Universal Mental Health Screening in Pediatric Primary Care: A Systematic Review

doi:10.1016/j.jaac.2013.08.013

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 52, Issue 11, November 2013, Pages 1134-1147.e23

https://doi.org/10.1016/j.jaac.2013.08.013 Get rights and content

Objective

Universal mental health screening in pediatric primary care is recommended, but studies report slow uptake and low rates of patient follow-through after referral to specialized services. This review examined possible explanations related to the process of screening, focusing on how parents and youth are engaged, and how providers evaluate and use screening results.

Method

A narrative synthesis was developed after a systematic review of 3 databases (plus follow-up of citations, expert recommendations, and checks for multiple publications about the same study). Searching identified 1,188 titles, and of these, 186 full-text articles were reviewed. Two authors extracted data from 45 articles meeting inclusion criteria.

Results

Published studies report few details about how mental health screens were administered, including how clinicians explain their purpose or confidentiality, or whether help was provided for language, literacy, or disability problems. Although they were not addressed directly in the studies reviewed, uptake and detection rates appeared to vary with means of administration. Screening framed as universal, confidential, and intended to optimize attention to patient concerns increased acceptability. Studies said little about how providers were taught to explore screen results. Screening increased referrals, but many still followed negative screens, in some cases because of parent concerns apparently not reflected by screen results but possibly stemming from screen-prompted discussions.

Conclusions

Little research has addressed the process of engaging patients in mental health screening in pediatric primary care or how clinicians can best use screening results. The literature does offer suggestions for better clinical practice and research that may lead to improvements in uptake and outcome.

Section snippets

Search Strategy

PubMed, PsycInfo, and EMBASE were searched for studies of universal mental health screening in pediatric primary care in developed countries. A research librarian and an expert in systematic reviews were consulted on database selection and search term development. Terms were identified using each database's controlled vocabulary and other key words within 4 domains: mental health, children, primary care, and screening. Three authors (K.F., L.W., and R.Z.) came to consensus on the final terms

Results

Initial searches produced 1,263 titles of possible relevance (Figure 1). Of these, we screened the 1,188 unique titles and abstracts. Review of these titles and abstracts, plus searches for articles possibly related to those found to be in range, resulted in a preliminary review of 186 full-text articles. The final narrative synthesis included 45 articles describing 38 studies. The most common reasons for exclusion after full-text review were that the article was a review article without

Discussion

For mental health screening to succeed, respondents must be willing to divulge potentially sensitive information and agree to its meaning and validity. This review found that current use in primary care, at least as reflected in the contents of published reports, places little emphasis on steps that would make this possible. Published reports give little explanation of how the purpose of screening is explained or what youth are told about who will have access to the information. Assistance with

