The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care

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.