Approaches to recognition and management of childhood psychiatric disorders in pediatric primary care

Self-reported late effect symptom clusters among young pediatric cancer survivors

PURPOSE

Most survivors of childhood cancer experience subsequent chronic conditions but little is known about concurrent symptoms. This study seeks to identify late effect symptom clusters among young pediatric cancer survivors.

METHODS

Survivors ≥ 18 or parents of survivors < 18 years enrolled in an institutional cohort study indicated (yes/no) if they experienced certain symptoms after treatment. The sample was randomly divided in half for exploratory factor analyses to identify symptom clusters followed by confirmatory factor analyses. Symptoms with ≥ 10% prevalence were included. Cluster structure generalizability across subgroups was examined using congruence coefficients.

RESULTS

The sample included 579 survivors (74% non-Hispanic white, 45% leukemia, 12.8 ± 4.5 years at survey, 5.9 ± 3.5 years since therapy). Respondents averaged three symptoms. Three clusters were identified: (1) gastrointestinal: abdominal pain, diarrhea, constipation, nausea, vomiting (Cronbach's α = 0.74); (2) psychological: depression, anxiety, memory problems, anger management problems, sleep problems (α = 0.71); and (3) neurologic: problems walking, numbness/tingling, fatigue, back pain, chronic pain, weakness/inability to move legs (α = 0.71). Confirmatory factor analysis confirmed the three-cluster structure (standardized root mean square residual: 0.09; parsimonious goodness of fit: 0.96; Bentler-Bonett normed fit index: 0.95). The gastrointestinal and psychological clusters were generalizable across most subgroups while the neurologic cluster varied across age and race/ethnicity subgroups.

CONCLUSION

Three distinct late effect symptom clusters were identified in young childhood cancer survivors with gastrointestinal and psychological clusters remaining relatively stable across subgroups. Future studies should focus on the characteristics of patients who experience these symptoms, especially those with high symptom burden, and the synergistic impact on quality of life.

Prevalence, Comorbidity, and Continuity of Psychiatric Disorders in a 15-Year Longitudinal Study of Youths Involved in the Juvenile Justice System

Importance

Previous studies have found that one-half to three-quarters of youths detained in juvenile justice facilities have 1 or more psychiatric disorders. Little is known about the course of their disorders as they age.

Objective

To examine the prevalence, comorbidity, and continuity of 13 psychiatric disorders among youths detained in a juvenile justice facility during the 15 years after detention up to a median age of 31 years, with a focus on sex and racial/ethnic differences.

Design, Setting, and Participants

The Northwestern Juvenile Project is a longitudinal cohort study of health needs and outcomes of 1829 randomly selected youths in a temporary juvenile detention center in Cook County, Illinois. Youths aged 10 to 18 years were interviewed in detention from November 20, 1995, through June 14, 1998. Participants were reinterviewed up to 12 times during the 15-year study period through February 2015, for a total of 16 372 interviews. The sample was stratified by sex, race/ethnicity (Black, Hispanic, and non-Hispanic White), age (10-13 years or 14-18 years), and legal status (processed in juvenile or adult court). Data analysis was conducted from February 2014, when data preparation began, to March 2020.

Exposures

Detention in a juvenile justice facility.

Main Outcomes and Measures

Psychiatric disorders, assessed by the Diagnostic Interview Schedule for Children, version 2.3 at the baseline interviews. Follow-up interviews were conducted using the Diagnostic Interview Schedule for Children, version IV; the Diagnostic Interview Schedule, version IV; and the World Mental Health Composite International Diagnostic Interview (beginning at the 6-year follow-up interview).

Results

The study included 1829 youths sampled at baseline (1172 males and 657 females; mean [SD] age, 14.9 [1.4] years). Although prevalence and comorbidity of psychiatric disorders decreased as the 1829 participants aged, 52.3% of males and 30.9% of females had at least 1 or more psychiatric disorders 15 years postdetention. Among participants with a disorder at baseline, 64.3% of males and 34.8% of females had a disorder 15 years later. Compared with females, males had 3.37 times the odds of persisting with a psychiatric disorder 15 years after baseline (95% CI, 1.79-6.35). Compared with Black participants and Hispanic participants, non-Hispanic White participants had 1.6 times the odds of behavioral disorders (odds ratio, 1.56; 95% CI, 1.27-1.91 and odds ratio, 1.59; 95% CI, 1.23-2.05, respectively) and greater than 1.3 times the odds of substance use disorders (odds ratio, 1.90; 95% CI, 1.55-2.33 and odds ratio, 1.39; 95% CI, 1.11-1.73, respectively) throughout the follow-up period. Behavioral disorders and substance use disorders were the most prevalent 15 years after detention.

Conclusions and Relevance

This study's findings suggest that persistent psychiatric disorders may complicate the transition from adolescence to adulthood, which is already challenging for youths involved in the juvenile justice system, many of whom are from racial/ethnic minority groups and low-income backgrounds. The pediatric health community should advocate for early identification and treatment of disorders among youths in the justice system.

Counterpoint: Risks of Implementing Measurement-Based Care in Child and Adolescent Psychiatry

Psychiatric measurement-based care has a significant role in nonpsychiatric medical and surgical settings for identifying mental illness and plays a research role in generating aggregated data. Psychiatric illnesses are multifactorial and not uniform in nature, patient distress/suffering have a complex etiology, and appropriate treatments are varied. Measures commonly used in measurement-based care are subjective ratings of symptom severity. In clinical mental health settings, measurement-based care may contribute more of a qualitative role as part of the psychiatric input to the identification and severity of illness. Psychiatrists must limit the use of measurement-based care in assisting the assessment of patient progress.