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Utilizing screening as a trauma-responsive approach in pediatric health care settings
2024, Current Problems in Pediatric and Adolescent Health Care
Given the widespread impact of child trauma, it is important that child- and family-serving systems adopt trauma-informed care. Because of their integral relationships with families, pediatricians and family medicine physicians play critical roles in disrupting negative societal and developmental cascades for trauma-exposed youth through their potential for early identification and intervention. When implemented alongside organization-wide trauma-informed care practices, trauma screening is one concrete trauma-informed care practice that has shown both feasibility and positive impacts on pediatric healthcare. In support of this practice, the Care Process Model for Pediatric Traumatic Stress (CPM-PTS) helps pediatric care providers to identify and respond to children and adolescents who may need trauma-focused supports. In this paper we discuss the importance of pediatric physicians adopting trauma-informed care and how evidence-based screening practices in pediatric settings is a trauma-responsive approach with great potential for meeting unmet needs among trauma-exposed children and families.
Psychometric properties of the Distress Questionnaire-5 (DQ5) for measuring psychological distress in adolescents
2024, Journal of Psychiatric Research
Screening for psychological distress may assist in identifying at-risk adolescents. While several measures of adolescent psychological distress have been used, most have limited or suboptimal psychometric properties. This study aimed to assess the psychometric properties of the Distress Questionnaire-5 (DQ5), a brief measure of psychological distress, in a large community-based sample of adolescents. Data for the study (n = 3117) were drawn from the baseline and 6-week follow-up assessments of the Future Proofing Study, which collected data from three cohorts of Year 8 students (M = 13.9 years; 48% female) between August 2019 and May 2022. Participants completed the DQ5 at each measurement occasion, as well as measures of depression, generalised and social anxiety, and suicidal ideation. The DQ5 had good fit to a unidimensional construct, with standardised factor loadings ranging between 0.69 and 0.90. The scale had strong criterion (AUC ranged from 0.84 to 0.93) and predictive (AUC ranged from 0.81 to 0.87) validity when compared against indicators for depression, generalised anxiety, social anxiety and suicidal ideation. The DQ5 cut-point of ≥14 had 80% sensitivity and 90% specificity for identifying adolescents meeting symptom thresholds for any of the assessed mental health conditions. Changes in DQ5 scores over 6 weeks had moderate associations with changes in other symptom scales, suggesting sensitivity to change. In conclusion, the DQ5 demonstrates strong psychometric properties and is a reliable measure of psychological distress in adolescents. Given its brevity and ease of interpretation, the DQ5 could be readily used in schools to screen for psychological distress in students.
Preferences and experiences of pediatricians on implementing national guidelines on universal routine screening of adolescents for major depressive disorder: A qualitative study
2023, Comprehensive Psychiatry
To explore the preferences of pediatricians for key factors around the implementation of universal routine screening guidelines for major depressive disorder in adolescent patients in a primary care setting.
Semi-structured qualitative interviews were conducted with U.S. pediatricians. Participants were recruited by convenience sampling and snowball sampling. Qualitive data were summarized using thematic analysis to identify themes relevant to preferences around implementing screening strategies for adolescent patients. Recruitment ended upon reaching thematic saturation when no new themes were revealed.
Of the 14 participants, 11 identified as female, 3 male, 10 white, and 4 Asian. Top themes among pediatrician participants were around the screening modality (14/14 participants), screening validity (14/14), time barriers (14/14), and confidentiality barriers (12/14). Less frequently mentioned themes by pediatricians were workplace coordination and logistics (7/14), alternative starting ages for screening (7/14), more frequent screenings than annual screenings (3/14), and additional clinical training regarding depression diagnosis and treatment (2/14).
Pool of interviewed participants was limited by diversity in terms of geography, race/ethnicity, or practice settings.
To promote the uptake of universal routine screening of adolescent major depression, pediatricians expressed it was important to address key implementation factors regarding the screening modality, screening validity, time constraints, and confidential care concerns in a primary care delivery context. Findings could be used to inform the development of implementation strategies to facilitate depression screening in primary care. Future research is needed to quantitively assess decisions and tradeoffs that pediatricians make when implementing universal screening to support adolescent mental health.
Clinical Update: Child and Adolescent Behavioral Health Care in Community Systems of Care
2023, Journal of the American Academy of Child and Adolescent Psychiatry
Citation Excerpt :
These services can encompass BH education for and consultation to PCPs and other members of the primary care team, positive parenting programs, universal BH screening, targeted BH assessment, patient/family engagement in BH services, management of psychotropic medications as indicated, provision of or referral to psychotherapy as indicated, crisis management, and referral to specialty BH care for severe/complex/treatment unresponsive/unsafe presentations. These primary care−based services have been found in an emerging body of research to be needed, acceptable, feasible, and effective in achieving a range of positive BH outcomes, and to be scalable to large populations of youth.102-110 For a current comprehensive review of BH services in pediatric primary care, see the AACAP Clinical Update on Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care.111
The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of community systems of care as they pertain to the delivery of behavioral health care to children and adolescents
