APA has collaborated with the American Academy of Pediatrics (AAP) to create a manual on the classification of mental diagnoses in children and adolescents for pediatricians and primary care clinicians. The goal is to improve the rate of recognition and diagnosis of mental disorders among these practitioners.

Harold Pincus, M.D., APA's deputy medical director in the Office of Research, served as the liaison representative to the AAP Task Force on Coding for Mental Health in Children.

"This collaborative effort has been positive in increasing communication between psychiatrists and pediatricians," Pincus told Psychiatric News. "The manual can be used as an educational tool to enhance pediatricians' awareness of the salience of mental disorders in children."

Pincus noted that the Classification of Child and Adolescent Mental Diagnoses in Primary Care is compatible with the DSM-IV-PC, which was published two years ago by the American Psychiatric Press Inc. This was a collaborative project between APA and primary care organizations.

"The section on childhood mental disorders in the DSM-IV-PC was expanded into a much larger and detailed version by the AAP," said Pincus.

An estimated 40 percent or more of general pediatric practice time is devoted to emotional and behavioral problems of patients and their families, according to an AAP publication description.

Moreover, primary care clinicians "need to identify and refer patients who exhibit more serious mental disorders to mental health clinicians," states the manual's introduction.

Michael Jellinek, M.D., a pediatrician and a liaison representative to the AAP task force from the American Academy of Child and Adolescent Psychiatry (AACAP), told Psychiatric News, "We felt that DSM-IV was not sufficiently developmental in its focus or organized for primary care clinicians and pediatricians. To make this manual more user friendly, we started with symptoms in the diagnostic process because that is what patients commonly discuss with pediatricians." The diagnoses for disorders used in the pediatric version are compatible with DSM-IV, he noted.

Jellinek chaired the AAP severity and functional assessment work group and participated in the formatting and organization work group.

Jeffrey Newcorn, M.D., a consultant from APA to the AAP task force, commented, "DSM-IV did not highlight mental health problems seen in pediatric practice." In contrast, the pediatric version "highlights environmental influences and the fact that children can have similar kinds of problems but present them differently depending on their age," said Newcorn.

These problems may need intervention but may not be considered severe enough by pediatricians to warrant a psychiatric diagnosis, he added.

Newcorn is director of the Division of Child and Adolescent Psychiatry at Mount Sinai Medical Center in New York City. He participated in the DSM-IV child and adolescent work group, the DSM-IV-PC work group, and the AAP environmental and interactional factors work group.

The manual has two major sections. The first defines children's responses to environmental situations and potentially stressful events. To help clinicians evaluate the impact of stressors, key risk and protective factors are listed.

The child-manifestations section is organized into 10 major categories of behaviors. Each category includes presenting complaints, definitions, epidemiological information, and descriptions of normal variations, problems, and disorders. Examples of symptoms are provided that may occur during infancy, early and middle childhood, and adolescence.

To facilitate a differential diagnosis, an algorithmic format is presented for each behavioral category.

According to Jellinek, the new pediatric book will be used as a training tool for pediatricians. He met with about 20 pediatricians who specialize in behavioral disorders last month in Chicago to discuss training goals and techniques. This group plans to train pediatric faculty and residents at their respective institutions using the manual and other materials. Eventually the training will be broadened to include other primary care disciplines.

Newcorn mentioned that the AAP task force considers its first pediatric effort "largely a work in progress. A lot of decisions had to be made about profiles at the problem level and diagnostic threshold without empirical data. That will most likely need refinement in the future."

Other organizations that had liaison representatives to AAP's Task Force on Coding for Mental Health in Children included the the American Academy of Family Physicians, the American Medical Association, the Society for Pediatric Psychology, the National Institute of Mental Health, and the Health Resources and Services Administration.

The Classification of Child and Adolescent Mental Diagnoses in Primary Care is available from the AAP by calling (800) 433-9016.

(Psychiatric News, November 1, 1996)