Promoting Optimal Development: Screening for Behavioral ... · environmental, familial, and psychosocial risks.11–13 In families in which parents are in military service, parental

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Promoting Optimal Development:Screening for Behavioral and EmotionalProblemsCarol Weitzman, MD, FAAP, Lynn Wegner, MD, FAAP, the SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, COMMITTEE ONPSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COUNCIL ON EARLY CHILDHOOD, AND SOCIETY FOR DEVELOPMENTAL ANDBEHAVIORAL PEDIATRICS

abstract By current estimates, at any given time, approximately 11% to 20% of childrenin the United States have a behavioral or emotional disorder, as defined in theDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between37% and 39% of children will have a behavioral or emotional disorderdiagnosed by 16 years of age, regardless of geographic location in the UnitedStates. Behavioral and emotional problems and concerns in children andadolescents are not being reliably identified or treated in the US healthsystem. This clinical report focuses on the need to increase behavioralscreening and offers potential changes in practice and the health system, aswell as the research needed to accomplish this. This report also (1) reviewsthe prevalence of behavioral and emotional disorders, (2) describes factorsaffecting the emergence of behavioral and emotional problems, (3) articulatesthe current state of detection of these problems in pediatric primary care, (4)describes barriers to screening and means to overcome those barriers, and(5) discusses potential changes at a practice and systems level that areneeded to facilitate successful behavioral and emotional screening.Highlighted and discussed are the many factors at the level of the pediatricpractice, health system, and society contributing to these behavioral andemotional problems.

SCOPE OF THE PROBLEM AND NEED FOR THIS REPORT

Behavioral and emotional problems during childhood are common, oftenundetected, and frequently not treated despite being responsible forsignificant morbidity and mortality. By current estimates, approximately11% to 20% of children in the United States have a behavioral oremotional disorder at any given time.1,2 Estimated prevalence rates aresimilar in young 2- to 5-year-old children. Developmental and behavioralhealth disorders are now the top 5 chronic pediatric conditions causingfunctional impairment.3,4 Even greater numbers of children have

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit fromexpertise and resources of liaisons and internal (AAP) and externalreviewers. However, clinical reports from the American Academy ofPediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-3716

DOI: 10.1542/peds.2014-3716

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

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behavioral or emotional problemscausing impairment or distress thatdo not meet criteria of the Diagnosticand Statistical Manual of Mental Dis-orders, Fifth Edition for a disorder.The purpose of this report is toprovide pediatricians with a rationalefor and guidance to implementscreening for behavioral and emo-tional problems in primary care set-tings. However, in evaluating andpromoting optimal child developmentand well-being, the domains of de-velopment and behavior must beconsidered together within the con-text of the family. These domains arenot separate constructs but ratherparts of a whole. Therefore, thisreport emphasizes that behavioralscreening must always be 1 compo-nent of a comprehensive develop-mental and behavioral screeningprogram that extends through child-hood and adolescence.

EPIDEMIOLOGY OF BEHAVIORAL ANDEMOTIONAL DISORDERS

It is estimated that 25% to 40% ofchildren with 1 disorder will have atleast 1 additional mental health orbehavioral diagnosis at a giventime.1,5,6 The most common co-occurring conditions are attention-deficit/hyperactivity disorder(ADHD) and oppositional defiantdisorder, but co-occurrence of anxietyand depression is also common.

Between 37% and 39% of childrenwill have a behavioral or emotionaldisorder diagnosed by 16 years ofage, with the most common diagnosesbeing impulse control/disruptivebehavior problems, anxiety, and mooddisorders.1,7,8 Between 23% and61% of children with a diagnosis at 1time will have a diagnosis in thefuture, although it is not always thesame diagnosis.1

Approximately 50% of adults withbehavioral health problems reportthat their disorders emerged in earlyadolescence.9 Anxiety disorders andADHD are the earliest disorders toemerge, often in the preschool and

early school-age years, withsubstance abuse being the latest toemerge. An approximately 2- to 4-year period between symptomappearance and disorder has beendemonstrated, suggesting that theremay be opportunities for secondaryprevention or early intervention.6

FACTORS AFFECTING THE EMERGENCEOF BEHAVIORAL AND EMOTIONALPROBLEMS

In 2010, more than 1 in 5 childrenwere reported to be living inpoverty.6,10 Economic disadvantage isamong the most potent risks forbehavioral and emotional problemsdue to increased exposure toenvironmental, familial, andpsychosocial risks.11–13 In families inwhich parents are in military service,parental deployment and return hasbeen determined to be a risk factorfor behavioral and emotionalproblems in children.14 Data from the2003 National Survey of Children’sHealth demonstrated a strong linearrelationship between increasingnumber of psychosocial risks andmany poor health outcomes,including social-emotional health.15

