Behavioral and mental health screening tools for pediatric primary care providers

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In 2021, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association jointly declared a national emergency in child and adolescent mental health,¹ followed by a public health advisory issued by the United States Surgeon General.² Although the COVID-19 global pandemic ushered in new health challenges, the status of youth mental health had been declining for more than a decade prior with rising rates of anxiety, depression, and suicide.³ Public dialogue surrounding issues of mental health has also evolved, with rising awareness and decreasing stigma. This brings unprecedented opportunity for pediatric healthcare professionals to engage in efforts to improve health outcomes through early identification and intervention.

The National Association of Pediatric Nurse Practitioners called to prioritize integrating pediatric mental health into primary care, with specific practice recommendations.⁴ Improving access to care in this way adopts a holistic approach that facilitates continuity of care by minimizing fragmentation of care, and decreasing wait times for referral, and cost barriers associated with specialty care. Pediatric primary care providers are well-positioned to provide timely care for families from a trusted source.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a strategy being more widely adopted in pediatric primary care. Because symptoms of mental health disorders can present across physical, behavioral, and cognitive domains, it is important to help families differentiate normal emotions in the spectrum of the human experience from early emergence of signs of concern to diagnosable disorder. Pediatric primary care providers are well-situated to initiate health screenings. Integration of mental health screening is an essential first step in this process and should use validated, reliable scales.

Motivational interviewing and cognitive behavioral therapy

Motivational Interviewing can help facilitate a patient-centered approach during screenings that fosters open communication, self-reflection, and readiness for change by engaging children and families in a supportive, nonjudgmental dialogue. It can reduce resistance to mental health interventions by engaging with empathy, reflective listening, and collaborative goal-setting to encourage positive behavioral changes.

When mental health screenings indicate signs of concern but do not yet rise to the level of diagnosable disorder, early intervention strategies can include family-centered behavioral interventions, coaching to promote positive parenting, and pragmatic supports such as education resources (e.g. Individualized Education Plan or 504), financial supports (e.g. government assistance, Children’s Health Insurance Program), employer assistance programs, community and peer connections, and legal and advocacy services, among others.

Cognitive Behavioral Therapy (CBT) is a structured, evidence-based response paradigm that helps children and teens manage anxiety and depression by identifying and challenging negative thought patterns and developing healthier coping strategies. It improves emotional regulation and resilience by teaching skills such as problem-solving, relaxation techniques, and gradual exposure to feared situations and is considered the gold standard of treatment in treating pediatric anxiety.⁵ The COPE (Creating Opportunities for Personal Empowerment) program is an evidence-supported CBT program that has demonstrated efficacy in primary care delivery as well as estimated cost savings of $14,262 for every hospitalization prevented.⁶

National network of child psychiatry access programs

Primary care clinicians should be aware of the National Network of Child Psychiatry Access Programs (NNCPAP).⁷ This initiative helps primary care providers in 49 states and several United States territories quickly connect with child psychiatrists for guidance on mental health care. Potential service connections include phone consults, patient care coordination or referral services, telehealth consultations, and free education for primary care providers to enhance preparedness to recognize and respond to mental health symptoms of concern.

The pediatric mental health specialist

The Pediatric Mental Health Specialist (PMHS) certification offers a pathway for Advanced Practice Registered Nurses (APRNs) who are already licensed to practice in their state and nationally certified in designated population foci to advance their education and training to meet pediatric mental health needs in primary care.⁸ It is estimated that enrollment in Pediatric Mental Health Nurse Practitioner (an APRN specialty that manages mental health across the lifespan) has grown by more than 1,000% in the last decade, demonstrating a demand for increased access to mental health care.⁹ In the face of continued dramatic shortages of child and adolescent psychiatrists, commercial insurers are working to equip pediatricians to create formal pathways to partnerships between primary and specialty care.¹⁰

Challenges remain in mental health integration into primary care including education resources and training for providers, reimbursement in integrated care models, time constraints, stigma in seeking care, and misinformation available in the public sector. However, integrating pediatric mental health into primary care by initiating mental health screening is a crucial step toward ensuring early intervention, improving access to care, and fostering healthier futures for children and families.

Mental and behavioral health screening tools

Age-appropriate mental health screening tools are easily accessible for use by pediatric primary care providers (PCP) when available on a drop-down menu in the electronic medical record (EMR). Completion of age-appropriate screening tool(s) at the beginning of each well-child health care visit provides essential information for the PCP to continue with a more detailed assessment of the mental health status while interacting with our pediatric populations and parents throughout the physical exam. A variety of screening tools are available from the prenatal period to young adulthood. When these tools are routinely administered, PCPs can quickly identify potential and actual behavioral and mental problems and can design an individualized treatment plan at that visit.

