Abstract: Based in the multicultural context of Montreal, Quebec, Canada, this article reviews Shared Care and Collaborative Care models which privilege consultations between primary and specialty care in children’s mental health. An overview of Canada’s two largest child psychiatric epidemiological studies outlines the nonclinical community prevalence in Ontario (18.5%) and Quebec (15%) of children’s mental health problems along with salient family and community risk factors. Given the high prevalence of children’s mental health problems and the burden of care undertaken by primary care practitioners, the interface between the first line of care and mental health services is crucial yet often characterized by poor communication, a lack of mutual comprehension, and limited collaboration.[1] Collaborative mental health care has been defined as "a family physician or other primary care provider working together with a psychiatrist or other mental health worker in a mutually supportive partnership.”[1] This definition is extended to describe a spectrum of partnerships in Child and Adolescent Psychiatry (CAP): Shared Care, Collaborative Care, and related collaborative community practices. The author’s experience with these models is presented with an overview of a pilot study on CAP Shared Care in Montreal.[2] Two other recent trends in Quebec are explored: an innovation called “Medical Specialists Responding in Child and Adolescent Psychiatry” (MSRCAP) for community mental health care teams and the pair aidant or “peer helper” model reaching out to patients and families with a member who suffers from mental health problem to serve as a helper, a model, and part of the support network. Key Words: children’s mental health, psychiatric epidemiology, shared care, collaborative care, community consultations Special issue on Child & Adolescent Psychiatry, World Social Psychiatry [serial online] 2022 [cited 2022 Aug 22];4:78-84. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/2/78/354177 DOI: 10.4103/wsp.wsp_19_22

1. Volume 4 • Issue 2 • May-August 2022
WorldSocial
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Ofcial Journal of the World Association of Social Psychiatry
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SPECIAL THEME ISSUE
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Theme Issue Editor: Andres J. Pumariega
Theme Issue Co-Editors:
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2. 78 © 2022 World Social Psychiatry | Published by Wolters Kluwer - Medknow
Children’s Mental Health
Services: Access to Care and
Mental Health Gaps
One of the most pressing problems in
Canadian health care concerns the access
to mental health care for the general
population and even more critically for
children and youth. This is the territory
of the Global Mental Health (GMH)
Movement’s key notion of mental health
gaps, that is, the gap between known
mental health problems in the community
and access to mental health care.[1,2]
Simply
stated in public health terms, our goals
should be to improve access to care and
to reduce mental health treatment gaps in
children’s mental health services.
Our Canadian health‑care system has
responded in the past few decades with
Address for correspondence:
Prof. Vincenzo Di Nicola,
Department of Psychiatry and
Addiction Medicine, Faculty
of Medicine, University of
Montreal, Montreal University
Institute of Mental Health,
Montreal, QC, Canada.
Department of Psychiatry and
Behavioral Sciences, School of
Medicine and Health Sciences,
The George Washington
University, Washington, DC,
USA.
E‑mail: vincenzodinicola@
gmail.com
Access this article online
Website:
www.worldsocpsychiatry.org
DOI: 10.4103/wsp.wsp_19_22
Quick Response Code:
Abstract
Based in the multicultural context of Montreal, Quebec, Canada, this article reviews shared care
and collaborative care models which privilege consultations between primary and specialty care in
children’s mental health. An overview of Canada’s two largest child psychiatric epidemiological
studies outlines the nonclinical community prevalence in Ontario (18.5%) and Quebec (15%) of
children’s mental health problems along with salient family and community risk factors. Given
the high prevalence of children’s mental health problems and the burden of care undertaken by
primary care practitioners, the interface between the first line of care and mental health services
is crucial yet often characterized by poor communication, a lack of mutual comprehension, and
limited collaboration. Collaborative mental health care has been defined as “a family physician or
other primary care provider working together with a psychiatrist or other mental health worker in a
mutually supportive partnership.” This definition is extended to describe a spectrum of partnerships
in child and adolescent psychiatry (CAP): shared care, collaborative care, and related collaborative
community practices. The author’s experience with these models is presented with an overview of
a pilot study on CAP shared care in Montreal. Two other recent trends in Quebec are explored:
an innovation called “Medical Specialists Responding in Child and Adolescent Psychiatry” for
community mental health‑care teams and the pair aidant or “peer helper” model reaching out to
patients and families with a member who suffers from mental health problem to serve as a helper, a
model, and part of the support network.
