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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Promoting Optimal Development:


Screening for Behavioral and Emotional
Problems
Carol Weitzman, MD, FAAP, Lynn Wegner, MD, FAAP, the SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, COMMITTEE ON
PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COUNCIL ON EARLY CHILDHOOD, AND SOCIETY FOR DEVELOPMENTAL AND
BEHAVIORAL PEDIATRICS

abstract By current estimates, at any given time, approximately 11% to 20% of children
in the United States have a behavioral or emotional disorder, as dened in the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between
37% and 39% of children will have a behavioral or emotional disorder
diagnosed by 16 years of age, regardless of geographic location in the United
States. Behavioral and emotional problems and concerns in children and
adolescents are not being reliably identied or treated in the US health
system. This clinical report focuses on the need to increase behavioral
screening and offers potential changes in practice and the health system, as
well as the research needed to accomplish this. This report also (1) reviews
the prevalence of behavioral and emotional disorders, (2) describes factors
affecting the emergence of behavioral and emotional problems, (3) articulates
the current state of detection of these problems in pediatric primary care, (4)
This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have led describes barriers to screening and means to overcome those barriers, and
conict of interest statements with the American Academy of (5) discusses potential changes at a practice and systems level that are
Pediatrics. Any conicts have been resolved through a process
approved by the Board of Directors. The American Academy of needed to facilitate successful behavioral and emotional screening.
Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
Highlighted and discussed are the many factors at the level of the pediatric
practice, health system, and society contributing to these behavioral and
Clinical reports from the American Academy of Pediatrics benet from
expertise and resources of liaisons and internal (AAP) and external emotional problems.
reviewers. However, clinical reports from the American Academy of
Pediatrics may not reect the views of the liaisons or the
organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of


treatment or serve as a standard of medical care. Variations, taking SCOPE OF THE PROBLEM AND NEED FOR THIS REPORT
into account individual circumstances, may be appropriate.
Behavioral and emotional problems during childhood are common, often
All clinical reports from the American Academy of Pediatrics undetected, and frequently not treated despite being responsible for
automatically expire 5 years after publication unless reafrmed,
revised, or retired at or before that time. signicant morbidity and mortality. By current estimates, approximately
www.pediatrics.org/cgi/doi/10.1542/peds.2014-3716
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
DOI: 10.1542/peds.2014-3716
similar in young 2- to 5-year-old children. Developmental and behavioral
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). health disorders are now the top 5 chronic pediatric conditions causing
Copyright 2015 by the American Academy of Pediatrics functional impairment.3,4 Even greater numbers of children have

