Child and Adolescent Mental Health and General Pediatrics: A Call for Papers

Letter from the Editor Child and Adolescent Mental Health and General Pediatrics: A Call for Papers Research into mental health issues for children and youth has played a prominent role in papers published in Ambulatory Pediatrics.1– 4 A moderate amount of evidence suggests increasing rates of several mental health conditions among children and adolescents throughout the world and, along with major changes in the organization of care (limiting access to diagnosis and treatment) and financing of mental health services, has made mental health concerns even more prominent in general pediatrics. Epidemiology/Disparities Whether rates of attention deficit hyperactivity disorder (ADHD), depression, and autism spectrum disorders have substantially increased in the past two decades remains controversial.5–7 Good evidence documents increasing rates of disability among children and youth under 20 years of age; and mental health conditions contribute substantially to these rates.8 Clearly, some of the growth in frequency of diagnoses reflects improved diagnostic acumen, broadened diagnostic categories (e.g., the autism spectrum), as well as reasons to label a child as having a mental health condition (e.g., to improve eligibility for services or support programs). Nonetheless, the current high prevalence of these conditions likely does reflect real changes in rates over the past few decades. One can speculate on various reasons for any increases. Traumatic experiences clearly influence the mental health of children and youth, especially in the genesis of post-traumatic stress disorder – and large numbers of young people worldwide have faced dramatic traumatic exposures, including natural disasters in New Orleans and Pakistan, wars in several parts of the world, terrorist attacks, and violence in many urban settings.9–11 Growth in rates could reflect other causes. Have changes in children’s physical and social environments (prenatally, perinatally, or after birth) led to increasing mental illness? What might unrecognized toxins, unbridled growth of media, and changing diets in many parts of the world do to the developing brain?12 Poverty affects rates and severity of most mental health conditions, as do race and ethnicity independently. Clearly, poor children have poor access to mental health services, especially preventive services, but do poor children also experience a combination of community and family deprivation that directly causes poor mental health?13 A small but growing number of studies documents racial and ethnic differences in the diagnosis and treatment of children’s mental health conditions. Do mental health conditions have different manifestations in different cultural settings?7 How do culture and race affect the acceptability and efficacy of treatments? Diagnosis and Treatment in Primary Care Diagnosis and treatment of children’s mental health conditions have greatly improved in the past two decades. Tremendous growth in pharmacologic agents, accompanied by research into new behavioral and psychotherapeutic techniques, has greatly expanded available treatments. New methods will likely radically change the diagnoses of ADHD, autism, and depression. Will earlier identification follow these changes? New genetic and metabolic research will likely provide even more targeted therapies and new understanding of underlying biologic pathways that could lead to new preventive strategies. Much more research has addressed diagnosis and treatment – much less opportunities for prevention, but evidence that rates have truly increased should lead to a search for ways to prevent the expression of mental health conditions. Organization and Financing of Pediatric Mental Health Services Children and youth receive substantial amounts of mental health services from schools and the juvenile justice system – although these sectors have had little services or efficacy research. Financing of mental health services for children remains fragmented and fragile. Poor reimbursement from public and private insurers has led many mental health providers to accept no insurance. Primary care providers, despite increasing training and capability to address children’s mental health issues, rarely receive adequate financial support for the time needed to assess children carefully and to diagnose mental health conditions such as depression and ADHD with the full information most guidelines recommend. So, the mental health of children and adolescents has very much become a primary care issue, but primary care providers lack the health care financing to make the system work well for them. Within the health sector, changing financing of mental health services has created barriers to access to specialized mental health services, leading to greater demands that primary care practices diagnose and treat pediatric mental health conditions. New models of collaborative practice have gained prominence with these changes, including examples where mental health providers co-locate with primary care practitioners, with the close consultation also allowing primary care providers to improve their clinical mental health skills. A program in Massachusetts offers primary care providers easy access to consultation from a team of child psychiatrist, social worker, and case assistant. Although this team does not provide ongoing care, it does help primary care providers to get advice on what they can (and cannot) do and it offers sources of referrals to other mental health AMBULATORY PEDIATRICS Copyright © 2006 by Ambulatory Pediatric Association

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Volume 6, Number 5 September–October 2006

