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INTRODUCTION

Pediatric primary care settings are often the first entry points for identification of mental and behavioral health issues for the 14%–20% of affected children and adolescents. Beyond addressing identified and diagnosable mental health conditions, pediatric primary care settings are tasked with (1) prevention and health promotion, (2) screening and surveillance, (3) early identification, (4) risk and crisis evaluation and triage, (5) initiating treatment for low acuity issues, and (6) triage and referral around complex behavioral health and psychosocial issues for the child, their family, and the environments in which the child interacts.

Primary care providers see approximately 75% of children with psychiatric disturbances, and half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. Parents and children often prefer discussing these issues with pediatric providers who they already know and trust. As a result, pediatric primary care providers play an important role in the prevention, identification, initiation, management, and coordination of mental health issues, in addition to providing behavioral and developmental care and support for children and adolescents. Many factors contribute the fact that only 15%–25% of children with diagnosable disorders have access to and are seen by mental health specialists: the shortage of mental health providers, particularly in rural regions and for medically underserved communities, the stigma attached to receiving mental health services, chronic underfunding for behavioral/mental health services, institutional barriers within the public mental health system, and disparate insurance benefits. In contrast, more than 78,000 board-certified pediatricians and innumerable midlevel pediatric providers are in a unique position to identify issues affecting the emotional health of children and to initiate treatment or referrals to other providers.

Emotional problems that develop during childhood and adolescence can significantly impact development and may continue into adulthood. In fact, most adult psychiatric disorders involve childhood onset. Many disorders do not present as an all-or-none phenomenon, but rather progress from less severe concerns, such as adjustment problems or perturbations in functioning, to significant disturbances and severe disorders. The chronicity of these disorders provides many opportunities for pediatricians to evaluate and manage emotional problems and behavioral conditions early on when improvement can be achieved with less intensive interventions. These opportunities, when missed, can result in downward spiral of school and social difficulties, poor employment opportunities, poverty in adulthood, and increased health care utilization and costs as adults. These outcomes are even more pronounced for children and adolescents from underserved, low socio-economic backgrounds.

Pediatricians and other primary care providers may be the first, or only, medical professional to identify a behavioral/mental health problem. Pediatricians working in specialty care settings, hospitalists, and intensivists will also encounter and need to treat children and adolescents with emotional and behavioral problems. This chapter reviews prevention, surveillance, and screening for mental and behavioral health concerns; situations that may arise in the context of such assessments; psychiatric illnesses commonly identified and diagnosed during childhood or adolescence; current treatment recommendations; and indications for ...

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