Before becoming a child psychiatrist, it was as a general pediatrician that I first witnessed the growing need to assess and effectively treat child and adolescent mental health concerns. It has been reported that about one in five children meet diagnostic criteria for having a mental health disorder, yet only about 20% ever receive treatment; it is what the American Academy of Pediatrics has labeled “the new morbidity.”1,2
One way to address this rising public health challenge is to assemble for primary care providers, well-organized and easy-to-use advice from child mental health experts, in which the basics of child mental health evaluation and management are clearly outlined. The editors of Pediatric Annals have therefore decided to dedicate two full editions to this task. In this month’s issue, you will find detailed and practical advice about the process of screening and assessing child mental health problems from experts in each field. Next month’s issue (Volume 40, Number 11), will focus on how to treat these conditions.
Adelaide S. Robb, MD, is a child psychiatry researcher at Children’s National Medical Center in Washington, DC. She and Angelica L. Kloos, MD, offer us an insightful discussion of what has become a controversial topic in diagnosis: pediatric bipolar disorder (see page 481). Herein they draw an important distinction between children with chronic, severe mood dysregulation (a common problem) and children with true bipolar disorder (a relatively uncommon problem). These two groups of children have different symptom etiologies, different prognoses, and therefore different recommended treatment approaches.
Karen Toth, PhD, and Gary Stobbe, MD (see page 488), are child autism specialists who discuss the current means of diagnosing an autism spectrum disorder, as well as addressing proposed changes in the diagnostic criteria in the upcoming Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Children with autism spectrum disorders (ASD) have social and communication impairments (such as failing to respond to their names) that are detectable at a very early age. It is not until children are older than 2 years of age that we start to see the autism-related appearance of repetitive, stereotyped behaviors and interests.
Matthew G. Biel, MD, MSc and Maria E. McGee, MD, MS, MPH (see page 493), are child mental health experts from Georgetown University Hospital, who discuss the process of diagnosing attention-deficit/hyperactivity disorder (ADHD). Even providers who are already comfortable with how to diagnose ADHD in children may learn things from this article, such as why to avoid giving a stimulant as a “diagnostic trial,” or why it is important to be cautious when using psychological tests to confirm a diagnosis, and why and when to use “broadband” and “narrowband” rating scales.
Barry Sarvet, MD, is a child psychiatrist who runs a primary care consulting service in Massachusetts. He and Sara Brewer, MD, review how to diagnose different types of anxiety disorders in children (see page 499). They said because anxiety generates the symptom of avoidance, without active surveillance there is a tendency to minimize or a failure to recognize presentations of anxiety altogether. Understanding anxiety physiology (including activation of the “fight or flight” system) is an important means of both recognizing anxiety in children, and a means of understanding its treatment.
Michael D. Kisicki, MD, a primary care consultant as well as a child psychiatrist at a juvenile detention facility in Seattle, along with William French, MD, share their insights about the diagnosis of disruptive behavior disorders (see page 506) and demystify the etiology and perpetuating factors behind them.
Lauren Boydston, MD, is a child psychiatrist and primary care consultant who shares her insights on the diagnosis of depression in children (see page 512). She points out differences between child and adult forms of depression, such as the fact that children and adolescents are less able than adults to reflect that they feel “depressed.” Young people who are depressed may appear irritable, act out, or simply exhibit a loss of interest in activities they used to enjoy.
These articles, I believe, will help facilitate the confident assessment of mental health issues by primary care physicians in the pediatric setting. I welcome your comments. Email me at: Robert.Hilt@seattlechildrens.org.
- Foy JMAmerican Academy of Pediatrics Task Force on Mental Health. Enhancing pediatric mental health care: report from the American Academy of Pediatrics Task Force on Mental Health. Introduction. Pediatrics. 2010;125Suppl 3:S69–S74. doi:10.1542/peds.2010-0788C [CrossRef]
- 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. Committee on Psychosocial Aspects of Child and Family Health. Pediatrics. 2001;108(5):1227–1230.