Pisani, Anthony R. PhD; leRoux, Pieter DLitt et Phil; Siegel, David M. MD, MPH
Although behavioral health (BH) problems were identified more than 30 years ago as “new morbidities” threatening pediatric populations and continue to be highly prevalent today,1–3 the specialty mental health care system remains fragmented and difficult for children and their families to access.4–7 Therefore, pediatric primary care often becomes the de facto BH care system for children. To meet this need, pediatricians must learn to screen for and assess psychosocial problems, provide counseling to children and families, and refer to, collaborate with, and develop coordinated systems of care with BH specialists.8
In 2009, the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Academy of Pediatrics (AAP) released a joint position paper9 stating that initial mental health needs identification, assessment, and care should occur in the child's familiar primary care setting; primary care providers should be taught to identify and coordinate care for mental health problems; primary care providers should be able to collaborate with pediatric mental health professionals continuously; and administrative and financial models should support such collaboration. Among their recommendations was colocation of mental health professionals within pediatric medical settings.9 Later that year, the AAP proposed several competencies designed to prepare pediatricians to provide mental health care in their practices.10 The need to establish such competencies and collaborative practice models is particularly salient in urban settings, where socioeconomic problems place many patients at heightened psychosocial risk.11
The Accreditation Council for Graduate Medical Education requires pediatric residency programs to provide “an integrated experience that incorporates developmental and behavioral issues into ambulatory and inpatient experiences throughout the three years” and to train residents in collaboration and coordination of care for children and adolescents who require referral to BH specialists.12 The literature documenting how residencies meet these curricular obligations is sparse. In searches of the MEDLINE and PubMed databases in October 2009, we found only one article describing a program that explicitly targeted skill and comfort with BH referral, coordination, and collaboration by integrating BH training into pediatric residents' regular ambulatory experiences.13
In this article, we describe an urban pediatric ambulatory practice and training program that addresses patients' clinical needs while educating pediatric residents and postdoctoral psychology fellows in collaborative BH care through side-by-side learning and practice. We reflect on the past and current state of the program, share data demonstrating progress toward meeting the program's goals, and discuss the lessons we have learned, which may assist those who wish to develop a similar program.
Developing a Program of Integrated BH Education
Rochester General Pediatric Associates (RGPA) is an ambulatory pediatric clinic located in Rochester General Hospital (RGH), a multiservice community teaching hospital. RGPA serves a diverse patient population in urban Rochester, New York, and provides care during the course of more than 30,000 visits per year. Pediatric primary care is provided by attending pediatricians, nurse practitioners, and four continuity clinic teams (each of which includes five to seven pediatric residents across levels of training). RGPA is the primary continuity clinic for approximately half of the 46 residents in the University of Rochester School of Medicine and Dentistry's (URSMD's) pediatric residency program each year. Residents spend one-half day per week in continuity clinic.
RGH's pediatric leaders in 1993 identified a need for improved BH care and education to assist pediatric residents (and their attending preceptors), who often felt overwhelmed by the volume of emotional and behavioral problems among their patients and requested resources to facilitate collaborative patient management. The leadership team established the following goals:
1. to provide easy access to BH services for children and their families;
2. to improve residents' skill and comfort in collaborating with BH specialists; and
3. to develop a stable, viable, and replicable clinical and educational infrastructure for collaborative BH care.
Forming the BH team
Accordingly, RGH's pediatric leadership consulted with the family programs director in the URSMD Department of Psychiatry about how to develop a collaborative system of pediatric and BH training and patient care modeled after RGH's family medicine program.14 A faculty psychologist (P.lR.) was recruited in 1994 to assess the mental health needs of RGH's pediatric outpatient and inpatient units, to instruct pediatric residents in psychosocial theories, and to recommend ways to improve children's access to BH care. He was available on-site on a limited basis to consult with and educate inpatient providers (one morning per week) and to discuss problematic cases with providers in the ambulatory practice (one afternoon per week). Throughout this formative process, he consulted with senior psychology faculty in family medicine for their input based on their experience developing similar programs.
