The Importance of Working and Learning Together

The Child and Adolescent Psychiatrist
Michael S. Jellinek, MD.

Pediatricians and child psychiatrists share a heartfelt commitment to the well-being of children. Both are concerned about emotional illness, divorce, substance use, domestic violence and other social issues impacting children, as well as the needs of special populations of children, such as those in foster care. Although such issues once fell primarily within the purview of child psychiatrists, the prevalence of psychiatric disorders in children—ranging from 10% to 20%, depending on study methods and population—has made them major concerns for pediatricians as well. Pediatricians in primary care are often the first to see children with emotional disorders, and pediatric subspecialists frequently face emotional issues in children with cancer, seizures, or other chronic diseases. Yet despite the commonalities of professional concerns and mission, there is a sense that pediatrics and child psychiatry are farther apart than they should be.

Our current system of health care financing has contributed to this distance. Third party
payers’ reimbursement to pediatricians for practice time spent addressing patients’
emotional disorders is low or non-existent. Reimbursement for psychiatrists is also low
and structured to provide incentives for time spent on psychopharmacology. Moreover,
for-profit managed care companies have cleaved mental health services from general
insurance, disrupting medical referral patterns and making it difficult to access
comprehensive care. Although such plans often limit the availability of child psychiatrists
to pediatricians, even the current rate of referrals often overwhelms the limited number
of child psychiatrists. Despite the higher prevalence of emotional disorders in poor
children, many Medicaid programs provide inadequate coverage.

Both the American Academy of Pediatrics (AAP) and the American Academy of Child
and Adolescent Psychiatry have made efforts to bridge the gaps between the fields.
Recent publications, such as Bright Futures: Mental Health and the Classification of
Child and Adolescent Mental Diagnoses in Primary Care—Child and Adolescent version (DSM-PC), are the result of genuine collaboration between the two specialties. There
are liaison and communication efforts between the academies. The AAP has increased —
at least modestly—the emphasis on training in behavior and development. However,
such requirements are difficult to fulfill due to insufficient faculty, funding, and curricular materials, and thus do not fully prepare pediatricians to deal with the high prevalence of mental health and psychosocial problems they will encounter in practice.

This manual is a valuable, practical contribution to filling the breach. The three cases
presented are indisputably germane to both pediatrics and child psychiatry; the authors
are clinical experts; and the editors are distinguished, experienced leaders in the field.
These case studies have been thoughtfully presented to address educational needs, build
collaboration, and improve understanding between pediatricians and child psychiatrists. Clearly, meeting the mental health needs of children will require a societal commitment
to invest in our children as well as continued work at the Board and Academy levels. But
we also should remember that, ultimately, care is given by a doctor in an office, consulting and referring to colleagues, based on what each has learned through the case method.
This manual should be widely adopted by training programs. Its use will enrich the educational process, and improve the care of children.

The Pediatrician
Mark L.Wolraich, M.D.

We have made great strides in better defining mental illness in children in recent years.
There have been improvements in defining diagnostic criteria and in understanding the pathophysiology of many conditions. We have more and safer medications with
demonstrated efficacy in children, and better-defined psychosocial interventions with
proven efficacy. Unfortunately, the benefits of those advancements have yet to be
realized by many of the children and families who need them. The translation of science into practice has lagged, and the capacity of the mental health services system to meet
the needs of children has not only failed to keep pace with scientific advances,
but in some areas has even declined.

It is clear that the emotional well-being of children is not important just to the mental
health community, but it is also a vital concern of primary care clinicians. Most mental disorders do not present as an all-or-none phenomenon: They fall within a developmental spectrum that runs from normal and problematic behaviors to disorders described in DSMPC. In their milder and earlier stages, most disorders present first to primary care clinicians, as do many of the environmental situations increasing the risk of mental disorders. Therefore, primary care clinicians play an important role in screening for conditions and providing early or less intensive interventions. Given their large numbers, pediatricians have the capacity to manage emotional conditions early, when they may be prevented or ameliorated.

Communication and coordination between pediatricians and child psychiatrists is essential
if we are to succeed at this task. Primary care clinicians can help children and families
with complex needs only if there is appropriate communication between specialties. Child psychiatrists can provide the needed expertise in direct service where it is available. They can also provide critically important consultation to primary care physicians when psychiatric services are limited, especially as access to therapeutic interventions becomes more challenging in a system that restricts services and places mental health service in a separate health care system.

This manual is designed to help pediatricians and child psychiatrists to collaborate more
effectively for the benefit of the child. It employs a successful model of case-based
sessions in collaborative office rounds as the basis for the curriculum. By providing
instructions for including these educational activities in residency training programs, the
manual illustrates how pediatric and psychiatric trainees can work and learn together