Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

We review recent research on the presentation, nosology and epidemiology of behavioral and emotional psychiatric disorders in preschool children (children ages 2 through 5 years old), focusing on the five most common groups of childhood psychiatric disorders: attention deficit hyperactivity disorders, oppositional defiant and conduct disorders, anxiety disorders, and depressive disorders. We review the various approaches to classifying behavioral and emotional dysregulation in preschoolers and determining the boundaries between normative variation and clinically significant presentations. While highlighting the limitations of the current DSM-IV diagnostic criteria for identifying preschool psychopathology and reviewing alternative diagnostic approaches, we also present evidence supporting the reliability and validity of developmentally appropriate criteria for diagnosing psychiatric disorders in children as young as two years old. Despite the relative lack of research on preschool psychopathology compared with studies of the epidemiology of psychiatric disorders in older children, the current evidence now shows quite convincingly that the rates of the common child psychiatric disorders and the patterns of comorbidity among them in preschoolers are similar to those seen in later childhood. We review the implications of these conclusions for research on the etiology, nosology, and development of early onset of psychiatric disorders, and for targeted treatment, early intervention and prevention with young children.

Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology.

OBJECTIVE: Policy discussions regarding the mental health needs of children and adolescents emphasize a lack of use of mental health services among youth, but few national estimates are available. The authors use three national data sets and examine ethnic disparities in unmet need (defined as having a need for mental health evaluation but not using any services in a 1-year period) to provide such estimates. METHOD: The authors conducted secondary data analyses in three nationally representative household surveys fielded in 1996–1998: the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey. They determined rates of mental health service use by children and adolescents 3–17 years of age and differences by ethnicity and insurance status. Among the children defined as in need of mental health services, defined by an estimator of mental health problems (selected items from the Child Behavior Checklist), they examined the association of unmet need with ...

https://ajp.psychiatryonline.org/doi/pdfplus/10.1176/appi.ajp.159.9.1548

Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status

OBJECTIVE
Policy discussions regarding the mental health needs of children and adolescents emphasize a lack of use of mental health services among youth, but few national estimates are available. The authors use three national data sets and examine ethnic disparities in unmet need (defined as having a need for mental health evaluation but not using any services in a 1-year period) to provide such estimates.


METHOD
The authors conducted secondary data analyses in three nationally representative household surveys fielded in 1996-1998: the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey. They determined rates of mental health service use by children and adolescents 3-17 years of age and differences by ethnicity and insurance status. Among the children defined as in need of mental health services, defined by an estimator of mental health problems (selected items from the Child Behavior Checklist), they examined the association of unmet need with ethnicity and insurance status.


RESULTS
In a 12-month period, 2%-3% of children 3-5 years old and 6%-9% of children and adolescents 6-17 years old used mental health services. Of children and adolescents 6-17 years old who were defined as needing mental health services, nearly 80% did not receive mental health care. Controlling for other factors, the authors determined that the rate of unmet need was greater among Latino than white children and among uninsured than publicly insured children.


CONCLUSIONS
These findings reveal that most children who need a mental health evaluation do not receive services and that Latinos and the uninsured have especially high rates of unmet need relative to other children. Rates of use of mental health services are extremely low among preschool children. Research clarifying the reasons for high rates of unmet need in specific groups can help inform policy and clinical programs.

Unmet Need for Mental Health Care Among U.S. Children

This study examined how well private-practice pediatricians can identify emotional/behavioral problems among preschool children. Children aged 2 through 5 (N = 3876) were screened during a visit to 1 of 68 pediatricians who rendered an opinion about the presence of emotional/behavioral problems. Subsequently, children who scored above the 90th percentile for behavioral problems on the Child Behavior Checklist, along with children matched on age, sex, and race who had screened low, were invited for an intensive second-stage evaluation. There were 495 mothers and children who participated in that evaluation, which included a behavioral questionnaire, maternal interview, play observation, and developmental testing. Two PhD-level clinical child psychologists rendered independent opinions about the presence of an emotional/behavioral disorder. The psychologists identified significantly higher rates of problems overall--13.0% when the criterion was independent agreement that the child had an emotional/behavioral problem and a regular psychiatric diagnosis was assigned, vs 8.7% based on pediatricians' ratings. Prevalence rates based on psychologists' independent ratings were significantly higher than pediatricians' for both sexes, 4- through 5-year-olds, and whites, but not for 2- through 3-year-olds, African-Americans, and all minorities. Prevalence rates based on psychologists' ratings were significantly higher than the pediatricians' for all subgroups when V-code diagnoses were included in the psychologists' ratings. Overall, pediatricians' sensitivity was 20.5%, and specificity was 92.7%. At least 51.7% of the children who had an emotional/behavioral problem based on the psychologist's independent agreement had not received counseling, medication, or a mental health referral from the pediatrician.(ABSTRACT TRUNCATED AT 250 WORDS)

Behavioral and Emotional Problems Among Preschool Children in Pediatric Primary Care: Prevalence and Pediatricians' Recognition

