• CNS infections or parainfectious syndromes
• Substance abuse, toxic ingestions, medication adverse effects
• Intracranial trauma or other injury
• CNS tumors
• Endocrine disorders
  • Thyroid or adrenal dysfunction
• Metabolic disorders
  • Abnormal glucose
  • Sodium
  • Potassium
  • Calcium
• Migraines
• Seizure disorders
• Hematologic disorders
  • Porphyria
  • Severe anemia
• Hypoxia
• Other cardiopulmonary disturbances

• Attention deficit/hyperactivity disorder (ADHD) may be difficult to distinguish from mood (depression or bipolar disorder), anxiety (including school phobia), post-traumatic stress, and tic disorders, substance abuse, hearing or vision impairment, and learning disabilities.
• Social withdrawal may be a sign of depression, neglect, PDD, sensory impairment (e.g., deafness), or learning disability.
• Psychotic symptoms are seen not only in psychotic disorders, but also in mood disorders (depression, bipolar disorder), borderline personality disorder, and substance abuse.

• There is strong evidence for a heritable/genetic risk of bipolar disorder (manic-depression), schizophrenia, and depression. There is less strong, but growing evidence that other conditions, e.g., anxiety, ADHD, pervasive developmental disorder (PDD), and tic disorders, may be genetically transmissible. Twin studies (monozygotic versus dizygotic) suggest that personality disorders have a significant genetic component.
• Many disorders, e.g., ADHD (between 3:1 to 9:1), depression (1:2), etc., have distinct male:female preponderance.
• Prevalence estimates vary widely, due to differing definitions of “psychopathology.” Median rates are 8% for preschoolers, 12% for preadolescents, and 15% for adolescents.
• Suicide is epidemic. Eight percent of high school students attempt suicide, 25% of which require medical attention. Fifty percent of attempters seek medical care in the month preceding their attempt, 25% in the preceding week.
• Conservative estimates of the prevalence of depression in children and adolescents range from 5% to 10%.
• Eating disorders, while relatively uncommon (0.5% to 1% prevalence), have a 5% to 15% mortality rate.

• A psychobehavioral assessment should include a history of the presenting complaint, a past medical, developmental, and behavioral/psychiatric history, and a complete familial history and review of systems.
• The “SHADSSS” mnemonic is a useful inventory of psychosocial functioning. It is structured such that the least threatening topics are asked first, the most intimate last. All of these areas of psychosocial functioning should be assessed in all patients.
  • School (in school? grades? relationships with peers and teachers?)
  • Home (living situation? relationship with parents? siblings?)
  • Activities (how does the patient spend their free time?)
  • Depression
  • Substance abuse (including alcohol and tobacco)
  • Sexuality (including abuse, STDs, and pregnancy)
  • Safety (suicidality, homicidality, plans for revenge or violence)

• Constitution of household, custody/visitation arrangements
• Who supervises the child or provides child care
• Stressors on the family (emotional, financial, interpersonal, violence within the family, involvement with law enforcement or social services, etc.)
• Strategies used by the family in coping with conflicts, problems, stressors, etc.

• The use of screening questionnaires (see BIBLIOGRAPHY), parent monitoring forms/diaries, and direct observation of parent-child interactions can be used, depending on the practitioners experience, familiarity, and confidence with these modalities, as well as the practice setting. Screening for maternal depression may also be important in detecting psychosocial dysfunction.
• The Pediatric Symptom Checklist (PSC) is a brief, parent completed questionnaire, which has been validated in a number of pediatric settings. A multitude of other screening tools have been developed, which are of varying utility to the pediatric practitioner.
• Conners Rating Scales alone are not sufficient to diagnose ADHD. It is a clinical diagnosis, based on pervasive inattention, hyperactivity, or impulsivity across different settings.
• Published in 1996 by the American Academy of Pediatrics, the Diagnostic and Statistical Manual for Primary Care (DSM-PC), child and adolescent version, is the result of collaborative efforts by pediatricians (primary care, and behavioral and developmental specialists), and child psychiatrists, psychologists, and neurologists. It provides a concise, user-friendly guide for diagnosing mental disorders in children and adolescents.

