Child and Adolescent Mental Health within Primary Care: A Study of General Practitioners’ Perceptions

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  • Child and Adolescent Mental HealthwithinPrimary Care: A Study of General PractitionersPerceptionsKatrina Cockburn1 & Paul Bernard21Clairmont Family Centre, Princes Street, Bishop Auckland, County Durham, UK2Mulberry Centre, Darlington Memorial Hospital, Hollyhurst Road, Darlington, UK

    Background: Primary Care teams play an important role in the provision of mental health care to children andyoung people. Methods: We developed and distributed a questionnaire to all General Practitioners withinone Health Authority area. Results: Many of the respondents rated as less than satisfactory their competenceand their knowledge and skills in important areas of child and adolescent mental health practice. A significantminority expressed a high level of interest in child and adolescent mental health and most respondentsreported that they would value further training. Conclusions: General Practitioners should be provided withmore training and support in their role as providers of child and adolescent mental health care.

    Keywords: Child and adolescent mental health; general practitioner; training

    IntroductionThe importance of the role that general practitioners(GPs) play within adult mental health has been recog-nised for many years (Shepherd et al., 1966; Goldberg &Huxley, 1980, 1992). A number of studies have ad-dressed GPs perceptions, attitudes and training needsin relation to adult mental health practice in primarycare (Turton, Tylee, & Kerry, 1995; Kerwick et al.,1997). More recently there has been an increasingrecognition of the importance of the role that GPs (andother members of the primary care team) can playwithin child and adolescent mental health (CAMH).Mental health problems in children and young peopleare common and frequently persistent, but only a smallminority of those with a disorder receives input fromspecialist mental health services (Meltzer et al., 2000).Children and young people attend primary care settingsfrequently. Many children and young people attending aGP meet criteria for a psychiatric disorder (Garralda &Bailey, 1986; Kramer & Garralda, 1998). Those withmental disorders attend more frequently than others(Meltzer et al., 2000). The need to enhance and supportthe role of primary care within CAMH was clearly statedby the NHS Health Advisory Service report Together westand (NHS Health Advisory Service, 1995) and theAudit Commission report Children in mind (AuditCommission, 1999). This approach was given furtherbacking by The NHS plan (NHS, 2000).In comparison to adult mental health, research into

    child and adolescent mental health practice in primarycare is still at an early stage (Bernard & Garralda, 1995;Kramer & Garralda, 2000; McDonald & Bower, 2000).In a recent Finnish study (Heikkinen et al., 2002) GPsrated many of their child psychiatric skills as in-adequate. Little has been published concerning GPs

    views of child and adolescent mental health practice inprimary care. In this study, therefore, we set out toinvestigate GPs perspectives about their knowledge,skills, competence and training needs in relation tochild and adolescent mental health.

    Participants and methodsWe developed a new 35-item questionnaire coveringgeneral and specific aspects of CAMH practice in pri-mary care. In developing the questionnaire we drewupon the literature about adult mental health practicewithin primary care and were assisted by colleagueswith research experience in the interface betweenCAMHS and primary care. We piloted the questionnairewith a small group of GPs. The questionnaire askedabout:

    relevant training experiences

    skills and competence in CAMH practice in primarycare

    knowledge in key areas

    level of interest in CAMH

    knowledge about local specialist CAMH services

    training needs.

    The options for the ratings of knowledge, skills andcompetence were less than satisfactory, satisfactoryand more than satisfactory. In the analyses and pres-entation of the results, the latter two categories werecombined into satisfactory or above. The sample con-sisted of all 324 GPs (based in 95 practices) listed in theHealth Authority database for the six Primary CareGroups in the County Durham and Darlington Health

    Child and Adolescent Mental Health Volume 9, No. 1, 2004, pp. 2124

    2004 Association for Child Psychology and Psychiatry.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

  • Authority area. This is a mixed urban and rural areawith a population of approximately 600,000; it includesfarming communities, ex mining villages, a number ofsmall towns and the University City of Durham. Amulti-disciplinary specialist CAMHS team serves eachof the six Primary Care Group areas.The questionnaire was posted to GPs via their prac-

    tice managers in June 2000. Non-responders receivedtwo further postings. The data were analysed using theSPSS for Windows statistical package.

    ResultsWe received completed questionnaires from 244 GPs(75% of the 324).

    The sampleAll respondents were GP principals. One-hundred-and-sixty-nine (69%) were male. The median age range was4150 years.

    Knowledge, skills and competence in CAMHpracticeThe questionnaire asked about knowledge and skillsrelevant to GPs everyday work in primary care. Weasked respondents to rate their competence in dealingwith mental health problems in different age groups.Table 1 gives a summary of the ratings. Respondentsthen rated their competence in dealing with differentsorts of mental health problems in children and ado-lescents. Table 2 shows the types of disorders that weasked about and the ratings given.We also asked the GPs to rate their knowledge in

    some specific areas. Table 3 shows the areas of inquiryand summarises the ratings. The questionnaire nextasked GPs to rate their skills in certain areas. Table 4shows the areas covered and the ratings given.

