Pediatricians in this sample frequently diagnosed and treated ADHD. For all other behavioral health disorders, pediatricians reported variability in both comfort and practice. They frequently provided both pharmacologic and nonpharmacologic treatments for children and adolescents with mild to moderate behavioral health disorders but not for severe disorders. Although they identified needs for additional education for anxiety and depression, the majority did not identify educational needs for several high-prevalence behavioral health disorders, including conduct disorder and substance abuse.
Pediatric primary care clinicians have unique opportunities and a growing sense of responsibility to prevent and address mental health and substance abuse problems in the medical home. In this report, the American Academy of Pediatrics proposes competencies requisite for providing mental health and substance abuse services in pediatric primary care settings and recommends steps toward achieving them. Achievement of the competencies proposed in this statement is a goal, not a current expectation. It will require innovations in residency training and continuing medical education, as well as a commitment by the individual clinician to pursue, over time, educational strategies suited to his or her learning style and skill level. System enhancements, such as collaborative relationships with mental health specialists and changes in the financing of mental health care, must precede enhancements in clinical practice. For this reason, the proposed competencies begin with knowledge and skills for systems-based practice. The proposed competencies overlap those of mental health specialists in some areas; for example, they include the knowledge and skills to care for children with attention-deficit/hyperactivity disorder, anxiety, depression, and substance abuse and to recognize psychiatric and social emergencies. In other areas, the competencies reflect the uniqueness of the primary care clinician's role: building resilience in all children; promoting healthy lifestyles; preventing or mitigating mental health and substance abuse problems; identifying risk factors and emerging mental health problems in children and their families; and partnering with families, schools, agencies, and mental health specialists to plan assessment and care. Proposed interpersonal and communication skills reflect the primary care clinician's critical role in overcoming barriers (perceived and/or experienced by children and families) to seeking help for mental health and substance abuse concerns.
ABSTRACT. There remain large discrepancies between pediatricians' practice patterns and the American Academy of Pediatrics (AAP) guidelines for the assessment and treatment of children with attention-deficit/hyperactivity disorder (ADHD). Several studies raise additional concerns about access to ADHD treatment for girls, blacks, and poorer individuals. Barriers may occur at multiple levels, including identification and referral by school personnel, parents' help-seeking behavior, diagnosis by the medical provider, treatment decisions, and acceptance of treatment. Such findings confirm the importance of establishing appropriate mechanisms to ensure that children of both genders and all socioeconomic, racial, and ethnic groups receive appropriate assessment and treatment. Publication of the AAP ADHD toolkit provides resources to assist with implementing the ADHD guidelines in clinical practice. These resources address a number of the barriers to office implementation, including unfamiliarity with Diagnostic and Statistical Manual of Mental Disorders criteria, difficulty identifying comorbidities, and inadequate knowledge of effective coding practices. Also crucial to the success of improved processes within clinical practice is community collaboration in care, particularly collaboration with the educational system. Such collaboration addresses other barriers to good care, such as pressures from parents and schools to prescribe stimulants, cultural biases that may prevent schools from assessing children for ADHD or may prevent families from seeking health care, and inconsistencies in recognition and referral among schools in the same system. Collaboration may also create efficiencies in collection of data and school-physician communications, thereby decreasing physicians' nonface-to-face (and thus nonreimbursable) elements of care. This article describes a process used in Guilford County, North Carolina, to develop a consensus among health care providers, educators, and child advocates regarding the assessment and treatment of children with symptoms of ADHD. The outcome, ie, a community protocol followed by school personnel and community physicians for >10 years, ensures communication and collaboration between educators and physicians in the assessment and treatment of children with symptoms of ADHD. This protocol has the potential to increase practice efficiency, improve practice standards for children with ADHD, and enhance identification of children in schools. Perhaps most importantly, the community process through which the protocol was developed and implemented has an educational component that increases the knowledge of school personnel about ADHD and its treatment, increasing the likelihood that referrals will be appropriate and increasing the likelihood that children will benefit from coordination of interventions among school personnel, physicians, and parents. The protocol reflects a consensus of school personnel and community health care providers regarding the following: (1) ideal ADHD assessment and m...
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