Abstract
Keywords
There has been increasing recognition in recent years of the extent and implications of child and adolescent mental health problems. Yet attention to child mental health problems is patchy and often lacking. At any one time, the majority of children with disorders are not under the care of specialist psychiatric or other mental health services. Disorders are often chronic and contact with specialist services is likely to be episodic.
Children with psychiatric disorders consult their general practitioners, primary care or family doctors and services. Primary care thus has potentially a role in identifying and attending to children with disorder, in referring to specialist services, in supporting the work of specialist services and families after recovery or during relapse.
This paper will discuss the role of general practice in the identification and management of child psychiatric disorders and in the promotion of child and adolescent mental health. Research in the area is still in its infancy, but existing evidence will be outlined as appropriate.
Role of general practice in the attention to child and adolescent mental health problems
Organization of primary care services
Primary care services are widely set up to provide the first gate for access to health care but their organization varies in different countries. The principles of universal coverage (a lifespan approach whereby all age groups and family members are included), easy access and continuity of care are generally regarded as underpinning primary care services, but they are not fully and universally implemented.
In the UK the general practice or primary health-care service is free and universal. It is centred round the work of primary care doctors, who sometimes work together from health centres attending to their surrounding catchment area. Many practices have nurses attached with a special commitment to supervise the development and heath of young children under 5 years of age (paediatric nurses or health visitors). Some practices also employ counsellors or psychologists. About one in 10 patients seen are referred on to secondary or specialist health services.
Although the main task of general practitioners is reactive and responsive to requests for care from registered patients, their service also has a health promotion component with involvement in vaccination programmes and health screening initiatives. In the child health field, paediatric nurses or health visitors, some of whom may be attached to primary care, have a primary health promotion brief.
Frequency of child and adolescent psychiatric disorders among children attending primary care services
Some 2–5% of children and adolescents who attend primary care clinics in different countries present with psychological problems [1–4]. Educational and psychosocial problems are also reasons for consultations. However there is evidence that psychiatric disorders are present in many more children as associated factors of somatic presentations. Psychiatric interviews carried out with children and their parents following general practice contact have found psychiatric disorders in about one in 10 to one in four across different countries. The rates are probably higher in adolescents [5–10].
There are indications that psychiatric disorders contribute to these somatic consultations by making it more likely for children to attend with somatic symptoms. This is suggested by the comparatively high rates of disturbance among consulting children in relation to general population expectation and may be particularly marked in the more psychosocially advantaged areas, among adolescents and in frequent primary care attending children [6–10]. Increased primary care use has been found among children with behavioural and psychiatric disorders [11–14].
There is little specificity in the types of physical symptoms presented by children with psychiatric disorders when they attend primary care. However, a sense of poor physical wellbeing might contribute. For example, when compared with other attenders, those with psychiatric disorder have been described as more tired and lethargic, in poorer health, more handicapped by their physical symptoms and with higher levels of impairing physical symptoms [4, 15].
The associated psychiatric disorders of school children and adolescents attending primary care are more likely to be emotional than disruptive in nature, and they tend to be linked to family stress including poor maternal mental health. The confident management of these disorders and of associated family stress is specially called for in primary care.
Are psychiatric disorders recognized and treated by general practitioners?
As with adults with psychiatric disorders attending general practice, recognition of child and adolescent psychiatric disorders by primary care doctors is limited. This is not altogether surprising since most children do not present with psychological or behavioural problems and there may be few indications of these problems during the consultation.
There is wide variation between doctors in rates of recognition. Doctors' assessments are usually highly specific, few non-disturbed children and adolescents being identified by them, but they miss a considerable percentage of disturbed children. Recognition is higher when children have severe problems [9, 16]. It is also associated with child's age (higher in 7–14-year-olds), the presence of social stresses such as being on welfare and of broken homes, and with certain presenting symptoms, for example chronic conditions, digestive problems and ill-defined symptoms [17, Gledhill J et al.: unpublished data].
Recognition is not surprisingly associated with psychological and behavioural presentations at the surgery. Surveys asking doctors about the treatment they provide in these circumstances report that most children are not under specialist care and some help is given in primary care. This includes supportive therapy or counselling and suggestions for environmental change [2, 18]. However, little is known about the exact nature of these interventions. Young mothers in health clinics prefer statements by doctors reflecting empathy and encouragement over the simple expression of support [19], but this in itself would be insufficient to guide mothers into improving the management of difficult behavioural problems or emotional changes in their children.
Earlier surveys of prescribing practice in primary care indicated that in some services about 11% of children with mental health problems were prescribed psychotropic medication, mainly amphetamines [2]. A diagnosis of attention deficit disorder in some primary care clinics in the USA virtually predicted the use of stimulant medication and the lack in the use of other treatments [20]. There has recently been a trend for increased primary care psychotropic medication use for children, even preschoolers [21], raising the issue of overprescribing and the need to monitor what treatments are being provided for children with psychiatric disorders in primary care.