During the first year, the faculty psychologist focused his half-days in the inpatient unit and ambulatory practice on brief crisis interventions with children and families. To help residents who felt overwhelmed by patients' BH needs, he used a family resiliency framework15 to structure work related to psychosocial problems. This type of framework targets interventions toward key processes that have been identified by clinical and social science research as important for individuals and families to thrive in the face of stress and vulnerability: belief systems (meaning in adversity, positive outlook, transcendence and spirituality), organizational patterns (flexibility, connectedness, social and economic resources), and communication/problem-solving (clarity, open emotional expression, collaborative problem-solving). Although pediatricians and psychologists have different roles, skills, and time frames for addressing these targets, his goal was to develop a shared framework for a collaborative primary health care team.
By the second year, the faculty psychologist's time increased to 2.5 days per week, which included educational activities on the inpatient services but was increasingly focused on outpatient activities. He organized other URSMD BH personnel into an informal BH care team that was integrated into the clinical and training structure of the RGPA continuity clinics.
Initiating the psychology fellowship
In 1998, the RGH chief of pediatrics and the URSMD family programs director asked the faculty psychologist to consider establishing a postdoctoral psychology training program with a focus on family systems pediatrics. The educational rationale was compelling. Training mental health professionals as colearners in a pediatric residency outpatient practice would expose them to the presenting problems and types of families commonly seen in pediatric primary care and educate them about that setting's culture and needs. Later that year, RGPA implemented a two-year psychology fellowship in family systems pediatrics that included collaborative clinical training in the ambulatory setting and a comprehensive curriculum in family systems theory and primary care psychology.16,17
Key Elements of Clinical and Educational Infrastructure
The pediatric continuity clinic structure that resulted from this process has the following features:
* a BH team that participates in each of the four resident continuity clinics at RGPA
* brief didactic talks and discussion at the beginning of each clinical session, in which pediatric residents and psychology fellows present and participate
* a joint preceptor model, in which pediatric and BH faculty precept pediatric residents and psychology fellows in a shared space
* a collaborative patient care model, in which pediatric residents and psychology fellows share care of patients with BH problems and see a proportion of them together
* informal opportunities for pediatric residents and psychology fellows to exchange ideas and experiences
The BH team at RGPA consists of two postdoctoral psychology fellows (one first year, one second year) and three faculty members with joint appointments in pediatrics and psychiatry, who spend portions of their time in both departments. One of these faculty members and one of the psychology fellows are fully integrated into each of the four pediatric continuity clinics. They attend the weekly preclinic talks, consult with pediatric residents and their preceptors, see patients alone and with pediatric clinicians, and participate in social functions with the continuity clinic group.
The weekly preclinic talks typically address growth, development, immunizations, screening, and diagnosis and treatment of medical conditions in pediatric primary care, as well as psychosocial topics. Psychology fellows present four to six of these talks per year, on topics ranging from identifying depression to using the family genogram and the family resiliency approach to evaluate BH problems. At the beginning of each training year, the fellows present a brief seminar, entitled “The Art of the Behavioral Health Referral,” which provides a rationale for integrated care, case examples of typical collaborative opportunities, and examples of language to use with parents and children to introduce the idea of involving a BH specialist in their care. This seminar often creates a forum for senior residents and second-year fellows to share with their junior colleagues stories of successful collaborative care. Through these didactics, as well as the shared precepting and shared patient care described below, the training of the psychology fellows occurs in concert with that of the pediatric residents.
After the preclinic talk, the pediatric residents, psychology fellows, and faculty preceptors begin a full afternoon of patient care. The conference room in which the team gathered for the talk becomes the “home base” for shared precepting, documentation, consultation, and any downtime that might arise because of late, canceled, or missed appointments. Although it is not possible to predict who will be in the conference room at any given time, it is common to find psychology and pediatric trainees working side by side around the table. For example, a psychology fellow or faculty member might be writing a progress note from a therapy visit while sitting next to a pediatric resident who is discussing findings from a well-child visit with a medical preceptor. These hoped-for coincidences offer rich educational opportunities.