Primary care provider utilization and satisfaction with a health system navigation program for adolescents with behavioral health needs

Approximately 49.5% of the adolescents report a mental health disorder; only about half of the children and adolescents with mental health disorders seek treatment from a mental health professional. Stigma and poor access to behavioral health providers are leading barriers to care. A large ambulatory health system implemented a BH navigation program to facilitate referrals from primary care physicians (PCPs), including pediatricians and family physicians, to BH providers. We studied PCP adoption of BH navigation services over a 4-year period, from July 2014 to June 2018. We retrieved operational data regarding service utilization, patient information from electronic health records and PCP information from administrative data, and surveyed PCPs for their appraisals of navigation services. Four thousand five hundred and fifty-five referrals were made for 3,912 patients from 290 PCPs (71% of PCPs in the health system). Depression (39%), anxiety (25%), and attention-deficit hyperactivity disorder (7%) were the most frequent reasons for referral. Referrals increased dramatically in the first half of the study period and decreased afterwards. Ninety-one percent of the PCPs agreed or strongly agreed that navigation enhanced their clinical care at 12-month survey. More than 90% of the PCPs rated the referral process, communication with navigation staff, and the overall experience as above average or excellent at 12 months. There was a decrease in these evaluation indicators after 2.5 years. The initial high referral volume reflects a need for BH navigation services. However, challenges remain to maintain positive PCP assessment in the face of such demand.

Identification and Utility of a Short Form of the Pediatric Symptom Checklist-Youth Self-Report (PSC-17-Y)

Abstract. The Pediatric Symptom Checklist-Youth self-report (PSC-Y) is a 35-item measure of adolescent psychosocial functioning that uses the same items as the original parent report version of the PSC. Since a briefer (17-item) version of the parent PSC has been validated, this paper explored whether a subset of items could be used to create a brief form of the PSC-Y. Data were collected on more than 19,000 youth who completed the PSC-Y online as a self-screen offered by Mental Health America. Exploratory factor analyses (EFAs) were first conducted to identify and evaluate candidate solutions and their factor structures. Confirmatory factor analyses (CFAs) were then conducted to determine how well the data fit the candidate models. Tests of measurement invariance across gender were conducted on the selected solution. The EFAs and CFAs suggested that a three-factor short form with 17 items is a viable and most parsimonious solution and met criteria for scalar invariance across gender. Since the 17 items used on the parent PSC short form were close to the best fit found for any subsets of items on the PSC-Y, the same items used on the parent PSC-17 are recommended for the PSC-Y short form.

Increasing Access to Psychiatric Services in Schools: The Bridge Program

One in 5 youth experience a psychiatric disorder in any given year, but fewer than half of these youth receive mental health services. This lack of service utilization is often attributed to structural and perceptual barriers, and school-based mental health programs have been proposed as a means of addressing these barriers and increasing youths' access to services. While universal prevention programs and targeted treatments may benefit most youth receiving services in schools, collaborations between schools and child psychiatry may benefit youth with the most severe symptoms and the greatest impairment. This article describes the Bridge Program, a school-based psychiatric program funded by a county-wide mental health tax initiative designed to provide psychiatric services in local schools without any out-of-pocket expenses for youth and families within 10 days of referral. Two case reports provide a description of the delivery of psychiatric services through the Bridge Program. Future research is needed to compare the feasibility and effectiveness of different approaches to increasing access to youth psychiatric care.

Impacting Pediatric Primary Care: Opportunities and Challenges for Behavioral Research in a Shifting Healthcare Landscape

Behavior analysts have long recognized the potential of a partnership with pediatric medicine as an opportunity to expand the influence of behavior analysis and positively impact population health. Despite significant achievements in this domain, the impact of behavioral science on the daily practice of pediatrics has been limited. In this commentary, the authors argue that the current health care and research environments are ripe for a renewed focus on behavioral modification in pediatric primary care, with a particular emphasis on the study of high-frequency, low-intensity problems. They provide some analysis of why behavioral pediatrics has failed to gain traction in primary care, describe aspects of the current primary care practice and research landscapes that provide opportunities for an expanded portfolio of research, identify several exemplars from the behavior analytic literature that have influenced pediatric primary care or have the potential to do so, and make recommendations for producing influential data.

Using Immediate Response Technology to Gather Electronic Health Data and Promote Telemental Health Among Youth

Introduction:

A sizeable number of youth are currently struggling with anxiety, depression, and suicidal thoughts, yet many will not receive treatment. We sought to better understand if immediate response technology (IRT) could be used to gather mental health care data and educate youth on telemental health (TMH) resources.

Methods:

Using an IRT imbedded within an interactive, media-rich school-based presentation, we gathered mental health history and preferences for TMH resources from 2,789 adolescents with a wide range of demographic and psychological characteristics.

Results:

More than 80 percent of adolescents satisfied inclusion criteria for survey completion, and responses were statistically comparable across four diverse high school settings. Using Chi-squared analyses, we found that less than 10 percent of adolescents, especially girls and those with high depression/anxiety scores, had previously used TMH resources. After interacting with the IRT, many more (29 percent to 43 percent) expressed willingness to use these resources.

Discussion:

The IRT system was effective in gathering mental electronic health data, delivering targeted mental health education, and promoting positive attitudes towards TMH among adolescents.

Conclusions:

IRTs and other non-formalized technologies should be explored as cost-effective, easy-to-implement resources for electronic health data gathering and health care education.

Enhancing Pediatricians' Behavioral Health Competencies Through Child Psychiatry Consultation and Education

The objective of this study was to assess feasibility, utilization, perceived value, and targeted behavioral health (BH) treatment self-efficacy associated with a collaborative child and adolescent psychiatry (CAP) consultation and BH education program for pediatric primary care practitioners (PCPs). Eighty-one PCPs from 41 member practices of a statewide pediatric practice association affiliated with an academic medical center participated in a program comprising on-demand telephonic CAP consultation supported by an extensive BH learning community. Findings after 2 years of implementation suggest that the program was feasible for large-scale implementation, was highly utilized and valued by PCPs, and was attributed by PCPs with enhancing their BH treatment self-efficacy and the quality of their BH care. After participation in the program, nearly all PCPs believed that mild to moderate presentations of common BH problems can be effectively managed in the primary care setting, and PCP consultation utilization was congruent with that belief.

Adolescent Self-Screening for Mental Health Problems; Demonstration of an Internet-Based Approach

OBJECTIVE

To examine the prevalence of positive screening scores, construct validity, and opportunities for follow-up in a large sample of adolescents who chose to fill out the Pediatric Symptom Checklist-Youth Form (PSC-Y) through the Mental Health America (MHA) Web site.

METHODS

MHA sent researchers a deidentified data set of all PSC-Y data submitted to MHA from May 15, 2015 to May 14, 2016. The analytic data set contained 29,886 PSC-Y forms from youth aged 11 to 17 years who sought out the Web site and chose to fill out the PSC-Y anonymously and independently online. The prevalence of impairment on the PSC-Y was calculated overall and for various subgroups. Next steps reported by at-risk youth were also examined.