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FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 135, number 2, February 2015
behavioral or emotional problems early school-age years, with response system effectively and can
causing impairment or distress that substance abuse being the latest to lead to adverse long-term structural
do not meet criteria of the Diagnostic emerge. An approximately 2- to 4- and functional changes in the brain
and Statistical Manual of Mental Dis- year period between symptom and elsewhere in the body. The 2012
orders, Fifth Edition for a disorder. appearance and disorder has been American Academy of Pediatrics
The purpose of this report is to demonstrated, suggesting that there (AAP) Policy Statement Early
provide pediatricians with a rationale may be opportunities for secondary Childhood Adversity, Toxic Stress, and
for and guidance to implement prevention or early intervention.6 the Role of the Pediatrician:
screening for behavioral and emo- Translating Developmental Science
tional problems in primary care set- FACTORS AFFECTING THE EMERGENCE Into Lifelong Health advocated
tings. However, in evaluating and OF BEHAVIORAL AND EMOTIONAL viewing the causes and consequences
promoting optimal child development PROBLEMS of toxic stress from the same
and well-being, the domains of de- In 2010, more than 1 in 5 children perspective as other biologically
velopment and behavior must be were reported to be living in based health impairments.19
considered together within the con- poverty.6,10 Economic disadvantage is
text of the family. These domains are among the most potent risks for POLICIES IN PLACE
not separate constructs but rather behavioral and emotional problems
parts of a whole. Therefore, this In 2004, the AAP established the Task
due to increased exposure to Force on Mental Health, which
report emphasizes that behavioral environmental, familial, and
screening must always be 1 compo- articulated mental health
psychosocial risks.1113 In families in competencies for primary care;
nent of a comprehensive develop- which parents are in military service,
mental and behavioral screening developed guidance for addressing
parental deployment and return has systemic and nancial barriers to
program that extends through child- been determined to be a risk factor
hood and adolescence. providing mental health care in
for behavioral and emotional primary care settings; and provided
problems in children.14 Data from the tools and strategies to assist
EPIDEMIOLOGY OF BEHAVIORAL AND 2003 National Survey of Childrens pediatricians in applying chronic care
EMOTIONAL DISORDERS Health demonstrated a strong linear principles to children with mental
It is estimated that 25% to 40% of relationship between increasing health problems.20 The Task Force
children with 1 disorder will have at number of psychosocial risks and also provided guidance (through
least 1 additional mental health or many poor health outcomes, identifying tools and describing
behavioral diagnosis at a given including social-emotional health.15 strategies) to providers on adapting
time.1,5,6 The most common co- The Adverse Childhood Experience current practice to include mental
occurring conditions are attention- Study surveyed 17 000 adults about health care. A recent publication
decit/hyperactivity disorder early traumatic and stressful articulated an initial blueprint for
(ADHD) and oppositional deant experiences. Two-thirds of behavioral and emotional screening
disorder, but co-occurrence of anxiety respondents experienced at least 1 in pediatric practice.21 The current
and depression is also common. type of childhood psychosocial risk, statement supports the Task Force
and 20% experienced more than 3. guidance by providing the evidence
Between 37% and 39% of children Adverse early experiences were
will have a behavioral or emotional supporting screening for emotional
related to increased rates of health and behavioral concerns.
disorder diagnosed by 16 years of problems in adulthood including
age, with the most common diagnoses obesity and cardiovascular disease as
being impulse control/disruptive well as substance abuse, mental CURRENT STATE OF DETECTION OF
behavior problems, anxiety, and mood health problems, and poor health- BEHAVIORAL AND EMOTIONAL
disorders.1,7,8 Between 23% and related quality of life. As the Adverse PROBLEMS IN PEDIATRIC SETTINGS
61% of children with a diagnosis at 1 Childhood Experience Study score Behavioral and emotional problems
time will have a diagnosis in the increased, so did the number of risk and concerns in children and
future, although it is not always the factors for the leading causes of adolescents are not being reliably
same diagnosis.1 death.16,17 Shonkoff uses the phrase identied or treated in the US health
Approximately 50% of adults with toxic stress to describe high system.6,2225 Current estimates
behavioral health problems report cumulative psychosocial risk in the suggest that fewer than 1 in 8
that their disorders emerged in early absence of supportive caregiving18,19; children with identied mental health
adolescence.9 Anxiety disorders and this type of unremitting stress problems receive treatment. Even
ADHD are the earliest disorders to ultimately compromises childrens when a child or adolescent is well
emerge, often in the preschool and ability to regulate their stress known in a pediatric practice, only