The Adverse Childhood ExperienceStudy surveyed 17 000 adults aboutearly traumatic and stressfulexperiences. Two-thirds ofrespondents experienced at least 1type of childhood psychosocial risk,and 20% experienced more than 3.Adverse early experiences wererelated to increased rates of healthproblems in adulthood includingobesity and cardiovascular disease aswell as substance abuse, mentalhealth problems, and poor health-related quality of life. As the AdverseChildhood Experience Study scoreincreased, so did the number of riskfactors for the leading causes ofdeath.16,17 Shonkoff uses the phrase“toxic stress” to describe highcumulative psychosocial risk in theabsence of supportive caregiving18,19;this type of unremitting stressultimately compromises children’sability to regulate their stress

response system effectively and canlead to adverse long-term structuraland functional changes in the brainand elsewhere in the body. The 2012American Academy of Pediatrics(AAP) Policy Statement “EarlyChildhood Adversity, Toxic Stress, andthe Role of the Pediatrician:Translating Developmental ScienceInto Lifelong Health” advocatedviewing the causes and consequencesof toxic stress from the sameperspective as other biologicallybased health impairments.19

POLICIES IN PLACE

In 2004, the AAP established the TaskForce on Mental Health, which“articulated mental healthcompetencies for primary care;developed guidance for addressingsystemic and financial barriers toproviding mental health care inprimary care settings; and providedtools and strategies to assistpediatricians in applying chronic careprinciples to children with mentalhealth problems.”20 The Task Forcealso provided guidance (throughidentifying tools and describingstrategies) to providers on adaptingcurrent practice to include mentalhealth care. A recent publicationarticulated an initial blueprint forbehavioral and emotional screeningin pediatric practice.21 The currentstatement supports the Task Forceguidance by providing the evidencesupporting screening for emotionaland behavioral concerns.

CURRENT STATE OF DETECTION OFBEHAVIORAL AND EMOTIONALPROBLEMS IN PEDIATRIC SETTINGS

Behavioral and emotional problemsand concerns in children andadolescents are not being reliablyidentified or treated in the US healthsystem.6,22–25 Current estimatessuggest that fewer than 1 in 8children with identified mental healthproblems receive treatment. Evenwhen a child or adolescent is wellknown in a pediatric practice, only

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50% of those with clinicallysignificant behavioral and emotionalproblems are detected.23 Otherinvestigators have found similarlyhigh failure of detection rates rangingfrom 14% to 40%.22,24 Surveyedpediatricians, however,overwhelmingly endorse that theyshould be responsible for identifyingchildren with ADHD, eating disorders,depression, substance abuse, andbehavior problems.26

Clinicians’ ability to identifydevelopmental and behavioralproblems in primary care, on thebasis of clinical judgment alone in theabsence of a standardized measure,has been shown to have lowsensitivity, ranging from 14% to 54%and a specificity ranging from 69% to100%.27 Providers are less likely toidentify problems in minority ornon–English-speaking children andadolescents.25

In a study of clinicians in more than200 practices, pediatric providersreported using a standardizedmeasure to assess mental healthproblems in 20.2% of all visits, with50.2% of providers reporting neverusing any formal measure.28 Fewerthan 7% of providers reported usinga standardized measure during 50%or more of visits.28

BARRIERS TO SCREENING

Pediatricians report a lack ofconfidence in their training andability to successfully managechildren’s behavioral and emotionalproblems29 with only 13% ofpediatricians reporting confidence.30

Common barriers to adopting newscreening practices in pediatricsinclude lack of time,30 long waits forchildren to be seen by mental healthproviders, and lack of availablemental health providers to referchildren.31,32 Liability issues havebeen identified as a barrier toscreening and managing childrenwith behavioral and emotionalproblems. Pediatricians have alsoraised concerns about the increasing

number of mandates outlined inpractice guidelines with ever-shrinking time for healthmaintenance visits as a result ofreimbursement pressures.33

AVAILABLE TOOLS TO SCREEN FORBEHAVIOR AND EMOTIONAL PROBLEMS

Behavioral and emotional screeninginstruments have many of the sameadvantages and limitations asdevelopmental screeninginstruments. They involve a timecommitment for parents or guardiansto complete and for staff andclinicians to score, interpret, andreport the results.32

Screening instruments can be used topredict risk of a disorder but do notmake the diagnosis. There are global(broadband) scales that may screenfor several conditions, and there aredomain-specific (single-condition)tools are most useful for screening fora specific problem, such as substanceuse or adolescent depression andsuicidality.32

Pediatricians should be aware of thesociodemographic characteristics ofpopulations enrolled in validationstudies as they make decisionsregarding any screening instrumentsused. Pediatricians need to considerthe literacy and health literacy levelsof parents, guardians, children, andadolescents completing screens,whether the instrument should beadministered in English or anotherlanguage, and whether the personcompleting the screen will needadditional help.

