insurance reimbursement pattemns in primary care, and the multiplicity and complexity of child and family mental-health-related problems are three formidable obstacles (8). Studies oflarge pediatric populations in primary health care settings indicated that a significant proportion ofdiagnosable psychiatric disorden in children and adolescents goes undetected and untreated (9,10). Data suggest that in the primary care setting, parents frequently express concerns related to their children’s mental health (1 1 , 1 2) and that diagnosable psychiatric disorders are common (13,14). However, much less is known about pediatricians’ actual case management patterns or their responsiveness to parental concerns and children’s mental health problems (15,16). Psychosocial problems and concemns ofchildren and families in pnimary care settings are a potentially important area for the mental health professions. Linked services offered by pediatricians and child psychia-
May
1992
Vol.
43
No.
5
trists are becoming more common, as are systematic screening and referral networks. To date, however, much of the attention to mental health issues in primary care has been limited to the pediatric research literature. Psychiatrists and psychologists who seek to broaden the scope of their work to include early intervention and prevention of children’s psychological and developmental problems recognize the unique opportunities in primary care health settings. This paper describes results from a survey ofparents and providers in both private and public pediatric primary care settings. The goals of the study were to investigate factors hypothesized to influence parentphysician interactions about childnen’s mental health in public and private settings and to examine pediatnicians’ responsiveness and case management practices pertinent to these concerns. The starting point for this survey was parental concerns and motivation to seek help in the primary care setting. We were most interested in describing interactions between parents and pediatricians within a cooperative model of service deliverythat is, a model of interaction in which both parents and providers are presumed to have some level of interest in addressing children’s mental health problems. We did not examine children with clinically significant mental health problems whose parents reported no concern due to a lack ofawareness, misrepmesentation, on active denial. We mecognize that these children represent an important clinical subgroup in need of professional attention in primary care, but they were not the focus of this initial survey.
489
In addition, the study focused on parental concerns rather than on diagnosable psychiatric disorders. We chose this approach because of the nature of the population served in primary care pediatrics-namely, younger children-and because of
could confound comparisons between the two setting types. However, the samples reflect the practice settings studied, in terms both of socioeconomic skew and of provider characteristics. Our findings mepresent parent-physician interactions as
the
they
suggestion
in the
epidemiologi-
cal literature that parental concerns are often a useful index to current and future psychiatric problems in children (14). Because we chose to study well-child visits, and because we did not target specifically defined psychiatric disorders, the aim was not to derive prevalence rates for disorders. Rather, the study was an attempt to describe parent-physician interactions and pediatricians’ case management practices related to parents’ psychosocial concerns. Methods Sample. A one-page, bilingual survey in Spanish and English was administered to all parents accompanying children on well-child visits to a large urban ambulatory care center and to three private-practice settings. A total of 1,378 visits were surveyed over a 14-month period. Included were 655 visits to the urban center and 723 visits to the private practices. Initially, the survey completion rate was 95 percent in the urban care center, but the rate gradually decreased
to
around
60
percent
as
repeat patient visits occurred. The completion rate in the pnivate-practice settings averaged 80 percent, based on weekly comparisons between the number of surveys completed and the number of appointments kept at these sites. The urban care center serves pnimanly an indigent, minority patient population, while the private practices serve a primarily white, multiclass patient population. The providems in the urban came center were resident
physicians
and
more
senior,
board-certified pediatric physicians. Providers in the private-practice settings were all board-certified pediatric physicians. It is clear that sharp differences in social class, race, and provider factors, all of which are characteristic of the two-tiered health care delivery system in the United States (17,18),
490
occur
in
two
rather
disparate
primary
care practice types, where it was inherently difficult to separate out effects that may have been due to differences in the populations served rather than to type of setting. Survey. The survey form was completed by the child’s accompanying parent (typically the mother) and then placed in the medical chart for all patients seen in well-child care. Patient-oriented items in the survey asked for the age and gender of the child and the composition of the household, including the number of parents in the home. Other items asked about the family’s insurance status, its racial identification, and the primary language spoken in the home. Parents indicated whether they had concerns in any of four areas listed in the survey: behavior problems at home or school, developmental delays or learning difficulties, parent-infant interaction problems, and family on personal problems that might be affecting the child. These broad categories were thought to touch on the most common mental-health-related concerns ofparents. An additional item asked parents whether they were willing to discuss these concerns with the pediatnician. they were
If they were asked to give
not willing, the reason for
seeking help outside the care setting. After the parent responded first part of the survey, the completed it. Providers whether they were willing the parents’ concerns and how they addressed the during the visit by checking more of five case disposition ses: reassurance or guidance intervention made during cial appointment made plementing intervention, referred out of the clinic, or
primary to the provider indicated to discuss reported concerns one or respongiven, visit, spefor imfamily no action
taken. Data
May
1992
analysis.
Initial
Vol. 43
data
anal-
No.
5
yses focused on the frequencies with which parents expressed any of the four concerns listed in the survey. The rates of providers’ case disposition responses were also measured. Rates were compared by type of setting and across the whole sample. Subsequent analyses sought to model factors associated with two outcome variables of interest: successful parent-provider interactions and out-of-clinic referrals for subspecialty mental health services or evaluations. These models were derived by multiple logistic regression analysis, a technique that can be used for two major purposes. First, it can identify important variables that affect the occurrence of a particular event or outcome. Second, it is used to predict, for an individual or a group ofindividuals, the probability of occurrence of that event. In this study, multiple logistic regression analysis was used for the first punpose, to identify important variables influencing out-of-clinic referrals for psychosocial problems and successful parent-physician interactions. Successful i nteractions were defined as visits in which a parental concern was stated, the parent mdicated a willingness to discuss the concern with the provider, and the provider addressed the concern duning the visit. Unsuccessful intenactions were characterized either by the parent’s indicating unwillingness to discuss the concern on by the provider’s failing to address the concern during the well-child visit. It is important to note that the success or failure of the provider-parent interaction does not reflect on the clinical status ofthe child or on treatment outcome. Rather, success on failure refers only to the final status of the parent-provider interaction relevant to parental concerns.
Results Sample and site characteristics. As was anticipated, significant diffemences
between
the
clinic
types
were
found for race, insurance status, and primary language spoken in the home. A significantly greater proportion of black and Hispanic families were treated in the public clinic (34 and 52 percent, respectively, of the total patients seen) than in the
Hospital
and
Community
Psychiatry
Table
sponse to parental concerns are shown in Table 2. It is noteworthy that significant differences were detected between clinic types in three of the provider responses. Providers in the urban setting tended to
1
Types
ofpsychosocial
visits,
by public
concerns
or private
by parents care setting
during
reported
health
1,378
well-child
pediatric
Setting
Public (N=655)
Psychosocial
concern
N
Behaviorproblem problem
93 52
25
3.8
50
7.6
Total (N=1,378)
rely
%
N
%
12.9
192
13.9
7.2
1 53
11.1
or personal
18
2.5
43
3.1
41
5.7
91
6.6
problem
,
df=
1 , p=.OO2,
180
for comparison
147
27.5
between
clinic
20.3
327
less
frequently
23.7
settings
failed
to meet
statistical private settings (6 and 2 percent, respectively) (X2=622.97, df=1, p< .001). More families receiving Medicaid visited the public clinic than the private practices (83 and 16 percent, respectively; X241313 df= 1 , p< .00 1). Also, more families treated at the public clinic spoke Spanish at home than did families treated in the private settings (25 and 4 percent, respectively; 2 124.36,
df=
1, p