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PEDIATRICS Volume 135, number 2, February 2015 385
50% of those with clinically number of mandates outlined in feelings not noticed by outside
signicant behavioral and emotional practice guidelines with ever- observers, such as those associated
problems are detected.23 Other shrinking time for health with anxiety or depression. Most self-
investigators have found similarly maintenance visits as a result of report versions are normed on
high failure of detection rates ranging reimbursement pressures.33 patients 8 years and older.
from 14% to 40%.22,24 Surveyed The research on behavioral and
pediatricians, however, emotional screening in younger
overwhelmingly endorse that they AVAILABLE TOOLS TO SCREEN FOR
BEHAVIOR AND EMOTIONAL PROBLEMS children is more limited than in
should be responsible for identifying school-age children, but increasingly,
children with ADHD, eating disorders, Behavioral and emotional screening
reliable, brief measures suitable for
depression, substance abuse, and instruments have many of the same
use in primary care exist, and new
behavior problems.26 advantages and limitations as
ones are being developed,35,36
developmental screening
Clinicians ability to identify making it possible to screen children
instruments. They involve a time
developmental and behavioral and adolescents from aged 6 months
commitment for parents or guardians
problems in primary care, on the through 18 years of age.
to complete and for staff and
basis of clinical judgment alone in the Behavior and emotional screens
clinicians to score, interpret, and
absence of a standardized measure, available in the public domain can be
report the results.32
has been shown to have low found in Appendix 1.
sensitivity, ranging from 14% to 54% Screening instruments can be used to
and a specicity ranging from 69% to predict risk of a disorder but do not
100%.27 Providers are less likely to make the diagnosis. There are global OVERCOMING BARRIERS TO SCREENING
identify problems in minority or (broadband) scales that may screen The policy statement The Future of
nonEnglish-speaking children and for several conditions, and there are Pediatrics: Mental Health
adolescents.25 domain-specic (single-condition) Competencies for Pediatric Primary
tools are most useful for screening for Care outlined the skills pediatricians
In a study of clinicians in more than
a specic problem, such as substance need in the area of mental health.37
200 practices, pediatric providers
use or adolescent depression and The AAP Task Force on Mental Health
reported using a standardized
suicidality.32 has developed materials to help
measure to assess mental health
problems in 20.2% of all visits, with Pediatricians should be aware of the pediatricians assess their current
50.2% of providers reporting never sociodemographic characteristics of practice and readiness to change and
using any formal measure.28 Fewer populations enrolled in validation to code accurately for mental health
than 7% of providers reported using studies as they make decisions screening and services.38,39 The AAP
a standardized measure during 50% regarding any screening instruments also developed a Web site providing
or more of visits.28 used. Pediatricians need to consider resources and materials free of
the literacy and health literacy levels charge (http://www2.aap.org/
of parents, guardians, children, and commpeds/dochs/mentalhealth/
BARRIERS TO SCREENING KeyResources.html)40 as well as
adolescents completing screens,
Pediatricians report a lack of whether the instrument should be Addressing Mental Health Concerns
condence in their training and administered in English or another in Primary Care: A Clinicians
ability to successfully manage language, and whether the person Toolkit,41 which is available for
childrens behavioral and emotional completing the screen will need a fee.
problems29 with only 13% of additional help. Professional organizations, including
pediatricians reporting condence.30
Pediatricians should be familiar with the AAP, Society for Developmental
Common barriers to adopting new
the psychometric properties of an and Behavioral Pediatrics, American
screening practices in pediatrics
instrument and under what Academy of Child and Adolescent
include lack of time,30 long waits for
conditions reported sensitivities and Psychiatry, and National Alliance on
children to be seen by mental health
specicities were obtained.32 Like Mental Illness, provide ongoing
providers, and lack of available
developmental screening tools, continuing medical education and
mental health providers to refer
behavioral and emotional screening resources.
children.31,32 Liability issues have
been identied as a barrier to tools should have a sensitivity and
screening and managing children specicity of $0.70.34 LESSONS LEARNED FROM
with behavioral and emotional Once the patient is old enough to DEVELOPMENTAL SCREENING
problems. Pediatricians have also answer reliably, self-report versions Many barriers to behavioral and
raised concerns about the increasing can provide information about emotional screening are similar to

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386 FROM THE AMERICAN ACADEMY OF PEDIATRICS
those identied when developmental programs that have been shown to practice and can provide timely
screening was proposed as a regular promote childrens social-emotional assistance for behavioral emergen-
part of pediatric care. In 2006, the development through positive cies as well as support the primary
AAP policy statement Identifying parenting,4651 possibly preventing care provider in implementing and
Infants and Young Children With the emergence of problems. interpreting the ofce screening
Developmental Disorders in the 1. Readying the Practice. As was seen program.
Medical Home: An Algorithm for in developmental screening, front- Another model of a successful col-
Screening and Surveillance42 was end work is needed to train and laboration program between pri-
published. Since the publication of the prepare an ofce to adopt screen- mary providers and child
statement, 44.8% of pediatricians ing practices. It may be helpful to psychiatrists, the Massachusetts
reported using standardized enlist the assistance of local men- Child Psychiatry Access Project,
developmental screening tools more tal health professionals or promotes access to psychiatric
often, and 72.2% reported using developmental-behavioral pedia- consultation for primary care
standardized autism screening tools tricians in selecting and imple- providers through a network of
more often.43 National demonstration menting screening procedures. childrens mental health collabo-
projects including the Assuring Better ration teams. The overall aim is to
2. Identifying Resources. Before ini-
Child Development Screening
tiating a behavioral and emotional improve access to treatment of
Academy44 and the AAPs
screening program, pediatricians children with mental health con-
Developmental Surveillance and
need to determine what they will cerns (http://www.mcpap.com/
Screening Policy Implementation
do when a child or parent has about.asp). This type of program
Project45 achieved high levels of
a positive screening result. Pedia- currently is being implemented in
screening in primary care. These
tricians should familiarize them- more than 30 states.
projects provided valuable lessons
selves with local resources and 3. Establishing Ofce Routines for
about implementing a screening
identify referral sources. In the Screening. As with developmental
program (Table 1) and behavioral
absence of this, pediatricians are screening, children should be
and emotional screening may follow
likely to feel frustrated and over- screened at regular intervals for
similar patterns. Similar large-scale
whelmed when they identify chil- behavioral and emotional prob-
initiatives may need to be developed
dren and adolescents in need of lems with standardized, well-
to determine the best practices for
services but are unable to nd validated measures beginning in
implementing a behavioral and
appropriate, high-quality treat- infancy and continuing through
emotional screening program.
ment of them. Pediatricians will adolescence. Screening beginning
need to work with the community in the rst year of life can identify
GUIDANCE FOR PEDIATRICIANS to advocate for more treatment disturbances in attachment, regu-
and intervention services. lation, and the parent-child re-
The following steps and Table 2 are
designed to give pediatricians a clear Increasing numbers of practices have lationship, although the optimal
road map to implement behavioral colocated a mental health provider approaches to screening infants
and emotional screening in practice. (eg, psychologist, licensed clinical and very young children are less
Although distinct from screening, social worker, licensed therapist) clear-cut than screening children
pediatricians should familiarize within the practice. These pro- at older ages. Ongoing care
themselves with evidence-based viders are integrated into the involves maintaining a good his-
tory regarding factors that can in-
uence the early parent-child
TABLE 1 Lessons Learned From Implementing a Screening Program relationships, such as discipline
What Promoted Screening Implementation What Challenges Remained practice, parenting stress, psycho-
Creating an ofce-wide implementation system Consistent referral of children with failed screens social risks, and positive parenting.
Dividing responsibility among staff Distributing screens to children at screening ages
but not to others
Currently, developmental and
Actively monitoring implementation and Maintaining consistent screening practice during behavioral/emotional screenings are
continuing to make changes busy times viewed as separate constructs, and
Choosing screens perceived to least disrupt Coping with screening gaps due to staff turnover most well-validated measures screen
clinic ow
for them independently. Developmental
Aligning screening measures with those used Not screening when surveillance raised concerns
in community based programs Tracking referrals through a distinct screening is commonly perceived as
implementation system from screening identifying disordered expressive and
Nonadherence to the 30-mo screen because of receptive language, ne and gross
expected nonreimbursement motor skills, self-help skills, and

