Physician Identification and Management of Psychosocial Problems in Primary Care

Abstract

Often the burden of identifying children with behavioral or developmental problems is left up to the primary care physician (PCP). However, previous literature shows that PCPs consistently underidentify children with developmental/behavioral problems in pediatric primary care. For the current study, questionnaires containing three vignettes followed by questions addressing common psychosocial problems, general questions about their practice and training, and the Physician Belief Scale were distributed to physicians. Results indicated that physicians were better at identifying severe problems, had more difficulty identifying psychosocial problems with mild symptomatology, and tended to refer to a medical specialist or mental health professional more often for severe problems, depression or a developmental problem. Physicians tended to view treating psychosocial problems favorably.

Appendix

Vignette 1: Mild Hyperactivity

Tanen’s mother tells the pediatrician that she’s concerned about Tanen’s hyperactive behavior. At 3 1/2 years old, Tanen has recently been enrolled in a nursery school for three half-days a week. She notes that Tanen runs around during the play sessions in circles and sometimes knocks over things. When the teacher tries to get the children to snack time, Tanen often wants “just one more” turn around the play area. At home sometimes Tanen seems just to talk constantly and wants to ride the trike at “breakneck” speed. She has a hard time getting Tanen to sleep at naptime because Tanen’s so wound up and won’t settle down. Tanen sleeps well at night.

In the mornings, however, Tanen will sit at the kitchen table coloring and drawing for 20 min or more. When she sits Tanen down to read a book, Tanen loves turning the pages and pointing to the pictures that go with the story.

On observation Tanen is a very inquisitive child who asks constant questions while being examined. When the doctor tells Tanen not to play with the blood pressure cuff, Tanen responds by asking more questions but doesn’t return to the pressure cuff. Physical and developmental assessment is normal to advanced.

The nursery school teacher is contacted and says, “Tanen is a handful but responds well to explanations and re-direction. Tanen seems very bright.” She does not feel that Tanen is much more active than the other children in the class.

Vignette 2: Severe Hyperactivity

Tanen’s mother tells the pediatrician she is concerned about the reports she receives from school that Tanen, who is 6 years old, often disrupts the classroom with talking out of turn and saying things that aren’t related to what the class is doing. The parents have been concerned about Tanen since about age 4 because Tanen often seems “all wound up” and is difficult to settle for naps or at mealtimes. In addition, when Tanen is asked to put away toys or get ready for bed Tanen frequently resists and has temper tantrums, which may last for several minutes. Sometimes Tanen’s temper tantrums have been so severe that the family has been to the emergency room because Tanen was “head banging” on a piece of furniture and for twisting an ankle when kicking the furniture. Last year’s kindergarten teacher reported that Tanen was a “difficult child” who took up much of her time to tend to Tanen climbing on furniture and knocking into objects or other classmates. The teacher also reported that Tanen often bugged other children and had difficulty sharing and following the rules in a game. The other students complained when being paired with Tanen for an activity.

Tanen is the first child of parents who both work “to make ends meet.” A younger sibling was born 2 years ago and the parents feel that Tanen’s problems really became apparent then. Tanen has a normal early medical history except for frequent ear infections between 18 months and 3 years of age. However, the last ear infection was a little more than a year ago and a hearing test was normal.

Vignette 3: Mild Depression

“Fergit seems less interested in schoolwork and practicing the piano. Is this a phase? Fergit’s my first child to reach adolescence and I don’t know what to expect.” On further history, Fergit’s mother noted that Fergit’s appetite had increased and Fergit seemed to be staying up later at night, claiming to be unable to fall asleep. Fergit seems more irritable and moody, choosing to spend more time alone in the room and less time with Fergit’s 10-year-old sibling. When asked by Fergit’s mother, Fergit said, “I just don’t feel like doing schoolwork and practicing the piano anymore.” Overall, Fergit, a 9th grader, is keeping up in school and in three extracurricular activities. Fergit has a best friend and mentioned hanging out with a group of people from school at the mall last week.

