Screen Early for Behavioral, Emotional Problems in Kids: AAP

Pam Harrison

January 26, 2015

A new report issued by the American Academy of Pediatrics (AAP) recommends screening for behavioral and emotional problems in children to promote optimal development.

"The prevalence of behavioral and emotional problems in children is actually quite high, but much of it goes undetected," lead author Carol Weitzman, MD, professor of pediatrics, Child Studies Center, Yale School of Medicine, New Haven, Connecticut, told Medscape Medical News.

"And pediatricians are in a good place to have that kind of screening done because they are likely to see children who have undetected problems.

"What we'd like to do is find children who firstly have potentially severe problems who are not yet receiving treatment but also to find children with milder problems where we can intervene early and maybe avoid the problem from becoming more severe."

The report was published in the February issue of Pediatrics.

Growing Comfort Level

According to the AAP, the first step to implementing screening for behavioral and emotional problems is to "ready the practice." Among the many elements that have to be factored into this initial step is to identify a "practice champion."

All staff should be trained in screening procedures, and clinicians should develop a screening "roadmap" that staff can follow from administration of the screening test to the referral process.

"It's not easy, and it really means making some changes to your practice that requires some 'front-end work,' " Dr Weitzman acknowledged.

However, the one piece of "good news," she said, is that many practices are already starting to integrate developmental screening (screening for autism, for example) into practice and have gotten fairly comfortable with the idea of screening children for developmental disorders in general.

"In many ways, I feel that this experience may have paved the way for us to take on a bigger and broader effort for behavioral and emotional screening," she suggested.

Pediatricians will also need to identify referral resources with the needed areas of expertise.

"One of the major disincentives to wanting to screen is when you detect children with a problem and you have no place to send them, because we don't have enough mental health providers for children," Dr Weitzman said.

To ensure that they are not left "holding the bag," Dr Weitzman suggests that pediatricians identify where their referrals will go, and on a wider scale, advocate for a stronger workforce of pediatric mental health care providers wherever possible.

Establishing Processes

Practitioners also need to establish office routines for screening and surveillance. Conveniently, many of the screening tools are questionnaires that are already available online.

This means that parents can often fill them out at home or in the waiting room on a tablet.

The questionnaires are then scored, and the clinician receives a completed questionnaire on receiving the patient without having to go through the process itself.

This should help streamline the filling out of screening tools and reduce the burden on practice, said Dr Weitzman.

Screening should also be implemented in the first year of life, as the authors of the report recommend, and then repeated at regular intervals throughout childhood and adolescence.

Clinicians should also establish a registry of children who have positive screens along with family psychosocial risk and monitor children with heightened surveillance and more frequent screening when there are significant risk factors for behavioral and emotional problems.

"It has to be a practice-wide initiative. But it can be your front staff or a lot of different people with a lot of different roles. What you want is for the clinician to see a scored questionnaire before patients get into the examining room, and then all the clinician has to do is the interpretation and very brief documentation that shouldn't take that long," she said.

Tracking referrals in turn requires a mechanism by which to track the progress of children referred for assessment or treatment. Clinicians also need to document families' experiences with referral resources.

Fair Compensation

Dr Weitzman also believes pediatricians should advocate for fair payment for these additional referral efforts.

"Sure, you can do the screens, but they can generate a lot of non-face-to-face work — we have to make phone calls and follow-up on these calls and collect information about families' experiences with our referrals, and we need to be advocating very aggressively about payment for these activities," she said.

Financial incentives to screen for behavioral and emotional problems in children are not all that great at the moment, Dr Weitzman admits.

But there is now a new code that pediatricians can use to cover behavioral and emotional screening, so there is some financial incentive to expand screening efforts.

Once practitioners have taken care of the front-end work to get the system up and running, routine screening can become an office-based intervention that does not simply fall on the shoulders of the clinician but is shared by the whole practice team.

"If people perceive that this is simply going to be a burden on their practice and there's not a lot of financial remuneration for the effort, it's going to be hard to convince people to do this," said Dr Weitzman.

"But there is already pressure from outside — some states are already mandating that practitioners do this — so part of this is not necessarily going to be by choice.

"So hopefully this statement will help people have a blueprint for a screening program so that if one is mandated, at least they are going to do it well."

Filling a Gap

Commenting on the new recommendations for Medscape Medical News, Adelaide Robb, MD, chief, Division of Psychology and Behavioral Health, Children's National Health System, Washington, DC, said the call for expanded screening in childhood and adolescence is really needed.

"Many times when we see children in mental health care, they have been struggling for a long period of time and usually come to our attention because there has either been a crisis — a suicide attempt, for example, because of severe depression — or somebody else in the family noticed something and brought it to the parents' attention," she noted.

But Dr Robb added that mental health disorders during childhood and adolescence are actually more common than garden variety disorders such as asthma, which pediatricians routinely screen for more or less at every visit.

Given this, "we should be screening for mental health care disorders too, firstly because they cause a lot of impairment if they go untreated, and secondly because we now have good treatments available for most emotional disorders in childhood, and I think children deserve early identification and treatment so these issues don't get in the way of going to school, home life, and getting along with their friends," Dr Robb said.

The only downside of expanded screening is not having anyone to whom pediatricians can refer the child, Dr Robb added.

"You need to have both the screening and the capacity for intervention and treatment," she emphasized, echoing Dr Weitzman's call for more mental health care professionals who can care for children and adolescents in the United States and elsewhere.

Dr Weitzman and Dr Robb report no relevant financial relationships.

Pediatrics. Published online January 26, 2015. Full text

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