PROMOTING HIGH-VALUE MENTAL HEALTH CARE

Barriers to Increasing Access to Brief Pediatric Mental

Health Treatment From Primary Care
Erin Schoenfelder Gonzalez, Ph.D., Nathaniel Jungbluth, Ph.D., Carolyn A. McCarty, Ph.D., Robert Hilt, M.D.

A quality improvement process targeted mental health required more intensive treatment. Acceptability of the
care uptake and system capacity in an underserved program was high for participating families, referrers, and
region. The pediatric program created pathways for rapid clinicians. Brief treatment met most participating families’
referral from primary care and schools to four sessions of needs. The process demonstrated barriers to mental
evidence-based treatments for disruptive behavior and health care access and delivery and the need for inte-
depression with community clinicians. Of 250 referrals, 46 grated and multitiered care delivery.
families enrolled in treatments for disruptive behavior and
21 for depression. Many families did not respond or Psychiatric Services 2022; 73:235–238; doi: 10.1176/appi.ps.202000457

More than 25% of pediatric primary care patients present to project period for working within existing community care
care with a psychosocial problem (1), yet less than one-third systems provided opportunities to understand system bar-
of children referred to mental health treatment by their pri- riers and to test solutions designed to improve care delivery
mary care provider (PCP) complete an outpatient visit (2, and quality.
3). Although most parents report interest in receiving child The state-funded quality improvement process was con-
behavioral treatments through primary care (4), existing ducted in Benton and Franklin counties, located in South
referral and handoff processes to mental health care are Central Washington State, with limited specialized health
insufficient to engage the majority of families. Additionally, services and without integrated services in primary care. Over
evidence-based treatments (EBTs) for pediatric mental 29 months, we sought referrals from primary care (and later
health problems can be lengthy, cost-intensive, and burden- from schools) of children with disruptive behavior problems
some. Common barriers to engagement include lack of and adolescents with depression, all with Medicaid insurance.
trained providers, limited treatment capacity, and logistical We developed brief treatments to enhance system capac-
and transportation problems among patients. Thus, there is ity and family engagement. Two four-session First Approach
a need to improve integration of mental health care with Skills Training (FAST) treatment manuals were adapted
primary care through consultation or team-based processes from full-length EBTs and reviewed by child clinical psy-
and to develop briefer and more targeted EBTs to increase chologists, psychiatrists, and community therapists. Both
treatment uptake, retention, and reach (5). manuals are available for free (https://www.seattlechildrens.
In response to a state initiative to improve access to org/healthcare-professionals/access-services/partnership-
behavioral treatments in remote areas with minimal uptake access-line/pal-plus). The programs were designed for
of and demand for primary care–embedded mental health
services, we conducted a quality improvement process to
provide rapid access to brief behavioral treatment for chil- HIGHLIGHTS
dren and adolescents in an underserved region of Washing-
• A pilot program targeted increased system capacity
ton State. The process created pathways from primary care and rapid referrals from primary care and schools to
clinics and schools to regional mental health clinicians brief pediatric mental health treatment.
trained in brief EBTs. We evaluated the feasibility of imple- • A direct referral pathway was insufficient to overcome
menting the program, acceptability of the model, and pre- barriers to treatment access.
liminary clinical outcomes. We hypothesized that increasing • Embedded mental health care should remain a focus
availability of and access to brief EBTs would increase ser- of efforts to reduce barriers to mental health care.
vice uptake for pediatric primary care patients. The 2-year

