Most common psychiatric problems in children and adolescents do not come to professional attention. Of the remainder, a significant proportion are brought to the pediatrician. Observations of office practices suggest that many of these problems are either overlooked or untreated.1 As a result, a major area of potential pediatric care remains underdeveloped.
The behavioral problems that pediatricians could treat are legion. Some practitioners are already treating these problems; others consider themselves untrained in counseling, although they may be aware of its desirability; and still others do not see themselves as potential psychotherapists. A disinclination to engage in psychotherapy may stem from the physician's mindset.2 The ambiguities of psychiatric care, the apparent passivity of the psychotherapeutic role, and doubts as to its efficacy are some of the reasons for such a stance.
The cumulative result is little mental health care for most young patients and a feeling on the part of some parents that pediatricians are neither willing nor competent to care for such problems.3
Pediatricians are constantly charged with responsibility for a myriad of aspects of their patients' lives from exercise and schooling to delinquency and substance abuse. However worthy of attention each problem may be, it is understandable that an apparently endless list of worthy expectations can become enervating. Each area has its own apologists, usually subspecialists inclined to stress the importance of their own areas of expertise.
Why, then, do mental health issues deserve pediatric attention? Because of their frequency and because no other professionals regularly encountering disturbed children have primary responsibility for behavioral problems. Exercise is promoted by the coach; academics by the teacher; delinquency is a legal concept; and substance abuse is a political football. Behavioral problems are overlooked by everyone who can overlook them, including parents. The pediatrician is often the first professional who sees such problems from a position of acknowledged responsibility for the welfare of the child.
Of the relatively few emotional problems actively assessed and treated by pediatricians, even fewer are referred for treatment by mental health professionals. Referrals are few because of cost, stigma, dissatisfaction with outcome, or simply because referrals are unavailable: child psychiatry is the single medical specialty in shortest supply in North America. Currently there are only 40% of the number of child psychiatrists needed to meet minimal requirements.4 Because that 40% is generally located in larger urban settings, the situation in smaller communities is even less favorable.
Given the shortage of child psychiatrists, their most efficient roles may lie in diagnostic assessment, as medical/psychopharmacologic members of treatment teams, and as caretakers of only the sickest children. The majority of disturbed children in active treatment currently are not seen by psychiatrists. For those requiring medical management, an expanded pediatric role seems essential if overall national needs are to be met.
While many pediatricians are aware of psychopathology in certain patients, efficiency in diagnosis will require methods such as questionnaires and structured instruments to assess difficulties more precisely as well as to uncover unsuspected problems.5 Effective diagnosis assumes a willingness to deal with detected pathology. Referral to mental health professionals, where available, will still be indicated in many instances, but in even more cases motivated pediatricians can do as good a job with much less patient resistance. With respect to the emotional vicissitudes of everyday life, it has not been convincingly shown that one specialty is more effective over another.
A more realistic system of reimbursement for psychological care by the pediatrician will be required. Such financing will only emerge when a sufficient number of pediatricians truly wish to perform such care. Pediatricians have shown themselves ready and able to alter practice patterns in behavioral areas such as physical, and more recently sexual, abuse. The same alteration of pediatric practice must now occur for emotional pathology.
1. Costello EJ: Primary care pediatrics and child psychopathology: A review of diagnostic, treatment, and referral practices. Pediatrics 1986; 78:1044-1051.
2. Brown HN, Zinberg NE: Difficulties in the integration of psychological and medical practices. Am J Psychiatry 1982; 139:1576-1580.
3. Hickson GB, Altmeier WA, O'Connor S: Concerns of mothers seeking care in private pediatric offices: Opportunities for expanding services, Pediatrics 1983; 72:619-624.
4. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services: Vol. I. Summary. US Department of Health and Human Services, Health Resources Administration Office of Graduate Medical Education, 1981.
5. Jellinek MS, Murphy JM: Screening for psychosocial disorders in medical practice. Am J Dis Child 1988; 142:1153-1157.