KiDS 0-18 Integrative Pediatrics Behavioral Health Evaluation and Management Visit
Primary Recommendations for Structured Assessment
The primary care clinician should conduct a comprehensive behavioral health evaluation using standardized screening tools at specific age intervals (9,18,24,30, and 48 months for developmental screening, with behavioral screening at every visit from infancy through adolescence), combined with a thorough mental status examination and risk assessment to determine appropriate level of care and intervention. 1
Core Components of the Evaluation Visit
Initial Screening and Surveillance
Implement age-specific standardized screening tools rather than relying solely on clinical observation, as parent-completed questionnaires are the most useful in pediatric settings 1
For infants and toddlers (9-30 months): Use the Ages and Stages Questionnaire–Social Emotional or the Brief Infant-Toddler Social and Emotional Assessment 1
For children 48 months through adolescence: Utilize the Pediatric Symptom Checklist-17 (PSC-17) or Strengths and Difficulties Questionnaire for broad behavioral screening 1, 2
For children 6 years and older: Consider the Vanderbilt ADHD Rating Scales to screen for ADHD, oppositional defiant disorder, conduct disorder, anxiety, depression, and academic/behavioral performance 1
For adolescents with depression concerns: Implement the Patient Health Questionnaire-9 (PHQ-9), as brief 2-question screens have demonstrated utility in detecting depression 1, 2
For anxiety screening: Use the Screen for Child Anxiety Related Emotional Disorders (SCARED) 2
Mental Status Examination Requirements
Conduct a structured mental status examination that specifically assesses: 1
- Appearance and behavior
- Thought process and thought content (including presence/absence of hallucinations or delusions)
- Mood and affect
- Insight and judgment
- Signs of self-injury or toxidromes
- Assessment for delirium when indicated
Risk Assessment Protocol
For patients with suicidal ideation or self-injury: 1
- Interview patients and caregivers both together and separately to obtain comprehensive information
- Obtain collateral information from multiple sources, as patients frequently minimize symptom severity
- Conduct personal and belongings search, change patient into hospital attire, and place in safe environment with close supervision
- Assess for continued desire to die, agitation, severe hopelessness, inability to engage in safety planning, inadequate support system, or inability to receive adequate follow-up care
Critical caveat: No validated criteria exist for assessing suicide risk level, but expert consensus identifies these high-risk indicators requiring higher level of care 1
Medication Review and Management
When conducting medication reviews: 1
- Inquire about previous medication reactions, as atypical responses (idiosyncratic, disinhibition, or paradoxical reactions) may be more common in certain populations
- Begin with lower medication dosages to observe patient response
- Document adherence to prescribed medication regimen
- Note that there are no rigorous evidence-based guidelines for psychotropic medications in children with autism spectrum disorders or developmental disabilities, though no known contraindications exist for common sedating medications 1
Diagnostic Laboratory and Imaging Considerations
Avoid routine laboratory testing and neuroimaging unless clinically indicated: 1
- Obtain diagnostic testing only based on specific findings from history and physical examination
- For clinically stable patients (alert, cooperative, normal vital signs, noncontributory history/physical, psychiatric symptoms), routine laboratory testing is not indicated
- Reserve testing for patients with altered mental status, unexplained vital sign abnormalities, or new-onset/acute changes in psychiatric symptoms
- Brain CT scans have extremely low yield in psychiatric presentations without focal neurologic findings (only 1.2-5% show abnormalities, none clinically significant)
Multidisciplinary Assessment Team
The ideal assessment team should include: 3
- Psychologist
- Physician (developmental pediatrician, neurologist, or child psychiatrist if significant behavioral problems present)
- Speech-language pathologist
For formal neuropsychological assessment: 3
- Strongly recommended for all children with risk conditions
- Reevaluation approximately every 3 years due to complex and changing developmental profiles
- Critical during transition periods (primary to secondary school, adolescence)
Information Gathering Requirements
Document multiple information sources: 1
- Clinical interviews with patient and family members (with dates)
- Psychometric assessment results with standardized scores
- Review of previous medical records
- Collateral information from teachers and other involved professionals
- Use multiple informants (adolescents, parents, teachers) for comprehensive evaluation
Behavioral Health Screening Advantages in Primary Care
Primary care settings offer unique advantages for behavioral health screening: 1
- Ideal for identifying high-risk, difficult-to-reach populations (homeless adolescents, school dropouts, those without primary care access)
- Teenagers and parents report favorable attitudes toward mental health screening in medical settings
- 99% of physicians and 97% of nurses report brief validated screening tools do not interfere with patient care
- Reduces stigma by providing care in familiar, destigmatized environment 4
Follow-Up and Monitoring Structure
Establish systematic follow-up based on risk stratification: 1
- High-risk patients: Periodic reevaluation at 12-24 months, 3-5 years, and 11-12 years of age
- Low-risk patients: Heightened surveillance at every medical home visit
- Patients with identified concerns: Referral for formal developmental and medical evaluation with early intervention services
- Continue developmental surveillance at every well-child visit regardless of risk level
Referral Criteria
Make referrals for comprehensive evaluation when: 1
- Screening tools identify potential delays or concerns
- High-risk stratification at initial visit or periodic reevaluation age
- Failed heightened developmental surveillance
- Behavioral or mental health concerns identified by screening
- Inadequate support system or inability to receive adequate monitoring
Common pitfall to avoid: Parents and patients may be hesitant to mention behavioral problems during routine follow-up, so directly question them about these concerns rather than waiting for them to volunteer information 1
Documentation for Billing
Structure documentation to support appropriate CPT coding by including: 1
- Time spent in evaluation and management
- Complexity of medical decision-making
- Number of problems addressed
- Amount and complexity of data reviewed
- Risk of complications or morbidity
The chronic care model applies: Recognize ADHD and other behavioral health conditions as chronic conditions, treating children as youth with special health care needs requiring ongoing management 1