PEDIATRICS Vol. 108 No. 5 November 2001, pp. 1227-1230

AMERICAN ACADEMY OF PEDIATRICS:
The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care

Committee on Psychosocial Aspects of Child and Family Health

	ABSTRACT

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In 1993, the American Academy of Pediatrics adopted the policy statement "The Pediatrician and the `New Morbidity.'" Since then, social difficulties, behavioral problems, and developmental difficulties have become a main part of the scope of pediatric practice, and recognition of the importance of these areas has increased. This statement reaffirms the Academy's commitment to prevention, early detection, and management of behavioral, developmental, and social problems as a focus in pediatric practice.

	ONCE A NEW MORBIDITY

In 1991, the American Academy of Pediatrics (AAP) Task Force on the Future Role of the Pediatrician in the Delivery of Health Care made reference to the 1800s, when pediatrics developed as a medical specialty. "A focus on growth and development was established rapidly, and it was recognized that the child's health was influenced greatly by family attitudes, environment, and socioeconomic class."¹ Thus, the concept of morbidity associated with environmental and psychosocial issues in child health care is not new. Social and behavioral issues were recognized by the early leaders in pediatrics, and the style in which they are addressed constitutes the art of pediatric practice. Carl C. Fischer spoke in 1969 about the role of the AAP in child health care: "The founding fathers, in their wisdom, established the major objective of the Academy, which is to foster and stimulate interest in pediatrics and correlate all aspects of the work for the welfare of children which properly comes within the scope of pediatrics."²

Public health initiatives, such as immunizations and improved public hygiene, and specific treatments with new technologies for disease, equip pediatricians at the beginning of this century with the ability to offer prevention, cure, and resolution of ailments and injuries, now a standard expectation of pediatric practice. These advances have led to an emphasis on specialization as an essential component of training for the care of patients. Pediatricians are now challenged to place more attention on activities related to the quality of outcomes, chronic disease management, and the psychosocial consequences of chronic conditions as the behavioral needs of our patients are now recognized as core elements of pediatric care.

	THE CURRENT ENVIRONMENT

Although dealing with social, developmental, and behavioral issues may once have been considered an art, advances in the social sciences have established a knowledge base of specific skills and interventions effective in dealing with many psychosocial issues.^3,4 For example, there is a better understanding of long-term consequences of divorce,⁵ child sexual abuse,⁶ and the ongoing effects of attention-deficit/hyperactivity disorder into adulthood.^7,8 The field of pediatric psychopharmacology has been rapidly evolving over the past decade with the introduction of new medications such as selective serotonin reuptake inhibitors and atypical antipsychotics.^9,10 The practicing pediatrician must have a broader knowledge base to identify these problems and intervene and has a responsibility to become knowledgeable about approaches that work.

When this topic was last reviewed,¹¹ the new morbidities in pediatric practice demanded competence in the following areas of knowledge:

• physical and environmental factors affecting behavior, including risk factors, and their impact, prevention, and management;
• normal variations of behavior and emotional development and how to help parents deal with them;
• behaviors affecting physical health, including risk factors (eg, medical adherence, smoking), and their impact, prevention, and management;
• mild and moderate behavioral problems, including detection, evaluation, and management; and
• severe behavioral deviations, including recognition, preliminary evaluation, and appropriate referral.

These morbidities remain important foci in the care of children and families. The purpose of this statement is to reaffirm the commitment of the AAP to prevention, early detection, and management of behavioral, developmental, and social problems as a focus in pediatric practice.

	NEWER MORBIDITIES

Now an increasingly complex environment brings newer morbidities to the attention of pediatric practitioners, such as:

• school problems, including learning disabilities and attention difficulties;
• child and adolescent mood and anxiety disorders;
• the alarming increase in adolescent suicide and homicide;
• firearms in the home;
• school violence;
• drug and alcohol abuse;
• human immunodeficiency virus and acquired immunodeficiency syndrome; and
• the effects of media on violence, obesity, and sexual activity.

These are the morbidities that place our patients at risk. The mortality of meningococcemia is appreciated by all pediatricians, but the morbidity of depression and the mortality of adolescent suicide are more appreciable.^12-14 In other words, after infancy, children in the United States are more likely to die from injuries or violence and suicide than from infectious disease.

In addition, pediatricians are challenged in their practices by aspects that relate to quality of life, social justice, equality in health care access, population and public health, and personal and institutional values, including but not limited to:

• poverty;
• homelessness;
• single-parent families;
• the effects of parental divorce on children;
• the struggles of working parents; and
• issues of child care policy and quality.

Pediatricians' creativity, flexibility, patience, and commitment are being challenged in ways that test the very original motivations for choosing pediatrics as a profession and vocation.

