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INTRODUCTION

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Mental illness affects between 14% and 20% of children and adolescents. The prevalence is higher for those juveniles living in poor socioeconomic circumstances. Unfortunately, the shortage of mental health providers, stigma attached to receiving mental health services, chronic underfunding, institutional barriers of the public mental health system, and disparate insurance benefits have contributed to the fact that only 2% of these children are actually seen by mental health specialists. About 75% of children with psychiatric disturbances are seen in primary care settings, and half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. Parents and children often prefer discussing these issues with someone they already know and trust. As a result, pediatric primary care providers are compelled to play an important role in the prevention, identification, initiation, management, and coordination of mental health care in children and adolescents.

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Despite being strategically positioned as the gatekeeper for identifying these concerns, primary care providers identify fewer than 20% of children with emotional and behavioral problems during health supervision visits when these concerns are also present. In addition, these problems are not identified when they begin (and are more readily amenable to treatment). This gatekeeper role has become more important over the past decade as advances in mental health awareness and treatment have improved opportunities for early identification and intervention. This role is especially critical since child psychiatry remains an underserved medical specialty, with only 7400 board-certified child and adolescent psychiatrists in the United States. In contrast, the more than 50,000 board-certified pediatricians and innumerable midlevel pediatric providers in the United States are in a unique position to identify issues affecting the emotional health of children and to initiate treatment or referrals to other providers.

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Emotional problems that develop during childhood and adolescence can have a significant impact on development and may continue into adulthood; in fact, most "adult" psychiatric disorders have their onset during childhood. Most disorders do not present as an "all-or-none" phenomenon; rather, they progress from adjustment concerns to perturbations in functioning to significant disturbances and severe disorders. Pediatricians have the capacity to manage emotional problems and behavioral conditions early on, when improvement can be achieved with less intensive interventions. If pediatricians and schools do not appropriately identify mental health problems, provide education about the benefits of intervention, and encourage and initiate intervention, childhood-onset disorders are more likely to persist, cause worsening impairment, and lead to a downward spiral of school and social difficulties, poor employment opportunities, and poverty in adulthood, as well as increased health care utilization and costs as adults.

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Pediatricians and other pediatric care providers may be the first or sometimes only medical professional in a position to identify a mental health problem. This chapter reviews prevention, surveillance, and screening for mental illness; situations that may arise in the context of such assessments; illnesses that are often diagnosed during childhood or adolescence; current recommendations for interventions and use ...

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