Primary care referral of children with psychosocial problems

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 21150 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.