A search of the literature on this topic from 2002 was initially conducted in 2016 and repeated in 2019 and 2021, yielding 1,604 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 1,684 total citations, of which 1,184 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 156 based on relevance to the topic.
The systems of care approach, arising in the 1980s, expanded child and adolescent behavioral health care from the core services of psychotherapy, medication management, inpatient psychiatric services, and residential treatment to include home- and community-based treatment and support services; promotion, prevention, and early intervention programs; and specialized services for very young children and youth and young adults of transition age. These services and supports are delivered by a large multidisciplinary workforce and are governed by key principles, including a biopsychosocial case conceptualization; family-driven, youth-guided, strengths-based, and trauma-informed care. Services in the least restrictive setting; continuity of care across transitions; a public health framework for service delivery; promotion of wellness and resilience; and elimination of health disparities. Challenges to systems of care implementation include funding availability, workforce shortages, deficiencies in cross-systems collaboration, and variability in insurance coverage. Although controlled studies have failed to provide convincing evidence of favorable outcomes from the whole systems of care approach, uncontrolled research has demonstrated increased access to care, positive clinical and functional outcomes, improved family functioning, and reductions in costs, particularly when research is focused on specific behavioral health problems, specific interventions such as Wraparound care, or highly specified groups of youth.
Health professionals who are educated in the systems of care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.
Prevalence and Co-Occurrence of Developmental and Emotional-Behavioral Problems in Young Children
2023, Academic Pediatrics
A limited number of studies have estimated the prevalence of emotional-behavioral disorders among young children. None have assessed their co-occurrence with developmental delays using standardized assessment tools. Our objective was to estimate the prevalence of emotional-behavioral disorders and their co-occurrence with developmental delays among young children (2–5.5 years).
Parents of young children (N = 987) enrolled from pediatric waiting rooms completed developmental-behavioral screening questionnaires. Based on results, 585 families were invited to and 439 completed evaluations that included structured diagnostic interviews with parents to assess child psychopathology (Preschool Age Psychiatric Assessment (PAPA)), developmental testing with children (including the Bayley Scales of Infant and Toddler Development, third Edition for children ≤ 42 months; Differential Ability Scales, second Edition for older children), and videotaped observation to establish whether autism risk was sufficient to warrant further evaluation.
According to PAPA algorithms, 23.0% of children met criteria for a DSM-IV disorder, while 9% qualified for a developmental delay. Presence of delay doubled the odds of having a DSM-IV disorder (OR = 2.1; CI: 1.02–4.3), and presence of disorder doubled the odds of having a moderate-to-severe developmental delay (OR=2.0; CI: 1.10–3.50). Prevalence of DSM-IV disorders (48.8% (95% CI: 33.5–64.5%)) and developmental delays (57.5% (95% CI: 41.7–71.9%)) were both higher among children at risk for autism. While developmental delay did not vary by race/ethnicity, prevalence of DSM-IV disorders was lower among African-American/Black (10.6%; CI: 2.9–18.3) and Hispanic/Latino children (11.1%; CI: 4.3–17.9).
Developmental delays and emotional-behavioral disorders among young children seen in pediatric settings are characterized by high prevalence and substantial co-occurrence.
Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care
2023, Journal of the American Academy of Child and Adolescent Psychiatry
The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of collaborative mental health care in the pediatric primary care setting.
A search of the literature on this topic from 2001was conducted initially in 2016, yielding 2,279 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 2,467 total citations, of which 1,962 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 219 based on topic relevance. A follow-up search from 2016 was conducted in 2021, yielding 2 additional citations based on nonduplication from initial search and topic relevance.
The collaborative care approach, arising in the 1990s and gaining momentum in the 2000s, aims to extend behavioral health care to the primary care setting. The goal of collaborative care is to conserve the sparse specialty care workforce for severe and complex psychiatric disorders through shifting certain specialty mental health tasks (eg, assessment; patient self-management; brief psychosocial intervention; basic psychopharmacology; care coordination) to primary care. Collaborative care can be delivered on a spectrum ranging from coordinated to co-located to integrated care. Although each of these models has some empirical support, integrated care—a multidisciplinary team-based approach—has the strongest evidence base in improving clinical outcomes and patient satisfaction while constraining costs. Challenges to integrated care implementation include insufficient mental health education and insufficient specialist consultative and care coordination support for primary care practitioners; space, time, and reimbursement constraints in the primary care setting; discomfort among primary care practitioners in assuming mental health tasks previously undertaken by specialists; and continuing need for and unavailability of ongoing specialty mental health care for severe and complex cases. Essential supporting activities for effective collaborative care include patient and family engagement, professional education and training, evaluation/demonstration of impact, fiscal sustainability, and advocacy for model dissemination.
Health professionals who are educated in the collaborative care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

