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ARTICLE: Kelly J. Kelleher, Thomas K. McInerny, William P. Gardner, George E. Childs, and Richard C. Wasserman Increasing Identification of Psychosocial Problems: 1979-1996 Pediatrics 2000; 105: 1313-1321 [Abstract] [Full text] [PDF]

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Increasing Identification of Psychosocial Problems: An Underestimate of True Prevalence

Daniel B Kessler   (9 June 2000)

Response to Dr. Kessler

Kelly Kelleher   (21 June 2000)

Increasing Identification of Psychosocial Problems: An Underestimate of True Prevalence 9 June 2000
Daniel B Kessler, Developmental and Behavioral Pediatrician Children's Health Center of St. Joseph's Hospital and Medical Center, Phoenix, AZ Send letter to journal: Re: Increasing Identification of Psychosocial Problems: An Underestimate of True Prevalence dkessle{at}chw.edu Daniel B Kessler	Dr. Kelleher and his colleagues have done an excellent job in identifying the increase in psychosocial problems in children 4- to 15 years of age. I believe there argument that the increase represents a true increase in the absolute number of children with psychosocial difficulties and the increase frequency of these problems rather than better identification is also well supported. However, because of the design of the study, being that is represents "clinician-identified psychosocial problems" rather than parent-identified psychosocial problems means that it is a conservative estimate at best of their true occurrence in the general population. There is an extensive literature (Young, Davis, Schoen, Parker. Arch Pediatr Adolesc Med. 1998;152:255-262; Lavigne, Binns, Christoffel, et al. Pediatrics. 1993;91:649-655; Horwitz, Leaf, Leventhal, et al. Pediatrics. 1992;89:480-485; Hickson, Altemeier, O'Connor. Pediatrics. 1983;72:619- 624) especially in preschool children, which attests to the fact that more parents sitting in pediatricians' offices have concerns about problems of a psychosocial nature than about their child's physical health (Hickson, Altemeier, O'Connor, 1983). Parents hesitate to ask their pediatricians for help in these areas because they don't expect their pediatricians to be either knowledgeable regarding these concerns, or helpful in their resolution. Parents definitely want more help from their pediatricians than they are currently getting (Young, Davis, Schoen, Parker, 1998) and pediatricians aren't identifying many children in need of services (Horwitz, et al., 1992). The forces and trends in health care identified by Kelleher, et al. (not their proposed solutions) aren't likely to make things any easier. If you have limited time to deal with the concerns of your parents and psychosocial concerns will take up more of your time (and are unlikely to be reimbursed or even covered by your contract because of "mental health carve-outs") you are less likely to even ask the questions. If people are asking why good kids, from good neighborhoods, and attending good schools can shoot their peers and teachers, the answers aren't very far away.
Response to Dr. Kessler 21 June 2000
Kelly Kelleher, Pediatrician Childrens Hospital and University of Pittsburgh Send letter to journal: Re: Response to Dr. Kessler kelleherkj{at}msx.upmc.edu Kelly Kelleher	We thank Dr. Kessler for his comments on our article which we understand to include the following points: a) our estimates of the extent of psychosocial need are low, b) parents underreport these problems to their clinicians and c) parents would like to get more help from their primary care clinicians. We concur with Dr. Kessler that many patients with psychosocial problems are not identified by their clinicians. We have reported on this elsewhere (1,2). We note that as compared to standardized research instruments, clinicians describe some children with 'normal' scores as having psychosocial problems and miss many others who parents rate very high on symptom checklist scales. However, our point in this article was not to identify the specific prevalence, but to use identical methods almost two decades later to show a relative change. We also agree with Dr. Kessler about the underreporting of problems to clinicians. He does an admirable job of summarizing the relevant literature here. Moreover, many of the clinicians in our study validated his final point about families wanting more help from clinicians. We hope our work furthers the discussion around ways in which primary care clinicians can help such families. 1. Kelleher KJ, Childs GE, Wasserman RC, McInerny TK, Nutting PA, Gardner WG: Insurance status and recognition of psychosocial problems: A report from PROS and ASPN. ARCHIVES OF PEDIATRIC AND ADOLESCENT MEDICINE, Nov 1997; 151: 1109-1115. 2. Gardner WP, Nutting PA, Kelleher KJ, Werner JJ, Farley T, Stewart L: Family APGAR: A measure of family dysfunction or individual support. In press, JOURNAL OF FAMILY PRACTICE.