Children infrequently receive timely care for mental and behavioral health problems: the average time from the start of child mental health symptoms until a young person enters mental health treatment is 8–10 years (Kessler et al. 2005). In many systems of care, only about one in five children with a diagnosable mental health disorder will receive treatment during childhood (U.S. Public Health Service Office of the Surgeon General 1999). For those children identified in primary care to be in need of a behavioral health intervention, a little more than half of those referred to a specialist will attend even a single treatment appointment (Rushton et al. 2002).
The reasons for this underuse of specific mental health treatments during childhood are numerous. Barriers include stigma, poor problem recognition, limited family or practitioner understanding of treatments, insurance coverage barriers, complicated referral processes, and limited availability of mental health specialists.
There are far more community issues to address than any of us as individual practitioners could change all at once. Thankfully, opportunities are now increasing for practitioners to participate in meaningful improvements in community behavioral health systems. Through payer supports and system redesigns, primary care practices may be able to develop collaborative or integrated care partnerships with mental health specialists. Doing so brings specialist support directly into sites where people are already receiving medical services. Research has determined that such arrangements can be clinically more effective and even save money for the overall care system, which has captured the attention of health systems and payers.
10Regardless of the specific system of care available in your community, we would like to point out certain general clinical steps that appear along the path of addressing child behavioral health problems in community settings. If you are a primary care practitioner or a health system representative working to improve community behavioral health, identifying opportunities to improve any of the following areas is likely to improve the health of children:
• Recognition of mental distress
• Screening for mental distress
• Diagnosis of a particular mental disorder
• Education about mental health treatment
• Teaching patients and caregivers self-help strategies
• Initiation of counseling and therapy
• Appropriate prescription of medications
Before a child can receive services, he or she first must be recognized as needing some form of assistance. We point this out because caregivers have wide variations in their view of what requires professional help. The same set of disruptive behaviors may lead one caregiver to write it off as “Oh, he’s just being a boy” but lead another caregiver to demand immediately to see a professional. Families may actively resist acknowledging or may simply fail to recognize when the child has a problem that treatment could help. Therefore, a key initial step in the process is for family members, friends, school representatives, and primary care practitioners to help parents recognize what can and cannot be helped through mental health treatment and overcome stigma barriers when necessary. Education about general signs of trouble to watch for— such as decreasing school performance or losing the ability to have fun—can aid with problem recognition.
Proactively looking for mental health problems through direct questioning or evaluating symptoms with a behavioral health rating scale is worthwhile, but only if practitioners are 11available to interpret that information and recommend appropriate actions. Rating scales are very useful for their ease of administration and ability to identify unrecognized problems, to obtain clinical data from multiple informants, and to provide assessments of symptom severity to follow.
Rating scales are also inherently imperfect; they should never be the sole basis for making a diagnosis. This is because questions might be misinterpreted, might be answered untruthfully, or might simply have been the wrong questions to ask. For instance, an adolescent with recent-onset inattention problems may have a depressive disorder or an anxiety disorder missed if the only diagnostic assessment was an attention-deficit/hyperactivity (ADHD) disorder symptom rating scale. An adolescent who denies having depressive symptoms on a rating scale but is engaging in recurrent self-harm should still receive specialized care. Thus, the most valuable steps in a rating scale screening process are practitioners helping to select the correct scales, interpreting the results in the context of a person’s personal situation, and taking a helpful action for any positive screening results.
Making a mental health diagnosis and developing a treatment plan can be challenging for a mental health care practitioner who has up to an hour to complete his or her assessment. For those who are less experienced or have only 15 minutes to assess a person, the task quickly becomes overwhelming. Within a strictly limited and very short time frame, all that we would reasonably ask of a clinician is to identify the child’s leading problem and its probable rather than definitive origin.
A well-supported DSM-5 (American Psychiatric Association 2013) diagnosis subsequently requires three things: 1) that a child’s clinical presentation fulfills the specific symptom-based diagnostic criteria, 2) that those symptoms are not caused by other diagnoses or stressors, and 3) that those symptoms are impairing a child’s functioning. Because challenges occur at each step, we recommend breaking up the process into several steps. In an initial brief assessment with incomplete information, we recommend that clinicians consider using less specific diagnoses, such as disruptive behavior disorder, unspecified, or depressive disorder, unspecified. 12The diagnosis then can be clarified over time through gathering more information at subsequent appointments. This multistep approach allows the time needed to gather collateral information, such as ADHD rating scales completed by both teachers and family members for subsequent review.
