By Ronald Seifer, Ph.D.
Most anyone who has received medical care in the past few years can attest to its fragmented nature. These days, consumers are often required to build relationships with multiple providers in multiple settings, each of whom addresses only a small portion of an individual's medical needs. Thus, one of the major challenges facing both the professionals providing behavioral health services and their consumers is negotiating the complicated matrix of settings and providers to address what are often multifaceted family and social problems.
December 2010 Vol. 26, No. 12
This article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.
A parallel problem is finding efficient ways of determining whether individuals require more than routine care and surveillance - an enterprise we refer to as screening.
Children vary on their timing of achieving developmental milestones, as well as the degree to which they exhibit adaptive and maladaptive social/emotional behaviors. The vast majority of these variations are normative, but well-designed screening tools can point to areas where more investigation is warranted.
Two fundamental principles motivate such efforts: First, identification of problems early in life (more specifically, early in development) is best suited to promoting healthy adaptation. Second, behavioral health problems are often difficult to detect, especially when they are less entrenched (yet easier to treat). Thus, active efforts to screen large populations will result in identifying many otherwise undetected behavioral health problems, and likely result in better long-term outcomes.
In recent years, the American Academy of Pediatrics, and more recently the Federal Government, have recommended explicit ages (9, 18, and 30 months) at which general developmental screening should occur. In conjunction with Medicaid regulations, many states have mandated that insurance companies reimburse providers for this service. A major challenge, however, is to provide practitioners with evidence-based tools with which to conduct such screening. Even more important is for the practitioners to have the appropriate resources to interpret the screening information, follow up on screens indicative of potential problems, and identify appropriate surveillance or intervention consistent with the followup assessments.
In some respects, developmental screening is even more complicated in early-care settings. There are no general mandates, guidelines, or financing for developmental and behavioral health screening. A small number of children in early care settings do have such structure (Head Start is a notable example), but even these settings are typically ill equipped to effectively engage in the full range of activities implicit in the screening agenda.
One of the main challenges in integrating behavioral health screening in both medical and early care settings is the diversity of training among the different professional groups involved in those settings. Medical professionals, especially physicians and nurses, receive minimal training specific to behavioral health, a situation that is particularly evident in infants, toddlers, and preschool-age children.
Similarly, educational opportunities and standards are only beginning to emerge for the workforce in child care and early education settings specific to the developmental status of the populations served. One approach to addressing such challenges is to locate behavioral health professionals at the pediatric and early care sites where children naturally congregate.
As will be elaborated below, optimal integration is achieved not by simple colocation of professionals practicing their individual disciplines, but by sharing expertise and responsibility for addressing behavioral health issues. Identification of appropriate methods for sharing of expertise (that is not burdensome to otherwise busy professionals) is critical to success of the integrated care enterprise. One approach to this problem is to build on the medical home concept in pediatric settings, and the early learning community concept in early care and education settings. Each of these movements share an appreciation of the need for multiand transdisciplinary approaches to serving children and families in an integrated, holistic fashion. Furthermore, sharing of information and expertise between pediatric and early care settings is a long-term goal of such approaches.
Locating behavioral health professions in close proximity to medical or early care teams does not directly result in serving child and family needs in an integrated manner. And providing pediatric and early care settings with a screening instrument does not necessarily result in serving child and family needs in an integrated manner. Simple colocation does not solve the problem of fragmented domains of specialization. Without appropriate mechanisms for effective communication; reduction in duplication of efforts; shared service delivery mechanisms; and child/family focused planning, such arrangements can result in additional burden on children and families without effectively identifying and addressing the developmental needs of the children. For example:
Michael received a positive screen in his pediatrician's office. However, an appropriate second-level assessment was not made because the behavioral health professional was not accessed (e.g., scheduling problems, no referral made, lack of proper insurance coverage). And the screening results were therefore not shared with the Michael's early education setting. The situation only served to make additional work for Michael's family and his providers - without additional progress on addressing his developmental needs.
Mental health consultation models indicate one direction for integrating pediatric developmental screening and care. Fundamental to this approach is the idea that professionals with expertise in behavioral health provide their colleagues with specific expertise to expand the scope of their practice, guidance regarding where the limits of their expanded practice lie, and support for those situations where presenting issues are outside these boundaries.
Furthermore, the mental health consultants, by virtue of their colocation, are available for professional-to-professional consultation, which in many cases can mitigate the need for referral of a child/family to additional practitioners. This in turn can remove barriers to care by eliminating the need for additional appointments, travel, missed work, missed school, and healthcare expenses incurred.
Many of the activities described above are not currently covered in traditional healthcare systems. The screenings themselves are, even in the best of circumstances, covered at only a few ages in the first 5 years of life, and even then at very low monetary levels. A comprehensive screening program would incur substantial amounts of uncompensated activity.
Behavioral health professional time is rarely reimbursed for any activity outside of direct contact with patients who qualify for a behavioral illness diagnosis. Similarly, additional time of medical professionals required to address behavioral health needs typically cannot be billed to health insurers, unless families attend separate appointments. Health professionals' time spent consulting with one another, or with nonmedical professionals, is nonreimbursable as well. Thus, there is system building required to provide the financial supports for the various professionals to engage in the work described herein.
Finally, all of these joint activities (specific contact with children and families, arranging for colocation and consultation, organizing systems to implement screening and follow-up, and working together to arrange adequate financing) all require joint planning in the context of strong relationships among the professionals involved. Such efforts take time, often months, or years to become fully operational. The payoffs at the end of these efforts are early identification to reduce morbidity and maximize adaptation in children and families; more efficient delivery of care when needed; and lowered long-term costs by preventing some of the disorders and school failures that require costly interventions.
Ronald Seifer, Ph. D., is a professor in the Department of Psychiatry and Human Behavior at Brown University, and Director of Research at Bradley Hospital.
Center on the Developing Child at Harvard University (2010). The foundations of lifelong health are built in early childhood - www.developing child.harvard.edu.
Hagan JF, Shaw JS, Duncan P: Bright Futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics, 2008.