Shared patient care
Whereas shared didactics and precepting take place behind the scenes, patients and their parents witness cooperation between their medical and BH providers through scheduled joint visits and spontaneous “pull-in” consults. Preceptors encourage residents who identify a candidate for BH treatment to introduce the child and family to a psychology fellow or faculty member. Once the patient enters BH treatment in the clinic, the pediatric resident is encouraged to join the therapist for all or part of any visit. The pace of primary care and limitations of reimbursement mechanisms prohibit multiple, extended shared visits, but fellows are trained to leverage physician credibility, insight, and support of the behavioral treatment process through brief (five- to seven- minute) entrées into the family consultation room.
Psychology fellows and pediatric residents spend unplanned, informal time together, due to their shared workspace, scheduling, and the rhythm of the practice. These brief moments of downtime foster collegiality as residents and psychology fellows learn about each other's families, career plans, training experiences, communication preferences, and professional pet peeves.
Evaluating the Program's Progress
Consistent with a developmental program evaluation approach,18,19 we sought evidence from available data sources that could provide meaningful indicators of progress or failure with respect to each of our program's three goals. Additional details concerning our evaluation methods and outcomes data for 10 years (1998-2008) are provided in Table 1.
Goal 1: Easy access to BH care
Patient visits and appointment availability.
From 1998 through 2008, the number of patients able to see a BH specialist at RGPA increased significantly each year (Table 1). Access time was also reduced, compared with that of community mental health centers, because BH appointment scheduling occurred immediately, at the point of service.
Referral and scheduling process.
Traditionally, when a pediatrician and parent agree that BH referral is indicated, the parent receives a name or list of names to contact and, when required, the parent or the pediatrician's office must secure insurance authorization for referral. Often, the parent must complete a telephone intake interview with a mental health agency before an appointment will be scheduled.
By contrast, our referral and scheduling process leverages colocation of BH and pediatric providers to minimize the absolute time from the pediatrician's referral to the child's visit with a BH provider. First, residents and other pediatric providers regularly page psychology fellows and faculty to meet and establish initial rapport with prospective patients at the time of referral (which has been shown in a different primary care setting to increase first appointment show rates20); such unbilled patient contacts may include a brief crisis visit, if needed. Parents can schedule a BH appointment before leaving the clinic—including obtaining insurance authorization, if required—without the need for a preappointment intake interview. The simplicity of the referral process, as well as the familiarity of the care setting, potentially reduce the stigma and intimidation commonly cited as barriers to access.4,9
Goal 2: Resident skill and comfort collaborating with BH specialists
From 1998 through 2008, 48 pediatric residents and 8 psychology fellows completed their training at RGPA. Fifty-eight percent of these pediatric residency graduates went on to careers that included primary care practice, which is typical for our (and most) residency programs. Sixty-three percent of the psychology fellows went on to careers that included practice or consultation in primary care pediatrics. Comparison data from other programs that train fellows in primary care psychology were not available, but among all psychologists, only 4% practice in primary care.21
As we showed in the companion study published in this issue,22 former URSMD pediatric residents who trained side by side with BH professionals at RGPA were more likely to report having gained experience collaborating with BH specialists and feeling prepared to do so when they entered practice than were their residency peers who trained in a outpatient setting without integrated BH care. In 2008, we discussed progress toward this goal during unstructured interviews with four pediatric faculty members who were continuously present before and after the joint training program was established. They reported that they had observed a change in residents' and other primary care providers' approach to difficult BH cases from a referral mode (“sending” patients to the psychologist) to a collaborative one (“sharing patients” with the psychologist). The tone of discourse about behavior and family problems in the clinic also changed. Whereas previously some residents openly expressed reluctance and frustration in working with patients with psychosocial problems, residents' disparaging remarks about “behavioral stuff” became less common and less socially acceptable as their appreciation of the BH team grew. This created a more productive educational environment. One of the faculty members stated, “We at least have a chance at getting [the residents] to enjoy this part of the job.”
To provide insight into residents' subjective experiences of the integrated BH experience, we include below an excerpt of a note sent to program faculty by a former resident who is now in clinical practice:
You have … heard many times how special the clinic at RGH was and I firmly believe that it was one of the most formative parts of my pediatric training.… I know I would have never been comfortable with … collaboration with my psychology colleague if I had not been exposed to that point of reference in training. The collaborative approach with families and external supports is so valuable in what I do every day.
Goal 3: Clinical and educational infrastructure
Faculty growth and stability.
