Promoting Optimal Development: Screening for Behavioral and Emotional Problems

Behavioral and emotional problems during childhood are common, often undetected, and frequently not treated despite being responsible for significant morbidity and mortality. By current estimates, approximately 11% to 20% of children in the United States have a behavioral or emotional disorder at any given time.^1,2 Estimated prevalence rates are similar in young 2- to 5-year-old children. Developmental and behavioral health disorders are now the top 5 chronic pediatric conditions causing functional impairment.^3,4 Even greater numbers of children have behavioral or emotional problems causing impairment or distress that do not meet criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition for a disorder. The purpose of this report is to provide pediatricians with a rationale for and guidance to implement screening for behavioral and emotional problems in primary care settings. However, in evaluating and promoting optimal child development and well-being, the domains of development and behavior must be considered together within the context of the family. These domains are not separate constructs but rather parts of a whole. Therefore, this report emphasizes that behavioral screening must always be 1 component of a comprehensive developmental and behavioral screening program that extends through childhood and adolescence.

It is estimated that 25% to 40% of children with 1 disorder will have at least 1 additional mental health or behavioral diagnosis at a given time.^1,5,6 The most common co-occurring conditions are attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder, but co-occurrence of anxiety and depression is also common.

Between 37% and 39% of children will have a behavioral or emotional disorder diagnosed by 16 years of age, with the most common diagnoses being impulse control/disruptive behavior problems, anxiety, and mood disorders.^1,7,8 Between 23% and 61% of children with a diagnosis at 1 time will have a diagnosis in the future, although it is not always the same diagnosis.¹ 

Approximately 50% of adults with behavioral health problems report that their disorders emerged in early adolescence.⁹ Anxiety disorders and ADHD are the earliest disorders to emerge, often in the preschool and early school-age years, with substance abuse being the latest to emerge. An approximately 2- to 4-year period between symptom appearance and disorder has been demonstrated, suggesting that there may be opportunities for secondary prevention or early intervention.⁶ 

In 2010, more than 1 in 5 children were reported to be living in poverty.^6,10 Economic disadvantage is among the most potent risks for behavioral and emotional problems due to increased exposure to environmental, familial, and psychosocial risks.^11,–13 In families in which parents are in military service, parental deployment and return has been determined to be a risk factor for behavioral and emotional problems in children.¹⁴ Data from the 2003 National Survey of Children’s Health demonstrated a strong linear relationship between increasing number of psychosocial risks and many poor health outcomes, including social-emotional health.¹⁵ The Adverse Childhood Experience Study surveyed 17 000 adults about early traumatic and stressful experiences. Two-thirds of respondents experienced at least 1 type of childhood psychosocial risk, and 20% experienced more than 3. Adverse early experiences were related to increased rates of health problems in adulthood including obesity and cardiovascular disease as well as substance abuse, mental health problems, and poor health-related quality of life. As the Adverse Childhood Experience Study score increased, so did the number of risk factors for the leading causes of death.^16,17 Shonkoff uses the phrase “toxic stress” to describe high cumulative psychosocial risk in the absence of supportive caregiving^18,19; this type of unremitting stress ultimately compromises children’s ability to regulate their stress response system effectively and can lead to adverse long-term structural and functional changes in the brain and elsewhere in the body. The 2012 American Academy of Pediatrics (AAP) Policy Statement “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health” advocated viewing the causes and consequences of toxic stress from the same perspective as other biologically based health impairments.¹⁹ 

In 2004, the AAP established the Task Force on Mental Health, which “articulated mental health competencies for primary care; developed guidance for addressing systemic and financial barriers to providing mental health care in primary care settings; and provided tools and strategies to assist pediatricians in applying chronic care principles to children with mental health problems.”²⁰ The Task Force also provided guidance (through identifying tools and describing strategies) to providers on adapting current practice to include mental health care. A recent publication articulated an initial blueprint for behavioral and emotional screening in pediatric practice.²¹ The current statement supports the Task Force guidance by providing the evidence supporting screening for emotional and behavioral concerns.

Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the US health system.^6,22,–25 Current estimates suggest that fewer than 1 in 8 children with identified mental health problems receive treatment. Even when a child or adolescent is well known in a pediatric practice, only 50% of those with clinically significant behavioral and emotional problems are detected.²³ Other investigators have found similarly high failure of detection rates ranging from 14% to 40%.^22,24 Surveyed pediatricians, however, overwhelmingly endorse that they should be responsible for identifying children with ADHD, eating disorders, depression, substance abuse, and behavior problems.²⁶ 

Clinicians’ ability to identify developmental and behavioral problems in primary care, on the basis of clinical judgment alone in the absence of a standardized measure, has been shown to have low sensitivity, ranging from 14% to 54% and a specificity ranging from 69% to 100%.²⁷ Providers are less likely to identify problems in minority or non–English-speaking children and adolescents.²⁵ 