View all citing articles on Scopus

: This article is discussed in an editorial by Dr. Michael S. Jellinek on page 1131.

: Clinical guidance is available at the end of this article.

: This work was supported by the National Institute of Mental Health (NIMH) grant P20 MH 086048.

: The authors gratefully acknowledge the guidance of Andrea Villanti, Ph.D., and Donna Hesson, M.L.S., of the Johns Hopkins School of Public Health for guidance with systematic literature review methods.

: Disclosure: Drs. Wissow, Brown, Fothergill, Gadomski, Hacker, and Salmon, and Ms. Zelkowitz report no biomedical financial interests or potential conflicts of interest.

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ReviewUniversal Mental Health Screening in Pediatric Primary Care: A Systematic Review

Objective

Method

Results

Conclusions

Section snippets

Search Strategy

Results

Discussion

Acad Pediatr

Acad Pediatr

J Adolesc Health

Ann Epidemiol

J Am Acad Child Adolesc Psychiatry

Acad Pediatr

J Pediatr

J Adolesc Health

J Pediatr Health Care

Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status

Am J Psychiatry

Psychiatric disorders in adolescents in primary care

Br J Psychiatry

Policy statement—the future of pediatrics: mental health competencies for pediatric primary care

Pediatrics

Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement

Pediatrics

Behavioral health screening policies in Medicaid programs nationwide

Psychiatr Services

Primary care pediatricians' roles and perceived responsibilities in the identification and management of maternal depression

Pediatrics

Improving recognition of adolescent depression in primary care

Arch Pediatr Adolesc Med

Increases in behavioral health screening in pediatric care for Massachusetts Medicaid patients

Arch Pediatr Adolesc Med

Adolescent behavioral risk screening and use of health services

Admin Policy Ment Health

Mental health screening in pediatric practice: factors related to positive screens and the contribution of parental/personal concern

Pediatrics

Setting the stage for success: implementation of developmental and behavioral screening and surveillance in primary care practice—the North Carolina Assuring Better Child Health and Development (ABCD) project

Pediatrics

Screening for behavioral health problems in primary care

Curr Opin Pediatr

Screens and doors: the management of adolescent depression in primary care

Arch Pediatr Adolesc Med

Detecting emotional disorders in young people in primary care

Curr Opin Psychiatr

Psychiatric diagnosis—is it universal or relative to culture?

J Child Psychol Psychiatry

Requests, blocking moves, and rational (inter)action in survey introductions

Am Sociol Rev

Answering autobiographical questions: the impact of memory and inference on surveys

Science

Epidemiology

Improving colorectal cancer screening in primary care practice: innovative strategies and future directions

J Gen Intern Med

Organizing care for patients with chronic illness

Milbank Q

Assessment of young children's social-emotional development and psychopathology: recent advances and recommendations for practice

J Child Psychol Psychiatry

Screening and case finding instruments for depression (review)

Cochrane Database Syst Rev

Screening and case-finding instruments for depression: a meta-analysis

Can Med Assoc J

Screening and identification in pediatric primary care

Behav Modif

Evaluation of the Patient Health Questionnaire-9 item for detecting major depression among adolescents

Pediatrics

Screening, triage, and referral of patients who report suicidal thought during a primary care visit

Pediatrics

Use of the pediatric symptom checklist in strategies to improve behavioral health care

Psychiatr Services

Behavioral health screening in urban primary care settings: construct validity of the PSC-17

J Dev Behav Pediatr

Review
Universal Mental Health Screening in Pediatric Primary Care: A Systematic Review