PROBLEM
Pediatricians, in collaboration with families and schools, are critical providers of guidance and intervention for children across the spectrum of development. Prevention efforts, early recognition, and effective referral for children with significant psychopathology can be a challenge for busy practitioners in a complicated and fragmented de facto mental health system. Recent tragic events have brought mental health issues greater public attention; yet available mental health services do not meet the needs of the population (Swick et al, 2002). According to the Surgeon General's Report on Mental Health (1999), about 21 percent of the child and adolescent population have a diagnosable mental health disorder, although only nine percent receive care from the health care sector, particularly the specialty mental health sector. The Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services (VDMHMRSAS) estimates that as many as 100,000 children and adolescents in the Commonwealth (9 to 11% of th population) have a serious mental health disturbance. Minority populations are especially underserved in Central Virginia with multiple challenges to seeking mental health services. Mental health providers often have long waiting periods and are unable to see patients with the frequency needed (Kataoka et al, 2002).
GOALS & OBJECTIVES
The overall goals of the Central Virginia Continuing Education and Collaborative Office Rounds (CECOR) are to enhance the understanding of psychosocial aspects of child development and to develop collaborative models of identification, care, triage and referral for a spectrum of psychological and psychiatric conditions in the context of resources available in Virginia. Objectives to address these goals include: 1. Recruit and develop a collaborative learning team of pediatricians and child psychiatrists. 2. Enhance pediatricians' skills in supporting healthy family behaviors and promoting mental health. 3. Enhance pediatricians' understanding of psychosocial aspects of child development, psychiatric disorders, and disability and increase their ability to help children and families deal with these issues. 4. Enhance the capacity of participants to manage common mental health conditions and distinguish between those that require a referral and those that do not. 5. Heighten awareness of the range of participants' competencies and strengthen orientation to consult with or refer to other professionals as appropriate. 6. Enhance participants' cultural and linguistic competence.
METHODOLOGY
Experienced clinician teachers in the Departments of Psychiatry (Drs. O'Keefe and Al-Mateen) and Pediatrics (Drs. Ragazzi and Bodurtha) will co-moderate the sessions, which will consist of 90 minute case conferences, held monthly over breakfast. The agenda will include presentation of a case, delineation of the problems identified and learning needs of the participants, as well as a didactic presentation by one of the child psychiatrist faculty on the particular disorder emphasized, and relevant aspects of evaluation and treatment. Following the presentation, the group will discuss similar cases they have encountered, difficulties experienced in managing the patients, support they would need from a psychiatrist or other resources, and the degree to which they would feel comfortable managing similar cases. We will encourage all participants to present their own cases, however the moderators will ensure that a full spectrum of developmental levels and clinical conditions are discussed, using our own case experiences as necessary. Throughout the series, we will consider the contributions of race, gender and ethnicity as they affect case management. Later sessions will include discussion of specific minority groups present in the population of our area, including African-American, Native American, Hispanic, Asian, and sexual-minority youth. The overall direction of the series will be organized along the continuum of development from infancy through adolescence, with the inclusion of both mild and severe deviations from normal development. In addition, several sessions will focus on social factors that place children and youth at higher risk for psychiatric disorders, such as poverty, exposure to violence in the home and community, and parenting problems including parental mental illness and substance abuse.
The "Bright Futures" Mental Health Practice Guide will be our primary reference book, although it will be supplemented with more detailed information about local resources. Costs for the program will include providing this book and its accompanying "Mental Health Toolkit" to each pediatrician, modest breakfasts for 12-15 participants per month, and the CME credits each participant will earn.
COORDINATION
Drs. O'Keefe and Ragazzi will coordinate the program and provide study group faculty oversight. They have been meeting twice weekly in the preparation of this grant, and plan monthly coordination meetings if the grant is awarded. The VA-LEND program, under Dr. Bodurtha's leadership will provide administrative (fiscal and secretarial) coordination for the grants as it has eight years of experience in providing coordination of interdisciplinary training in family-centered, community-based settings under the auspices of Virginia Commonweath University's Patnership for Persons with Disabilities, a University Center of Excellence for persons with disabilities.
Urban child psychiatrists from the Richmond Behavioral Health Authority and Henrico Area Mental Health and Mental Retardation Services, child advocates from the Action Alliance for Virginia's Children and Youth and the Title V agency have all written letters of collaboration to assist in data-sharing, resource information and additional educational planning. One of our primary moderators (Dr. Ragazzi) is the medical director of Care Connection for Children, a regional program for CSHCN, and will assure that Title V connections are enhanced. Dr. Bodurtha directs the LEND program, which has strong Title V connections; she is a member of the Office of Family Health Services State Advisory Board at VDH< which reviews public health prevention programs.
EVALUATION
The primary method of evaluation of the program will be via comparison of pre and post-participation surveys of our participants regarding relevant aspects of their practices, such as the percentage of their patients with psychiatric disorders, the number referred for mental health services, time spent on psychosocial issues, comfort-level with psychosocial and cross-cultural issues, the use of mental health related screening instruments, and familiarity with mental health resources in the community. In addition we will use some objective measures, such as patient satisfaction surveys (voluntary-feedback from these will be shared with the group without identification of practice or provider); proportion of website discussion focused on psychosocial issues (as opposed to medication management); and feedback from both pediatrician and child psychiatry participants about consultations in which they collaborate, and the collaborative office rounds themselves.
ANNOTATION
The purpose of the project is to foster joint pediatrics-child psychiatry continuing education in the psychosocial-developmental aspects of child health. In communities with limited mental health specialty services, it is necessary that pediatricians become more skilled in identification, care, triage and referral of psychiatric conditions. We will utilize a study group approach that emphasizes the practical challenges confronted by community-based practitioners; working towards a goal of enhancing their understanding of psychosocial aspects of child development, and increasing their ability to manage common mental health conditions and make appropriate referrals for specialty mental health services. Evaluation of the program will be via comparision of pre and post-participation surveys of our participants regarding aspects of their practices such as the percentage of their patients with psychiatric disorders, the number referred for mental health services, comfort-level with psychosocial issues, the use of mental health related screening instruments, and familiarity with mental health resources in the community.
KEYWORDS
collaborative office rounds, health supervision, mental health, pediatricians, psychosocial factors, training, urban populations
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