Abstract
Introduction
There have been various strategies employed to improve the ability of primary care physicians to identify and intervene in the mental health concerns of young children. In this study we assessed community physician needs and ability to identify mental health problems in children less than 6 years of age.
Methods
Two surveys were conducted. The purpose of the surveys was to identify the learning needs among primary care physicians and their capacity to serve very young children.
Results
Most physicians reported that they did not have enough knowledge and support to detect and manage mental health problems in young children and that they received minimal undergraduate training.
Conclusions
Community physicians require primary mental health care support to serve the mental health concerns of young children age 0–6.
Keywords: early childhood, preschool, identifying mental problems, primary care
Résumé
Introduction
Plusieurs stratégies ont été mises de l’avant pour faciliter le travail du médecin généraliste au niveau de l’identification et de l’intervention des problèmes de santé mentale chez les jeunes. Dans cette étude, nous avons évalué les besoins d’un groupe de médecins ainsi que leurs habiletés à identifier les problèmes de santé mentale chez les moins de 6 ans.
Méthodologie
Nous avons effectué deux sondages dont le but était d’identifier les besoins d’apprentissage et leurs capacités de desservir les très jeunes enfants.
Résultats
La plupart ont été d’avis que leur niveau de connaissances et le support disponible ne leur permettaient pas d’identifier et d’intervenir dans les problèmes de santé mentale des très jeunes enfants, d’autant plus qu’ils avaient reçu peu de formation à ce sujet durant leurs études.
Conclusion
Les médecins généralistes ont besoin d’un soutien professionnel pour desservir les très jeunes enfants présentant des problèmes de santé mentale.
Keywords: jeune enfance, préscolaire, identification de problèmes de sainté mentale, soins primaires
INTRODUCTION
Providing mental health care in primary pediatric and family practice settings is an ideal mechanism for identification and early intervention with infants and young children who are at risk for developing serious mental disorders (Kelleher et al., 2000; Lavigne et al., 1998). Untreated mental health problems often lead to hospitalization and poor developmental outcomes for affected children at considerable cost to society. Chabra, Chavez, and Taylor (1997) found that mental disorders, among children aged 1–5 years, numbered among the causes of hospitalization thought of as preventable and called for further efforts to address this problem through improved access to primary care and education. To this end there have been various strategies employed to improve the ability of primary care physicians to identify and intervene in the mental health concerns of young children during the regular visits to their practices (Campo, et al., 1999; Cassidy & Jellinek, 1998; Gardner, et al. 2000; Hack & Jellinek, 1997). Furthermore, standard approaches to assessment, such as use of the Pediatric Symptom Checklist (PSC: Navon, Nelson, Pagano, & Murphy, 2001), are proving useful in identifying youth at risk of behavioral health problems and developing strategies to meet their mental health needs (Navon, Nelson, Pagano, & Murphy, 2001). These studies, among others (Lavigne, et al. 1996, 1998) have indicated that the presentation of psychosocial problems in primary care parallels the rates of mental disorders in the larger pediatric population, thereby supporting the need to develop a better understanding of primary mental health care programs directed at identification and intervention with infants and young children.
The Collaborative Mental Health Care service (CMHC) and its evaluation framework (Sobel et al., 2001) was developed in the Calgary Health Region in response to the direction to provide mental health support in a primary care environment. Collaborative care involves multidisciplinary consultation to enhance the identification and the development of treatment and management strategies for the families of young children presenting with, or seen to be at risk, for developing mental health problems. The emphasis is on early identification and intervention.
In practice, a consultant from the CMHC team usually meets with the primary care provider and/or the child and parents to explore the presenting concerns. The consultant may offer a treatment approach, management strategy or the opportunity for referral to an agency or service in the community. The primary care provider has regular access to the consultants. More complex cases may involve other members of the collaborative care team and case management on an interim basis until more specialized treatment can be obtained.
The CMHC team has identified essentially six components deemed central to supporting primary care providers:
Consultations to primary care providers about individual children/families. The focus is to identify risk and protective factors, assess the severity of the child’s presentation, screen for developmental, emotional or behavioral concerns and offer assistance and facilitate referral to other community or hospital-based services.
Direct clinical Intervention is provided to parents or the parent-child dyad. Children considered for direct clinical intervention have cumulative risk factors, decreased protective factors and an increased severity of presentation often requiring immediate response.
CMHC provides education and training in early childhood mental health and development to expand the competencies of caregivers and service providers.
Consultation to agencies contributes to the overall quality of an agency’s program or to assist the program in solving issues that affect more than one child/family or staff member.
CMHC is committed to ongoing evaluation of the services provided and to developing a research focus with respect to best clinical practices and the model of service offered.
Promotion of an understanding of the importance of children’s mental health issues in community initiatives, and the integration of strategies that further the emotional health of young children.
Taken together, the CMHC team’s activities are intended to lead to an enhanced capacity among primary care physicians and other professional health care providers to intervene with pediatric, mental health issues in the primary care environment. As well, the consultation process should lead to optimal use of secondary, tertiary and other community based services. Also, regularly scheduled education and training of primary care providers has the effect of increasing community awareness of the antecedents for optimal mental health among children and increased knowledge of how to access service and resources when the need arises.
