Aspects of mental health communication skills training that predict parent and child outcomes in pediatric primary care

Abstract

Objective

Training in communication can change clinician behaviors, but brief training may function by altering attitudes rather than teaching new skills. We used data from a trial of mental health training for office-based primary care to determine indicators of uptake that predicted parent and child outcomes.

Methods

Clinicians (n = 50) were randomized to be controls or receive training. Uptake was determined comparing pre- and post-training visits with standardized patients (SPs) coded for skills and patient centeredness. Clinical outcomes were assessed by recruiting and following 403 children/youth ages 5–16 making visits to participants. At 6 months, change in mental health was assessed by parent and youth reports using the Strengths and Difficulties Questionnaire.

Results

Trained clinicians used more agenda setting, time, and anger management skills than controls and showed increased patient centeredness toward SP parents, but not adolescents. Increased patient-centeredness toward parents predicted improvement in child/youth symptoms and functioning (rated by parents), and improvement in youth-rated symptoms. Increased skills alone were not associated with improvement, but patients of clinicians above the mean for both skill and patient-centeredness change improved most.

Introduction

Many though not all studies find that training can alter medical providers’ communication with patients in a variety of clinical contexts [1], [2], [3], [4]. Finding corresponding impact on clinical outcomes has been more difficult [5], but changes have been found in patient satisfaction [6], [7], psychosocial distress [8], and child functioning [9]. Outcomes do seem to be related to active versus passive involvement in the training [10], and some authors have speculated [11], [12] that rather than imparting specific skills, training changes provider attitudes toward patients in general or toward a particular clinical situation. Providers then, in turn, may not so much use new skills as change their overall way of interacting with patients, building better relationships that then result in better clinical outcomes [13], [14].

We designed and tested a communications skills training program for pediatric primary care providers to improve children's emotional and behavioral problems [9]. The skills taught were chosen to enable providers to increase patient expectations for positive outcomes, reach agreement on the nature of problems and desired treatment, and influence behavior change. The training also sought to improve providers’ expectations surrounding mental health care by providing an approach consistent with their existing pediatric knowledge and by teaching skills directly applicable to concerns about the length of mental health-related visits. In our initial intention to treat analysis, parents seeing trained providers had greater reductions in distress than parents seeing control providers, and the functioning of minority children seeing trained providers improved more than that of minority children seeing control providers.

Because any provider training uses scarce trainer and clinician resources, we wanted to better understand how the training may have related to clinical outcomes. We hypothesized that training could relate to outcomes in either or both of two ways. First, clinicians might use the skills that we taught, which had been chosen based on evidence for their effectiveness in primary care and psychotherapy [15], [16], [17], [18], [19], [20]. Second, clinicians might respond to the training's overall theme of the feasibility of engagement with mental health problems with a change their style of interaction with patients with mental health problems. Specifically, they might adopt a more patient-centered form of interaction, engaging in more psychosocial interaction and showing more empathy with and responsiveness to psychosocial distress [21], [22]. Because our training was brief (only a few hours), we hypothesized that providers with some prior exposure to mental health-related skills might demonstrate greater training uptake because they already had some underlying familiarity with the material. We also hypothesized that providers with more positive attitudes toward mental health care would have greater uptake.