    Interest in CAMH and knowledge of localspecialist CAMH provisionThe questionnaire asked respondents to rate theirinterest in child and adolescent mental health on ascale of 010. The median rating was five; 45% ofrespondents gave a rating of six or above; 18% gave arating of eight or above.

    We also asked respondents about their knowledge oflocal specialist CAMH provision and referral proce-dures. Forty-five percent rated their knowledge of theseas less than satisfactory.

    Analysis in relation to age and genderWe looked for associations between demographicattributes of the respondents (gender and age) and twoareas: level of interest in CAMH, and perceived com-petence in CAMH practice. A summary rating of com-petence was derived from the ratings of the items shownin Table 1. Respondents were divided into two agegroups: 40 years and younger (34%); 41 years and older(66%). Analyses were performed using the Mann-Whitney U test.Female GPs were more interested in CAMH than male

    GPs (Z 3.9, p < .01). Twenty-five per cent of femaleGPs as opposed to 14% of male GPs rated their interestas eight or above on the scale of 010. There was nodifference in levels of interest between the older and theyounger groups of respondents (Z 0.45, p .65).There was no difference in ratings of competence

    between male and female respondents (Z )0.72,p .47) and between the older and younger groups ofrespondents (Z 0.28, p .78).

    Training and experienceThe questionnaire listed training experiences of likelyrelevance to child and adolescent mental health prac-tice within primary care. Respondents were asked toindicate whether they had received these experiences,and (if they had) to indicate how useful the experienceshad been in preparing the individual to meet the mental

    Table 1. Competence in relation to age group

    Age groupLess than


    or above

    Pre-school children n 239 128 (54%) 111 (46%)Children aged 5 to 12 n 238 123 (52%) 115 (48%)Adolescents (age 13 to 18) n 240 121 (50%) 119 (50%)

    Table 2. Competence in relation to type of problem

    Type of problemLess than


    or above

    Emotional disorders n 243 96 (40%) 147 (60%)Disruptive behaviour disorders n 243 178 (73%) 65 (27%)Psychosomatic disorders N 243 93 (38%) 150 (62%)Eating disorders N 240 164 (68%) 76 (32%)

    Table 3. GPs perceived knowledge in child and adolescentmental health

    Area of knowledgeLess than


    or above

    Child development n 240 31 (13%) 209 (87%)Aetiology of mental health

    problems in childrenand adolescents n 243

    134 (55%) 109 (45%)

    Nature and course of mentalhealth problems in childrenand adolescents n 242

    155 (64%) 87 (36%)

    Treatment / managementof mental health problemsin children and adolescents n 242

    174 (72%) 68 (28%)

    Table 4. GPs perceived skills in child and adolescent mentalhealth

    Area of skillsLess than


    or above

    Communication with childrenand adolescents n 242

    26 (11%) 216 (89%)

    Recognition of mentalhealth problems n 242

    53 (22%) 189 (78%)

    Management of mentalhealth problems n 242

    157 (65%) 85 (35%)

    Assessment of suicidal risk n 241 162 (67%) 79 (37%)Use of psychotropic medication n 242 205 (85%) 37 (15%)

    22 Katrina Cockburn

  • health needs of their child and adolescent patients.Table 5 lists the training experiences and summarisesthe findings. We also asked respondents to indicateareas in which they would value further training.Table 6 summarises the responses.

    DiscussionIn this questionnaire study of General Practitioners inone Health Authority area, many of the respondentsrated as less than satisfactory their competence andtheir knowledge and skills in important areas of childand adolescent mental health practice in primary care.Relatively few respondents had received training thatthey perceived as having been useful. A substantialproportion of GPs showed a considerable level of inter-est in CAMH.Strengths of the study include the sample size and

    good response rate. A limitation of this kind of study isthat it is based on self-assessment only. Studies looking

    at GPs knowledge (Tracey et al., 1997) and technicalclinical skills (Jansen et al., 1995) show relatively poorcorrelations between the results of self-assessmentsand more objective measures. Ours was a study ofpractitioners perceptions and attitudes which webelieve are of crucial importance when considering therole of the primary care team in the delivery of CAMHprovision, and when planning continuing medical edu-cation.Just under half of the GPs rated their competence in

    dealing with mental health problems (Table 1) as sat-isfactory or above; this pattern of results applied to allof the three age groups enquired about. Comparisonwith the results of a study by Turton et al. (1995) sug-gests that GPs feel considerably less competent in childand adolescent mental health than they do in adultmental health. This may reflect the fact that adultpsychiatry is a much more clearly recognised part of theGPs role; also that many GPs have worked in adultpsychiatry posts during their training and considerableattention is given to adult mental health during GPtraining and continuing medical education.Perceptions of competence varied considerably

