Published online September 1, 2004
PEDIATRICS Vol. 114 No. 3 September 2004, pp. 601-606 (doi:10.1542/peds.2004-0090)
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Diagnosis and Treatment of Behavioral Health Disorders in Pediatric Practice

Jane Williams, PhD*, Kurt Klinepeter, MD*, Guy Palmes, MD{ddagger}, Anita Pulley, MSN, RN§ and Jane Meschan Foy, MD*

* Departments of Pediatrics
{ddagger} Psychiatry, Wake Forest University Health Sciences, Winston-Salem, North Carolina
§ Northwest Area Health Education Center, Winston-Salem, North Carolina

Objective. There has been a strong push toward the recognition and treatment of children with behavioral health problems by primary care pediatricians. This study was designed to assess the extent to which a sample of primary care pediatricians diagnose and treat behavioral health problems and to identify factors that may contribute to their behavioral health practice.

Methods. A standard interview was conducted with 47 pediatricians who work in primary care settings in a predominantly urban setting in North Carolina. Pediatricians' responses to questions about the estimated percentage of children in their practice with a behavioral health disorder, tools used to make diagnoses, frequent and infrequent diagnoses made, comfort level with making a diagnosis, reasons for not making a diagnosis, use of psychotropic medications, types of nonmedication interventions provided, educational background, and needs involving behavioral health issues were evaluated.

Results. Pediatricians estimated that the average percentage of children in their practices with a behavioral health disorder was 15%. The study did not find significant differences in perceptions related to time in practice or gender of the pediatric provider. The most frequent behavioral health diagnosis was attention-deficit/hyperactivity disorder (ADHD), and the majority incorporated behavioral questionnaires, expressed a high level of comfort with the diagnosis, and frequently or occasionally prescribed stimulants. Variability was noted in both practice and comfort for other behavioral health disorders. Slightly fewer than half of the pediatricians frequently diagnosed anxiety and depression. Those who make these diagnoses commonly incorporated questionnaires and reported frequent or occasional use of selective serotonin reuptake inhibitors. Comfort in making the diagnosis of anxiety was highly associated with use of selective serotonin reuptake inhibitors. The vast majority (96%) of pediatricians provided nonmedication interventions, including supportive counseling, education for coping with ADHD, behavior modification, and/or stress management. Diagnosis and treatment of severe behavioral health disorders were infrequent throughout the pediatric practices. Areas of greatest educational interest included psychopharmacology, diagnosis and treatment of depression and anxiety, and updates on ADHD. The majority of pediatric providers did not identify a need for education about several high-prevalence disorders that they do not frequently diagnose or treat, including conduct disorder and substance abuse.

Conclusions. Pediatricians in this sample frequently diagnosed and treated ADHD. For all other behavioral health disorders, pediatricians reported variability in both comfort and practice. They frequently provided both pharmacologic and nonpharmacologic treatments for children and adolescents with mild to moderate behavioral health disorders but not for severe disorders. Although they identified needs for additional education for anxiety and depression, the majority did not identify educational needs for several high-prevalence behavioral health disorders, including conduct disorder and substance abuse.

Key Words: children's behavioral health problems • primary care pediatricians

Abbreviations: AAP, American Academy of Pediatrics • ADHD, attention-deficit/hyperactivity disorder • SSRI, selective serotonin reuptake inhibitor

Accepted Mar 4, 2004.




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