Mental Health Screening and Assessment

Pediatric primary care visits, especially well visits, provide a vital opportunity to proactively screen for behavioral, emotional and developmental concerns. Identifying these concerns early allows for timely intervention, improved outcomes and stronger relationships between patient families and providers.  Untreated mental health concerns are associated with lower academic achievement, poor health outcomes, increased legal trouble, greater family conflict and poorer social functioning during childhood and into adulthood. As mental and behavioral health challenges continue to rise nationally, pediatric clinicians are increasingly called upon to support mental health and can integrate validated screening tools into routine care.

Why routine mental health screening matters

Pediatric patients rarely present with clear-cut mental health symptoms. Often, concerns may manifest as physical complaints, behavioral changes or academic issues. Early identification through screening tools can unearth underlying issues, such as anxiety, attention-deficit/hyperactivity disorder (ADHD), depression or trauma exposure. Additionally, consistent screening normalizes conversations about mental health, reduces stigma and improves caregiver engagement.

Primary care providers (PCPs) are uniquely positioned to identify concerns early, offer interventions and refer to behavioral health services when needed. Research has shown that relying solely on clinical judgment positively identifies only 30% of clinical patients, whereas providers identify 70% of patients when using a validated screening measure. Systematic screening also helps practices meet quality metrics and enhance value-based care. The American Academy of Pediatrics’ (AAP) Bright Futures Guidelines recommend universal and targeted mental health screening across childhood and adolescence. These recommendations serve as a roadmap to help practices implement standardized screening protocols.

Broadband mental health screeners

Broadband screeners assess a wide range of emotional and behavioral symptoms across different domains. These tools are especially useful during well-child visits when no specific concern has been raised.

Common broadband screeners include:

• Survey of Well-being of Young Children (SWYC): A parent-reported questionnaire assessing behavior, development and family life.
• Early Childhood Screening Assessment (ages 18 to 60 months)
• Pediatric Symptom Checklist (PSC or PSC-Y): A parent- and youth-reported measure assessing internalizing, externalizing and attention symptoms.
• Strengths and Difficulties Questionnaire (SDQ): Available in parent-, teacher-, and self-report versions, this tool evaluates emotional symptoms, conduct problems, hyperactivity or inattention, peer relationship problems and prosocial behavior.

Broadband screeners are excellent for flagging general concerns but may lack the specificity needed to guide diagnosis or treatment planning. A positive result on a broadband screener should prompt further evaluation, including considering a targeted screen and assessment or referral to behavioral health.

Implementation tip: The key is to review and act on the results during the same visit. 

Narrowband mental health screeners

Narrowband screeners are designed to assess specific symptom clusters or diagnoses, such as depression, anxiety, ADHD or autism. These tools are best used when a concern has already been raised by the child, caregiver or school, or if flagged by a broadband screener. However, the AAP Bright Futures Guidelines recommend universal screening at certain ages for certain conditions. Results should be reviewed in real time to guide the visit and document clinical decision-making.

Examples of narrowband screeners include:

• Patient Health Questionnaire-9 (PHQ-9) Modified for Adolescents: A brief tool to assess depressive symptoms and suicide risk in teens.
• Screen for Child Anxiety Related Emotional Disorders (SCARED): Evaluates anxiety symptoms across several subtypes (e.g., social, generalized, separation).
• Vanderbilt Assessment Scales: Used for ADHD diagnosis and monitoring, with both parent and teacher versions.
• Preschool ADHD rating Scale IV – Preschool Version: Used to identify symptoms of inattention, hyperactivity and impulsivity in children ages 3 to 5 years old.
• Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F): Screens for autism spectrum disorder in toddlers aged 16-30 months.
• Patient-Reported Outcomes Measurement Information System (PROMIS®): Provides a wide range of narrow-band measures that providers can use when they suspect a specific disorder, such as anxiety or depression.
• EAT-26: Screener for eating disorders.

Implementation tip: Be prepared to interpret positive screens through a clinical lens —explore context, assess functional impact and validate symptoms before jumping to conclusions or referrals. Additionally, consider screening with multiple narrow-based screens as mental health concerns have overlapping symptoms. For example, your patient may not be concentrating due to a mood disorder instead of ADHD, which is what the family is worried about.

