Diagnosing Psychosocial Problems

(1)

COMMENTARIES

899

JOHN

F.

ROSEN, MD

Albert Einstein College of Medicine

Montefiore

Medical

Center/Pediatrics

Bronx,

New York 10467

REFERENCES

1. Fairbrother G, Friedman S. DuMont KA, Lobach KS. Markers for pri-mary care: missed opportunities to immunize and screen for lead and tuberculosis by private physicians serving large numbers of inner-city Medicaid-eligible children. Pediatrics. 1996;97:785-790

2. Grant JP. Child Health and Human Rights. (Also see Appendix C)

Wash-ington, DC: Institute of Medicine, National Academy of Sciences Press 1994

3. Children ‘s Rights in America: U.N. Convention on the Rights of the Cl,ild

Compared with United States Law. Cohen CP, Davidson, HA, eds.

Amer-ican Bar Association, Center on Children and the Law and Defense for Children International-USA. New York: American Bar Association Press; 1990

4. The State of Americas Children: Yearbook 1994. Washington, DC:

Chil-dren’s Defense Fund; 1994

Diagnosing

Psychosocial

Problems

In

April

1996,

the

American

Academy

of

Pediat-rics

(AAP)

Task

Force

on

Mental

Health

Coding

for

Children

completed

4 years

of

work

on

the

devel-opment

of

a

classification

system

for

children’s

mental

health

appropriate

for

primary

care

clini-cians

with

the

publication

of

the

Diagnostic

and

Statistical

Manual

for

Primary

Care-Child

Version

(DSM-PC).

This

work

represents

a

multidisci-plinary

effort

spearheaded

by

the

AAP

and

sup-ported

by

grants

from

the

Bureau

of Maternal

and

Child

Health,

the

Robert

Wood

Johnson

Founda-tion,

and

the

Friends

of

Children

Fund

to

create

a

more

prevention-oriented,

developmentally

based

system

for

classifying

psychosocial

diagnoses

of

children

and

adolescents

in

primary

care

with

mental

health

symptoms.

The

system

was

developed

in an

effort

to enhance

diagnostic

practices

of

primary

care

clinicians

for

pediatric

mental

health

problems.

Pediatricians

and

family

physicians

underdiagnose

psychiatric

disor-ders

in children

and

adolescents.’2

There

are

various

reasons

for

this.

First,

reimbursement

systems

have

discouraged

payment

for

primary

care

treatment

or

diagnosis

of mental

disorders

to the

point

that

some

clinicians

intentionally

misdiagnose

mental

disor-ders

to enhance

reimbursement.3

Second,

diagnostic

distinctions

have

not

had

clear

treatment

implica-tions

for

primary

care

clinicians.

Third,

prior

work

suggests

that

many

primary

care

providers

are

not

comfortable

treating

patients

with

psychosocial

problems.4’5

At the

same

time,

primary

care

clinicians

have

complained

about

the

lack

of

attention

to

pre-ventive

services

and

normal

development

in

prior

psychiatric

classification

systems.

This

new

effort

at-tempts

to

close

some

of

the

gap

by

designing

a

Received for publication Aug 1, 1995; accepted Aug 28, 1995.

Reprint requests to (K.J.K.) University of Pittsburgh, 3510 Fifth Aye, Suite 1,

Pittsburgh, PA 15213.

Acad-emy of Pediatrics.

system

that

is: (1)

compatible

with

current

psychiat-nc

diagnostic

systems,

(2)

more

user

friendly

to

pri-mary

care

practitioners,

(3) prevention

and

develop-mentally

oriented,

and

(4)

multidisciplinary.

The

DSM-PC

child

version

is

composed

of

two

principal

sections:

the

first

is a listing

or classification

of events

or

situations

that

represent

important

fac-tors

to

consider

in

the

assessment

of

child’s

mental

health

(Table

1 is

a sample

from

that

section);

the

second

section

is

a

list

of

conditions

organized

around

symptom

clusters

that

primary

care

clini-cians

might

encounter,

arranged

from

less

severe

to

more

severe

presentations

(Table

2 is a sample

from

that

section).

