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Enhancing Pediatric Mental Health Care: Algorithmsfor Primary Care

In 2004, the American Academy of Pediatrics (AAP) Board of Directorsappointed the Task Force on Mental Health and charged it to assistpediatricians and other primary care clinicians* in enhancing themen-tal† health care they provide. The task force determined that 3 goalswere important to accomplishing its purpose:Goal 1: Facilitate system changesGoal 2: Build skillsGoal 3: Incrementally change practice

The task force recommended addressing the goals sequentially; thatis, before implementing the clinical process proposed in this report,clinicians need to (1) accomplish system changes such as payment formental health services provided by primary care clinicians1,2 and de-velopment of clinical relationships with mental health specialists,3 (2)achieve mental health competencies,4 and (3) enhance their office sys-tems by applying chronic care methods to the care of children withmental health problems.5 Strategies the task force used to addressthese goals are summarized in the introduction to this supplement.6

In this report, the task force proposes a clinical process for deliveringmental health services in pediatric primary care settings. The reportsummarizes key features of this clinical process, then provides algo-rithms developed in collaboration with informaticians from the AAPCouncil on Clinical Information Technology; these algorithms areintended to ensure clarity of the proposed process and facilitate itstranslation to electronic systems. Appendix S5 lists procedural codesthat can be used in billing for each step of the process. An accompa-nying toolkit to assist with implementation is scheduled for distribu-tion in spring 2010.

The concepts and process proposed in this report were devel-oped by consensus of 4 groups, the members of which are listed in

*Throughout this document, the term “primary care clinicians” is intended to encompasspediatricians, family physicians, nurse practitioners, and physician assistants who provideprimary care to infants, children, and adolescents.†Throughout this statement, the term “mental” is intended to encompass “behavioral,” “neu-rodevelopmental,” “psychiatric,” “psychological,” “social-emotional,” and “substance abuse,”as well as adjustment to stressors such as child abuse and neglect, foster care, separationor divorce of parents, domestic violence, parental or family mental health issues, naturaldisasters, school crises, military deployment of children’s loved ones, and the grief and lossaccompanying any of these issues or the illness or death of family members. It also encom-passes somatic manifestations of mental health issues, such as fatigue, headaches, eatingdisorders, and functional gastrointestinal symptoms. This is not to suggest that the full rangeor severity of all mental health problems is primarily managed by pediatric primary careclinicians but, rather, that children and adolescents may suffer from the full range andseverity of mental health conditions and psychosocial stressors. As such, children withmental health needs, just as children with special physical and developmental needs, arechildren for whom pediatricians, family physicians, nurse practitioners, and physician assis-tants provide a medical home.

AUTHOR: Jane Meschan Foy, MD, for the AmericanAcademy of Pediatrics Task Force on Mental Health

Department of Pediatrics, Wake Forest University School ofMedicine, Winston-Salem, North Carolina

ABBREVIATIONSAAP—American Academy of PediatricsEI—early interventionIDEA—Individuals With Disabilities Education ActADHD—attention-deficit/hyperactivity disorder

Address correspondence to Jane Meschan Foy, MD, Departmentof Pediatrics, Wake Forest University School of Medicine, MedicalCenter Blvd, Winston-Salem, NC 27157. E-mail:[email protected]

www.pediatrics.org/cgi/doi/10.1542/peds.2010-0788

doi:10.1542/peds.2010-0788F

Accepted for publication Mar 24, 2010

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2010 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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Appendix S6. These members recog-nized that the “primary care advan-tage”7 is the opportunity for longitu-dinal relationships with children andfamilies—relationships that engenderthe trust to raise difficult issues andprovide clinicians the insight neces-sary to note changes or concerns oftheir own. The psychiatry literaturevalidates that a trusting therapeuticalliance predicts a person’s engage-ment in care for mental illness and afavorable outcome of that care overand above any specific treatment in-cluding medications.8

KEY FEATURES OF THE RECOMMENDEDPROCESS FOR ADDRESSINGCHILDREN�SMENTAL HEALTH NEEDSIN PRIMARY CARE SETTINGS

The task force members determinedthat the primary care process formen-tal health care should:

● Build on the unique skills of primarycare clinicians and the unique oppor-tunities of the primary care setting.These opportunities include promo-tion of social-emotional health andresilience in children and families;recognition of adverse childhood ex-periences and environmental stres-sors associated with emotional andbehavioral problems in children andadolescents; intervention to preventmental health problems and/or toaddress emerging mental healthproblems; and care of children withmental health disorders in a non-stigmatizing and supportive medicalhome, coordinated with mentalhealthspecialty services, school, childcare, and social services. Among themost important of the primary careopportunities is the primary care cli-nician’s capacity to have a positiveimpact on a child’s mental healthproblems without knowing preciselythe child’s diagnosis: evidence-based“generic” or “common-factors” inter-ventions (see Table 1).

● Fit the rapid pace of primary carepractice and not place additional bur-dens on clinicians already stressedby a full agenda and productivityrequirements.

● Normalize conversations about men-tal health and substance use to com-municate the importance of chil-dren’s mental health, signal theclinician’s openness to mental healthconcerns, and destigmatize mentalhealth/substance use topics.

● Reflect confidence in the child’s and

family’s capacity to be or to becomementally healthy or to maximize func-tion in the face of mental illness.Rather than the traditional medicalmodel, which focuses solely on prob-lems and risks, a process for effectivementalhealthcarebuildsonchildandfamily strengths and protective fac-tors. (Formore information, see Table2 and Fig 1 in the accompanying taskforce report, “Enhancing PediatricMental Health Care: Strategies forPreparing a Community.”3)

TABLE 1 Generic or Common-Factors Interventions: HELP

Primary care clinicians are accustomed to a certain level of diagnostic uncertainty. Children who presentwith fever are typically triaged on the basis of the child’s clinical appearance: the very toxic-appearingchild may require further diagnostic assessment and admission to the hospital for observation andpresumptive treatment; the child with clinical findings that suggest a specific diagnosis may be treatedas an outpatient and return for further attention if recovery does not progress as expected; the childwith mild symptoms may simply require parental reassurance, symptomatic care, and monitoring.Clearly, in many instances the clinician can relieve parental distress and decrease the child’sdiscomfort without knowing exactly what is causing the child’s symptoms.Similarly, in the absence of an emergent need, clinicians presented with a child’s mental health problemcan often take steps to address parents’ distress and children’s symptoms without knowing thespecific diagnosis. They may offer parenting strategies to cope with common behavioral problems.They may offer advice about lifestyle issues that affect mental health, such as sleep, exercise, sunlight,diet, and 1-on-1 time for the parent and child. They can use effective family-centered techniques knownas common factors, so called because they are common factors in a number of evidence-basedinterventions.9–12 These factors can be represented by the mnemonic HELP:H Hope: increase the family’s hopefulness by describing your realistic expectations for

improvement and reinforcing the strengths and assets you see in the child andfamily.

E Empathy: communicate empathy by listening attentively.L2 Language: use the child or family’s own language to reflect your understanding of

the problem as they see it and to give the child and family an opportunity tocorrect any misperceptions.Loyalty: communicate loyalty to the family by expressing your support and yourcommitment to help.

P3 Permission: ask the family’s permission for you to ask more in-depth questions ormake suggestions for further evaluation or management.Partnership: partner with the child and family to identify any barriers or resistanceto addressing the problem, find strategies for bypassing or overcoming barriers,and find agreement on achievable steps that are aligned with the family’smotivation.Plan: establish a plan (or incremental first step) through which the child and familywill take some action(s), work toward greater readiness to take action, ormonitor the problem and then follow-up with you, based on the child and family’spreferences and sense of urgency. (The plan might include, eg, gatheringinformation from other sources such as the child’s school, making lifestylechanges, applying parenting strategies or self-management techniques,reviewing educational resources about the problem or condition, initiatingspecific treatment, seeking referral for further assessment or treatment, and/orreturning for further family discussion.)

Considerable evidence suggests that medical generalists can readily learn and retain thesetechniques.12–14

Note that the use of multiple, brief visits (in contrast with the 45- to 60-minute visits common inmental health specialty practice)will often be necessary to address a child’s mental health concerns in a busy primary care practice. Experienced primary careclinicians can readily acquire skills in bringing a visit to an efficient close and increasing the likelihood that youth and familieswillcontinue in care.3 Results of studies in adult primary care have suggested that applying common-factors skills such as thoserepresented by the HELP mnemonic can improve patient outcomes without increasing the length of visits.15

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● Incorporate tools for assessingthe functioning of the child andfamily—routinely during health su-pervision visits, when faced withsocial-emotional challenges or symp-toms, and periodically to monitorprogress in mental health care.

