Psychosocial Functioning Should Be Eighth Vital Sign, Doctors Say

By Carolyn Crist

July 31, 2020

NEW YORK (Reuters Health) - During routine well-child visits, pediatricians measure blood pressure, temperature, pulse, height, weight and other factors, and they should screen for mental-health concerns as well, according to two child psychiatrists.

Although medical groups have long recognized the importance of psychosocial screening, the tool still isn't a regular part of check-ups, the two write in JAMA Pediatrics.

"We spend the time to take vital signs that show little variation during childhood, such as heart rate and respiratory rate, yet the vital sign that would show the biggest variation for some children is emotional and psychosocial development," said Dr. Michael Jellinek of Massachusetts General Hospital and Harvard Medical School, in Boston.

Psychosocial issues have become some of the most common chronic health disorders among children and teens, with a prevalence nationwide of 10% to 20%, added Dr. Jellinek, one of the authors.

"This is becoming even more important now during the pandemic, and we will see the effects after COVID-19," he told Reuters Health by phone. "Some kids are showing signs of distress."

Dr. Jellinek and co-author Dr. J. Michael Murphy, also at Mass General and Harvard, write about the importance of seeing psychological and social functioning as a vital sign that can indicate serious consequences later. For instance, attention-deficit disorder can affect schooling, self-esteem, high school dropout rates, risky behaviors and substance use. Depression also links to higher rates of substance use, suicidal thoughts and suicide, they write.

The Pediatric Symptom Checklist, which Drs. Jellinek and Murphy created in the late 1990s, has been recommended by the American Academy of Pediatrics and was endorsed by the National Quality Forum in 2018. The checklist gauges a child's responses to questions about daily life, including school, activities, family, friends and their mood. A high score indicates that the patient may be facing stress.

Two versions exist - the original 35-question survey and a shorter 17-item survey - that give an overall score, as well as three subscores about attention, internal stress such as depression or external stress such as food insecurity or parental issues. The checklist takes about five minutes to complete, the authors note, and is available online for free.

Drs. Jellinek and Murphy also analyzed more than 100,000 screenings from annual well-child visits across the U.S. during the past decade and found that about 12% of children scored above the threshold that could indicate a problem. Boys tend to score higher than girls before puberty, they write, and girls tend to score higher than boys after puberty. In addition, children in lower socioeconomic households tend to score higher for external stressors.

Importantly, two major challenges often hinder doctors from implementing the tool, Dr. Jellinek said. Many health-insurance companies don't reimburse for the screening, and pediatricians often don't receive enough training during their residencies to address psychosocial issues. They can refer families to specialists, but those are in short supply in many areas across the U.S.

At the same time, some states are making progress, Drs. Jellinek and Murphy says. Massachusetts is now reimbursing doctors for screenings and for spending time on follow-up. Several major electronic medical record companies have also incorporated the tool, which is being used by doctors and social-services groups in California and Maryland.

At Mass General, the checklist is given on a tablet in the waiting room or in the patient portal, and studies have recorded an increase in the number of children who receive mental-health services after a screening.

"These psychosocial challenges are really common, but unfortunately, most kids fly under the radar and don't receive treatment. Screening is a first step toward connecting kids with care," said Dr. Emily Becker-Haimes of the University of Pennsylvania in Philadelphia, who wasn't involved with the article but has studied tools to measure mental health in kids.

"Speaking about psychosocial health will also help to destigmatize mental-health care," she told Reuters Health by phone. "We need to value mental health in the same way we do physical health, and this is a particularly good time to discuss it given the increased risk for challenges with COVID-19."

SOURCE: JAMA Pediatrics, online July 20, 2020.