Pediatric Annals

Special Issue Article 

Screening for Mental Health Problems in Pediatric Primary Care

John T. Parkhurst, PhD; Susan Friedland, MD

Abstract

Systematic mental health screening is a recommended but controversial process in the pediatricians' behavioral health tool kit. Although the American Academy of Pediatrics and other organizations promote routine behavioral health screening, implementing an effective and sustainable screening program can be challenging. We discuss the rationale for and barriers to screening in pediatric settings, identify accessible validated tools that can be easily incorporated into practice, and suggest a practical strategy for implementing a more accurate screening system for common mental health concerns in pediatric primary care. [Pediatr Ann. 2020;49(10):e421–e425.]

Abstract

Systematic mental health screening is a recommended but controversial process in the pediatricians' behavioral health tool kit. Although the American Academy of Pediatrics and other organizations promote routine behavioral health screening, implementing an effective and sustainable screening program can be challenging. We discuss the rationale for and barriers to screening in pediatric settings, identify accessible validated tools that can be easily incorporated into practice, and suggest a practical strategy for implementing a more accurate screening system for common mental health concerns in pediatric primary care. [Pediatr Ann. 2020;49(10):e421–e425.]

Early identification of mental health concerns in children and adolescents promotes their future psychosocial and physical health.1 Pediatricians are likely the first professional contact for children and adolescents with mental health concerns.2 Pediatricians typically have longstanding relationships with children and families, are experts at establishing trust and rapport, and both patients and parents value having their pediatrician address their concerns.3,4 Pediatricians overwhelmingly endorse their responsibility for identifying mental health concerns,5 and they manage one-third of children with behavioral health diagnoses, including 40% of children identified with attention-deficit/hyperactivity disorder (ADHD).6 Many pediatricians feel they need more training to identify and treat mental health concerns.7,8

Systematic screening improves the detection of mental health problems.9 Without the use of screening tools, pediatricians' detection of mental health concerns is low,7 and the positive predictive value of pediatrician's clinical judgment is at a near-chance (50%) level.10,11 Screening tools improve both the efficiency and comprehensiveness of the clinical encounter (J. T. Parkhurst, PhD, A. T. Vesco, PhD, R. B. Ballard, MD, J. V. Lavigne, PhD, unpublished data, January 2020), and are increasingly linked to value-based care through accountable care organizations and patient-centered medical homes.9,12

Challenges of Behavioral Health Screening in Pediatric Primary Care

Despite the obvious benefits to children and families of initiating and providing mental health care in pediatric primary care, challenges to transforming the pediatric scope of practice are substantial. Pediatric clinic visits are often short, time pressure during office hours is unremitting, and reimbursement for behavioral health services is low.2 Incorporating screening into a practice's workflow initially requires new office processes for completion, scoring, interpretation, discussion, and documentation. The screening program must be maintained over time. The improved identification of mental health problems may also increase the need for mental health referrals in the face of limited community resources. Despite the availability of many no-cost, valid screening tools for pediatric mental health problems, more than half of primary care providers have never or rarely incorporated standardized mental health screening tools into their practices.13

Guidelines for Behavioral Health Screening in Primary Care

Core pediatric mental health competencies involve the screening, clinical assessment, early intervention, referral, and co-management of mental health disorders.8 Three primary care practice organizations, including the US Preventive Services Task Force, Bright Futures/American Academy of Pediatrics, and the American Academy of Pediatrics Task Force on Mental Health (TFOMH) have issued screening recommendations.14 Both Bright Futures and the TFOMH recommend psychosocial assessments to include use of mental health screening instruments from birth to age 21 years.14 TFOMH, specifically, proposes selective screening between the ages of 0 and 5 years, with systematic screening for mental health at well-child check-ups and at times of concern.14

Universal and Targeted Screening

To be consistent with the above guidelines, pediatricians will need to use both universal and targeted screening measures. If screening for a broad set of symptoms is intended, a validated “universal” tool is recommended. If the aim is to identify unidimensional conditions such as ADHD, depression, or anxiety disorders, a targeted screening approach is appropriate.15

Even the best screening tools have some degree of measurement error, as represented by their rates of false positives and false negatives. To reduce false positives, a sequential screening approach is useful.16 This sequential method sustainably improves the accurate detection of a behavioral health disorder.

In practice, the sequential approach to screening begins with a universal screening tool. If the results of the screen are above an identified cutoff, a second targeted screen is applied, to more specifically detect the disorder. The second tool selected in the sequential process typically has higher specificity for the disorder of interest than the first tool. Accuracy of detection is improved by the sequential use of two screenings.

Choosing Screening Tools

There are close to 20 validated behavioral health screening tools in the public domain.14,17 The pediatrician should keep two primary criteria in mind when selecting a screening tool.