Keywords: Children’s mental health, collaborative care, community consultations, psychiatric
epidemiology, shared care
Beyond Shared Care in Child and Adolescent Psychiatry: Collaborative
Care and Community Consultations
Perspective/Viewpoint
Vincenzo Di
Nicola1,2
1
Department of Psychiatry and
Addiction Medicine, Faculty
of Medicine, University of
Montreal, Montreal University
Institute of Mental Health,
Montreal, QC, Canada,
2
Department of Psychiatry and
Behavioral Sciences, School of
Medicine and Health Sciences,
The George Washington
University, Washington, DC,
USA
How to cite this article: Di Nicola V. Beyond
Shared Care in Child and Adolescent Psychiatry:
Collaborative Care and Community Consultations.
World Soc Psychiatry 2022;4:78-84.
a series of innovations and adaptations
in the provision of mental health care,
starting with shared care and collaborative
care (Canadian Collaborative Mental
Health Care).[3]
This has been both
popular and helpful for several reasons.
In a context where there are never enough
child psychiatrists,[4]
“the multiplier
effect”[5]
expands the outreach of Child
and Adolescent Psychiatry (CAP), a
medical subspecialty in Canada requiring
a minimum of 6 years of postgraduate
medical training, first in general psychiatry
then in CAP, allowing the transfer of
subspecialist knowledge and clinical
skills to primary care physicians along
with specific advice and supervision for
individual cases.
Shared care simply describes the key
notion that the health of populations and
clinical services from access to care to
evidence‑based treatment interventions
and follow‑through services are a shared
responsibility.[6‑8]
This was just the opening
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are
licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Submission: 29‑06‑22
Acceptance: 30‑06‑22
Decision: 30-06-22
Web Publication: 22-08-22

3. Di Nicola: Beyond shared care in child and adolescent psychiatry
World Social Psychiatry | Volume 4 | Issue 2 | May-August 2022 79
step for an innovative movement in the evolution of a
spectrum of services – from shared care and collaborative
care to a broader range of collaborative partnerships and
practices, including community consultations through the
comparatively new role of “Medical Specialists Responding
in Child and Adolescent Psychiatry” (MSRCAP) for
community mental health teams in Quebec. The goal is
for better coordination and where possible integration of
primary care with behavioral and mental health services.[9]
Ideally, this should start early with the teaching of CAP to
family medicine[10]
and pediatrics trainees.
Kates,[6]
a Canadian leader in shared care, set out the
parameters of this approach:
• “Collaborative mental health care refers to a family
physician or other primary care provider working
together with a psychiatrist or other mental health
worker in a mutually supportive partnership”
• “The responsibilities of care are shared and apportioned
according to the respective skills of the providers and
the (changing) treatment needs of the patient”
The key premises for this approach include these salient
observations:[6]
• The family doctor or other first‑line practitioners play a
key role in mental health care
• 25% of individuals seen in general practice have an
identifiable psychiatric problem (which is nonetheless
not always identified)
• This mental health problem is often anxiety or
depression
• The majority of cases are treated by first‑line
practitioners and are not referred to mental health
services.
Complicating matters, the interface between primary care
providers and specialized mental health care at all ages,
including children and youth, “is characterized by bad
communication, a lack of mutual comprehension, and
limited collaboration.”[6]
Primary care practitioners feel
overburdened by clinical demands, do not always feel
sufficiently trained or supported, and complain about
waiting lists and limited specialized services.
