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Impact of Stressful Climates on Provider Perceptions of Integrated Behavioral Health Services in Pediatric Primary Care

An Exploratory Study

Hsiung, Kimberly S. BS*; Hart, Jonathan MS; Kelleher, Kelly J. MD, MPH; Kolko, David J. PhD, ABPP*,†

Journal of Developmental & Behavioral Pediatrics: December 2019 - Volume 40 - Issue 9 - p 686–695
doi: 10.1097/DBP.0000000000000712

Objective: Pediatric primary care providers (PCPs) work in challenging environments and are increasingly called to implement complex interventions, such as behavioral health (BH) service integration. We explore how perceived stressful practice climates (1) change over time in and (2) influence provider perceptions of collaborative care versus usual care, 2 models of integrated BH care.

Methods: Secondary exploratory analysis using hierarchical linear modeling was performed on an 18-month cluster-randomized trial of 8 pediatric primary care practices to Doctor-Office Collaborative Care (DOCC), where an on-site care manager delivered BH services in coordination with PCPs, or Enhanced Usual Care (EUC), where a care manager facilitated referrals to local BH providers. Various indicators of PCP perceptions of BH services, including satisfaction with practice, burdens and beliefs regarding psychosocial problems, and effectiveness in treating behavioral problems, were assessed as outcomes. Moderators were 2 domains of stressful climates, role conflict and role overload.

Results: Role conflict and role overload stayed stable in both conditions. Role conflict strengthened the positive effect of DOCC on PCP perceived effectiveness in treating behavioral problems (β [SE], 0.04 [0.02]; p = 0.04) and improvement in managing oppositional/aggressive behavior (0.02 [0.01]; p = 0.02). Role overload strengthened the positive effect of DOCC on PCP-perceived improvement in managing attention-deficit hyperactivity disorder (0.03 [0.01]; p = 0.01). Stressful climates did not influence perceptions for EUC providers.

Conclusions: Providers experiencing more stressful practice climates developed more positive perceptions of collaborative care. This may encourage stressed providers to make effective practice changes and promote practice integration of BH services.

This article has supplementary material on the web site:

*Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA;

Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA;

Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH.

Address for reprints: Kimberly S. Hsiung, BS, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261; e-mail:

This study was supported by the NIH T32 MH018951 grant under Dr. David Brent, MD, as well as the Roth Fellow Award under Dr. Loren Roth, MD. The parent study was supported by National Institute of Mental Health grant 063272 and funded by the National Institutes of Health (NIH).

Disclosure: The authors declare no conflict of interest.

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Received December 07, 2018

Accepted June 17, 2019

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