First, a screening tool should be chosen to match the practice population. The age range and demographics of the validation sample are of primary importance. Not all tools function reliably across all ages, and one should confirm that selected measures have been validated for the ages and demographics of the intended patient population. For example, the widely used National Institute for Children's Health Quality (NICHQ) Vanderbilt ADHD screening tool has only been validated in patients age 6 to 12 years,18,19 and its use with children outside this age range is inappropriate.

Second, screening tools should have adequate ability to detect the mental health concerns of interest. The sensitivity and specificity of a measure indicate the degree of confidence a pediatrician can have in a tool's ability to effectively identify patients with a concern. As a reminder, sensitivity refers to the proportion of people with a diagnosis having a positive test result, whereas specificity represents the proportion of people without a diagnosis having a negative test result. Few screening tools meet the best-case scenario range of sensitivity >.80 and specificity >.80,14 but tests with values close to this ideal are needed.

Sequential Screening Process for More Accurate Detection

A common screening practice is to use targeted screening measures for the most common conditions such as ADHD, anxiety disorders, and depression (Figure 1). Although this approach is often used, we demonstrate in the following example how the practice of using a targeted screening tool leads to unacceptable high rates of false positives. The Patient Health Questionnaire 9 (PHQ-9) has good sensitivity of 89.5% and reasonably good specificity of 77.5% for predicting adolescent depression, using a total cut-off score of ≥11.15 If a pediatrician were using only this tool to detect adolescent depression, given the lifetime prevalence of adolescent depression (11%20) and a yearly patient population of 2,500 patients, 245 adolescents with depression would be detected (true positives), but an additional 501 false positives would be identified, substantially increasing the number of adolescents unnecessarily sent for evaluation. Minimizing false positives will improve the efficiency of the screening process by ensuring that a problem is likely present, and that a referral is both appropriate and necessary.

Model of sequential screening process in primary care. PHQ, Patient Health Questionnaire; PSC-17, Pediatric Symptom Checklist; SCARED, Screen for Child Anxiety and Related Disorder; SMFQ, Short Mood and Feelings Questionnaire.

Figure 1.

Model of sequential screening process in primary care. PHQ, Patient Health Questionnaire; PSC-17, Pediatric Symptom Checklist; SCARED, Screen for Child Anxiety and Related Disorder; SMFQ, Short Mood and Feelings Questionnaire.

To reduce false-positive diagnoses, both universal and targeted approaches to screening can be used sequentially to improve both the breadth and the accuracy of identified problems. Sequential screening, using first a universal, then a targeted measure, helps pediatricians screen and identify behavioral health concerns with greater sensitivity and specificity.16

Broad, multidimensional measures such as the parent-completed Pediatric Symptom Checklist (PSC)-1721 are good universal starting points for systematic screening. The PSC-17 is brief, easily scored, and validated across a wide age range (age 4 to 17 years). The sensitivity and specificity of the PSC-17 is adequate for total problems and most subscales, which include scales for internalizing (eg, depression and anxiety), externalizing (eg, oppositional behavior), and attention problems (Table 1). When the scale or total score is above the cut-off, a second targeted screen should be completed to further confirm a working diagnosis.

Sensitivity, Specificity, and Cut-Off Scores for Measures

Table 1.

Sensitivity, Specificity, and Cut-Off Scores for Measures

Consider the example described above regarding the false-positive rates when using the PHQ-9 alone. Had a PSC-17 internalizing scale been administered first and followed up by the administration of the PHQ-9, fewer true cases of depression would be identified (128 rather than 245 cases). Those with a score above the cut-off on one but not both measures would need careful follow-up at the next visit. However, false positives would be reduced by 73% (from 501 to 133 cases), substantially reducing the burden on the practice for assessing the child or referring for specialty evaluation.

Three freely available and commonly used screening tools for mood and anxiety disorders allow relatively quick interpretation. After a positive PSC-17 internalizing cut-off (≥5) or total score (≥15), either the Screen for Child Anxiety and Related Disorder (SCARED),22 a 41-item anxiety scale with parent and youth forms, or the Short Moods and Feelings Questionnaire (SMFQ),23 a 13-item scale for mood disorder with both parent and youth forms, may be administered. Both have adequate sensitivity and specificity values (Table 1). Alternatively, the PHQ-9 is a youth self-report tool used to assess adolescent depression (age 11–17 years).

