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Primary Care Referral of Children With Psychosocial Problems
Jerry Rushton, MD, MPH;
David Bruckman, MS;
Kelly Kelleher, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:592-598.
ABSTRACT
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Objectives To examine primary care provider referral patterns for patients with
psychosocial problems and to understand the factors that influence whether
a mental health referral is made.
Design Secondary analysis of the Child Behavior Study data collected during
1994-1997 from background survey of providers, visit survey of providers and
parents, and follow-up survey of parents.
Setting Two hundred six primary care offices in the United States, Canada, and
Puerto Rico.
Patients Four thousand twelve of 21 150 patients aged 4 to 15 years in the
Child Behavior Study with a clinician-identified psychosocial problem.
Main Outcome Measures Referral for psychosocial problem at index visit and reported follow-up
with mental health care provider within 6 months.
Results Six hundred fifty (16%) of 4012 patients with psychosocial problems
were referred at the initial visit. In multivariate analysis, significant
factors associated with likelihood of referral included patient factors (severity,
type of problem, academic difficulties, prior mental health service use) and
family factors (mental health referral of parent); however, none of the provider
factors were significant. Clinicians reported frequent barriers to referral
and mental health services in the general background survey; however, these
factors were rarely reported as influences on individual management decisions.
Only 61% of referred families reported that their child saw a mental health
care provider in the 6-month period after the initial primary care referral.
Conclusions Most psychosocial problems are initially managed in primary care without
referral. However, referral is an important component of care for patients
with severe problems, and many families are not effectively engaged in mental
health services, even after a referral is made.
INTRODUCTION
PATIENTS WITH psychosocial problems (PSPs) make up a notable portion
of pediatric patients in primary care—more than 25% of pediatric patients
have a mental or behavioral problem.1 Pediatric
mental health disorders range from self-limited or mild problems to severe,
debilitating illnesses, such as depression and psychosis, that account for
significant morbidity, mortality, and health care expenditure.2
Most children and adolescents in the medical system are treated within primary
care3-4; however, some PSPs require
referral to mental health specialists for further evaluation, counseling,
or additional treatment.5-6 Very
little is known about the process of pediatric primary care providers' management
decisions and triage of patients for mental health referral.
The role of family physicians, pediatricians, and other primary care
providers has continued to evolve with managed care and changes in health
care organization. Gatekeeping and the judicious referral of patients to appropriate
services are key components of primary care.7-8
Previous work has shown that clinician referrals and mental health service
use may be influenced by patient age, sex, race, diagnosis, family history,
parental requests, insurance type, clinician sex, and other factors.9-13
Forrest et al9-10,14
have described general issues related to primary care–specialist interactions;
however, mental health referrals have not been a main focus of these studies.
Referral and management decisions are often more complex for PSPs.15 Attention-deficit/hyperactivity disorder, depression,
and other mental health problems require comprehensive assessment and treatment
strategies involving families, schools, and clinicians, in addition to youth.
Stigma, lack of access to specialists, and poor reimbursement for behavioral
services further impede referrals and engagement of families into effective
services.16-17 Studies have described
factors that influence the diagnosis and treatment of PSPs,3, 18-27
yet the referral process has generally been overlooked. Prior studies of referral
for mental health disorders have been unable to examine clinician and system
factors because of limited sample sizes and lack of geographic practice diversity.
Given the additional complexities of mental health referrals, we believe that
clinician and health system factors could have important potential effects
on management decisions.
Our study was designed to build on previous work of the Child Behavior
Study (CBS) and to focus specifically on the referral process. Our goals were
(1) to describe perceived barriers in the referral process, (2) to understand
how patients with PSPs are triaged in primary care, (3) to examine factors
influencing the decision to refer a patient, and (4) to identify challenges
to completion of referrals and mental health care delivery. Understanding
these issues is key to planning and implementing initiatives to improve quality
of care and outcomes for children and adolescents.
PARTICIPANTS AND METHODS
STUDY POPULATION
We performed a secondary analysis of the CBS. The CBS was an office-based
survey conducted from October 1994 to June 1997 through the Ambulatory Sentinel
Practice Network, Pediatric Research in Office Settings (PROS) network, and
2 smaller Midwest practice networks. The CBS survey items were developed by
3 focus groups of PROS providers and pilot tested on more than 1000 patients.