● Take into consideration the many fac-tors that may impede families fromseeking or using mental health ser-vices for their children (eg, stigma,family conflict or dysfunction, culturaldifferences in conceptualizing mentalhealth problems, a sense of hopeless-ness about recovery, inadequate fi-nancial resources or insurance cov-erage, or inaccessibility of specialtymental health services).

● Provide for effective partnership ofprimary care clinicians, families, men-talhealthprofessionals,developmental-behavioral and adolescent special-ists, educators, andagency personnelin both the assessment and care pro-cesses (see the accompanying taskforce reports “Enhancing PediatricMental Health Care: Strategies forPreparing a Community”3 and “En-hancing PediatricMental Health Care:Strategies for Preparing a PrimaryCare Practice”5). It is critically impor-tant that relationships and proce-dures, worked out in advance, includeprotocols for sharing informationamong health professionals, schools,and agencies and for managing psy-chiatric and social emergencies iden-tified by the primary care clinician.

● Reflect the many factors that contrib-ute to decision-making about mentalhealth care, including urgency of theneeds, comfort of the primary careclinician, family preferences, and ac-cess to resources.

● Be consistent with evidence-basedbest practices, to the extent the evi-dence exists.

● Reflect the prevalence of substanceuse among children and adoles-cence, not just of illegal substancesbut prescription drugs that arereadily accessible in many house-

holds (see Table 3). Not only do sub-stances have a direct effect on thedeveloping brains of young peopleand on their behavior, but theiruse also has an indirect effectthrough association with violence,car crashes, sexual activity, inter-personal conflict, and academicfailure.

● Recognize the chronicity of manymental health problems in childhoodand adolescence and incorporateevidence-based principles of chroniccare management, such as those ap-plied to asthma and diabetes,17 with-out losing sight of each child’s poten-tial for recovery (see “Strategies forPreparing a Primary Care Practice”5).

● Ensure appropriate payment of pri-mary care clinicians.

For definitions, see the introduction tothis supplement.6

ALGORITHMS THAT DESCRIBE THEPROCESS

The following algorithms represent anidealized process for themental healthcare of children in primary care set-tings. The figures in the algorithm donot represent a particular time frame:several steps in the process may takeplace at 1 contact, and 1 step in theprocess may require several contacts.For points at which data from outsidesources are needed or referrals are

TABLE 2 Protective (Resilience) Factors inChildren and Youth

Demonstrates physical, cognitive, emotional,social, and moral competenciesEngages in behaviors that promote wellness andcontribute to a healthy lifestyleForms caring, supportive relationships withfamily, other adults, and peersEngages in a positive way with the life of thecommunityDisplays a sense of self-confidence, hopefulness,and well-beingDemonstrates resiliency when confronted withlife stressorsDemonstrates increasingly responsible andindependent decision-making

Adapted from Hagan JF, Shaw JS, Duncan PM, eds. BrightFutures: Guidelines for Health Supervision of Infants, Chil-dren, and Adolescents. 3rd ed. Elk Grove Village, IL: Amer-ican Academy of Pediatrics; 2008:521.

TABLE 3 Trends in Monthly and Annual Prevalence of Use of Various Drugs in Grades 8, 10, and 1216

8th-Graders, % 10th-Graders, % 12th-Graders, %

Previous Year Previous 30 d Previous Year Previous 30 d Previous Year Previous 30 d

Alcohol: 30.3 Alcohol: 14.9 Alcohol: 52.8 Alcohol: 30.4 Alcohol: 66.2 Alcohol: 43.5Drunk: 12.2 Drunk: 5.4 Drunk: 31.2 Drunk: 15.5 Drunk: 47.0 Drunk: 27.4Marijuana: 11.8 Marijuana: 6.5 Marijuana: 26.7 Marijuana: 15.9 Marijuana: 32.8 Marijuana: 20.6Inhalants: 8.1 Inhalants: 3.8 Vicodin: 8.1a Amphetamines: 3.3a Vicodin: 9.7a Narcotics other than heroin: 4.1a

Amphetamines: 4.1a Amphetamines: 1.9a Amphetamines: 7.1a Inhalants: 2.2 Amphetamines: 6.6a Amphetamines: 3.0a

OTC cough/coldmedications: 3.8

Inhalants: 6.1 Tranquilizers: 2.0a Tranquilizers: 6.3a;barbiturates: 5.2a

Barbiturates: 2.5a

Tranquilizers: 2.6a OTC cough/coldmeds: 6.0

OTC cough/coldmedications: 5.9

Tranquilizers: 2.7a

Cigarettes: 6.5; smokelesstobacco: 3.7



OTC indicates over-the-counter.a Prescription medication.

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made, the process will necessarily ex-tend to a return visit. A number of activi-ties may occur before or after an en-counter, such as preencounter parent/youth reports with validated tools. Thetask force invites clinicians to developtheir ownpace, informedby available re-sources, practice capacity, patient pref-erences, and circumstances.

Algorithm A (Fig 1) provides a frame-work for promoting social-emotionalhealth and identifying and respondingto new mental health concerns,whether raised by parents in schedul-ing the visit or suggested by the data-collection and assessment activitiesdescribed. The ongoing care of chil-dren with identified mental health con-cerns is addressed in Algorithm B.

The task force suggests that primarycare clinicians consider a sequence of

implementation that begins with Algo-rithm B, ensuring sound proceduresfor managing children with identifiedconditions before attempting to iden-tify additional children with occultmental health needs. (See “Strategiesfor Preparing a Primary Care Prac-tice”5 for rationale and furtherdiscussion.)

Algorithm A: Promoting Social-Emotional Health, IdentifyingMental Health and Substance UseConcerns, Engaging the Family,and Providing Early Intervention inPrimary Care

A1a: Visit (Prenatal, Nursery, orPrimary Care) Scheduled

Scheduling of any visit at any age cantrigger data-gathering in advance ofthe visit, as described in step A2a.

A2a: Collect and Review Previsit Data

To create efficiency during scheduledvisits, clinicians can adopt the use of aprevisit questionnaire, either paper orelectronic, filled out at the patient’shome or in the waiting room. Thisquestionnaire can incorporate vali-dated instruments to screen for men-tal health problems and assess psy-chosocial functioning; these tools canbe scored or interpreted before thevisit. Such an approach enables the cli-nician to focus on building rapport andexploring findings rather than on rotedata-gathering, while still being sys-tematic in obtaining information. Suchan approach is particularly importantif a visit is scheduled for 1 of the follow-ing reasons:

● the parent or child has a mentalhealth concern;

FIGURE 1Algorithm A: promoting social-emotional health, identifying mental health and substance use concerns, engaging the family, and providing EI in primarycare.


● the clinician has previously identi-fied a mental health concern (eg, atan acute care or emergency depart-ment visit) and asked the child toreturn for further assessment;

● the child is in foster care or the ju-venile justice system or, for any rea-son, is at increased risk for psycho-social problems (eg, homelessness,school dropout, death of a lovedone, exposure to violence or otheradverse childhood experience, pa-rental mental illness);

● the child’s child care provider orteacher has expressed concernabout the child’s development or be-havior (or the child has been sus-pended or expelled); or

● the child has a chronic medicalcondition or disability that placeshim or her at greater risk thanother children for mental healthproblems.‡

A structured process, developed by thepractice in advance (see “Strategiesfor Preparing a Primary Care Prac-tice”5), should ensure that the follow-ing content is covered:

● the family’s priorities for the visit;

● family/social history (includingstresses, support system, environ-mental risk assessment, trauma,separation, and loss);

● identification of the child’s and fam-ily’s strengths;

● functional assessment of the childand family by using validatedinstruments (see discussion inSupplemental Appendix S12);

● temperament19 and risk behaviors;

● school or child care reports, par-ticularly if school or child carepersonnel have expressed con-cerns; and

● appropriate validated screeningtool(s) for age (see discussion inSupplemental Appendix S12).

Electronic questionnaires provide anopportunity for the use of “item re-sponses.” For example, the computerasks the respondent 2 or 3 basicquestions. If the answer is no tothose questions, the respondentmoves on; if the answer is yes, thecomputer asks more questions. Ifprevisit data collection is not feasi-ble, the clinician will need to incorpo-rate data collection into the clinicalencounter. In this case, explorationof positive findings may require afollow-up encounter.

A3a: Provide Initial ClinicalAssessment; Observe Child-ParentInteractions

During the face-to-face encounter, theprimary care clinician can completethe following steps:

● Identify, elicit, or review the child’sand family’s priorities for the visit.