Fergit is a well-appearing 14-year-old, tanner stage 5, and wearing baggy clothes. Physical exam was unremarkable and a review of systems yielded no additional symptomatology. Fergit answered to feeling down at times, not usually lasting more than a few hours, and has been getting frustrated a little more easily, especially with parents. Fergit gets along well with friends and is on the freshman soccer team. Fergit found school a little more difficult and often didn’t feel like doing all of the homework, but was able to maintain a C average. Fergit said, “My mother gets down on me for not helping around the house, when some friends leave me out of some planned events, and whenever I get a poor grade in school and it makes me sad sometimes. All in all, I just like hanging out with my friends more than my family lately.”

Vignette 4: Severe Depression

Fergit is a 15-year-old patient whom you have followed since age 6. Fergit originally came to you at age 9 drinking approximately 2 gallons of water per day along with other fluids. Your evaluation shows that Fergit had diabetes insipidus and a pituitary lesion. Fergit was “cured” and began lifetime hormonal replacement therapy.

At age 11 Fergit developed severe fatigue, for which no identifiable medical cause could be found. At age 12 Fergit developed abdominal pain without an identifiable medical cause. At age 14 Fergit developed knee and leg pain that proved to be reflex sympathetic dystrophy. Fergit receives extensive physical therapy and treatment at a medical center pain program. Fergit’s mother wanted an appointment to see you because of Fergit’s lack of energy, annoyance with frequent doctor visits, and appears depressed. Fergit’s mother reported that grades at school are poor and that Fergit often sleeps 12–14 h a day and still has trouble getting up for school. Fergit’s mother has also noticed that Fergit seems to spend a lot of time in alone in a room and friends have not been over lately. She reported that Fergit has been becoming increasingly frustrated with every little thing and that asking Fergit to do a small task can turn into a huge fight, which often leaves both of them in tears. Sometimes Fergit says to her that it would be better if he was not around. During your evaluation, you repeat a physical and find his exam results to be at baseline; he is in the 75th percentile for height and 25th percentile for weight.

Fergit avoided eye contact and responded to questions with one to two word phrases. Fergit looked tired and appeared disinterested in what was being said during the exam. Fergit’s affect was flat and Fergit was observed to be grimacing during much of the visit.

Vignette 5: Mild Anxiety

At a well child check up, Nebit’s mother indicated that she has concerns about her child’s behavior. Nebit is a 2-year old whose parents are concerned about Nebit’s difficulty relating to other children. Nebit’s mother said, “Nebit has always been good and quiet, even as a baby. Nebit’s temperament has always been so calm and sweet. I remember that Nebit was always a little shy around strangers, but always warmed up to them when I was around.”

Whenever unfamiliar children come into the home, Nebit avoids them initially, but eventually learns to make relationships with children as they become more familiar. The parents describe Nebit as always being a shy child who has difficulty managing new situations. Nebit’s parents have always had to help their child deal with new events, including social situations.

On the other hand, Nebit’s strengths include a good sense of humor and positive relationships with older siblings. Nebit’s mother said, “Nebit stays at home with me and is not around other children very often, except for siblings.” Nebit’s mother expressed concern about the lack of interaction with other children and that social skills will be delayed if she does not put Nebit in daycare.

Vignette 6: Severe Anxiety

Nebit’s nursery school teacher called home because she was very concerned about Nebit’s difficulty establishing contact with other children, despite repeated opportunities to do so. Nebit prefers to stay near the teacher and avoid other children for the most part. Nebit also cries and screams and is difficult to calm own after being dropped off at school. Almost every day, Nebit’s mother has to stay a couple of hours before being able to sneak out.

