Primary care pediatricians address a wide range of issues during routine outpatient visits and are often perceived as the primary source of treatment for any and all problems and increasingly feel on the front line in the care of the childhood emotional and behavioral problems.1 It is not unusual for the physician to be near completion of a typical 10-minute appointment and to hear the parent mention the child's difficulty with attention, mood, or anxiety. The primary care pediatrician is typically well known to the family as a caregiver to multiple children, occasionally over generations, or as a friend and neighbor. The child's provider looks to the primary care pediatrician to either validate or dismiss their concerns and perhaps to explain how such problems were identified. Unfortunately, there is little time to pursue these questions in depth, particularly when other patients are waiting to be seen. The pediatrician must then decide whether to interrupt the flow of patients to address the problem, ask the parent to schedule another appointment when the issue can be more completely reviewed, or refer to a mental health professional. Rushton et al., in a recent survey of primary care physicians on their management of childhood depression, found that only 8% believed they had adequate training and only 11% felt comfortable with the task, whereas 52% believed that managing depression was too time-consuming for their office schedule.2
Meanwhile the US Surgeon General has declared a crisis in the area of access to mental health care to children and adolescents3 and primary health care is often cited as part of the solution.4 The pediatrician may feel caught between initiating treatments for which many feel ill-prepared or taking on the often daunting challenges of negotiating in a complicated and frustrating mental health system.
These joint crises - access to mental health care and pressure on primary health care providers to meet mental health needs - are well-recognized by both the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP). The two organizations have collaborated along with others in the production of two important documents, both sponsored by the federal Maternal and Child Health Bureau (MCHB), that begin to address to the challenges of developing a shared language and set of procedures to address mental health care and concepts within primary health care: the Diagnostic and Statistical Manual for Primary Care, Child and Adolescent Version (DSM-PC, CAV)5 and Bright Futures in Practice: Mental Health.6 The latter is a set of guidelines and tools for practitioners involved in the health care of children and adolescents and arises from the Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, a 12-year project of the MCHB, which always had a strong focus on mental health. Both documents have been welcomed by the AACAP as fruits of an exciting new era of collaboration between mental health and pediatrics.7 The American Academy of Pediatrics recognizes the importance of psychiatric issues for their patients and the need to develop psychosocially sophisticated primary care and has recently been successful in obtaining three grants through the MCHB that have the potential to address aspects of the psychosocial care of children; two projects are based on Bright Futures: the development of an education center and a project to implement Bright Futures guidelines within the pediatric community. A third, the Pediatrics Collaborative Care Program, is developing a plan to implement enhanced care of mental health issues within pediatrics. The American Academy of Child and Adolescent Pediatrics is represented on the advisory committees for both projects.
The AAP has recently released guidelines for attentiondeficit/hyperactivity disorder treatment and is now working on addressing barriers to the implementation of the guidelines; the AACAP has worked with AAP throughout this 5-year project and continues to do so. In addition, the AACAP has appointed liaison representatives to eight other AAP committees that focus on a wide variety of shared issues. Furthermore, AAP and AACAP staff keep close contact on legislative and other issues where joint advocacy for children and adolescents may be needed.
Together we can develop models of integrative care that work. In this spirit, this issue of Pediatric Annals focuses on the psychiatric care of children in a primary pediatric setting and has been developed by the members of the AACAP Committee for Liaison with Primary Care. It is intended to be a practical guide for dealing with the common challenges and frustrations that accompany the care of behavioral and emotional problems in children. Drs. Anthony Guerrero, D. Christian Derauf, and Mai Anh K. Nguyen begin by discussing some of the psychiatric disorders frequently uncovered by pediatricians. The diagnoses include postpartum depression seen in mothers during the first year of their child's life, autism diagnosed in the context of a neurodevelopmental disorder, the use of corporal punishment and its relationship to youth violence, attention-deficit/hyperactivity disorder and mood disorders including depression and bipolar disorder. Dr. Jonathan Slater reviews pain syndromes in the pediatric patient and the important role of the general pediatric practitioner when differentiating functional from organic etiologies. In addition to a discussion of somatoform and pain disorders, Dr. Slater reviews possible treatment options. Evidence of child abuse typically appears first in the primary care setting. Dr. Jeanette M. Scheid addresses this public health problem from a psychiatric perspective, considering clinical presentations, risk factors, barriers to assessment and treatment, and possible interventions. Psychiatric cases present practical challenges for the pediatrician and the need for proper assessment and treatment requires a clear understanding of service delivery. Dr. Pilar Bernal considers the importance of appropriate care, probable obstacles to treatment, and the domains of research that are essential to the development of effective services. Collaboration between Child and Adolescent Psychiatry and Pediatrics goes beyond practical considerations to an understanding of the priorities, motivations, and even histories of the respective specialties. Dr. Gregory Fritz provides a unique, fascinating, and informative review of the factors that bring us together and occasionally pull us apart. The resident perspective on the role of Child and Adolescent Psychiatry in a Pediatric Training Program is provided by Dr. Aaron W. Calhoun, a second-year pediatric resident at Children's Memorial Hospital in Chicago.
1. Torstenson OL. The treatment of mood disorders in children and adolescents by general pediatricians. Biol Psychiatry. 2001;49:970-972.
2. Rushton JL, Clark SJ, Freed GL. Primary care role in the management of childhood depression: a comparison of pediatricians and family physicians [comment]. Pediatrics. 2000:105(4 Pt 2):957-962.
3. Report on the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. Washington. DC: US Public Health Service; 2000.
4. Wells KB, Kataoka SH, Asarnow JR. Affective disorders in children and adolescents: addressing unmet need in primary care settings. Biol Psychiatry. 2001 ;49:1 111-1120.
5. Wolraich ML, Felice ME. Drotar D, eds. The classification of child and adolescent mental disorders in primary care. Elk Grove Village, Dl: American Academy of Pediatrics; 1996.
6. Jellinek M. Patel BP, Froehle MC. eds. Bright Futures in Practice-Mental Health. Arlington. Va: National Center for Education in Maternal and Child Health; 2002.
7. Wren FJ. A Bright Future for Collaboration between Pediatrics and Psychiatry. Newsletter of the American Academy of Child and Adolescent Psychiatry. 2002.