Integrating screeners into your workflow

Successful screening requires thoughtful integration into your clinic's workflow. There are many ways to integrate screening into your process, including:

• Pre-visit screenings through patient portals
• Medical assistant or nursing staff distribution during rooming
• Designated behavioral health staff review (if available)
• Electronic medical record (EMR) templates for documentation and scoring

Both the screening score and your clinical interpretation should be properly documented, and clear internal protocols should outline who scores the screeners, when results are reviewed and how positive screens are managed.

Screening is only effective when coupled with clinical interpretation and appropriate follow-up. Screeners are just the start. The clinical conversation, brief interventions and appropriate referrals are what bring value to the process. As part of the conversation, normalize the process for families by explaining that screening is a routine part of care that promotes overall health and well-being. And always be prepared for positive results with a toolkit of interventions, like handouts and referral pathways.

Billing and reimbursement for screening

Behavioral health screening is reimbursable and supports the financial sustainability of integrated care. The most commonly used codes are:

• 96127: Brief emotional/behavioral assessment (e.g., depression inventory, ADHD scale) per standardized instrument. This can be billed for each completed and reviewed screener, up to four times per visit by some insurers.
• 96110: Developmental screening (e.g., M-CHAT, SWYC, Ages and Stages Questionnaire)

Additional billing guidance to keep in mind:

• Screeners must be standardized and scored.
• Results must be documented and used in medical decision making.
• Check with payers for specific coverage policies and limits.
• Clear documentation is key. If you incorporate time-based billing (e.g., prolonged services or Evaluation and Management (E/M) based on total time) when mental health concerns extend the visit, make sure that it is accurately tracked.
• Establish a screening protocol that includes documentation templates, standard billing practices and EMR integration to streamline reimbursement and avoid missed opportunities.

Environmental factors impacting mental health

Young children are especially vulnerable to environmental influences. Below are a few environmental areas to consider while caring for families with young children.

Social determinants of health

Social determinants of health are recognized as environmental conditions across 5 domains that have a significant impact on young children’s physical health, mental health, wellbeing and development.  These domains include:

• Economic stability (e.g., poverty, food insecurity)
• Education access and quality (e.g., early childhood education)
• Healthcare access and quality (e.g., health insurance status)
• Neighborhood and built environment (e.g., neighborhood violence)
• Social and community context (e.g., concerns about immigration status)

Implentation Tip: It may be helpful to screen for social determinants of health and have resources available to positive responses. Findhelp.org and 211colorado.org are websites that can help you search for community resources.

Parenting stress

Parenting stress is significantly associated with children’s externalizing and internalizing mental health concerns.Specifically addressing parenting stress is important. Parent behavior does not fully explain the significant relationship between parenting stress and young child mental health concerns, but parenting stress is linked to teacher ratings of young children’s mental health concerns.

Evidence-based interventions that support families, such as behavioral parent training, can help young children and their parents.

Trauma

Trauma can be caused by a variety of events ranging from intentional violence (e.g., physical or sexual abuse, domestic violence, witnessing caregiver being harmed), disasters/accidents (e.g., car accident, forest fire) and medical procedures. Early childhood trauma can have a lasting impact on child development and their families.

The National Childhood Traumatic Stress Network provides a wealth of information and resources on early childhood trauma, including its effects on young children, methods to screen and assess trauma and appropriate interventions to recommend for early childhood trauma. The National Institute of Health provides a fact sheet on helping children cope with trauma.

Mental health referrals

If screening reveals mental health issues, healthcare professionals can support the family in accessing high-quality mental health services within the community. Children's Hospital Colorado's Pediatric Mental Health Institute provides evidence-based comprehensive mental health services.

For more information, providers can call 720-777-6200. The Colorado Pediatric Psychiatry Consultation & Access Program can offer provider-to-provider consultations on patients you have questions about while patients are awaiting higher levels of care. Additional Colorado mental health services can be found through the Colorado Department of Human Services.