Over the past 2 centuries there have been dramatic epidemiologic shifts in the causes of childhood morbidity and mortality, largely as a result of improvements in personal and public health practices, nutrition and oral rehydration, the advent of antibiotics and vaccinations, improvements in midwifery practice, and technological advances in the care of the premature infant. During the 1960s and 1970s new child health problems were identified that had their origin in the altered physical and social environments of modern life. These conditions, such as behavioral and learning problems in preschool and school-aged children, teenage substance abuse and pregnancy, lead poisoning, and accidents came to be called the new morbidities.1 In subsequent years, the list of these conditions was expanded to include intentional injuries (homicide, suicide, and child abuse), chronic conditions such as asthma, diabetes and obesity, and mental and emotional disorders. At the present time, unintentional injuries are the leading cause of mortality among children and young adults aged 1 to 24 years.2 Furthermore, homicide and suicide, respectively, are currently the second and fourth leading causes of death overall among children and adolescents aged 1 to 19 years.
It is not surprising, then, that national organizations have called for a renewed commitment to the psychosocial aspects of pediatric care3 and for the provision of services to support the development of healthy families; to enhance early identification and intervention for children, youth, and families at risk for or involved in violence; and to increase access to health and mental health care.4
According to a 1999 report from the U.S. Surgeon General,5 approximately 20% of children and adolescents have psychiatric conditions resulting in impairment; yet, only about 20% of children and adolescents with emotional disturbance receive any kind of mental health services. Although child and adolescent psychiatrists are often considered the medical specialists responsible for treating psychiatric conditions and addressing psychosocial problems, statistics suggest that the already significant shortage of child and adolescent psychiatrists likely will become more severe in the next several decades.5 For example, the current supply of 6,300 child psychiatrists is estimated to be somewhere between 4,000 and 24,000 fewer than what is actually needed.5 Furthermore, given that the population of children and adolescents is projected to grow by more than 40% in the next 50 years, these shortages likely will become even more pronounced. It is clear that pediatricians and other child health care providers increasingly will be faced with psychosocial morbidities mat might be mitigated if early identification and intervention were practiced in pediatric settings (eg, primary care and subspecialty clinics).
This article focuses on mental health concerns that are common, are associated with significant morbidity and mortality during childhood and adolescence, and benefit from early identification and treatment. Through an extended case vignette, we discuss how these conditions may be identified and addressed in primary care practice.
CASE VIGNETTE WITH DISCUSSION
Patient at 1 week
Johnny is a 1 -week-old infant who presents to the clinic following discharge from the nursery. His mother, a 20-year-old first-time mother, reports difficulty with breastfeeding. She appears sad and tired and has difficulty concentrating on the interview. Johnny's weight has dropped 8% since birth and he is mildly jaundiced, but otherwise appears healthy.
The mother reports that Johnny's father is no longer involved, as there had been domestic violence early during the pregnancy. She lives with her extended family and has reasonable support from various relatives. She admits to sad feelings, crying ' spells, and difficulty sleeping, even when others are watching the baby. She endorses a history of depression as a teenager and denies any suicidal or homicidal ideations or current threats from the baby's father. You administer appropriate screening tools for postpartum depression, provide resources for domestic violence, and subsequently refer her, through her primary care physician, for psychiatric care.
Discussion: Given the frequency of well-child visits in the first year of life, the pediatrician is often in the best position to screen for postpartum mood conditions. This group of disorders includes: (1) postpartum blues (or adjustment reactions), which occur within the first several days postpartum but remit by 2 weeks, with a prevalence of 25% to 85%; (2) postpartum depression (or major depression with postpartum onset), which occurs witfiin weeks following delivery and lasts for several months, with a prevalence of 10% to 15%; and (3) postpartum psychosis (or mood disorder with psychotic features), which occurs acutely within a few weeks following delivery with a prevalence of 0.1% to 0.2%. 6 Despite the high prevalence of postpartum depression, it remains undetected in roughly 80% of cases.
Aldiough tire pediatrician is not the primary physician for die mother, careful screening for postpartum depression using selected questions or questionnaires such as the Clinical Epidemiological Scale for Depression (CES-D)7 can improve detection of postpartum mood conditions. Such conditions may have an adverse effect on breastfeeding success,8 adherence to prevention practices for young children,9 and die socioemotional and behavioral development of children.10,11,12 More seriously, tìiey may result in harm to self or baby. Furthermore, as illustrated in this case, in the course of obtaining a social history the pediatrician can elicit risk factors for postpartum depression, including a personal and family history of depression, stressful life events, and lack of support. Prodromal symptoms to a major depressive episode can include excessive anxiety, insomnia, and difficulty concentrating. It is important to ask about any suicidal or homicidal ideations and about any history of violence in die environment, as the latter can be bodi a stressor for die motiier and a risk factor for mortality in the infant.
