Identifying Child Mental Health Problems in Primary Care

This post will discuss an article published in 2019 in the European Journal of General Practice. The article up for discussion today is titled, “Factors associated with the identification of child mental health problems in primary care - a systematic review”, and was written by Koning, Büchner, Verbiest, Vermeiren, Numans, & Crone. The primary goal of this study was to systematically review literature that has evaluated how we assess child mental health problems in primary care settings.

Systematic reviews provide a fantastic way for us (the consumer of the review) to comprehensively understand what type of work has been published in a particular area of interest. We can use systematic reviews as a resource to strengthen our understanding of a concept without the need to independently read all studies published on the topic.

What did they do?

The authors of this review included published articles that focused on the identification of child mental health problems in primary care settings. Through this review, the authors also sought to investigate potential factors of increased risk for mental health problems that can be easily identified by a primary care physician (PCP) using common mental health screening tools.

Why did they do it?

As highlighted by the authors of the review, early identification of mental health problems in children is incredibly important to not only provide adequate treatment, but also to aid in the prevention of increased adversity later on in life. The implementation of mental health care in a primary care setting provides a unique opportunity for early identification of mental health problems, especially in children, who are typically seen at minimum, on a yearly basis by a PCP. The practice of implementing mental health care into primary care has become much more widely recognized; however, existing literature suggests that nearly half of the children with mental health problems go unrecognized by PCP. The present study aimed to close this gap by reviewing the existing literature regarding factors associated with the identification of mental health problems in children.

How did they do it?

This study conducted a systematic review of existing literature regarding the identification of child mental health problems in a primary care setting. The final group of studies assessed consisted of 26 studies published between 1992 and 2018. Of the 26, 12 studies were completed in the United States, 11 in the Netherlands, and 3 in the United Kingdom. Included studies met the following criteria:

1. Focused on children aged 0– 18 years who visited a PCP
2. Examined PCP-identified mental health problems
3. Explored factors associated with identified mental health problems

The authors defined “mental health problems” as any emotional, behavioral or developmental problems causing mild to severe impairment. Data regarding direct factors associated with the identification of mental health problems were collected from each study.

What did they find?

24 studies included information on factors associated with mental health problems identified by child, parent and professional questionnaires, and 7-30% of children were identified as having a mental health problem by their PCP.

On average, more mental health problems were identified in children whose parents reported problems in school. Problems were also identified more frequently in children who had experienced major life events (e.g. divorce of parents) in the past year. Somatic complaints and prior treatment for a mental health problem were also associated with increased mental health problem identification. Parent and family characteristics were generally inconclusive regarding association to detection of a mental health problem, however, children living in adverse environments or a deprived area were more likely to be identified as having a mental health problem. Primary care physicians who were recently trained to identify mental health problems had higher rates of such identification, on average.

The second goal of the systematic review was in relation to the identification of children with an increased risk of mental health problems. Of the studies included for review, 13 compared PCP identification with scores on mental health assessment tools. PCPs recognized mental health problems in 26–60% of the children with corresponding elevated scores on mental health assessments. Overall, PCP’s identified children with an increased risk of mental health problems when the children were older, were boys, were well-known to their clinician, were visiting specifically for a psychosocial problem, or when a mental health assessment questionnaire was utilized.

What does it all mean (our take)?

Overall, the strategies that are being used in many primary care settings to evaluate the mental health of their patients, especially children, can certainly be improved. The desire to integrate mental health care into a primary health care center has been proven to be prominent, however, it is extremely common for primary care providers to utilize brief screening measures which do not always provide complete or accurate results, resulting in a substantial amount of patients (specifically children, as identified in this article) slipping through the cracks, and not receiving the care they may need.

This article brings a great opportunity to the forefront of mental health care, specifically for children in a primary care setting. There is a continued need to leverage PCP visits as an opportunity to screen for mental health problems, specifically in children. It provides a great opportunity for all different types of care providers to engage in early assessment and subsequent intervention efforts.