Between the ongoing shortage of child psychiatrists, ever-evolving changes in health care policy and medical insurance, and documented increases in the rates of many psychiatric disorders, it can be difficult for pediatricians to define their role in delivering quality mental health care. To get some perspective on these issues, I talked with Dr. Joseph F. Hagan Jr., a pediatrician from Burlington, Vt. Dr. Hagan has been involved in shaping pediatric mental health care policy for years as the former chair of the American Academy of Pediatrics’ (AAP) Committee on the Psychosocial Aspects of Child & Family Health and current member of the Bright Futures Steering Committee. He is also running this year to be the president-elect of the national AAP.
Q: What do you see as some of the key issues affecting child mental health care?
A: One of the things I haven’t heard a lot about is that there are not enough therapists to see children. The system has traditionally been based upon procedures and not on time, and that’s a problem. Therapists get paid less than the shop rate of your local auto mechanic, and of course, anyone who sees children has to talk with schools and parents outside of the session. That’s nonbillable, and we wonder why nobody will see children. Mental health is part of health, and the earlier we invest, the bigger the return. Because our practice was certified as a Family Centered Medical Home and now has access to a Community Health Team, my life has changed because we now have services that we didn’t have before. The problem with screening in the past has been "What if you find something?" Now we have so much more to offer.
Q: How much should a pediatrician really be expected to know and do when it comes to child behavioral problems? Is there a floor of knowledge and skills when it comes to mental health that all pediatricians should attain?
A: I think there definitely is. I would say that this could happen in steps. The AAP’s Taskforce for Mental Health really helped lay this out, but we already knew this. Behavioral and mental health problems can be managed in our offices, and everyone ought to be able to manage the majority of children with attention-deficit/hyperactivity disorder (ADHD), but also those with oppositional defiant disorder, anxiety, and depression. There are certain mental health problems that are part of pediatrics. To refer a standard ADHD child is absurd, because it really is a day-to-day problem that needs to be managed in your primary care medical home. Everybody needs to know how to do that and do it well. It is a chronic illness, and you need to hang in there with these children. That’s the basic floor. I think the floor is extended in being able to identify postpartum depression because we know that’s crucial and to be able to identify families who are really struggling with social determinants of health. This is going to be a big push in the forthcoming edition of Bright Futures. I think you also need to be able to identify anxiety and depression and be able to take the first steps in that. And maybe you should know how to treat them with selective serotonin reuptake inhibitors (SSRIs) if that should become important. I think you also should be able to talk about preventive things and ought to know that there is this thing called CBT (cognitive-behavioral therapy), and which therapists are in town who do CBT. You’ve got to know your community nonmedication options and access them before you decide upon meds.
Q: Psychiatric medications certainly have become even more controversial lately. What advice do you have for pediatricians when they prescribe them?
A: Tell families the expected effects and potential side effects. If you don’t, Dr. Google will. Start low and go slow, but titrate until desired effect of recovery. Remember if you are 100% anxious and miserable, you’ll look and feel great when you’re only 50% anxious, but you’re still only halfway better! It’s also important to discuss with your patient when you start meds, how long you are going to continue them, lest they feel good and stop prematurely.
Q: There are a lot of efforts these days to extend the education of pediatricians and provide consulting back up while the patient remains directly in the care of pediatrician. Do you think those efforts are enough or should we be more focused on providing more psychiatrists and other mental health clinicians that pediatricians can refer to?