Patient at 1 5 months
Johnny is now 15 months old, and presents for his well-child check. His mother is concerned that he is not yet talking. On the other hand, he is interested in other children and able to point out objects to elicit other people's interest. There is no history of pica or loss of any developmental milestone. The mother relates tiTat things are going well at home. Johnny appears happy and well cared for, and his examination is unremarkable. You refer him for age 0-to-3 services and a hearing evaluation.
Discussion: The Quality Standards Subcommittee13 of me American Academy of Neurology and die Child Neurology Society recommends diat autism be specifically considered in developmental screens, as routine developmental surveillance may often miss delays in social developmental milestones. Autism affects roughly one in 500 children and is therefore more common tìian otiier pediatric conditions that are screened for and tihat require early, specific intervention to limit morbidity, including phenylketonuria and congenital hypothyroidism. Indications for immediate referral include any loss of developmental skills and/or me absence of babbling, pointing, or otìier gestures by 12 months, single words by 16 months, or two-word spontaneous phrases by 24 monms. Any failures of routine developmental screens should prompt audiological assessment, consideration of lead screening, and a specific screen for autism, such as me Checklist for Autism in Toddlers (CHAT),14 which has a high specificity for mis condition.15
When the diagnosis of autism or a pervasive developmental disorder is likely, appropriate referral for specific and intensive early behavioral intervention should occur. These interventions are based on the notion mat autism (but probably not childhood disintegrative disorder or Rett's disorder) is a static process that affects those portions of the brain involved in social development, which can still progress, albeit at a delayed rate. Furthermore, mese interventions, based upon behavioral principles such as isolation and repetition of component tasks, allow the development of other skills whose development would ordinarily be motivated by a social desire to please (eg, language and motor skills)
Patient at 3 years
Johnny is now 3 years old. When asked about behavioral concerns, his mother reports that he becomes fussy and oppositional very easily, throwing significant tantrums. He is also very active. The mother has tried to do time outs, but with little effect. She states that she sends him to the comer for 30 minutes, but he argues and throws further tantrums. He seems to listen, however, to his uncle (one of his four main caregivers), who tends to use corporal punishment.
You commend Johnny's mother on her efforts and her commitment to avoid using corporal punishment, and you spend the next few visits collaborating with her and the other caregivers in the family on behavioral management techniques. You also ensure that his language development is progressing well with early intervention services, because you feel that difficulty with verbal communication could predispose to tantrums.
Discussion: In its statement on youth violence prevention, the American Academy of Pediatrics cites avoidance of corporal punishment, minimization of violence exposure in general, and elimination of firearm availability as key tasks for the pediatrician.16 Straus et al. report a positive correlation between spanking and antisocial behavior 2 years later, even with other factors controlled, and they conclude that "replacing violent discipline with nonviolent discipline could reduce the level of violence in American society."'7 Kazdin reports favorable evidence for the efficacy of behaviorally based parent management training.18 Clearly, pediatricians can play a vital role in giving parents concrete alternatives to corporal punishment and in helping parents to develop effective methods of discipline. For example, in Johnny's case, this might include optimizing the baseline positive relationship between child and parent (eg, giving attention to good behavior and withdrawing it for bad behavior, rather than the other way around), applying the principles of immediacy and minimization of negative attention (initiating "time out" with minimal words), and ensuring that all other caregivers implement consistent methods.
Patient at 7 years
Johnny is now 7 years old. At a well child visit, his mother reports that he is failing second grade, which she attributes to his difficulty paying attention. After a careful evaluation and discussion with Johnny's teacher, you conclude that Johnny most likely has attentiondeficit/hyperactivity disorder (ADHD). A mental health provider at the school had already alerted the mother to this possibility. She had previously been unwilling to consider medications, but you are able to respond appropriately to her concerns. At a follow-up visit, you prescribe a stimulant medication and provide additional behavioral management counseling.
