GP/FPs in the Canadian province of BC, who are the predominant providers of primary health care to children, report a fairly consistent exposure to common childhood behavioral and emotional concerns in their practices. They report an intermediate level of comfort and skill in dealing with these patients overall, with the highest level for mood disorders and lowest for behavior problems. Caring for these children frequently involves collaboration with consultants. Self-reported comfort/skill was an important predictor of a GP/FP's tendency to take primary responsibility for a case, and self-reported comfort/skill was in turn related to previous educational exposure to this field, and beliefs about mental health problems in children. These findings have implications for physician education and primary care practice and organization of services.
Our results are consistent with other studies that have found an important role for physician self-efficacy in predicting physician practices [13, 14], as would be predicted from social cognitive theory . A previous study found pediatrician confidence in diagnosis and management of children and youth with depression to be associated with higher perceived responsibility for treating these cases, which is in turn predictive of the physician's prescribing medication and scheduling further appointments . Although our results explain only a portion of the variation in physicians' comfort and skill, the consistent predictions from CME related to children's behavioral and emotional problems, and physicians' beliefs about the care of these problems, are notable. Participation in educational programs has been found to increase physicians' sense of professional efficacy in other studies , underlining the potentially important role for appropriate CME. Our finding that participation in CME and physician beliefs are both important factors in self-efficacy, raises the intriguing possibility that some of the benefits of participation in CME may be mediated through effects on attitudes and beliefs over-and-above simple knowledge acquisition. It has, in fact, been suggested that focusing on attitudes and beliefs may be a legitimate and important way to enhance skills and confidence among GP/FPs in relation to mental health problems .
We would point out that our results should not be interpreted as showing a direct benefit of physician CME on physician practice with children with behavioural and emotional problems, or on patient outcomes. The likelihood of physician CME resulting in changes in physician behavior and patient outcomes depends in large part on the type of CME activity undertaken, with certain types of CME being relatively ineffective and others being quite effective [18–20]. Our survey did not enquire about the types of CME activities in which physicians had participated. In relation to educational effects more broadly, previous studies from the USA have reported mixed results for effects of specialized training in psychosocial issues on the practice of primary care physicians with children with these problems. In one study, no effect of such training on treatment decisions was found , while in another study, more intensive levels of advanced training did result in better identification and management practices .
Our study raises questions about why GP/FPs feel more comfortable and confident in dealing with children with mood disorders, and less so those with behavior problems, and why they tend to refer children with behavior problems and ADHD more frequently than dealing with these cases themselves. Children's behavior problems may pose challenges because clear diagnostic criteria and management algorithms are lacking for this diffuse and heterogeneous group of clinical scenarios. An increased emphasis during physician training on understanding child development, and on learning practical strategies (such as contingent reinforcement) to deal with aberrant behavior, may enable GP/FPs to feel more confident with these problems. ADHD, on the other hand, continues to be a source of concern for many GP/FPs, in spite of accepted diagnostic criteria, evidence-based practice guidelines, and effective treatments. Previous research from Australia identified diagnostic issues and complexities, time intensiveness, and insufficient education and training as contributing to GP/FP's reluctance to take primary responsibility for children with ADHD, while a US study of primary care providers found that higher severity of child psychosocial problems, and poorer family functioning, predicted referral to specialized mental health services .
The higher reported level of involvement and comfort/skill in dealing with mood disorders may reflect primarily work with adolescents, in which GP/FPs utilize strategies that are successful with adult patients, and drawing on the fairly extensive exposure to psychosocial medicine in family practice training. We cannot address this possibility directly from data obtained from respondents in our survey, but we note that over 2/3 of pediatric cases of depression seen in a recent study of US pediatricians, did indeed involve youth 13 – 18 years of age . We note, however, that the diagnostic and treatment approaches used for adults may not be appropriate for younger children, especially in light of concerns about the effectiveness and safety of specific serotonin reuptake inhibitor (SSRI) medications that have arisen since the time of our survey . An apparent trend for more respondents to report high rather than low levels of comfort/skill for mood disorders compared with social-emotional difficulties, may be attributable in part to the terminology used in the survey. Although behavioral and social-emotional problems that would be considered subthreshold for specific diagnoses occur relatively frequently in primary care settings [26, 27], it is possible that these non-specific and somewhat ambiguous terms may evoke uncertainty in the mind of clinicians trained in diagnostic and management approaches aimed at clearly delineated entities. Physician's responses in this survey might therefore reflect either uncertainty about how to cope with such problems in children, or perhaps about what was being referred to in the survey.
Strengths of our study include its careful sampling base of GP/FPs from across the province of BC, and its breadth and depth of scope. This is one of very few studies to examine how GP/FPs as a group, deal with children presenting with a range of behavioral and emotional problems, while at the same time exploring factors that underlie some of the physicians' practice patterns, preferences and perceptions. Certain limitations of this work also need to be acknowledged. Cross-sectional studies are limited in their ability to arrive at conclusions about causality. Hence we cannot be sure, for example, that attending CME increases comfort and skill levels. It is possible that physicians who attend CME on certain topics may be particularly interested and motivated in those areas. Nevertheless, our study highlights important associations, a number of which fit with causal expectations suggested by other studies and theory. We also cannot be sure that the views of our respondents reflect all GP/FPs' perceptions and practices, given our 64% response rate, although this was considerably higher than the 54% reported for physician postal surveys overall . Finally, the extent to which our findings from a Canadian health care context would generalize to settings where patients' medical needs are not covered under a system of universal health insurance coverage, or where GP/FPs are less extensively involved in primary care, is unknown. However, our findings are consistent with those from other settings.[6–8, 11] It is interesting to note that while primary care pediatricians in the USA report relatively low levels of confidence in their diagnostic and management skills for depression in children and youth most still become directly involved in some aspect of these patients' care , in a similar fashion to GP/FPs in BC. These observations underline the need for better support for primary care physicians in their role with these children, through increasing self-confidence and self-efficacy.