Referral to specialist mental health services
General practitioners have long been a major source of referrals to child psychiatric clinics. However, this is usually only a small proportion of children with disorder seen by the general practitioner. Each doctor refers few children over the course of a year and over and above obvious recognition we have very little information on what determines referral. Appropriately, most studies investigating this have found that the presence and severity of the child's psychiatric disorder are associated with referral, so are male sex, antisocial symptoms, psychosocial disadvantage, an appreciation by the parents of disorder in their child, and in a number of cases active request by the parents for referral [22–24].
Length of time the doctor has known the patient also contributes, the doctor's role in the processes being often quite passive [17, 25]. In some cases this will be accounted for by different perceptions by parents and doctors about the nature of the children's difficulties. For example, more general practitioners than parents are unsure whether hyperactivity is a medical disorder warranting a diagnosis and specific treatment; doctors tend to see hyperactivity more as a passing phase related to family stresses [26] and therefore less likely to require specialist psychiatric treatment.
Not all children referred by primary care doctors to child psychiatrists have diagnosable psychiatric disorders. There are indications that for a number of parents, the difficulty experienced in controlling and coping with exuberant activity in somewhat rebellious children in the context of adverse social circumstances leads to referral in the absence of formal child psychopathology [23].
Psychiatric treatments in primary care
Work in adult mental health has shown that primary care interventions can be instituted and be effective for individual problems. Far less is known about what are possible interventions for children with mental health problems in primary care. Most studies have been simple before-and-after designs without control groups using a variety of techniques. Although this introduces methodological limitations, these studies outline interventions that are feasible and often well received. Most interventions studied fall within the category of shifted outpatient clinics by child mental health specialists in the primary care setting. This section will consider first work within the shifted outpatient clinic model and second consultation–liaison models of work.
Shifted outpatient clinic
It is clearly feasible and potentially beneficial for mental health professionals to offer short interventions in primary care. Finney et al. [27] provided individualized treatments guided by problem-specific protocols to children and adolescents with behaviour and mental health problems attending primary care. The majority of parents and behavioural checklists reported high satisfaction and clinical improvements. Finney et al. showed the benefits of a primary care intervention for children with recurrent abdominal pain [28]. More complex treatment approaches such as family therapy clinics have been implemented [29]. Coverly et al. [30] described a protocol-guided, single psychiatric intervention in primary care to mothers of frequently attending schoolchildren and the majority of mothers attended and found this helpful. Westman and Garralda [31] piloted a brief psychotherapeutic intervention for adolescents with depressive and anxiety disorders attending a health promotion clinic in primary care. Though attendance rates were poor, the small number of adolescents who attended tended to report benefits.
Consultation–liaison
An alternative approach is the development of psychiatric consultation–liaison whereby psychiatrists visit health centres to see selected patients conjointly with general practitioners or hold regular discussions at the health centre or surgery or even arrange regular and coordinated home visits. The aim is to help general practitioners identify and manage psychiatric morbidity in general practice, to help define the best time for specialist referral, and to share with the primary care team the continuing burden of chronically sick children [32]. Consultation–liaison will often involve members of the multidisciplinary psychiatric and primary care teams. This approach has the advantage of providing time for the growth of understanding of what professionals want from each other, a common and acceptable meeting ground, and the development of mutual trust and respect.
There is currently active interest in the UK in the development of primary care child and adolescent mental health workers to help take on some of these liaison tasks. Though their role is to be mainly consultative and facilitative of the interface between primary care and specialist child and adolescent mental health services, it is expected that primary care workers will do some face-to-face clinical work and have a base in both primary care and specialist services.
New initiatives to improve identification and to manage the interface with specialist services
A number of approaches have attempted to improve recognition of child psychiatric disorders by primary care doctors and their teams. There are simple, quick, easy-to-complete questionnaires to screen children and young people with behaviour problems, depression and parent–teenager conflict in primary care and paediatric settings [33–35]. The use of opening questions during the consultation about existing emotional or behavioural problems in the children will similarly prove useful [7]. Exploration of the actual rather than the ostensible reason for seeking paediatric attention may also reveal family stresses possibly related to child psychopathology [36]. To be truly helpful, these techniques require additional training of primary care workers. The contribution of nurses is particularly important for young preschool children, and the appointment of counsellors and psychiatrically trained nurses offers the opportunity to set up screening clinics.
Giel et al. [37] provided brief training sessions for family workers in the use of a small set of simple questions to help identify probably disturbed children in various developing countries. This resulted in increased awareness by primary care workers, better identification of severe psychiatric problems (for example, emergencies such as suicidal behaviour, depression or psychosis), neuropsychiatric problems (epilepsy and mental retardation) and more favourable attitudes towards their management.
Bernard et al. [38] developed a training package on child and adolescent mental health problems for primary doctors in training. Unlike the training provided by Giel et al. this emphasized the more common and comparatively less severe psychiatric disorders. The training included preparatory reading [39] and teaching sessions with problem exercises, role-play and video-vignettes. Evaluation demonstrated enhanced detection of child psychiatric disorder as well as improved self-perceived competence and knowledge among general practitioner trainees. Gledhill et al. [unpublished data] have tested a package to train general practitioners in the identification and management of adolescent depression opportunistically during routine consultations for any kind of presentation. Its use resulted in improved detection of adolescent depression by general practitioners and in positive feedback by doctors and adolescents. Sanci et al. [40] have demonstrated that specific training for general practitioners can influence the quality of medical consultations with adolescents in primary care and achieve sustainable improvements in knowledge, skill and self-perceived competence. These are basic requirements for the development of more specific mental health promotion initiatives in primary care.