Evidence-based screening tools

Edinburgh Postpartum Depression Screening

Postpartum depression is one of the most common complications of pregnancy. One in every 8 women in the United States experience postpartum depression.¹¹ A 2010 clinical report from the American Academy of Pediatrics (AAP) described the need for assessing postpartum women in pediatric primary care offices for depression.¹² In 2019, the AAP recommended screening postpartum women in pediatric primary care offices using the Edinburgh postnatal depression scale (EPDS) at their infants 1, 2, 4, and 6-month-old routine health care visits.¹³ In 2022, Lamere and Golova conducted a statewide quality improvement project that included 224 postpartum women to evaluate the impact of routine screening for postpartum depression using the EPDS at well-child visits.¹⁴ Study results showed that women with a history of a prior mental health condition and women who experienced food and/or housing insecurity had a statistically significant higher rate of screening positive on the EPDS.¹⁴ Thus, it was and remains an essential role for pediatric primary care providers (PCPs) to screen women for postpartum depression to identify and refer the women for treatment to protect not only themselves and the infant.

The EPDS is a self-reported response to a 10-item scale that measures symptoms of depression and has been validated for use during the prenatal and postpartum periods.¹⁵ A total score of 10 or higher on the EPDS identifies the woman as at risk for depression.¹⁵ The role of the pediatric PCP is to make an immediate referral to either her Obstetrician, primary care provider, or mental health specialist. The PCP should make a follow-up phone call to ensure that the infant's mother has scheduled an appointment. Repeat screening with the EPDS at the next infant well-child appointment should be completed, and documented, and if necessary, recommendations for follow-up with the woman’s providers should be discussed.

Infant/toddler/preschooler

The following tools are available for screening infants, toddlers, and preschool-age children for use in office-based practices. We selected screening tools that are evidence-based and available for free to use in pediatric practices.

Survey of Wellbeing in Young Children (SWYC)

The Survey of Well-being of Young Children (SWYC) is available for free as a set of comprehensive screening instruments for children under 5 years old.¹⁶ The SWYC was developed by professors at Tufts University School of Medicine, Drs. Ellen Perrin, Chris Sheldrick, and Kate Mattern. Numerous age-specific forms are available for parents to complete which enable PCP to assess the behavior of children under 5 years old, their development, parent concerns, and family questions.¹⁶ In the developmental domain, all parents complete a checklist that assesses their child’s developmental milestones. There are 10 questions the parents respond to concerning their child's motor skills/development, language, as well as their child’s social and cognitive development.¹⁶ The number of questions asked on each of the tools makes the checklist parent-friendly.

The SWYC also has a milestone calculator in which infants at 1-month, 0 days to 3 months can be assessed with the 2-month-old form.¹⁶ The SWYC has sequential forms that mirror the routine child health care visits from 2 months old through the age of 60 months which assess children from 59 months 0 days to 65 months, 31 days old, labeled the 60-month form. These forms are found on the SWYC website labeled ‘Age-Specific Forms’.¹⁶

The SWYC also has a Baby Pediatric Symptom Checklist (BPSC), the Preschool Symptom Checklist (PPSC), and the Parent’s Observations of Social Interactions Checklist (POSI).¹⁶ The parents complete these brief forms and the PCP can assess the emotional, and behavioral status of the child.

While the creators encourage the use of their tools, they discourage any changes to their work, since their research is ongoing and evidence-based. They welcome feedback from users directly on their website. They are encouraging direct translation of their work into other languages and thus far the forms have been translated into 13 languages.¹⁶ A manual and provider resources for providers are also available on the SWYC website.¹

Brief Infant/Toddler Emotional Assessment

The Brief Infant-Toddler Social and Emotional Assessment (BITSEA) is a 42-item questionnaire, which takes about 6 minutes to complete. There are two forms, a parent form and a provider form National Child Traumatic Stress Network (NCTSN).¹⁷ It was designed and validated as an early detection screening tool for toddlers between 12 to 36 months old.¹⁸ A validation study that included 2060 toddlers revealed that the BITSEA problem scale differentiated toddlers with and without psychosocial problems.¹⁷ The BITSEA-parent form is available for free on the (NCTSN) website (https://www.nctsn.org/ ).¹⁷ In integrated pediatric primary care/mental health care practices, the BITSEA is a valuable screening tool when the history reveals that the toddlers' social and emotional development is outside of the expected norms. Toddlers who screen positive are then further tested with the Infant Toddler Social Emotional Assessment (ITSEA) tool by the mental health provider. For practices without an integrated model, the PCP who uses the BITSEA would refer the toddler for further behavioral and mental health assessments and treatment.