As part of developing our service, we asked participants to complete a survey at a national family medicine continuing medical education conference in order to assess their training needs. Our main goal was to identify the learning needs among primary care physicians. This paper outlines our findings.
METHODS
Participants
The sample for Phase I of the study consisted of 104 physicians attending a two day Continuing Medical Education Conference. The sample for Phase II of the study consisted of 30 regional physicians who responded to a mail out of the same survey.
Measures
Phase I: A recent Family Practice — Continuing Medical Education Conference attended by about 120 physicians incorporated our survey into their conference program syllabus. The survey consisted of basic questions of interest to the core program. It focused on the types of mental health problems that the physicians encountered in younger children, how they dealt with these problems, their perceived ability and level of skill in dealing with these problems, and their primary care needs in order to better deal with the problems of this age group. Further, it invited those interested to respond to a second level of survey.
Phase II: In Phase II, the original survey was mailed out to 120 physicians in Calgary, along with a covering letter requesting that they complete the survey. The response rate for this survey of the approximately 120 surveys mailed was about 30 or 25 per cent.
Results
Phases I And II
The main findings from the Phase I and II Physician survey results that are of relevance to the Phase III study are embodied in the responses to survey question #5. In question #5 physicians were asked if they had enough knowledge and support to detect and manage mental health problems in young children (Table #1) and if they were confident about detecting and managing these difficulties (Table #2). Most physicians reported not having enough knowledge and support to detect and manage mental health problems in young children, even though most felt somewhat confident in being able to manage these problems.
Table 1.
Physician ability to detect and manage mental health problems in young children.
| Do you have enough knowledge and support to detect and manage mental health problems in young children? | Survey 1 (% Sample CME Physicians, n = 104) | Survey 2 (% Sample, NE Calgary Physicians, n = 30) |
|---|---|---|
| Yes | 13 | 33 |
| No | 87 | 67 |
Table 2.
Physician confidence about detecting and managing mental health problems in young children.
| How confident are you that you can detect and manage these difficulties? | Survey 1 (% Sample CME Physicians, n = 104) | Survey 2 (% Sample, NE Calgary Physicians, n = 30) |
|---|---|---|
| Very | 4 | 10 |
| Somewhat | 76 | 73 |
| Not at all | 18 | 17 |
Physicians were also to estimate the percentage of their patients 5 years of age and under (Table #3) and the percentage of adult patients with mental health problems with young children, aged 5 or less. A substantial number of physicians reported seeing children are 5 years of age and under. The physicians were largely unaware of whether or not the adults with mental problems had very young children.
Table 3.
Percentage of patients 5 years of age and under.
| % patients < 5 years | Survey 1 (% Sample CME Physicians, n = 104) | Survey 2 (% Sample, NE Calgary Physicians, n = 30) |
|---|---|---|
| 0–5% | 28 | 21 |
| 6–15% | 48 | 45 |
| 16–25% | 26 | 14 |
| 26–35% | 1 | 7 |
| >35% | 1 | 14 |
Lastly, physicians were asked about the level of undergraduate medical training they received regarding the detection and intervention of mental health problems in very young children (Table 5). Most physicians reported having received minimal training.
Table 5.
Medical training about early childhood mental health.
| Pediatric Mental Health Training | Survey 1 (% Sample CME Physicians, n = 104) | Survey 2 (% Sample, NE Calgary Physicians, n = 30) |
|---|---|---|
| Minimal | 62 | 53 |
| Some | 36 | 40 |
| Comprehensive | 0 | 6 |
DISCUSSION
The results of the two surveys were comparable. The results indicate that a large proportion of physicians seeing very young children in their practices require additional resources to learn to identify and manage the mental health concerns of very young children. Furthermore, the results also indicate that undergraduate training could improve physician training, enabling them to better identify and manage the mental health concerns of very young children. Given that parental mental disorder is one of the most salient risks predicting subsequent mental disorder in offspring, it is important to improve physician access to basic information about developmental risks for very young children. Early intervention is known not only to be cost effective, but it is the only strategy that can intervene to improve the developmental outcomes of children suffering from or at risk of developing a mental. Usually, these children do not receive the required care until many developmental milestones have been passed and their ability to recover minimized.
CONCLUSIONS
Primary care consultation is a particularly important prevention strategy because it provides early identification and the potential for intervention, two key factors that are thought to help correct the developmental trajectories of at-risk infants and young children.
Improving identification is both an indicator of physician learning within the rubric of a primary care consultation model and may lead to improved management of early childhood psychosocial problems (Wildman, 1997).
Table 4.
Percentage of adult patients with mental health problems are parents of young children (aged 5 or less).
| Estimated Adult patients with mental health problems who have young children | Survey 1 (% Sample CME Physicians, n = 104) | Survey 2 (% Sample, NE Calgary Physicians, n = 30) |
|---|---|---|
| Don't Know | 38 | 27 |
| 1–9% | 20 | 27 |
| 10–19% | 23 | 23 |
| 20–29% | 12 | 7 |
| 30–39% | 2 | 3 |
| >40% | 4 | 0 |
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