Partnership Access Line

Partnership Access Line
In this chapter, various clinical tools from the Partnership Access Line (PAL) Washington website (www.palforkids.
org) are used to assist the primary care provider in diagnosis and treatment of the more common psychiatric
conditions. The PAL algorithms are useful for treatment of specific diagnoses, considering alternative diagnoses in
the differen- tial, and reviewing medication treatment tables for specific information regarding psychopharmacologic
treatments.
American Academy of Pediatrics: Children’s Mental Health in Primary Care: http://www.aap.org/mentalhealth/index.html.

American Academy of Pediatrics Committee on Community
Health Services: The pediatrician’s role in community pediat-
rics. Pediatrics 2005;115:1092–1094 [PMID: 15805396].

Bright Futures Mental Health: http://www.brightfutures.org/mentalhealth/pdf/index.html; http://www.brightfutures.org/men-
talhealth/pdf/tools.html.
Hacker KA, Arsenault LN, Williams S, Digirolamo AM: Mental
and behavioral health screening at preventive visits: oppor- tunities for follow-up of patients who are nonadherent with the next
preventive visit. AMJ Pediatr 2011;158(4):666–671.e2 [Epub 2010 Nov 11] [PMID: 21074180].
Massachusetts Child Psychiatry Access Project: http://www .mcpap.com/.
Sheldrick RC, Merchant S, Perrin EC: Identification of developmental-behavioral problems in primary care: a systematic review.
Pediatrics 2011;128(2):356–363 [Epub 2011 Jul 4] [PMID: 21727101].
U.S. Surgeon General’s National Action Agenda: http://www. surgeongeneral.gov/cmh/childreport.htm.
Zero to Three: http://www.zerotothree.org.
Summary of the Pediatrician’s Role
Given these calls for a new pediatric role as the gatekeeper for socioemotional health, the expanding role of the
primary care pediatric provider encompasses the following broad categories: prevention, identification, assessment,
initiation, management, coordination, and collaboration (Table 7–1).
IDENTIFICATION & ASSESSMENT DURING HEALTH MAINTENANCE VISITS
Most families seek help from their primary care providers when they are concerned about a child’s health, growth, or
development. Historically, the most efficient indicator in eliciting psychosocial problems is the history provided by
187
Table 7–1. The pediatric primary care provider’s role in mental health.
4. 5.
Casa: How are things going at home (including siblings, family stresses, and relationship with parents)?
Happiness: How would you describe your mood? How would you describe your child’s mood?
ChAPter 7
Role Specific Activities

Prevention Screen and address social risk factors on intake Screen and refer for early socioemotional risk
Identification Shared family concern Surveillance Screening
Assessment Interview and Physical Assessment tools Comorbid conditions
Psychoeducation about condition and treatment options
Initiation • Wait and watch

• Refer to mental health for further evaluation • Refer for therapy
• Start medication
Management Monitor condition for improvement Monitor for side effects
With social work, therapist, psychologist, or
Coordination
psychiatrist
Collaboration With mental health service providers With child protection With local schools
parents or guardians and interview and observation of the child. The possible approaches to identification of
problems include surveillance, screening, and assessment.
Surveillance consists of the following elements: check- ing in, eliciting concerns, asking open-ended questions,
watching and waiting, listening for red flags, identifying risk factors, and monitoring closely over time. Like vital
signs, which represent an essential component of the physical evaluation, the essential components of the primary
care surveillance for mental health concerns should generally include a review of the youth’s general functioning in
different aspects of their life. Five questions forming the mnemonic PSYCH can be addressed to parents and youth as
a surveillance means of uncovering areas of concern.
1. Parent-child interaction: How are things going with you and your parents? Or you and your infant (or toddler)?
2. School: How are things going in school (or child care; academically, behaviorally, and socially)?
3. Youth: How are things going with peer relationships/ friendships (how does child get along with same-aged
peers)?
Many pediatric practices are hampered by lack of con- tinuity and not enough time for in-depth surveillance. In
addition, surveillance is notoriously tied to office and provider characteristics. Given current time constraints for
current pediatric visits, and the fact that only 18% of parents reporting elevated behavior problems in children
actually told their providers about it, surveillance is currently con- sidered nonoptimal. Although part of the clinical
interview with families, surveillance is not a separate and billable service under current Medicaid and insurance
reimbursement plans, whereas formal screening is.
Screening is the process of using standardized instru- ments to identify areas of risk, delay, or concern. Newborn
hearing, vision, and developmental screenings are common in today’s pediatric practice. However, the morbidity
asso- ciated with developmental, emotional, and psychosocial problems requires that socioemotional screening also
be per- formed to identify the presence of symptoms of emotional, behavioral, or relationship disorders. Screening
tools are brief, easy to use, and can be administered as a questionnaire or using an interview format. A positive
screen warrants a more complete assessment. The use of screening tools can also lead to early identification and
interrupt the adjust- ment-perturbation-disturbance-disorder pathway. Newer methods of eliciting socioemotional
and behavior concerns have been developed (see section below on Tools). Helpful information can also be obtained
from broad screening checklists and symptom-specific questionnaires (such as depression or anxiety self-report
inventories). Questions can be incorporated into the general pediatric office screening forms, or specific
questionnaires can be used.
Tools for Mental Health Screening in the Office Setting
Given the low rates of identification of psychosocial problems by pediatric surveillance, the use of standardized
screening tools has become standard practice. Typically, broad screeners that elicit information regarding multiple
domains are employed first and are followed by targeted screens to address symptomatology, severity, impairment,
and context of specific psychosocial problems.
Multiple Screening Tools: http://www.mcpap.com/tools_index.asp. http://www.brightfutures.org/mentalhealth/pdf/tools.html.

http://www.palforkids.org. http://www.schoolpsychiatry.org. http://www.wpic.pitt.edu/research.
188

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Partnership Access Line

American Academy of Pediatrics: Children’s Mental Health in Primary Care: http://www.aap.org/mentalhealth/index.html.

Health Services: The pediatrician’s role in community pediat-

rics. Pediatrics 2005;115:1092–1094 [PMID: 15805396].

Massachusetts Child Psychiatry Access Project: http://www .mcpap.com/.

U.S. Surgeon General’s National Action Agenda: http://www. surgeongeneral.gov/cmh/childreport.htm.

Zero to Three: http://www.zerotothree.org.

Summary of the Pediatrician’s Role

IDENTIFICATION & ASSESSMENT DURING HEALTH MAINTENANCE VISITS

Role Specific Activities

Initiation • Wait and watch

Tools for Mental Health Screening in the Office Setting

Multiple Screening Tools: http://www.mcpap.com/tools_index.asp. http://www.brightfutures.org/mentalhealth/pdf/tools.html.

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