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

Psychosocial dysfunction in children, first recognized more than 20 ye ars ago as the ''new morbidity'' in pediatric practice, is now the lea ding cause of disability in childhood and adolescence.(15-17, 30) Epid emiologic 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 pedi atric office visits reflect behavioral, psychosocial, and educational concerns, and most children in the United States with a psychiatric di sorder receive care only from their pediatricians, making primary care clinics the ''de facto mental health service'' for most children in n eed of such care.(14) In addition, with the advent of managed care, pe diatricians are increasingly becoming ''gatekeepers'' who identify and refer children with mental health problems. Despite the growing preva lence of psychiatric illness in children, four out of five children wi th diagnosable behavioral and emotional problems are not identified by their pediatricians, and even fewer receive mental health services.(1 4) Furthermore, children are more likely to be recognized and treated if their behavior upsets or annoys adults than if their psychiatric sy mptoms lead to school failure and poor functioning at home. Poor child ren are among the least likely to receive adequate mental health atten tion.(44) Numerous studies have shown that untreated mental health pro blems result in high rates of medical services(29) and place children at high risk for chronic psychosocial morbidity, including antisocial and self-injurious behavior.(31, 33, 40) Some obstacles to recognition by pediatricians are long-standing. Parents may be reluctant to raise psychosocial concerns, pediatricians map wish to avoid stigmatizing l abels, pediatric training underemphasizes mental health and behavioral problems, and reimbursement for psychosocial services is low or unava ilable for pediatricians. New hurdles have emerged as efforts to conta in medical costs, such as managed care systems and capitation, have le d to shortened office visits, larger panel sizes, constraints on refer rals, and even disincentives to recognize children in need.(23) This i ntroduction describes the most common psychiatric conditions presentin g to pediatric clinics and discusses approaches to identification, ass essment of severity, and treatment planning. Within treatment planning are highlighted guidelines for consulting a pediatric psychopharmacol ogist because medication is often an important feature of a comprehens ive treatment plan.