Pediatricians should be familiar withthe psychometric properties of aninstrument and under whatconditions reported sensitivities andspecificities were obtained.32 Likedevelopmental screening tools,behavioral and emotional screeningtools should have a sensitivity andspecificity of $0.70.34

Once the patient is old enough toanswer reliably, self-report versionscan provide information about

feelings not noticed by outsideobservers, such as those associatedwith anxiety or depression. Most self-report versions are normed onpatients 8 years and older.

The research on behavioral andemotional screening in youngerchildren is more limited than inschool-age children, but increasingly,reliable, brief measures suitable foruse in primary care exist, and newones are being developed,35,36

making it possible to screen childrenand adolescents from aged 6 monthsthrough 18 years of age.

Behavior and emotional screensavailable in the public domain can befound in Appendix 1.

OVERCOMING BARRIERS TO SCREENING

The policy statement “The Future ofPediatrics: Mental HealthCompetencies for Pediatric PrimaryCare” outlined the skills pediatriciansneed in the area of mental health.37

The AAP Task Force on Mental Healthhas developed materials to helppediatricians assess their currentpractice and readiness to change andto code accurately for mental healthscreening and services.38,39 The AAPalso developed a Web site providingresources and materials free ofcharge (http://www2.aap.org/commpeds/dochs/mentalhealth/KeyResources.html)40 as well as“Addressing Mental Health Concernsin Primary Care: A Clinician’sToolkit,”41 which is available fora fee.

Professional organizations, includingthe AAP, Society for Developmentaland Behavioral Pediatrics, AmericanAcademy of Child and AdolescentPsychiatry, and National Alliance onMental Illness, provide ongoingcontinuing medical education andresources.

LESSONS LEARNED FROMDEVELOPMENTAL SCREENING

Many barriers to behavioral andemotional screening are similar to

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those identified when developmentalscreening was proposed as a regularpart of pediatric care. In 2006, theAAP policy statement “IdentifyingInfants and Young Children WithDevelopmental Disorders in theMedical Home: An Algorithm forScreening and Surveillance”42 waspublished. Since the publication of thestatement, 44.8% of pediatriciansreported using standardizeddevelopmental screening tools moreoften, and 72.2% reported usingstandardized autism screening toolsmore often.43 National demonstrationprojects including the Assuring BetterChild Development ScreeningAcademy44 and the AAP’sDevelopmental Surveillance andScreening Policy ImplementationProject45 achieved high levels ofscreening in primary care. Theseprojects provided valuable lessonsabout implementing a screeningprogram (Table 1) and behavioraland emotional screening may followsimilar patterns. Similar large-scaleinitiatives may need to be developedto determine the best practices forimplementing a behavioral andemotional screening program.

GUIDANCE FOR PEDIATRICIANS

The following steps and Table 2 aredesigned to give pediatricians a clearroad map to implement behavioraland emotional screening in practice.Although distinct from screening,pediatricians should familiarizethemselves with evidence-based

programs that have been shown topromote children’s social-emotionaldevelopment through positiveparenting,46–51 possibly preventingthe emergence of problems.

1. Readying the Practice. As was seenin developmental screening, front-end work is needed to train andprepare an office to adopt screen-ing practices. It may be helpful toenlist the assistance of local men-tal health professionals ordevelopmental-behavioral pedia-tricians in selecting and imple-menting screening procedures.

2. Identifying Resources. Before ini-tiating a behavioral and emotionalscreening program, pediatriciansneed to determine what they willdo when a child or parent hasa positive screening result. Pedia-tricians should familiarize them-selves with local resources andidentify referral sources. In theabsence of this, pediatricians arelikely to feel frustrated and over-whelmed when they identify chil-dren and adolescents in need ofservices but are unable to findappropriate, high-quality treat-ment of them. Pediatricians willneed to work with the communityto advocate for more treatmentand intervention services.

Increasing numbers of practices havecolocated a mental health provider(eg, psychologist, licensed clinicalsocial worker, licensed therapist)within the practice. These pro-viders are integrated into the

practice and can provide timelyassistance for behavioral emergen-cies as well as support the primarycare provider in implementing andinterpreting the office screeningprogram.