As noted above, BH integration started in 1994 with one part-time BH faculty member. By 2008, the program had four part-time faculty persons (2.0 FTE) and two nearly full-time fellows (1.75 FTE). From 1998 through 2008, there was no turnover in faculty, and only one fellow did not complete the full two-year fellowship.
Institutional commitment and financial sustainability.
A vital element of the program's success was the unwavering commitment of the Department of Pediatrics at RGH and URSMD, sometimes in the face of interinstitutional tensions and financial shortfalls. Funding BH faculty salaries required a combination of clinical revenue and departmental support for educational time. A progressive local health insurance payer agreed to reimburse mental health services provided by fellows in the pediatric clinic (similar to an earlier arrangement with the family medicine clinic), and other insurers later followed suit. As the program matured, fellows became more clinically productive, and fellows' stipends became entirely offset by patient care revenue. Psychologist faculty support for clinical supervision collectively constituted approximately 0.5 FTE. Although combined expenses for salary, stipend, space, and infrastructure were not trivial, the department and hospital leadership team viewed the costs as reasonable “overhead” for an important program that provided necessary patient care and innovative residency education. As the number of BH visits increased, the program covered an increasing proportion of these overhead costs, including about half of the BH faculty members' salaries.
In 2005, a psychology faculty member associated with another URSMD pediatric residency teaching practice, which had ad hoc BH consultation but not fully integrated training and care, heard informal reports from pediatric residents and psychology fellows about our program, learned of our presentations at professional meetings,23–27 and inquired about how to replicate RGPA's integrated continuity clinic teams. In the following academic year, that practice began to incorporate psychology fellows. Also in 2005, pediatric colleagues from another university consulted with our team following a presentation28 and have since launched initiatives with similar goals for collaborative care and education, further substantiating the clinical and educational value of the integrated model.29–31
Lessons Learned and Future Directions
Our program grew out of the need to respond to challenges that many residency practices face in providing BH care to children and BH training for residents. Several key themes, described below, characterize our effort (List 1).
Although there were pediatric mental health centers in the community, the lack of infrastructure for collaboration with primary care providers and obstacles to patient access left our residents (and attendings) feeling discouraged about referrals. When RGH pediatric leaders recognized this clinical and educational dilemma, they responded by partnering with colleagues in other departments who were experienced in integrated BH care and education. These partners' expertise and the legacy of biopsychosocial medicine at URSMD accelerated the development and implementation of a sustainable program.
The importance of adopting the family resiliency framework15 and creating shared space to facilitate integration cannot be overstated. The framework provides pediatric residents and psychology fellows with a common and hopeful language for talking about psychosocial problems while emphasizing strength and adaptation rather than focusing on dysfunction. Colocation of pediatric and psychology trainees—with common exam rooms, support staff, and supervision space—creates the social conditions for initial and ongoing reciprocal influence of attitudes and behaviors across disciplines.32
The team conference room, which complements the other common spaces and shared support staff, serves as the “cultural hub” through which clinical and educational exchange flows. Occupancy of the conference room is fluid, and we regularly find psychology and pediatric trainees working there at the same time.
Throughout the practice, in the conference room and other shared spaces, trainees listen to nearby discussions and enter and exit them with relative ease. In contrast to a typical BH training culture, psychology fellows discover that in our clinic it is commonplace and socially appropriate for a professional to enter a room, interject into an existing conversation, and then leave it midstream to answer a page. They develop the ability to judge whether their input on a psychosocial aspect of a case may be useful and ask a question or offer an idea without seeming intrusive. Likewise, the common precepting environment allows a pediatric resident to feel comfortable interrupting a psychology fellow to ask about an issue with a mutual patient or responding to a fellow's medical or neurodevelopmental questions (see Appendix 1 for an example).
Too often, fear of the unknown and the stigma and complexity of seeking mental health care overshadow parents' desire to get help for their children, and, despite the best of intentions, many families do not act on mental health referrals.33 Being introduced to a compassionate and interested counselor by a trusted pediatrician in her or his office can put patients and their families at ease. A study of one rural family medicine center found that 76% of patients kept their first appointment with a BH provider following an in-person, prereferral introduction compared with 44% of those who did not have such personal contact.20 Further, joint patient contact avoids evoking feelings among family members of rejection or abandonment—as if their doctor were sending them away—and provides a context for moving seamlessly between discussion of mind (and behavior) and body, thereby weakening the medical tradition of separating the two.
