Psychiatry Research Updates: Youth Primary Care and Aggression


How Many Teens Actually Go When Referred for Mental Health Services?

The American Academy of Pediatrics recommends mental health screening as a standard part of well-child physicals. A recent study of adolescents looked at how often they are referred for mental health services by their primary care providers, and when referred, at how often teens followed through with these referrals.

The retrospective chart review of 227, 14- to 17-year-olds with commercial insurance compared teens who screened “positive” (n=117) for mental health referral according to the Pediatric Symptom Checklist or Youth-Pediatric Symptom Checklist to those who were propensity-score-matched negative screens (n=110). Children who were currently receiving mental health care were not included in the study group.

Of the positive youth, 54% were referred for mental health services. Almost half of these (46%) received some type of contact with mental health services—for example a phone call or scheduling an appointment. However, only 18% actually completed a face-to-face mental health visit within the following six months.

PCPs used ICD-9 codes or other notes to provide mental health diagnoses to 39% of the positive screens in the initial screening visit. Of these youths, 57% were referred for mental health services, compared to only 19% of those who screened positive but were not given a psychiatric diagnosis by the PCP.

In addition, children who stated that they had a mental health problem for which they needed help were more likely to be referred (48% of the positive screens) (Hacker K et al, J Adolesc Health 2014;Feb 12, online ahead of print).

CCPR’s Take: This study shows that something is missing in terms of teens with mental health issues going from primary to specialty care. It should be noted that 57% of the teens who were diagnosed with a psychiatric disorder— ranging from depression to disruptive disorders—by their primary care doctors were referred for specialty mental health care. That means 43% were not. It’s not clear where these kids went from there.


Fish Oil Doesn’t Curb Aggressive Behavior

Aggressive behavior is a huge problem in child psychiatry. In fact, some estimates say as many as 80% of children and adolescents referred for psychiatric care have some type of aggression, including oppositional defiant disorder or conduct disorder (Connor D, The Carlat Child Psychiatry Report 2010;1(1):4-5).

Almost all aggression needs to be treated with psychosocial interventions. When those don’t work well enough, many of us resort to medication. But what if a natural treatment with some evidence in other psychiatric disorders, such as ADHD, could help treat aggressive behavior in children as well?

A group of researchers in Australia set out to answer this question in a small, randomized, controlled study of fish oil as a treatment for aggressive behavior. Unfortunately, results were not in favor of fish oil. Supplementation with fish oil showed no benefit in improving scores on two standard ratings of aggressive behavior.

In this study, 21 children, mean age of 10.3, were randomized to either six weeks of fish oil capsules (4 g/day, containing 400 mg EPA and 2,000 mg DHA), followed by six weeks of placebo; or six weeks of placebo capsules, followed by six weeks of fish oil capsules (4 g/day).

More than half of participants met criteria for conduct disorder (52.4%) and 76% met criteria for ADHD. Children with developmental, psychotic, substance use, and bipolar disorders and those with PTSD were excluded.

Aggressive behavior was measured based on the Children’s Aggression Scale-Parent Version (CAS-parent) and the Modified Overt Aggression Scale (MOAS). Secondary outcomes, including general functioning, symptoms of ADHD, and cognitive function, were also measured.

As would be expected, supplementation with fish oil increased serum concentrations of EPA and total omega-3s and omega-6s in participants. But there were absolutely no improvements on any measures of aggression after supplementation with fish oil.

In fact, there was a small worsening of scores on a secondary measure rating conduct problems on the Strengths and Difficulties scale (SDQ) compared to placebo. However, fish oil showed a significant improvement in a different SDQ secondary measure rating hyperactivity (Dean AJ et al, J Child Adolesc Psychopharmacology 2014;24(3):140- 148).

CCPR’s Take: Omega-3s and other fatty acids are regularly touted as treatments for psychiatric illnesses, but unfortunately this study, like many others, doesn’t show that to be the truth. So we won’t be recommending omega-3 fatty acids as a treatment for aggression.

But what about those children in the study whose aggression worsened with fish oil? Should we be discouraging parents of children with aggression from using omega-3s at all, even for their other purported benefits? The study’s several limitations and small size suggest waiting for more research before taking this step.

Psychiatry Research Updates: Youth Primary Care and Aggression

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This article was published in print May 2014 in Volume:Issue 5:3.

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APA Reference
Psychiatry Report, T. (2016). Psychiatry Research Updates: Youth Primary Care and Aggression. Psych Central. Retrieved on October 21, 2019, from


Scientifically Reviewed
Last updated: 21 Feb 2016
Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2016
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