Mental health promotion in primary care
Primary care services often have an important health prevention role, which would be expected to apply to child and adolescent mental health problems.
Pioneering work in this area was carried out by Cullen [41] an Australian general practitioner. He arranged to see mothers of young children over the first 5 years of the child's life when he explored child-rearing concepts and attitudes. Beneficial effects were reported in childhood and on follow up into early adulthood [42].
Counselling of mothers with puerperal depression by child health nurses can lead to significantly improved rates of recovery, and this may be expected to have beneficial effects on the child's cognitive and emotional development [43]. Tsiantis et al. [44] have described a programme to train primary health care workers in the promotion of children's early psychosocial development through contact with mothers from conception until their child is 2 years old. Davis and Spurr [45] evaluated the offer of a parent-counselling programme by health and clinical medical officers for parents of preschool children. The authors point to positive outcomes in terms of parental wellbeing and child behavioural problems. These are interesting initiatives with a primary care component and with the potential to help promote child and adolescent mental health.
More ambitious community parenting promoting programmes, including preventive home visiting can lead to significant long-term psychosocial benefits for mothers and improved parenting [46]. Webster Stratton [47] described the implementation of one of these programmes that focused on social and cognitive stimulation. This resulted in improved competency in parenting and in child social competence, in less conduct problems and non-compliance. Trained nurses within primary care may possibly implement aspects of these programmes. Alternatively, and perhaps more realistically in the short term future, primary care could contribute by identifying high-risk families and facilitating referral to existing community programmes of this type.
Implications for planning of service, clinical practice and research
The high rates of psychiatric disorder among children and adolescents attending primary care, together with the increasing expectation that primary care attends to these problems and contributes to the promotion of child and adolescent mental health, has implications for service planning and for clinical practice.
Training on the nature of child and adolescent psychopathology
Increasing knowledge on the nature of the common and severe psychiatric disorder is a necessary prerequisite. Medical and nursing school teaching and postgraduate training in general practice is still very uneven across different institutions. There is an ongoing need for academic institutions to develop, update and document the quality, breadth and reach of teaching and training programmes to ensure universal coverage.
Information and advice
Primary care teams are in a good position to draw parent and youngster's attention to suitable written and electronic information and to complement this with clarification of the meaning of the symptoms presented and basic advice about its management. The challenge is to distil the main knowledge and management principles of child psychiatric disorders in a way that can be conveyed in an authoritative and empathic manner by a generalist medical service during a brief intervention.
Screening for psychiatric disorders
Most children with psychiatric disorders attending clinics present with somatic symptoms. Screening for psychopathology will therefore require special skills from general practitioners in changing the focus from somatic to psychological concerns. Existing research provides information about areas that may be targeted most profitably. This may focus more on psychosocially advantaged areas, on children and young people who are frequent primary care attenders, those with psychosomatic presentations or who are particularly handicapped by their physical symptoms and children in particularly stressful psychosocial circumstances. The most commonly uncovered disorders are likely to be emotional in nature in older schoolchildren and adolescents and may be predominantly oppositional defiant in younger children.
Primary care interventions for child psychiatric problems
A case can be made for the development of both shifted child psychiatric or other mental health outpatient clinics and for the provision of more primary appropriate interventions by general practitioners themselves and their staff.
Shifted outpatient clinics
In shifted outpatient clinics mental health professionals, counsellors or psychologists do outpatient clinics in the primary care setting. The shifted clinic may have the advantage of de-stigmatizing and facilitating attendance. However it would be unrealistic to expect universal coverage through these clinics. They will be valuable if adequately monitored and evaluated and if the latter provides justification for future developments.
Complex specialist interventions
Another suggestion is to adapt more complex specialist interventions to primary care settings so that general practitioners and their staff (or community paediatric services) can deliver these opportunistically during consultations. On the face of it this seems a more attractive approach. It will however, require a high level of motivation by primary care doctors and their staff in developing new skills.
Referral to specialist services
Protocols refining the criteria for severity, psychosocial complexity and likely response to treatments may be developed jointly by child and adolescent mental health and primary care services. The development of primary care mental health worker posts may be monitored for more and more accurate identification and management of child and adolescent psychopathology in the primary care setting and for more efficient referrals to specialist clinics.
Child mental health promotion in primary care
Some members of the primary care team, for example health visitors and school nurses, may become particularly active in this area. Information giving about healthy parenting strategies and screening of children at risk for psychopathology should be incorporated into their role through basic training. They will be in an excellent position to identify and refer children and families who may benefit from community psychosocial treatment packages.
Concluding remarks
There is evidence that primary care services can influence child and adolescent mental health. Enough is known to target training and service developments. Future research should help clarify what interventions are helpful for whom in this setting.