RESULTS

Of all respondents, 77.4% of youth screened positive on the PSC-Y. Significant associations between positive screening and self-ratings of a need for help, previous history of mental health treatment, and low family income provided construct validation for the online PSC-Y. Almost two-thirds of positively screened youth stated that they planned to get some kind of help in the future and 10% indicated that they planned to seek professional treatment.

CONCLUSIONS

The large number of respondents suggested that many adolescents use the Internet to learn about mental health and that a very high percentage of them might be at risk. The availability of brief, free Internet-based psychosocial screens might offer a viable way to identify at-risk youth and provide them with pathways to additional support and/or treatment.

Pediatric Community Mental Health

The emotional health and wellbeing of children and adolescents and their families is of utmost importance. Pediatricians are at the front line in identifying mental illness in children and adolescents and either linking them to resources in the community or providing treatment options themselves. Collaboration and integrative health care models is the cornerstone of effective strategies to provide access and quality mental health care to children and families in communities across the country.

The PSC-17: Subscale Scores, Reliability, and Factor Structure in a New National Sample

BACKGROUND

The Pediatric Symptom Checklist-17 (PSC-17) is a widely used, briefer version of the PSC-35, a parent-completed measure of children's psychosocial functioning. Despite the extensive use of the PSC-17 over the past 15 years there has not been a large-scale replication of the original derivation study.

OBJECTIVE

To examine the prevalence of positive screens, reliability, and factor structure of PSC-17 scores in a new national sample and compare them with the derivation sample.

METHODS

Data were collected on 80 680 pediatric outpatients, ages 4 to 15 years, whose parents filled out the PSC-17 from 2006 to 2015 via the Child Health and Development Interactive System, an electronic system that presents and scores clinical measures.

RESULTS

The rates of positive screening on the overall PSC-17 (11.6%) and on the internalizing (10.4%) and attention (9.1%) subscales were comparable to rates found in the original sample, although the rate of externalizing problems (10.2%) was lower than in the derivation study. Reliability was high (internal consistency 0.89; test-retest 0.85), and a confirmatory factor analysis provided support for the original 3-factor model.

CONCLUSIONS

Fifteen years after the PSC-17 was derived in a large nationally representative outpatient pediatric sample, a new and larger national sample found rates of positive screening, reliability, and factor structure that were comparable. Findings from this study support the continued use of the PSC-17 clinically as a screening tool in pediatric settings and in research.

Influence of Child Factors on Health-Care Professionals' Recognition of Common Childhood Mental-Health Problems

Early recognition of childhood mental-health problems can help minimise long-term negative outcomes. Recognition of mental-health problems, needed for referral and diagnostic evaluation, is largely dependent on health-care professionals' (HCPs) judgement of symptoms presented by the child. This study aimed to establish whether HCPs recognition of mental-health problems varies as a function of three child-related factors (type of problem, number of symptoms, and demographic characteristics). In an online survey, HCPs (n = 431) evaluated a series of vignettes describing children with symptoms of mental-health problems. Vignettes varied by problem type (Attention-Deficit/Hyperactivity Disorder (ADHD), Generalised Anxiety Disorder (GAD), Autism Spectrum Disorder (ASD), Conduct Disorder (CD) and Major Depressive Disorder), number of symptoms presented (few and many), and child demographic characteristics (ethnicity, gender, age and socio-economic status (SES)). Results show that recognition of mental-health problems varies by problem type, with ADHD best recognised and GAD worst. Furthermore, recognition varies by the number of symptoms presented. Unexpectedly, a child's gender, ethnicity and family SES did not influence likelihood of problem recognition. These results are the first to reveal differences in HCPs' recognition of various common childhood mental-health problems. HCPs in practice should be advised about poor recognition of GAD, and superior recognition of ADHD, if recognition of all childhood mental-health problems is to be equal.

Parent Reports of Mental Health Concerns and Functional Impairment on Routine Screening With the Strengths and Difficulties Questionnaire

OBJECTIVE

This study used the Strengths and Difficulties Questionnaire (SDQ) to describe the prevalence of parent-reported mental health (MH) concerns in youth presenting for primary care appointments and to examine relationships between children's MH issues and functional impairment. We hypothesized that increased MH symptomology would be associated with increased impairment and family burden.

METHODS

Parents of 4- to 17-year-old children were approached at routine visits in 13 primary care sites. Chi-square tests, independent sample t tests, and a 1-way analysis of variance (ANOVA) were used to make comparisons between demographic groups. Age-, sex-, and race-adjusted ordered logistic regression models and ANOVAs examined relationships between impact and SDQ scales.

RESULTS

Boys had higher total Hyperactivity and Peer Problems. Adolescents showed higher Emotional Symptoms, while younger children showed more Hyperactivity. Latinos reported more Conduct Problems, Hyperactivity, and Peer Problems. Latinos also indicated less distress on the child, impairment at home and school, and family burden. Regression analyses indicated increased odds of impairment with higher scale scores. MH symptoms identified with the SDQ in pediatric primary care settings were associated with parent-reported impairment affecting youth and their families.

CONCLUSIONS

The presence of significant impairment suggests that parents' concerns identified by screening are likely to be clinically important and worthy of practice strategies designed to promote assessment, treatment, and referral for these common problems. Identifying and exploring parents' concerns with strategic use of screening tools may allow primary care providers to directly engage families around the MH issues that affect them most.

The implementation of a clinical toolkit and adolescent depression screening program in primary care

PROBLEM/BACKGROUND: Adolescent depression is a growing problem for today's society with only 30% receiving services.

AIM AND METHODS

The aim of this project was to increase identification and treatment of depressed adolescents, and comfort levels of primary care providers with the implementation of a depression-screening program and use of a clinical depression toolkit within a primary care setting.

SETTING

The setting was a private pediatric practice in central Maine.

RESULTS

Over an 8-week period, 266 adolescents were screened. Twelve adolescents (4.5%) received a diagnosis of depression and 11 received treatment within 8 days. Survey results showed a significant increase in providers' feelings of comfort and accountability.

CONCLUSION

This project demonstrates that it is feasible to implement a depression screening and treatment program in primary care. It demonstrates that primary care providers can increase their comfort and feelings accountability in treating depression in primary care, thus increasing access for this monumental and potential catastrophic problem.