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Letter from the Editor

AMBULATORY PEDIATRICS

Table 1. Mental Health and General Pediatrics: A Call for Papers Topic Areas of Interest: Epidemiology and etiology of pediatric mental health conditions Prevention in mental health and primary care Disparities (especially, socioeconomic status, race, ethnicity) Cultural implications in child mental health Models of care and their evaluation Financing and incentives for pediatric mental health Policy analysis of pediatric mental health Manuscripts due May 15, 2007 Publication: November 2007

providers when needed for longer-term interventions. This service allows primary care providers to strengthen their skills in assessment and in psychopharmacology as well as giving guidance on critical items for followup and monitoring. Mental Health and Primary Care: A Call for Papers In responding to challenges of increasing prevalence of mental health conditions, children’s exposures to toxic environments and events, and the transformation of mental health services for children and youth, the general pediatric community is also undergoing transformation. We see a good number of questions that merit attention from the research community: Are rates of children’s mental health conditions increasing? If so, which ones? And why are they increasing? What opportunities exist for prevention? How does poverty influence the onset, severity, and response to treatment of children’s mental health conditions? Are there critical developmental times when poverty has more or less effect? What are the ways that culture and community interact with mental health conditions of children and youth? What protects certain children from these conditions and what preventive lessons relate to culture and community? How do culture, community, and other sociodemographic factors influence access to mental health services from different sectors and how do they influence the uptake of treatment and its effects? What models of care work best to improve prevention and treatment of mental health conditions among children and adolescents in primary care settings? What financial arrangements or incentives could enhance primary care provision of mental health diagnosis and treatment? With this growth in impact of children’s mental health on general pediatrics, Ambulatory Pediatrics seeks manuscripts on children’s mental health, especially in these areas of epidemiology, disparities, prevention, organization, and financing of care (Table). We plan to publish a series of papers together in the last issue of 2007. For this issue, we should have manuscripts submitted no later than May 15, 2007. Authors should otherwise follow the instructions in the journal or the website for submission, according to usual journal categories of research article, brief report, and commentary. We look forward to your submissions. James M. Perrin, MD Editor-in-Chief REFERENCES 1. Cooper WO, Arbogast PG, Ding H, Hickson GB, Fuchs DC, Ray WA. Trends in prescribing of antipsychotic medications for US children. Ambul Pediatr 2006;6:79 – 83. 2. Stein RE, Silver EJ. Patterns of medical, educational, and mental health service use in a national sample of US children. Ambul Pediatr 2003;3:87–92. 3. Gardner W, Kelleher KJ, Pajer KA, Campo JV. Primary care clinicians’ use of standardized tools to assess child psychosocial problems. Ambul Pediatr 2003;3:191–5. 4. Ortega AN, Goodwin RD, McQuaid EL, Canino G. Parental mental health, childhood psychiatric disorders, and asthma attacks in island Puerto Rican youth. Ambul Pediatr 2004;4:308 –15. 5. Barbaresi WJ, Katusic SK, Colligan RC, Weaver AL, Jacobsen SJ. The incidence of autism in Olmsted County, Minnesota, 1976-1997: results from a population-based study. Arch Pediatr Adolesc Med 2005;159:37– 44. 6. Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry 1996;35:1427–39. 7. Horn IB, Beal AC. Child health disparities: framing a research agenda. Ambul Pediatr 2004;4:269 –75. 8. Perrin JM. Health services research for children with disabilities. Milbank Q 2002;80:303–24. 9. Fairbrother G, Stuber J, Galea S, Fleischman AR, Pfefferbaum B. Posttraumatic stress reactions in new York City children after the September 11, 2001, terrorist attacks. Ambul Pediatr 2003;3:304 –11. 10. DeBellis M, Van Dillen T. Childhood Post-Traumatic Stress Disorder: An Overview. Child Adolesc Psychiatr Clin N Am 2005;14:745–72. 11. Fremont WP. Childhood reactions to terrorism-induced trauma: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2004;43:381–92. 12. Kimmel CA, Collman GW, Fields N, Eskenazi B. Lessons learned for the National Children’s Study from the National Institute of Environmental Health Sciences/U.S. Environmental Protection Agency Centers for Children’s Environmental Health and Disease Prevention Research. Environ Health Perspect 2005;113:1414 – 8. 13. Spencer N. Social, economic, and political determinants of child health. Pediatrics 2003;112(3 Part 2):704 – 6.