The Pediatrician as Gatekeeper to Mental Health Care for Children: Do Parents' Concerns Open the Gate?

doi:10.1097/00004583-199005000-00018

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 29, Issue 3, May 1990, Pages 453-458

https://doi.org/10.1097/00004583-199005000-00018 Get rights and content

Data from a study of children seen for pediatric care in a Health Maintenance Organization are used to examine factors which influence the likelihood that a pediatrician will identify a psychiatric problem and refer an identified child to a mental health specialist for further evaluation and treatment. Parental level of distress, family psychiatric history, and discussion of parental concerns with the pediatrician were found to be important. Characteristics of the service delivery system which may impede appropriate identification and referral are discussed. Implications for participation of child and adolescent psychiatrists in the training of pediatricians are presented.

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Parents of 1449 Australian children aged 6 to 10 years recruited from the general community, completed measures of sleep problems (Pediatric Sleep Survey Instrument), psychological distress (Strengths and Difficulties Questionnaire), and frequency of allergic diseases.
Sleep and psychological distress scores were in the reference range. After controlling for coexisting allergic diseases, allergic rhinitis was associated with sleep routine problems, morning tiredness, night arousals, sleep disordered breathing and restless sleep; asthma with sleep routine problems, sleep disordered breathing and restless sleep; and eczema with restless sleep. Path analyses revealed that sleep problems mediated the association between asthma and allergic rhinitis but not eczema with psychological distress.
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Family History of Mental Health Disorders and Parental Help-Seeking for Behavioral Health Concerns in Pediatric Primary Care Offices
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It is critically important to examine the parents’ perspective and their role in pediatric primary care settings, as children are often dependent on their parents/caregivers to recognize problems and seek help from professionals on their behalf (Sayal et al., 2010). Because it is up to the parents to raise concerns, parental expression plays a key role in the pediatric primary care interaction with regard to identification and treatment of mental health needs (Dulcan et al., 1990; Wildman, Kizilbash, & Smucker, 1999). However, despite this unique position, some parents fail to discuss problems concerning their child's mental and behavioral health, even when the parent recognizes a problem (Horwitz et al., 1998; Sayal & Taylor, 2004).
Pediatric mental health needs are common in primary care, but many children never access treatment. With parents as a critical gatekeeper, it is important to identify barriers and facilitators to treatment access and explore the role of family history.
Parents/caregivers (N = 1,763) with children aged 3–17 years were recruited in the original study and participated in a 71-item survey that addressed mental health–related communication.
An association was found between family history of mental health disorders and recognition of behavioral concerns, and between anxiety/depression disorders and sharing of concerns. In addition, parents with a family history were less likely to feel completely satisfied with time spent discussing mental health or with how the provider answered questions.
Although fear of stigma has been previously cited in the literature as a barrier to accessing treatment, findings suggest a family history of mental health disorders can facilitate parental help-seeking steps.
Psychological distress and parent reporting on child health: The case of developmental delay
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Caregiver-completed screening questionnaires are a common first step in the identification of developmental delay. A caregiver’s mood and anxiety level, however, may affect how he or she perceives and reports possible problems.
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Of our 857 children, 9% had at least one domain below −2 standard deviations on the BSID, and 17.3% had positive ASQ results. Caregiver distress predicted a positive ASQ substantially and significantly more strongly among BSID-positive children than among others. This translates into slightly reduced ASQ specificity but greatly improved sensitivity among caregivers with higher distress.
At low to moderate levels of distress, greater distress is associated with greater ASQ accuracy.
Pediatric Community Mental Health
2016, Current Problems in Pediatric and Adolescent Health Care
The emotional health and wellbeing of children and adolescents and their families is of utmost importance. Pediatricians are at the front line in identifying mental illness in children and adolescents and either linking them to resources in the community or providing treatment options themselves. Collaboration and integrative health care models is the cornerstone of effective strategies to provide access and quality mental health care to children and families in communities across the country.
Gender differences of children's developmental trajectory from 6 to 60 months in the Taiwan Birth Cohort Pilot Study
2011, Research in Developmental Disabilities
Citation Excerpt :
Parental reports on the problems of their children are highly predictive of true problems and can also increase the accuracy of clinical judgments in detecting children's developmental problems (Dulcan et al., 1990; Glascoe, 1997; Glascoe, Altemeier, & MacLean, 1989; Glascoe & Dworkin, 1995; Glascoe, Foster, & Wolraich, 1997; Lung, Shu, Chiang, & Lin, 2010).
The parental report instrument is the most efficient developmental detection method and has shown high validity with professional assessment instruments. The reliability and validity of the Taiwan Birth Cohort Study (TBCS) 6-, 18- and 36-month scales have already been established. In this study, the reliability and validity of the 60-month scale was tested. The gender differences in children's longitudinal gross motor, fine motor, language and social development were also investigated. Using the dataset from the Taiwan Birth Cohort Pilot Study (TBCS-p), 2048 infants were followed up when they were 6-, 18-, 36- and 60-month-old. At the final stage, 1620 children were followed up. Development of the children was measured using the TBCS 6-, 18-, 36-, and 60-month developmental scales. The reconstructed TBCS 60-month scale yielded 16 items measuring children's development in the four dimensions of gross motor, fine motor, language and social. The scale yielded an internal consistency of 0.39–0.71. Structural equation modeling also showed good construct and predictive validity, in that the 6-, 18-, and 36-month scales were predictive of the 60-month scale. No gender differences between the gross motor dimension was found. Gender had an effect on the fine motor dimension at 36 and 60 months, language dimension at 36 months, and social dimension at 18, 36 and 60 months. Gender had a transient effect in language development and social development a continuous effect from 18 to 60 months. Thus different gender norms may need to be established to prevent misdiagnosis. The TBCS scale is a valid and reliable developmental screening instrument that can be used in continuous surveillance of children's development in community and clinical settings from 6 months to 5 years of age.
Factors influencing time lag between first parental concern and first visit to child psychiatric services in children with autism spectrum disorders in Japan
2011, Research in Autism Spectrum Disorders
Citation Excerpt :
It is recommended that a network be created between local institutions (i.e., those in the medical, heaDrlth, welfare, and educational sectors) and hospitals that offer child psychiatric services, so that they can share information pertaining to updated diagnostic evidence and to which children may have ASDs. Furthermore, it is recommended that other institutions – at least primary healthcare providers – refer children with ASDs as soon as possible, in order to initiate early intervention (Dulcan et al., 1990; Menahem, 1987). Family composition was also found to correlate with time lag, and there are some possible explanations for this.
The early assessment of autism spectrum disorders (ASDs) is important to improving patient outcomes, allowing family members to prepare for and cope with symptoms, and assisting in plans for appropriate educational opportunities. However, little is known about factors that influence the time lag between the parents’ first concerns and the first visit to a hospital that offers child psychiatric service. We investigated factors associated with the time lag between the first parental concern and the first visit to a hospital that offers child psychiatric services, among children in Japan with ASDs. A questionnaire was distributed to caregivers of ASD children, through child psychiatrists who work at 16 leading hospitals in child psychiatric services in Japan (N = 1513). We found that a younger child age, a caregiver's lack of knowledge of whom to consult when first concerned about symptoms, and the typically indirect means of attaining services (especially without a referral) each heightened the odds of there being a longer time lag. Visiting another institution, and then going to a hospital that offers child psychiatric services without a referral, was a typical scenario that often led to such time lags. A national health policy to facilitate a referral system that coordinates hospitals that offer child psychiatric services with other medical institutions, the health sector, the welfare sector, and educational institutions is needed, to promote the timely provision of child psychiatric services.