In a study of clinicians in more than 200 practices, pediatric providers reported using a standardized measure to assess mental health problems in 20.2% of all visits, with 50.2% of providers reporting never using any formal measure.²⁸ Fewer than 7% of providers reported using a standardized measure during 50% or more of visits.²⁸ 

Pediatricians report a lack of confidence in their training and ability to successfully manage children’s behavioral and emotional problems²⁹ with only 13% of pediatricians reporting confidence.³⁰ Common barriers to adopting new screening practices in pediatrics include lack of time,³⁰ long waits for children to be seen by mental health providers, and lack of available mental health providers to refer children.^31,32 Liability issues have been identified as a barrier to screening and managing children with behavioral and emotional problems. Pediatricians have also raised concerns about the increasing number of mandates outlined in practice guidelines with ever-shrinking time for health maintenance visits as a result of reimbursement pressures.³³ 

Behavioral and emotional screening instruments have many of the same advantages and limitations as developmental screening instruments. They involve a time commitment for parents or guardians to complete and for staff and clinicians to score, interpret, and report the results.³² 

Screening instruments can be used to predict risk of a disorder but do not make the diagnosis. There are global (broadband) scales that may screen for several conditions, and there are domain-specific (single-condition) tools are most useful for screening for a specific problem, such as substance use or adolescent depression and suicidality.³² 

Pediatricians should be aware of the sociodemographic characteristics of populations enrolled in validation studies as they make decisions regarding any screening instruments used. Pediatricians need to consider the literacy and health literacy levels of parents, guardians, children, and adolescents completing screens, whether the instrument should be administered in English or another language, and whether the person completing the screen will need additional help.

Pediatricians should be familiar with the psychometric properties of an instrument and under what conditions reported sensitivities and specificities were obtained.³² Like developmental screening tools, behavioral and emotional screening tools should have a sensitivity and specificity of ≥0.70.³⁴ 

Once the patient is old enough to answer reliably, self-report versions can provide information about feelings not noticed by outside observers, such as those associated with anxiety or depression. Most self-report versions are normed on patients 8 years and older.

The research on behavioral and emotional screening in younger children is more limited than in school-age children, but increasingly, reliable, brief measures suitable for use in primary care exist, and new ones are being developed,^35,36 making it possible to screen children and adolescents from aged 6 months through 18 years of age.

Behavior and emotional screens available in the public domain can be found in Appendix 1.

The policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care” outlined the skills pediatricians need in the area of mental health.³⁷ The AAP Task Force on Mental Health has developed materials to help pediatricians assess their current practice and readiness to change and to code accurately for mental health screening and services.^38,39 The AAP also developed a Web site providing resources and materials free of charge (http://www2.aap.org/commpeds/dochs/mentalhealth/KeyResources.html)⁴⁰ as well as “Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit,”⁴¹ which is available for a fee.

Professional organizations, including the AAP, Society for Developmental and Behavioral Pediatrics, American Academy of Child and Adolescent Psychiatry, and National Alliance on Mental Illness, provide ongoing continuing medical education and resources.

Many barriers to behavioral and emotional screening are similar to those identified when developmental screening was proposed as a regular part of pediatric care. In 2006, the AAP policy statement “Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Screening and Surveillance”⁴² was published. Since the publication of the statement, 44.8% of pediatricians reported using standardized developmental screening tools more often, and 72.2% reported using standardized autism screening tools more often.⁴³ National demonstration projects including the Assuring Better Child Development Screening Academy⁴⁴ and the AAP’s Developmental Surveillance and Screening Policy Implementation Project⁴⁵ achieved high levels of screening in primary care. These projects provided valuable lessons about implementing a screening program (Table 1) and behavioral and emotional screening may follow similar patterns. Similar large-scale initiatives may need to be developed to determine the best practices for implementing a behavioral and emotional screening program.

The following steps and Table 2 are designed to give pediatricians a clear road map to implement behavioral and emotional screening in practice. Although distinct from screening, pediatricians should familiarize themselves with evidence-based programs that have been shown to promote children’s social-emotional development through positive parenting,^46,–51 possibly preventing the emergence of problems.

• 1. Readying the Practice. As was seen in developmental screening, front-end work is needed to train and prepare an office to adopt screening practices. It may be helpful to enlist the assistance of local mental health professionals or developmental-behavioral pediatricians in selecting and implementing screening procedures.

• 2. Identifying Resources. Before initiating a behavioral and emotional screening program, pediatricians need to determine what they will do when a child or parent has a positive screening result. Pediatricians should familiarize themselves with local resources and identify referral sources. In the absence of this, pediatricians are likely to feel frustrated and overwhelmed when they identify children and adolescents in need of services but are unable to find appropriate, high-quality treatment of them. Pediatricians will need to work with the community to advocate for more treatment and intervention services.

