promoting optimal development: screening for behavioral ... · environmental, familial, and...
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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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Referenceshttp://pediatrics.aappublications.org/content/135/2/384#BIBLThis article cites 41 articles, 8 of which you can access for free at:
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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
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