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PEDIATRICS Volume 135, number 2, February 2015 387
TABLE 2 Steps to Implement Behavioral and Emotional Screening in Practice depression, when systems are in
1. Readying the practice place, to ensure accurate diagnosis,
Describe and evaluate current efforts already in place treatment, and follow-up.53
Identify a practice champion Pediatricians should use targeted
Train all staff
screening for other problems, such as
Consider incremental screening and actively monitor implementation
Develop a screening roadmap from providing the screen through the referral process suicidality or anxiety, if there is
Add behavior and emotional problems to the problem list and update this at each visit concern raised by the provider,
Problem solve challenges that arise across the entire practice patient, or parent or the child is at
Determine how to best publicize new screening practices to families high risk.
Consider additional costs for procuring screening tools, etc
Prepare for psychiatric emergencies that may present in the ofce Childrens behavioral and emotional
2. Identifying resources problems are frequently associated
Identify referral resources that include the following:
with family psychosocial risk. Family
Areas of expertise
Hours of operation psychosocial screening can provide
Payment methods important information about
Ability to treat nonEnglish speakers potential protection or lack thereof
Develop a plan for bidirectional communication for a child who may or may not yet
Learn about emergency mental health services
show signs of behavioral or emotional
Partner with adult providers and community resources to help parents with identied psychosocial
risk problems. Early detection and
3. Establishing ofce routines for screening and surveillance treatment of family psychosocial risk
Implement screening in the rst year of life and at regular intervals throughout childhood and may potentially avert the emergence
adolescence of problems in the child. Only
Incorporate screening for family psychosocial risks and strengths
Determine appropriate screening intervals for the practice (combined with or distinct from
a limited number of well-validated
developmental screening intervals) based on things such as clinic ow, allotted time to discuss screens suitable for use in primary
screening results, etc care for broad screening of family
Partner with parents to formulate a plan when there is a failed screen psychosocial risk and family support
Identify strengths of the child and communicate these to the family
and functioning are available,
Screen when the child, family, or provider has concerns
Establish a registry of children with positive screens and family psychosocial risk although a few show promise.5456
Monitor children with signicant risk factors with heightened surveillance and more frequent There are screening measures for
screening specic psychosocial stressors, such
4. Tracking referrals as maternal depression, and these
Develop a mechanism to track progress of children referred for assessment or treatment (eg,
successful referral, evaluation or initiation of treatment)
have been shown to be feasible in
Collect information about families experience with referral resources pediatric settings.57,58 Family
5. Seeking payment screening for psychosocial risk within
Familiarize the practice with appropriate CPT codes for screening, care plan oversight, face-to-face pediatric settings, however, raises
and nonface-to-face services and reimbursement by different insurance companies
a number of dilemmas, including
Track billing and reimbursement for screening efforts
6. Fostering collaboration concerns about liability and payment
Explore colocated or other innovative models of care and partnerships with mental health and who is responsible for an adults
professionals well-being after a problem is
detected.59
4. Tracking Referrals. If the child was
cognitive milestones, whereas Beginning in early adolescence, referred for services after screen-
behavioral and emotional screening screening for substance use should be ing, it is important for pediatricians
identies problems in areas including implemented.21,52 Substance use and to inquire as to whether referrals
social-emotional regulation, mood dependence have consistently been were completed and services were
and affect, attention, and found to be 1 of the most prevalent obtained or understand what bar-
interpersonal skills. There is behavioral health diagnoses in riers parents have experienced and
a signicant yet incomplete overlap adolescents. Identifying and treating how these can be overcome. Fur-
between developmental and behavior a behavioral or emotional problem thermore, it is important for
problems. Studies have revealed that without detecting and treating co- pediatricians, with parental per-
children with cognitive, language, occurring substance use will likely mission, to obtain information from
and social impairments and lead to ineffectual treatment. The US the referral and to learn whether
developmental disabilities, in general, Preventive Services Task Force services obtained were effective
are far more likely to manifest recommends screening all and whether symptoms in the child
behavioral and emotional problems.12 adolescents (1218 years of age) for have been reduced or eliminated.