Modified Checklist for Autism in Toddlers- Revised and

Modified Checklist for Autism in Toddlers- Revised-Follow up

The (M-CHAT-R) has been used to screen toddlers for autism for several years. In 2017, Campbell and colleagues conducted a quality improvement (QI) study to improve the quality of screening for toddlers to assess for symptoms of autism.¹⁹ The QI team implemented a digital version of the Modified Checklist for Autism in Toddlers-Revised with Follow-up (M-CHAT-R/F) in an academic pediatric primary care clinic setting. Physicians who participated in the clinical portion of the study completed both pre and post-intervention surveys to determine changes in attitudes towards the feasibility and value of screening toddlers for identification of symptoms and referral for further evaluation of an autistic spectrum disorder (ASD).¹⁹ Documentation of the screening results in the EMR increased from 54% to 92%. Management of children who screened positive on the M-CHAT-R/F increased from 25% to 85%.9 Ninety percent of the physicians who participated in the study reported that the digital screening form improved their clinical assessment of the risk of autism.¹⁹

In 2023, Aishworiya and colleagues reported the results of a meta-analysis on the M-CHAT-R/F as a screening tool for ASD from a global sample that involved different countries, including the United States, and individuals who spoke eight languages.²⁰ Fifteen studies were included in the meta-analysis.²⁰ Study results showed that the sensitivity was 82.5% which indicates that the M-CHAT-R/F is a good screening tool.²⁰ The authors concluded that their meta-analysis supported the M-CHAT-R/F as a screening questionnaire for ASD. Furthermore, the data revealed that a positive screen on the M-CHAT-R/F is predictive of a diagnosis of ASD in approximately 50% of toddlers.²⁰ An important additional finding was that the M-CHAT-R/F was predictive of a toddler having any developmental disorder in about 90% of the toddlers screened.²⁰ Thus, screening with the M-CHAT-R/F plays a significant role in assessing toddlers not only for autism, but also for other developmental disorders based on findings from a comprehensive history and physical examination, and further appropriate screenings.

School-age Children

Pediatric Symptom Checklist and Youth-Pediatric Symptom Checklist

School-aged children can be assessed for psychosocial concerns as part of the routine screening during annual well-child visits using the Pediatric Symptom Checklist (PSC).²¹ The PSC is an easy-to-use tool for the assessment of cognitive, emotional, and behavioral problems in school-aged children and young adolescents. The PSC checklist has two versions one for the parent to complete (PSC) and one for the child to complete as a self-report about themselves (Y-PSC). For the child to accurately complete the Y-PSC checklist, it is recommended that the (pre)-adolescent be 11 years old or older, be able to read the checklist, or be willing to have one of the nurses or health care providers read the checklist to the child to obtain accurate and useable data. Parents should not be asked to read the Y-PSC to their child since the child may be concerned about answering those questions which would invalidate the checklist results.

Both the PSC and the Y-PSC each contain 35 questions. Responses to each of the questions are ‘never’, ‘sometimes’, or ‘often; and scored as zero, one, or two, respectively. Scoring for the PSC and Y-PSC are available in the instructions for the use of the tools.²¹ Data from administration of the PSC and Y-PSC studies show that two out of three children and/or adolescents who screen positive will display behavioral and psychological problems at the moderate to serious level of impairment.²¹

Consistent with all screening tools, if the score on the PSC and/or the Y-PSC indicates a need for further evaluation, the PCP should make a referral to a behavioral mental health specialist. Given the current mental health crisis among youth and long waits for appointments, HCPs may consider referring school-age children and adolescents with identified behavioral and mental health problems for further evaluation services in the school health centers by a psychologist, a physician, or a nurse practitioner.

School-age and Adolescent Anxiety Screening Tool

The Screen for Child Anxiety-Related Emotional Disorders (SCARED)

The SCARED tool has been used in pediatric clinical practice to assess children for anxiety. There is both a parent and child version of the SCARED tool (SCARED-P and SCARED-C).²² Each tool consists of 41 items that were designed to assess a child's recent anxiety symptoms. A three-point Likert scale of 0, indicating not true or hardly ever true, one (1) indicating somewhat or sometimes true, and two (2) indicating very true or often true.²²

In 2019, four authors from the Division of Emotion and Developmental Branch of the National Institute of Mental Health studied informant discrepancy between parent and child on the SCARED tool.²² The study examined 1092 anxious youth, ages 7 to 18 years old, and healthy parent-child dyads.²² The study was rigorously conducted and included test-retest reliability on a subset of the parent-child dyads. Overall study findings revealed that parents report fewer symptoms than their children with the child’s anxiety level more noticeable when the child entered the study with a diagnosis of anxiety.²² Based on the study findings, the researchers suggested combining the parent-child scores to better understand the anxiety experiences.²² Best practices forthe use of screening tools, including the SCARED tool, is to refer the child who screened positive for anxiety for a complete behavioral and mental health examination to identify the best available evidence-based treatment plan for the individual child and family as a whole.

