Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.1
An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.2 According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.3 In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.3 In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.4 The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.
MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).7 The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.
The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).11 Since 2011, there are more than 400 PMHSs certified in the United States.
At a federally qualified health center
Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.