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More than 14 million children and adolescents in the United States, or 1 in 5, have a diagnosable mental health disorder that requires intervention or monitoring and interferes with daily functioning.¹ While many children with mental health disorders are not being diagnosed, primary care clinicians have been identifying children with emotional and behavioral disorders at an increasing rate. The need for primary care clinicians to manage children with mental health concerns will only continue to increase in the future. Primary care clinicians are, and will continue to be, an important first resource for parents who are worried about their child's behavioral problems. 

Children’s Mental Health and the Medical Home
The State of Children’s Mental Health
  • Approximately 21% of U.S. children and adolescents meet diagnostic criteria for a mental health (MH) or substance abuse (SA) disorder with impaired functioning, yet only about 20% receive needed services.
  • Minority children are disproportionately represented among the underserved.
  • In addition to children with diagnosable disorders, many children in the U.S. have MH symptoms that do not rise to the level of a disorder:
-16% of children and adolescents have impaired MH functioning and do not meet criteria for a disorder.

-13% of school-aged children and 10% of pre-school children with normal functioning have parents with behavioral concerns about them.

-50% of adults with MH disorders experienced emergence of their symptoms by the age of 14 years.
  • Children without diagnosable conditions are typically not included in the target population of MH specialty systems, private or public.

The Primary Care Advantage
Primary care clinicians offer a setting that encourages trusting, longitudinal relationships with the child and family. Beginning in infancy, primary care clinicians can nurture resilience; identify adverse childhood experiences and other risks to healthy psychosocial development; screen routinely for emerging symptoms and for problems in child or family functioning; and intervene when risks, concerns, or symptoms arise. The skills necessary to identify and address undifferentiated psychosocial problems and emerging symptoms are fundamental to pediatric practice.

A Medical Home for Children with Mental Health Problems
Children with MH/SA problems---whether risk factors, emerging symptoms, or diagnosable disorders---are children with special health care needs who need and deserve a primary care medical home, just like children with asthma or diabetes. Primary care clinicians are familiar with chronic care principles and can readily apply them to the care of children with MH/SA problems.

The Charge for AAP and its Members
Mental health care IS mainstream pediatrics. Primary care clinicians, if trained and supported, are ideally positioned to identify children with mental health problems, to triage for emergencies, to initiate care, and to collaborate with MH/SA specialists in facilitating a higher level of care when needed. The AAP urges primary care clinicians to expand their comfort and skills in diagnosing and managing (or co-managing) children with common disorders including, at a minimum, ADHD, anxiety disorders, depression, and substance abuse.

The AAP recognizes that many of those children who are served in the MH or SA specialty system—particularly those with severe and persistent mental illness requiring intensive levels of care—lose contact with their pediatric medical home. The AAP urges that primary care clinicians make efforts to engage these children and their families in the full range of primary care services and engage their MH/SA providers and other community partners (eg, schools, child care and Early Intervention providers, juvenile justice system, social services) in one collaborative, family-centered system of care that transects traditional silos.

Task Force on Mental Health (2004 - 2010)
In 2004, in response to the growing need to address children's mental health concerns in primary care, the AAP Board of Directors formed the American Academy of Pediatrics (AAP) Task Force on Mental Health (TFOMH). The Task Force (TFOMH) articulated (with the AAP Committee on Psychosocial Aspects of Child and Family Health) mental health competencies for primary care; developed guidance for addressing systemic and financial barriers to providing mental health care in primary care settings; and provided tools and strategies to assist pediatricians in applying chronic care principles to children with mental health problems.

Jane Meschan Foy, MD, FAAP (chairperson, lead author)
Paula Duncan, MD, FAAP
Barbara Frankowski, MD, MPH, FAAP
Kelly Kelleher, MD, MPH, FAAP
Penelope K. Knapp, MD, FAAP
Danielle Laraque, MD, FAAP
Gary Peck, MD, FAAP
Michael Regalado, MD, FAAP
Jack Swanson, MD, FAAP
Mark Wolraich, MD, FAAP

Margaret Dolan, MD, FAAP, Consultant
Alain Joffe, MD, MPH, FAAP, Consultant
Patricia O’Malley, MD, FAAP, Consultant
James Perrin, MD, FAAP, Consultant
Thomas K. McInerny, MD, FAAP, Consultant
Lynn Wegner, MD, FAAP, Consultant

Terry Carmichael, MSW, Liaison, National Association of Social Workers
Darcy Gruttadaro, JD, Liaison, National Alliance on Mental Illness
Garry Sigman, MD, FAAP, Liaison, Society for Adolescent Medicine
Myrtis Sullivan, MD, MPH, FAAP, Liaison, National Medical Association
L. Read Sulik, MD, FAAP, Liaison, American Academy of Child and Adolescent Psychiatry
 

Mental Health Leadership Work Group (2011 - 2013)
After the TFOMH sunset, the Mental Health Leadership Work Group (MHLWG) was formed to facilitate integration of the TFOMH’s work into the fabric of the AAP and pediatric practice. Its activities focus on transforming systems, transforming practice, building clinician skills, disseminating clinical tools, enhancing community resources for MH/SA care, and partnering with families and organizations.
Examples include training primary care clinicians in the requisite mental health competencies, enlisting quality improvement methodology to implement practice changes, advocating for appropriate payment for mental health care, reducing administrative barriers, and identifying new collaborative models. The MHLWG will be calling upon various AAP committees, sections, councils, and programs to assist in addressing these key areas. Members of the MHLWG will be reaching out to select organizational partners for assistance in undertaking this charge. For questions regarding the plans of the MHLWG, please feel free to contact Linda Paul at lpaul@aap.org or 800/433-9016, ext 7787 or John Duby, MD, FAAP at jduby@aap.net or 330-543-6037.

John Duby, MD, FAAP, Chairperson
David Bromberg, MD, FAAP
Marian Earls, MD, FAAP
Jane Meschan Foy, MD, FAAP
Alain Joffe, MD, FAAP
Cori Green, MD, FAAP, Consultant
Kelly J. Kelleher, MD, MPH, FAAP, Consultant
R. Franklin Trimm, MD, FAAP, Consultant


1 US Department of Health and Human Services (USDHHS). Mental Health: A Report of the Surgeon General. Washington, DC: US Government Printing Office; 2000. Available online at http://profiles.nlm.nih.gov/ps/retrieve/ResourceMetadata/NNBBHS.
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