Emergency department visits in the United States for pediatric depression: estimates of charges and hospitalization

OBJECTIVES

The objective of this study was to calculate national estimates of depression-related emergency department (ED) visits and associated health care resource use among children and adolescents 17 years or younger. Another goal was to explore the effects of certain sociodemographic and health care system factors and comorbidities on ED charges and subsequent hospitalization in the United States.

METHODS

The authors analyzed data from the 2006 and 2009 National Emergency Department Sample (NEDS), the largest source of U.S. ED data. ED visits with all listed diagnoses (i.e., principal diagnosis plus secondary conditions) of depression were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 293.83, 296.2X, 296.3X, 300.4, and 311. Population-based estimates of ED visits, hospitalization, resource use, comorbidities, and demographics associated with pediatric depression were calculated. Potentially significant covariate associations were also explored using ED charges and hospital admission from the ED.

RESULTS

The 2006 and 2009 NEDS sample contained 365,713 ED visits for pediatric depression; the majority were made by adolescents (87.9%). Of these, 27.2% were admitted to the hospital, 69.5% were treated and released, and <0.1% died in ED. The ED charges in 2012 U.S. dollars summed to a hospital bill of $443.8 million, with the ED plus inpatient charges ($1.2 billion) being more than double that amount. The median inpatient length of stay (LOS) was 4.0 days. Suicide and intentional self-inflicted injury were attempted by 31.4% of the patients. Attention-deficit, conduct, and disruptive disorders; anxiety disorders; substance use disorders; asthma; and infections were the most common comorbidities. In year 2009, a higher number of diagnoses, older age, being female, key comorbidities, and suicide and intentional self-inflicted injury were significantly associated with higher ED charges (all p < 0.05). Increased odds of hospital admission from the ED were significantly associated with a higher number of diagnoses, key comorbidities, and suicide and intentional self-inflicted injury (all p < 0.05).

CONCLUSIONS

Pediatric depression is common in the ED and is associated with significant burden to the health care system. Certain factors such as a higher number of diagnoses, key comorbidities, and suicide and intentional self-inflicted injury are associated with increased health care costs and resource use. Special attention should be given to these factors, when present.

Effect of St John's wort on bone formation in the orthopaedically expanded premaxillary suture in rats: a histological study

BACKGROUND/OBJECTIVE

The aim of this study was to investigate the effect of systemic St John's wort (Hypericum perforatum) on bone formation in the expanded premaxillary suture in rats.

MATERIALS/METHODS

A total of 28 rats were randomly divided into four groups of equal numbers: control (C); only expansion (OE); St John's wort extract given only during the expansion and retention period (a total of 17 days; SJW group); and St John's wort extract given during the nursery phase before expansion (a period of 40 days), and during the expansion and retention periods (a total of 57 days; N + SJW group). After the 5 day expansion period was completed, the rats in the OE, SJW, and N + SJW groups underwent 12 days of mechanical retention, following which they were killed, and their premaxilla dissected and fixed. Histological examination was performed to determine the number of osteoclasts and capillaries, as well as the number of osteoblasts, inflammatory cell infiltration, and the amount of new bone formation.

RESULTS

Statistical analysis showed that the number of osteoclasts and capillaries, and the inflammatory cell infiltration, as well as new bone formation, were higher in the SJW and N + SJW groups than in the other groups. However, statistical analysis demonstrated that among these two groups, all parameters, with the exception of the number of capillaries, were higher in the N + SJW group than the SJW group.

CONCLUSIONS/IMPLICATIONS

Although more effective in long-term usage, systemic use of St John's wort hastens new bone regeneration at the premaxillary suture and may help prevent relapse after expansion.

Improving Outcomes for Children With Developmental Disabilities Through Enhanced Communication and Collaboration Between School Psychologists and Physicians

A renewed call for enhanced communication and collaboration between school psychology and medicine is envisioned, in light of a transdisciplinary model, where school psychologists, family physicians, and other health professionals transcend disciplinary boundaries. Recommendations for optimal communication and collaboration are described, as well as challenges inherent in such an endeavor. School psychologist–physician collaboration has the potential to result in significant improvements in outcomes for families and children with developmental disabilities. A case illustration highlights the major points mirrored in the discussion, and conclusions are drawn regarding necessary components for meaningful change to occur.

Is the Children's Depression Inventory Short version a valid screening tool in pediatric care? A comparison to its full-length version

OBJECTIVE

This is the first study to validate and to compare the Children's Depression Inventory (CDI) and its short version (CDI:S) as screening tools for medically ill children.

METHODS

A sample of 406 pediatric hospital patients, aged 9 to 12 years (56.2% male, 77.1% inpatients), completed the German CDI. Criterion validity of the 26-item CDI and the 10-item CDI:S was calculated by receiver operating characteristic (ROC) curves. DSM-IV diagnoses of depression based on the structured diagnostic interview for mental disorders in children and adolescents (Kinder-DIPS) served as the reference standard. Areas under the ROC curves as well as sensitivities and specificities for the optimal cutoffs were compared for both versions.

RESULTS

Diagnoses of major or minor depression were established for 7.4% of the children. Areas under the curve for the 26-item CDI (87.7%) and the 10-item CDI:S (88.2%) were comparable. For the CDI, the cutoff≥12 yielded the best balance between sensitivity (83.3%) and specificity (82.7%). At the optimal cutoff≥3, the CDI:S resulted in a high sensitivity of 93.3% and a specificity of 70.7%. Thus, the CDI:S proved to be as sensitive as the CDI, but was less specific than the full-length version.

CONCLUSION

Both the CDI and the CDI:S are valid screening instruments for depression in medically ill children. The sensitive and brief CDI:S is a promising tool in time-pressed settings such as pediatric care, but has to be followed by a thorough diagnostic assessment to rule out false positive cases.

Screening for depression in adolescents: validity of the patient health questionnaire in pediatric care

BACKGROUND

This study examines the criterion validity of the Patient Health Questionnaire 9-item (PHQ-9) and 2-item (PHQ-2) version as a depression-screening instrument for adolescents.