Another model of a successful col-laboration program between pri-mary providers and childpsychiatrists, the MassachusettsChild Psychiatry Access Project,promotes access to psychiatricconsultation for primary careproviders through a network ofchildren’s mental health collabo-ration teams. The overall aim is toimprove access to treatment ofchildren with mental health con-cerns (http://www.mcpap.com/about.asp). This type of programcurrently is being implemented inmore than 30 states.

3. Establishing Office Routines forScreening. As with developmentalscreening, children should bescreened at regular intervals forbehavioral and emotional prob-lems with standardized, well-validated measures beginning ininfancy and continuing throughadolescence. Screening beginningin the first year of life can identifydisturbances in attachment, regu-lation, and the parent-child re-lationship, although the optimalapproaches to screening infantsand very young children are lessclear-cut than screening childrenat older ages. Ongoing careinvolves maintaining a good his-tory regarding factors that can in-fluence the early parent-childrelationships, such as disciplinepractice, parenting stress, psycho-social risks, and positive parenting.

Currently, developmental andbehavioral/emotional screenings areviewed as separate constructs, andmost well-validated measures screenfor them independently. Developmentalscreening is commonly perceived asidentifying disordered expressive andreceptive language, fine and grossmotor skills, self-help skills, and

TABLE 1 Lessons Learned From Implementing a Screening Program

What Promoted Screening Implementation What Challenges Remained

• Creating an office-wide implementation system • Consistent referral of children with failed screens• Dividing responsibility among staff • Distributing screens to children at screening ages

but not to others• Actively monitoring implementation andcontinuing to make changes

• Maintaining consistent screening practice duringbusy times

• Choosing screens perceived to least disruptclinic flow

• Coping with screening gaps due to staff turnover

• Aligning screening measures with those usedin community based programs

• Not screening when surveillance raised concerns• Tracking referrals through a distinctimplementation system from screening

• Nonadherence to the 30-mo screen because ofexpected nonreimbursement

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cognitive milestones, whereasbehavioral and emotional screeningidentifies problems in areas includingsocial-emotional regulation, moodand affect, attention, andinterpersonal skills. There isa significant yet incomplete overlapbetween developmental and behaviorproblems. Studies have revealed thatchildren with cognitive, language,and social impairments anddevelopmental disabilities, in general,are far more likely to manifestbehavioral and emotional problems.12

Beginning in early adolescence,screening for substance use should beimplemented.21,52 Substance use anddependence have consistently beenfound to be 1 of the most prevalentbehavioral health diagnoses inadolescents. Identifying and treatinga behavioral or emotional problemwithout detecting and treating co-occurring substance use will likelylead to ineffectual treatment. The USPreventive Services Task Forcerecommends screening alladolescents (12–18 years of age) for

depression, when systems are inplace, to ensure accurate diagnosis,treatment, and follow-up.53

Pediatricians should use targetedscreening for other problems, such assuicidality or anxiety, if there isconcern raised by the provider,patient, or parent or the child is athigh risk.

Children’s behavioral and emotionalproblems are frequently associatedwith family psychosocial risk. Familypsychosocial screening can provideimportant information aboutpotential protection or lack thereoffor a child who may or may not yetshow signs of behavioral or emotionalproblems. Early detection andtreatment of family psychosocial riskmay potentially avert the emergenceof problems in the child. Onlya limited number of well-validatedscreens suitable for use in primarycare for broad screening of familypsychosocial risk and family supportand functioning are available,although a few show promise.54–56

There are screening measures forspecific psychosocial stressors, suchas maternal depression, and thesehave been shown to be feasible inpediatric settings.57,58 Familyscreening for psychosocial risk withinpediatric settings, however, raisesa number of dilemmas, includingconcerns about liability and paymentand who is responsible for an adult’swell-being after a problem isdetected.59

4. Tracking Referrals. If the child wasreferred for services after screen-ing, it is important for pediatriciansto inquire as to whether referralswere completed and services wereobtained or understand what bar-riers parents have experienced andhow these can be overcome. Fur-thermore, it is important forpediatricians, with parental per-mission, to obtain information fromthe referral and to learn whetherservices obtained were effectiveand whether symptoms in the childhave been reduced or eliminated.

