The difference between “normal” irritability and more serious mood disorders in children can be difficult for pediatric primary care providers (PCPs) to discern, and the assessment challenge may impede timely mental health diagnoses and early initiation of appropriate treatment, according to new research.
A qualitative study comparing the way family medicine and pediatric vs specialty care providers evaluate and treat school-aged children who present with irritability found clear differences between clinicians’ self-perceived ability to evaluate the mental health status of these patients. Management approaches also differed between PCPs and specialty care providers.
Irritability is a common chief complaint with children that ranges from episodic, developmentally appropriate moodiness to sustained, chronic temper outbursts. It is a symptom of and perhaps precursor to various mental health diagnoses, including bipolar disorder and disruptive mood dysregulation disorder (a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]). Therefore, assessment of irritability warrants investigation, Anna L. Scandinaro, a medical student from Penn State College of Medicine, Hershey, Pennsylvania, and colleagues write in an article published online April 5 in Primary Care Companion for CNS Disorders.
The study sample included 17 family medicine, pediatric, and psychiatry care providers from a single facility who participated in in-depth interviews from June to August 2016 about how they differentiate normal from abnormal irritability in children and adolescents in clinical practice. “We were especially interested in the family medicine setting, since it is a generalist practice in which complex health issues may present and often the first source of mental health care for children,” the authors write.
Participants answered questions about how they define and evaluate irritability in their patients, how they differentiate between normal and abnormal irritability, and how confident they were in their ability to make that distinction. Care providers also answered questions that gauged the knowledge and use of the DSM-5, which includes irritability as a symptom for various mental health diagnoses, and their awareness of changes specific to the addition of disruptive mood dysregulation disorder.
Psychiatry practitioners reported significantly greater exposure to irritability as a complaint than primary care practitioners, “most likely due to the focus of psychiatry participants on children referred for this purpose,” the authors write. The groups also differed in confidence regarding their capacity to assess irritability (R = 0.63; P = .007), with all psychiatric providers rating their ability as “above average.”
Regarding their awareness and use of supportive resources, psychiatry providers were significantly more likely to report above-average knowledge of the DSM (R = 0.72; P = .001), and they were more likely to identify the manual as their most frequently used resource for management decisions related to irritability.
PCPs reported using UpToDate, the online decision support tool, most often. Although a widely used, evidence-based tool, UpToDate may not provide information specific enough to appropriately inform clinical decision making around irritability, the authors suggest, noting that the information it provides can vary on the basis of search parameters. For example, “when typing irritability in children into the search field of UpToDate, the first return was infantile colic, the next was pediatric bipolar disorder, and the following 8 were on a variety of physiologic entities,” they write. “When the search criterion was changed to irritability in adolescents, the first entry was on pharmacotherapy for anxiety disorders in children and adolescents, followed by autism therapies, adolescent eating disorder, and information on various medications mostly for psychiatric use.”
With respect to diagnostic considerations, no general consensus emerged for a “gold standard” for evaluating irritability in school-aged children, the authors report. Participants expressed a desire for more concrete guidelines, and there was a universal sense across family practice, pediatric, and psychiatric providers that time-limited patient encounters prevented a thorough assessment of children and adolescents, they write.
Providers’ clinical assessment of irritability also differed. Although PCPs tended to consider the developmental appropriateness of the behavior relative to peers and siblings, and to focus on parent- and teacher-reported functional disruption and parental distress, psychiatric providers were more likely to focus on specific signs of the irritability and possible causes, such as disrupted sleep, medication adverse effects, disturbing imagery in mood diaries, poor coping skills, and developmental differences compared with peers.
Management approaches differed as well. “[I]t was interesting to note that family medicine participants were comfortable with prescribing antidepressants and anxiolytics but would refer the patient to psychiatry if other treatment options were indicated,” the authors report, whereas psychiatric providers were more likely to apply behavioral interventions and therapy, offer support for environmental modifications, and advocate parent and community education about the patients’ needs.
Despite the resource limitations for primary care physicians and the absence of a true gold standard assessment tool, “the psychiatry respondents expressed a wish for PCPs to be more involved in assessing and treating irritability, while family medicine and pediatric providers expressed a wish to learn more about assessment and treatment,” according to the authors.
Family medicine providers in particular expressed their need for additional training and tools geared specifically to irritability. “Family medicine practitioners are more likely to be providing care over a longer period — from birth to adulthood, and they have limited clinic time to devote specifically to mental health issues,” the authors write. “At a minimum, family medicine providers need an efficient screening tool to address any safety issues that may be associated with irritability and potential violence.”
The availability and expansion into underserved areas of telehealth services has the potential to address some of the perceived insufficiencies, the authors hypothesize. In particular, they describe a telephonic psychiatric consultation service program that offers PCPs access to child mental health services including virtual consultations with pediatric psychiatrists. “These telecommunications allow patients to remain safely in primary care settings and receive continuing treatment there,” they write.
The observations from this qualitative study should be used to structure larger investigations across multiple primary care settings to inform future understanding and diagnostic tools for clinicians, “especially those without access to specialty training on irritability,” the authors write. “Through better understanding of how to accurately diagnose children and adolescents on the irritability spectrum, misdiagnosis will be reduced and treatment will be enhanced, leading to overall improved mental health.”
This study was funded by a Qualitative Research Initiative Award and a grant from the Penn State College of Medicine. The authors have disclosed no relevant financial relationships.
Prim Care Companion CNS Disord. Published online April 5, 2018. Abstract
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