METHODS

Three hundred twenty-two adolescents aged 13-16 were recruited from pediatric hospitals. Criterion validity of the PHQ-9 and PHQ-2 was assessed against diagnoses of any depressive disorder provided by a structured diagnostic interview. Areas under the receiver operating characteristics curve (AUCs) and sensitivities and specificities at optimal cutoff points were computed for both versions of the PHQ. Besides the dimensional algorithm, a categorical algorithm was applied for the PHQ-9. Validity measures of both scoring procedures of the PHQ-9 as well as PHQ-2 were compared statistically. In addition, unaided clinical depression diagnoses by the attending pediatricians were evaluated.

RESULTS

Using the dimensional algorithm, the AUCof the PHQ-9 (93.2%) was significantly higher than that of the PHQ-2 (87.2%). At optimal cutoffs, there was no significant difference in sensitivity (PHQ-9: 90.0%, PHQ-2: 85.0%), but in specificity (PHQ-9: 86.5%, PHQ-2: 79.4%). Although the categorical algorithm of the PHQ-9 was most specific (94.7%), sensitivity was just above chance (52.5%). The unaided clinical diagnoses yielded a sensitivity of 12.5% and a specificity of 96.0%.

CONCLUSIONS

The dimensional algorithm of the PHQ-9 demonstrated high criterion validity, whereas the categorical algorithm should not be applied due to its low sensitivity. Even though the PHQ-2 performed well, validity of the PHQ-9 was still superior. Hence, the PHQ-9 can be recommended as depression screener for adolescents to improve recognition rates in pediatric care.

Substance use disorders in children and adolescents with attention-deficit/hyperactivity disorder: implications for treatment and the role of the primary care physician

OBJECTIVES

Review the association between attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) in children and adolescents. Discuss treatment implications and the role of the primary care physician in the management of this comorbidity.

DATA SOURCES

Articles published from 1991 to 2007 were identified through a MEDLINE search using the search terms attention-deficit/hyperactivity disorder and substance use disorder.

STUDY SELECTION

Publications cited include reviews of substance use disorders in children and adolescents with ADHD, manuals of diagnostic tests, and 69 studies of substance use disorders in children and adolescents with ADHD. No non-English-language publications were identified.

DATA SYNTHESIS

Recent reports identify SUD in a high proportion of respondents with ADHD and ADHD in a high proportion of respondents with many types of SUD. Factors that appear to increase the risk for SUD include comorbid psychiatric disorders, particularly conduct disorder. Pharmacotherapy for ADHD appears not to increase the risk for subsequent SUD. Guidelines for the evaluation and treatment of patients with comorbid ADHD and SUD are outlined. Psycho-stimulants carry the risk for misuse by both patients and family members through diversion. Although nonstimulants such as atomoxetine have low abuse potential, they appear to be less efficacious than stimulants. Formulations that have the potential to lower the abuse liability of stimulants are being developed. These include a transdermal form of methylphenidate that has been shown to be efficacious in the treatment of ADHD and a prodrug stimulant, lisdexamfetamine, recently approved for the treatment of ADHD. Clinical data indicate that lisdexamfetamine is efficacious, and significantly lower likability scores were seen with lisdexamfetamine than with equivalent oral doses of d-amphetamine sulfate.

CONCLUSIONS

Pharmacotherapy may reduce the risk for SUD in patients with ADHD. Psycho-stimulants remain the first-line therapy for the core symptoms of ADHD. New formulations of pharmacologic agents with a reduced potential for abuse are being developed.

Depression in pediatric care: is the WHO-Five Well-Being Index a valid screening instrument for children and adolescents?

OBJECTIVE

This study investigated the criterion validity of the WHO-Five Well-Being Index (WHO-5) in screening for depression in pediatric care.

METHOD

A total of 446 children aged 9 to 12 and 324 adolescents aged 13 to 16, recruited from pediatric hospitals, completed the WHO-5 and a structured diagnostic interview serving as the gold standard. Diagnoses of depressive disorder included major depression and minor depression. Criterion validity was analyzed using the area under the receiver operating curve (AUC). Sensitivity and specificity were computed for optimal cutoffs. Additionally, unaided clinical diagnoses of depression made by the attending pediatricians were assessed.

RESULTS

Diagnoses of depressive disorder were established for 3.6% of children and 11.7% of adolescents. AUCs were .88 for the child and .87 for the adolescent sample. A cutoff score of 10 for children maximized sensitivity (.75) and specificity (.92). For the adolescent sample, decreasing the cutoff score to 9 yielded optimal sensitivity (.74) and specificity (.89). Sensitivity of the unaided clinical diagnosis of depression was .09, while specificity was .96.

CONCLUSIONS

The WHO-5 demonstrated good diagnostic accuracy for both age groups. Further evidence is needed to support the feasibility of the WHO-5 as a depression screening instrument used in pediatric care.

An assessment of satisfaction with ambulatory child psychiatry consultation services to primary care providers by parents of children with emotional and behavioral needs: the massachusetts child psychiatry access project university of massachusetts parent satisfaction study

This study evaluated parents' experience with University of Massachusetts (UMass) Child Psychiatry Access Project (MCPAP), a consultation service to primary care providers (PCP), aimed at improving access to child psychiatry. Parent satisfaction questionnaire was sent to families referred to UMass MCPAP by their PCP, asking about their concerns leading to the referral, the satisfaction from the service provided, adequacy of the follow up plan, and outcome. Seventy-nine percent of parents agreed or strongly agreed that the services provided were offered in a timely manner. Fifty percent agreed or strongly agreed that their child's situation improved following their contact with the services. Sixty-nine percent agreed or strongly agreed that the service met their family's need. The results suggest moderate to high parental satisfaction with MCPAP model, but highlight ongoing challenges in making successful referrals for children's mental health services in the community, following MCPAP recommendations.

Priority mental health disorders of children and adolescents in primary-care pediatric settings in India 2: diagnosis, pharmacological treatment and referral

The advent of pediatric psychopharmacology has enormously improved psychiatric care of children and adolescents. Nonetheless, our practice of diagnosis, treatment and referral in primary-care pediatric settings is not optimum as current evidence based knowledge is not regularly applied in the actual clinical circumstances. To help primary-care pediatricians minimise this in research-clinical practice, pharmacological treatment and referral in their clinical practice, they need to follow a two-tier diagnostic and multi axial treatment approach. The two-tier diagnostic approach of using a screening measure followed by confirmation of the screen positive cases with reference standard clinical criterion, improves the sensitivity and specificity. The multiaxial treatment has the advantage of offering a holistic approach to the intervention and improve prognosis from the interacting axes. The primary-care physician should be aware of the medications of choice for the Priority Mental Health Disorders and their drug interactions. Finally, referral of cases with atypical presentations, multiple comorbidities and poor response to the first-line of treatment needs referral to the next tier in the system.