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patients with mild-to-moderate acuity without immediate families attended the screening (34% of referred), 46
safety risks or with a different primary treatment need. enrolled, and 26 completed the program. Mean6SD age was
We supported patients with higher acuity and needs 7.362.27, and 77% (N536) were male. Of those who
in accessing other services through the same com- attended the screening, 28% (N513) identified as White, 9%
munity mental health centers where FAST programs (N54) as mixed race, and 30% (N514) as Hispanic; nine
were delivered. participants spoke primarily Spanish. The primary reasons
The FAST-Behavior (FAST-B) program was designed for for declining the program were caregiver’s preference for
children ages 4–12 with a primary disruptive behavior prob- individual child therapy and family scheduling barriers. Sev-
lem, including oppositional behavior, attention-deficit hyper- eral children were screened out during the initial phone call
activity disorder, parent-child relational problems, and/or because of a primary mood disorder, suicidality, high-risk
adjustment problems. Content was adapted from the Defiant aggression, or trauma-related problems and referred to tra-
Children manual (6) and included skills training for one-on- ditional community mental health treatment services. Of
one play time, labeled praise, planned ignoring, incentives, those who attended the screening, 43% (N520) completed
and time-out. Children referred to more intensive commu- all sessions.
nity services included those with autism spectrum disorder, For FAST-D, we received 80 referrals (N545 from PCPs),
primary posttraumatic stress or depression, and open child and 58 families responded to contact. Of these, 38 adoles-
welfare investigations. cents attended screening (48% of referred), 21 initiated
The FAST-Depression (FAST-D) program was developed treatment, and 15 completed the program. Mean age was
for adolescents ages 12–17 with mild-to-moderate depressive 13.661.53, and 55% (N524) were female. Of those who
symptoms. The protocol was adapted from the Behavioral attended the screening, 19% (N57) identified as White, 5%
Activation for Adolescent Depression manual (7) and included (N52) as mixed race, and 10% (N54) as Hispanic; two par-
psychoeducation on depression, sleep hygiene, goal setting, ticipants spoke primarily Spanish. Notably, PCPs referred
and activities planning. Adolescents with primary anxiety fewer patients to FAST-D than to FAST-B and tended to
disorders, posttraumatic stress, substance abuse, eating dis- refer individuals with more severe and complex cases. We
orders, bipolar disorder, ongoing self-injury, or active suici- received nearly an equal number of referrals to FAST-D
dality were referred to higher-intensity care. from schools as from PCPs and in only half the time. A
We remotely trained three mental health clinicians from majority of youths screened for the program showed severe
community mental health agencies to deliver the programs. depressive symptoms, suicidal ideation, or other risk factors
Training was manual based and consisted of 4–6 hours of necessitating more intensive community treatment, which
training, via videoconferencing, with clinical psychologists was facilitated by the clinician. Of those who attended the
specializing in EBTs as well as weekly phone consultation. screening, 71% (N515) completed all sessions.
To improve the referral and handoff process to behav- We administered family acceptability questionnaires
ioral treatment, we created a one-step phone or fax referral adapted from existing surveys (8) privately after the final
pipeline directly to clinicians. We advertised the program to session. Questionnaires were completed by 23 FAST-B
PCPs through a regional medical conference, an e-mail reg- caregivers, 15 FAST-D caregivers, and 13 adolescents who
istry, and recruitment visits to primary care offices. When attended FAST-D. All respondents reported that the pro-
program capacity remained after 14 months, we invited gram was helpful, that they would recommend it, and that
school-based referrals through phone calls and school staff they were satisfied overall. Most caregivers in both tracks
trainings. reported that the program met most or all of their needs.
After being referred to the program, families received up Most FAST-B caregivers (N520 of 23) agreed that there
to three outreach phone calls and one letter from the were enough sessions, whereas nine of 15 FAST-D caregivers
clinician within 2 weeks. Responding families were phone and nine of 13 of adolescents agreed. Most adolescents
screened for eligibility and then invited to attend an (N57 of 13) reported they would have been “not at all like-
in-person screening at the clinician’s clinic. Enrolled families ly” to seek mental health treatment if not offered FAST-D.
were offered four free 1-hour FAST treatment sessions. Study clinicians completed an acceptability rating scale
Clinicians sent “faxbacks” to PCPs describing the referral after seeing several patients and again after the project
outcome and sent treatment summaries if the families had ended. Initial clinician acceptability for FAST-B (N53 clini-
enrolled. Families that were ineligible or declined the pro- cians) was very high for ease of use and comfort with the
grams were connected to other local services. Because FAST manual; high for training, user-friendliness, consultation,
clinicians were located within community mental health and appropriateness of content; and moderate for flexibility
centers, they could provide immediate access to full-length and length of the program. FAST-D acceptability (N52
treatments in that setting and, in many cases, could provide clinicians) was very high for user-friendliness, ease of imple-
the higher-level intervention themselves or offer a direct mentation, training, and consultation and high for flexibility,
handoff to a colleague. appropriateness, and length. After the pilot, FAST-B clini-
For FAST-B, we received 140 referrals (N5104 from cians (N52) rated all acceptability items highly, except for
PCPs), and 84 families responded to contact. Of these, 47 split responses (moderate/high) on fit of the program. The

