A Time for Action: Tackling Paediatric Behavioural and Emotional Disorders

Z. Yusuf1, F. Sharif1

1. Paediatric Department, Midlands Regional Hospital, Mullingar, Co Westmeath, Republic of Ireland

A paediatric consultation may unexpectedly veer in any direction. For example, an 8 year old with headaches may reveal that he has auditory hallucinations and thoughts of self-harm. Or a 2 year old with challenging “terrible twos” behaviour is revealed to have abused the family dog. Children rarely attend a general paediatrician with concerns over behaviour or mood, and a seemingly routine consultation may deviate down another path.

Paediatricians commonly encounter behavioural and emotional disorders such as disruptive behaviour disorders, anxiety and mood disorders, eating disorders, schizophrenia, autistic spectrum disorder, attention deficit disorder, and obsessive compulsive disorder. Behavioural and emotional disorders are among the most prevalent chronic medical conditions, and it is believed that socio-economic disadvantage and “toxic stress” are amongst the most potent risk factors.1,2 The World Health Organisation estimates that 10-20% of children and adolescents worldwide experience mental health disorders, and the 2012 “My World” National Survey of Youth Mental Health reports that almost one in three young people in Ireland have experienced mental health difficulties.1,3

It is imperative that we identify children requiring support as there is evidence that children benefit from early intervention, and that behavioural and emotional disorders have implications into adult life.1,3 A Oireachtas education committee were told of the large number of suspensions and expulsions of Irish school boys aged 12 years to 16 years.4 Many of these children demonstrate challenging behaviours that are not being identified early, and are not being appropriately supported. Instead, children are reprimanded and their education interrupted when they demonstrate disruptive behaviour.4 Paediatric behavioural or emotional disorders not only affect developmental potential and learning opportunities, but are also associated with conditions such as obesity, cardiovascular disease, substance abuse, and mental health issues in adult life.1,3

Studies have shown that children identified as at risk of behavioural or emotional disorders through routine screening benefit from early intervention, and demonstrate a subsequent improvement in their social and emotional development.5,6 Yet despite this evidence, fewer than 1 in 8 children receive treatment.2 This calls for evaluating our approach and the systems we have in place to optimise care for our paediatric population.

First, children should be seen by skilled professionals competent in identifying behavioural and emotional disorders. Unfortunately, while paediatricians feel that they play a pivotal role in identifying and managing behavioural and emotional disorders, a survey conducted by the American Academy of Pediatrics (AAP) found that only 13% felt confident in their training and ability to detect and manage these conditions.2 In Ireland children have 22 contacts from birth to 14 years of age with a health care professional at key developmental stages.7 Developmental assessment is formally undertaken by a public health nurse at 1 week of birth, 3 months of age, 9 months of age, 2 years of age and 3 years of age.7 The assessment is guided by Mary Sheridan’s book “From Birth to Five Years,” and the hope is to introduce the Ages and Stages Screening Questionnaire at the 2 year assessment in January 2019.8 Currently, visits do not involve a standardised tool and social and emotional disorders are not formally assessed.8 Furthermore, Paediatric Specialist Registrars receive varying degrees of exposure during their training to behavioural and emotional disorders, while most General Practitioners have never received formal training in this area. It is imperative, therefore, that we review our current training standards and ensure that paediatric trainees, general practitioners, and public health nurses feel confident in identifying behavioural and emotional disorders, and understand the appropriate referral and management pathways.

Second, the AAP recommends that health care professionals avail of screening tools when assessing children as clinical judgement has low sensitivity and specificity.2 Several tools exist, such as the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE), Paediatric Symptom Checklist (PSC), Brief Infant-Toddler Social and Emotional Assessment (BITSEA), Strengths and Difficulties Questionnaire, and National Initiative for Children’s Healthcare Quality (NICHQ) Vanderbilt Assessment Scale.1 However, in a study of clinicians in over 200 practices it was found that paediatric providers rarely use screening tools to assess mental health problems.2 Paediatric providers reported that a standardised measure was used to assess mental health problems in only 20.2% of all visits, with 50.2% admitting to never using a formal measure.2 Furthermore, less than 7% of providers used a standardised measure during 50% or more of visits.2 Many of these screening tools are simple to administer, and it is important that health care professionals are familiar with them and incorporate them into their regular practice when they have a concern about a patient.

