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INTRODUCTION

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Pediatric primary care settings are often the first points of entry into mental health systems for the 14%–20% of children and adolescents affected by mental or behavioral health issues. Beyond addressing identified and diagnosable mental health conditions, pediatric primary care settings are tasked with: (1) screening and surveillance, (2) early identification, and (3) triage and referral around complex behavioral health issues for the child, their family, and the environments with which the child interacts. Primary care providers see approximately 75% of children with psychiatric disturbances; half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. Parents and children often prefer discussing these issues with someone they already know and trust. As a result, pediatric primary care providers play an important role in the prevention, identification, initiation, management, and coordination of mental health, as well as behavioral and development care for children and adolescents. Unfortunately, the shortage of mental health providers, stigma attached to receiving mental health services, chronic underfunding, institutional barriers within the public mental health system, and disparate insurance benefits contribute to the fact that only 2% of children with diagnosable disorders are seen by mental health specialists.

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Despite being strategically positioned as the gatekeepers for identifying mental health and behavioral concerns, primary care providers typically identify fewer than 20% of children with emotional and behavioral problems during routine health supervision visits. In addition, these problems may not be identified when they initially emerge and are more amenable to treatment. This gatekeeper role has become increasingly important over the past decade as advances in mental health awareness and treatment have improved opportunities for early identification and intervention. This role is especially critical because child psychiatry remains an underserved medical specialty, with only 8300 practicing child and adolescent psychiatrists in the United States. In contrast, the more than 50,000 board-certified pediatricians and innumerable midlevel pediatric providers are in a unique position to identify issues affecting the emotional health of children and to initiate treatment or referrals to other providers.

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Emotional problems that develop during childhood and adolescence can significantly impact development and may continue into adulthood. In fact, most “adult” psychiatric disorders involve childhood onset. Many disorders do not present as an “all-or-none” phenomenon, rather they progress from less severe concerns, such as adjustment problems or perturbations in functioning, to significant disturbances and severe disorders. Pediatricians have the capacity to manage emotional problems and behavioral conditions early on, when improvement can be achieved with less intensive interventions. If pediatricians and schools do not appropriately identify mental health problems, provide education about the benefits of intervention, and encourage and initiate intervention, childhood-onset disorders are more likely to persist, cause worsening impairment, and lead to a downward spiral of school and social difficulties, poor employment opportunities, and poverty in adulthood, as well as increased health care utilization and costs as adults. These outcomes are even more pronounced for children and adolescents from underserved, low socio-economic status ...

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