Increasing numbers of practices have colocated a mental health provider (eg, psychologist, licensed clinical social worker, licensed therapist) within the practice. These providers are integrated into the practice and can provide timely assistance for behavioral emergencies as well as support the primary care provider in implementing and interpreting the office screening program.

Another model of a successful collaboration program between primary providers and child psychiatrists, the Massachusetts Child Psychiatry Access Project, promotes access to psychiatric consultation for primary care providers through a network of children’s mental health collaboration teams. The overall aim is to improve access to treatment of children with mental health concerns (http://www.mcpap.com/about.asp). This type of program currently is being implemented in more than 30 states.

• 3. Establishing Office Routines for Screening. As with developmental screening, children should be screened at regular intervals for behavioral and emotional problems with standardized, well-validated measures beginning in infancy and continuing through adolescence. Screening beginning in the first year of life can identify disturbances in attachment, regulation, and the parent-child relationship, although the optimal approaches to screening infants and very young children are less clear-cut than screening children at older ages. Ongoing care involves maintaining a good history regarding factors that can influence the early parent-child relationships, such as discipline practice, parenting stress, psychosocial risks, and positive parenting.

Currently, developmental and behavioral/emotional screenings are viewed as separate constructs, and most well-validated measures screen for them independently. Developmental screening is commonly perceived as identifying disordered expressive and receptive language, fine and gross motor skills, self-help skills, and cognitive milestones, whereas behavioral and emotional screening identifies problems in areas including social-emotional regulation, mood and affect, attention, and interpersonal skills. There is a significant yet incomplete overlap between developmental and behavior problems. Studies have revealed that children with cognitive, language, and social impairments and developmental disabilities, in general, are far more likely to manifest behavioral and emotional problems.¹² 

Beginning in early adolescence, screening for substance use should be implemented.^21,52 Substance use and dependence have consistently been found to be 1 of the most prevalent behavioral health diagnoses in adolescents. Identifying and treating a behavioral or emotional problem without detecting and treating co-occurring substance use will likely lead to ineffectual treatment. The US Preventive Services Task Force recommends screening all adolescents (12–18 years of age) for depression, when systems are in place, to ensure accurate diagnosis, treatment, and follow-up.⁵³ Pediatricians should use targeted screening for other problems, such as suicidality or anxiety, if there is concern raised by the provider, patient, or parent or the child is at high risk.

Children’s behavioral and emotional problems are frequently associated with family psychosocial risk. Family psychosocial screening can provide important information about potential protection or lack thereof for a child who may or may not yet show signs of behavioral or emotional problems. Early detection and treatment of family psychosocial risk may potentially avert the emergence of problems in the child. Only a limited number of well-validated screens suitable for use in primary care for broad screening of family psychosocial risk and family support and functioning are available, although a few show promise.^54,–56 There are screening measures for specific psychosocial stressors, such as maternal depression, and these have been shown to be feasible in pediatric settings.^57,58 Family screening for psychosocial risk within pediatric settings, however, raises a number of dilemmas, including concerns about liability and payment and who is responsible for an adult’s well-being after a problem is detected.⁵⁹ 

• 4. Tracking Referrals. If the child was referred for services after screening, it is important for pediatricians to inquire as to whether referrals were completed and services were obtained or understand what barriers parents have experienced and how these can be overcome. Furthermore, it is important for pediatricians, with parental permission, to obtain information from the referral and to learn whether services obtained were effective and whether symptoms in the child have been reduced or eliminated. This follow-up may require a separate office system than screening procedures.

• 5. Seeking Payment. One of the biggest “systems” hurdles facing pediatricians is the difficulty obtaining payment for screening patients for behavioral and emotional problems and for screening families for psychosocial risk and functioning. The adoption of the proposed screening and surveillance practices, may lengthen visit time to discuss results without additional payment to support that time and create significant non–face-to-face work.⁶⁰ This includes referring patients and families to appropriate resources, tracking referrals, communicating with other professionals (which may require reviewing lengthy reports and school plans), and following up with children and families. Overcoming this critical barrier is fundamental to transforming pediatric practice to a medical home model. With the advent of reimbursable billing codes for screening, including Current Procedural Terminology (CPT) codes 96110 and 99420, some practices are beginning to see some financial payment for the addition of screening programs. Additionally, a new CPT code for brief behavioral assessment, 96127, has been included in CPT 2015 to allow the separate reporting of this service.

• 6. Fostering Collaboration. Innovative collaborations have been well described and include colocation and integrated and consultative models, such as the Massachusetts Child Psychiatry Access Project, the North Carolina Chapter AAP/NC Pediatric Society (ICARE), and the Washington Partnership Access Line.^61,–64 Innovative means of consultation and collaboration will continue to evolve with emerging technology.⁶⁵ These relationships help build the capacity of pediatricians to manage various behavioral and emotional problems in the office. This is particularly true for the management of subthreshold problems not meeting the severity level warranted to refer for treatment.

