Brief, Rapid Response, Parenting Interventions Within Primary Care Settings

Health care reform and the Patient Protection and Affordable Care Act (ACA) present new challenges for all health care providers, especially those in pediatrics. The largest challenge involves the full integration of the provision of health services for the child and family. This includes addressing both the physical needs and the increasing number of mental health needs, for both the child and family unit.1 The ACA, like most other health care initiatives, is modeled around adult health care needs, including chronic illnesses, as well as quality measures that focus on individual patient-centered outcomes.2 Translating these initiatives into the pediatric care setting will require creativity because the pediatric primary care setting is less extensively characterized by issues related to chronic illness. While the American Academy of Pediatrics (AAP), as part of the patient-centered medical home model (PC-MHM), endorses the provision of supports to maximize the social and psychological well-being of families,3 , 4 much flexibility exists regarding implementation strategies. The purpose of the this paper is to discuss a novel approach for integrating brief, rapid response, evidence-based parenting interventions into the pediatric primary care setting as a response to the ACA and the AAP’s PC-MHM recommendations.

Health Care Reform and a Need for Integrated Services

As childhood social, behavioral, and neurodevelopmental conditions continue to grow in prevalence in the pediatric population,5 it has become especially important to develop novel approaches to care delivery in the primary care setting. It is estimated that 13–20% of children living in the USA experience social-emotional problems.6 Research suggests that many of these social-emotional problems are clinically significant but do not necessarily rise to a level of psychiatric diagnosis and could benefit from parental behavioral supports and intervention—an area where access to service remains low.7 A truly integrated primary care approach that maximizes positive developmental trajectories for children and their families has the potential to reduce long-term comorbid mental health conditions.

The concepts and ideas contained in the ACA are focused around the “triple aim” of improving the patient’s experience of care, improving the health of the population, and reducing health care costs.8 The key to achieving the triple aim is in balancing health care goals, policies, and outcomes which will require providers to view health care from a different lens—one where providers accept the responsibility for all components of the triple aim and view the population they care for as a whole.8 Pediatric health care providers (HCPs) must place a greater emphasis on prevention and quality outcomes, through integrated services, or forgo reimbursement.9

Over the past few decades, services for children and families have developed into a unique patchwork of programs with variable quality and focus; thus, the need for innovative methods for delivery of services to children and families is imperative.10 , 11 What has been traditionally viewed as “primary care” needs to be redesigned into a more integrated, multidisciplinary model. Pediatric HCPs were the pioneers in developing the concept of the PC-MHM. Today, pediatric providers have an opportunity to blaze a new trail modeling greater and more expanded, integrated care for families. This is critically important regarding primary prevention of behavioral problems, specifically targeting the area of early response and support for childhood behavioral and mental health concerns. Because pediatric HCPs have frequent contact with families and children in the early years, they are well positioned to provide a critical link both in intercepting problems and in providing support for parents to manage early behavioral challenges before they develop into long-term mental health comorbidities.12 – 14 The AAP has long recognized the need for pediatric providers to build on the continuity relationships and trust that they hold with families in order to develop a healthy, therapeutic relationship with regard to behavioral counseling.12

Family-Focused Positive Parenting Interventions

In an effort to meet the needs of families under the ACA’s call for quality innovative delivery designs, family-focused parenting interventions need to be fully integrated and rapidly delivered within the pediatric primary care office. The development and implementation of programs and practices that promote both child and family health and well-being into the larger system of social and psychological support for families has been recommended by the AAP, the Institute of Medicine, and the National Research Council.10 , 12 , 15 , 16 Working with parents on parenting strategies specific to their child and family’s concerns reduces the frequency and severity of problematic behaviors, thus reducing long-term behavioral and mental health disorders.17 Research indicates that parenting programs also provide “care” to the caregiver by bolstering parenting resilience, focusing on the parent’s strengths, reducing parent stress levels, reducing acts of child maltreatment, and improving overall family functioning.18 – 20 Delivering a parenting intervention in the pediatric primary care setting provides parents with private, immediate, and efficient access to these services without referral to an outside provider. The recognition of both need and provision of parental support through the offering of effective behavioral strategies underscores the foundation of the patient/family-centered primary care medical home. Therefore, a truly integrated service, such as this, satisfies the ACA’s quality indicators of being efficient, effective, patient/family-centered, and cost-effective.

