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July 2011

Behavioral Health Screening and Intervention in Primary Care

Author Affiliations

Author Affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle.

Arch Pediatr Adolesc Med. 2011;165(7):669. doi:10.1001/archpediatrics.2011.19

It should come as no surprise that families with increasing frequency bring to the attention of pediatricians and other primary care providers concerns around the behavioral problems of their children. To a significant degree, the growing destigmatization of mental health concerns among the public has increased the comfort of parents addressing the behavioral problems of their children to providers. The positive engagement that most families have with their children's primary caregivers supports their willingness to address and listen to concerns around their children's emotional and cognitive behavior and development. Despite increased parental concerns, many primary care providers have not chosen to either screen for behavioral concerns or act when identified—what a significant missed opportunity to prevent and intervene early in potential behavior problems that are likely to significantly affect child development and well-being. The reason for the lack of activity derives from both practice and reimbursement constraints. Lack of time or skill in providing an intervention for identified problems as well as the low reimbursement for both screening and counseling impede action. As identified in the screening and assessment article in this issue by Kuhlthau et al,1 increases in evidence-based behavioral screening, as required through the Early Periodic Screening, Diagnosis, and Treatment statute, were only achieved in Massachusetts with the successful initiation of a lawsuit with mandates around screening and subsequent incentives to providers, and even then, many providers continue to overlook screening and those who do use it struggle with finding an adequate number of child mental health professionals to whom to refer their patients. Even with universal screening, we are not likely to improve outcomes unless interventions are evidence based. Without a doubt, strategies to integrate behavioral health into primary care need to be expanded. It will take more than mandates requiring children be provided behavioral health treatment as a component of a medical home. Continuing education and residency programs will need to be provided that equip the workforce with skills to advocate and provide effective treatment for children. Practices will need to increasingly employ child mental health specialists who can work in collaboration with their primary care colleagues, and children's mental health providers will need to understand the various systems that parents and their children need to navigate to achieve positive outcomes. Effective, well-researched interventions exist for many child and adolescent disorders; however, their implementation is not often practiced. It is shameful but more importantly harmful that effective evidence-based treatments are not provided to needy children. The time has come to have as an expectation that all primary care practices are supported and have competence in addressing the emotional well-being of their child and adolescent patients.