• Children on psychotropic medications should be monitored for adverse effects.
• Stimulants: frequent assessment of growth, heart rate, and blood pressure every 3 to 6 months. Those on pemoline (Cylert) should have LFTs checked every 6 to 12 months.
• Tricyclic antidepressants: baseline ECG (before starting medication), and ECGs 1 month after starting medications and every 6 months thereafter.
• Antipsychotics: reassessment at 2, 4, and 12 weeks after starting medication, and every 3 to 6 months thereafter for adverse effects (dystonia, anti-cholinergic symptoms, movement disorders).

• Not asking about behavioral or psychiatric problems. Parents are often reluctant to talk about such problems, thinking such problems are stigmatizing.
• Missed psychiatric diagnosis, especially suicidality, homicidality, or plans for revenge or violence.
• Confusing the degree of medical severity of a suicide attempt with the degree of suicide intent, i.e., “(S)he isn’t significantly injured, so (s)he isn’t seriously suicidal.” Children and adolescents often misjudge the lethality of their suicide methods. All attempts must be taken seriously.
• Deciding on a diagnosis and/or treatment without a complete evaluation. Many psychiatric disorders can present in similar fashion (see Differential Diagnosis). The success of any treatment plan, as well as avoidance of erroneously “labeling” a child (with an incorrect diagnosis), depends on an accurate diagnosis, based on a thorough bio-psycho-social evaluation.
• Many patients with primary psychiatric disorders will present with vague physical complaints. All patients with such complaints should be screened for psychiatric problems.
• Delay in diagnosis or referral for treatment, e.g., prognosis for learning disabilities and hearing impairment is associated with timely intervention.

Q: When should a child be referred to a specialist?
A: Whenever there is uncertainty about diagnosis or management, or when the treatment needs of the patient exceed the practitioner’s capacity to provide them.

Q: How do you get children and families to talk about their problems?
A: There is no ‘trick.’ Being a patient, empathetic, non-judgmental listener is the best strategy.

Q: What is constitutes a psychiatric emergency?
A: Any situation where the safety or functioning of the child, family, or another person is endangered.

Cantwell DP. Attention deficit disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996;35(8):978–987.

Clark LR, Ginsburg KR. How to talk to your teenage patients. Contemp Adolesc Gynecol 1995;Winter:23–27.

DeGruy FV, Pincus H. The DSM-IV-PC: a manual for diagnosing mental disorders in the primary care setting. J Am Board Fam Pract 1996;9(4):274–281.

Dworkin PH. Detection of behavioral, developmental, and psychosocial problems in pediatric primary care practice. Curr Opin Pediatr 1993;5(5):531–536.

Finney JW, Weist MD. Behavioral assessment of children and adolescents. Pediatr Clin North Am 1992;39(3):369–378.

Kaplan HI, Sadock BJ, Grebb JA, eds. Synopsis of psychiatry. Baltimore: Williams & Wilkins, 1994.

Murphy JM, Arnett HL, Bishop SJ, Jellinek MS, Reede JY. Screening for psychosocial dysfunction in pediatric practice. A naturalistic study of the pediatric symptom checklist. Clin Pediatr (Phila) 1992;31(11):660–677.

Roberts RE, Attkisson C, Rosenblatt A. Prevalence of psychopathology among children and adolescents. Am J Psych 1998;155(6):715–725.

Slap GB, Vorters DF, Khalid N, Margulies SR, Forke CM. Adolescent suicide attempters: do physicians recognize them? J Adolesc Health 1992;13(4):286–292.

Spencer T, Wilens T, Biederman J. Psychotropic medications for children and adolescents. Child Adolesc Psych Clin N Am 1995;4(1):97–121.

Stancin T, Palermo TM. A review of behavioral screening practices in pediatric settings: do they pass the test? J Dev Behav Pediatr 1997;18(3):183–194.

Wolralch ML. Diagnostic and statistical manual for primary care (DSM-PC) child and adolescent version: design, intent, and hopes for the future. J Dev Behav Pediatr 1997;18(3):171–182.