    across the different problem areas that we enquiredabout (Table 2). The higher ratings in relation to emo-tional disorders and psychosomatic disorders may re-flect the fact that GPs are used to dealing with similarpresentations in their adult patients. Respondents feltless competent in dealing with disruptive behaviourdisorders and eating disorders. The former may not beseen as medical in nature and therefore not within theGPs remit; the latter present relatively infrequently andare anxiety provoking for many professionals.Ratings of knowledge also varied considerably across

    the areas of enquiry (Table 3). The higher ratings forknowledge about child development is understandablein that child surveillance and child health are clearlyrecognised elements of the GPs role. Ratings of know-ledge in areas more specific to CAMH were considerablylower. More than two-thirds of respondents rated theirknowledge about the treatment/management of mentalhealth problems in children and adolescents as lessthan satisfactory.The respondents ratings of their skills (Table 4)

    showed similar variation. Nearly nine out of tenrespondents rated their skills in communication withchildren and young people as satisfactory or above.Ratings of skills in recognition of child and adolescentmental health problems were markedly higher thanratings of skills in management of these problems. Morethan two-thirds of respondents rated their skills in

    Table 5. Training experiences and their perceived usefulness

    Training experience

    Number (%)who stated they

    had the experience

    Number (%*)who found thetraining useful

    CAMH teaching in medical school 104 (43%) 41 (39%)CAMH teaching on vocational training scheme 64 (27%) 47 (73%)Hospital paediatric experience 194 (81%) 64 (33%)Community paediatric experience 33 (42%) 19 (58%)Psychiatry experience 121 (51%) 56 (46%)Continuing medical education in CAMH 40 (16%) 34 (85%)

    * percentage of those who had the experience

    Table 6. Areas in which further training would be valued


    Number (%)valuing further

    training in this area

    Use of psychotropic medication 195 (89%)Knowledge about treatment/management

    of CAMH problems189 (87%)

    Dealing with mental health problemsin adolescents

    188 (87%)

    Assessment of suicide risk 185 (87%)Dealing with eating disorders 182 (86%)Dealing with disruptive behaviour disorders 180 (85%)Management of mental health problems 183 (85%)Dealing with mental health problems

    in children aged 5 to 12 years173 (82%)

    Knowledge about the nature and courseof mental health problems

    172 (81%)

    Dealing with mental health problemsin pre-school children

    169 (79%)

    Dealing with psychosomatic disorders 159 (78%)Dealing with emotional disorders 149 (76%)Knowledge about the aetiology

    of mental health problems152 (74%)

    Recognition of mental health problems 148 (74%)Knowledge of local provision

    and referral procedures138 (70%)

    Communication with childrenand adolescents

    119 (70%)

    Knowledge of child development 75 (52%)

    CAMH within Primary Care 23

  • assessment of suicidal risk as less than satisfactory.Skills in the use of psychotropic medication received thelowest rating of all items in the questionnaire. It may bethat many GPs see medication and assessment of riskin this population as not being within their remit.The ratings of level of interest in CAMH were

    encouraging, particularly in that a substantial minorityof GPs expressed quite a high level of interest. FemaleGPs were more interested than male GPs. Nearly half ofthe respondents expressed inadequate knowledgeabout local CAMH provision and referral procedures.Few of the GPs indicated that they had received

    training in CAMH that was perceived to be useful. Themost common training experience (hospital paediatrics)was rated as the least useful; the least common (con-tinuing medical education about CAMH) was rated asthe most useful. Most respondents indicated that theywould value further training in all of the areas of CAMHpractice enquired about. These findings are in line withthose of a recent study in North Staffordshire (Foreman,2001). GPs in this large sample had had less postgra-duate training in CAMH than in any other specialty;about three-quarters of respondents wanted furthertraining in child and adolescent mental health.The findings of this study support the generally

    accepted view that General Practitioners should beprovided with more training and support in their role asproviders of child and adolescent mental health care. Inour view, energies should be focused in the followingfive areas.First, CAMH should receive sufficient priority and

    time within the curriculum so that medical students(many of whom will become GPs) gain a basic groundingin child and adolescent mental health. Second, trainingin child and adolescent mental health should beincorporated into every GP vocational training scheme.At least one specifically designed and evaluated teach-ing package is available for this purpose (Bernard et al.,1999). Third, child and adolescent psychiatrists and GPtutors in each locality should liaise to ensure that, de-spite competing priorities and full curricula, child andadolescent mental health is given time in the pro-gramme of continuing medical education for GPs.Fourth, CAMH teams should ensure that there is timededicated for consultation, advice and support to localGPs (and the other members of the primary care teams).Primary Mental Health Workers (PMHWs) fulfil thisfunction in many localities; further research is neces-sary to establish what are the most effective models ofPMHW practice. Fifth, General Practitioners with aparticular interest in child and adolescent mentalhealth should be given opportunities to further extendtheir knowledge and skills and perhaps to becomespecialist GPs (NHS, 2000) in relation to their childand adolescent mental health expertise.

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    24 Katrina Cockburn


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