Adolescent and parent experiences with a primary care/Internet-based depression prevention intervention (CATCH-IT)

This article describes a mixed-methods approach to understand the experience of adolescents involved in the Internet-based intervention for depression, Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training (CATCH-IT), as well as the experiences of their parents while they were involved. Qualitative analysis was done with grounded theory-based categorization of interview comments and typed program responses (adolescents only) into themes. Quantitative analysis was done with self-report surveys. The article describes the nine themes reflecting the adolescent experience and the three themes reflecting the parent experience. The article also describes the results of the quantitative surveys of helpfulness and attitudes change, which were favorable of the Internet-based intervention. Separate models explaining the psychological transformation of the adolescents and the experience of the parents are proposed. The positive experience of the adolescents and parents involved in CATCH-IT is discussed in the context of growing interest in how best to utilize Internet-based interventions for mental illness, and suggestions are made for future investigation.

Physician "costs" in providing behavioral health in primary care

OBJECTIVE

To examine pediatricians time spent, and resulting reimbursement payments for, addressing behavioral health concerns in a rural primary care pediatric practice.

METHODS

Research assistants observed 228 patient visits in a rural pediatric primary care office. The length of the visit (in minutes), content of visit, number and type of codes billed, and related insurance reimbursement amounts were recorded. Interrater reliability, scored for 22% of patient visits, was ≥90%.

RESULTS

Medical only visits lasted, on average, 8 minutes as compared with behavioral only visits that required nearly 20 minutes of physician time. Pediatricians billed up to 10 different billing codes for medical only visits but only billed 1 code for behavioral only visits. Consequently, pediatricians were reimbursed significantly less, per minute, for behavioral only visits as compared with those sessions addressing medical only or a combination of medical and behavior concerns.

CONCLUSION

Findings converge with previous research, demonstrating that behavioral health concerns dramatically affect the length of visit for primary care physicians. Moreover, this study is the first to document the specific impact of such concerns on pediatrician reimbursement for providing behavioral services. These results provide further support for integrating behavioral health services into pediatric primary care settings, thus allowing physicians to refer more difficult patients with behavioral issues to in-house collaborating behavioral health providers who can spend additional time necessary to address the behavioral health issue and who are licensed to receive mental health reimbursement.

Telemental Health and Web-based Applications in Children and Adolescents

The authors conducted a review of the literature with regard to child and adolescent mental health intervention, from which they identified 20 unique publications and 12 separate interventions. These interventions encompassed depression, anxiety, substance abuse, eating disorders, and mental health promotion. Studies were heterogeneous, with a wide range of study designs and comparison groups creating some challenges in interpretation. However, modest evidence was found that Internet interventions showed benefits compared with controls and preintervention symptom levels. Interventions had been developed for a range of settings, but tended to recruit middle-class participants of European ethnicity. Internet interventions showed a range of approaches toward engaging children and incorporating parents and peers into the learning process.

Pediatrician-psychiatrist collaboration to care for children with attention deficit hyperactivity disorder, depression, and anxiety

OBJECTIVE

To describe pediatrician experiences collaborating with psychiatrists when caring for children with attention deficit hyperactivity disorder (ADHD), depression, and anxiety.

METHOD

A random sample of Massachusetts primary care pediatricians completed a mailed self-report survey.

RESULTS

Response rate was 50% (100/198). Most pediatricians preferred psychiatrists to initiate medications for anxiety (87%) or depression (85%), but not ADHD (22%). Only 14% of respondents usually received information about a psychiatry consultation. For most (88%), the family was the primary conduit of information from psychiatrists, although few (14%) believed the family to be a dependable informant. Despite this lack of direct communication, most pediatricians reported refilling psychiatry-initiated prescriptions for ADHD (88%), depression (76%), and anxiety (72%).

CONCLUSIONS

Pediatricians preferred closer collaboration with psychiatrists for managing children with anxiety and depression, but not ADHD. The communication gap between psychiatrists and pediatricians raises concerns about quality of care for children with psychiatric conditions.

Improving access to mental health care for children: the Massachusetts Child Psychiatry Access Project

BACKGROUND

Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance.

METHODS

Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35,335 encounters. PCC surveys assessed satisfaction and impact on access to care.

RESULTS

The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10,114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0-245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs.

CONCLUSIONS

PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.

Physician identification and management of psychosocial problems in primary care

Often the burden of identifying children with behavioral or developmental problems is left up to the primary care physician (PCP). However, previous literature shows that PCPs consistently underidentify children with developmental/behavioral problems in pediatric primary care. For the current study, questionnaires containing three vignettes followed by questions addressing common psychosocial problems, general questions about their practice and training, and the Physician Belief Scale were distributed to physicians. Results indicated that physicians were better at identifying severe problems, had more difficulty identifying psychosocial problems with mild symptomatology, and tended to refer to a medical specialist or mental health professional more often for severe problems, depression or a developmental problem. Physicians tended to view treating psychosocial problems favorably.

Policy statement--The future of pediatrics: mental health competencies for pediatric primary care

Pediatric primary care clinicians have unique opportunities and a growing sense of responsibility to prevent and address mental health and substance abuse problems in the medical home. In this report, the American Academy of Pediatrics proposes competencies requisite for providing mental health and substance abuse services in pediatric primary care settings and recommends steps toward achieving them. Achievement of the competencies proposed in this statement is a goal, not a current expectation. It will require innovations in residency training and continuing medical education, as well as a commitment by the individual clinician to pursue, over time, educational strategies suited to his or her learning style and skill level. System enhancements, such as collaborative relationships with mental health specialists and changes in the financing of mental health care, must precede enhancements in clinical practice. For this reason, the proposed competencies begin with knowledge and skills for systems-based practice. The proposed competencies overlap those of mental health specialists in some areas; for example, they include the knowledge and skills to care for children with attention-deficit/hyperactivity disorder, anxiety, depression, and substance abuse and to recognize psychiatric and social emergencies. In other areas, the competencies reflect the uniqueness of the primary care clinician's role: building resilience in all children; promoting healthy lifestyles; preventing or mitigating mental health and substance abuse problems; identifying risk factors and emerging mental health problems in children and their families; and partnering with families, schools, agencies, and mental health specialists to plan assessment and care. Proposed interpersonal and communication skills reflect the primary care clinician's critical role in overcoming barriers (perceived and/or experienced by children and families) to seeking help for mental health and substance abuse concerns.

