PROBLEM
Of youth 9-17 years 20% have a diagnosable mental disorder. About 5% are extremely impaired by mental, behavioral and emotional disorders. Mental and behavioral disorders and serious emotional disturbances in children and adolescents can lead to school failure, alcohol or illicit drug use, violence, or suicide. According to Healthy People 2010, evidence that mental disorders are highly responsive to appropriate treatment promises to eliminate the stigma that create barriers to treatment.
Because access to mental health services for children and adolescents, especially in rural areas, is extremely limited due to the scarcity of child psychiatrists and psychologists as well as poor reimbursement, responsibility for triage, and often, total care falls onto the pediatrician. Yet, training for these problems is generally limited in residency. Therefore, there is an urgent need for ongoing education regarding psychosocial development, pathology, and treatment. Once excellent model that has been developed by the Maternal and Child Health Bureau is the Collaborative Office Rounds (COR) program. The purpose of this program is to use a study group approach to learning that emphasizes the practical challenges confronted by community-based practitioners in addressing mental health problems of pediatric patients and their families.
GOALS & OBJECTIVES
The primary goal of this COR project is to foster joint pediatrics-child psychiatry continuing education in the psychosocial aspects of child health. This will be accomplished by: Enhancing community pediatricians' understanding of psychosocial aspects of child development, disorders, and disability. Expanding power to discriminate between transient disturbances and more serious psychiatric disorders. Strengthening orientation to consult with or refer to mental health professionals. Promoting collaboration between pediatricians and child psychiatrists. Facilitating a more comprehensive approach to health supervision for mental health as outlined in Bright Futures. Enhancing cultural and linguistic competence.
The goal and objectives will be accomplished through a monthly breakfast meeting of a core group of five community pediatricians, three community child psychiatrists, one Developmental-Behavioral Pediatrics Fellow, One Child Psychiatry Fellow, two co-moderators (one pediatrics, one Child Psychiatry). Occasional guest speakers/discussants/observers from community mental health agencies will be invited.
METHODOLOGY
Meetings will be held each first Tuesday of the month, 7-8 AM at the Boar's Head Inn (owned by the University of Virginia Foundation) will buffet breakfast provided. The format will be case-based around a specific theme coinciding with the objectives of the COR. For example, parents of a 14-year-old girl are concerned that she is not eating, cannot get to sleep at nigh, has lost interest in school, and has abandoned her friends. The case presentation by a pediatrician participant is followed by a short didactic lecture (by a child psychiatry participant or guest) or literature review on the topic. Discussion centers on whether this represents a transient mental health disturbance or a serious underlying psychiatric disorder. Two of the meetings during the year will be held in the evening to coincide with the monthly continuing medical education of the pediatricians in Harrisonburg, located in the Shenandoah Valley. The main meeting will take place in Charlottesville but will be transmitted to Rockingham Memorial Hospital by the University of Virginia Telemedicine Office. These sessions will fulfill an outreach opportunity to practicing pediatricians in a rural area who otherwise do not have access to the University's academic resources.
FORMAT: The format will be case-oriented accompanied by a concise didactic presentation of the issue to be discussed including definitions (DSM and DSM-PC), typical clinical presentation, pathophysiology, course, and treatment options. The process will be sensitive to differences in levels of training, experience, and specialities present. Cases will be presented by all participants including pediatricians, psychiatrists, trainees, and from time to time special guests (e.g. community mental health or social agency staff). Both the case presenter and discussant will be identified in schedules prepared 6 months in advance. Selected articles on the topic will be distributed before each meeting.
The Boar's Head Inn is a facility operated by the University of Virginia, conveniently located to all participants. The time best suited to busy practitioners in this community is early morning. Thus, the meetings will be held monthly from 7-8 AM with breakfast served from 6:45 AM. To accommodate rural health participants in Harrisonburg, Virginia, two meetings will be held in the evening from 6:30 to 7:30 PM at the Kluge Children's Rehabilitation Center in Charlottesville, very near the Boar's Head Inn. Telemedicine facilities are available at this center. Dinner will be served.
COORDINATION
The KCRC services (and are training program) are closely coordinated with the Title V and othe federal poverty programs (CSHCN, WIC, Medicaid), state agencies (health, substance abuse, education), and community services (public and private schools, United Way, social services). Mr. Frank Heron in the Philadelphia regional MCH office and Ms. Nancy Bullock of the Virginia Health Department were consulted regarding this proposal. The University of Virginia is one of six sites of Virginia Care Connection for Developmental-Behavioral Pediatrics. Our program works closely with Virginia's only LEND program at Virginia Commonwealth University, which serves Richmond and central Virginia.
EVALUATION
The University of Virginia furnishes an evaluation form that will be used at each meeting in conjunction with CME credit. In order to assess whether COR participants apply new knowledge in the context of their practices and draw upon professional contacts developed through core, a separate evaluation form that assesses specific COR objectives will be distributed to the members annually. The COR Moderators will attend the annual meeting to compare format and evaluations with other COR programs for ideas to improve the process. Annually, the Advisory Committee will meet to discuss the COR Program, its accomplishments and shortcoming, and suggestions for changes, if needed, for the following year. To facilitate reporting requirements, the MCH-proposed training administrative data set presented in Appendix G of the Grant Application guidance will be used to collect data prospectively.
ANNOTATION
The Collaborative Office Rounds (COR) at the University of Virginia will bring community pediatricians and child psychiatrists together for monthly case discussions regarding children and adolescents with behavioral, emotional, and somatoform disorders. Each case presentation will be followed by a short didactic sessions or literature review on the topic. Then, the pediatricians and psychiatrists will discuss management with focus on what the pediatrician can and should do and when patients should be referred to mental health specialists. Dimensions of cultural influences, poverty, and psychopharmacology will be emphasized. Because mental health resources are particularly scarce in rural areas, pediatricians from the Shenandoah Valley will participate either directly or via telemedicine.
KEYWORDS
Behavioral Pediatrics, mental health, collaborative office rounds, behavioral disorders, pediatricians, rural population
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