General practitioners' everyday clinical decision-making on psychosocial problems of children and youth in the Netherlands

Abstract

Background: Psychosocial problems in children and youth are common and may negatively impact their lives and the lives of their families. Since general practitioners (GPs) play a crucial role in detecting and intervening in such problems, it is clinically necessary to improve our insight into their clinical decision-making (CDM). The objective of this study was to explore which mechanisms underlie GPs' everyday CDM and their options for management or referral.

Material and methods: This was a mixed methods study in which qualitative (interview substudy) and quantitative (online survey substudy) data were collected from GPs. Using a question framework and vignettes representative of clinical practice, GPs' CDM was explored. GPs were selected by means of an academic research network and purposive sampling. Data collection continued in constant comparison between both substudies. Using grounded theory, data from both substudies were triangulated into a flowchart consisting of mechanisms and management/referral options.

Results: CDM-mechanisms were divided into three groups. GP-related mechanisms were GPs' primary approach of the problem (somatically or psychosocially) and their self-assessed competence to solve the problem based on interest in and knowledge about youth mental health care. Mechanisms related to the child and its social context included GPs' assessment whether there was psychiatric (co)morbidity, their sense of self-limitedness of the problem and assessed complexity of the problem. Whether GPs' had existing collaboration agreements with youth care providers and how they experienced their collaboration were collaboration-related mechanisms.

Conclusion: The current study contributes to a relatively unexplored research area by revealing GP's in-depth thought processes regarding their CDM. However, existing research in this area supports the identified CDM mechanisms. Future initiatives should focus on validating CDM mechanisms in a larger population. If confirmed, mechanisms could be integrated into GP training and may offer guidelines for regulating proper access to mental health care services.

Fig 1. Simplified overview of the Dutch youth care system in relation to the social and medical domains concerning a child and its family and/or social network¹.

¹Figure derived from: Akwa GGZ [Internet]. Utrecht; c2022 [cited 2022 Feb 21]. Generieke module Samenwerkingsafspraken (jeugd); [about 9 screens]. Available from: https://www.ggzstandaarden.nl/generieke-modules/landelijke-samenwerkingsafspraken-jeugd-ggz/inleiding/doelstelling-van-deze-standaard (in Dutch).

Fig 2. Methods: Processes related to data acquisition and data analysis (convergent design)¹.

¹Figure derived from: Creswell JW, Plano Clark VL. Choosing a mixed methods design. In: Creswell JW, Plano Clark VL, editors. Designing and conducting mixed methods research. Thousand Oaks: SAGE Publications Ltd; 2017. p. 53–106. ²CDM = Clinical Decision-Making. ³Sampling criteria included district in which GPs’ general practices were established (with a maximum of one GP per district for the interview sub-study), GPs who reported seeing psychosocial problems among children and youth a minimum of three times per two weeks and experienced GPs who worked for themselves.

Fig 3. Flowchart of mechanisms for GPs’ everyday clinical decision-making when encountering psychosocial problems in children and youth^1,2.

¹Presented flowchart shows GPs’ sequence of reflections and decisions when confronted with psychosocial problems in children and youths during office hours. ²Boxes show in-depth considerations related to a specific mechanism.