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388 FROM THE AMERICAN ACADEMY OF PEDIATRICS
This follow-up may require a sepa- behavioral and emotional problems domain screening tools and have used
rate ofce system than screening in the ofce. This is particularly emerging computer technology to
procedures. true for the management of sub- facilitate behavioral/emotional
5. Seeking Payment. One of the big- threshold problems not meeting screening. There have been many
gest systems hurdles facing the severity level warranted to re- examples of colocated practices, and
pediatricians is the difculty fer for treatment. national organizations, such as the
obtaining payment for screening AAP, have strongly advocated for
patients for behavioral and emo- FUTURE DIRECTIONS payment for these integrated practice
tional problems and for screening models. The lessons learned through
As medical practice continues to shift developmental screening
families for psychosocial risk and into more electronic formats,
functioning. The adoption of the implementation have been used to
standardized screening instruments make behavioral and emotional
proposed screening and surveil- will need to be formatted for screening a more routine component
lance practices, may lengthen visit electronic health record systems, to of pediatric health supervision. The
time to discuss results without ad- facilitate a wide implementation of investments described in this report,
ditional payment to support that screening. Automating guidelines and nancial and otherwise, are critical to
time and create signicant non scoring of screening measures, ensure a future of thriving and strong
face-to-face work.60 This includes providing decision support that is infants, children, and adolescents
referring patients and families to integrated into electronic health who will mature into healthy adults.
appropriate resources, tracking records, and providing patients with
referrals, communicating with opportunities for greater LEAD AUTHORS
other professionals (which may participation in their health care via Carol Weitzman, MD
require reviewing lengthy reports portals into their electronic medical Lynn Mowbray Wegner, MD
and school plans), and following up record have already shown
with children and families. Over- promise.66,67 Paper-and-pencil CONTRIBUTING AUTHORS
coming this critical barrier is fun- screening methods will need to be Laura Joan McGuinn, MD
damental to transforming pediatric transformed into Web-based Alan L. Mendelsohn, MD
Patricia Gail Williams, MD
practice to a medical home model. versions, smartphone apps, and Terry Stancin, PhD
With the advent of reimbursable waiting room tablets to successfully
billing codes for screening, in- harness available technology.65,68 SECTION ON DEVELOPMENTAL AND
cluding Current Procedural Termi- These changes will be critical areas BEHAVIORAL PEDIATRICS EXECUTIVE
nology (CPT) codes 96110 and needing further evaluation to COMMITTEE, 20132014
99420, some practices are begin- determine best practices.69 Nathan J. Blum, MD, Chairperson
ning to see some nancial payment Additional system challenges that will Michelle M. Macias, MD, Immediate Past
Chairperson
for the addition of screening pro- need to be addressed are included in
Nerissa S. Bauer, MD, MPH
grams. Additionally, a new CPT Appendix 2. Carolyn Bridgemohan, MD
code for brief behavioral assess- Edward Goldson, MD
Laura J. McGuinn, MD
ment, 96127, has been included in SUMMARY
Carol Weitzman, MD
CPT 2015 to allow the separate
Evaluating and promoting optimal
reporting of this service. LIAISONS
child development and well-being
6. Fostering Collaboration. Innovative includes assessing developmental and Pamela High, MD Society for Developmental and
collaborations have been well de- behavioral domains in the context of Behavioral Pediatrics
scribed and include colocation and Susan Levy, MD Council on Children with Disabilities
the family. Behavioral and emotional
integrated and consultative models, problems are common, persistent, CONSULTANT
such as the Massachusetts Child and cause signicant functional Lynn Mowbray Wegner, MD
Psychiatry Access Project, the impairment for many children and
North Carolina Chapter AAP/NC adolescents. A 2- to 4-year window STAFF
Pediatric Society (ICARE), and the may exist between initial Linda B. Paul, MPH
Washington Partnership Access presentation of symptoms and the
Line.6164 Innovative means of COMMITTEE ON PSYCHOSOCIAL ASPECTS OF
development of a disorder, suggesting
CHILD AND FAMILY HEALTH, 20132014
consultation and collaboration will an opportunity to intervene before
continue to evolve with emerging Benjamin S. Siegel, MD, Chairperson
problems become more serious in
Michael W. Yogman, MD, Chairperson-Elect
technology.65 These relationships children.6 In recent years, many Thresia B. Gambon, MD
help build the capacity of pedia- pediatricians have taken advantage of Arthur Lavin, MD
tricians to manage various more widely disseminated public LTC Keith M. Lemmon, MD

