Addressing Clinical Complexity and Ambiguity in Pediatric Collaborative Care

At first glance, Jason’s case seemed perfectly straightforward. At the age of 8, he presented with hyperactivity and inattention to his pediatrician, who initiated a trial of psychostimulant medication. After early improvement, his symptoms gradually recurred. At that point, the pediatrician asked the integrated behavioral health clinician on the primary care team to get involved. A more detailed evaluation uncovered substantial clinical complexity including emotional dysregulation, executive functioning deficits, learning disabilities, parental homelessness, exposure to domestic violence, intergenerational trauma, parental mental health issues, and clinical features suggesting the possibility of a genetic syndrome. Prior to this presentation in primary care, he had been seen briefly in a specialty mental health clinic but was terminated from treatment due to inconsistent attendance.

The collaborative care model (CoCM), initially utilized for the treatment of depression in the IMPACT study, is widely viewed as a leading model for integrated care in primary care settings, with over 80 randomized, controlled trials demonstrating superior clinical effectiveness and improved access to care in relation to “treatment as usual.” Yet it has been slow to be applied to the pediatric setting. Child psychiatrists have been hesitant to adopt the collaborative care model, often out of concern that the diagnostic complexity and ambiguity of children would be paved over and that children would be channeled into simplistic treatment plans.

In a CoCM implementation for pediatric primary care at Baystate Health in Springfield, Mass., an embedded master’s-level therapist, off-site child and adolescent psychiatrist, and primary care provider worked together as a team to construct a comprehensive formulation of Jason’s mental health needs. An initial treatment plan included the initiation of trauma-focused therapy for the child and parent, clinical genetics consultation, helping the parent advocate for special education assessment, coordination of mental health services for the parent, and the monitoring of disruptive behavior symptoms with the Vanderbilt Rating Scale. Psychostimulant treatment was discontinued and further medication trials were deferred pending response to psychosocial interventions. The formulation and plan will be adjusted in an iterative process as additional assessments are completed, special educational plans made, and psychosocial interventions coordinated.

In children’s mental health, regardless of setting, clinicians must understand the developmental context of symptoms, acknowledge the dependency of children on parents and caregiving systems, and work to clarify ambiguous and comorbid diagnostic presentations on a regular basis. In pediatric applications of CoCM, the therapist/care manager must do the following:

The role of the consulting child psychiatrist, analogous to adult collaborative care models, includes assisting the pediatrician and therapist in clarifying the diagnostic formulation, recommending as needed adjustments in the overall treatment plan, and providing consultation and education to the pediatrician regarding psychopharmacological treatments.

Jason’s case is by no means uncommon in the primary care setting. Although his case is multidimensional and his diagnosis is uncertain, his care will conform to the defining characteristics of CoCM in that it will be measurement guided, evidence based, team driven, and population focused.

Although Jason’s case is much more complex than a case of straightforward ADHD, scores on the Vanderbilt Rating Scale will be useful for tracking his response to treatment. Reviewing his case in a patient registry will help his therapist and primary care provider to keep track of his progress in treatment and flag his case for ongoing review with the consulting child psychiatrist. His therapist will utilize evidence-based, trauma-focused treatments in the treatment plan and coordinate services.

Even though it’s unlikely that Jason’s needs will be fully resolved in a time-limited episode of care, CoCM leverages the longitudinal engagement of the primary care team for long-term monitoring of the child throughout development. After initial therapeutic gains and implementation of a sound special education plan, he will undergo ongoing screening and clinical monitoring by the primary care team. Future episodes of integrated behavioral health treatment may be provided as needed throughout his development. ■