When multiple problems are identified in an initial very brief appointment, working with a young person and his or her caregivers to jointly identify the leading problem allows for a more practical use of time. For instance, if a child is having screaming tantrums, is hitting other children, is sleeping poorly, and sometimes appears anxious, the identified leading problem may be the unsafe externalizing behaviors. In that case, the child’s sleep problems and intermittent anxiety might be set aside to explore further at the next appointment.
Educating children and families about their diagnosed mental health disorders has intrinsic value. Besides fulfilling an inherent desire to better understand problems, the ultimate purpose of providing psychoeducation is to increase the child’s and his or her caregiver’s ability to achieve health. Resistance to bringing a child to see a mental health practitioner or to trying out an appropriate psychiatric medication is common. So even if you make the best diagnosis possible, it does little good unless you connect the diagnosis to treatment. We keep the timeless advice of the physician Henry Cohen (1943) in mind: “All diagnoses are provisional formulae designed for action” (p. 24).
Therefore, we follow referral recommendations with educating the family about the value of receiving mental health services. This helps a patient and his or her caregivers visualize the process of treatment, what is known about the anticipated response to treatment, and what is likely to happen without treatment. For instance, we might help a caregiver with reluctance to see a mental health specialist understand that it takes an episode of untreated major depression a mean of about 8 months to self-resolve, which, if that happens, is a great deal of life and normal development for a child to miss out on (Birmaher et al. 2007). For a family who, because of the child’s dysfunction, has lost some of their empathy for their child (which can happen with externalizing problems such as 13oppositional defiant disorder), providing blame-free psychoeducation about the condition and the likelihood of response to treatment can also help can also help to reestablish caregiver empathy and support.
Even though a primary care practitioner might prefer to have a mental health practitioner initiate all forms of intervention for an identified disorder, this delays care. Delays can occur from stigma-related resistance to following through on a referral, challenges in negotiating insurance restrictions, and having to wait for a local practitioner to become available. We prefer that some form of treatment plan initiation occur right away, through the kind of steps that would be appropriate for a family primary care practitioner to recommend.
What would be appropriate treatment to recommend without a mental health practitioner? The first step in treatment plan initiation could be coaching the child and family on self-help measures they can implement now. For example, the practitioner could address a young person’s poor sleep habits, which accompany many different mental and behavioral health problems. Coaching how to improve a child’s sleep hygiene, such as restricting access to text messaging after a certain time at night, can reduce daytime irritability and initiate improvements in mood, as we discuss in Chapter 14, “Psychosocial Interventions.”
We also recommend a few situation-specific self-help readings or videos, which are known generically as bibliotherapy. Behavior management training for disruptive behavior is a prime example, because we know that a motivated parent can make significant changes in the child’s discipline plan and environment from such references alone, without a therapist’s involvement (Lavigne et al. 2008). Many high-quality books, Web sites, and videos are available that motivated parents can use to try implementing evidence-based disruptive behavior management or cognitive-behavior therapy informed skills. However, even when parents use high-quality self-help tools, this is less likely to make a difference with more severe symptoms, more overall family dysfunction, and more diagnostic complexity.
We recommend psychotherapy for any young person who meets criteria for a mental health diagnosis with moderate to severe symptoms or for mild symptoms that are persistent and dysfunctional enough to warrant the investment of a young person’s time. There are exceptions to this broad generalization about when to recommend psychotherapy; for instance, even in severe cases of ADHD, the young person may be treated successfully with medications alone, but this situation is an exception to the rule. The specific preferred forms of psychotherapy will differ by disorder type, so we encourage you to identify the diagnosis first and then consider the options we describe in Chapter 15, “Psychotherapeutic Interventions.” Because many families avoid going to psychotherapy, you should learn their concerns and address them. For instance, “You looked like you weren’t very happy with the idea of working with a therapist...what comes to mind for you about this?”