● Review previsit questionnaire, otherdata collected, progress on any pre-vious concerns, and adjustment andprogress in child care, preschool,or school.

● Broaden the agenda by indicatingopenness to mental health issues.For example, elicit further informa-tion about any current concerns,the child’s or family’s past or cur-rent sources of care for the con-cerns, and progress on previousconcerns; if screening tools havebeen completed, use any positive re-sponses as a springboard to furtherdiscussion and clarification. Askbroad, open-ended questions suchas, “What has been the hardest partabout taking care of Jonah?” fol-lowed by, “What has been the bestpart?” Such questions convey theclinician’s interest in family func-tioning and invite vexing questionsthat may have been posed to rela-

tives and friends but may have notbeen felt appropriate for this medi-cal setting. Whatever methods areused to gather information, includeinquiry about parental well-being(looking particularly for problemswith parental mood, affect, or attach-ment to the child), the child’s develop-mentally specific symptoms of emo-tional disturbance (see Table 1 inSupplemental Appendix S13), and thechild’s and family’s strengths (seestep A4a).

● Observe parent-child interaction.20,21

● Interact with the child.

● Complete interview and physicalexamination (including vision andhearing screening, because a sen-sory deficit may cause academic orbehavioral difficulties).

● Identify the child’s and family’sstrengths.

Primary care clinicians can gain addi-tional insights from examining theirown reaction to the parent and childand considering the family’s culturalcontext.22,23

Additional physical assessment maybe indicated in response to mentalhealth concerns. Developmental disor-ders, epilepsy, sleep disorders, and en-docrine disturbances are among con-ditions that may first manifest withbehavioral or emotional symptoms.The extent of the physical examinationand related testing depends on thetype and severity of concerns raised.Repeated somatic complaints or exac-erbation of a chronic medical condi-tion may be the initial presentation ofan emotional difficulty, so these symp-toms may prompt further mentalhealth assessment. Interpretation offindings may vary according to age.For example, physical symptoms, suchas growth failure, might signal mentalor emotional concerns in infants andyoung children. During middle child-hood, academic difficulties can signal

‡Unidentified mental health problems in childrenand youth with special health care needs may con-tribute to poor control of medical conditions, som-atization, and overutilization of medical services byboth the child and parents.18

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mental health concerns or learningdisabilities. In adolescents, schooldropout or risky behaviors such assexual activity or substance use maybe associatedwithmental health prob-lems. See Table 2 in SupplementalAppendix S13 for additional informa-tion.

At this point in the algorithm, the clini-cian need not feel pressed to make adiagnosis but simply to determine ifthere may be a mental health concernin the child or family.

The increasing independence of ado-lescents, and the likelihood that par-ents and guardians may not be fullyaware of their adolescents’ activitiesor feelings, reinforce the need forprivate, confidential discussions be-tween clinicians and their adoles-cent patients. These discussionsshould augment, not replace, discus-sions with parents. Youth and par-ents differ in their ability to report onvarious mental health conditions: aparent may have a more accuratepicture of the effects of externalizingsymptoms (eg, hyperactivity, inatten-tion, oppositionality), whereas youthmay be better able to articulate thetoll of internalizing symptoms orconditions (eg, anxiety or depres-sion); or the youth and parents maydisagree about the nature or impor-tance of symptoms. As part of thesediscussions, clinicians are obliged toaddress confidentiality and its limitswith both adolescents and theirparents.24,25

A4a: Acknowledge and ReinforceStrengths

Effective mental health care requiresthat clinicians move from a medicalmodel focused on problems to a morecomprehensive view of the child’sand family’s capacities. There are8 empirically determined inde-pendent “intelligences”: linguistic,logical-mathematical, spatial, bodily

kinesthetic, musical, interpersonal,intrapersonal, and naturalistic.26 Ac-knowledging strengths (�1 of theseintelligences; talents; qualities suchas resilience, generosity, courage,tenacity, goal-orientation, focus; so-cial supports such as strong familybonds, extended family support, orgood peer relations; healthy behav-iors such as regular exercise/sleeproutines, participation in extracur-ricular or spiritual/religious activi-ties; or attitudes such as hope, opti-mism, and motivation to seek help)can build rapport, provide ground-work for an intervention plan, andfacilitate accomplishment of subse-quent steps.27 Diagnosing strengthsmay also stimulate the family to pro-vide further opportunities for thechild’s development of competence,serving as a buffer for the challengesand peer pressures of adolescenceand offering alternatives to riskyactivities.27

A5a: Concerns (Symptoms, FunctionalImpairment, Risk Behaviors,Perceived Problems)?

No, There Are No ConcernsIf the child and family show no

signs of functional impairment ordistress and no risk behaviors areidentified and no mental health con-cerns are raised by the family, de-rived from screening or perceived bythe clinician, the clinician can moveto step A6a.

Yes, There Are ConcernsAny positive findings (functional im-

pairment; symptoms concerning to thechild, family, or clinician; family dis-tress; family member with mental ill-ness; exposure to trauma; environ-mental risks such as a weapon in thehome of a child with suicidal or homi-cidal thoughts; risky behaviors; or per-ceived problems) necessitate furtherattention by the clinician, beginningwith step A8a below.

A6a: Provide Anticipatory Guidancefor Age per Bright Futures, ConnectedKids, or KySS

Strategies to promote mental healthand provide anticipatory guidance ap-propriate to the child’s age are pro-vided in Bright Futures,28 ConnectedKids,29 and KySS (Keep Your Children/Yourself Safe and Secure).30 See also“Strategies for Preparing a PrimaryCare Practice”5 and Appendix S2 andAppendix S7 for parenting resourcesand evidence-based programs for pro-moting mental health and enhancingschool success.

A7a: Return to Routine HealthSupervision

Clinicians can broaden the agenda toother issues and return to step A1a atthe next scheduled contact.

A1b: Acute Care Visit

Because families sometimes miss rou-tine health supervision visits, clini-cians who are interested in elicitingmental health concerns will increasetheir effectiveness if they use the op-portunity of acute care visits to elicitmental health concerns.

A2b: Incorporate Brief Mental HealthUpdate

The task force has drawn from the ex-pertise of its professional members,opinions of its youth and family mem-bers, and informal trials in primarycare practices to develop the recom-mendation that clinicians use acutecare visits as an opportunity to per-form a brief mental health update (see“Strategies for Preparing a PrimaryCare Practice”5). There is a compellingneed for further research to documentcosts and benefits of this approachand to establish best practice. The taskforce recognizes that incorporating amental health update during acutecare visits may be daunting in somepractice environments. Cliniciansmight consider implementing acute




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care mental health activities incre-mentally, beginning perhaps with chil-dren who have missed routine healthsupervision visits or those in certainhigh-risk groups, such as children infoster care. Alternatively, clinicianscan use the context of the acute carevisit (eg, an injury) to lead naturallyinto mental health topics (eg, “Hadyou or your friends been drinkingwhen this happened?” or “Has thisperson [the perpetrator of the injury]ever threatened you or injured youbefore?”).

Because of the association betweensleep difficulties and mental healthconditions, questions regarding sleepare helpful throughout childhood. Thewording of such questions is impor-tant to adolescents, whomay have con-flict with their parents around sleepissues. The task force recommendsthat clinicians avoid questions that re-quire only yes or no answers andphrasing such as, “Are you gettingenough sleep?” Instead, cliniciansmight ask, for example, “How hard isit for you to fall asleep when youwant to?”

Responses to these questions provideinformation that can alert clinicians tothe need for more extensive assess-ment. In the absence of any concern,3 to 5 general questions can be com-pleted in as many minutes. AppendixS8 provides examples. If a concern isidentified, the clinician can expressinterest, triage for emergencies as instep 8a, and plan with the family toaddress the concern at a scheduledfollow-up visit (step 1a). (The HELPmnemonic, shown in Table 1, providesguidance for engaging the family andclosing the visit supportively.)

During adolescence, it is importantthat the clinician address questions tothe patient in a private setting and ex-plain the conditional confidentiality ofthe conversation. The clinician canquestion younger children privately,

depending on practice protocols andthe comfort of the patient and parent.In all instances, the clinician shouldalso direct questions to the parents.Discrepancies in responses betweenthe parent and child may signal differ-ent levels of awareness, varying per-ceptions of the importance of an issue,or family conflict that should be ex-plored further.

