Above and below the threshold: severity of psychiatric symptoms and functional impairment in a pediatric sample

Pediatricians are sufficiently concerned about the importance of "subthreshold" mental health problems to have joined in the movement to create a Diagnostic and Statistical Manual of Mental Disorders for the primary care setting (DSM-PC), with the aim of establishing a set of criteria for disorders that do not meet the severity requirements of the American Psychiatric Association's current DSM. An element in the argument for a DSM-PC is that there is a high level of functional impairment and need for treatment in children with mental health problems below the DSM threshold. This was examined in 789 children aged 7 through 11 recruited sequentially from the pediatric clinics of a health maintenance organization, compared with 134 age-matched children seen in a psychiatric clinic. Of the pediatric patients, 22% had one or more clinical-level DSM-III diagnoses, and 42% had a threshold-level disorder, compared with 65% and 34%, respectively, of psychiatric patients. In the pediatric sample, most threshold, and all clinical-level disruptive behavior disorders were associated with significant levels of functional impairment. There was little evidence that emotional disorders (anxiety and depression), even at the clinical level, were associated with significant impairment. One implication of these results is that pediatricians can expect one child in five to have a clinical-level DSM disorder. A second is that intervention at low levels of disruptive behavioral symptomatology may be needed if significant functional impairment is to be avoided.