In

addition

to

the

two

sections

noted,

instructions

on

the

use

of the

manual

and

assessing

severity

are

incorporated

in

the

brief

volume.

Preliminary

interest

in

this

type

of

classification

system

has

been

widespread

because

of

the

high

prevalence

of

psychosocial

problems

in

primary

care

pediatrics.

The

implications

for

better

commu-nication

between

researchers

and

clinicians

are

ev-ident.

Perhaps

more

importantly,

the

implications

for

training

clinicians

with

an

eye

toward

devel-opment

and

prevention

are

also

significant.

Fi-nally,

many

individuals

involved

in

the

develop-ment

of this

system

hope

that

it also

will

become

the

basis

for improved

reimbursement

to clinicians

when

they

need

to

reassure

parents

about

their

children’s

behaviors

that

are

variations

of

normal

development

or

when

they

attempt

to

prevent

more

serious

conditions

from

arising.

What

remains

unclear

is how

much

this

classifi-cation

system

will

contribute

to

the

daily

practice

of

primary

care

pediatrics.

The

importance

of

the

close

collaboration

and

improved

communication

from

this

project

among

pediatricians,

psychia-trists,

and

psychologists

should

not

be

underesti-mated.

It

is

also

apparent

that

the

synthesis

of

much

of

the

psychiatric

nomenclature

and

some

developmental

information

into

one

concise

work

will

aid

in

the

teaching

of,

and

research

on,

psy-chosocial

issues

in

primary

care

for

children.

But

the

work

of

the

task

force,

the

AAP,

and

others

interested

in improving

primary

care

management

of

psychosocial

problems

must

go

beyond

the

re-lease

of

a

new

classification

system

to

working

toward

enhancing

reimbursement

of

counseling

services

when

appropriate,

supporting

aggressive

educational

strategies,

such

as

those

designed

for

the

American

Psychiatric

Association’s

DSM-IV,

and

continuing

efforts

to

support

better

coverage

by

payers

for

integrated

mental

health

and

pri-mary

care

services.

It is only

with

these

steps

that

dramatic

changes

in diagnostic

practices

are

likely.

Fortunately,

the

first

steps

toward

these

neces-sary

follow-up

actions

are

beginning

to

happen.

Negotiations

are

underway

through

the

AAP

to

improve

reimbursement

for

counseling

services

conducted

by

pediatricians,

and

this

system

may

allow

common

terminology

for

the

parties

in-volved

in

such

discussions,

because

it is

compati-ble

with

DSM

and

International

Classification

of

Diseases

systems

that

are

currently

used

for

reim-bursement

calculations.

Second,

the

AAP

has

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

(2)

TABLE 1. Marital Discord, V61.1/Divorce, V61.O*

900 COMMENTARIES

Risk Factors Protective Factors

Close emotional relationship with the noncustodial parent Consistent explanation and exoneration of the child Childhood guilt about believing one is the cause of the marital Absence of litigation/parental discord

discord

Sudden, unexplained divorce Greater hostility in divorce

Ongoing contact with both parents

Sparing children from the emotional conflict of the parents Persistent conflict and litigation (particularly about custody) Continued cooperation between parents to support needs

of child Parental mental illness

*Definition: unresolved hostility, violence, or severe disagreement with or denigration of the partner. The children’s parents alter their

relationship so that the children’s contact with either parent or their perception of the stability and friendliness of the relationship may be substantially changed. This may involve separation after prolonged cohabitation or legal termination of the marriage.

TABLE 2. Secretive Antisocial Behaviors

Developmental Vanations/ Problem

V.65.4, secretive antisocial behaviors, variations

As noted in the preliminary comments, secretive antisocial behaviors appear at low base rates during early and middle

childhood,

with a normative increase toward adolescence. Mild levels of cheating, lying, and taking of small objects are usually not of clinical concern during childhood, and some evidence exists that some experimentation with alcohol and substances in adolescence does not portend maladjustment.

