The PSC proved to be a valid, reliable method for increasing awareness of behavioral health problems in pediatric primary care settings. It was also shown to be a quick, easy, and effective way to screen large numbers of pediatric patients in busy, resource-challenged, and ethnically diverse health centers.
Twenty-five percent of the children in our sample received a positive score on the PSC—a rate comparable to those found in other studies at low-income pediatric clinics in Boston (20
). Using overall ratings for level of functioning derived from in-depth clinical interviews with parents as the gold standard, the English and Spanish versions of the PSC demonstrated high rates of sensitivity and specificity among school-aged children (93 percent), evidence of their validity with a low-income urban pediatric population. The Spanish version of the checklist was subsequently revised in response to its relatively weaker sensitivity and specificity among pre-school-aged children from Spanish-speaking families.
The estimated level-of-functioning ratings for the whole sample suggest a high rate—20 to 25 percent—of moderate to severe behavioral health impairment among the pediatric population, confirming the need for pediatricians to include an assessment of behavioral health problems within the scope of their work.
The multidisciplinary team meetings provided an important means by which to improve linkages between the health centers’ primary care services, behavioral health providers, and health maintenance organizations. Through these case reviews, it was readily apparent that several of the children were seriously dysfunctional and had already been referred multiple times; yet there was a lack of follow-through. Many of the families were so chaotic that traditional models of clinic-based psychotherapy were judged inadequate. In some families, protective or parenting issues were noted that required a significantly different approach.
Perhaps the most compelling evidence in this study for increased attention to pediatric behavioral health problems is the fact that only about one-third of the children with significant behavioral health disorders whose cases were reviewed by the multidisciplinary team were receiving needed services. Even among the most impaired children—those classified as severely to very severely emotionally disturbed—only about one-half were receiving any behavioral health services at all. A reported shortage of existing services due to staff turnover and long waiting lists may account in part for this deficiency. However, for many cases, services deemed to be effective, such as parenting classes and outreach teams to engage resistant families in treatment, were either unavailable locally or unknown.
The results of our study also imply a basic systemic health care problem characterized by inadequate follow-through on referrals by families of children with significant behavioral health disorders and a lack of awareness about, or availability of, needed behavioral health care resources in the primary care setting. This observation suggests the need for enhanced care referral and tracking systems as well as for ongoing education of the pediatric staff about available behavioral health resources.
Although behavioral health programs traditionally focus on the identification and treatment of behavioral health disorders such as depression, anxiety, substance abuse, and conduct disorders, Neighborhood Health Plan is explicitly aware that myriad psychosocial stressors experienced by its members often contribute to the advent or exacerbation of such disorders. Poverty, inadequate housing, domestic abuse, gang violence, readily available illicit drugs, child abuse and neglect, poor nutrition, and inadequate education, among other problems, clearly have a deleterious impact on the overall health of this population, including behavioral health.
Although the amelioration of socially based stressors is not customarily within the purview of health maintenance organizations, Neighborhood Health Plan and its subcontractor, Beacon Health Strategies, collaborate actively with the Massachusetts Division of Medical Assistance (Medicaid), the Department of Mental Health, child welfare agencies, community programs, and other resources in an effort to meet the broader psychosocial needs of its members. In addition, Neighborhood Health Plan pays the health centers with which it has contracts an enhanced rate to support the work of their social services departments in helping members address these psychosocial stressors.
As the next step in improving the early identification and treatment of children at risk, the researchers developed a pediatric preventive behavioral health clinical guideline (26
) that incorporates the PSC. This guideline has been adopted by Neighborhood Health Plan. It features a highly specialized intensive case management component for the most impaired children, offering out-reach and other nontraditional behavioral health services to meet the needs of the client and the family. Neighborhood Health Plan and Beacon are currently working with Massachusetts General Hospital and the health centers to implement the guideline, with the goal of improving access to appropriate behavioral health services.
An outcome of this study was the development of a pediatric preventive behavioral health care clinical guideline designed to more effectively meet the needs of children at risk We hope the information in the study will be of value to other behavioral health organizations and pediatric practices that are striving to improve the overall health status of children and their families.