	THE BARRIERS

If we embrace the importance of these morbidities, how will we meet these challenges? Why has a good idea not taken hold? Why do disciplines struggle over the conceptualization of these problems and implementation of effective treatments? To practice effectively in this arena, pediatricians must overcome existing educational, economic, and time management obstacles.

	THE PATH TOWARD CHANGE

The pediatrician's professional competence and job satisfaction in managing behavioral issues can be enhanced by several changes.

Training and Continuing Medical Education

Pediatric residency training is largely focused on major physical illness in tertiary care hospitals and, to a limited degree, on behavioral issues. Limited training opportunities are provided to integrate psychosocial issues into primary care.

Training in ambulatory settings must expand the emphasis on behavioral, developmental, and psychologic issues. More extensive developmental, behavioral, and adolescent training during residency will better equip pediatricians to address these practice challenges. The experience must be supervised by faculty with training and/or experience in the behavioral/developmental aspects of pediatrics.¹⁵

Continuing medical education training in the areas of developmental and behavioral pediatrics are now provided by the AAP and other sources.

Improving Diagnostic Skills

The Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version¹⁶ describes the full range of psychosocial and behavioral problems encountered by pediatricians, from normal variant behavior through problem behaviors, to syndromic or diagnosable levels. The DSM-PC classification of coding of mental conditions in children allows for early identification and enhances the understanding and management of a broader range of psychosocial issues in pediatrics. The DSM-PC describes problems intrinsic to the child and situational diagnoses that complicate a child's function. The DSM-PC is an essential part of the primary care pediatrician's library, providing accurate and appropriate diagnoses and allowing the documentation of services provided and claims submissions for appropriate reimbursement.

Improving Interviewing Skills

Interviewing skills are essential to all aspects of medicine. There is a need to better learn how to elicit information, including using a narrative interview approach, allowing the child, adolescent, and parents to tell their stories, even when it means giving up control of the interview. There is a need to effectively communicate empathy. Pediatricians also need to recognize their own experience, culture, and values and the impact of their personal issues on the therapeutic relationship. As a skill to be learned, interviewing needs to include supervised practice and feedback as well as mentoring. Formalized and tested screening tools are available to cast a wider net to screening. Many practices develop their own questionnaires to assist in screening and in the interviewing process. Internet-based screening tools are also available to facilitate referral to community mental health services and to improve access.¹⁷

Improving Pediatric Counseling Skills

Counseling is a skill that is underused in the management of behavioral problems. With a combined knowledge of psychosocial issues, interviewing skills, and diagnostic understanding, pediatricians can effectively counsel patients and families and improve many of the behavioral problems they encounter at early stages of their presentation.

Establishing a Comprehensive Mental Health Model

A collaborative model that integrates physical and mental issues, considers positive and negative aspects of child and family adjustment, and encourages the clinician to make behavioral diagnostic judgments is also important. Strong consideration should be given to an interdisciplinary approach in the ambulatory clinical setting with mental health professionals and physicians working side by side.¹⁸ Collaborative approaches can also be created for smaller practices where on-site mental health professionals are not available.

Allocating Time Realistically

Child health supervision visits are effective for detecting abnormalities and preventing illness. When psychosocial issues are detected during such a visit, there may be insufficient time to address the problems adequately. Although developmental issues reflecting normal variations may be managed within the context of health supervision visits, more complex issues, such as divorce, bereavement, school failure, domestic violence, or homosexuality, require additional visits with ample time to discuss the problem. The individual skill level of the pediatrician will determine the complexity of psychosocial issues that he or she can manage effectively.

Ensuring Adequate Reimbursement

Pediatricians must advocate for themselves in their individual practices and for the practice of pediatrics at large by negotiating managed care and fee-for-service contracts with third party payers that ensure reimbursement for excess services provided and by advocating for the mandatory inclusion of benefits for these services in families' insurance contracts, both public and private.

	CONCLUSION

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The "new morbidity" represents a shift in the understanding of what impacts the health of children and families. Pediatricians witness complex psychosocial family issues and care for the patients impacted by them; understanding and addressing these issues will make the pediatrician more effective in serving children and families. The cooperation of pediatric residency directors, educators, practicing pediatricians, and developmental and behavioral pediatricians will be required for training residents and experienced pediatricians. To effectively address these new morbidities, pediatricians will need a model that encompasses expanded areas of competence in child behavior, development, and family function.