The study was approved by the University of Pittsburgh (Pittsburgh, Pa) institutional
review board. Previous studies have described additional details of the survey
items, patient population, and practice networks involved.19, 25, 27-29
The survey involved 401 clinicians from 206 practices in the United
States, Canada, and Puerto Rico, who recruited patients aged 4 to 15 years
to participate in the study. Data were collected from the 3 surveys: (1) a
background survey of clinician practice characteristics, perceived barriers,
and beliefs regarding mental health care using a structured questionnaire;
(2) a visit survey completed at the initial visit by both parents (or caregivers)
and clinicians; and (3) a follow-up survey of parents conducted 6 months after
the initial visit survey.
The CBS produced a sample of 22 059 children seen in office visits.
Among those visits, 909 (4%) had inadequate or missing data that precluded
further analyses, resulting in a study sample of 21 150. Clinicians identified
a PSP in 4012 (19%) of 21 150 children at the index visit. Our analysis
focused on the 4012 PSP patients with a clinician-identified PSP at the index
visit.
We also reviewed data from the follow-up study, which was conducted
6 months after the index visit. Families were selected for the follow-up survey
based on their insurance status. African American children were oversampled
to include more managed care patients and children, who have been known to
be underrepresented in the PROS network. Of note, the method of selection
of follow-up subjects changed during data collection; thus, statistical analyses
were limited to general descriptive statistics. A total of 1970 patients and
families were included in the follow-up study; 1354 (69%) were successfully
followed up.
OUTCOMES AND VARIABLES
We examined different outcomes for each of the 3 surveys. For the background
clinician survey, we analyzed yes/no and Likert responses to questions regarding
general practice barriers to PSP referrals. Multiple items queried provider
time pressures, perceived effectiveness of medications and treatment, clinician
satisfaction, belief in the biomedical model, and related topics. The main
outcome variable for the visit survey was referral for a PSP vs no referral.
This dichotomous outcome was obtained from the clinicians' yes or no responses
to the following item "Did you refer this patient for mental health treatment
today?" Follow-up questions using multiple-choice answers and write-in options
asked clinicians to list reasons for referral or reasons why they did not
believe that a referral was indicated at that time. Finally, we analyzed the
follow-up survey outcome of parent-reported mental health care provider visits
in the 6 months after initial referral to determine the rate of use of mental
health services.
Independent variables linked to all 3 surveys included parent-clinician
visit survey responses on patient factors (age, sex, race, school performance);
family factors (family structure, family dysfunction, and family mental health
referral); PSP type and related factors (clinician diagnosis, comorbidity,
and Pediatric Symptom Checklist items); clinician factors (age, sex, specialty,
practice type and setting, and attitudes toward PSP treatment); and health
system factors (patient insurance type, access to mental health care providers,
and wait time for referral appointment).
The family APGAR score is a 5-item scale that measures family cohesion,
support, and functioning.30 The Pediatric Symptom
Checklist is a 35-item instrument that has been validated and reported in
other CBS publications.31-32 and
includes subscales to identify patients with internalizing features, externalizing
features, and attention issues.31 The Physician
Belief Scale is a measure of clinicians' reported burdens and beliefs regarding
psychosocial issues using 32 items from the survey.22-23
ANALYSIS
All analyses were conducted using SAS version 6.12 (SAS Corporation,
Cary, NC). Univariate statistics described patients, clinicians, and descriptive
information on general treatment by diagnosis. Bivariate comparisons used
the Pearson  2 and the Fisher exact 2 tests
(2-tailed) to determine associations between referral and patient, family,
clinician, and health system factors. Significance was set at P<.05, unless noted to correct for multiple comparisons.
Data on clinician beliefs and practice characteristics were merged with
patient data using a clinician identifier. Since each participating CBS clinician
often saw more than one study patient, common data elements were correlated
across patients seen by a common provider. To adjust for these correlated
measurements, a hierarchical model using clusters of patients seen by a given
clinician was analyzed using a generalized linear mixed model (SAS GLIMMIX
macro).33-37
This method was used to determine associations among clinician-level variables,
where the degrees of freedom reflected the adjusted number of clinician clusters.38 The same method was used in multivariate modeling
of patient and clinician factors associated with the odds of referral of a
patient with a PSP.39 Variable selection used
univariate associations suggestive of referral (P<.20).