Adolescents caution that questions onsubstance abuse and other sensitivetopics may seem intrusive and be un-likely to yield a candid response duringa brief mental health update. A fram-ing statement such as, “Many youngpeople I’m seeing feel lots of stressthis time of year” or “. . .lots of pres-sure to use drugs,” or a circular ques-tion such as “Do any of your friendssmoke, drink, or use other drugs?”may be better received than directquestions about the adolescent’s be-haviors. If the clinician has cause forconcern, such as deteriorating schoolperformance or injuries, or if this is anissue that he or she is already follow-ing, more specificity is warranted. TheAdolescent Health Working Group’s Be-havioral Health: An Adolescent Pro-vider Toolkit31 provides tools to aid inconversing with adolescents. The num-ber 1 reason that teenagers do not dis-close sensitive information is that cli-nicians do not assure them ofconfidentiality.32

A3b: Concerns?

Thesemight be the child’s, the family’s,or the clinician’s concerns.

No, There Are No ConcernsProceed to step A7b.

Yes, There Are ConcernsIf mental health or substance abuse

concerns are raised by parents, chil-dren, youth, or the clinician as a resultof the brief mental health update, theprocessmoves on to triaging for emer-gencies: step A4b/A8a.

A7b: Return to Acute Care Visit

If no concerns are raised, clinicianscan acknowledge the child’s and fami-ly’s strengths and return to the acutecare visit.

A4b/A8a: Emergency?

The presence of a mental health,substance use, or social-emotionalconcern triggers the triage process.Psychiatric and social emergencies in-clude sexual or physical abuse, suicid-ality, threat of violence to or by thechild, psychosis, addiction to or with-drawal from substances, acute intoxi-cation, and family dysfunction or so-cial circumstances that threaten thesafety of the child (eg, domestic vio-lence). Inadequate family resources(eg, homelessness or hunger) mayalso pose urgent health and safety risks.Supplemental Appendix S14 provides atool for assisting in identifying suiciderisk.

Primary care clinicians must have asystem in place to ensure immediateevaluation of children with suicidalthoughts (see “Strategies for Prepar-ing a Primary Care Practice”5) or them-selves ask key questions regardingsuicidal thoughts, presence of a plan,access to lethal weapons such as fire-arms, and support systems. On the ba-sis of responses, the clinician can as-sess the level of risk and determine ifimmediate intervention is indicated.

No, Findings Do Not Suggest anEmergencyGo to box A6b.

Yes, Findings Suggest an EmergencyGo to A5b/A9a.

A6b: Return to Acute Care Visit; Planto Enter Algorithm at Step A1a

If there are no findings that suggest apsychiatric or social emergency, applythe generic skills represented by theHELP mnemonic (Table 1). The planmay involve an incremental first step

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toward addressing a barrier or re-turning to the algorithm at step A1a.

A5b/A9a: Facilitate Referral forSpecialty Services or EmergencyFacility; Reenter Algorithm atAppropriate Point (or A1a)

The presence of certain psychiatric orsocial emergencies (eg, suspicion ofabuse or neglect, risk of homicide)may require immediate action man-dated by state law (eg, reporting to so-cial services or legal authorities) andsteps to protect the safety of anyonethreatened by the emergency, as wellas referral for psychiatric care. Ide-ally, procedures would have been es-tablished in advance with mentalhealth specialty and social service pro-viders in the community or region (see“Strategies for Preparing a Communi-ty”3 and “Strategies for Preparing aPrimary Care Practice”5). The clinicianshould provide medical care as indi-cated, follow procedures for notifica-tion of authorities, provide reassur-ance to the child and family about theclinician’s ongoing interest in the childand family, and put in place a plan tofollow-up and provide other medicalhome services.

The clinician can facilitate sharing ofinformation with mental health spe-cialty or social service providers by ob-taining written permission from thefamily for exchange of information. Af-ter receiving mental health specialtycare and/or social services for theemergent issue(s), children who areup-to-date on routine health supervi-sion ideally reenter the primary careprocess at step B1b of Algorithm B;those who are not up-to-date wouldideally reenter at step A1a of AlgorithmA. In either case, information about thechild’s and/or family’s progress inmental health specialty treatmentand/or social services is critical to pri-mary care follow-up.

A10a: Provide Initial Intervention;Facilitate Referral of Family Memberfor Specialty Services if Indicated

If there are no signs of an emergentsituation, the clinician can provideinitial common-factors interventions(see Table 1, HELPmnemonic). The planof action might require multiple visitsand include any of the following ele-ments, in accordance with the family’swishes:

● Offer to provide advice, if wanted, onparenting techniques to addressacute problems (eg, toileting, home-work, sibling conflicts, anger out-bursts) and general steps the familycan take to enhance the child’s andfamily’s mental health, such as im-proving sleep hygiene or nutrition,reducing time spent watching tele-vision or using electronic media, in-creasing outdoor time, increasingphysical activity, learning stressmanagement techniques, or sched-uling a special time each day for theparent to give 1-on-1 attentionto each child. Resources includeBright Futures in Practice—MentalHealth,33,34 the American Academy ofChild and Adolescent PsychiatryWeb site,35 the AAP Healthy ChildrenWeb site,36 and AAP publications andbrochures.

● Inquire about any traumatic eventsor losses in the life of the child andfamily that may have triggered thechild’s symptoms ormay be contrib-uting to the child’s or family’s prob-lems in coping. Examples of suchevents or losses include the death ofa loved one or pet; a move; home-lessness; conflict, separation, or di-vorce of parents; military deploy-ment of the parent(s) or other lovedones; incarceration of the child or aloved one; breakup of a relationship;abuse or bullying by the child ortargeting the child; exposure to

violence (either directly or emotion-ally, through death or injury of aloved one); or a natural disaster. Itis necessary to inquire separately ofyouth and parents, because someevents that affect children and ado-lescents may go unrecognized bythe parent or be confidential fromthe parent, and some parents maybe reluctant to discuss some eventsor losses in front of their children. Inthe case of trauma exposure, the cli-nician should allow the child toshare his or her own narrative ofthe experience but not lead the childand family into reliving the incident,which may result in further traumato those who experienced it. Chil-dren vary widely in their reactionsto trauma and loss, depending ontheir developmental level, tempera-ment, previous state of mentalhealth, coping mechanisms, paren-tal responses, and support system.It is important for the primary careclinician to express empathy, to as-sess the functional impact of theloss or trauma on the child and fam-ily, to offer support, to put in placea mechanism for monitoring thechild’s and family’s short-term andlong-term progress, and to continueoffering empathy and support witheach contact. Guides are availableto help clinicians in this process.37 Ifthe impact is severe and/or persis-tent, it may be appropriate to offercounseling through a communityreferral.

● Offer community resources and ed-ucational materials that may aid thechild or parents in understandingthe mental health problem(s) beingaddressed. These resources canalso include important Web sites(eg, www.healthychildren.org,36

www.nami.org,38 www.chadd.org,39

www.napnap.org,40 www.ffcmh.org,41

www.samhsa.gov,42 www.aacap.org,35


and www.compassionatefriends.org43).

● If a family member has medical,mental health, or social needs thatcontribute to the child’s problem orto family stress, explore this per-son’s readiness to seek and accepthelp and initiate referrals as appro-priate, taking care to avoid “blam-ing” language.

If screening-tool results and/or otherfindings suggest that the child’s prob-lem falls into certain common symp-tom “clusters,” there may be strate-gies that motivated parents can learnduring brief primary care encountersand/or from well-vetted resources.The task force developed guidancerelated to children from birth to 5years of age with symptoms of social-emotional problems and for olderchildren with the symptom clusters ofinattention and impulsivity, anxiety, de-pression, disruptive behavior and/oraggression, substance abuse, andlearning difficulties.

At the close of every visit, ensure thatall steps in the HELP mnemonic (seeTable 1) have been completed. Applica-tion of this approach has been shownto be effective in decreasing the par-ents’ distress and improving chil-dren’s functioning across a number ofmental health problems.12 Using thisapproach in multiple visits may yieldadditional benefits. The clinician canmonitor the child’s progress by enlist-ing the parents to observe for persis-tence or worsening of symptoms, bymaking telephone contact with thefamily at appropriate intervals, and/orby inquiring at the time of return visits.

A11a: Further Diagnostic AssessmentNeeded?

NoIn the absence of functional im-

pairment or indications of a specific,

treatable condition, further assess-ment may not be necessary. Examplesinclude a 10-year-old who is attend-ing a new school and experiencingdecreased sociability; an adolescentmother with mild anxiety; sleepless-ness after a minor motor vehiclecrash; increased parent-child conflictat a time of family stress; and flare-upsof chronic but relatively mild problemsrelated to temperament or delayed so-cial skills.