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 PROMOTING HIGH-VALUE MENTAL HEALTH CARE

FAST-D clinician (N51) rated all aspects as highly health assessment may have prevented milder cases from
acceptable. being identified. Relative to PCPs, school staff appeared bet-
PCPs referring at least two patients received a digital sat- ter able to identify adolescents with depression, highlighting
isfaction questionnaire, and five of the 13 who completed it benefits of including schools in primary care and mental
indicated that the program was easy to refer to, was a valu- health care collaborations.
able additional service, and addressed patients’ needs. Four Our project demonstrated the need for integrated mental
of five reported that communication with the clinician was health care to provide a “warm handoff” in a comfortable
easy. PCPs were split (three agreeing, two disagreeing) on and familiar primary care setting. Routine pediatric mental
whether they could now better meet patients’ mental health health screening measures allow PCPs to identify patients
needs. with mild-to-moderate acuity cases and make immediate
FAST-B parents rated child behavior problems on the treatment recommendations. After the initial project period,
Home Situations Questionnaire (HSQ) at each session. Ado- we transitioned to provide FAST training and weekly
lescents attending FAST-D completed the Patient Health videoconferencing consultation to mental health clinicians
Questionnaire–9 at each session; their caregivers completed integrated within pediatric primary care practices across
the Short Moods and Feelings Questionnaire at baseline and Washington State and incorporated their feedback to
the final session. All caregivers completed select subscales improve FAST usability in collocated service settings. We
of the Weiss Functional Impairment Rating Scale–Parent have observed that referrals and handoffs are more effective
(WFIRS-P) at baseline and the final session. We estimated in this context. By request from PCPs, we also developed a
preliminary effect sizes of clinical outcomes for families FAST pediatric anxiety manual. Additionally, telehealth
who completed at least one treatment session by using delivery during the COVID-19 pandemic has facilitated pro-
paired t tests and the formula for Cohen’s dav (9). For FAST-B, gram access and should remain a delivery format for brief
there was significant improvement on the HSQ (t52.79, treatments. We also learned that intensive community treat-
df545, p50.008; dav50.40) and WFIRS-P (t54.39, df517, ments are often unavailable, and our brief programs likely
p,0.001; dav50.81). FAST-D had a smaller sample and constitute an appropriate first step for families waiting to
small but nonsignificant effect size for adolescent-reported initiate additional care. Referring families with higher acuity
depressive symptoms and functional impairment and a to a separate program creates additional care barriers for
moderate but nonsignificant effect size for parent-reported them. One benefit of offering FAST in community mental
depressive symptoms. health centers was that no additional contact was needed for
We originally hypothesized that creating brief EBTs with most referred families to initiate more intensive treatment.
direct referral pathways from primary care would increase However, integrated mental health care should incorporate
pediatric mental health treatment uptake in an underserved stepped-care models, in which lower and higher acuity serv-
region. However, our service model was insufficient to ices are available with a single entry point or completion of
accomplish this goal and required improvements along the a lower-intensity treatment leads directly to a higher level of
way. Our project succeeded in increasing availability of brief care, when needed.
EBTs; acceptability was high for participating families, most Our project was limited in scope. Only those who com-
of whose needs were met by brief treatment. Program com- pleted the program rated acceptability, and those who initi-
pletion rates were comparable to mental health care gener- ated the treatment reported clinical outcomes; families with
ally and better than therapy in community mental health more hardship and barriers were underrepresented by our
settings (10). However, our approach did not substantially data. A strength of the program was its deployment focus,
increase treatment uptake. Rates of in-person session atten- meaning that our model could be replicated in other com-
dance for referred patients (34% [N547] for those with munities with traditional health care infrastructure. Our
disruptive behavior and 48% [N538] for those with depres- program could be appropriate for remote areas with insuffi-
sion) exceeded the 30% threshold observed in previous cient demand for embedded mental health care because a
studies (2, 3), but most referrals still did not initiate treat- single regional program can serve many clinics. Further-
ment. Our program highlights continued service barriers more, implementing this project in a “real-world” setting
and potential solutions to improve treatment access. The allowed us to observe and respond flexibly to barriers, for
introduction of a novel provider and location outside of the example, by increasing communication with PCPs, adding
familiar primary care environment and a time gap of several school referrals, and partnering with primary
days since leaving clinic likely constituted barriers to access care–embedded clinicians during a second phase. Our find-
and engagement. Over time, not being colocated and inte- ings demonstrate that brief behavioral treatments can
grated within the clinic likely also diminished our program’s expand system capacity and meet the needs of lower-acuity
visibility to PCPs, who are notoriously busy. Inappropriate families, but do not substantially increase service uptake.
referrals received support in accessing alternative services, Rather than replicating our program model, future efforts
but nonenrollment in our program may have discouraged should focus on integration with primary care, where fami-
referrers. The lack of routine behavioral health screenings in lies have greater access to and comfort with treatment and
local practices and PCP bandwidth for in-depth mental care teams can work collaboratively.

