The purpose of this career development proposal is to provide a framework for developing knowledge in four distinct areas of need related to the provision of mental health care by generalist clinicians caring for children. The major project works in partnership with a large, multidisciplinary medical practice to develop and evaluate a practical, readily replicable provider training intervention to improve generalist mental health care. Two supporting projects include a) a qualitative study of issues surrounding competency and informed consent for adolescents receiving mental health care in generalist settings, and b) development of a workable measure of therapeutic alliance applicable to mental health care by generalists Community surveys from a variety of settings find that from 15-20% of school age children have one or more mental health conditions sufficiently severe to warrant treatment. Even where specialty mental health consultation is available, a substantial proportion of children's mental health problems appear to be identified and treated by generalists. Though many generalist providers are strongly committed to treating mental health problems, evaluations suggest that anywhere from 15 to 40% of children identified by generalists get no treatment. Training programs for generalists treating adults show that mental health care can be improved, but these studies have used highly selected groups of providers, intensive training programs, and, in some cases, major changes in the organization of care. The main work in this project will involve a partnership with pediatric and family practice providers from a large, regional, multispecialty medical group serving 18 sites in urban and suburban communities. In collaboration with the practice, we will pilot and implement an Internet-based provider training program, and test it using a practical and yet experimentally sound method for assessing utilization and outcomes among children and their families. Two related studies will provide important, specific insights for future interventions. The first will study attitudes and knowledge related to adolescents' independent, consent for receiving mental health services in primary care settings. The second will explore how concepts of therapeutic alliance, which have been shown to predict treatment outcome in specialized mental health services, can be applied to mental health care provided by generalists.
