Pediatric patients are presenting with increasingly complex developmental, behavioral, and mental health (DBMH) concerns, and primary care clinicians are often the first – and sometimes only – line of care.
“Coming out of nurse practitioner [NP] school, we are given the basic knowledge of caring for mental health and behavioral health conditions, and we [we are not seeing] basic stuff anymore,” said Katie Erdlitz, DNP, CRNP, CPNP-PC, PMHS, in an interview with The Clinical Advisor. “We’re seeing more complicated cases, and so we have to increase our knowledge on this topic.”
Dr Erdlitz, a clinician at Fairhope Pediatrics in Fairhope, Alabama, discussed the critical need for universal anxiety, depression, and suicide screening in children at the American Association of Nurse Practitioners (AANP) annual conference in San Diego, California.1 She emphasized the need for providers “to recognize and address DBMH concerns, even outside well-child checkups, because early identification can change outcomes,” using the example of screening adolescents for suicide risk at every visit.
Data from the 2023 National Survey of Children’s Health revealed that 1 in 4 US children aged 3 to 17 years had at least 1 DBMH concern (25.8%).2 While half of all mental health disorders can be diagnosed before age 14 years, an estimated 50% of children with a diagnosable psychiatric condition never receive appropriate treatment.3 The Centers for Disease Control and Prevention (CDC) backed this finding in a 2021 study that included children aged 2 to 8 years. It was reported that 45.8% of young children with at least 1 DBMH disorder did not receive any mental health services when needed.4
DBMH Conditions and Disorders Typically Present in Pediatric Patients
- Anorexia Nervosa
- Anxiety
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Autism
- Avoidant/Restrictive Food Intake Disorder (ARFID)
- Binge Eating Disorder
- Bulimia Nervosa
- Conduct Disorder (CD)
- Depression
- Intellectual Disability
- Obsessive Compulsive Disorder (OCD)
- Oppositional Defiant Disorder (ODD)
- Pica
- Post-Traumatic Stress Disorder (PTSD)
- Rumination Disorder
- Tourette Syndrome
Barriers to Mental Health Care for Children
As a result of certain barriers to care, DBMH conditions often go undiagnosed and untreated. These barriers include a lack of specialized providers, limited knowledge among general health providers, social stigma or embarrassment, and financial concerns. The aforementioned CDC study, for example, found that the most reported barriers to health care for children with DBMH disorders were “problems getting an appointment (72.1%), issues related to cost (39.3%), and needed services not being available in the area (38.5%).”4
Dr Erdlitz often sees DBMH misconceptions and stigmatization from parents during patient visits. “I’ll have parents say, ‘We had a family member who committed suicide shortly after taking the medicine, so we don’t believe in medicine for depression,’ or – which this part really breaks my heart – they’ll say, ‘[My children are] just doing this for attention,’” she recalled.
Largely contributing to limited DBMH care accessibility is geographic location. “Some areas of our nation do not have mental health providers to offer this care,” Dr Erdiltz said. Approximately 122 million people in the US live in areas with mental health care service shortages.5 Among these areas, 61% are rural or partially rural,6 and an estimated 12 million children live in rural areas across the country.7 Beyond DBMH care service shortages, rural environments are also associated with higher rates of poverty, uninsurance/public insurance, and isolation among children.8 Dr Erdilitz added that many pediatric patients treated at her practice are on Medicaid.
Screening and Misdiagnosis of Pediatric DBMH Disorders
The most commonly diagnosed DBMH conditions in pediatric patients are attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression, with children who exhibit depression often diagnosed with multiple comorbid conditions.
Data from the 2022 National Survey of Children’s Health showed that 7 million (11.4%) US children between the ages of 3 and 17 years have been diagnosed with ADHD.9
However, Dr Erdiltz said that ADHD is often misdiagnosed in children with anxiety, or anxiety alongside another mental health disorder. Stimulants prescribed for ADHD, she said, can worsen anxiety symptoms in some cases, necessitating a thorough re-evaluation of symptoms. “That’s when you have to take a step back and say, ‘Okay, let’s start over, let’s re-evaluate the symptoms, how [are they] presenting, what things are going on at school and at home,’ ” she said. When diagnosing ADHD in children under age 6, Dr Erdiltz said that clinicians exercise caution, as hyperactivity can be normal for that age group.
In addition to evaluating for ADHD, primary care providers should conduct assessments for DBMH risk factors every time they see their patient, she said, regardless of the type of appointment. Specifically, clinicians should always consider anxiety, depression, and self-harm and/or suicidal ideation. “ ‘What if [the child] is attention-seeking?’ We’re still going to treat them, make sure that they’re safe,” Dr Erdiltz said, in reference to parents’ comments she has encountered in her practice.
I’ll have parents say, ‘We had a family member who committed suicide shortly after taking the medicine, so we don’t believe in medicine for depression,’ or – which this part really breaks my heart – they’ll say, ‘[My children are] just doing this for attention.’
She shared that her team uses the Vanderbilt Assessment Scales for ADHD evaluation in children aged 6 to 12 years, for example. There are various screening tools for DBMH concerns, and with appropriate “clinical judgment,” these can be applied to patients “outside of that age range.” In children who present with characteristics aligned with autism assessment scales, Dr Erdiltz recommended that clinicians make a referral for speech and occupational therapy ahead of a diagnosis, “because the sooner that you get that patient in for treatment and therapy, the better.”
Treatment Plans and Multiple Comorbid Conditions
Children with DBMH comorbidities require careful monitoring, considering that multiple diagnoses often result in overlapping mental health care plans.
Common Treatments for DBMH Conditions
- Behavioral management therapy
- Cognitive behavioral therapy
- Eye Movement Desensitization and Reprocessing (EMDR) therapy
- Medication
- Neurofeedback
- Parent-child interaction therapy
- Play therapy
- Problem-solving and social skills training
- Speech and occupational therapy
Multiple studies have shown that 73.8% of children diagnosed with depression also had an anxiety disorder.10 In 2022, 77.9% of children with ADHD had 1 or more co-occurring DBMH conditions, with anxiety being the second most common diagnosis (39.1%).9 As first-line pharmacologic treatment for depression and anxiety, selective serotonin reuptake inhibitors (SSRIs) are prescribed, while central nervous system (CNS) stimulants are taken for ADHD. Using both concurrently can have damaging outcomes, such as serotonin syndrome, and the clinician must consider all risks on a case-by-case basis.
“One thing that we run into frequently is medication interactions, and making sure that we’re looking to see what interactions are present,” Dr Erdiltz noted. “Ninety percent of the time, there’s going to be at least a mild interaction between some of these medicines that we use.”
Integration of therapies in children with multiple DBMH diagnoses requires collaboration built upon trust between providers and parents, said Dr Erdiltz. As noted, some psychiatric medications cause side effects that may necessitate supplemental therapies. CNS stimulants, such as methylphenidate and amphetamine, can be appetite-suppressing, leading to nutritional deficiencies and weight loss during childhood development. The clinician should prescribe evidence-based diet changes or refer the patient to a dietitian. “One of the biggest things that we do is making sure that [the family] is connected with the correct people, because it’s not just an ‘us’ treatment, it’s a collaborative treatment,” she said.
The same applies to therapies supporting neurodevelopmental disorders, such as autism. Although autism presents differently depending on the child, sensory overstimulation, verbal delay, and intellectual disability are common symptoms. In some cases, the patient may require not only speech and occupational therapy, but also behavioral therapy or parent-child interaction therapy, said Dr Erdiltz, which may make parents wary. She emphasized that establishing trust over the course of several visits and providing educational resources is key to successfully “getting everybody on board.”
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