TABLE 2 Steps to Implement Behavioral and Emotional Screening in Practice

1. Readying the practice• Describe and evaluate current efforts already in place• Identify a practice champion• Train all staff• Consider incremental screening and actively monitor implementation• Develop a screening roadmap from providing the screen through the referral process• Add behavior and emotional problems to the problem list and update this at each visit• Problem solve challenges that arise across the entire practice• Determine how to best publicize new screening practices to families• Consider additional costs for procuring screening tools, etc• Prepare for psychiatric emergencies that may present in the office

2. Identifying resources• Identify referral resources that include the following:• Areas of expertise• Hours of operation• Payment methods• Ability to treat non–English speakers

• Develop a plan for bidirectional communication• Learn about emergency mental health services• Partner with adult providers and community resources to help parents with identified psychosocialrisk

3. Establishing office routines for screening and surveillance• Implement screening in the first year of life and at regular intervals throughout childhood andadolescence

• Incorporate screening for family psychosocial risks and strengths• Determine appropriate screening intervals for the practice (combined with or distinct fromdevelopmental screening intervals) based on things such as clinic flow, allotted time to discussscreening results, etc

• Partner with parents to formulate a plan when there is a failed screen• Identify strengths of the child and communicate these to the family• Screen when the child, family, or provider has concerns• Establish a registry of children with positive screens and family psychosocial risk• Monitor children with significant risk factors with heightened surveillance and more frequentscreening

4. Tracking referrals• Develop a mechanism to track progress of children referred for assessment or treatment (eg,successful referral, evaluation or initiation of treatment)

• Collect information about families’ experience with referral resources5. Seeking payment• Familiarize the practice with appropriate CPT codes for screening, care plan oversight, face-to-faceand non–face-to-face services and reimbursement by different insurance companies

• Track billing and reimbursement for screening efforts6. Fostering collaboration• Explore colocated or other innovative models of care and partnerships with mental healthprofessionals

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This follow-up may require a sepa-rate office system than screeningprocedures.

5. Seeking Payment. One of the big-gest “systems” hurdles facingpediatricians is the difficultyobtaining payment for screeningpatients for behavioral and emo-tional problems and for screeningfamilies for psychosocial risk andfunctioning. The adoption of theproposed screening and surveil-lance practices, may lengthen visittime to discuss results without ad-ditional payment to support thattime and create significant non–face-to-face work.60 This includesreferring patients and families toappropriate resources, trackingreferrals, communicating withother professionals (which mayrequire reviewing lengthy reportsand school plans), and following upwith children and families. Over-coming this critical barrier is fun-damental to transforming pediatricpractice to a medical home model.With the advent of reimbursablebilling codes for screening, in-cluding Current Procedural Termi-nology (CPT) codes 96110 and99420, some practices are begin-ning to see some financial paymentfor the addition of screening pro-grams. Additionally, a new CPTcode for brief behavioral assess-ment, 96127, has been included inCPT 2015 to allow the separatereporting of this service.

6. Fostering Collaboration. Innovativecollaborations have been well de-scribed and include colocation andintegrated and consultative models,such as the Massachusetts ChildPsychiatry Access Project, theNorth Carolina Chapter AAP/NCPediatric Society (ICARE), and theWashington Partnership AccessLine.61–64 Innovative means ofconsultation and collaboration willcontinue to evolve with emergingtechnology.65 These relationshipshelp build the capacity of pedia-tricians to manage various

behavioral and emotional problemsin the office. This is particularlytrue for the management of sub-threshold problems not meetingthe severity level warranted to re-fer for treatment.

FUTURE DIRECTIONS

As medical practice continues to shiftinto more electronic formats,standardized screening instrumentswill need to be formatted forelectronic health record systems, tofacilitate a wide implementation ofscreening. Automating guidelines andscoring of screening measures,providing decision support that isintegrated into electronic healthrecords, and providing patients withopportunities for greaterparticipation in their health care viaportals into their electronic medicalrecord have already shownpromise.66,67 Paper-and-pencilscreening methods will need to betransformed into Web-basedversions, smartphone apps, andwaiting room tablets to successfullyharness available technology.65,68

These changes will be critical areasneeding further evaluation todetermine best practices.69

Additional system challenges that willneed to be addressed are included inAppendix 2.

SUMMARY

Evaluating and promoting optimalchild development and well-beingincludes assessing developmental andbehavioral domains in the context ofthe family. Behavioral and emotionalproblems are common, persistent,and cause significant functionalimpairment for many children andadolescents. A 2- to 4-year windowmay exist between initialpresentation of symptoms and thedevelopment of a disorder, suggestingan opportunity to intervene beforeproblems become more serious inchildren.6 In recent years, manypediatricians have taken advantage ofmore widely disseminated public

domain screening tools and have usedemerging computer technology tofacilitate behavioral/emotionalscreening. There have been manyexamples of colocated practices, andnational organizations, such as theAAP, have strongly advocated forpayment for these integrated practicemodels. The lessons learned throughdevelopmental screeningimplementation have been used tomake behavioral and emotionalscreening a more routine componentof pediatric health supervision. Theinvestments described in this report,financial and otherwise, are critical toensure a future of thriving and stronginfants, children, and adolescentswho will mature into healthy adults.