V71 .02, secretive antisocial behaviors, problem Secretive antisocial behaviors become

troublesome when their rates, intensity, and consequences increase and when parents or

care

givers begin to suspect a pattern of lying to hide the offending actions.

Common Developmental Presentations

Infancy Not relevant. Early childhood

The child

occasionally cheats during games, lies to deny

responsibility for misbehavior, and secretly takes small amounts of money from parents. Middle childhood The child occasionally rips and tears papers during a

tantrum, cheats on tests at school, and has a single episode of minor shoplifting.

Adolescence

The adolescent occasionally experiments with a drink of alcohol or smoke of marijuana.

Special information

The occasional occurrence of and the lack of harm resulting from selected covert actions signal normative, as opposed to troublesome levels of covert behavior.

Infancy Not relevant. Early childhood

The child lies intentionally to escape punishment, becomes fascinated with matches, and rips up papers after

arguments.

Middle childhood

The child sometimes shoplifts relatively unsubstantial items and hides parents’ belongings after stressful incidents. May occasionally take money from parents or others.

Adolescence

The adolescent

sometimes shoplifts, sometimes causes mild

damage to property, regularly deposits graffiti on walls, and begins to use alcohol on a repetitive basis but not to a sufficient degree to warrant a conduct disorder or substance abuse disorder diagnosis.

Special information

For a problem, as opposed to a disorder, behaviors are not

frequent

and levels of harm are relatively low. These

behaviors can be associated with dysfunctional family interaction and/ or patterns of abuse. These possibilities should always be evaluated.

ceived

support

to

develop

a comprehensive

edu-cational

package

around

the

DSM-PC

child

version

and

to

begin

the

dissemination

process.

Finally,

the

rapid

spread

of

capitation

and

man-aged

care

reimbursement

strategies

may

encour-age

primary

care

mental

health

service

delivery

in

an effort

to prevent

later

and

more

costly

referrals.

Although

it is likely

that

the

DSM-PC

child

version

will

change

with

additional

research

and

input

from

practitioners,

this

initial

effort

by

primary

care

and

specialty

clinicians

to work

together

on

a

classification

system

may

act

as

one

piece

in

the

puzzle

toward

improving

mental

health

services

for

children

and

adolescents

with

behavioral

and

emotional

problems

in primary

care

settings.

KELLY

J.

KELLEHER,

MD,

MPH

Departments of Pediatrics

and

Psychiatry University of Pittsburgh

School

of Medicine

Pittsburgh, PA 15213

MARK

L. WouucH,

MD

Division

of Child

Development

Vanderbilt

Medical

Center

Nashville, TN 37237

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

(3)

COMMENTARIES

901 ACKNOWLEDGMENT

This work was supported in part by the Staunton Farm

Foun-dation of Pittsburgh.

REFERENCES

I. Horwitz SM, Lea PJ, Leventhal JM, Forsyth B, Speechley KN.

Identifi-cation and management of psychosocial and developmental problems

in community-based, primary care pediatric practices. Pediatrics. 1992; 89:480-465

2. Costello EJ, Costello AJ, Edelbrock C, et al. Psychiatric disorders in pediatric primary care. Arch Cen Psychiatry. 1988;45:1107-1116

3. Rost K, Smith GR, Matthews D, Guise B. The deliberate mis-diagnosis of major depression in primary care. Arch Fam Med. 1994;3:333-337 4. Sharp L, Pantell RH, Murphy LO, Lewis CC. Psychosocial problems

during child health supervision visits: eliciting, then what? Pediatrics.

1992;89:619-623

5. Shapiro S. German PS, Skinner EA, et al. An experiment to change

detection and management of mental morbidity in primary care. Med Care. 1987;25:327-339

CORPORATE

BODY

OF SENSE

EXPERIENCE

Our

statements

about

the

external

world

face

the

tribunal

of sense

experience

not

individually,

but

only

as a corporate

body.

Quine WV. From a Logical Point of View. Cambridge: Harvard University Press; 1961.

Submitted

by Student

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

(4)

1996;97;899

Pediatrics

Kelly J. Kelleher and Mark L. Wolraich