Nebit is three years old and is an only child of a single mother. Nebit’s mother and father have been divorced since Nebit was born. Nebit’s mother stated, “Nebit cries often when taken to preschool and often has temper tantrums in the morning in order to be able to stay home. Sometimes I allow Nebit to stay home.” Nebit’s mother reported many nights that she let’s Nebit sleep in her bed to avoid Nebit’s temper tantrums or nightmares about sleeping alone in a room. Nebit also has difficulty when going over to Dad’s house for the weekend and often expresses worry that something is going to happen to Mom. Nebit’s teacher noted that Nebit’s avoidance of peer contact has been interfering with relationships with others who tend to avoid Nebit.

Vignette 7: Mild Developmental Problem

Mrs. Smith, Shin’s mother, consults you about the sudden onset of daytime urinary wetting. Shin is 4 1/2 years old and had achieved both daytime and nighttime continence for 1 year. In the last 2 weeks, Shin has been wetting at home and at nursery school. Shin has been enrolled in nursery school for about a year. You learn that the child’s teacher retired a month ago and has been replaced by another teacher. Shin’s mother is also 4 months pregnant.

You conduct a physical exam that gives results within normal limits. A urinalysis is likewise normal and a urine culture is pending. An interview with the child indicates excitement about the upcoming birth of a sibling. Shin’s mother reports that open visitation is encouraged at school and due to cross-supervision the likelihood of sexual contact is remote.

Discussion with the nursery school teacher indicates that she feels that toileting issues at school are best handled on a “scheduled” basis so as not to interrupt “educational” opportunities at school. Both Shin’s mother and teacher report that Shin is a good child with a good temperament. Shin teacher did not report any problems in making friends or learning. During the physical exam, Shin followed directions and sat quietly while talking with Shin’s mother.

Vignette 8: Severe Developmental Problem

Shin is a good-looking 4-year-old. Shin is strong and runs gracefully. But something about Shin is very odd. Shin just doesn’t seem like other kids in the nursery class. Shin talks a lot, sometimes nonstop, but doesn’t join circle time conversation. Shin is really into movies like Aladdin and Beauty and the Beast and will watch them over and over again.

Shin doesn’t look at you. It is almost as if you are not there, or worse, that you are a table or a chair. If you ask Shin, “how are you?” the reply comes, “Shin, how are you?” over and over as you try to make conversation. The echoed expressions ring in your ear and sound bizarre.

Shin’s parents observe their child dancing and singing a lot. Shin loves to play-but not with other children-with sand and water. Shin gets wound up in things and very focused. Shin gets furious when told to stop playing in the water to come to lunch. Shin does not seem to enjoy it when people, including Shin’s parents, touch or hug the child and often does not respond to their touch.

Shin has strong dislikes. Loud noises bother Shin. Shin whines when having to put a wool sweater on. Shin wriggles to get away from the tag on the T-shirt. Shin complains about smells that are barely apparent to others. Shin was an easy baby so all of this difference and trouble are a surprise to Shin’s parents. In addition, Shin’s daycare provider has recently reported concerns to Shin’s parents about learning issues, especially Shin’s language development and verbal skills.

Vignette 9: Control

At a well child check up, Nish’s mother told the physician that, “Nish is doing well.” Nish, who just turned six years old, has started kindergarten and is adjusting well at school. Nish has attended kindergarten all day for the past two months and is learning letters of the alphabet. Nish’s mother indicated that Nish was a little scared the first couple of days and cried for a few minutes before she left the school, but has had no problems since then.

Nish lives at home with both parents and two older siblings. Nish’s mother indicated that behavior was good at home, but that occasionally Nish would say “no,” when asked to do a chore, but after Nish’s mother threatened to use time out, Nish completed the task with little resistance. She said that Nish’s defiance usually occurred if seeing the older siblings acting defiant to their mother. Most of the time, Nish and the older siblings get along.

Nish enjoys playing with the other children in the neighborhood and likes to play games outside, like basketball, softball, baseball, and tag. Nish’s father works late hours, but always makes time for the kids on the weekends. Nish’s mother worries about the late hours that her husband works, but admits that since she is a homemaker, the father’s income is needed really badly. Recently, Nish’s father, lost his job, but was able to get another one within the month.

You conduct a physical exam, which produces results within normal limits.