Discussion: Pediatricians can employ practice parameters of the American Academy of Pediatrics in assessing and treating ADHD, which affects around 7% of children, and can consider referral for specialty mental health care if response to treatment is not optimal.1921 Even if they choose to refer early, pediatricians can have an important role in helping families by addressing common misperceptions about the treatment of ADHD. For example, they can help families understand that stimulants, rather than being nonspecific calming pills, act via neurobiologically specific mechanisms;22 pharmacotherapy of ADHD likely does not increase risk for a substance use disorder, and may even decrease it;23 stimulants are more effective than behavioral treatments alone for core ADHD symptoms;24 and overall, stimulants are not likely over-prescribed for ADHD.25
Patient at 13 years
Johnny is now 13 years old. He is no longer taking a stimulant medication, and you have not seen him in more than 3 years because they lived elsewhere. His mother's chief concerns are that he is very moody, that he becomes angry very quickly, that he has made suicide gestures when unable to have his way, and that he has a bravado that gets him into frequent trouble at school. He does not sleep very well. He apparently has been receiving counseling services through the school.
You notice that Johnny and his mother argue constantly during the visit. There is no history of substance use or general medical problems. There is a family history of law violations, drug use, and possible manic symptoms. You perform an appropriate medical evaluation and subsequently recommend that they see a child and adolescent psychiatrist. They appreciate the genuineness of your concern. Before they leave, you give them the phone number to the suicide/crisis hotline.
Discussion: Johnny's symptoms (eg, irritability, suicide gestures, disturbed sleep) suggest an affective illness, such as major depression or bipolar disorder. His history of ADHD is significant, because it may often precede the emergence of bipolar disorder. While these two conditions may be difficult to differentiate clinically because of overlapping symptoms such as hyperactivity, questionnaires such as the Young Mania Rating Scale can identify specific symptoms of a bipolar mania.26
Major mood disorders are a significant risk factor for adolescent suicide and violence.27 According to Biederman, up to 40% of teenagers with conduct disorder may have a mania that responds favorably to treatment with a mood stabilizer.28 Even though teenagers with delinquent behaviors frequently may receive behavioral health services through the school or legal system, the pediatrician can play an important role in the teenager's overall care by screening for symptoms of a major mood disorder (including major depression, using tools such as the Children's Depression Inventory [CDI]29), considering general medical conditions (eg, thyroid dysfunction, substance use, effects of other medications) that may result in mood symptoms, referring appropriately for child and adolescent psychiatric care, providing resources for management of crises and suicidal behavior, and providing ongoing primary medical care and care coordination.
Whether pediatricians should initiate medication treatment for mood disorders, including major depression, is a controversial and complex issue. While there is some evidence that serotonin-selective reuptake inhibitors may be effective for adolescent major depression,30 the pediatrician should be aware that 20% to 40% of youth presenting with what appears to be a major depressive episode eventually declare themselves to have a bipolar disorder,31 the symptoms of which could be exacerbated by antidepressant treatment. While it may be possible to identify youth at risk for bipolar disorder on the basis of family history, the decision is sufficiendy complex,32 and the risks of morbidity and mortality from these illnesses sufficiendy great, that we recommend mat pediatricians and child and adolescent psychiatrists closely collaborate for suspected cases of mood disorders that present in this age group.
Because of the significant morbidity and mortality associated with psychiatric disorders and adverse psychosocial circumstances, screening for such conditions ideally should be as well researched, as readily accepted, as routinely implemented, and as effective as any other screening for serious medical conditions affecting children and adolescents. This article provides a basic framework with which to approach psychosocial screening in the primary care setting and may stimulate further interest and work in this area.
1. Haggerty RJ, Roghmann KJ, Pless IB. Child Health and the Community. New Brunswick, NJ: Transaction Publishers; 1993:94-116.
2. MacDorman MF, Minino AM, Strobino DM, Guyer B. Annual summary of vital statistics - 2001. Pediatrics. 2002;110:1037-1052.
3. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care. Pediatrics. 2001;108:1227-1230.
4. Commission for the Prevention of Youth Violence. Youth and Violence: Medicine, Nursing, and Public Health: Connecting the dots to prevent violence. 2000. Available at: http://www.ama-assn.org/violence. Accessed April 23, 2003.
5. American Academy of Child and Adolescent Psychiatry. AACAP Work Force Data Sheet 2000. http://www.aacap.org/training/workforce.htm
6. Gise LH, Weston SC. Postpartum Depressions. In: Medical-Psychiatric Practice, Volume 2. Stoudemire A, Fogel BS (eds). Washington DC: American Psychiatric Press; 1993;246257.
7. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement. 1977;1:385-401.