Residents and fellows observe how providers in the other discipline interact with the patient around the presenting problem. Following interdisciplinary patient encounters, trainees often remark, with surprise and admiration, “I never would have thought of asking in that way.” This mutual respect provides an entrée to discussion of role definition and how to organize tasks together according to each discipline's strengths and expertise.
Our program's development and implementation, from initial discussions of integrating the training of pediatric residents and postdoctoral psychology fellows to full program realization, took years. URSMD's biopsychosocial legacy made it no less necessary to “sell” the idea to colleagues and administrators at both the university and RGH and arrive at conceptual common ground before program implementation could start. However, once joint training began, feedback from residents, fellows, faculty, and patients' parents gave the program momentum that has continued to the present.
Limitations related to program outcomes measurement
Rather than prospectively defining and tracking outcome measures, we gathered data for outcomes measures (such as those presented in Table 1) as they became apparent, which resulted in more data availability in some years than others. This evaluation approach is congruent with the nature of real-world program development, which usually occurs incrementally in response to context-specific demands and opportunities.18,19 Empirical study of educational innovation of this kind should focus on prospective and objective measurement of resident skill acquisition, clinical practice patterns, and patient outcomes. True randomized control is not applicable to evaluating an educational innovation that involves developing a new clinic infrastructure. However, naturally occurring comparisons, such as differences in training models used in URSMD's pediatric continuity clinics that we explored when surveying our alumni,22 hold promise for systematic assessment of a program of this kind.
This program assessment meets the criteria that Glassick34 developed for evaluating educational scholarship: clear goals, adequate preparation, appropriate methods, significant results, effective communications, and reflective critique. Our goals were to provide easy access to BH care for the children in our practice, to improve pediatric resident education in collaboration and BH care, and to develop an infrastructure that would support these goals over time. Support from leadership and recruitment of experienced faculty prepared us to develop the appropriate methods for our setting. We have demonstrated significant results by developing a collaborative team, side-by-side education of pediatricians and psychologists, and a model that has proven portable to other settings. We have communicated about our model through professional presentations and through discussions with community stakeholders. The present article furthers that communication and includes an assessment and critique of the program.
Joint training of pediatric residents and psychology fellows has served the educational and clinical mission of RGPA's resident continuity clinics and provides an example of the kind of collaborative system and infrastructure that Horwitz et al,35 Kelleher et al,8,36 and the AACAP and AAP9 have identified as essential to overcoming barriers to providing effective primary mental health care. Despite periodic fiscal, political, and logistical challenges, our pediatric residents and psychology fellows have trained and practiced together for more than a decade in a program that is expected to continue indefinitely.
The initiation and success of any program depend on a combination of need, timing, expertise, and resources, along with organizational leadership, will, and persistence. Even with many of these elements in place, it took our program more than 10 years to reach its current level of success. We continue to teach trainees that integrated care is essential for comprehensively and effectively managing complex psychosocial problems, as well as being a means to providing patients with easy access to BH care while maintaining pediatrician involvement in their BH care after referral. We aim to build on the evidence of our progress toward the program's identified educational and clinical goals and to further establish this model as a proven approach to collaborative pediatric education and BH patient care.
The authors would like to thank the faculty and staff of Rochester General Pediatric Associates, especially Larry Denk, MD, and Roger Yeager, PhD. The authors wish to thank Susan H. McDaniel, PhD, and the faculty of the University of Rochester Institute for the Family for their inspiration and guidance throughout the development of this program. They gratefully acknowledge Constance D. Baldwin, PhD, and Erin Rogers, MPH, for their assistance with this article.
Dr. Pisani received funding from the National Institutes of Mental Health (T32 MH20061, Conwell, PI).
Portions of this article were previously presented at the 114th Annual Convention of the American Psychological Association, New Orleans, Louisiana, August 2006, and the Annual Meeting of the Pediatric Academic Societies, Vancouver, British Columbia, May 2010.
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