Barriers to the Identification and Management of Mental Health Issues in Pediatric Primary Care

Sarah M Horwitz, PhD ¹, Kelly J Kelleher, MD ², Ruth EK Stein, MD ³ and et al. ⁴. ¹ Epi/Bio, Case, Cleveland, OH, 44106; ² Pediatrics, OSU, Columbus, OH, 43205 and ³ Pediatrics, AECOM/CHAM, Bronx, NY.

 

Background: Child and mother mental health (MH) issues are often not identified or managed in pediatric primary care. Although there has been some research on the barriers to optimal practice for these problems, a comprehensive examination of barriers across multiple child and maternal issues guided by a clear conceptual model is not available.

 

Objective: To determine whether: (1) perceived barriers to care for MH issues aggregate into patient, physician and system-areas; and (2) physician, patient and practice characteristics are associated with different types of barriers for children and mothers.

 

Design/Methods: AAP Periodic Survey 59 fielded in 2004 randomly sampled 1600 pediatrician members. Of the 1294 non-trainees, 745 or 57.5% responded. Responses to questions on perceived barriers were factor analyzed and resulting scales were used as dependent variables in the logistic regression analyses. Since responders were more likely to be female and younger, all analyses were weighted.

 

Results: 55.5% of the sample is female, 40.5% is < 39 years of age, 71.1% identify themselves as white, 40.1% of the sample had been in practice for < 9 years, 231 or 33.6% had a mental health-related fellowship and 687 or 92% reported that they were involved in direct patient care. Factor analyses showed 5 unique clusters of barriers: physician inadequacies in identification management (IM) for children and for mothers; maternal issues; systems issues for children and for mothers. Physician inadequacies for IM in children were related to providing MH services, fellowship-level training in MH, while no physician or patient characteristics distinguished pediatricians IM for mothers. Physicians who did not provide MH care, who had no MH-related fellowship and who practiced in rural areas saw maternal issues as barriers. Finally, female pediatricians more frequently endorsed systems barriers with respect to children and pediatricians working in HMOs or medical school practice settings were least likely to endorse systems barriers for mothers.

 

Conclusions: Barriers to pediatric primary care for MH care cluster into physician, patient and systems issues and are distinct for children versus maternal problems. Different characteristics are associated with the 5 barrier clusters, suggesting that interventions to overcome barriers must be multifaceted and tailored.