LEAD AUTHORS

Carol Weitzman, MDLynn Mowbray Wegner, MD

CONTRIBUTING AUTHORS

Laura Joan McGuinn, MDAlan L. Mendelsohn, MDPatricia Gail Williams, MDTerry Stancin, PhD

SECTION ON DEVELOPMENTAL ANDBEHAVIORAL PEDIATRICS EXECUTIVECOMMITTEE, 2013–2014

Nathan J. Blum, MD, ChairpersonMichelle M. Macias, MD, Immediate PastChairpersonNerissa S. Bauer, MD, MPHCarolyn Bridgemohan, MDEdward Goldson, MDLaura J. McGuinn, MDCarol Weitzman, MD

LIAISONS

Pamela High, MD – Society for Developmental and

Behavioral Pediatrics

Susan Levy, MD – Council on Children with Disabilities

CONSULTANT

Lynn Mowbray Wegner, MD

STAFF

Linda B. Paul, MPH

COMMITTEE ON PSYCHOSOCIAL ASPECTS OFCHILD AND FAMILY HEALTH, 2013–2014

Benjamin S. Siegel, MD, ChairpersonMichael W. Yogman, MD, Chairperson-ElectThresia B. Gambon, MDArthur Lavin, MDLTC Keith M. Lemmon, MD

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Gerri Mattson, MDLaura Joan McGuinn, MDJason Richard Rafferty, MDLawrence Sagin Wissow, MD, MPH

LIAISONS

Ronald T. Brown, PhD – Society of Pediatric

Psychology

Terry Carmichael, MSW – National Association of

Social Workers

Jody K. Gurtler – National Association of Pediatric

Nurse Practitioners

Mary Jo Kupst, PhD – Society of Pediatric Psychology

Leonard Read Sulik, MD – American Academy of Child

and Adolescent Psychiatry

CONSULTANT

George J. Cohen, MD

STAFF

Stephanie Domain, MS, CHES

COUNCIL ON EARLY CHILDHOOD, 2013–2014

Elaine Donoghue, MD, Co-ChairpersonDanette Swanson Glassy, MD, Co-ChairpersonMary Lartey Blankson, MD, MPHBeth A. DelConte, MDMarian Frances Earls, MDDina Joy Lieser, MDTerri Denise McFadden, MDAlan L. Mendelsohn, MDSeth J. Scholer, MD, MPHElaine E. Schulte, MD, MPHJennifer Cohen Takagishi, MDDouglas Lee Vanderbilt, MDPatricia Gail Williams, MD

LIAISONS

Abbey D. Alkon, RN, PNP, PhD – National Association

of Pediatric Nurse Practitioners

Victoria Chen – Section on Medical Students,

Residents, and Fellowship Trainees

Barbara U. Hamilton, MA – Maternal and Child Health

Bureau Child, Adolescent and Family HealthClaire Lerner, LCSW – Zero to Three

Stephanie Olmore – National Association for the

Education of Young Children

ADVISOR

Susan S. Aronson, MD

STAFF

Jeanne M. VanOrsdal, MEdCharlotte O. Zia, MPH, CHES

SOCIETY FOR DEVELOPMENTAL ANDBEHAVIORAL PEDIATRICS BOARD OFDIRECTORS, 2012–2013

Michelle M. Macias, MD, PresidentJohn C. Duby, MD, President-ElectMarilyn Augustyn, MD, Secretary-TreasurerDesmond Kelly, MD, Immediate Past PresidentCarolyn E. Ievers-Landis, PhD

Robert Needlman, MDNancy Roizen, MDFranklin Trimm, MDLynn Wegner, MDBeth Wildman, PhD

CONSULTANT

Terry Stancin, PhD

EXECUTIVE DIRECTOR

Laura Degnon, CAE

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APPENDIX

1Behavioral

andEm

otionalScreeningMeasuresforUsein

PrimaryCare

inthePublicDomaina

Category

ScreeningTool

AgeGroup

No.ofitems

AvailableForm

sReported

Psychometrics/Other

Link

GeneralBehavioral

Screens

Youngchildren

(0–5)

Baby

PediatricSymptom

Checklist

2–17

mo

12Parent

completed

Retest

reliabilityandinternal

reliability.0.7

https://sites.google.com

/site/swycscreen

PreschoolPediatricSymptom

Checklist

18–60

mo

18Parent

completed

https://sites.google.com

/site/swycscreen

StrengthsandDifficulties

Questionnaire

3–17

y25

items

Parent/teacher

3(4)-y-old;parent/

teacher4–10-y-old;p

arent/teacher

follow-upform

savailable

Variableacross

culturalgroups;

sensitivity:63%

–94%,specificity:

88%–96%;availablein

.70

languages

http://www.sdqinfo.org

School-age

and

adolescent

children

StrengthsandDifficulties

Questionnaire

3–17

y25

items

Parent/teacher

4–10-y-old;p

arent/

teacher11–17-y-old;youth

self

report

11–17-y-old;parent/teacher/

selffollow-upform

savailable

Variableacross

culturalgroups;

sensitivity:63%

–94%,specificity:

88%–96%;availablein

.70

languages

http://www.sdqinfo.org

PediatricSymptom

Checklist—

174–16

y17

items

Parent

completed;youth

self-report

.10

y;pictorialversionavailable

Variablepsychometrics

fordetectionof

psychiatricproblems;availablein

multiple

languages

http://www.massgeneral.org/psychiatry/

services/psc_hom

e.aspx

PediatricSymptom

Checklist—

354–16

y35

items

Parent

completed;youth

self-report

.10

y;pictorialversionavailable

Sensitivity:80%

–95%,specificity:

68%–100%

;availablein

multiple

languages

http://www.massgeneral.org/psychiatry/

services/psc_hom

e.aspx

Psychosocial

Screens

WE-CARE

(Well-Child

Care

Visit,

Evaluation,Community

Resources,Advocacy,

Referral,Education)

Parent

10items

Parent

completed

http://pediatrics.aappublications.org/

content/120/3/547.full#sec-1

Family

Psychosocial

Screen

Parent

∼50

items

Parent

completed

Variablepsychometrics

fordetection

ofspecificpsychosocial

problems;

cutpoints

forvariousdomains

recommended

http://depts.washington.edu/dbpeds/

Screening%

20Tools/

FamPsychoSocQaire.pdf

Survey

ofWellbeing

inYoungChildren

Parent

9items

Parent

completed

Preliminaryfindings

show

prom

ise

https://sites.google.com

/site/swycscreen/

parts-of-the-sw

yc/fam

ily-questions

AdverseChildhood

Experience

Score

Parent

10items

Parent

completed

Increasing

scoreassociated

with

many

adversephysical

andmentalhealth

outcom

es

http://acestoohigh.com/got-your-ace-score

ScreensforSpecificDisorders

Parental

oradolescent

depression

EdinburghMaternal

Depression

Parent(m

other)

10items

Parent

self-report

Sensitivity

86%;specificity78%

http://www.fresno.ucsf.edu/pediatrics/

downloads/edinburghscale.pdf

2QuestionScreen

(Modificationof

thePatient

Health

Questionnaire—2

Parent,

adolescents

2items

Parent

oradolescent

self-report

Sensitivity:83%

–87%;specificity:

78%–92%

http://www.uphp.com/Two_Question_

Screen.pdf;http

://www.cqaimh.org/pdf/

tool_phq2.pdf

Patient

Health

Questionnaire

(PHQ

)—9

Parent

9items

Parent

orAdolescent

self-report

Sensitivity:88%

formajor

depression;

specificity:88%

formajor

depression

http://www.integration.samhsa.gov/

images/res/PHQ

%20-%20Questions.pdf

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APPENDIX

1Continued

Category

ScreeningTool

AgeGroup

No.ofitems

AvailableForm

sReported

Psychometrics/Other

Link

GeneralBehavioral

Screens

Center

forEpidem

iologic

StudiesDepression

Scale

Parent;

adolescents

.14

y(m

odified

versionfor

childrenas

youngas

6available)

20items

Parent

completed;youth

self-report

Coefficienta..9;sensitivity

91%;

specificity81%.P

sychom

etrics

forchildren,14

indicate

measure

may

notdiscriminatewellbetween

depressedandnondepressed

youth.

http://cesd-r.com

MoodandFeelings

Questionnaire

Hasbeen

used

about

childrenas

youngas

7

Shortversion;

9items;long

version:34

items

Parent

completed;youth

self-report

Parent

report

versionhasshow

na

sensitivity

of75%–86%

and

specificityof

73%–87%

http://devepi.mc.duke.edu/m

fq.htm

l

Substance

abuse

CRAFFT

(Car,R

elax,Alone,

Forget,Friends,Trouble)

11–21

yold

Threescreener

questions,then

6items

Interviewof

youth;youthself-report

versionavailable

Sensitivity

76%–93%,specificity76%

to94%;availablein

multiplelanguages

http://www.ceasar-boston.org/CRAFFT

CAGE-AID

Adolescents

4items

Youthself-report

Oneor

morepositiveansw

ersis

associated

with

asensitivityof

79%

andspecificityof

77%,$

2answ

ers

70%

and85%

http://www.integration.samhsa.gov/

images/res/CAGEAID.pdf

Anxiety

Screen

forChild

Anxiety

RelatedDisorders(SCARED)