A variable reflecting early patient enrollment was included to test the Hawthorne
effect. Iterative logistic regression models, with referral as the response,
were run on patient-level variables to generate a condensed list of independent
variables suggestive of referral (P<.10). Patient
variables were placed in a general linear mixed model with clinician variables
(at the clinician and patient level), and model selection proceeded until
a parsimonious group of variables was generated. Goodness-of-fit measures
confirmed appropriate model and covariance selection.
RESULTS
Table 1 presents the sample
of 4012 patients with PSPs. Four hundred one physicians participated in the
study, and 385 different clinicians cared for the 4012 patients with PSPs.
Characteristics of these clinicians are presented in Table 2.
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Table 1. Demographics of a Pediatric Patient Population of 4012 With
Psychosocial Problems*
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Table 2. Demographics of Clinician Population Managing 385 Pediatric
Patients With Psychosocial Problems*
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BACKGROUND SURVEY RESULTS
Data from the initial clinician survey were obtained prior to patient
enrollment to describe general barriers to referrals in their practice. In
general, access to mental health specialists was a major barrier reported
by clinicians. On a Likert scale asking the availability of child mental health
services in the community, only 12.7% of clinicians reported that services
were "very accessible," 1.7% reported that services were "not available,"
and most were evenly distributed between these extremes. When asked about
general restrictions by managed care, 52.8% reported "sometimes" or "very
often" having restrictions on referral to child psychiatrists and 56.0% were
sometimes or very often restricted in their referrals to psychologists.
For managed care patients, many clinicians reported several general
barriers to psychosocial referrals, including difficulty obtaining an appointment
(65.6%), lack of pediatric specialists (61.1%), limited acceptance of Medicaid
(60.7%), provider panel restrictions (58.6%), complex appeals processes (54.3%),
and complex authorization (44.7%). Clinicians reported these barriers more
commonly for managed care patients in comparison with responses on the same
items regarding fee-for-service patients.
VISIT SURVEY DATA
Referral and Management of Patients With PSPs
Next, we described the actual management and referrals from the visit
survey data. The most common management strategy for a patient with a PSP
(n = 4012) at the initial visit was watchful waiting/no treatment (38.4%)
followed by primary care counseling alone (33.4%), primary care counseling
with medication prescription (18.0%), or prescribing medication alone (10.2%).
Six hundred fifty (16.2%) of all PSP patients were referred at the index visit.
Of the 650 patients who received a referral, most (72.8%) received primary
care counseling as well. Nearly one quarter (24.2%) received referral with
medication and primary care counseling. Almost 20% (19.1%) of the 650 referred
patients received referral alone. Additional details of counseling and medication
treatment in the CBS have been described by Gardner et al.25
Table 3 presents the frequency
of PSP by number of patients. The most commonly reported types of PSP were
attention-deficit/hyperactivity and behavioral/conduct problems. Substance
abuse, mental retardation, and psychotic episodes were rarely reported problem
types.
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Table 3. Referral Rates by Problem Type for All Pediatric Patients
With Previously Diagnosed and New Psychosocial Problems (PSPs)
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Table 3 also presents referral
rates by PSP type. Psychotic episodes, substance abuse, emotional problems,
and adjustment reaction were somewhat more likely to generate a referral than
other types of PSP. Children with attention problems, developmental delays,
and mental retardation were somewhat less likely to be referred. Some patients
had 2 or more identified PSPs, resulting in column totals exceeding the total
number of patients.
When only patients with a newly diagnosed PSP were considered (n = 1299),
the overall referral rate was 27.4%. The right-hand column in Table 3 presents referral rates by PSP type for patients with new
PSPs. Although referral rates were generally higher for new PSPs, trends among
the PSP types remained, with attention-deficit and somatic complaints less
likely to generate a referral at the initial visit.