Given the sometimes critical shortage of mental health
resources, collaborative partnerships among second‑line
CAP, first‑line children’s community mental health
services, and primary medical care have become a pressing
priority. In this approach, CAPs function as consultants
aiding primary care physicians (including pediatricians and
family practitioners) to enlarge the range and severity of
problems that they can manage. Key factors include rapid
and easy access to children’s mental health services as
they need arises.[6,11,12]
The Canadian Collaborative Mental
Health Care association[3]
is very active with an annual
conference[13]
and offers a Child and Youth Mental Health
Toolkit[14]
and Child and Youth Mental Health General
Screening Questionnaires.[15]
In a study of one specific interface, pediatrician–
child psychiatrist partnerships improve access to
mental health‑care services with a combination of
indirect (physician to physician discussions), direct (patient
consultations), and follow‑through care of patients for
more severe cases.[16]
This reinforces our approach in CAP
deploying the “the multiplier effect.”[5]
The USA has also made significant advances in this area,
notably in the partnership between Pediatrics and CAP.[17]
The formation of the National Network of Child Psychiatry
Access Programs[18]
in 2011 and the Massachusetts Child
Psychiatry Access Project[19]
along with the Washington
State model[20]
with their Integrated Care Training Program
at the University of Washington[21]
are proven and effective
models of collaboration in children’s mental health care.
The Global Burden of Care: Child
Psychiatric Epidemiology
To put the needs of children’s mental health care in context,
we need to understand the global burden of care that they
represent by studying nonclinical community samples.
North American and worldwide comparisons in child
psychiatric epidemiology are based on populational surveys
of 6–14‑year‑old children, documenting retrospective
6‑month community prevalence rates of children’s mental
disorders. The Isle of Wight surveys undertaken in Britain
in the mid‑1960s created the conceptual apparatus and
methodology for these studies whose principal investigator
offered a 25‑year review of the advances in children’s
psychiatric epidemiology.[22]
The worldwide average of
these studies demonstrates that about 20% of children are
affected by mental health problems, broadly defined (not
necessarily DSM/ICD psychiatric diagnoses). Prevalence
rates vary between 17.6% and 22% of child psychiatric
disorders in nonclinical community samples of children
and adolescents.[23]
Pioneering child psychiatric epidemiological studies have
been conducted in Canada’s two largest provinces.
The Ontario Child Health Study (OCHS) conducted
at McMaster University in the 1980s established that
18.5% of children 6–14 years in Ontario were affected
with a definable mental health problem in the preceding
6 months.[23,24]
Follow‑up studies revealed important
changes in the profiles of children’s mental problems
in Ontario. In the two decades between 1983 and 2014,
studies revealed:[24]
• Dramatic jump of boys 4–11 with attention‑deficit
hyperactivity disorder (ADHD)
• Teens saw a steep increase in anxiety and depression in
boys and girls
• Substantial drop in the prevalence of conduct disorder
among boys
• Among immigrants: 50% drop in prevalence of
children’s disorders

4. Di Nicola: Beyond shared care in child and adolescent psychiatry
80 World Social Psychiatry | Volume 4 | Issue 2 | May-August 2022
• Strong evidence that poverty increases the risk for
childhood disorder in combination with contextual
factors such as neighborhood antisocial behavior
• Geographic shift in prevalence from large urban areas
to small‑medium urban and rural areas.