As medical practice continues to shift into more electronic formats, standardized screening instruments will need to be formatted for electronic health record systems, to facilitate a wide implementation of screening. Automating guidelines and scoring of screening measures, providing decision support that is integrated into electronic health records, and providing patients with opportunities for greater participation in their health care via portals into their electronic medical record have already shown promise.^66,67 Paper-and-pencil screening methods will need to be transformed into Web-based versions, smartphone apps, and waiting room tablets to successfully harness available technology.^65,68 These changes will be critical areas needing further evaluation to determine best practices.⁶⁹ Additional system challenges that will need to be addressed are included in Appendix 2.

Evaluating and promoting optimal child development and well-being includes assessing developmental and behavioral domains in the context of the family. Behavioral and emotional problems are common, persistent, and cause significant functional impairment for many children and adolescents. A 2- to 4-year window may exist between initial presentation of symptoms and the development of a disorder, suggesting an opportunity to intervene before problems become more serious in children.⁶ In recent years, many pediatricians have taken advantage of more widely disseminated public domain screening tools and have used emerging computer technology to facilitate behavioral/emotional screening. There have been many examples of colocated practices, and national organizations, such as the AAP, have strongly advocated for payment for these integrated practice models. The lessons learned through developmental screening implementation have been used to make behavioral and emotional screening a more routine component of pediatric health supervision. The investments described in this report, financial and otherwise, are critical to ensure a future of thriving and strong infants, children, and adolescents who will mature into healthy adults.

Carol Weitzman, MD

Lynn Mowbray Wegner, MD

Laura Joan McGuinn, MD

Alan L. Mendelsohn, MD

Patricia Gail Williams, MD

Terry Stancin, PhD

Nathan J. Blum, MD, Chairperson

Michelle M. Macias, MD, Immediate Past Chairperson

Nerissa S. Bauer, MD, MPH

Carolyn Bridgemohan, MD

Edward Goldson, MD

Laura J. McGuinn, MD

Carol Weitzman, MD

Pamela High, MD – Society for Developmental and Behavioral Pediatrics

Susan Levy, MD – Council on Children with Disabilities

Lynn Mowbray Wegner, MD

Linda B. Paul, MPH

Benjamin S. Siegel, MD, Chairperson

Michael W. Yogman, MD, Chairperson-Elect

Thresia B. Gambon, MD

Arthur Lavin, MD

LTC Keith M. Lemmon, MD

Gerri Mattson, MD

Laura Joan McGuinn, MD

Jason Richard Rafferty, MD

Lawrence Sagin Wissow, MD, MPH

Ronald T. Brown, PhD – Society of Pediatric Psychology

Terry Carmichael, MSW – National Association of Social Workers

Jody K. Gurtler – National Association of Pediatric Nurse Practitioners

Mary Jo Kupst, PhD – Society of Pediatric Psychology

Leonard Read Sulik, MD – American Academy of Child and Adolescent Psychiatry

George J. Cohen, MD

Stephanie Domain, MS, CHES

Elaine Donoghue, MD, Co-Chairperson

Danette Swanson Glassy, MD, Co-Chairperson

Mary Lartey Blankson, MD, MPH

Beth A. DelConte, MD

Marian Frances Earls, MD

Dina Joy Lieser, MD

Terri Denise McFadden, MD

Alan L. Mendelsohn, MD

Seth J. Scholer, MD, MPH

Elaine E. Schulte, MD, MPH

Jennifer Cohen Takagishi, MD

Douglas Lee Vanderbilt, MD

Patricia Gail Williams, MD

Abbey D. Alkon, RN, PNP, PhD – National Association of Pediatric Nurse Practitioners

Victoria Chen – Section on Medical Students, Residents, and Fellowship Trainees

Barbara U. Hamilton, MA – Maternal and Child Health Bureau Child, Adolescent and Family Health

Claire Lerner, LCSW – Zero to Three

Stephanie Olmore – National Association for the Education of Young Children

Susan S. Aronson, MD

Jeanne M. VanOrsdal, MEd

Charlotte O. Zia, MPH, CHES

Michelle M. Macias, MD, President

John C. Duby, MD, President-Elect

Marilyn Augustyn, MD, Secretary-Treasurer

Desmond Kelly, MD, Immediate Past President

Carolyn E. Ievers-Landis, PhD

Robert Needlman, MD

Nancy Roizen, MD

Franklin Trimm, MD

Lynn Wegner, MD

Beth Wildman, PhD

Terry Stancin, PhD

Laura Degnon, CAE