Referral Providers
Of the 650 children who were referred at the initial visit, the most
common mental health care providers patients were referred to included child
psychologists (28%), psychologists (22%), counselors/therapists (20%), social
workers (12%), school services (12%), and child psychiatrists (11%). Primary
care providers referred patients to developmental/behavioral pediatricians
(4%) and general psychiatrists (2%) less frequently. Almost one quarter of
the 250 clinicians reported that psychologists or counselors were present
in their offices or practices at least 1 day per week. Five percent of providers
reported that their practice group or office included a psychiatrist or child
psychiatrist.
Most referrals were arranged by the patient/family (57%). The primary
care office sometimes arranged appointments (23%) but the primary care provider
rarely had direct contact with the mental health specialist (12%). The clinician's
estimate of wait time for a referral appointment was 2 weeks (median, 14 days),
with 10% of patients expected to wait more than 30 days.
Reasons for Referral
When clinicians were asked why they referred a patient to a specific
mental health care provider in the visit survey, the most commonly cited reasons
were the specialist's expertise (39%), availability (16%), and insurer requirement
(12%). Proximity (4%), having only one specialist available (1%), and cost
(1%) were less commonly cited reasons for the referral.
The most common clinician-reported reasons for nonreferral included
the ability of the clinician to manage the patient in his or her primary practice
(46%), the patient was already receiving services (35%), or the problem was
self-limiting (15%). In 3% of the cases, the patient/parent refused, citing
a lack of need. Several other barriers were rarely given as reasons for a
referral not being made for a specific patient encounter—less than 2%
reported lack of insurance, lack of effectiveness, financial disincentives
to the referring clinician, lack of availability, past reimbursement denials,
or paperwork. These data specific to patient encounter were in marked contrast
to the data from the general clinician survey.
Factors Influencing Referral
We used generalized linear mixed modeling to further analyze factors
associated with clinician referral of a patient for a PSP (n = 4012) while
considering covariates and clinician-clustering effects. Table 4 presents the significant model variables, coefficients,
SEs, significance levels, and odds ratios (ORs) of a mental health referral
at the index visit. The factors associated with referral dealt with the patient's
problems—new or severe PSP, high Pediatric Symptom Checklist score,
low/dropping grades, prior use of mental health services, and specific PSP
types. Attention-deficit/hyperactivity disorder and mental retardation were
significantly less likely to be referred at the index visit (OR, <1.0).
Other factors related to the visit—referral of a family member, psychological
reason for the visit (vs well-child care or acute medical problem), and visit
duration were also significantly associated with referrals in our analysis.
Family factors of significance included low maternal education and family
dysfunction (family APGAR score). The clinician-specific, insurance, and health
system factors were not significant in any multivariate modeling.
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Table 4. Factors Significantly Associated With Referral of Children
With Psychosocial Problems (PSPs)*
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Some pairs of independent variables were interrelated to referral, such
that interactions with modification of ORs occurred. In general, these effects
were small and thus interaction terms were not included in the final model.
However, one significant interaction occurred between family dysfunction (indicated
by a low family APGAR score  5) and 3 variables: comorbidity, minority
status, and attention-deficit/hyperactivity disorder. This interaction term
had an important effect such that patients with a normal family APGAR score
who were identified with attention problems had nearly half (OR, 0.55) the
odds of obtaining a referral. Yet when the family APGAR score indicated family
dysfunction along with attention problems, the odds of referral was increased
(OR, 1.76).
FOLLOW-UP DATA
Finally, we examined utilization data obtained from parents at 6 months.
One hundred sixty-four (25%) of 650 patients who were initially referred were
included in the 6-month follow-up survey. At 6 months, 61.0% of the referred
patients had been treated or evaluated by a mental health care professional
(psychiatrist, psychologist, therapist, social worker, or mental health counselor).
Less than a third of the referred patients (30.5%) saw a mental health care
provider more than once in the follow-up period. Use of medical services in
the 6 months after referral was common, with 133 (81.1%) of 164 returning
to their primary care provider and 41 (25.0%) of 164 receiving care in an
emergency department. Of the patients who were seen by a mental health specialist
in the 6 months following referral, 43.0% of parents (43/100) reported mental
health visit(s) in a school setting, 84.0% in a clinic or private office,
and 13.0% in overnight hospitalization.