	RECOMMENDATIONS

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1. Residency training programs should reflect in their curricula psychosocial issues that affect children and their families.
2. Practicing pediatricians are encouraged to increase their knowledge of developmental and behavioral aspects of child health care.
3. Pediatricians should develop an increased understanding of positive and negative factors that influence child psychosocial development.
4. Pediatricians should enhance their interviewing, counseling, and referral skills to better address psychosocial aspects of child and family health care.
5. Pediatricians are strongly encouraged to establish side-by-side practice with mental health professionals to address more complex psychosocial issues encountered in clinical practice.
6. Pediatricians are strongly encouraged to use DSM-PC coding to convey to insurance companies and health financing institutions the importance and value of pediatricians spending time addressing psychosocial issues.
7. The pediatrician should become familiar with mental health referral processes and community resources in the mental health field to ensure access and continuity of services.
8. Pediatricians should advocate for children's mental health needs within their professional communities and the education system, as well as among legislators.
9. Pediatricians should enhance their understanding of the newer psychotropic medications and establish collaborative working relationships with child and adolescent psychiatrists.

Committee on Psychosocial Aspects of Child and Family Health, 2001-2002

Joseph F. Hagan, Jr, MD, Chairperson

William L. Coleman, MD

Jane M. Foy, MD

Edward J. Goldson, MD

Barbara J. Howard, MD

Ana Navarro, MD

Thomas J. Sullivan, MD

J. Lane Tanner, MD

Liaisons

F. Daniel Armstrong, PhD

Society of Pediatric Psychology

David R. DeMaso, MD

American Academy of Child and Adolescent Psychiatry

Peggy Gilbertson, RN, MPH, CPNP

National Association of Pediatric Nurse Practitioners

Sally E. A. Longstaffe, MD

Canadian Paediatric Society

Consultants

Javier Aceves, MD

George J. Cohen, MD

Staff

Karen Smith

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

	ABBREVIATIONS

AAP, American Academy of Pediatrics; DSM-PC, Diagnostic and Statistical Manual for Primary Care.

	REFERENCES

Top Abstract Conclusion Recommendation References

1. American Academy of Pediatrics Task Force Report on the future role of the pediatrician in the delivery of health care. Pediatrics 1991; 87:401-409 [Abstract/Free Full Text]
2. Fischer CC The role of the American Academy of Pediatrics in child health care. Pediatr Clin North Am 1969; 16:957-961 [Medline]
3. Ferris TG, Saglam D, Stafford RS, Changes in the daily practice of primary care for children. Arch Pediatr Adolesc Med 1998; 152:227-233 [Abstract/Free Full Text]
4. Young KT, Davis K, Schoen C, Parker S Listening to parents. A national survey of parents with young children. Arch Pediatr Adolesc Med 1998; 152:255-262 [Abstract/Free Full Text]
5. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health The pediatrician's role in helping children and families deal with separation and divorce. Pediatrics 1994; 94:119-121 [Abstract/Free Full Text]
6. Beitchman JH, Zucker KJ, Hood JE, daCosta GA, Akman D, Cassavia E A review of the long-term effects of child sexual abuse. Child Abuse Negl 1992; 16:101-118 [CrossRef][Medline]
7. American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105:1158-1170 [Abstract/Free Full Text]
8. Spencer T, Biederman J, Wilens T, Harding M, O'Donnell D, Griffin S Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adolesc Psychiatry 1996; 35:409-432 [CrossRef][Medline]
9. Bailey RA, Hendren RL A primer on adolescent psychopharmacology. Adolesc Med 1997; 8:33-55 [Medline]
10. Katic A, Steingard RJ, Schmidt C An update on adolescent psychopharmacology. Adolesc Med 1998; 9:217-228 [Medline]
11. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health The pediatrician and the "new morbidity." Pediatrics 1993; 92:731-733 [Abstract/Free Full Text]
12. Jellinek MS, Snyder JB Depression and suicide in children and adolescents. Pediatr Rev 1998; 19:255-264 [Free Full Text]
13. Beasley PJ, Beardslee WR Depression in the adolescent patient. Adolesc Med 1998; 9:351-362 [Medline]
14. Weissman MM, Wolk S, Goldstein RB, Depressed adolescents grown up. JAMA 1999; 281:1707-1713 [Abstract/Free Full Text]
15. Accreditation Council for Graduate Medical Education. Program requirements/Pediatricscompetencies. Available at: http://www.acgme.org. Accessed June 29, 2001
16. American Academy of Pediatrics. The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Wolraich ML, Felice ME, Drotar D, eds. Elk Grove Village, IL: American Academy of Pediatrics; 1996
17. Pediatric development and behavior. Developmental-Behavioral Pediatrics Online Community. Available at: http://www.dbpeds.org/handouts.Accessed June 29, 2001
18. Coleman WL, Howard BJ Family-focused behavioral pediatrics: clinical techniques for primary care. Pediatr Rev 1995; 16:448-455 [Abstract/Free Full Text]