Pediatricians' role in providing mental health care for children and adolescents: do pediatricians and child and adolescent psychiatrists agree?

BACKGROUND

Many children who have a mental health disorder do not receive mental health services and are seen only in primary care settings. Perceptions of pediatricians and mental health specialists regarding the role that pediatricians should have in diagnosing and managing children's mental health problems have not been studied.

OBJECTIVE

To examine whether primary care pediatricians (PCPs) and child and adolescent psychiatrists (CAPs) agree about: (1) the pediatrician's role in identification, referral, and treatment of childhood mental health (MH) disorders; and (2) barriers to the identification, referral, and treatment of childhood MH disorders.

METHODS

Surveys were mailed in 2005 to 338 PCPs and 75 CAPs in 7 counties surrounding Cleveland, Ohio. Each group was asked whether they agreed that PCPs should be responsible for identifying, treating, or referring 7 prevalent childhood MH problems. Barriers that PCPs face in identification, referral, and treatment of MH problems were also assessed. Analyses were weighted for nonresponse; group differences were assessed via Rao-Scott chi test and weighted regression analyses.

RESULTS

Approximately half of PCPs and CAPs returned the survey. With the exception of attention deficit hyperactivity disorder (ADHD), the majority of PCPs and CAPs agreed that pediatricians should be responsible for identifying and referring, but not treating child MH conditions. For ADHD, PCPs were more likely than CAPs to agree that pediatricians should identify and treat affected children. PCPs were more likely than CAPs to agree that pediatricians should be responsible for identifying child/adolescent depression and anxiety disorders; the majority of both groups agree that PCPs should be responsible for referring, but not treating these conditions. Both groups agree that lack of MH services is a barrier to identification, treatment, and referral of child MH problems for PCPs. CAPs were more likely to agree that pediatrician's lack of training in identifying child mental health problems was a barrier, whereas PCPs were more likely to endorse lack of confidence in their ability to treat child MH problems with counseling, long waiting periods to see MH providers, family failure to follow through on referrals, and billing/reimbursement issues as barriers.

CONCLUSIONS

Most PCPs and CAPs believe it is pediatricians' responsibility to identify and refer, but not treat, the majority of children's mental health problems. Both groups agree that mental health services are not readily available. Future efforts are needed to support PCPs and CAPs in their combined effort to address the mental health needs of children.

Enhancing communication skills for pediatric visits through on-line training using video demonstrations

BACKGROUND

Training in communication skills for health professionals is important, but there are substantial barriers to individual in-person training for practicing clinicians. We evaluated the feasibility and desirability of on-line training and sought suggestions for future courses.

METHODS

Based on successful in-person curricula for communication skills and our previous on-line curricula, we created an on-line course consisting of 28 modules (4.75 hours CME credit) about communication skills during pediatric visits that included a mental health concern; each module included a brief case, a multiple choice question, an explanation, and a 1-2 minute video demonstrating key skills. Specific communication skills included: greeting, setting an agenda, discussing diagnosis and treatment, and managing negative interactions. The course was announced by emails in spring, 2007; the course was available on-line for 60 days; we aimed to enroll 50 clinicians. Outcomes were analyzed for those who evaluated the course within 75 days of its initial availability.

RESULTS

Overall, 61 clinicians registered, of whom most were nurses (N = 24), physicians (N = 22), or psychologists or social workers (N = 12). Of the 36 (59%) clinicians who evaluated the course, over 85% agreed that all course objectives had been met; over 90% reported greater confidence in greetings and agenda-setting; and over 80% reported greater confidence in discussing diagnosis and treatment and managing negative interactions. Nearly all, 97% would recommend the course to other clinicians and trainees. Suggestions for improvement included a library of additional video vignettes and written materials to accompany the on-line training.

CONCLUSION

On-line training in communication skills for pediatric mental health visits is feasible, desirable and associated with increased confidence in key skills. Positive feedback from clinicians suggests that a comparison of on-line versus in-person training is warranted.

Behavioral health practices in the midst of black box warnings and mental health reform

A standard guide was readministered to 42 primary care pediatricians after community interventions to assess changes in their behavioral health practices. Among the outcome findings: increased screening of young children (6 months to 5 years); attention deficit hyperactivity disorder continued to be the most frequent diagnosis, with a high level of diagnostic comfort and use of stimulants; decreased comfort in the diagnosis and treatment of depression, with a significant decline in use of selective serotonin reuptake inhibitors; nearly all continued to offer nonmedication, behavioral health treatment; and a significant increase in use of social workers for community referrals. Structured interventions had limited influence on the process of change. Black box warnings exerted a powerful effect on prescribing practices. Systemic changes involving financial incentives, increased access to mental health providers, practice guidelines, and technology for continuing education may offer possibilities for changing practice patterns.

Comparison of the PSC-17 and alternative mental health screens in an at-risk primary care sample

OBJECTIVE

To validate the 17-item version of the Pediatric Symptom Checklist (PSC-17) as a screen for common pediatric mental disorders in primary care.

METHOD

Patients were 269 children and adolescents (8-15 years old) whose parents completed the PSC-17 in primary care waiting rooms. Children were later assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL). The PSC-17's subscales were compared with K-SADS-PL diagnoses and measures of anxiety, depression, general psychopathology, functioning, and impairment.

RESULTS

In receiver operating characteristics analyses, the PSC-17 subscales performed as well as competing screens (Child Depression Inventory, the parent and child Screens for Child Anxiety-Related Disorders) and Child Behavior Checklist subscales (Aggressive, Anxious-Depressed, Attention, Externalizing, Internalizing, and Total) in predicting diagnoses of attention-deficit/hyperactivity disorder, externalizing disorders, and depression (area under the curve > or =0.80). The instrument was less successful with anxiety (area under the curve = 0.68). None of the screens were highly sensitive, many were insensitive, and all would have low positive predictive value in low-risk primary care populations.