Less than half of patients with a new diagnosis of PSP (44.9%) saw a
mental health care provider during the 6-month follow-up period. Factors that
showed a trend toward greater likelihood of follow-up with a mental health
care provider within 6 months of referral included patients with low/dropping
grades, patients who had previously received mental health services, and patients
from nonrural areas. Patients with referral appointments arranged by their
parents or providers instead of office staff tended to have better follow-up
results. Patients referred to child psychiatrists tended to have better follow-up
compliance, and patients with a referral to social workers had lower rates
of completion of a mental health visit. Patients who expected to wait 3 weeks
or longer for an appointment were less likely to see a mental health specialist
during the follow-up period. Many other patient, family, clinician, and insurance
factors did not seem to affect rates of follow-up, although statistical power
and interpretation were limited by sampling strategy and sample size.
COMMENT
The referral process is a complex but important part of primary care
and the mental health care system. Most children with PSPs are initially treated
in primary care and not referred. Even in a subsample of patients with a newly
identified PSP, most patients (76%) are not initially referred. Referral rates
vary somewhat by type of PSP but only the few patients with psychotic episodes
are referred most of the time. Many primary care providers report that problems
can be managed in primary care or are self-limited. In particular, attention
problems and somatic complaints are less likely to be referred. These findings
illustrate the broad scope of primary care in providing services to children
with PSPs. Our study demonstrates the important role of primary care in the
management of children in addition to recognition and assessment.
Our study found that most patients with PSPs are referred to psychologists
or counselors instead of psychiatrists. Most of these providers are selected
based on expertise and availability; cost and payer requirements are less
commonly cited factors. The decision to refer a patient with a PSP to a specialist
or to manage the patient within primary care seems to be influenced by several
factors primarily related to patient, family, and problem characteristics.
Despite concerns that clinicians' management decisions are potentially influenced
by insurance, financial pressures, or other beliefs about mental health, our
results demonstrate that most clinician and health system factors are not
significantly associated with referral practices for specific patients.
However, responses from the background clinician survey on general practice
and beliefs are different compared with the results from the actual patient
visit data. Clinicians commonly report access limitations for many managed
care and Medicaid patients in the background survey but rarely cite these
barriers when making specific patient management decisions. This may represent
differences in approaches to individual patients or possibly methodological
effects of the background survey items that are more readily endorsed. It
seems that clinicians are more reluctant to change their practices or to report
influence by insurance and other factors when individual patients are discussed.
Another possibility is that providers and primary care practice groups may
have limited remaining options available for the management and referral of
children with PSPs due to previous effects of health care organizations and
insurance companies. Challenges to mental health care delivery may be taking
place on a broader scale that is not reflected in decisions regarding individual
patients.
These results suggest that the factors most clinically relevant and
patient-centered are given the greatest weight in management decisions. However,
before we can conclude that the current rate of referral for PSPs is reasonable
or appropriate, we need to examine long-term outcomes and view primary providers
in a system of care. An important but overlooked issue in mental health service
is referral follow-up and completion. Effective engagement in treatment is
necessary for many children with more serious mental conditions; yet, as our
study shows, referral from primary care is not the end of the process. Many
families do not access the recommended mental health services within 6 months,
especially for children with a newly identified PSP. The follow-up rate with
a mental health referral appointment of 61% was similar to other studies of
mental health services and general referral follow-up rates.40-41
Other barriers of access, scheduling, and wait time may also affect the completion
of a referral. We need to study referrals as part of a long-term process and
not as an end point. Adherence and noncompliance are serious issues that clinicians
must address and discuss with families, just like any medication or treatment
recommendation.
Data from a separate PROS network study demonstrated that for all types
of referrals, greater pediatrician communication with specialists resulted
in higher rates of referral completion, provider communication, and provider
satisfaction.10 We must build on these results
to design and implement effective interventions to engage families in the
long-term treatment and follow-up often required for PSPs. This may include
a public health approach to reduce stigmatization of mental health disorders,
changes in health systems to enhance tracking of referrals and primary care–specialty
interactions, and individual clinician efforts. Although a great deal of attention
has been focused on primary care recognition of PSPs, these providers also
have an important role in motivating patients with identified problems to
seek appropriate mental health services.