YesIndications for further diagnostic

assessment include impaired func-tioning; screening results that suggestthe probability of a disorder; symp-toms that worsen or persist despiteinitial intervention; a parent or childwho manifests distress out of propor-tion to findings; and clinician concernor discomfort.

A12a: Collect and Review Data FromCollateral Sources

If findings point to academic or behav-ioral problems in school or difficultywith peers, primary care cliniciansneed information from the child’sschool and/or child care provider. Of-fice procedures should ensure thatparents of school-aged children com-plete a form that authorizes the schooland primary care clinician to exchangeinformation. Specifically, the primarycare clinician is looking for detailsabout the child’s functioning in theschool setting and any discrepancy be-tween cognitive ability and academicachievement that would suggest alearning disability. Developing a com-munity understanding about the roleof school personnel in collecting datafor primary care clinicians and therole of primary care clinicians in in-forming school personnel about stu-dents’ medical and mental healthneeds greatly facilitates interaction

between the primary care clinicianand school personnel44 (see “Strate-gies for Preparing a Community”3 and“Strategies for Preparing a PrimaryCare Practice”5). The primary care cli-nician can also request informationabout preschool-aged children fromtheir child care provider(s).45

If parents are separated, divorced, orin conflict, it is important to gather in-formation from the parent who is notrepresented at the visit, if that parentis involved in the child’s life. If a grand-parent, foster parent, or other guard-ian is involved in the care of the child,information from this individual is alsoimportant. Several validated toolshave parent versions that can be usedfor this purpose (see SupplementalAppendix S12). Use of a tool does notsubstitute for including this caregiverin future discussions involving thechild.

If there has been previous involve-ment of other agencies or health pro-fessionals with the child or family,clinicians need to obtain the youth’sand family’s (or guardian’s) consent torequest records from these sources.For children in foster care, it is criti-cally important to work through caseworkers to collect information frombiological and foster parents if adultswho are unfamiliar with the child’shistory accompanied the child to thevisit.

A13a: Proceed to Algorithm B

Algorithm B (Fig 2) describes theprocess of further assessment andcare for children who present withor manifest mental health concernsthat negatively affect their function-ing and/or do not respond to initialintervention.

For some children and families, theneed for additional assessment willcause increased anxiety, and somemay respond to this anxiety with re-

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sistance. Clinicians can comfort andreassure the child and family by fullyunderstanding the family’s opinions,preferences, cultural perspective onseeking mental health care, resources(including health insurance coverage),and priorities; establishing agreementon the nature and implications of cur-rent concerns and the family’s readi-

ness to seek further consultation ortreatment; emphasizing strengths andassets; and rolling with resistance tofurther assessment (eg, by offering afollow-up conference to discuss fur-ther if the family is not ready). If theassessment process is deferred to asubsequent visit because of time pres-sures, the need to collect further infor-

mation, or the family’s lack of readi-ness, then clinicians may choose tofollow-up with a telephone call. Itis important to use office trackingmechanisms to ensure follow-up ofchildren and families who are notyet ready to take action (see “Strate-gies for Preparing a Primary CarePractice”5).

FIGURE 2Algorithm B: assessment and care of children with identified social-emotional, mental health (MH), or substance abuse (SA) concerns, ages 0 to 21 years.


Algorithm B: Assessment and Careof Children With Identified Social-Emotional, Mental Health, orSubstance Abuse Concerns, Ages 0to 21 Years

B1a: Further Assessment Needed forMental Health/Substance AbuseConcern

Enter the algorithm at this point if asocial-emotional or mental health con-cern or functional impairment hasbeen previously identified by the pri-mary care clinician; if symptoms iden-tified by screening instruments, ques-tionnaire, interview, or observationsuggest the probability of a disorderand/or do not respond to the initial in-tervention; or if the parent or childmanifests distress out of proportion tofindings. In making this decision, con-sider the persistence and severity ofthe problem and the family’s andchild’s readiness to seek help. If thefamily or child is not ready to seekhelp, apply common-factors tech-niques (see the HELP mnemonic in Ta-ble 1) to reach agreement on an incre-mental step.

B1b: Child Receiving Mental Health/Substance Abuse Specialty Services

Enter the algorithm at this point if thechild is currently involved in mentalhealth specialty care. The primarycare clinician can express interest incollaborating with the mental healthspecialist(s) and move on to step B2b/B4a. If the primary care clinicianmeetsresistance, he or she can explore itsroots as in Algorithm A, step A10a.

B2a: Who Will Provide FurtherAssessment?

At this point the clinician will con-sider findings from earlier steps in theprocess, his or her own competenceto provide further assessment in thearea(s) suggested by earlier findings;

and family preferences and resources,including health insurance benefitsand any health plan requirements foraccessing mental health services. Thetask force offers the following as gen-eral guidance.

Children Younger Than 5 Years of AgeThe task force has developed guid-

ance for primary care clinicians inassessing and responding to social-emotional problems in children youngerthan 5 years of age and disturbancesin parent-child relationships. Thisguidance includes indications for re-ferral to a developmental-behavioralpediatrician, mental health specialistwith expertise in early childhood, ther-apist for the parent or the parent-childdyad, specific professional (eg, speechpathologist), developmental evaluationteam, or other community resource.Every community in the United

States has an agency assigned by thestate to provide Early Intervention (EI)services. These include assessmentand care coordination, as mandatedby the Individuals With Disabilities Ed-ucation Act (IDEA), for children frombirth to 3 years of age with develop-mental problems; however, generaland subspecialty pediatric assess-ment are often not included in the EIassessment process. Children 0 to 3years of age who qualify for services(occupational, physical, or speechtherapy; education) must receive themin the least restrictive environment(usually their home) on the basis oftheir documented delay in language,motor, personal social, and/or adap-tive domains. Some states extend EIservices to 0- to 36-month-old childrenwho are at risk for developmentalproblems, as well as those with diag-nosed problems. The IDEA specifiesthat states receiving certain catego-ries of federal funding must provideassessment and an Individual FamilyServices Plan to all 0- to 3-year-oldswho are substantiated as abused or

neglected or who are identified as af-fected by illegal substance abuse orwithdrawal symptoms that result fromprenatal drug exposure. Developmen-tal and educational services for chil-dren aged 3 to 5 years are also man-dated and regulated by the IDEA. Inmost states, the public school systemis responsible for developmental as-sessment and education of childrenwith significant delays, whereas inother states, the EI programs continueto provide assessment and servicesfor this age group.Examples of problems that require

further evaluation by 1 of these re-sources include disordered parent-childrelationship, parental mental illness,language or communication delay, dis-ruptive behavior with aggression, abuseor neglect of the child, and self-injury.See “Strategies for Preparing a PrimaryCare Practice”5 and Appendix S2 forevidence-based interventions for infantsand young children, their parents,and/or caregivers. High-quality childcare and preschool have a protectivelong-lasting benefit, especially for chil-dren at high developmental and behav-ioral risk; clinicians may also refer tothese programs. When community re-sources are insufficient or ineffective,primary care clinicians can partnerwithdevelopmental-behavioral pediatricians,early childhood educators, parent edu-cators, and mental health providers tobuild or strengthen the critically impor-tant service system for this population.

Children Aged 5 to 21 YearsPrimary care clinicians should con-

sider referring to a mental health spe-cialist for further evaluation childrenaged 5 to 21 years of age with 1 ormore of the following problems:

● suicidal intent;

● severe functional impairment;

● rapid cycling mood;

● depressive symptoms in a preado-lescent;

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● extreme outbursts/problems withconduct;

● severe eating problems;

● psychotic thoughts or behavior;

● self-injury;

● comorbidity of substance abuseand mental health problems;

● a score of 2 or more on the CRAFFT(car, relax, alone, forget, friends,trouble) screening tool46;

● attention-deficit/hyperactivity dis-order (ADHD) with comorbidities;and

● any other problem that the cliniciandoes not feel prepared to address.

Primary care clinicians with requi-site competencies4 can effectively as-sess children 5 to 21 years of age withmild-to-moderate levels of functionalimpairment associated with the fol-lowing symptom clusters:

● anxiety;

● inattention and impulsivity;

● disruptive behavior and aggression;

● depression;

● substance use; and

● learning difficulties.

Tools developed by the task forceoutline primary care assessment ofchildren with symptoms in each ofthese clusters and suggest specific in-dications for specialty referral of chil-dren who experience symptoms in thatcluster.