To target disruptive behavior concerns identified on the PSC-17 (total score ≥15, or ≥7 on the externalizing domain), the NICHQ Oppositional Defiant Disorder scale (the sum of items 19–26 of the NICHQ Vanderbilt Parent screen)19 can be used in sequence with the PSC-17. When the PSC-17 identifies a concern with attention, the pediatrician may then ask the patient's caregiver to collect the teacher's report of symptoms using the NICHQ Vanderbilt Teacher screen.18

Designing a Screening Program

When designing a behavioral health screening program for a primary care practice, practical considerations may take precedence. Important early considerations include identifying who will complete the screening (eg, caregiver or youth or both), how and when the completed screening tools will be collected and scored (electronic, nurse, other staff, or physician), in what form the screens will be presented to the clinician (electronic or paper copy), the process by which screens will be entered into the medical record, and the reimbursement codes entered (eg, CPT code 96127 for rating scale scoring and interpretation). Patients and parents usually complete screening prior to meeting with the pediatrician. Electronic completion mechanisms linked to electronic medical records are increasingly improving the burden of administering and scoring screening tools. Pediatric practices also need to prepare for a higher frequency of referrals for specialty behavioral health care. It is important to identify community treatment resources before a screening program starts.

Conclusion

Developing a screening program for pediatric primary care and selecting the tools used will require some compromises (initial time investment, prioritizing when and for what to screen, availability, and cost and length of screening tools). The systematic use of behavioral health screening can improve primary care pediatricians' rates of detection of mental health disorders,2 and facilitate early intervention and improve outcomes. Importantly, we do not recommend using single targeted symptom rating scales. We support using a universal screen followed by a targeted screening measure to improve the accuracy of clinical decision-making while reducing the practice burden resulting from false positives.

References

  1. Costello EJ. Early detection and prevention of mental health problems: developmental epidemiology and systems of support. J Clin Child Adolesc Psychol. 2016;45(6):710–717. doi:10.1080/15374416.2016.1236728 [CrossRef] PMID:27858462
  2. Wissow LS, van Ginneken N, Chandna J, Rahman A. Integrating children's mental health into primary care. Pediatr Clin North Am. 2016;63(1):97–113. doi:10.1016/j.pcl.2015.08.005 [CrossRef] PMID:26613691
  3. Chisolm DJ, Gardner W, Julian T, Kelleher KJ. Adolescent satisfaction with computer-assisted behavioural risk screening in primary care. Child Adolesc Ment Health. 2008;13(4):163–168. doi:10.1111/j.1475-3588.2007.00474.x [CrossRef] PMID:19779573
  4. Olson AL, Gaffney CA, Hedberg VA, Gladstone GR. Use of inexpensive technology to enhance adolescent health screening and counseling. Arch Pediatr Adolesc Med. 2009;163(2):172–177. doi:10.1001/archpediatrics.2008.533 [CrossRef] PMID:19188650
  5. Olson AL, Kelleher KJ, Kemper KJ, Zuckerman BS, Hammond CS, Dietrich AJ. Primary care pediatricians' roles and perceived responsibilities in the identification and management of depression in children and adolescents. Ambul Pediatr. 2001;1(2):91–98. doi:10.1367/1539-4409(2001)001<0091:PCPRAP>2.0.CO;2 [CrossRef] PMID:11888379
  6. Anderson LE, Chen ML, Perrin JM, Van Cleave J. Outpatient visits and medication prescribing for us children with mental health conditions. Pediatrics. 2015;136(5):e1178–e1185. doi:10.1542/peds.2015-0807 [CrossRef] PMID:26459647
  7. Sheldrick RC, Merchant S, Perrin EC. Identification of developmental-behavioral problems in primary care: a systematic review. Pediatrics. 2011;128(2):356–363. doi:10.1542/peds.2010-3261 [CrossRef] PMID:21727101
  8. Green CM, Foy JM, Earls MFCommittee on Psychosocial Aspects of Child and Family Health, Mental Health Leadership Work Group. Achieving the pediatric mental health competencies. Pediatrics. 2019;144(5):e20192758. doi:10.1542/peds.2019-2758 [CrossRef] PMID:31636144
  9. Pincus HA, Scholle SH, Spaeth-Rublee B, Hepner KA, Brown J. Quality measures for mental health and substance use: gaps, opportunities, and challenges. Health Aff (Millwood). 2016;35(6):1000–1008. doi:10.1377/hlthaff.2016.0027 [CrossRef] PMID:27269015
  10. Lavigne JV, Binns HJ, Christoffel KK, et al. Pediatric Practice Research Group. Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians' recognition. Pediatrics. 1993;91(3):649–655. PMID:8441575
  11. Costello EJ, Costello AJ, Edelbrock C, et al. Psychiatric disorders in pediatric primary care. Prevalence and risk factors. Arch Gen Psychiatry. 1988;45(12):1107–1116. doi:10.1001/archpsyc.1988.01800360055008 [CrossRef] PMID:3264146
  12. Asarnow JR, Kolko DJ, Miranda J, Kazak AE. The pediatric patient-centered medical home: innovative models for improving behavioral health. Am Psychol. 2017;72(1):13–27. doi:10.1037/a0040411 [CrossRef] PMID:28068135
  13. Kuhlthau K, Jellinek M, White G, Vancleave J, Simons J, Murphy M. Increases in behavioral health screening in pediatric care for Massachusetts Medicaid patients. Arch Pediatr Adolesc Med. 2011;165(7):660–664. doi:10.1001/archpediatrics.2011.18 [CrossRef] PMID:21383254
  14. Joseph J, Kagadkar F, Galanter CA. Screening for behavioral health issues in primary care. Curr Treat Options Pediatr. 2018;4(2):129–145. doi:10.1007/s40746-018-0118-z [CrossRef]
  15. Richardson LP, McCauley E, Grossman DC, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117–1123. doi:10.1542/peds.2010-0852 [CrossRef] PMID:21041282
  16. Lavigne JV, Feldman M, Meyers KM. Screening for mental health problems: addressing the base rate fallacy for a sustainable screening program in integrated primary care. J Pediatr Psychol. 2016;41(10):1081–1090. doi:10.1093/jpepsy/jsw048 [CrossRef] PMID:27289070
  17. American Academy of Pediatrics. Mental health screening and assessment tools for primary care. Accessed September 21, 2020. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf.
  18. Wolraich ML, Bard DE, Neas B, Doffing M, Beck L. The psychometric properties of the Vanderbilt attention-deficit hyperactivity disorder diagnostic teacher rating scale in a community population. J Dev Behav Pediatr. 2013;34(2):83–93. doi:10.1097/DBP.0b013e31827d55c3 [CrossRef] PMID:23363973
  19. Bard DE, Wolraich ML, Neas B, Doffing M, Beck L. The psychometric properties of the Vanderbilt attention-deficit hyperactivity disorder diagnostic parent rating scale in a community population. J Dev Behav Pediatr. 2013;34(2):72–82. doi:10.1097/DBP.0b013e31827a3a22 [CrossRef] PMID:23363972
  20. Avenevoli S, Swendsen J, He J-P, Burstein M, Merikangas KR. Major depression in the national comorbidity survey-adolescent supplement: prevalence, correlates, and treatment. J Am Acad Child Adolesc Psychiatry. 2015;54(1):37–44.e2. doi:10.1016/j.jaac.2014.10.010 [CrossRef] PMID:25524788
  21. Murphy JM, Bergmann P, Chiang C, et al. The PSC-17: subscale scores, reliability, and factor structure in a new national sample. Pediatrics. 2016;138(3):e20160038. doi:10.1542/peds.2016-0038 [CrossRef] PMID:27519444
  22. Birmaher B, Khetarpal S, Brent D, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry. 1997;36(4):545–553. doi:10.1097/00004583-199704000-00018 [CrossRef] PMID:9100430
  23. Rhew IC, Simpson K, Tracy M, et al. Criterion validity of the Short Mood and Feelings Questionnaire and one- and two-item depression screens in young adolescents. Child Adolesc Psychiatry Ment Health. 2010;4(1):8. doi:10.1186/1753-2000-4-8 [CrossRef] PMID:20181135