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: This research was supported by NIMH Contract No. 278-83-0006 (DB) and Clinical Research Center Grant MH 30915 from the National Institute of Mental Health, Elizabeth J. Costello, Ph.D., Principal Investigator. The authors would like to thank the staff and patients of HealthAmerica Inc., Pittsburgh, PA, for their time and cooperation. An earlier version of this paper was presented at the Annual Meeting of the American Academy of Child Psychiatry, October, 1986, Los Angeles, CA.

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SPECIAL ARTICLEThe Pediatrician as Gatekeeper to Mental Health Care for Children: Do Parents' Concerns Open the Gate?

J. Am. Acad. Child Psychiatry

J. Am. Acad. Child Psychiatry

J. Am. Acad. Child Psychiatry

J. Psychosom. Res.

Manual for the Child Behavior Checklist and Revised Child Behavior Profile.

DSM-III disorders in preadolescent children

Arch. Gen. Psychiatry

The mental health of children in an HMO program

J. Pediatr.

Testing of the NIMH Diagnostic Interview Schedule for Children (DISC) in a Clinical Population: Final Report. (Contract No. RI-P-DB-81–0027).

National Institute of Mental Health Diagnostic Interview Schedule for Children.

Primary care pediatrics and child psychopathology: A review of diagnostic, treatment, and referral practices

Pediatrics

Analysis of a data set on pediatric mental health care (#87M020293301D).

The new morbidity: Who should treat it?

J. Dev. Behav. Pediatr.

Service utilization and psychiatric diagnosis in pediatric primary care: The role of the gatekeeper

Pediatrics

Psychiatric disorders in pediatric primary care: Prevalence and risk factors

Arch. Gen. Psychiatry

The new hidden morbidity: Psychopathology in pediatric primary care

Pediatrics

Validity of the NIMH Diagnostic Interview Schedule for Children: A comparison between psychiatric and pediatric referrals

J. Abnorm. Child Psychol.

Age differences in the reliability of the psychiatric interview of the child

Child Dev.

Current status of behavioral pediatric training for general pediatric residents: A study of 11 funded programs

Pediatrics

SPECIAL ARTICLE
The Pediatrician as Gatekeeper to Mental Health Care for Children: Do Parents' Concerns Open the Gate?