B3a: Facilitate Referral toSpecialist(s) for Further Assessment

Clinicians in a wide range of disci-plines can provide diagnostic assis-tance in these situations, includingdevelopmental-behavioral pediatri-cians, neurodevelopmental pediatri-cians, adolescent medicine specialists,pediatric neurologists, psychiatrists, EIspecialists, clinical psychologists,school psychologists, clinical socialworkers, advanced practice nurses

with specialized psychiatric training,and substance abuse specialists.These professionals may practice inpublic mental health or developmentalclinics, in schools, in private practice,or in university settings.

If a mental health referral will requireauthorization by the family’s health in-surance plan; entry into a carved-out,or parallel, private behavioral healthinsurance plan; or entry into the publicmental health system, the family willlikely need guidance and time to re-search the options. If so, the cliniciancan bring the visit to a close (againfollowing the HELP mnemonic [Table1]) and schedule a return visit or anappointment with a staff member tofacilitate this process.

The decision to involve a specialist indiagnostic assessment means that theprimary care clinician’s role will in-clude communicating with the special-ist. As with any other specialty refer-ral, the process is enhanced byconveying to the specialist the natureof the concern and the primary careclinician’s specific questions, resultsof previous assessment and interven-tion efforts, and openness to discus-sion with the professional. Althoughthe Health Insurance Portability andAccountability Act (HIPAA) allows ex-change of information among profes-sionals who are involved in the care ofa mutual patient, many mental healthprofessionals are reluctant to shareinformation without express consentof the child and family. By obtainingwritten consent and sending it to themental health professional, the pri-mary care clinician can convey inter-est and facilitate communication.

Established relationships with special-ists greatly facilitate the primary careclinician’s role in making an effectivereferral. The Strategies for SystemChange in Children’s Mental Health: AChapter Action Kit1 and the AAP TaskForce on Mental Health reports “Strat-

egies for Preparing a Community”3 and“Strategies for Preparing a PrimaryCare Practice”5 have a number of sug-gestions for building these relation-ships at the practice, community, re-gional, and state levels. Integration of amental health professional within theprimary care practice is a model thathas particular promise. Primary careclinicians will likely experience growthin their own comfort and competenceas a result of interaction with mentalhealth professionals.

It is critical that the practice trackchildren referred for specialty care.If the family is unsuccessful in ac-quiring a timely assessment for thechild, the primary care clinician canoffer generic intervention efforts (asdescribed in Algorithm A), furtherprimary care assessment and man-agement strategies, or periodic tele-phone contacts to monitor for wors-ening or emergent problems. It maybe necessary in some instances touse emergency procedures to obtainneeded services.

B2b/B4a: Collect Reports andRecommendations

After requesting the (youth’s and) fam-ily’s permission to gather informationfrom other professionals and agenciesinvolved with the child, the primarycare clinician can send requests.

B5a: Provide Mental HealthAssessment

The primary care clinician and familymay decide to proceed with assess-ment by the primary care clinician ifthe child or adolescent does not showsigns of severe impairment and if theclinician feels comfortable with fur-ther steps in the assessment process,given the presenting symptoms. Usingexisting guidelines (eg, ADHD guide-lines from the AAP,47,48 Guidelines forAdolescent Depression in PrimaryCare [GLAD-PC],49,50 and “TreatmentRecommendations for the Use of Anti-


psychotics for Aggressive Youth[TRAAY]”51,52); practice parameters53,54;and expert opinion of task force mem-bers, the task force developed guid-ance to assist clinicians in further as-sessment of children with positivescreening results or clinical findingsthat fall into the following clusters ofsymptoms:

● social-emotional problems in chil-dren from birth to 5 years of age

● anxiety;

● depression;

● inattention, impulsivity;

● disruptive behavior, aggression;

● substance use; and

● learning difficulties.

B6: Interpret Findings to Family (andYouth as Appropriate); ConveyHopefulness About Treatment andRecovery

This is a critical point in the process.As the provider of medical home ser-vices, the primary care clinician has arole in interpreting diagnostic findingsto the family, educating the familyabout the child’s condition, reinforcingchild and family strengths, and creat-ing a sense of hopefulness about treat-ment and recovery. This conversationis critical regardless of whether or notthe family will seek specialty care andmay, in fact, contribute to the family’sreadiness to seek that care. To facili-tate this conversation and to offersome strategies for initiating care im-mediately, the task force has drawnfrom the common elements of effec-tive psychosocial interventions to pro-vide guidance in the primary caremanagement of common symptomclusters (listed above).

The suggestions outlined in the clusterguidance do not replace specialty carebut can offer the family some reliefwhile awaiting specialty care or whileachieving greater readiness to seekcare. In some situations, particularly

those that involve emerging conditionsor conditions associated with mildfunctional impairment, these interven-tions may themselves constitute effec-tive treatment.

If a specialist has been involved in thediagnostic process, the clinician maychoose to invite this individual to theconference, depending on family pref-erences and logistic considerations.Some children with severe emotionaldisturbance may have a mental healthor EI care manager involved in theircare; if so, his or her participation iscritically important to the process. Thecare manager may organize periodicmeetings of teachers, social workers,and agency representatives involvedwith the child and family. In the mentalhealth specialty system, such pro-cesses are part of a system-of-care ap-proach—an evidence-based care-coordination system built around thefamily’s strengths and priorities (see“Strategies for Preparing a Communi-ty”3 and “Strategies for Preparing aPrimary Care Practice”5). If so, the pri-mary care clinician (or his or her staffrepresentative), although often inad-vertently omitted, would likely be awelcome addition; joining that teammay substitute for convening a pri-mary care conference. Although par-ticipation in such activities is time-consuming, it may ultimately produceefficiencies in the care of children andadolescents with complex conditions.

If the inclusion of involved specialistsis not feasible, the primary care clini-cian needs previous information fromthem to ensure understanding of thechild’s problems and to discuss the op-tions for further care with the family(and youth, as appropriate). It is im-portant that the family not be placed inthe position of transmitting informa-tion between professionals who are in-volved in their child’s care.

Families also may use this opportunityto inform and educate the clinician

about the various facets of the child’scondition and specific preferences re-garding treatment options.

B7: Specialty Care§ Needed?

The answer will depend on clinical cir-cumstances, family preferences, andthe clinician’s comfort. If a child is infoster care, the decision may also de-pend on the preference or policy of thechild welfare agency that is overseeingthe child’s care.

To facilitate this conversation, theprimary care clinician needs currentinformation about evidence-based in-terventions appropriate to the child’scondition. Appendix S2, “Evidence-Based Child and Adolescent Psycho-social Interventions,” includes suc-cinct and reliable sources for thisinformation. The primary care clini-cian also needs to convey his or herown level of comfort with the child’sproblem and its severity and the levelof consultation and support available.

If the child’s problems fall intomultiplediagnostic domains but there is a pre-dominant area of concern, the clini-cian, in concert with the youth and/orfamily, may decide to address the pre-dominant concern first. The clinicianand family may decide to initiate carewithin the primary care setting and re-assess the need for consultation at alater date. Depending on the child’sand family’s level of readiness to seekhelp, the primary care clinician can ap-ply common-factors methods (see Ta-ble 1) to reach consensus on the nextsteps, which may involve implement-ing general management strategies orspecific treatment by the primary careclinician or the involvement of special-ist(s). If the family wishes to seek spe-cialty care, the primary care clinicianhas a role in providing care until thechild connects with the specialist andthen collaborating with specialist(s) tomonitor the child’s progress.

§See definition, Appendix S9.

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pediatrics.aappublications.org/cgi/content.full/peds.2010-0788O/DC1

If the clinician and family decide to in-volve 1 or more specialists, there are avariety of collaborative models thatcan be developed (see “Strategies forPreparing a Primary Care Practice”5).If the primary care clinician will be thesole provider of mental health care,the process continues at step B10.

B8: Facilitate Involvement ofSpecialist(s)

This step is similar to step B3a, inwhich the clinician and family chooseto involve 1 or more specialists in as-sessment. If the child is younger than 5years, the primary care clinicianshould consider referring him or herfor an assessment by a developmental-behavioral pediatrician, mental healthspecialist with expertise in early child-hood, a specific professional (eg,speech pathologist), and/or a develop-mental evaluation team. The local EIagency provides intervention andcare-coordination services for chil-dren from birth to 3 years of age inaddition to assessment as describedin step B3a; this agency or another,such as the public school system, pro-vides care coordination and educationof children aged 3 to 5 years to complywith the IDEA. For children aged 5 to 21years, the primary care clinician caninvolve a developmental-behavioral pe-diatrician, adolescent specialist, ormental health or substance abuse pro-fessional, depending on accessibilityand family resources.

