Collaborative Care Outcomes for Pediatric Behavioral Health Problems: A Cluster Randomized Trial

Kolko, David J.; Campo, John V.; Kilbourne, Amy M.; Hart, Jonathan; Sakolsky, Dara; Wisniewski, Stephen R.

doi:10.1542/peds.2013-2516

Cited by 211 publications

(260 citation statements)

References 37 publications

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“…12,27,28 The release of the AAP guidelines on ADHD care several years before those for anxiety and depression, and extensive quality improvement efforts to implement the ADHD guidelines, [29][30][31] help explain the degree of PCP involvement in the care of ADHD. These data support the importance of enhancing PCPs' capacity for mental health care through collaborative care models, which have been shown to improve mental health outcomes relative to community care, 32 as well as other strategies, such as expanding reimbursements beyond face-to-face visits. 33 Studies vary on whether children with ADHD who see psychiatrists or PCPs are more likely to be prescribed medications.…”

Section: Discussionsupporting

confidence: 52%

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

et al. 2015

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OBJECTIVE: To compare the mental health care US children receive from primary care providers (PCPs) and other mental health care providers.METHODS: Using nationally representative data from the Medical Expenditure Panel Survey (MEPS) from 2008 to 2011, we determined whether children and youth aged 2 to 21 years with outpatient visits for mental health problems in the past year saw PCPs, psychiatrists, and/or psychologists/social workers for these conditions. We compared the proportion of children prescribed psychotropic medications by provider type. Using logistic regression, we examined associations of provider type seen and medication prescribing with race/ethnicity, household income, insurance status, geographical area, and language at home. RESULTS:One-third (34.8%) of children receiving outpatient care for mental health conditions saw PCPs only, 26.2% saw psychiatrists only, and 15.2% saw psychologists/social workers only. Nearly a quarter (23.8%) of children saw multiple providers. A greater proportion of children with attention-deficit/hyperactivity disorder (ADHD) versus children with anxiety/mood disorders saw a PCP only (41.8% vs 17.2%). PCPs prescribed medications to a higher percentage of children than did psychiatrists. Children seeing a PCP for ADHD were more likely to receive stimulants or a-agonists than children with ADHD seeing psychiatrists (73.7% vs 61.4%). We found only limited associations of sociodemographic characteristics with provider type or medication use.

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Section: Discussionsupporting

confidence: 52%

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

et al. 2015

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“…Consistent with recent novel approaches to pediatric behavioral health, 23,41 we enrolled children in our trial based on presenting symptoms, as opposed to ultimate diagnoses. This family-centered approach represents a departure from much of the extant ADHD literature.…”

Section: Discussionmentioning

confidence: 99%

Collaborative Care for Children With ADHD Symptoms: A Randomized Comparative Effectiveness Trial

et al. 2015

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OBJECTIVES: Although many attention-deficit/hyperactivity disorder (ADHD) care models have been studied, few have demonstrated individual-level symptom improvement. We sought to test whether complementing basic collaborative care with interventions that address common reasons for symptom persistence improves outcomes for children with inattention and hyperactivity/impulsivity. METHODS:We conducted a randomized comparative effectiveness trial of 2 care management systems for 6-to 12-year-old children being evaluated for ADHD (n = 156). All participants received care management with decision support. Care managers in the enhanced care arm also were trained in motivational and parent management techniques to help parents engage in their child's treatment, address their own mental health needs, and manage challenging child behaviors. We used multivariable models to assess inattention, hyperactivity/impulsivity, oppositionality, and social skills over 1 year.RESULTS: Both treatment arms generated guideline concordant diagnostic processes in 94% of cases; 40% of children had presentations consistent with ADHD. For the entire sample, there were no differences in symptom trajectories between study arms; mean differences in change scores at 12 months were -0.14 (95% confidence interval -0.34 to 0.07) for inattention; -0.13 (-0.31 to 0.05) for hyperactivity/impulsivity; -0.09 (-0.28 to 0.11) for oppositionality; and 3.30 (-1.23 to 7.82) for social skills. Among children with ADHD-consistent presentations, enhanced arm participants experienced superior change scores for hyperactivity/impulsivity of -0.36 (-0.69 to -0.03), oppositionality -0.40 (-0.75 to -0.05), and social skills 9.57 (1.85 to 17.28).CONCLUSIONS: Among children with ADHD-consistent presentations, addressing barriers to engagement with care and challenging child behaviors has potential to improve the effectiveness of collaborative care. WHAT'S KNOWN ON THIS SUBJECT:Collaborative care is known to be an effective system to manage child behavioral health conditions in the primary care setting. WHAT THIS STUDY ADDS:Among urban children with attention-deficit/hyperactivity disorder, using lay care managers to address barriers to engagement with care and challenging child behaviors has the potential to improve the effectiveness of conventional collaborative care. Dr Silverstein conceptualized and designed the study, oversaw its implementation, and drafted the initial manuscript; Drs Hironaka and Walter conceptualized and designed the study, oversaw its clinical implementation, reviewed and revised the entire manuscript, and assisted in the interpretation of analyses; Dr Feinberg assisted in conceptualizing and designing the study, oversaw its clinical implementation at one site, assisted in the interpretation of analyses, and reviewed and revised the manuscript; Ms Sandler managed the data for the project, assisted in preparing the analyses, and reviewed and revised the manuscript; Ms Pellicer supervised the care managers for the project, and reviewed and...

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“…55 -58, 70 -73 In a cluster-randomized trial, on-site mental health care was associated with higher rates of treatment initiation and completion and with greater reductions in mental health symptoms and parental stress when compared with facilitated specialty care referral. 56 Integrated care models as described above hold promise for increasing access to mental health care for children living in poverty, but they also face challenges. Barriers unique to the primary care setting may include pediatric provider time limitations, space limitations, billing restrictions, competing priorities, inadequate training, pediatric providers' understanding of the role of mental health specialists, and difficulty integrating new behavioral health systems into a busy, complex practice setting.…”

Section: Strategies To Improve Mental Health Access and Outcomes In Pmentioning

confidence: 99%

Improving Mental Health Access for Low-Income Children and Families in the Primary Care Setting

et al. 2017

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Poverty is a common experience for many children and families in the United States. Children <18 years old are disproportionately affected by poverty, making up 33% of all people in poverty. Living in a poor or low-income household has been linked to poor health and increased risk for mental health problems in both children and adults that can persist across the life span. Despite their high need for mental health services, children and families living in poverty are least likely to be connected with high-quality mental health care. Pediatric primary care providers are in a unique position to take a leading role in addressing disparities in access to mental health care, because many low-income families come to them first to address mental health concerns. In this report, we discuss the impact of poverty on mental health, barriers to care, and integrated behavioral health care models that show promise in improving access and outcomes for children and families residing in the contexts of poverty. We also offer practice recommendations, relevant to providers in the primary care setting, that can help improve access to mental health care in this population.

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Collaborative Care Outcomes for Pediatric Behavioral Health Problems: A Cluster Randomized Trial

Cited by 211 publications

References 37 publications

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

Collaborative Care for Children With ADHD Symptoms: A Randomized Comparative Effectiveness Trial

Improving Mental Health Access for Low-Income Children and Families in the Primary Care Setting

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