What are the key components and goals of a KiDS 0 to 18 (Kids 0 to 18) Integrative Pediatrics Behavioral Health Evaluation and Management Visit?

KiDS 0 to 18 Integrative Pediatrics Behavioral Health Evaluation and Management Visit

Core Components and Goals

The primary goal of a KiDS 0 to 18 Integrative Pediatrics Behavioral Health Evaluation and Management Visit is to systematically identify, assess, and manage mental health and behavioral concerns in children and adolescents within the primary care setting, using standardized screening tools, comprehensive biopsychosocial assessment, and evidence-based brief interventions or appropriate referrals. 1

Essential Visit Components

Systematic Mental Health Screening

• Universal depression screening should begin at age 12 years using the PHQ-9, which has a sensitivity of 89.5% and specificity of 77.5% at a cutoff score of 11 for detecting major depressive disorder. 2
• Age-specific behavioral screening tools must be administered at designated intervals: Ages and Stages Questionnaire-Social Emotional at 9,18,24, or 30 months; Brief Infant-Toddler Social and Emotional Assessment at 18 and 30 months. 1
• For children 48 months through adolescence, use the Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire for comprehensive behavioral screening. 1
• The Vanderbilt ADHD Rating Scales should be used from age 6 years onward to screen for ADHD, oppositional defiant disorder, conduct disorder, anxiety, and depression symptoms. 1

Comprehensive Biopsychosocial Assessment

• The evaluation must incorporate biological, psychological, and psychosocial factors within a clinical formulation that includes the family's "lived experience" and leads to shared decision-making. 1
• Information must be gathered from multiple sources including parents, teachers, and other school personnel to document symptoms across multiple settings. 3
• Direct questioning about suicidal ideation should be embedded within depression symptom assessment, using questions such as "Have you ever thought about killing yourself or wished you were dead?" and "Have you ever done anything on purpose to hurt or kill yourself?" 2

Mental Status Examination

• Systematic observation and documentation of the child's presentation, affect, behavior, and cognitive functioning during the visit. 1
• Recognition that irritability, not sadness, may be the primary manifestation of depression in adolescents, requiring assessment for cranky mood, oppositional behavior, and loss of interest in previously enjoyed activities. 2

Risk Stratification and Management Algorithm

PHQ-9 Score-Based Management (for ages 12+)

• PHQ-9 score 1-7 (none/mild): Provide education about depression and normal stress responses, ensure adequate coping skills and access to resources, consider reassessment at future visits. 2
• PHQ-9 score 8-14 (moderate): Evaluate pertinent history and specific risk factors, consider referral to psychology or psychiatry for diagnostic evaluation, offer low-intensity intervention options. 2
• PHQ-9 score 15-27 (moderate to severe/severe): Make immediate referral to psychology and/or psychiatry for diagnosis and treatment, assess for risk of harm to self or others, evaluate for medical or substance-induced causes. 2
• Item 9 positive (self-harm thoughts): Immediate referral required for patients with specific plans or intent for self-harm, regardless of total score. 2

ADHD Evaluation and Management

• For any child age 4 years to 18th birthday presenting with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity, initiate formal ADHD evaluation. 3
• Diagnosis requires at least 6 inattention symptoms AND at least 6 hyperactivity-impulsivity symptoms, with clear functional impairment and symptom onset before age 12. 3
• For elementary and middle school-aged children (age 6-12 years) with ADHD, prescribe FDA-approved stimulant medication (methylphenidate or amphetamine) combined with parent training in behavior management and behavioral classroom interventions. 3
• Educational interventions including IEP or 504 plan are mandatory components of any ADHD treatment plan, regardless of whether medication is prescribed. 3

Brief Therapeutic Interventions

Common-Factors Approach (HELP Framework)

