Common mental health issues in pediatrics
Childhood psychosocial problems, considered “the new morbidity" almost forty years ago, have become widely acknowledged as among the most common, chronic conditions of children and adolescents (Haggerty et al., 1975; Kelleher et al., 1996; Kelleher et al., 2000). Epidemiologic studies report that between 2-25% of all American school-age children and 13% of preschoolers have an emotional and/or behavioral disorder (Costello et al., 1988; Brandenburg et al., 1990; Lavigne et al., 1993; Costello et al., 1996). The rates of psychosocial impairment are even higher in risk groups such as low income and/or single parent households (Buckner, 1998; Murphy, 1997).
Pediatricians have long been an important first resource for parents who are worried about their children's behavioral problems (Sharp et al., 1992). With the advent of managed care and especially capitated systems (Eisenberg, 1997), primary care providers assume an even greater "gatekeeping" responsibility to identify, manage, and refer children with emotional and/or behavioral disorders (Jellinek, 1994). However, studies estimate that only about 50% of these children are identified by their primary care physicians and that once identified, only a fraction of these children receive appropriate mental health treatment (Jellinek, 1982; Starfield, 1982; Costello, 1986; Sharp et al., 1992; Navon et al., 2001).
A number of studies (Ryan et al., 1992; Kelleher et al., 1998) have documented an increasing prevalence of behavioral and emotional problems in the US and other countries in children and adults. Despite the growing burden of psychosocial morbidity, pediatricians still do not receive adequate training concerning psychosocial problems (Wissow et al., 1994), are hesitant to attach potentially deleterious labels to children (Costello, 1986), do not have time during office visits to address psychosocial needs (Costello, 1986), and have limited access to mental health referral networks (Jellinek, 1982). Efforts such as the American Board of Pediatrics’ increasing ambulatory and behavioral training requirements and publications such as Bright Futures: Mental Health (Green, 1996; Jellinek et al., 2002a) and the Diagnostic and Statistical Manual for Primary Care (DSM-PC; American Academy of Pediatrics, 1996) have helped to increase awareness of psychosocial morbidity over the long-term, but, as of now, primary care pediatricians still struggle to provide psychosocial services and appropriate referrals (Kelleher et al., 1996). The move to managed care approaches in medicine and the increasing focus on productivity and profitability have created additional pressures for pediatric clinicians to limit attention on psychosocial problems.
The prevalence of psychosocial problems in US children
The past decade has produced a continuing stream of empirical and expert support for the notion that psychosocial dysfunction is one of the leading sources of problems among children. Both large studies (Kelleher et al., 2000; Blanchard et al., 2006) and pediatric authorities (American Academy of Pediatrics, 2001) have continued to endorse the view that psychosocial problems are a major concern for children and families in the US and that, although primary care pediatricians are already concerned about these problems, they should be doing even more as a part of routine care. Supporting these studies are others that have continued to document the fact that roughly half of all pediatric visits and half of all parent concerns during these visits are related to psychosocial problems (Wren et al., 2003).
More specifically, there is data showing that publicly insured children are at elevated risk for mental, emotional, and behavioral disorders (Health Resources and Services Administration, Maternal and Child Health Bureau, 2010). However, a 2010 report from the Department of Health and Human Services Office of Inspector General found that nearly 60 percent of children across nine states who attended a Medicaid well-child visit were not offered a complete screening (Office of the Inspector General, 2010).
A look at current thoughts on psychosocial screening in pediatrics
The need to focus more attention on children’s psychosocial problems has been underscored and raised to the level of policy recommendations by national benchmarking efforts like Healthy People 2010 (USDHHS, 2000a). Healthy People 2010 contained the official goals for US health as determined by the Surgeon General. Two of the HP 2010 goals related directly to psychosocial screening in pediatrics:
I Objective 18-6: “Increase the number of persons seen in primary care who receive mental health screening and assessment” (USDHHS, 2000a)
I Objective 18-7: “Increase the proportion of children with mental health problems who receive treatment” (USDHHS, 2000a)
The recommendation to screen has also been endorsed on a national level by the federal government. The report of the President’s 2003 New Freedom Commission on Mental Health prioritized the prevention and recognition of childhood emotional and behavioral problems through early mental health and developmental screening. Three years later, the Institute of Medicine issued a report calling attention to the need for effective coordination of care and the importance of identifying valid, age-appropriate screening tools for children and youth experiencing mental health problems (IOM). More recently, new federal health reform laws—the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010, together referred to as the Affordable Care Act—require that all new health plans provide preventive services, among which are guidelines from AAP’s Bright Futures calling for an assessment of psychosocial and behavioral health at all well child visits (Patient Protection and Affordable Care Act of 2010; USDHHS, 2011). The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) also includes provisions to ensure the development of appropriate quality measure sets and expand quality measure reporting.
Recommendations for an increased focus on routine screening of psychosocial problems in primary care have been echoed by numerous expert panels and medical bodies that include the American Academy of Pediatrics (AAP), American Medical Association, American Academy of Family Physicians, National Association of Pediatric Nurse Practitioners, US Preventive Services Task Force, and Society for Adolescent Medicine. The AAP Task Force on Mental Health recently released new guidelines and tools to improve the incorporation of mental health screening tools into pediatric practice
Routine screening for psychosocial problems in pediatrics has also become a matter of policy in the guidelines for Medicaid (Adams et al., 1998), the health insurance program that provides healthcare for twenty million of the nation’s poorest children (USDHHS, 1997). The settlement the Rosie D lawsuit in Massachusetts (Goldberg, 2007; Kuhlthau, 2011) was merely the latest in a series of legal challenges in more than a dozen states, all of which have come to the same conclusion, namely that screening for mental health and developmental problems MUST be a part of all well-child visits covered by Medicaid under its Early Periodic Screening Diagnosis and Treatment program (Semansky et al., 2003).
How Screening Can Help
One way to maintain efforts to find and intervene for children with psychosocial problems in the face of numerous financial and logistical barriers is to use brief parent-completed screening questionnaires, such as the PSC, as part of routine primary care visits to facilitate recognition and referral (Sturner, 1991). To improve the accuracy and efficiency of psychosocial surveillance it is important to use formal screening measures in addition to observation and interview. Having parents complete a simple questionnaire may improve the accuracy of the screening process while empowering them and conserving valuable professional resources. Parents can use this as an opportunity to provide information that they would not have otherwise not shared and by doing so provide more complete information with a small investment of professional time. A further advantage to screening using a parent-report measure like the PSC is heightening physicians' awareness and facilitating parent-physician discussions of pediatric mental health.