Finally, in a component study of access to children’s mental
health services in Ontario, the proportion of the children’s
population served increased, but most remained without
contact with mental health services.[24]
The Quebec Child Mental Health Survey (QCMHS),
conducted a decade later by the child epidemiological
research team at the University of Montreal, adapted the
research methodology.[25]
Previous studies focused more
on socioeconomic and sociodemographic characteristics
than on family characteristics. The Quebec investigators
noted that there were no accepted methods to analyze and
interpret the correlates of community studies so the goals
of the study were:[25]
• To identify correlates of DSM‑III‑R internalizing and
externalizing disorders according to informant (youth,
parent, and teacher), for three age groups (6–8, 9–11, and
12–14 years), including relevant family characteristics
• To interpret the relative importance of risk indicators by
ranking correlates according to strength and consistency
of association across age groups
The QCMHS results revealed:[25]
• The overall Quebec population shows 15% prevalence
of mental health problems in children aged 6–14 years
• This contrasts with an alarming rate of 60% in the
substudy of a disadvantaged neighborhood (Hochelaga–
Maisonneuve)
• Inconsistency of correlates across informants
• Individual and family characteristics make a more
important contribution than do socioeconomic
characteristics.
In conclusion, the QCMHS demonstrates the relevance of
“proximal variables” (or more psychological factors such
as family characteristics) in the development of children’s
psychopathology, also found in the OCHS.[26]
The substudy
of a disadvantaged neighborhood in Montreal offers a
complex portrait of the negative impacts of Adverse
Childhood Events (ACE)[27,28]
and the Social Determinants
of Health and Mental Health (SDH/MH)[1,29]
with an
alarming four‑fold increase of problems (60%) over the
provincial average (15%).
In light of the larger findings of the QCMHS that
demonstrated the important contribution of individual and
family aspects, we undertook a more detailed analysis
of single‑parent families in the substudy population, to
test the hypothesis that single‑parenthood increased the
risks for children’s mental health. Our substudy analysis
of single‑parent families offers a complex portrait of the
negative impacts of ACE and SDH/MH, revealing that:
• SDH/MH are multifactorial and multigenerational
• Affecting both more intimate family attachments and
broader social belonging
• Echoing the results of the OCHS.[26]
Informed by ACE, SDH/MH, and QCMHS studies, all
children’s services must address more complex and subtle
social determinants affecting children’s lives and reach
behind the populational parameters to engage the “narrative
resources” that developmental psychologist Jerome Bruner
identified.[30]
Narrative resources are rich and nourishing
when present, yet lead to the impoverishment of affective
and social capacities throughout the lifecycle when absent.
Mental health treatment gaps
The WHO Commission on Social Determinants of
Health (CSDH) study[1,31]
and the associated literature on
GMH reveals significant mental health treatment gaps,
that is the gap between known mental health problems
in the population and access to care.[2]
The WHO has
made concrete and specific recommendations to reduce
the treatment gaps.[31]
The spectrum of services under the
rubric of Shared Care and Collaborative Practices can
alleviate the treatment gap by multiplying the impact of
scarce resources. Related transdisciplinary practices may
also be very helpful especially in low‑ and middle‑income
countries (LMICs). In Brazil, for example, the integrative
community therapy model is a low‑cost, low‑tech
community approach that reaches hundreds, even thousands
of people with mental health problems using comparatively
few professional resources.[32]
Hôpital Maisonneuve‑Rosemont Pilot Study
of Shared Care in Child and Adolescent
Psychiatry: Outline and Satisfaction Survey
At the Child Psychiatry Service of the Hôpital
Maisonneuve‑Rosemont affiliated with the University of
Montreal, we developed a pilot study in 2006 to expand
outpatient child psychiatry consultations in pediatrics to
an extended network of community‑based primary care
pediatricians and family practitioners caring for children
and adolescents. We established clear definitions of our
pilot project that limited the CAP consultation to a key
medical question to be answered in a single session with
rapid access and feedback to the primary care practitioner
in our catchment area in Montreal east within a delay
of 3 days backed up by telephone follow‑up as needed.
A social worker acted as intake and liaison worker.