• H = Hope: Increase family hopefulness by describing realistic expectations for improvement and reinforcing strengths and assets in the child and family. 1
• E = Empathy: Communicate empathy by listening attentively, acknowledging struggles and distress, and sharing happiness experienced by the child and family. 1
• L = Language, Loyalty: Use the child or family's own language to reflect understanding of the problem and communicate loyalty by expressing support and commitment to help. 1
• P = Permission, Partnership, Plan: Ask permission to explore sensitive questions, partner with the family to identify barriers, and develop collaborative treatment plans. 1

Transdiagnostic Brief Interventions

• Brief interventions should be no more than 10 to 15 minutes per session to mitigate disruption to practice flow. 1
• Goals include improving patient functioning, reducing distress in patient and parents, and potentially preventing later disorders. 1
• For patients awaiting specialty referral, brief interventions help overcome barriers to accessing care and ameliorate symptoms while awaiting higher levels of care. 1

Family-Driven, Youth-Guided, Strengths-Based Framework

Core Principles

• Families must have the primary role in decisions regarding their children, including choosing supports, services and providers, setting goals, and monitoring outcomes. 1
• Active family participation has been shown to reduce child problem behaviors over time, improve family and youth functioning, and increase family empowerment and self-sufficiency. 1
• Youth should become active participants in treatment decisions through a therapeutic alliance that allows them to learn about their concerns, goals, and priorities for treatment. 1
• Strengths-based care highlights, identifies, and builds upon the competence of youth and their families during all phases of treatment, which has been shown to be effective in reducing functional impairment. 1

Trauma-Informed Care Integration

Essential Considerations

• Youth involved in behavioral health systems have a disproportionately high rate of trauma exposure and greater impairments at baseline compared to youth without such history. 1
• If trauma is not recognized and addressed, other interventions—regardless of how well intentioned—may be less effective. 1
• Trauma-informed care involves specific beliefs and practices centered on safety, trust, and empowerment that are relevant to individuals, organizations, and systems. 1
• Clinicians should understand the role that trauma can play in development and advocate for maintenance of a trauma-informed approach in all child-serving systems. 1

Coordination and Follow-Up

Medical Home Model

• Children with behavioral health concerns should be managed following principles of the chronic care model and medical home. 3
• Coordinating care between medical, educational, and behavioral health providers is crucial for optimal outcomes. 3
• Systematic follow-up is required to monitor treatment response, side effects, and functional outcomes. 3

Referral Pathways

• For identified or suspected problems requiring more formal evaluation, referral to appropriate behavioral or mental health specialists with ongoing monitoring by the pediatric healthcare provider is necessary. 1
• Provide written documentation to schools that includes medical diagnosis (if criteria are met) or description of symptoms requiring evaluation, with specific recommendations for IEP evaluation or 504 plan assessment. 3

Common Pitfalls to Avoid

• Do not screen without having a clear protocol for managing positive screens, as screening alone without intervention does not improve outcomes. 2
• Failing to obtain information from multiple settings and relying on a single informant can lead to misdiagnosis. 3
• Do not assume absence of current suicidal ideation means low risk, as patients who have previously attempted suicide remain at elevated risk if none of the factors that led to the attempt have changed. 2
• Misdiagnosing ADHD when symptoms are better explained by trauma, anxiety, or other conditions can occur if alternative causes are not systematically ruled out. 3
• Parents and patients may be hesitant to mention behavioral problems during routine clinical follow-up, therefore medical home providers must directly question them for concerns about these issues. 1

Billing and Documentation

Structured Documentation Requirements

• Patient and provider identification, visit information in list format. 1
• Clinical concerns, reason for consultation, medication review, information sources. 1
• Psychometric assessment results with specific scores and interpretation. 2
• Mental status examination findings. 1
• Diagnosis using DSM-5 criteria when applicable. 3
• Current medications with notes on efficacy and side effects. 1
• Risk assessment including self-harm and harm to others. 2
• Detailed plan including referrals, prescriptions, labs/diagnostics/imaging, and follow-up. 1
• Orders and visit diagnoses for billing purposes. 1