APPROACHES TO RECOGNITION AND MANAGEMENT OF CHILDHOOD PSYCHIATRIC DISORDERS IN PEDIATRIC PRIMARY CARE

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BACKGROUND

Psychosocial dysfunction in children, first recognized more than 20 years ago as the “new morbidity” in pediatric practice, is now the leading cause of disability in childhood and adolescence.15, 16, 17, 30 Epidemiologic research indicates that 14% to 20% of American children have one or more psychiatric disorders in the moderate to severe range,10 and the overall prevalence is rising.1 As many as half of all pediatric office visits reflect behavioral, psychosocial, and educational concerns,

COMMON CHILDHOOD PSYCHIATRIC DISORDERS

What are the major psychiatric disorders seen in pediatric practice? This discussion focuses on disorders with an overall prevalence among children of more than 2%—specifically, attention deficit-hyperactivity disorder (ADHD), anxiety disorders, major depression, substance-use disorders, and conduct disorder.

Clinical Interview

Asking questions about psychosocial functioning and being open to the answers given are critical to quality of care in light of the barriers to talking about these emotionally difficult issues. In recent studies, only one third of parents whose primary concern about their children was psychosocial planned to discuss this concern with the pediatrician. When psychosocial issues were raised, pediatricians responded only 40% of the time and even less when parents were less well educated. The

ASSESSING SEVERITY

DSM-PC provides the most practical guide to severity assessment, recommending that in primary-care contexts, severity be rated globally in terms of the child's overall status. DSM-PC proposes the following global ratings of severity:

  • Mild—unlikely to cause serious developmental difficulties or impairment of functioning

  • Moderate—may cause, or is causing, some developmental difficulties or impairment; further evaluation and intervention are warranted

  • Severe–is causing serious developmental

COMPREHENSIVE TREATMENT PLANNING

A comprehensive treatment approach to childhood psychiatric disorders encompasses the appropriate use of verbal therapies and medication and also examines the “fit” between the child and the environment. The child's day-to-day circumstances and activities can then be incorporated into a treatment plan.22 Making the environment therapeutic for the child involves assessing development and daily functioning in the context of family, peers, and school and identifying reasonable expectations.

CONSULTING A PEDIATRIC PSYCHOPHARMACOLOGIST

Traditionally, child psychiatric consultants have provided a broad range of services, including pediatric psychopharmacology, psychotherapy, parent guidance, and liaison with schools and agencies also involved with the child. In recent years, however, numerous forces have led to increasing emphasis on the use of medications in child psychiatry. These forces include the evolution of the Diagnostic and Statistical Manual of Mental Disorders (DSM), yielding increasingly sound diagnostic criteria

SUMMARY

Psychiatric disorders occur in 14% to 20% of American children and adolescents and are a leading cause of disability among them, yet fewer than one in five of these children are recognized. The most common psychiatric disorders presenting to pediatricians include ADHD, anxiety disorders, depression, substance-use disorders, and conduct disorder. Approaches to recognition include screening for psychosocial concerns using specific questions in the clinical interview, and using brief, written

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    Address reprint requests to Linden J. Cassidy, MD, Charlestown Health Care Center, 73 High Street, Charlestown, MA 02129–3096

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