$8y

41items

Parent

completed;youth

self-report

Coefficienta:.9

http://www.psychiatry.pitt.edu/research/

tools-research/assessm

ent-instrum

ents

Spence

Children’sAnxiety

Scale(SCAS)

2.5–6.5yand

8–12

y45

items

Parent

completed

2.5–6.5y;youth

self-report

8–12

yHigh

internal

consistencyandadequate

test–retest

reliabilityin

adolescents

http://www2.psy.u

q.edu.au/~sues/scas

ADHD

VanderbiltADHD

Diagnostic

RatingScales

4–18

y55-item

sparent

scale;43-item

steacherscale

Parent,teacher

completed;follow-up

form

savailable

Sensitivity

80%,specificity75%,retest

reliability.0.80

http://www.nichq.org/

toolkits_publications/com

plete_adhd/

03VanAssesScaleParent%20Infor.pdf;

http://www.brightfu

tures.org/

mentalhealth/pdf/professionals/

bridges/adhd.pdf

StrengthsandWeaknesses

ofADHD

Symptom

s(SWAN)

6–18

y30

items(18-item

available)

Parent,teacher

completed

http://www.adhd.net

SNAP-IV

6–18

y90

items(18-item

versionavailable)

Parent,teacher

completed

Coefficienta..90;availablein

multiple

languages

http://www.adhd.net

CAGE-AID,C

AGEQuestions

(Cut

Down,

Annoyed,

GuiltyandEyeOpener)adaptedto

includedrug

use;Sw

anson,

NolanandPelham

Questionnaire,Version

IV(SNAP-IV).

aThislistisnotmeant

tobe

exhaustivebutrepresentativeof

arangeofscreeninginstrumentssuitableforprimarycare

that

areinthepublicdomain.Psychometrics

may

vary

basedon

thefindings

ofdifferent

studiesandthereisconsiderable

variability

inthestrength

ofpsychometricreliabilitybetweenmeasures.

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APPENDIX 2 System Challenges

Resources • Identify national programs to assist parents and pediatricians in identifying mental health resources such as Help Me Grow,69 which hasestablished a centralized call center

• Advocate for a greater workforce of mental health providers and developmental-behavioral pediatricians• Advocate for additional community mental health services and ensure they are of high quality

Screening • Develop additional well-validated screens to identify psychosocial risk• Develop and validate screens appropriate for use in low-literacy and non–English-speaking populations

Payment • Advocate for payment forbehavioral, emotional, and substance abuse screeningnon–face-to-face time including care plan oversight, complex chronic care coordination and prolonged services

• Evaluate enhanced payment systems for medical-home practices and monitor financial viability of hiring care coordinators• Consider payment incentives for medical homes that include potentially enhanced reimbursement for behavioral and emotionalscreening, family psychosocial, or substance use screening and all follow-up care, case management, care plan oversight, and prolongedservices in their capitation calculations.

• Evaluate cost savings associated with the detection and treatment of behavioral and emotional problemsCollaboration • Establish payment for collaborative care models that include telephone communications between providers, etc.

• Develop efficient methods to ensure that results of community-based screening are reported to the medical homeOther • Develop quality improvement initiatives related to behavioral and emotional screening as a part of maintenance of certification

• Develop electronic health records that incorporate screening but maintain patient privacy regarding behavioral and emotional problemsand family psychosocial stressors

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DOI: 10.1542/peds.2014-3716 originally published online January 26, 2015; 2015;135;384Pediatrics 

SOCIETY FOR DEVELOPMENTAL AND BEHAVIORAL PEDIATRICSCHILD AND FAMILY HEALTH, COUNCIL ON EARLY CHILDHOOD, AND

OFBEHAVIORAL PEDIATRICS, COMMITTEE ON PSYCHOSOCIAL ASPECTS Carol Weitzman, Lynn Wegner and the SECTION ON DEVELOPMENTAL AND

ProblemsPromoting Optimal Development: Screening for Behavioral and Emotional

ServicesUpdated Information &

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SOCIETY FOR DEVELOPMENTAL AND BEHAVIORAL PEDIATRICSCHILD AND FAMILY HEALTH, COUNCIL ON EARLY CHILDHOOD, AND

OFBEHAVIORAL PEDIATRICS, COMMITTEE ON PSYCHOSOCIAL ASPECTS Carol Weitzman, Lynn Wegner and the SECTION ON DEVELOPMENTAL AND

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