The CBS study design has some limitations that have been previously
reported—reliance on parent and clinician reports to describe potential
influences on referral, use of general PSP categories instead of strict diagnostic
codes identified by criteria, and underrepresentation of minority patient
and clinician groups in the Ambulatory Sentinel Practice Network and PROS
practices.27, 42 It is notable
that many clinicians reported good access to mental health care providers
and one quarter had a counselor or other mental health care provider affiliated
with their practice at least 1 day per week. Thus, our sample may underestimate
the challenges that many clinicians face in accessing mental health care for
their patients.
Some limitations specific to our study include the outcomes of referral
and follow-up visits within 6 months. First, the referral data reflect care
delivery at the initial visit and may not have accounted for ongoing management
decisions, treatment, or referral by clinicians after the initial visit. Also,
the follow-up outcomes are based on parent recall and may not accurately reflect
use of mental health services for the specific PSP identified by the primary
care provider. Finally, respondents described completion of referral visits
but items did not address the content of services or patient adherence to
mental health care provider recommendations. Noncompliance with counseling,
medications, or follow-up appointments is yet another challenge and can diminish
effective receipt of services and affect long-term outcomes.
Primary care providers play a major role in the mental health system—many
clinicians provide counseling and treatment within the primary care system.
In addition, these providers serve as gatekeepers to determine access to specialty
mental health care and can function as coordinators of mental health services
and referrals. Although most patient encounters do not seem to be significantly
influenced by patient demographics, clinician factors, or health care system
barriers, the poor rate of follow-through with referrals demands attention.
Future research must address the referral process as a key component in the
long-term care of PSPs, which often requires the integration of multiple services
through multiple providers. We must continue to work with families and serve
their interests and needs but not leave the entire burden of traversing the
complex mental health system to parents. Primary care providers and the health
care system must assist families facing complex, chronic, and recurrent psychosocial
conditions in children to improve the processes of care and ultimately—patient
outcomes.
| What This Study Adds
This study adds to the understanding of the important interface between
primary care providers and mental health specialists and the referral process.
The decision to refer patients can be affected by many different factors,
such as patient, family, provider, and health care system factors. Our study
confirms that most patients with PSPs are initially managed in primary care
without referral, yet the decision to refer individual patients does not seem
to be influenced by provider characteristics, managed care, or health system
pressures. Thus, we make an important distinction between general barriers
to mental health care delivery and specific influences on individuals. Also,
we highlight the relatively poor rate of follow-through with mental health
services after a referral is made. This is an important link in the complex
pathway to effective mental health service delivery.
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AUTHOR INFORMATION
Accepted for publication February 21, 2002.
This study was supported by grant MH50629 from the National Institute
of Mental Health, Bethesda, Md (Dr Kelleher, Principal Investigator), grant
MCJ-177022 from the Health Resources and Services Administration Maternal
and Child Health Bureau, Rockville, Md, and the Staunton Farm Foundation of
Pittsburgh, Pa.
Presented in part at the Society for Pediatric Research Annual Meeting,
Baltimore, Md, April 29, 2001.
We acknowledge the contributions of PROS Network of the American Academy
of Pediatrics, Elk Grove Village, Ill; the Ambulatory Sentinel Practice Network,
Denver, Colo; the Wisconsin Research Network, Madison and the Minnesota Academy
of Family Physicians Research Network, St Paul. In addition, we are indebted
to Diane Comer for her support in the data preparation and review.
Corresponding author and reprints: Jerry Rushton, MD, MPH, Division
of General Pediatrics, University of Michigan, 300 N Ingalls Bldg, Room 6D05,
Ann Arbor, MI 48109-0456 (e-mail: jrushton{at}umich.edu).
From the Child Health Evaluation and Research Unit, Division of General
Pediatrics, University of Michigan, Ann Arbor (Dr Rushton and Mr Bruckman);
and the University of Pittsburgh School of Medicine and Children's Hospital
of Pittsburgh, Pittsburgh, Pa (Dr Kelleher).
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