In the first phase, a needs assessment was undertaken
with key stakeholders by questionnaire and focus‑group
follow‑ups with administrators and clinicians. The primary
care physicians (pediatricians and family physicians)
identified their priorities and needs:
• Rapid access to a CAP consultation for diagnosis and
treatment recommendations

5. Di Nicola: Beyond shared care in child and adolescent psychiatry
World Social Psychiatry | Volume 4 | Issue 2 | May-August 2022 81
• Clarify their role as primary care physicians and what
to expect from shared care
• Psychopharmacology expertise
• Better understanding of “complex cases” – chronicity,
comorbidity, and severity
• Identify difficult to serve and refractory cases and
recommend other interventions.
We then created an intake form and process to ensure
rapid access to the CAP shared care service. Time
slots were reserved specifically for CAP shared care
consultations which are also teaching clinics for medical
students and residents in psychiatry. An extensive
campaign was undertaken to promote the new service
which rapidly grew in popularity. The social worker
who acted as liaison with primary care physicians
ensured ongoing updates and refinements of the process
and together we conducted a survey about the level of
satisfaction with the CAP shared care service.[33]
The
pilot study identified the consultation requests received in
a 3‑month period (36 cases of 48 seen), examining such
parameters as age, diagnosis, and orientation after the
consultation [Tables 1‑3].
The recommendations that flowed from this pilot study
included:
• Focusing on ADHD, the most common reason for
referrals
• Referral mechanisms were clarified and simplified with
a structured intake form
• Clarification of the roles of the teams in CAP, pediatrics,
and family medicine for follow‑through care
• Continual evaluation of the intake form and process
• Consider expanding the shared care consultation to
primary care physicians in the community
We did follow‑through studies each year for the next
5 years, which showed a steady increase in service
utilization and a high level of satisfaction of both the
referring physicians (100% on most parameters, including
rapid access and response; 92% for diagnosis; and
somewhat lower for recommendations at 71%) as well
as the young patients and their families (over 90%).
The CAP shared care service was then expanded to all
the primary care physicians in the entire catchment area
of more than 100,000 youth (up to 18 years of age) in
Montreal east.
Beyond Shared Care: Innovations in Health
Care
In related innovations in health care, we have employed the
notion of the “patient partner” in the Faculty of Medicine
at the University of Montreal.[34]
In this approach, patients
and their significant others become partners in their own
care. This includes partners, spouses, and family members
for patients of all ages. This extended network can become
an integral part of the treatment team.[35]
The next step in this approach is the “peer helper” or pair
aidant in French. The “peer help mediator” becomes a
bridge between patients, their families, and the health and
social care services. Their presence as mediators improves
the patient–therapist relationship and enhances the patient’s
recovery.[36]
The Province of Quebec has recognized the practice of
MSRCAP for community mental health teams for the last
dozen years. I have been doing it for 35 years as a community
child psychiatrist for which I recently won recognition
from the Canadian Academy of Child and Adolescent
Psychiatry (CACAP) with the Naomi Rae‑Grant Award (2021)
for community child psychiatry. This extends the role of
consultant from individual providers to entire community
mental health teams, offering direct and indirect consultations,
peer supervision, and knowledge transfer and team building.