Sensitivity, Specificity, and Cut-Off Scores for Measures

Measure Age range, years Scale Cut-off Sensitivity, % Specificity, %



Total score ≥15 73 74


Internalizing scale ≥5 52 74


Externalizing scale ≥7 62 89
Pediatric Symptom Checklist-1721 4–17 Attention problems scale ≥7 59 91

Screen for Child Anxiety and
Parent total score ≥25 65 99
Related Disorders22 8–17 Youth total score ≥25 64 92

Short Mood and Feelings
Parent total score ≥11 75 73
Questionnaire23 8–18 Youth total score ≥11 71 83

Patient Health Questionnaire-915 11–18 Youth total score ≥11 89.5 77.5



ADHD combined total ≥6a 67 86
NICHQ Vanderbilt Parent Report19 6–12 ODD scale ≥10 88 85
Authors

John T. Parkhurst, PhD, is a Staff Psychologist, Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago; and an Assistant Professor, Northwestern University Feinberg School of Medicine. Susan Friedland, MD, is a Staff Psychiatrist, Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago; and an Assistant Professor, Northwestern University Feinberg School of Medicine.

Address correspondence to John Parkhurst, PhD, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Box 10, Chicago, IL 60611; email: jtparkhurst@luriechildrens.org.

Disclosure: The authors have no relevant financial relationships to disclose.

The authors thank the Pritzker Foundation for their generous support of our efforts to improve mental health care access and treatment.

10.3928/19382359-20200921-01

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