Table 5.

Representative quotes for barriers to and reinforcing factors in implementing TEACH training

Theme	Representative quotes
Barriers	….a questionnaire, under certain circumstances, may save time, but it won’t get you the right answers. So what I do, is I schedule separate visits for mental health discussions. If something comes up at a physical or at a sick visit, or somebody comes in with a complaint that is physical on the phone but I realize is mental health at the time, if we didn’t schedule it for a sufficient period of time, I would generally have them come back with notes and do a careful history to be sure that I get the right diagnosis. …some of the people in the group we’re working in …go to one clinic one day, and another clinic another day, and a third clinic on a third day And so, basically, they can’t see the patients more than once every couple of months… You can’t treat this problem if you’re not going to be able to see that patient weekly for a few weeks so you get them stabilized. From a clinical flow point-of-view, we have a busy practice, you know, it’s often the case that I get into the room, “Oh, you’re here for anxiety.” I look, there’s no anxiety questionnaire completed, so I’m pulling that out, I’m going through it. So, it bogs things down. I’m sure if I was just doing behavioral health, whoever was working with me would know if the main complaint is anxiety, or if that was the referral, they would be getting those forms done. I think part of what’s hard is not feeling like I have enough time to offer more than, “I hear you and I agree with you. These are a concern and here’s one thing to try.” That there’s usually not sufficient time to develop a more comprehensive plan. Then I think well, whew, maybe it’s good that there’s not more time ‘cause I don’t know if I have a depth of suggestions that’s beyond one or two… ..after I did the training and you sort of go home and say we are going to do this and it doesn’t take a couple 2 or 3 months and all of a sudden you know you have a few kids who you’ve done what they’ve said to do and it’s not working which is normal but then you get a little rattled … My biggest conundrum always is not do I feel comfortable using a medication; it’s how sure am I that I have the right diagnosis. If I think I have the right diagnosis, I don’t have any problems with the medications.
Reinforcing factors	…the factor that helped me to increase my ability was being able to call the psychiatrist on-call …reinforced what I learned in the training, so just having the availability… I really liked the CAP PC website, which I refer to quite a bit, for information for patients, and again, assessment scales. So much more readily handing out information. I keep some questionnaires ready ahead when the parents come in. One of my nurses does give it before I even go into the room. …the biggest thing has been the insight into how different it is to interview a child about these problems, and the fact that you do need to also interview the parent, and the use of the forms was totally like revolutionary to me. I was like, “Wow. There were forms I can use. That’s so great.” One of the things that really did change for me clinically, and for my colleagues, is that Dr. X {TEACH trainer} pointed out the importance of cognitive behavioral therapy as a proven therapy for kids, especially with anxiety. And so, I went about trying to identify clinicians in our community who would be willing to do it and are trained, and we found a couple. And so, I’ve been sending patients regularly that direction and have been mighty impressed with the positive feedback from the patients, from the parents.

Theme

Representative quotes

Barriers

….a questionnaire, under certain circumstances, may save time, but it won’t get you the right answers. So what I do, is I schedule separate visits for mental health discussions. If something comes up at a physical or at a sick visit, or somebody comes in with a complaint that is physical on the phone but I realize is mental health at the time, if we didn’t schedule it for a sufficient period of time, I would generally have them come back with notes and do a careful history to be sure that I get the right diagnosis.
…some of the people in the group we’re working in …go to one clinic one day, and another clinic another day, and a third clinic on a third day And so, basically, they can’t see the patients more than once every couple of months… You can’t treat this problem if you’re not going to be able to see that patient weekly for a few weeks so you get them stabilized.
From a clinical flow point-of-view, we have a busy practice, you know, it’s often the case that I get into the room, “Oh, you’re here for anxiety.” I look, there’s no anxiety questionnaire completed, so I’m pulling that out, I’m going through it. So, it bogs things down. I’m sure if I was just doing behavioral health, whoever was working with me would know if the main complaint is anxiety, or if that was the referral, they would be getting those forms done.
I think part of what’s hard is not feeling like I have enough time to offer more than, “I hear you and I agree with you. These are a concern and here’s one thing to try.” That there’s usually not sufficient time to develop a more comprehensive plan. Then I think well, whew, maybe it’s good that there’s not more time ‘cause I don’t know if I have a depth of suggestions that’s beyond one or two…
..after I did the training and you sort of go home and say we are going to do this and it doesn’t take a couple 2 or 3 months and all of a sudden you know you have a few kids who you’ve done what they’ve said to do and it’s not working which is normal but then you get a little rattled …
My biggest conundrum always is not do I feel comfortable using a medication; it’s how sure am I that I have the right diagnosis. If I think I have the right diagnosis, I don’t have any problems with the medications.

Reinforcing factors

…the factor that helped me to increase my ability was being able to call the psychiatrist on-call …reinforced what I learned in the training, so just having the availability…
I really liked the CAP PC website, which I refer to quite a bit, for information for patients, and again, assessment scales. So much more readily handing out information.
I keep some questionnaires ready ahead when the parents come in. One of my nurses does give it before I even go into the room.
…the biggest thing has been the insight into how different it is to interview a child about these problems, and the fact that you do need to also interview the parent, and the use of the forms was totally like revolutionary to me. I was like, “Wow. There were forms I can use. That’s so great.”
One of the things that really did change for me clinically, and for my colleagues, is that Dr. X {TEACH trainer} pointed out the importance of cognitive behavioral therapy as a proven therapy for kids, especially with anxiety. And so, I went about trying to identify clinicians in our community who would be willing to do it and are trained, and we found a couple. And so, I’ve been sending patients regularly that direction and have been mighty impressed with the positive feedback from the patients, from the parents.