One-on-one psychotherapy is not the only source of outpatient services for young patients. Locally available support groups, crisis intervention services, parenting classes, social skills groups, family therapy, special education services, and speech therapists are just a few other examples. Because caregivers’ own mental health difficulties may affect a young person’s mental health disorders, coaching a caregiver on his or her own appropriate use of psychotherapy may be a way to help a child or an adolescent. Use of a question such as the following may help: “With everything going on, do you have someone in your corner who is there just to help you?” Some primary care practitioners may choose to provide young people with motivational interviewing techniques to support their efforts to reduce substance abuse behaviors or learn to provide coaching on relaxation training or other cognitive-behavioral techniques during their own follow-up appointments.
Primary care practitioners often feel pressured to prescribe right away, in part because the prescription pad is one of the few treatment tools immediately available. This can be quite appropriate when the diagnosis is clear, significant rather than just mild symptoms are present, an evidence-supported 15medication option is available, and the practitioner has discussed the risks and benefits. We otherwise advise resisting an immediate prescription.
A near-universal recommendation when prescribing psychiatric medications to children is that some form of psychosocial intervention—therapy or changes in the child’s environment—should accompany their use. Other prescribing principles to keep in mind include starting with low doses and increasing slowly over time (“start low, go slow”) and changing only one medication at a time to avoid outcomes confusion.
In summary, here are suggestions for a primary care approach to child mental health treatment:
• Instill appropriate hope, even in the initial interview.
• Form a therapeutic alliance with the young person and his caregivers.
• Use rating scales to help gather more clinical information but be aware of their limitations.
• Ask for collateral information from other informants to help ensure a correct diagnosis.
• Interview adolescents alone to obtain a more complete history, especially for internalizing disorders.
• Note the child’s office behavior and interactions, which supply much of your child mental status examination findings.
• For an initial brief assessment, make only a provisional DSM-5 “unspecified” diagnosis.
• Expect to use more than one appointment to refine your diagnoses.
• Coach the family on pursuing their next best steps in care while screening for any barriers to address.
• For mild conditions, start with self-help approaches, bibliotherapy, and school interventions.
• Consider referring to specialist care anyone who is more ill or not improving.
• Use psychosocial interventions, such as psychotherapy, in most scenarios.
• If symptoms are moderate to severe, consider starting medication management with an evidence-supported strategy.
• Use your local specialists for support, to provide counseling, and to manage your more challenging patients.
• Schedule a follow-up appointment, even if patients were referred to specialty care.
As we assess young people, we find it helpful to remember a maxim of clinical practice: “When you hear hoof beats, think horses, not zebras.”
We find it to easier to detect psychiatric conditions in young people by recognizing the typical ages when different mental health conditions are likely to appear. For instance, you are unlikely to diagnose anorexia nervosa, bipolar disorder, or schizophrenia in a 4-year-old in a primary care clinic.
Still, there are not precise ages at which you should or should not consider a particular diagnosis. We can offer no firm rules. We can offer two pieces of prudent advice:
1. Remember the adage “Common things are common.” When you are seeing a 10-year-old, separation anxiety disorder is more likely than schizophrenia.
2. Consider that developmental delay can influence the age and appearance of a disorder. For instance, encopresis, which is rarely seen in teenagers, may be more likely in a 16-year-old with the approximate mental age of a 4-year-old.
We created Table 2–1 to help guide your diagnostic inquiries. You will notice that as children age, conditions such as encopresis and oppositional defiant disorder become less likely, whereas conditions such as bipolar disorder and schizophrenia become more likely. Overall, diagnosable conditions increase with age. We advise against diagnosing personality disorders until at least late adolescence because, by definition, a child’s personality is developing and changing more actively than is an adult’s personality.
Another way to think of the predicted likelihood of detecting specific disorders in children is in regard to their absolute frequencies of occurrence. According to National Comorbidity Survey data (Merikangas et al. 2010), anxiety disorders have a much earlier age at onset than many practitioners realize. Half of individuals who develop an anxiety disorder will have had symptom onset by age 6, half of those with behavior disorders will have had onset by age 11, and half of those with mood disorders will have had onset by age 13 (among adolescents who have a mental health diagnosis). Table 2–2 includes the relative distribution of the lifetime experience 17of mental health diagnoses in decreasing overall order of frequency among 13- to 18-year-old patients in this survey.