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AUTHOR AND ARTICLE INFORMATION 3. Rushton J, Bruckman D, Kelleher K: Primary care referral of
Seattle Childrens Hospital, Seattle (all authors); Department of Psychiatry children with psychosocial problems. Arch Pediatr Adolesc Med
and Behavioral Medicine (Schoenfelder Gonzalez, Hilt) and Department 2002; 156:592–598
of Pediatrics (McCarty), University of Washington School of Medicine, 4. Riley AR, Walker BL, Wilson AC, et al: Parents’ consumer prefer-
Seattle. Marcela Horvitz-Lennon, M.D., Kenneth Minkoff, M.D., and ences for early childhood behavioral intervention in primary
Esperanza Diaz, M.D., are editors of this column. Send correspondence care. J Dev Behav Pediatr 2019; 40:669–678
to Dr. Schoenfelder Gonzalez ([email protected]). 5. Rotheram-Borus MJ, Swendeman D, Chorpita BF: Disruptive
This work was funded by the Washington State Legislature and Wash-
innovations for designing and diffusing evidence-based interven-
ington State Health Care Authority. tions. Am Psychol 2012; 67:463–476
6. Barkley RA: Defiant Children: A Clinician’s Manual for Assess-
The authors report no financial relationships with commercial interests.
ment and Parent Training. New York, Guilford Press, 2013
Received June 18, 2020; revision received March 12, 2021; accepted 7. McCauley E, Schloredt KA, Gudmundsen GR, et al: Behavioral
April 15, 2021; published online June 15, 2021. Activation With Adolescents: A Clinician’s Guide. New York,
Guilford Publications, 2016
REFERENCES 8. Crawley SA, Kendall PC, Benjamin CL, et al: Brief cognitive-
1. Cunningham PJ: Beyond parity: primary care physicians’ per- behavioral therapy for anxious youth: feasibility and initial out-
spectives on access to mental health care: more PCPs have trou- comes. Cognit Behav Pract 2013; 20:123–133
ble obtaining mental health services for their patients than have 9. Lakens D: Calculating and reporting effect sizes to facilitate
problems getting other specialty services. Health Aff 2009; cumulative science: a practical primer for t-tests and ANOVAs.
28(suppl 1):w490–w501 Front Psychol 2013; 4:863
2. Hacker KA, Penfold R, Arsenault L, et al: Screening for behav- 10. Kim H, Munson MR, McKay MM: Engagement in mental health
ioral health issues in children enrolled in Massachusetts Medic- treatment among adolescents and young adults: a systematic
aid. Pediatrics 2014; 133:46–54 review. Child Adolesc Social Work J 2012; 29:241–266

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