Table 1: Reason for the shared care consultation
Identified problem ‑ DSM‑IV n (%)
ADHD 14 (38.8)
No comorbidity 6
With comorbidity 8
Tourette syndrome 1 (2.7)
Obsessive‑compulsive disorder 1 (2.7)
Language disorder 2 (5.5)
Pervasive developmental disorder 2 (5.5)
Depression 3 (8.3)
Anxiety/separation anxiety 6 (16.7)
Behavioural problem 7 (19.4)
Total 36 (100)
DSM‑IV: Diagnostic and statistical manual of mental disorders,
fourth edition, ADHD: Attention‑deficit hyperactivity disorder
Table 2: Shared care consultations by age group
Age group n (%)
0-5 4 (11.1)
6-8 15 (41.6)
9-10 7 (19.4)
11-12 6 (16.6)
13-16 4 (11.1)
17+ 0
Total 36 (100)
Table 3: Orientation of cases after the shared care
consultation
Orientation n (%)
Shared care (return to referring MD) 6 (16.6)
First‑line mental health team 22 (61.1)
First‑line psychosocial team 4 (11.1)
Other 4 (11.1)
Specialized clinics ‑ Second‑line CAP 2
CAS and other social services 2
Total 36 (100)
CAP: Child Adolescent Psychiatry, CPS: Child Protective Services,
MD: Referring physician

6. Di Nicola: Beyond shared care in child and adolescent psychiatry
82 World Social Psychiatry | Volume 4 | Issue 2 | May-August 2022
Continuum of collaborative care
We can place these innovations on a “spectrum of care”
or a “continuum of collaborative practices.” We start with
the traditional medical terms of first‑line care (generalist
or family physician and first‑line psychosocial services)
and second‑line care (specialty and subspecialty medical
services), then we can add Shared Care Consultations and
MSRCAP in between them to create bridges, enhancing
communication among health‑care providers and improving
access to care in children’s mental health. Doherty[11]
calls
for a “continuum of collaboration” based on the level of
physical integration of services [Figure 1].
In this conceptual model, the organization of service
providers range from the traditional (separate but equal
partners), to coordinated care (consultations and greater
communication), to colocation with either partner visiting
the other (as in a CAP doing onsite visits to a pediatric
clinic or a pediatrician working at a CAP clinic), and
finally, integrated care where both health‑care services
work together in a collaborative way in the same physical
environment.[11]
Another way to organize services uses
the Four Quadrant Clinical Integration Model[9]
in
which services are organized according to greater risk in
physical versus behavioral or psychiatric health risk and
status [Figure 2].
Conclusions
There are not enough psychiatric specialists and
subspecialists in any country, even in an advantaged and
progressive country with national health care like Canada,
but the issues of access to mental health care in both
general and child psychiatry are especially acute in LMICs
and the Global South,[37,38]
prompting the Royal College
of Psychiatrists (UK) to publish manuals to guide primary
care practitioners[4,39]
in those health‑care systems.
We must employ ways to “multiply” our impact through
indirect consultations to other physicians, mental health
professionals, and responding to community health and
social care teams to reach more of the population. This
increases not only our reach but our effectiveness and level
of mutual satisfaction.[5,40]
The ultimate goal is a better
integration of psychiatry and child psychiatry with primary
medical care.[9,41]
This is a GMH issue[42]
whose slogan, “No health without
mental health,”[43]
is acutely felt in children’s mental health
at all levels, from the study of mental health gaps[1,2,37]
to
the provision of care and mentoring trainees for the next
generation in the delivery of ever‑more responsive clinical
models of children’s mental health care.[5,10,44]
It reflects
the clinical salience of the SDH/MH,[1,29]
along with the
powerful populational data of the ACE study.[28,29]
While this is relevant and helpful in Canada, it is crucial
for the LMICs of the Global South.[37,38]
Furthermore,
collaborative care practices must be promoted as low‑tech
practical clinical tools for the social psychiatrist and a key
plank in the platform of 21st
century social psychiatry.[45]
Acknowledgments
The author gratefully acknowledges the valuable
collaboration of Francyne Brosseau, MSW, in the pilot
project and study of Shared Care in Family Medicine and
Paediatrics with the research support of the Department of
Psychiatry, Hôpital Maisonneuve‑Rosement. The author
conducted an analysis of the substudy of the QCMHS
focusing on single‑parent families in a disadvantaged
neighborhood of Montreal with Lise Bergeron, PhD, and
her associates at the Hôpital Rivières‑des‑Prairies, affiliated
with the Faculty of Medicine, University of Montreal. In
2021, the author was given the Naomi Rae‑Grant Award
by the CACAP in recognition of his work in collaborative
community child psychiatry
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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