8. Galler JR, Harrison RH, Biggs MA, Ramsey F, Forde V. Maternal Moods Predict Breatfeeding in Barbados. J Dev Behav Pediatr. 1999;20:8087.
9. McLennan JD, Kotelchuk M. Parental prevention practices for young children in the context of maternal depression. Pediatrics. 2000;105:1090-1095.
10. Goodman SH, Gotlib IH. Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychol Rev. 1999; 106: 458-490.
11. NICHD Early Child Care Research Network. Chronicity of Maternal Depressive Symptoms, Maternal Behavior, and Child Functioning at 36 Months: Results from the NICHD Study of Early Child Care. Washington, DC: NICHD Early Child Care Research Network, 1998.
12. Weinberg MK, Tronick EZ. The impact of maternal psychiatric illness on infant development. J Clin Psychiatry. 1998;59(Supplement 2):53-61.
13. Filipek PA, Accardo PJ, Ashwal S, et al. Practice parameter: Screening and diagnosis of autism. Neumlogy. 2000;55:468-479.
14. Baron-Cohen S, AUen J, Gillberg C. 1992. Can Autism be Detected at 18 Months? Br J Psychiatry. 1992;161:839-843.
15. Baird G, Charman T, Baron-Cohen S, et al. A screening instrument for autism at 18 months of age: a 6-year follow-up study. J Am Acad Child Adolesc Psychiatry. 2000;39:694-702.
16. American Academy of Pediatrics, Task Force on Violence. The Role of the Pediatrician in Youth Violence Prevention in Clinical Practice and at the Community Level. Pediatrics. 1999;103(1):173-181.
17. Straus MA, Sugarman DB, Giles-Sims J. Spanking by Parents and Subsequent Antisocial Behavior in Children. Arch Pediatr Adolesc Med 1997;151:761-767.
18. Kazdin AE. Parent management training: evidence, outcomes, and issues. J Am Acad Child Adolesc Psychiatry. 1997;36:1349-1356.
19. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics. 2000;105:1158-1170.
20. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical Practice Guideline: Treatment of the School-Aged Child With AttentionDeficit/Hyperactivity Disorder. Pediatrics. 2001;108:1033-1044.
21. Barbaresi WJ, Katusic SK, Colligan RC, et al. How common is attention deficit/hyperactivity disorder? Incidence in a population-based birth cohort in Rochester, Minn. Arch Pediatr Adolesc Med 2002;156:217-224.
22. Barkley RA. Attention-Deficit Hyperactivity Disorder. Sci Am. September 1998;66-71.
23. Biederman J, Wilens T, Mick E et al. Pharmacotherapy of Attention Deficit/Hyperactivity Disorder Reduces Risk for Substance Use Disorder. Pediatrics. 1999;I04:e20.
24. MTA Cooperative Group. A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit Hyperactivity Disorder. Arch Gen Psychiatry. 1999;56:1073-1086.
25. Jensen PS, Kettle L, Roper MT, et al. Are Stimulants Overprescribed? Treatment of ADHD in Four U.S. Communities. J Am Acad Child Adolesc Psychiatry. 1999;38:797-804.
26. Fristad MA, Weiler EB, Weller RA. The Mania Rating Scale: Can It Be Used in Children? A Preliminary Report. J Am Acad Child Adolesc Psychiatry. 1 992;3 1 :252-257.
27. Zametkin AJ, Alter MR, Yemini T. Suicide in teenagers: assessment, management, and prevention. JAMA. 2001;286:3120-3125.
28. Biederman J, Faraone SV, Chu MP, Wozniak J. Further evidence of a bi-directional overlap between juvenile mania and conduct disorder in children. JAm Acad Child Adolesc Psychiatry. 1999;38(4):468-76.
29. Kovacs M. The Children's Depression Inventory (CDI). Psychopharmacol Bull. 1985;21:995-998.
30. Emslie GJ, Rush AJ, Weinberg WA, Kowatch RA, Hughes CW, Carmody T, Rintelmann J. 1997. A Double-blind, Randomized, PlaceboControlled Trial of Fluoxetine in Children and Adolescents with Depression. Arch Gen Psychiatry. 1997;54:1031-1037.
31. American Academy of Child and Adolescent Psychiatry. Practice Parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder. J Am Acad Child Adolesc Psychiatry. 1997;36(10 Suppl):157S176S.
32. Hamilton JD. Dr. Evidence Based and the Skeptical Practicioner. AACAP News. November/December 2000; 31:260-261.