Primary care doctors may be unsure when kids' bad moods are serious or not

All children have moments of moodiness, but family medicine doctors and pediatricians may doubt their abilities to tell the difference between normal irritability and possibly bigger issues, according to Penn State researchers.

When the researchers interviewed a group of health care providers, they found that the primary care providers and pediatricians were less confident than the child and adolescent psychiatrists in their ability to tell whether irritability in young patients was normal or could be linked to a deeper mental health issues.

They also found that primary care providers and pediatricians were more likely to prescribe medications when they thought there was a problem, while psychiatrists were more likely to start with behavioral therapy.

Anna Scandinaro, a fourth-year medical student at Penn State College of Medicine, said that because of the issues and challenges that children may face, such as bullying, it's important for health care providers to be able to identify children and adolescents whose problems may go deeper than typical moodiness. She said increasing education for these providers may be a good place to start.

“We need to start asking if there's anything we can do to prevent these things from happening,” Scandinaro said. “There's a lot of concern right now about children's mental health, and we wanted to compare how different practitioners go about trying to figure out who's going through normal irritability and who may benefit from additional treatment.”

Irritability is a normal part of a child's development, but the researchers said it can also be a symptom of mental health disorders like disruptive mood dysregulation disorder. Scandinaro said it can be difficult for doctors to tell the difference between acute irritability — an adolescent being grumpy for a few days because he was grounded — and chronic irritability, which could signal possible problems with mental health.

Participants for the study were recruited from a large, academic medical center and included family medicine, pediatric and psychiatry providers. The researchers interviewed the 17 providers about how they define irritability in their school-age patients, how they evaluate irritability, and how they differentiate between normal and abnormal irritability, among other questions.

“We found that family medicine physicians and pediatricians feel as though they don’t have the resources and the training they need to effectively evaluate irritability in the clinic setting, especially in the limited amount of time that they have,” Scandinaro said. “But at the same time, there is a national shortage of child and adolescent psychiatrists, increasing the need for primary care providers to be more comfortable in determining who needs to see a specialist. So even though the study was preliminary, it shows we need to improve education for primary care providers.”

The researchers also found that while family medicine providers looked for anxiety and problems in school as symptoms of irritability, psychiatrists tended to check if children exhibited a negative mood or a hard time dealing with frustration. Family care providers also reported being comfortable prescribing medications but would be more likely to refer the patient to a specialist if more stronger medications and treatment were needed.

All participants agreed that a lack of time with patients, as well as few concrete guidelines about what defined irritability and how to treat it, made diagnosing patients more difficult.

While the results — published today (April 5) in the Primary Care Companion for CNS Disorders — suggest that primary care providers may not be confident evaluating irritability, even though the majority of children receive mental health care in a primary care setting, according to the National Institute of Mental Health.

Scandinaro said additional training and education may help primary care providers and pediatricians be more confident in diagnosing their younger patients.

“A possible next step could be to create an educational tool that could be used as a quick way for primary care providers to help evaluate their patient and to help them decide if it’s normal irritability or something that requires them to see a specialist,” Scandinaro said.

Scandinaro also noted that it's important for parents to follow their gut when they notice something seems wrong with their child, and they should always talk to their doctor if concerned.

“If you think that something is going on, make it a priority to talk to your doctor about it. Don’t be afraid to mention it if something seems not to be right,” Scandinaro said. “Irritability doesn't always mean that the child is bipolar or has a severe mental illness, and medication doesn’t always have to be the first option. But it's important to talk about it.”

Usman Hameed, assistant professor of psychiatry, and Cheryl A. Dellasega, professor of medicine and humanities, also participated in this research.

A Qualitative Research Initiative Award helped fund this project.

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