What are the recommended screening tools and interventions for depression, bipolar disorder, anxiety, and post-traumatic stress disorder (PTSD) in pediatric patients?

Recommended Screening Tools for Pediatric Mental Health Disorders

Depression Screening

For adolescents aged 12-18 years, use the PHQ-9 with a cutoff score of 11 or the PHQ-2 with a cutoff of 3 as your primary depression screening tools. 1

Validated Tools for Adolescents (Ages 12-18)

• PHQ-9 (cutoff ≥11): Sensitivity 89.5%, specificity 77.5% when validated against gold-standard diagnostic interview (DISC-IV) 1
• PHQ-2 (cutoff ≥3): Sensitivity 73.7%, specificity 75.2% - useful as a brief initial screen 1
• Alternative validated tools: Mood and Feelings Questionnaire, Columbia Depression Scale, PHQ-9 Modified for Teens 1

Children Under Age 12

• Insufficient evidence exists to recommend universal depression screening in children aged 7-11 years - the USPSTF gives this an "I" statement (insufficient evidence) 1
• No validated screening instruments have been tested in primary care settings for this age group 1

Implementation Requirements

Screening must only be implemented when adequate systems exist for accurate diagnosis, effective treatment, and appropriate follow-up - this is a critical caveat emphasized by the USPSTF 1

Anxiety Screening

Use the Screen for Child Anxiety Related Disorders-5 (SCARED-5) for anxiety screening in pediatric populations. 1

• The SCARED-5 has been validated in pediatric primary care settings 1
• Can be incorporated into broader behavioral health screening tools 1

PTSD Screening

For known trauma exposures, use the PTSD Reaction Index Brief Form; for general primary care screening, use the Pediatric Traumatic Stress Screening Tool. 2

Specific Assessment Approach

• Begin by directly asking: "Has anything scary or concerning happened to you or your family since the last visit?" 2
• Follow with open-ended questions to explore trauma exposure 2
• For adolescents: Incorporate trauma questions into the HEADSSS framework and ask about new substance use or risk-taking behaviors 2

Age-Specific Considerations

• For younger children: Ask parents about sleep problems, appetite changes, clinginess, behavioral regression, and unexplained physical complaints 2
• Critical pitfall: Do not rely solely on observable behaviors - most PTSD symptoms are internal and require direct questioning 2
• Screen children directly when age-appropriate, as parents and teachers often underestimate distress 2

Emergency Department Setting

• A 4-question adolescent suicide screen has good sensitivity and specificity across ED populations 1
• An 8-question screen effectively detects PTSD symptoms in children with traffic-related injuries 1
• The HEADS-ED (adapted from HEADSSS) shows good reliability and predictive validity for psychiatric evaluation needs 1

Bipolar Disorder Screening

Use the M-3 checklist bipolar module, which has a sensitivity of 0.88 and specificity of 0.70 for detecting bipolar disorder in primary care. 3

• The M-3 is a 1-page, 27-item self-rated tool that screens for multiple psychiatric disorders simultaneously 3
• Takes less than 5 minutes to complete in the waiting room 3
• 83% of clinicians can review it in ≤30 seconds 3

Multidimensional Screening Approaches

Combined Screening Tools

• Behavioral Health Screen (BHS): Screens for depression plus other psychiatric disorders and high-risk behaviors 1
• M-3 Checklist: Single tool screening for depression, bipolar disorder, anxiety, and PTSD with sensitivity 0.83 and specificity 0.76 for any psychiatric disorder 3

Important Caveat About Comprehensive Screening

Be cautious with overly broad screening tools - evidence suggests that too much information may overwhelm clinicians, resulting in positive depression screens being overlooked among multiple other issues 1

Practical Implementation Considerations

Frequency of Screening

• Annual screening is recommended for all adolescents aged 12-18 years 1
• The American Academy of Pediatrics Bright Futures program recommends annual screening for emotional and behavioral problems in all pediatric patients 1

Two-Phase Screening Process

• Initial screening should be followed by skilled clinician assessment incorporating contextual factors 1
• A positive screen does not automatically indicate need for treatment - requires clinical judgment and potentially formal diagnostic interview 1
• A negative screen does not preclude referral when clinical judgment or parental concerns warrant it 1

Common Pitfalls to Avoid

• Standardized tools are more sensitive than clinical judgment alone - do not rely solely on your clinical impression 1
• Underdiagnosis is common - many patients with PTSD do not voluntarily report symptoms, requiring direct screening 2
• For very young children (under age 5): Families are less likely to attend mental health consultant appointments even when referred, suggesting need for enhanced engagement strategies 4
• Ensure follow-up systems exist - screening without adequate treatment and follow-up systems can result in treatment failures or harms 1