Why Screen?
(Adapted from Jellinek, M. "Approach to the
Behavior Problems of Children and Adolescents." In T.A. Stern, J.B. Herman,
P.L. Slavin (Eds.) The MGH Guide to Psychiatry in Primary Care. 1998.
New York: McGraw-Hill: 437-443).
Why
screen for psychosocial problems?
- Studies indicate that less than 30 percent of children with substantial dysfunction are recognized by primary care clinicians. Nationally, referral rates of children seen by pediatricians to mental health services range from 1 to 4 percent. Often recognition depends on parental complaint or school report of overt behavioral problems; early recognition, prevention, and less overt dysfunction (such as secondary and childhood depression, or family factors such as divorce) are much less likely to be addressed.
- Children with chronic disease are about twice as likely to have a psychosocial disorder (those suffering from epilepsy are at highest risk). Psychosocial functioning also has an impact on medical compliance and is associated with higher utilization of primary care services.
- Children who have major difficulties in one area of functioning often demonstrate symptoms and difficulties in other areas of daily functioning. For example, if they are having school difficulties secondary to attention-deficit/hyperactivity disorder (ADHD), symptoms such as motoric activity or impulsivity will be evident at home and may interfere with other activities. Even less overt disorders such as learning disabilities or difficulties in peer relationships will often manifest as depressed mood at home, tension with siblings, or low self-esteem.
- Accidents, a leading cause of death in children and adolescents, are often secondary consequences of psychosocial stressors. Fires, falls from windows, drowning, and motor vehicle accidents are all more likely in the context of psychosocial dysfunction.
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How
can screening for psychosocial problems help children?
- Screening enables clinicians to recognize problems – quickly – and to provide help, preferably at an early and effective point. Screening tests are not designed to yield diagnoses or label children. For example, rather than review symptoms of diabetes in every child, a urine screening test helps the primary care clinician determine which children need further evaluation. Similarly, psychosocial screening is a starting point for further questions and assessment.
- A key component for determining appropriate treatment, as prescribed by the DSM-IV (Diagnostic and Statistical Manual of Mental Disorder. Fourth Edition) and the DSM-IV-PC (Diagnostic and Statistical Manual of Mental Disorder. Fourth Edition. Primary Care Version), is the extent of impairment or severity. Some presentations, such as psychosis or a serious suicide attempt, are clearly severe and will need to be referred for possible hospitalization. Other conditions, however, such as depression or ADHD, can vary widely in severity and in milder cases will be managed in primary care settings, some with support or changes in school program; others with psychotropic medications and more comprehensive treatment programs. Early recognition, at a point before damage to self-esteem, is both prognostically better for the child and economically better for the child’s family and for those funding services.
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