Mental Health Screening Tools Assist Pediatricians in Identifying Risk

Unaddressed mental health issues, such as depression and anxiety, among children and adolescents results in nearly two-thirds of those patients failing to receive proper treatment, according to a study conducted by Lisa Honigfeld, PhD, vice president of health initiatives with the Child Health and Development Institute of Connecticut, and her colleagues in the Department of Psychiatry at the University of Connecticut School of Medicine and Health Care.

Honigfeld and colleagues’ research shows that increasing the availability of accurate, reliable, easy-to-use, mental health screening tools for use by pediatric primary care (PPC) physicians during well-child visits could help increase the likelihood of diagnosis and treatment of mental health issues for pediatric patients.

Despite the fact that 1 out of 5 children aged 9 to 17 years meets the diagnostic criteria for a mental health disorder at some point during childhood, according to Honigfeld, little progress has been made in the attempt to improve on the identification and treatment of pediatric mental health issues. As a result, healthcare agencies are increasingly looking to PPC physicians as the front line in diagnosing and treating pediatric mental health disorders.

Honigfeld wrote that PPC providers “play a larger role in the care of children with attention and mood disorders than any other professional,” but that they often lack the appropriate tools and guidance when dealing with mental health issues in their practices, necessitating a look into developing evaluation, treatment, and guidance tools for these providers.

The study described and evaluated a quality improvement project that was designed to assist PPC physicians in assessing mental health in primary care settings. Because these physicians play such a significant role in identifying risk and established issues, it is important to encourage them to screen all patients for mental health concerns.

Screenings in PPC settings however, Honigfeld claims, are “thwarted by several systemic and practice-level barriers.” To address those barriers, Honigfeld and colleagues created, vetted, and tested a paper-based and computer-assisted version of an “evidence-based, best practice clinical care algorithm and toolkit” for use by PPC physicians.

The evaluation process took place over the course of 6 months among 7 PPC practices. For evaluation and testing purposes, the child and adolescent patients evaluated (ages 6 to 17 years) were divided into 2 cohorts. The first cohort was evaluated using the paper-based toolkit (482 patients), and the second was evaluated using the computer-assisted model (1208 patients).

The algorithms utilized standardized screening and assessment tools and, according to Honigfeld, included a “framework for treatment, referral, and symptom monitoring” as well as informational handouts for families that was developed by the American Academy of Child and and Adolescent Psychiatry.

The algorithms and toolkits, based on best-practices guidelines, were designed to gather information about current mental health state (via the Pediatric Symptom Checklist [PCS-17), Patient Health Questionnaire, and Center for Epidemiological Studies Depression Scale for Children), record a full mental health-based family history, and determine the need for any follow-up evaluation.

Follow-up evaluation was provided in the toolkit for pediatric patients scoring high on initial tests, via the Self-Report for Childhood Anxiety Related Disorders, the Car, Relax, Alone, Forget, Friends, Trouble screen. The algorithms guided PPC interpretation of evaluation results, helping them to identify characteristics of specific mental health issues. Toolkits also guided PPC physicians to set guidelines on education, referral, and treatment based on the algorithm results.

The data from the study showed that of 1208 patients screened during the 6-month study, 18% exhibited scores that would indicate risk of depression or anxiety. Follow-up, or “next-level,” assessment of these patients with positive screenings on early testing successfully ruled out or confirmed depression and anxiety in “red flagged” patients. Pediatric patients who positively screened for depression and/or anxiety were treated with positive results by PPC physicians according to guidelines suggested in the toolkit.

The study data found that use of the computer-based algorithm yielded significantly more accurate results than the paper version, and that PPC providers were more inclined to use the computer-based, versus paper-based, version of the assessment and toolkit. Overall, more than half of the pediatric patients at the 7 PPC clinics were screened for mental health issues as part of regular well-child services, but as Honigfeld pointed out, that is still “far below recommendations” from the American Academy of Psychiatry’s best practice guidelines.

PPC physicians responded to a poststudy survey indicating that the chief reason for omitting the mental health screening from well-child visits was concern about time restraints. Honigfeld and colleagues believe that with properly vetted, streamlined tools, more PPC physicians will opt to perform regular mental health screenings on their patients.

PPC physicians are, according to the article, “well positioned to serve as a hub for monitoring change in children’s mental health symptoms across development, when mental health can fluctuate and problems can emerge at various times and in response to various circumstances.” Honigfeld and colleagues note that their study provides data suggesting that supplying PPC providers with easy-to-use, valuable tools for assessment could increase opportunities for intervention and treatment for pediatric patients with mental health issues.

The article was published in the May/June 2017 issue of the Journal of Pediatric Health.

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