Lastly, in order to comprehensively tackle this problem, factors contributing to psychosocial problems must be addressed, as well as the supports available for children and families of children identified as at risk.6 While this is beyond the scope of this article, we would like to draw attention to an article in the Irish Times.9 In this article Michelle McDonagh highlights the lack of support at the primary care level, leaving the Child and Adolescent Mental Health Services (CAMHS) inundated with referrals. This creates a massive strain on a service which was designed for children with severe and enduring mental health illness. With over 2400 children currently on the CAMHS waiting list, and with over 80 posts across the CAMHS teams nationwide unfilled, the Irish mental health service has a long way to go in its delivery of mental health supports.9

Training clinicians to detect behavioural and emotional disorders and encouraging the use of standardised screening tools are simple measures that can make an invaluable change. Investing today in systems that facilitate early identification of behavioural and emotional disorders in children, and in systems that offer appropriate and timely intervention will have long lasting and rewarding effects. As the American activist Marian Wright Edelman eloquently said: “The question is not whether we can afford to invest in every child; it is whether we can afford not to”.10

Conflict of Interest:
The authors declare that there are no conflict of interest regarding the publication of this article.

Corresponding Author:
Dr. Zaheera Yusuf
Email: zaheera.yusuf@gmail.com.

References

1. Voigt RG, Macias MM, and Myers SM. AAP Developmental and Behavioural Pediatrics. American Academy of Pediatrics, 2011.
2. Weitzman C and Wegner L. Promoting Optimal Development: Screening for Behavioral and Emotional Disorders. Pediatrics. 135(2): 384 – 395. February 2015. http://pediatrics.aappublications.org/content/135/2/384.
3. World Health Organization. “Child and Adolescent Mental Health.” http://www.who.int/mental_health/maternal-child/child_adolescent/en/ . 2017. Accessed 12 January 2017.
4. O’Brien C. Concerns Over The ‘Huge’ Numbers of Suspensions of School Boys. Irish Times. https://www.irishtimes.com/news/education/concerns-over-the-huge-numbers-of-suspensions-of-school-boys-1.3136024?mode=amp. 27 June 2017. Accessed on 30 June 2017.
5. Briggs RD, Stettler EM, Silver EJ, Schrag RDA, Nayak M, Chinitz S, and Racine AD. Social- emotional screening for infants and toddlers in primary care. Pediatrics.129(2):e377-384. February 2012.
6. Brown CM, Copeland KA, Sucharew H, and Kahn RS. Social-Emotional Problems in Preschool Aged Children: Opportunities for Prevention and Early Intervention. Archives of Pediatric Adolescent Medicine. 166(10): 926. 2012.
7. Jennings, P. (2016, May 23). The National Healthy Childhood Programme: Making Every Contact Count. Health Service Executive. Retrieved from http://www.hse.ie/eng/health/child/nurture/healthy_childhood_prog.pdf
8. Best Health for Children Revisited. (2005). Training Programme for Public Health Nurses and Doctors in Child Health Screening, Surveillance, and Health Promotion. Health Service Executive. https://www.hse.ie/eng/services/Publications/Children/Appendix_2_Best_Health_for_Children_Revisted.pdf
9. McDonagh M. Over 2,400 Children Waiting for Child Mental Health Services. Irish Times. https://www.irishtimes.com/life-and-style/health-family/over-2-400-children-waiting-for-child-mental-health-services-1.3130980?mode=amp. 4 July 2017. Accessed on 20 July 2017.
10. Edelman, Marian Wright. The Measure of Our Success: A Letter to My Children and Yours. New York, Harperperennial, 1993.

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