CONCLUSIONS

The PSC-17 and its subscales are briefer than alternative questionnaires, but performed as well as those instruments in detecting common mental disorders in primary care. Continued research is needed to develop brief yet sensitive assessment instruments appropriate for primary care.

Use of an electronic record audit to enhance mental health training for pediatric residents

BACKGROUND

Increased emphasis has been placed in pediatric residency programs on the identification and treatment of child mental health disorders.

DESCRIPTION

An electronic record audit was developed to assess residents' behavioral health skills and optimize behavioral health training. Information from the electronic audit was used to provide feedback to preceptors, modify the training curriculum, and increase access to mental health referrals.

EVALUATION

The audit determined the frequency of detected mental health problems, types of disorders identified, use of screening instruments, and behavioral health interventions and/or referrals by pediatric residents over a 2-year period. However, measurement of the effectiveness of curriculum and training interventions was undetermined due to the evolving implementation of changes based on continuous audit findings.

CONCLUSIONS

Recommendations for future use of this technique include establishing baseline skills and targeting specific areas for training and evaluation, providing feedback to residents, and tracking specific patients over time.

Screening for behavioral health problems in primary care

PURPOSE OF REVIEW

The epidemiology of behavioral health disorders in children and the current literature on the identification of these problems within primary care are reviewed. Suggestions are offered on how to implement screening within primary care settings.

RECENT FINDINGS

The prevalence of behavioral health problems in children is approximately 12-27% yet the detection of these problems within the primary care setting is much lower. Although identification may be improving, underidentification and limited referral for services remain a significant problem. Few physicians use standardized instruments or DSM-IV criteria to identify children. Families, in addition, often do not disclose behavioral health concerns about their child to their physician. Multiple barriers exist for successful screening, including lack of training, limited time and poor reimbursement. Recent evidence suggests that a number of well validated instruments are now available for behavioral health screening within primary care.

SUMMARY

Pediatric settings hold the potential to be an optimal environment to address behavioral health concerns due to the frequent contact and trusted relationship many families have with their pediatrician. There is new evidence that screening can be thoughtfully implemented and that system change around the detection of behavioral health problems is possible.

Addressing behavioral health issues during well child visits by pediatric residents

The study examined practices by pediatric residents (n = 61) concerning psychosocial care during well child visits. A random sample (n = 719) of well child visits was selected, and a medical record review was conducted. Results suggested that a behavioral health issue was discussed in 38% of the cases. The most frequent type of problem discussed involved a medical component, while problems with mood were rarely discussed (<1%). Residents treated 67% of the cases and referred 20% of the cases with behavioral health concerns. Logistic regression suggested that residents were significantly more likely to treat medically focused problems (P = 0.05), but more likely to refer children with social/environmental or learning problems (P = 0.05). Results suggested the need for further training in recognition of internalizing disorders.

A model for training pediatricians to expand mental health services in the community practice setting

A model of training pediatricians in mental health diagnosis and intervention was developed to increase the pediatrician's competency in dealing with the increasing number of children with these problems. The model consisted of a pediatric psychiatrist working in collaboration with community pediatricians and training pediatricians in mental health interview and evaluation techniques, recognition and diagnosis of behavioral and mental disorders, and intervention and treatment. Following implementation of this model, the community pediatricians demonstrated an increase in mental health diagnoses in their practices. This model represents one approach in preparing pediatricians to respond to the increasing number of children with mental health and behavioral problems.

High and intermediate imperforate anus: psychosocial consequences among school-aged children

BACKGROUND/PURPOSE

Imperforate anus is an unusual malformation, which, even after surgical intervention, usually entails constipation and fecal incontinence. This study aimed to evaluate ongoing psychosocial effects of this birth defect in school-aged children.

METHODS

Twenty-five children born with high and intermediate imperforate anus participated in the study, along with their parents and classroom teachers. One group of healthy children and 1 group of children with juvenile chronic arthritis, along with their parents, served as controls. Children and parents individually answered a questionnaire devised for this study. Parents filled out the Child Behavior Checklist and the children's teacher filled out the Teacher's Report Form.

RESULTS

According to test results, children with imperforate anus were happy and optimistic. They liked school better and reported better relationships with schoolmates than the other children. The index group reported statistically significantly more frequent constipation. According to parental responses, the imperforate-anus children suffered from fecal incontinence and odor, as well as constipation (P < .001). Index-group parents reported on the Child Behavior Checklist that their children had more emotional and behavioral problems. On the Teacher's Report Form, teachers reported few problems for the same children.

CONCLUSIONS

Patients with imperforate anus did not experience psychosocial impairment despite significant functional problems.

Targeted child psychiatric services: a new model of pediatric primary clinician--child psychiatry collaborative care

Between 15% and 25% of children and adolescents seen in pediatric primary care have a behavioral health disorder with significant psychopathology, high functional impairment, and frequent psychiatric diagnostic comorbidity. Because child psychiatry services are frequently unavailable, primary care clinicians are frequently left managing these children without access to child psychiatry consultation. We describe Targeted Child Psychiatric Services (TCPS), a new model of pediatric primary clinician-child psychiatry collaborative care, and describe program utilization and characteristics of children referred over the first 18 months of the program using a retrospective chart review. The TCPS model can serve a large number of pediatric primary care practices and provide collaborative help with the evaluation and treatment of complex attention deficit hyperactivity disorder, depression, anxiety disorders, and pediatric psychopharmacology.

Psychiatry in orthodontics. Part 1: Typical adolescent psychiatric disorders and their relevance to orthodontic practice

Adolescence is a time of rapid physical and mental development. It is also a time when many diagnosable psychiatric diseases are first noticed. A prior study showed that a high rate of suicidal behavior is seen in orthodontic practices. The orthodontist is in a unique position among medical practitioners because treatment occurs over several years with frequent appointments. This article is a current review of the etiology, diagnosis, and therapy for several pertinent mental disorders that occur in adolescents, including mood disorders, schizophrenia, attention-deficit hyperactivity disorder, personality disorders, and eating disorders. All have been associated with high rates of suicidal behavior and completed suicides. With a keen eye for the development of psychiatric issues, the orthodontist is in a position to make appropriate referrals, if needed.