Positive parent training programs are family-centered, strength-based parenting interventions that teach parents the skills necessary to manage and prevent challenging child behaviors. The programs, often based in social learning theory, increase parental self-efficacy and parental resilience by empowering the parent and equipping them with the skills and confidence to manage family and parenting issues. Parenting programs vary in mode, length, intensity, format, and implementation costs; this enables practitioners to select which program fits their particular practice setting. Several evidence-based parenting programs exist including Triple P Positive Parenting Program,21 Bavolek’s Nurturing Program,22 and the Incredible Years.23 Because many of these programs can be delivered by a variety of health providers, they are ideal programs to be co-located within a pediatric primary care setting for children and families with less complex or mild-moderate behavioral concerns.

Integration into the Primary Care Setting

Integrating positive parent training programs as an office-based support is feasible, beneficial, and acceptable by parents.24 , 25 Researchers have found, within public and private sectors,26 that compliance with program attendance and program completion improved when programs are offered in the primary care location.24 This may be due to both the lack of outside behavioral and mental health services and lengthy waiting lists to access services.14 Other possible explanations include the following: the comfort of accessing services in the familiar primary care setting, a perceived feeling of fewer stigmas which can improve compliance with appointments and follow through,27 and a reduction in the burden on outside services reserving those for more difficult, complicated, or severe concerns.

Positive parent training programs may be delivered by an array of personnel including physicians, nurses, case managers, social workers, or other family support specialists allowing for a more cost-effective approach. Educational training often does not adequately prepare primary care providers to address even non-complicated behavioral health concerns,28 with which parents struggle. By using an evidence-based parent training program, HCPs can be accredited and trained in a program with proven outcomes as well as feel confident they are providing consistent information to families. Incorporation of monthly team meetings in the office setting can further ensure the fidelity of the program used.

Co-location of parent training within the primary care office requires outlining the process and flow within the office setting. Quick screening tools, such as the Children with Special Health Care Needs Screener29 or Pediatric Symptom Checklist,30 can be incorporated into the primary care visit to help the provider identify families who would benefit from these services. Once identified, brief support can be provided or it may be determined that a return consult visit would be more beneficial. Depending on the evidence-based parent training program being used, most have flexible formats allowing for individualized, brief (30 min or less) interventions. The use of several brief psychosocial interventions has been found to be feasible and successful in the adult primary care setting.31

Offices may also find it beneficial to provide group parent training which may be beneficial in determining if parents would benefit from individual consults. Additionally, individual sessions may serve as a bridge to longer-term professional mental health counseling while families are waiting for these (often hard to get) appointments. Ideally, next steps would include incorporation of this model of care into a large academic pediatric practice in order to assess feasibility, outcomes, costs, and patient experiences.11 , 32

Implications for Behavioral Health

Pediatric providers have the opportunity to lead the changes in health care reform through novel care delivery approaches. The need for this change is recognized by the AAP as their Vision of Pediatrics 2020 noted a much greater emphasis on the provision of mental health care by pediatric providers, requiring change of the traditional practice model and development of new skills and capacity by an empowered pediatric workforce.33 By providing early access and front-loading parenting supports in a child’s early years, providers can build on protective factors by supporting parents through parenting interventions.13 Pediatric primary care providers have an identified role to play in fostering family resilience in the context of challenging child behaviors,19 and the pediatric primary care setting is a promising and practical locale for a rapid response intervention when that is needed. By accomplishing this goal, pediatric practitioners may meet the triple aim of improving the patient experience, reducing cost, and improving the mental health of children and families.