Incorporating mental health care into primary visits
Pediatricians face rising demands in specialty care and mental health, with programs such as REACH helping them manage these challenges.
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General pediatric providers and pediatric specialists across multiple areas of medicine have told Contemporary Pediatrics that general providers are taking on more and more responsibilities. Longer wait times for pediatric specialty care, exacerbated by the COVID-19 pandemic, are still lingering and contributing to these added responsibilities.1
In addition, 1 in 10 children in the United States do not have a primary care doctor, a trend that is increasing. According to a 2024 study published in Frontiers, part of the reason for this struggle to find care is that medical practices have reached their maximum capacity of child patients who are covered by Medicaid, citing paperwork, low payment, and capitation as the primary drivers of low Medicaid participation.2
Even for children who are commercially insured, there has been an approximately 15% drop in the number of primary care visits in the past decade, further demonstrating the strain that the pediatric health care system is navigating.2
On top of these challenges, pediatric patients still face a mental health crisis, officially declared a national emergency in children and adolescents by the American Academy of Pediatrics (AAP) in October 2021.3
The AAP states that approximately 16% of children under 6 years of age have clinically significant mental health problems that require early-life clinical care. Whether patients present with dysregulated emotional or behavioral problems such as anger, aggression, or anxiety, or the inability to participate in family and community events, these issues rarely resolve without some capacity of specific intervention.4
These challenges often land first on the family’s pediatrician, who must not only manage a multitude of responsibilities but also must navigate an area in which they may not have a wealth of experience. A 2017 article published in Pediatrics noted that despite Accreditation Council for Graduate Medical Education requirements that ensure pediatric trainees complete a month each of developmental-behavioral pediatrics and adolescent medicine, an adequate depth of experience could be lacking. This doesn’t mean pediatric residents aren’t eager for additional opportunities to deliver mental health care in practice, even with the present challenges.5
The REACH Institute, a 501(c)(3) nonprofit organization, aims to deliver effective, scientifically proven mental health care to children and families by providing thousands of primary care physicians with training in evidence-based therapies to better diagnose, treat, and manage child mental health issues.6
The institute’s founder and board chair Peter S. Jensen, MD—a child and adolescent psychiatrist—acknowledged the challenges pediatricians may face when handling mental health issues in the primary care setting.
“At REACH, we've trained over 8000 pediatricians and family practitioners over the [past] 15 years, and what we've heard again and again is that the biggest challenge is finding the time and space in a busy practice to introduce and follow up on the topic,” Jensen told Contemporary Pediatrics in an interview.
“That's the first obstacle,” said Jensen. “The second is that primary care doctors and others in primary care don't get much training during residency. They've never had real practice in treating depression or maybe an anxiety disorder. They get a little exposure to [attention-deficit/hyperactivity disorder], but there is often so much more they need to learn how to do. So, the issues are time and space, background support and training, and then, of course, making sure they get paid for that work, which is so critical.”
Jensen stated there is a group of effective, free tools that function like checklists that are easily accessible online. Some are filled out by the parent, some by the child, but these tools can help the provider determine what a problem might be, even before a referral.
“For example,” said Jensen, “one of the older measures a lot of primary care providers have used is called the Pediatric Symptom Checklist (PSC-17).” Previously, a 35-item list, “researchers found they could reduce it to 17 items, which you can type into a web browser and download right away. This tool lets you separate a child who might have more attention problems from one who might have anxiety, depression, or other behavioral difficulties. It is easy to use, free, and can be integrated into the electronic health record. There are both parent and teen versions, and they can be transformative.”7
Jensen stated that physicians can get paid for using these tools, as most insurance companies and Medicaid allow billing codes for their use. On top of that, Jensen noted assessments taken are quick to complete but can offer strong indications of a potential mental health issue.
“These assessments take just a few minutes, provide valuable insights, and help point pediatricians in the right direction.”
He noted many providers are likely familiar with the Patient Health Questionnaire-9 (PHQ-9) tool, used to screen for depression. Other tools such as the Screen for Child Anxiety Related Emotional Disorders (SCARED) and Vanderbilt Diagnostic Rating Scale may also be familiar to general providers.7
MORE: Peter Jensen, MD, further discusses mental health in primary care
“However, it's one thing to know about these tools and another thing to actually implement them—distribute them, review the results, and interpret them,” Jensen added.
“Imagine a child comes in with significant school-related stress, worrying about falling behind, agonizing over tests at night, and having trouble falling asleep. You administer the SCARED or General Anxiety Disorder-7—both anxiety self-report scales—and confirm that 'this kid is high in anxiety,’” Jensen explained.7
“Then, in your practice, you say, 'I'm going to teach you how to do deep breathing. We're going to spend 3 minutes on this, and now I'm assigning it as homework. I want to see you back in 3 weeks. Mom, I want you involved in this too. Your daughter has to work on this; it's a skill,'” Jensen said as an in-office example.
“This simple intervention—teaching deep breathing and incorporating it into a protocol—could benefit many anxious children who need that kind of support. If every primary care provider learned how to use these exercises, it would make a significant impact,” Jensen concluded.
References:
1. O'Dwyer B, Macaulay K, Murray J, Jaana M. Improving access to specialty pediatric care: innovative referral and econsult technology in a specialized acute care hospital. Telemed J E Health. 2024;30(5):1306-1316. doi:10.1089/tmj.2023.0444
2. Wells J, Shah A, Gillis H, et al. Tiny patients, huge impact: a call to action. Front Public Health. 2024;12:1423736. doi:10.3389/fpubh.2024.1423736
3. AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. American Academy of Pediatrics. October 19, 2021. Accessed February 6, 2025. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/?srsltid=AfmBOoqgj3jdeCTzPdMP1X_SocPRGux5HWTag1bkUPhC7D93TUf4MJHm
4. Mental health in infants and young children: pediatric mental health minute series. American Academy of Pediatrics. Accessed February 6, 2025. https://www.aap.org/en/patient-care/mental-health-minute/mental-health-in-infants-and-young-children/?srsltid=AfmBOopzADBa2UacJuNtBEIXsMX6IE9WTaluk5Gmr2k9y484Cz0rSTo9
5. Raval GR, Doupnik SK, Closing the gap: improving access to mental health care through enhanced training in residency. Pediatrics. 2017;139(1):e20163181. doi:10.1542/peds.2016-3181
6. The resource for advancing children’s mental health. The REACH Institute. Accessed February 6, 2025. https://thereachinstitute.org/
7. Rating scales. The REACH Institute. Accessed February 6, 2025. https://thereachinstitute.org/training-old/rating-scales/