Adolescent/young adults

Patient health questionnaires: PHQ-2 and PHQ-9

There are a variety of screening tools that are available for the variety of problems adolescents and young adults encounter in their daily lives. Pediatric providers are familiar with the Patient Health Questionnaires (PHQ), the PHQ-2 which screens for depression with two Yes/No questions.²³ If the answer to either or both questions is yes, it is a positive screen and the HCP immediately screens using the PHQ-9, which contains 9 questions. The PHQ-9 screen has responses scored as 0 = Not at all; Several days = 1; more than half the days = 2; and Nearly every day = 3. Scores between 5 and 9 require close monitoring and may benefit from a referral for further assessments of depression and therapy. Scores greater than 9 indicate that the adolescent/young adult has screened positive and needs an assessment from a mental health specialist for assessment and treatment planning.²³ The PHQ-2 and PHQ-9 are reliable screening tools for depression and the best practice is to include the tools on the EMR dropdown menu for all well adolescent/young adult health care visits. Missing the diagnosis of depression has a high possibility of leading to the use of drugs or alcohol, eating disorders, and places the adolescent/young adult at risk for suicide.

CRAFFT, CRAFFT 2.1, CRAFFT 2.1+N screening tools

The CRAFFT tool is a valid and reliable substance use screening tool for adolescents/young adults between the ages of 12 and 21 years old.²⁴ Many HCPs are familiar with the CRAFFT tool and have used the tool in primary care offices for years. There are many advantages to using the CRAFFT tool including but not limited to being readily accepted by adolescents as a screening tool for high-risk behaviors such as riding in a car or driving a car while under the influence of illicit substances, substance use, and substance use disorders. The CRAFFT tool is evidence-based and has shown to be valid for adolescents from various socioeconomic and ethnically diverse backgrounds.²⁴ The CRAFFT and the CRAFFT 2.1 and CRAFFT 2.1+ N can be self-administered or provider administered, however, the recommendation from the researchers is to provide the opportunity for the adolescent to self-administer the tool just before the health care visit.²⁴

While many providers use the CRAFFT tool regularly in their offices, many may not know about the two new versions of the tool, specifically, the CRAFFT 2.1 and CRAFFT 2.1+N.²⁴ The CRAFFT 2.1 has been revised to include vaping with marijuana.²⁴ The CRAFFT 2.1 provides clinical talking points for the provider to talk with the adolescent using scientifically validated communication skills. The CRAFFT 2.1+N now contains more questions about tobacco and nicotine use.²⁴ Both of the new tools are available on the website for free use in clinical practices (https://crafft.org/get-the-crafft/). The CRAFFT tools and the website are examples of the integration of research and evidence-based practices directly into clinical practice to improve the overall health and well-being of the adolescent and young adult populations.

Ask Suicide-Screening Questions (ASQ) and toolkit

The Ask Suicide Screening Questions is a 20-second assessment that can be administered in a variety of health care settings to ascertain suicide risk in patients. Data shows that children, adolescents, and young adults between the ages of 10 years and 24 years old represent 15% of all suicides²⁵ Suicide is the second leading cause of death in the 10- to 24-year-old age group.²⁶ There are opportunities for HCPs to reduce the high suicide rate by connecting with children, adolescents, and young adults who are seen in an emergency department for self-harm behaviors. Post-ED visit follow-up in the primary care office offers the opportunity to talk with the individual and family members to create a plan to help the individual and to make referrals to mental health care specialists.

The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a toolkit that provides information on how to administer the Ask Suicide Screening Questions tool and ways to respond to the adolescent about the screening test results.²⁷ The toolkit is available free on their website.²⁷ (https://www.samhsa.gov/resource/dbhis/ask-suicide-screening-questions-asq-toolkit ). HCPs should consider having a nurse be an Office Based Champion for Suicide Prevention. This toolkit should be available in the primary care offices to standardize the care of those who have experienced harmful behaviors and those who have expressed suicidal thoughts or attempted suicide.

Discussion

A variety of age-appropriate screening tools have been presented that enable HCPs to identify behavioral and mental health problems at the earliest onset of symptoms. HCPs should evaluate their office practices to include screening tools as part of the dropdown menu on the EMR. Many of these screening tools provide valuable information for HCPs to design treatment plans that improve the behavioral and mental health status of children, adolescents, and young adults whose screen is positive on an age-appropriate screening tool. In addition, referrals to mental health specialists should be made to prevent harm and or attempted or completed suicides in the pediatric populations.

References

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