If mental health referral will requireauthorization by the family’s health in-surance plan; entry into a carved-out,or parallel, private behavioral healthinsurance plan; or entry into the publicmental health system, the family willlikely need guidance and time to re-search the options; if so, the cliniciancan bring the visit to a close (againfollowing the HELP mnemonic [Table1]) and schedule a return visit or an

appointment with a staff member tofacilitate this process.

The decision to involve a specialist oragency in treatment means that theprimary care clinician’s role will in-clude communicating with other careproviders. The process is enhanced byconveying to the referral source theresults of previous assessment and in-tervention efforts and openness to dis-cussion with the professional who willprovide therapy. Although the HIPPA al-lows exchange of information amongprofessionals involved in the care of amutual patient, many mental healthprofessionals are reluctant to shareinformation without express consentof the child and family. By obtainingwritten consent (or, for children in fos-ter care, enlisting the case worker’shelp in obtaining written consent ofthe legal guardian) and sending it tothemental health professional, the pri-mary care clinician can convey inter-est and facilitate communication.

As with referrals for diagnostic assess-ment, it is critical that the practice trackchildrenwhohavebeenreferred for spe-cialty treatment. If the family is unsuc-cessful inacquiring treatment ina timelyway, the primary care clinician can offerto continue generic intervention efforts(as described in Algorithm A), initiatetreatment, or make periodic telephonecontacts to monitor for worsening oremergent problems. Itmaybenecessaryinsome instances touseemergencypro-cedures to obtain needed services.

B9: Collect Reports and/or ConveneTeam to Review

Once the specialist has met with thechild and family to develop treatmentrecommendations, the primary careclinician needs feedback. Forms forexchange of information may facili-tate this process (see “Strategies forPreparing a Primary Care Practice”5

and Appendix S11). Telephone ande-mail contacts may be helpful in

some instances. Alternatively or ad-ditionally, the clinician may inviteother providers of care (includingcase workers for children in fostercare) to participate in a face-to-facemeeting with the family. For childrenin the foster care system it is criti-cally important not only to collect in-formation from case workers butalso to convey information back tothe worker. If the child changesplacement and the caregivers areunaware of what happened in the pe-diatrician’s office, the child does notreceive the benefit of continuity ofcare in the new placement.

B10: Collaboratively Develop a Family-Centered Care Plan

This process requires that the pro-fessionals involved reach consensuswith the family and with each otherabout a comprehensive plan of care.The focus of the care plan is seekingimprovement in the child’s overallemotional health and functioning.The care plan articulates the child’sand the family’s goals; child and fam-ily strengths; service and educa-tional needs; the roles of involvedservice providers, family members,and other caregivers; plans forfollow-up and routine health supervi-sion; plan for emergencies, if theyshould occur; and, ultimately, plansfor self-care and/or family care,transition to adult primary care andspecialty health services, and theother services and care coordina-tion needed to support the youngperson’s achievement of his or hereducational, social, and vocationalgoals in adulthood. Ideally, the fam-ily, other caregivers, school person-nel, case workers, and service pro-viders participate in the plan’sdevelopment, either by attending theconference or contributing recom-mendations before the conference.Together, they can set the timetable,determine need for involvement of


pediatrics.aappublications.org/cgi/content.full/peds.2010-0788Q/DC1

additional or alternative special-ist(s), and select interventions. Theycan also establish a plan for moni-toring treatment response andsafety and create a common under-standing of limits of confidentiality.For adolescents, direct input to theplan is critical for engagement andthe success of treatment.

For children previously involved inmental health specialty care, a careplan may be in place and may omitprimary care issues, such as healthylifestyle (eg, nutrition, exercise,sleep, stress management, socialsupport), routine health supervision,or care of chronic medical condi-tions. In this instance, the primarycare clinician can point to the rolesthat he or she can play in coordinat-ing and complementing the care ofthe mental health specialist(s).

It will be helpful for the primary careclinician to have available sample careplans for common mental health con-ditions and for common circum-stances such as foster care placementand parental separation or divorce,which signal traumatic transitions andrequire frequent follow-up. For chil-dren and youth in foster care, somestates are using Web-based medical“passports,” which include informa-tion on the child’s history, immuniza-tions, medications, chronic conditions,etc. The AAP Task Force on Foster Careand the AAP Council in Clinical Informa-tion Technology are developing guide-lines for medical passports (specifi-cally, the health-information contentneeded and who should have access tothe passport).

B11: Implement Chronic Care Protocol

Methods used tomonitor children withchronic medical conditions such asasthma and diabetes can be useful inthe care of children with mental healthand substance abuse conditions.“Strategies for Preparing a Primary

Care Practice”5 describes steps in im-plementing chronic care methods forchildren with mental health problems,as for other children and youth withspecial health care needs. It is impor-tant to institute a monitoring mecha-nism for children and youth who arenot yet ready to seek or accept care formental health problems, as well as forthose who are.

The interval between contacts will bedetermined by the acuity and severityof the child’s condition; the child’s andfamily’s strengths, needs, and prefer-ences; adverse effects and monitoringrequirements of any treatments; andthe level of the child’s impairment.Just as spirometry measures pulmo-nary function and assists the clinicianin monitoring children with asthma,global functional assessment scalesassist the primary care clinician inmonitoring children with mental ill-ness (see “Strategies for Preparing aPrimary Care Practice”5). There are ex-isting pediatric guidelines for assess-ment and treatment of ADHD47,48 andadolescent depression,49 treatment al-gorithms for depression,50,55 and prac-tice parameters from the AmericanAcademy of Child and Adolescent Psy-chiatry51–54 to assist clinicians whochoose to proceed with assessmentand treatment in the primary care of-fice. When children are being followedby specialist(s), the primary care clini-cian and specialist(s) need to developa coordinated follow-up plan in collab-oration with the family (see “Strate-gies for Preparing a Primary CarePractice”5).

B12: Is Concern Persisting?

Neither designation as a child or youthwith special health care needs nor theidentification or diagnosis of a mentalhealth concern or condition is neces-sarily permanent. Children and fami-lies can and do recover. To assess thechild’s current status, the primary

care clinician needs to gather and re-view progress reports from other pro-fessionals involved in the child’s care;for school-aged children, review func-tional assessment scales completedby the parent, teacher, and youth; andperformhis or her own clinical assess-ment. When pharmacologic agents arepart of the treatment plan, cliniciansmay also need to obtain laboratorytests to monitor levels and/or adverseeffects. At each contact, the clinicianalso needs to consider the routinehealth supervision requirements ofthe child and monitoring of comorbidmedical conditions.

YesIf a concern persists, the primary

care clinician should periodically re-convene a conference with the family(and youth) to determine if further as-sessment and/or a change of plan isindicated.

NoIf the child and family show no signs

that the concern is persisting, the cli-nician can move to step B13.

B13: Return to Routine HealthSupervision and Monitor for FurtherIssues

If and when a concern is resolved,children and youth can be returned tothe process of care described in Algo-rithm A.

CONCLUSIONS

To enhancemental health practice, thetask force recommends that primarycare clinicians begin by addressingsystemic issues such as payment andaccess to mental health specialty re-sources, achieving competence in coremental health skills, and preparing of-fice systems that integrate mentalhealth services and apply chronic caremethods to children with mentalhealth problems. The task force then

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proposes a clinical process, describedin this report, for promoting the social-emotional health of all children and foraddressing mental health concerns inprimary care settings. Two algorithmsdescribe this process, with text linkingthe reader to additional resources andreferences. The process is aimed atcommunicating the importance ofmental health care to children andfamilies, assisting parents in promot-ing their children’s social-emotionalhealth, increasing the likelihood thatconcerns will be identified promptly

and managed effectively, and enhanc-ing children’s opportunity to recoverfrom mental health problems.

AAP TASK FORCE ON MENTAL HEALTH

The AAP Task Force on Mental Healthincluded JaneMeschan Foy, MD (chair-person, lead author), Paula Duncan,MD, Barbara Frankowski, MD, MPH,Kelly Kelleher, MD, MPH, Penelope K.Knapp, MD, Danielle Laraque, MD, GaryPeck, MD, Michael Regalado, MD, JackSwanson, MD, and Mark Wolraich, MD;the consultants were Margaret Dolan,

MD, Alain Joffe, MD, MPH, PatriciaO’Malley, MD, James Perrin, MD,Thomas K. McInerny, MD, and LynnWegner, MD; the liaisons were TerryCarmichael, MSW (National Associa-tion of Social Workers), Darcy Grutta-daro, JD (National Alliance on MentalIllness), Garry Sigman, MD (Society forAdolescent Medicine), Myrtis Sullivan,MD, MPH (National Medical Associa-tion), and L. Read Sulik, MD (AmericanAcademy of Child and Adolescent Psy-chiatry); and the staff were Linda Pauland Aldina Hovde.