Knowing when different mental and behavioral health disorders typically appear in young people can help your diagnostic process. Any screening test or diagnostic inquiry has more positive predictive value the higher the overall prevalence of the condition being investigated. Therefore, on the basis of prevalence rates and our own clinical experiences, the following are our suggestions for routine consideration in your differential diagnosis at different age ranges.
Ages 0–5: Developmental impairments and disruptive behavior problems are the predominant issues at this age. General screening rating scales to consider at this age therefore include general developmental assessments, autism spectrum screens, and social-emotional learning measures.
Ages 6–12: Attention-deficit/hyperactivity disorder (ADHD), disruptive, impulse-control, and conduct disorders; intellectual disabilities; anxiety disorders; and mood disorders predominate at this age. General screening rating scales to consider at this age therefore include ADHD symptom rating scales, anxiety rating scales, and depression and autism spectrum measures.
Ages 13–18: Major depressive disorder, anxiety disorders, posttraumatic stress disorder, eating disorders, ADHD, substance use disorder, and conduct disorder predominate at this age. General screening rating scales to consider at this age therefore include ADHD symptom rating scales, anxiety rating scales, and depression rating scales.
18 19TABLE 2–1. Selected DSM-5 disorders to be considered at different ages
Preschool (2-5 years) |
School age (6-12 years) |
Adolescence (13-17 years) |
ADHD (age ≥ 3, if severe) |
ADHD |
ADHD |
Autism spectrum disorder |
Adjustment disorder |
Adjustment disorder |
Communication disorders |
Conduct disorder |
Anorexia nervosa |
Encopresis |
Encopresis |
Bipolar disorders |
Intellectual disability (intellectual developmental disorder) |
Intellectual disability (intellectual developmental disorder) |
Bulimia Conduct disorder |
Oppositional defiant disorder |
Insomnia disorder and parasomnias |
Persistent depressive disorder (dysthymia) |
Selective mutism |
Specific learning disorder |
|
Separation anxiety |
Major depressive disorder |
Intellectual disability (intellectual developmental disorder) |
Specific phobia |
Obsessive-compulsive disorder |
|
|
Oppositional defiant disorder |
Insomnia disorder |
|
Posttraumatic stress disorder |
Generalized anxiety disorder |
|
Tourette’s disorder (tics) |
Specific learning disorder |
|
Trichotillomania (hair-picking disorder) |
Major depressive disorder |
|
Social anxiety disorder |
Obstructive sleep apnea hypopnea |
|
Specific phobia |
Obsessive-compulsive disorder |
|
Somatic symptom disorder |
Oppositional defiant disorder |
|
|
Panic disorder |
|
|
Posttraumatic stress disorder |
|
|
Tourette’s disorder (tics) |
|
|
Trichotillomania (hair-picking disorder) |
|
|
Schizophrenia |
|
|
Social anxiety disorder |
|
|
Specific phobia |
|
|
Somatic symptom disorder |
|
|
Substance use disorders |
Note. ADHD=attention-deficit/hyperactivity disorder.
Source. American Psychiatric Association 2013.
20TABLE 2–2. Cumulative prevalence of DSM-IV disorders in adolescents, per the National Comorbidity Survey–Adolescent Supplement
Disorder |
Total prevalence (%) |
Presence of severe impairment among those with disorder (%) |
Specific phobia |
19.3 |
3 |
Oppositional defiant disorder |
12.6 |
52 |
Major depressive disorder or dysthymia |
11.7 |
74 |
Social phobia |
9.1 |
17 |
Drug abuse or dependence |
8.9 |
NR |
Attention-deficit/hyperactivity disorder |
8.7 |
8 |
Separation anxiety disorder |
7.6 |
8 |
Conduct disorder |
6.8 |
32 |
Alcohol abuse or dependence |
6.4 |
NR |
Posttraumatic stress disorder |
5.0 |
30 |
Bipolar disorder |
2.9 |
89 |
Eating disorder |
2.7 |
NR |
Agoraphobia |
2.4 |
100 |
Panic disorder |
2.3 |
100 |
Generalized anxiety disorder |
2.2 |
41 |
Note. NR=not reported.
Source. Derived from Merikangas et al. 2010.21