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PEDIATRICS Volume 135, number 2, February 2015 389
Gerri Mattson, MD Robert Needlman, MD 8. Kim-Cohen J, Caspi A, Moftt TE,
Laura Joan McGuinn, MD Nancy Roizen, MD Harrington H, Milne BJ, Poulton R. Prior
Jason Richard Rafferty, MD Franklin Trimm, MD juvenile diagnoses in adults with mental
Lawrence Sagin Wissow, MD, MPH Lynn Wegner, MD disorder: developmental follow-back of
Beth Wildman, PhD
a prospective-longitudinal cohort. Arch
LIAISONS
CONSULTANT Gen Psychiatry. 2003;60(7):709717
Ronald T. Brown, PhD Society of Pediatric
Psychology Terry Stancin, PhD 9. Kessler RC, Berglund P, Demler O, Jin R,
Terry Carmichael, MSW National Association of Merikangas KR, Walters EE. Lifetime
Social Workers EXECUTIVE DIRECTOR prevalence and age-of-onset
Jody K. Gurtler National Association of Pediatric Laura Degnon, CAE distributions of DSM-IV disorders in the
Nurse Practitioners National Comorbidity Survey Replication
Mary Jo Kupst, PhD Society of Pediatric Psychology [published correction appears in Arch
Leonard Read Sulik, MD American Academy of Child
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392 FROM THE AMERICAN ACADEMY OF PEDIATRICS
APPENDIX 1 Behavioral and Emotional Screening Measures for Use in Primary Care in the Public Domaina
Category Screening Tool Age Group No. of items Available Forms Reported Psychometrics/Other Link

General Behavioral Screens


Young children Baby Pediatric Symptom 217 mo 12 Parent completed Retest reliability and internal https://sites.google.com/site/swycscreen
(05) Checklist reliability .0.7
Preschool Pediatric Symptom 1860 mo 18 Parent completed https://sites.google.com/site/swycscreen
Checklist
Strengths and Difculties 317 y 25 items Parent/teacher 3(4)-y-old; parent/ Variable across cultural groups; http://www.sdqinfo.org
Questionnaire teacher 410-y-old; parent/teacher sensitivity: 63%94%, specicity:
follow-up forms available 88%96%; available in .70 languages
School-age and Strengths and Difculties 317 y 25 items Parent/teacher 410-y-old; parent/ Variable across cultural groups; http://www.sdqinfo.org
adolescent Questionnaire teacher 1117-y-old; youth self sensitivity: 63%94%, specicity:
children report 1117-y-old; parent/teacher/ 88%96%; available in .70 languages

PEDIATRICS Volume 135, number 2, February 2015


self follow-up forms available
Pediatric Symptom 416 y 17 items Parent completed; youth self-report Variable psychometrics for detection of http://www.massgeneral.org/psychiatry/
Checklist17 .10 y; pictorial version available psychiatric problems; available in services/psc_home.aspx
multiple languages
Pediatric Symptom 416 y 35 items Parent completed; youth self-report Sensitivity: 80%95%, specicity: http://www.massgeneral.org/psychiatry/
Checklist35 .10 y; pictorial version available 68%100%; available in multiple services/psc_home.aspx
languages

