Primary Care Pediatrics and Child Psychopathology: A Review of Diagnostic, Treatment, and Referral Practices

The quality of mental health care for children depends not only on specialist mental health services, but also on how effectively primary care providers identify, treat, and refer children with emotional and behavioral problems. Recent research has shown that primary care practitioners are the sole providers of mental health care to the majority of people with a mental disorder. For example, Regier et al1 calculated that in 1975 54.1% of persons with a mental disorder were treated only in a primary care or outpatient medical setting, with another 6% receiving care from both specialist mental health and primary care medical facilities. An additional 21.5% were not in treatment or received treatment from nonmedical agencies. If the data were extrapolated for all age groups, these rates would imply that only one child in five with a mental disorder is receiving specialist treatment, three are in the care of a pediatrician, and one is receiving no treatment. This would lead to the conclusion that pediatricians are, according to Regier et al,1 the de facto mental health service for most children in need of such care. It would lend support to the drive to increase pediatricians' awareness of, and training for, the mental health component of their work.2 In this paper, we review the published evidence as it applies to children. SCOPE This review includes the published studies of mental health problems diagnosed by primary care pediatricians, family practitioners, or pediatric nurse practitioners working in outpatient settings in the United States. These include private pediatric practices, group practices, health maintenance organizations (HMOs), and other types of prepaid group practices. The questions addressed are: (1) What proportion of the children seen by primary care pediatricians and their colleagues are diagnosed by them as having a mental disorder? (2) What proportion of children are referred for specialist evaluation and treatment? (3) What risk factors are associated with a higher probability of receiving a diagnosis of psychopathology? (4) How accurate are primary care pediatricians' diagnoses of mental health problems?