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In 2000, the SKIP program began a five-year research trial funded by NIMH to address child behavior problems in six large, urban and suburban, pediatric practices in and around Pittsburgh, PA. The trial was designed to investigate the benefits of specialized behavioral health services provided in the pediatric primary care setting (Kolko et al., 2010). SKIP began as a collaborative effort between the Department of Psychiatry at the University of Pittsburgh School of Medicine and the Children's Community Pediatrics of Children's Hospital.
The clinical trial that took place from 2000-2005 randomly assigned participants to one of two intervention conditions. The first group of children received a protocol for on-site, nurse-administered intervention (PONI). That is, children with behavior problems were seen and received treatment from a nurse trained specifically to work with children with behavior problems while working in their family pediatrician's office.
The second group received Enhanced Usual Care (EUC). For this group, study nurses assessed children, made recommendations for treatment, and referred them to a local community provider.
Thirty pediatricians participated in the study. Participating children ranged in age from 6-11 years old at the beginning of the study, and 163 chose to participate in the study, which not only provided treatment but also conducted follow-up assessments for one year after the completion of treatment for both PONI, where children were seen in pediatricians' offices, and EUC, where children were referred to outside provides.
The results of the study indicated that PONI cases were significantly more likely to receive mental health services, had higher rates of treatment completion, and reported fewer barriers to receiving service. The PONI group also showed greater instances of clinical improvement and reduced recidivism over time.
In 2005, we launched a 2-year pilot program that continued to utilize and improve upon mental health services provided in the pediatrician's office (Kolko et al., 2012). This new pilot program differed slightly from our former model. In place of nurses in the practices, master's-level therapists delivered services in as part of our Doctor-Office Collaborative Care (DOCC) model. Our scope of services expanded to include treatment of ADHD as well as behavior problems for children in pediatricians' offices.
During this phase of the study, four pediatric practices, including 24 physicians, participated and 78 children were enrolled in the study. A comparative EUC group was also utilized in this model, and children in the DOCC model again showed significant improvements in use and completion of services, achievement of individualized goals, reduced oppositionality, inattention, hyperactivity, and functional impairment; as well as overall improved clinical response. Parents and pediatricians reported satisfaction with the services provided as part of the DOCC intervention model.
In 2007, a 5-year research study began. It utilized our Clinical Care Managers (CCMs; each of whom is a master's level therapist) to provide treatment in 8 pediatric practices in the Pittsburgh area. The overall goal of this study was to assess the efficacy of the Doctor Office Collaborative Care (DOCC) model of treatment for adolescent behavioral problems, such as attention deficit/hyperactivity disorder (ADHD) and/or anxiety, within pediatric primary care offices. This model was compared to the Enhanced Usual Model (EUC), in which adolescents that met the study criteria would be randomly assigned to one of the two treatment models (Kolko et al., 2014).
The study involved 75 physicians and enrolled 321 children within the age range of 5-12, the average age resting at 8.0 years of age. This study followed the children and parent participants for 2.5 years following the completion of their treatment. In addition to following the DOCC model described above, it also incorporated training in ADHD medication protocol for practice physicians and a protocol for treating child anxiety. The study also utilized an automated (computerized) case monitoring routine to target child behavior problems, ADHD, and anxiety.
After the study’s completion in 2013, data were analyzed for several different variables. Those factors include: service use, completion, the results of standardized clinical rating scales from parents and children, remission rates based on diagnostic interviews, overall treatment response, and service satisfaction.
Though both the DOCC and EUC conditions showed improved outcomes, DOCC experienced significantly greater reductions in severity of behavior problems, hyperactivity, and internalizing problems, greater remission of behavior problems, and a higher proportion of treatment responders. Evidence was also found to support the conclusion that, parents’ rating of child difficulty and parent-child dysfunction also decreased over time for those in DOCC, as well. Overall, this study showed that a collaborative care management model that is integrated in a pediatric practice can enhance access to and completion of timely behavioral health services, child and parent outcomes, service satisfaction, and pediatrician’s management practices, relative to the EUC practices.