Psychosocial Screens

WE-CARE (Well-Child Care Visit, Parent 10 items Parent completed http://pediatrics.aappublications.org/


Evaluation, Community content/120/3/547.full#sec-1
Resources, Advocacy,
Referral, Education)
Family Psychosocial Screen Parent 50 items Parent completed Variable psychometrics for detection http://depts.washington.edu/dbpeds/
of specic psychosocial problems; Screening%20Tools/
cut points for various domains FamPsychoSocQaire.pdf
recommended
Survey of Wellbeing in Parent 9 items Parent completed Preliminary ndings show promise https://sites.google.com/site/swycscreen/

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Young Children parts-of-the-swyc/family-questions
Adverse Childhood Parent 10 items Parent completed Increasing score associated with many http://acestoohigh.com/got-your-ace-score
Experience Score adverse physical and mental health
outcomes

Screens for Specic Disorders

Parental or Edinburgh Maternal Parent (mother) 10 items Parent self-report Sensitivity 86%; specicity 78% http://www.fresno.ucsf.edu/pediatrics/
adolescent Depression downloads/edinburghscale.pdf
depression
2 Question Screen Parent, 2 items Parent or adolescent self-report Sensitivity: 83%87%; specicity: http://www.uphp.com/Two_Question_
(Modication of the Patient adolescents 78%92% Screen.pdf; http://www.cqaimh.org/pdf/
Health Questionnaire2 tool_phq2.pdf
Patient Health Questionnaire Parent 9 items Parent or Adolescent self-report Sensitivity: 88% for major depression; http://www.integration.samhsa.gov/
(PHQ)9 specicity: 88% for major depression images/res/PHQ%20-%20Questions.pdf

393
APPENDIX 1 Continued

394
Category Screening Tool Age Group No. of items Available Forms Reported Psychometrics/Other Link

General Behavioral Screens


Center for Epidemiologic Parent; 20 items Parent completed; youth self-report Coefcient a ..9; sensitivity 91%; http://cesd-r.com
Studies Depression Scale adolescents specicity 81%. Psychometrics
.14 y for children ,14 indicate measure
(modied may not discriminate well between
version for depressed and nondepressed youth.
children as
young as
6 available)
Mood and Feelings Has been Short version; Parent completed; youth self-report Parent report version has shown a http://devepi.mc.duke.edu/mfq.html
Questionnaire used about 9 items; long sensitivity of 75%86% and
children as version: 34 items specicity of 73%87%
young as 7
Substance CRAFFT (Car, Relax, Alone, 1121 y old Three screener Interview of youth; youth self-report Sensitivity 76%93%, specicity 76% to http://www.ceasar-boston.org/CRAFFT
abuse Forget, Friends, Trouble) questions, then version available 94%; available in multiple languages
6 items
CAGE-AID Adolescents 4 items Youth self-report One or more positive answers is http://www.integration.samhsa.gov/
associated with a sensitivity of 79% images/res/CAGEAID.pdf
and specicity of 77%, $2 answers
70% and 85%
Anxiety Screen for Child Anxiety $8 y 41 items Parent completed; youth self-report Coefcient a: .9 http://www.psychiatry.pitt.edu/research/
Related Disorders (SCARED) tools-research/assessment-instruments
Spence Childrens Anxiety 2.56.5 y and 45 items Parent completed 2.56.5 y; youth High internal consistency and adequate http://www2.psy.uq.edu.au/~sues/scas
Scale (SCAS) 812 y self-report 812 y testretest reliability in adolescents
ADHD Vanderbilt ADHD Diagnostic 418 y 55-items parent Parent, teacher completed; follow-up Sensitivity 80%, specicity 75%, retest http://www.nichq.org/
Rating Scales scale; 43-items forms available reliability .0.80 toolkits_publications/complete_adhd/
teacher scale 03VanAssesScaleParent%20Infor.pdf;
http://www.brightfutures.org/
mentalhealth/pdf/professionals/

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bridges/adhd.pdf
Strengths and Weaknesses 618 y 30 items (18-item Parent, teacher completed http://www.adhd.net
of ADHD Symptoms (SWAN) available)
SNAP-IV 618 y 90 items (18-item Parent, teacher completed Coefcient a ..90; available in http://www.adhd.net
version available) multiple languages
CAGE-AID, CAGE Questions (Cut Down, Annoyed, Guilty and Eye Opener) adapted to include drug use; Swanson, Nolan and Pelham Questionnaire, Version IV (SNAP-IV).
a This list is not meant to be exhaustive but representative of a range of screening instruments suitable for primary care that are in the public domain. Psychometrics may vary based on the ndings of different studies and there is considerable

variability in the strength of psychometric reliability between measures.

