Primary care doctors ill-equipped to discuss children's mental health, parents say

As the responsibility of identifying and treating youths with mental illness increasingly falls to primary care physicians, many parents believe those doctors aren't knowledgeable about the subject, and some say they feel as if their concerns aren't heard.

A survey of 554 parents and caregivers, released May 11 by the National Alliance on Mental Illness, found that 83% wanted to discuss mental health issues with their child's primary care physician even if the parents saw no evidence of problems. More than one in three families wants the doctor to initiate the conversation, and 32% prefer the discussion to take place in person without the child present. When those discussions happen, 42% of participants do not think physicians give them enough time to answer their questions. About half of parents said they didn't feel their child's primary care doctor was knowledgeable about mental illness.

Part of the problem is that some primary care physicians feel uncomfortable discussing mental health issues and identifying mental illness due, in part, to the lack of training they received on the subject, doctors say. Physicians also struggle to fit conversations about mental health into the limited time they have for each patient's office visit. These challenges mirror what is happening with primary care physicians who treat adults.

"It's not that primary care physicians aren't doing their job," said David Folsom, MD, MPH, a family physician and psychiatrist at the University of California, San Diego. "I think we have a fragmented system in which primary care physicians are almost always the first resource and in some places the only resource available. And that probably shouldn't be the way it is."

The influx of patients seeking help for mental illnesses in the offices of primary care physicians is largely a result of the nation's child psychiatrist shortage. There are only about 7,000 such specialists in the U.S., said Boston psychiatrist Eugene Beresin, MD, a spokesman for the American Academy of Child and Adolescent Psychiatry. But an estimated 30,000 child psychiatrists are needed to meet demand, he said. Too few students pursue the specialty, in part, because it requires additional years of training after medical school, according to mental health experts.

From June 1 to July 1, 2009, NAMI, the nation's largest grassroots mental health organization, conducted the online survey of families who have a child with a mental illness. Participants were polled on their experiences discussing mental health concerns about their child with primary care physicians and staff.

The goal was to inform doctors about what families think would make these interactions more effective. Respondents said they want early identification of mental illnesses, informational handouts on the diagnosed conditions, referrals to specialists and follow-up to ensure that they get needed help.

Katherine Gold, MD, called the survey "a wake-up call" for primary care physicians who do not discuss mental health issues during well-child visits because of unfamiliarity with the subject, among other reasons.

"The things [families] are asking for are very reasonable," said Dr. Gold, an assistant professor in the Dept. of Family Medicine and the Dept. of Obstetrics and Gynecology at the University of Michigan Medical School. "[They want] doctors who listen, reduce the stigma of mental health problems and who ask [if they have] concerns about" their child's mental health.

Recommendations for doctors

Family physician Toby Davis, DO, said the limited time he has for patient visits can be challenging, but he tries never to rush conversations with parents who are concerned about their child's mental health. The Meridian, Idaho, doctor said how he listens to parents' concerns has changed since his 5-year-old son was diagnosed with autism.

"I take all of their concerns seriously, even though they may sound like subtle complaints, like why a child doesn't talk as much as other kids," he said. "I allow parents to talk. I give them support, and I let them know that there is hope. I tell them, 'There are things that you can do.' "

Dr. Davis recommends that physicians ask parents of their young patients a few quick questions about the child's development and behavior. He said the question for parents can be as simple as, "How is their behavior?"

When physicians are concerned that there could be a problem, he recommends referring the patient to a mental health specialist. However, the wait for specialists, particularly in rural communities, can be up to a year. In those instances, Dr. Davis often calls the specialist and asks what he should advise families to do while they wait for appointments.

Dr. Gold said support staff, such as nurses and social workers, can help physicians care for patients with a mental illness by following up with individuals who were referred to specialists. She said scheduling an office visit to discuss a parent's mental health concerns gives doctors more time to address that particular issue.

One source of information for physicians is the American Academy of Pediatrics, which created a Task Force on Mental Health in 2004. The committee developed a tool kit, which includes information on how to screen, diagnose and treat common conditions. These conditions include anxiety, depression, learning difficulties and substance use and abuse.

This survey is like "a group of families telling us a message, and we really need to listen to it," said Chicago pediatrician Myrtis Sullivan, MD, MPH, who is part of the AAP task force. "No matter how well we do, there's always room" for improvement.