• Violence, including homicide, child abuse and neglect, and assault by peers and others, causes over 2000 deaths a year to US children aged 0 to 19 years. Homicide is a leading cause of death for US children and adolescents, and so a major cause of years of potential life lost. Infantile and adolescent patterns of homicide are recognized: child abuse by parents characterizes the former; gunshots and other assaults by peers characterize the latter. Nonfatal violent injury is far more prevalent than the fatalities. Reliable estimates indicate that each year close to 1 million female adolescents are sexually assaulted, and more than 1.5 million children and adolescents are abused by the adults responsible for them. Adolescents experience violent crimes at extremely high rates. Risk factors for violent injury are recognized. The most consistent include male sex (except for sexual abuse) and urban residence. Despite the toll of violence, surprisingly little is known about its origins and means to prevent it. The only prevention approach that has been both well evaluated and of apparent benefit is the home health visitor for prevention of child abuse in infants of young, impoverished, unmarried primiparous women. Many other approaches are plausible, promising, and/or being implemented, and these require thorough trial and evaluation. Research on numerous aspects of the precursors and correlates of violence against children is also needed. ( AJDC. 1990;144:697-706)

Violent death and injury in US children and adolescents.

Objectives To describe (1) primary care providers' experiences identifying and reporting suspected child abuse to child protective services (CPS) and (2) variables affecting providers' reporting behavior. Design and Methods Health care providers (76 physicians, 8 nurse practitioners, and 1 physician assistant) in a regional practice-based network completed written surveys that collected information about the demographic characteristics of each provider and practice; the provider's career experience with child abuse; and the provider's previous year's experience identifying and reporting suspected child abuse, including experience with CPS. Results All providers (N=85) in 17 participating practices completed the survey. In the preceding 1 year, 48 respondents (56%) indicated that they had treated a child they suspected was abused, for an estimated total of 152 abused children. Seven (8%) of 85 providers did not report a total of 7 children with suspected abuse (5% of all suspected cases). A majority of providers (63%; n=29) believed that children who were reported had not benefited from CPS intervention, and 21 (49%) indicated that their experience with CPS made them less willing to report future cases of suspected abuse. Providers who had some formal education in child abuse after residency were 10 times more likely to report all abuse than were providers who had none. Conclusions Primary care providers report most, but not all, cases of suspected child abuse that they identify. Past negative experience with CPS and perceived lack of benefit to the child were common reasons given by providers for not reporting. Education increases the probability that providers will report suspected abuse.

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Health care providers' experience reporting child abuse in the primary care setting

Objective To investigate the factors associated with mental health service use among young children. Method Five hundred ten preschool children aged 2 through 5 years were enrolled through 68 primary care physicians, with 388 (76% of the original sample) participating in a second wave of data collection, 12 to 40 months later. Consensus DSM-III-R diagnoses were assigned using best-estimate procedures. The test battery included the Child Behavior Checklist, a developmental evaluation, the Rochester Adaptive Etehavior Inventory, and a videotaped play session (preschool children) or structured interviews (older children). At wave 2, mothers completed a survey of mental health services their child had received. Results In logistic regression models, older children, children with a wave 1 DSM-III-R diagnosis, children with more total behavior problems and family conflict, and children receiving a pediatric referral were more likely to receive mental health services. Among children with a DSM-III-R diagnosis, more mental health services were received by children who were older, white, more impaired, experiencing more family conflict, and referred by a pediatrician. Conclusions Young children with more impairment and family conflict are more likely to enter into treatment. Services among young children of different races with diagnoses are not equally distributed. Pediatric referral is an important predictor of service use.

Mental Health Service Use Among Young Children Receiving Pediatric Primary Care

As awareness of the huge human and other costs of injury has grown, research has expanded. There has not been any standard set of terminology for use in this research. As a result, research and surveillance data are too often difficult to interpret and compare. To overcome this impediment to gains in needed knowledge about childhood injuries, a conference was held in 1989 by the National Institute of Child Health and Human Development to develop a set of standard definitions. The full conference report is available from the US Government Printing Office. This report presents excerpts, emphasizing those--core--variables likely to be of use to the largest number of investigators. The conference recommendations presented address cross-cutting factors (age, race/ethnicity, location, socioeconomic status, and biopsychosocial development), effect modifiers (exposure, medical risk factors, substance abuse, time, injury severity, and social risk factors), and specific injuries (motor vehicle injuries, central nervous system injuries, falls, fire/burns, drowning, and violence). It is expected that childhood injury investigators will strive to meet the recommendations of this conference and that use of these definitions will lead to improvements in research and, ultimately, to revision of the definitions.

Katherine Kaufer Christoffel

Papers

Behavioral and Emotional Problems Among Preschool Children in Pediatric Primary Care: Prevalence and Pediatricians' Recognition

Violent death and injury in US children and adolescents.

Health care providers' experience reporting child abuse in the primary care setting

Mental Health Service Use Among Young Children Receiving Pediatric Primary Care

Standard definitions for childhood injury research: excerpts of a conference report.