FROM THE AMERICAN ACADEMY OF PEDIATRICS


APPENDIX 2 System Challenges
Resources Identify national programs to assist parents and pediatricians in identifying mental health resources such as Help Me Grow,69 which has
established a centralized call center
Advocate for a greater workforce of mental health providers and developmental-behavioral pediatricians
Advocate for additional community mental health services and ensure they are of high quality
Screening Develop additional well-validated screens to identify psychosocial risk
Develop and validate screens appropriate for use in low-literacy and nonEnglish-speaking populations
Payment Advocate for payment for
behavioral, emotional, and substance abuse screening
nonface-to-face time including care plan oversight, complex chronic care coordination and prolonged services
Evaluate enhanced payment systems for medical-home practices and monitor nancial viability of hiring care coordinators
Consider payment incentives for medical homes that include potentially enhanced reimbursement for behavioral and emotional
screening, family psychosocial, or substance use screening and all follow-up care, case management, care plan oversight, and prolonged
services in their capitation calculations.
Evaluate cost savings associated with the detection and treatment of behavioral and emotional problems
Collaboration Establish payment for collaborative care models that include telephone communications between providers, etc.
Develop efcient methods to ensure that results of community-based screening are reported to the medical home
Other Develop quality improvement initiatives related to behavioral and emotional screening as a part of maintenance of certication
Develop electronic health records that incorporate screening but maintain patient privacy regarding behavioral and emotional problems
and family psychosocial stressors

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PEDIATRICS Volume 135, number 2, February 2015 395
health outcomes across groups, reecting a potential explanatory role of factors
such as daily hardships, caregiver depression, and HIV-related stigma.
doi:10.1542/peds.2015-0753

Weitzman, Wegner, the Section on Developmental and Behavioral Pediatrics,


Committee on Pyschosocial Aspects of Child and Family Health, Council on
Early Childhood, and Society for Developmental and Behavioral Pediatrics.
Promoting Optimal Development: Screening for Behavioral and Emotional
Problems. Pediatrics. 2015;135(2):384395
An error occurred in the American Academy of Pediatrics clinical report, titled
Promoting Optimal Development: Screening for Behavioral and Emotional Problems
published in the February 2015 issue of Pediatrics (2015;135[2]:384395). Reference 45
should be King TM, Tandon SD, Macias MM, et al. Implementing developmental
screening and referrals: lessons learned from a national project. Pediatrics. 2010;125
(2):350360. We regret the error.
doi:10.1542/peds.2015-0904

Butler et al. Growth Charts for Non-growth Hormone Treated Prader-Willi


Syndrome. Pediatrics. 2015;135(1):e126-e135
An error occurred in the article by Butler et al, titled Growth Charts for Non-
growth Hormone Treated Prader-Willi Syndrome published in the January 2015
issue of Pediatrics (2015;135[1]:e126e135; doi:10.1542/peds.2014-1711).
On page e129, Fig 1, A and B, the third percentile line is missing for both the male
and female subjects. This line is lower but closely parallels the other percentile
lines.
In the Figure Legend for Fig 1, this reads: (male subjects [upper] and female
subjects [lower]). This should have read: (male subjects [left] and female
subjects [right]).
doi:10.1542/peds.2015-0926

946 ERRATA
Promoting Optimal Development: Screening for Behavioral and Emotional
Problems
Carol Weitzman, Lynn Wegner and the SECTION ON DEVELOPMENTAL AND
BEHAVIORAL PEDIATRICS, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF
CHILD AND FAMILY HEALTH, COUNCIL ON EARLY CHILDHOOD, AND
SOCIETY FOR DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS
Pediatrics 2015;135;384; originally published online January 26, 2015;
DOI: 10.1542/peds.2014-3716

The online version of this article, along with updated information and services, is
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publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2015 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2015 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Promoting Optimal Development: Screening for Behavioral and Emotional
Problems
Carol Weitzman, Lynn Wegner and the SECTION ON DEVELOPMENTAL AND
BEHAVIORAL PEDIATRICS, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF
CHILD AND FAMILY HEALTH, COUNCIL ON EARLY CHILDHOOD, AND
SOCIETY FOR DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS
Pediatrics 2015;135;384; originally published online January 26, 2015;
DOI: 10.1542/peds.2014-3716

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2015 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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