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INTRODUCTION

Pediatric primary care settings are often the first entry points for identification of mental and behavioral health issues and connection to behavioral health systems for the 14%–20% of affected children and adolescents. Beyond addressing identified and diagnosable mental health conditions, pediatric primary care settings are tasked with (1) prevention and health promotion, (2) screening and surveillance, (3) early identification, (4) triage and initiating treatment for uncomplicated issues, and (5) referral around complex behavioral health and psychosocial issues for the child, their family, and the environments with which the child interacts.

Primary care providers see approximately 75% of children with psychiatric disturbances, and half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. Parents and children often prefer discussing these issues with pediatric providers who they already know and trust. As a result, pediatric primary care providers play an important role in the prevention, identification, initiation, management, and coordination of mental health issues, in addition to providing behavioral and developmental care and support for children and adolescents. Unfortunately, the shortage of mental health providers particularly in rural regions and for medically underserved communities, stigma attached to receiving mental health services, chronic underfunding for behavioral/mental health services, institutional barriers within the public mental health system, and disparate insurance benefits contribute to the fact that only 15%–25% of children with diagnosable disorders have access to and are seen by mental health specialists.

Ninety percent of children have visited a primary care provider in the previous year. Primary care providers are ideally positioned to identify mental health and behavioral concerns, but report time constraints and lack of training as barriers to identifying children with emotional and behavioral problems during routine health supervision visits. In addition, these problems may not be identified when they initially emerge and are most amenable to treatment. This gatekeeper role has become increasingly important over the past decade as advances in mental health awareness and treatment improved opportunities for early identification and intervention. The role is especially critical because behavioral health is an underserved medical specialty in many areas of the country, particularly in rural, low socioeconomic status (SES), and nonmetropolitan geographic regions. In contrast, more than 78,000 board-certified pediatricians and innumerable midlevel pediatric providers are in a unique position to identify issues affecting the emotional health of children and to initiate treatment or referrals to other providers.

Emotional problems that develop during childhood and adolescence can significantly impact development and may continue into adulthood. In fact, most adult psychiatric disorders involve childhood onset. Many disorders do not present as an all-or-none phenomenon, but rather progress from less severe concerns, such as adjustment problems or 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. When pediatricians miss opportunities to engage in prevention and health promotion activities, appropriately identify ...

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