What are the guidelines for mental health screening in children and adolescents in a primary care setting?

From the Guidelines

Mental health screening for children and adolescents in primary care settings should be implemented as a standard component of routine healthcare visits, using validated tools such as the Pediatric Symptom Checklist (PSC), Patient Health Questionnaire for Adolescents (PHQ-A), Screen for Child Anxiety Related Disorders (SCARED), or the Strengths and Difficulties Questionnaire (SDQ), as recommended by the U.S. Preventive Services Task Force 1.

Key Considerations

• The screening process should begin with brief questionnaires completed by parents for younger children (ages 3-11) and self-reporting tools for adolescents (ages 12-18) 1.
• Providers should incorporate these screenings during well-child visits, sports physicals, or other regular appointments, taking approximately 5-10 minutes to administer and score.
• When positive screens occur, follow-up assessments should be conducted using more specific tools targeting the identified concerns.
• The primary care setting provides a non-stigmatizing environment where families already have established relationships with providers, increasing the likelihood of honest reporting and follow-through with recommendations for further evaluation or treatment when needed.

Benefits of Screening

• Early identification of mental health conditions through systematic screening allows for timely intervention, potentially preventing progression to more serious conditions 1.
• Many mental health conditions begin in childhood or adolescence but often go undetected until symptoms become severe.
• Screening can help identify children and adolescents who may benefit from further evaluation or treatment, improving their overall mental health and well-being.

Tools for Screening

• The PHQ-A study had the highest positive predictive value, with sensitivity of 73% and specificity of 94% for a positive test result 1.
• The BDI studies reported sensitivity ranging from 84% to 90% and specificity ranging from 81% to 86% when a cutoff score of 11 was applied 1.
• The CES-D studies used different diagnostic cutoff scores, with sensitivity ranging from 18% to 84% and specificity ranging from 38% to 83% 1.

From the Research

Mental Health Screening for Children and Adolescents in Primary Care Setting

• The American Academy of Pediatrics recommends routine behavioral health screening for children and adolescents in primary care settings 2, 3.
• Implementing an effective and sustainable screening program can be challenging due to barriers such as lack of time, space, and reimbursement constraints 2, 4.
• Validated tools such as the Patient Health Questionnaire-9 (PHQ-9) can be used for depression screening, and symptom rating scales based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) can be used for attention deficit hyperactivity disorder (ADHD) assessment 5, 6.
• A two-stage screening process, combining screening with ongoing surveillance, can help detect children with mental, emotional, and behavioral problems 3, 5.
• Collaborative care approaches, which involve shifting certain specialty mental health tasks to primary care, can improve access to and quality of behavioral health care for children and adolescents 4.

Screening Tools and Methods

• The PHQ-9 is a widely validated screening tool for depression, with a recommended cut-off score of 10 5.
• Symptom rating scales, such as those based on the DSM-IV, are evidence-based assessment methods for ADHD 6.
• Brief, non-DSM based rating scales can be highly correlated with DSM scales and are more efficient for diagnosing ADHD 6.
• Parent and teacher ratings are necessary for clinical purposes, and observational procedures can be empirically valid but are not practical for clinical use 6.

Implementation and Challenges

• Insufficient mental health education and specialist consultative support can be challenges to implementing collaborative care in primary care settings 4.
• Space, time, and reimbursement constraints can also limit the implementation of mental health screening and collaborative care 2, 4.
• Patient and family engagement, professional education and training, and evaluation of impact are essential supporting activities for effective collaborative care 4.