REFERENCES

1. American Academy of Pediatrics, TaskForce on Mental Health. Strategies for Sys-tem Change in Children’s Mental Health: AChapter Action Kit. Elk Grove Village, IL:American Academy of Pediatrics; 2007.Available at: www.aap.org/mentalhealth/mh2ch.html. Accessed March 1, 2010

2. American Academy of Pediatrics, TaskForce on Mental Health; American Academyof Child and Adolescent Psychiatry, Commit-tee on Health Care Access and Economics.Improving mental health services in pri-mary care: reducing administrative and fi-nancial barriers to access and collabora-tion [published correction appears inPediatrics. 2009;123(6):1611]. Pediatrics.2009;123(4):1248–1251

3. American Academy of Pediatrics, TaskForce on Mental Health. Enhancing pediat-ric mental health care: strategies for pre-paring a community. Pediatrics. 2010;125(3suppl):S75–S86

4. American Academy of Pediatrics, Commit-tee on Psychosocial Aspects of Child andFamily Health and Task Force on MentalHealth. The future of pediatrics: mentalhealth competencies for pediatric primarycare. Pediatrics. 2009;124(1):410–421

5. American Academy of Pediatrics, TaskForce on Mental Health. Enhancing Pediat-ric mental health care: strategies for pre-paring a primary care practice. Pediatrics.2010;125(3 suppl):S87–S108

6. American Academy of Pediatrics, TaskForce on Mental Health. Introduction. Pedi-atrics. 2010;125(3 suppl):S69–S74

7. Harris M. Rural Private Pediatric PracticeOwnership and Management of a MentalHealth Practice [teleconference audiofile]. Elk Grove Village, IL: American Acad-emy of Pediatrics; October 25, 2006. Avail-

ableat:www.aap.org/mentalhealth/docs/MentalHlthRural-TeleConf.mp3. AccessedMarch 1, 2010

8. van Os TW, van den Brink RH, Tiemens BG,Jenner JA, van derMeer K, Ormel J. Commu-nicative skills of general practitioners aug-ment the effectiveness of guideline-baseddepression treatment. J Affect Disord. 2005;84(1):43–51

9. Grencavage LM, Norcross JC. Where are thecommonalities among the therapeutic com-mon factors? Prof Psychol Res Pr. 1990;21(5):372–378

10. Bickman L. A common factors approach toimproving mental health services. MentHealth Serv Res. 2005;7(1):1–4

11. Castonguay LG, Beutler LE. Principles oftherapeutic change: a task force on partic-ipants, relationships, and techniques fac-tors. J Clin Psychol. 2006;62(6):631–638

12. Wissow LS, Gadomski A, Roter D, et al. Im-proving child and parent mental health inprimary care: a cluster-randomized trial ofcommunication skills training. Pediatrics.2008;121(2):266–275

13. Finset A, Ekeberg O, Eide H, Aspegren K.Long-term benefits of communication skillstraining for cancer doctors. Psychooncol-ogy. 2003;12(7):686–693

14. Fallowfield L, Jenkins V, Farewell V, Solis-Trapala I. Enduring impact of communicationskills training: results of a12-month follow-up.Br J Cancer. 2003;89(8):1445–1449

15. Roter DL, Hall JA, Kern DE, Barker LR, ColeKA, Roca RP. Improving physicians’ inter-viewing skills and reducing patients’ emo-tional distress: a randomized clinical trial.Arch Intern Med. 1995;155(17):1877–1884

16. Johnston LD, O’Malley PM, Bachman JG,Schulenberg JE. Teen Marijuana Use TiltsUp, While Some Drugs Decline in Use [press

release]. Ann Arbor, MI: University of Michi-gan News Service; December 14, 2009. Avail-able at: www.monitoringthefuture.org/pressreleases/09drugpr.pdf. AccessedMarch 1, 2010

17. Wagner EH. Chronic disease management:what will it take to improve care for chronicillness? Eff Clin Pract. 1998;1(1):2–4

18. Bernal P. Hidden morbidity in pediatric pri-mary care. Pediatr Ann. 2003;32(6):413–418, 421–422

19. McInerny TK, Adam HM, Campbell DE, KamatDM, Kelleher KJ, eds. American Academy ofPediatrics Textbook of Pediatric Care. ElkGrove Village, IL: American Academy ofPediatrics; 2009

20. Casey PH, Barrett K, Bradley RH, Spiker D.Pediatric clinical assessment of mother-child interaction: concurrent and predictivevalidity. J Dev Behav Pediatr. 1993;14(5):313–317

21. Zero to Three. DC:0–3R: Diagnostic Classifi-cation of Mental Health and DevelopmentalDisorders of Infancy and Early Childhood.Revised ed. Washington, DC: Zero to ThreePress; 2005:41–52

22. Flores G, Rabke-Verani J, Pine W, SabharwalA. The importance of cultural and linguisticissues in the emergency care of children.Pediatr Emerg Care. 2002;18(4):271–284

23. Brotanek JM, Seeley CE, Flores G. The impor-tance of cultural competency in general pe-diatrics. Curr Opin Pediatr. 2008;20(6):711–718

24. American Academy of Pediatrics, Commit-tee on Adolescence. Achieving quality healthservices for adolescents. Pediatrics. 2008;121(6):1263–1270

25. AmericanMedical Association, Council on Sci-entific Affairs. Confidential health services foradolescents. JAMA. 1993;269(11):1420–1424


26. Gardner H. Intelligence Reframed: MultipleIntelligences for the 21st Century. New York,NY: Basic; 2000

27. Duncan PM, Garcia AC, Frankowski BL, et al.Inspiring healthy adolescent choices: a ra-tionale for and guide to strength promotionin primary care. J Adolesc Health. 2007;41(6):525–535

28. Hagan JF, Shaw JS, Duncan PM, eds. BrightFutures: Guidelines for Health Supervisionof Infants, Children, and Adolescents. 3rded. Elk Grove Village, IL: American Academyof Pediatrics; 2008

29. Spivak H, Sege R, Flanigan E, Licenziato V,eds. Connected Kids: Safe, Strong, SecureClinical Guide. Elk Grove Village, IL; Ameri-can Academy of Pediatrics; 2006. Avail-able at: www.aap.org/connectedkids/ClinicalGuide.pdf. Accessed March 15, 2010

30. Melnyk BM, Moldenhauer Z, eds. The KySSSM

(Keep Your Children/Yourself Safe and Se-cure) Guide to Child and Adolescent MentalHealth Screening, Early Intervention andHealth Promotion. Cherry Hill, NJ: NationalAssociation of Pediatric Nurse Practitio-ners, NAPNAP Foundation; 2006

31. Shalwitz J, Sang T, Combs N, Davis K, Bush-man D, Payne B. Behavioral Health: An Ado-lescent Provider Toolkit. San Francisco,CA: Adolescent Health Working Group;2007. Available at: http://ahwg.net/assets/library/98�behavioralhealthmodule.pdf. Ac-cessed January 13, 2010

32. Carlisle J, Shickle D, Cork M, McDonagh A.Concerns over confidentiality may deter ad-olescents from consulting their doctors: aqualitative exploration. J Med Ethics. 2006;32(3):133–137

33. Jellinek M, Patel BP, Froehle MC, eds. BrightFutures in Practice: Mental Health—Volume I. Practice Guide. Arlington, VA: Na-tional Center for Education in Maternal andChild Health; 2002

34. Jellinek M, Patel BP, Froehle MC, eds. BrightFutures in Practice: Mental Health—Volume II. Tool Kit. Arlington, VA: NationalCenter for Education in Maternal and ChildHealth; 2002

35. American Academy of Child and AdolescentPsychiatry. For Families. Available at: www.aacap.org/cs/forFamilies. Accessed March1, 2010

36. American Academy of Pediatrics. Healthy Chil-

dren. Available at: www.healthychildren.org.Accessed March 1, 2010

37. Coleman WL, Richmond JB. After the deathof a child: helping bereaved parents andbrothers and sisters. In: Carey WB, CrockerAC, Coleman WL, Elias ER, Feldman HM, eds.Developmental-Behavioral Pediatrics. 4thed. Philadelphia, PA: Saunders Elsevier;2009:366–372

38. National Alliance on Mental Illness Web site.Available at: www.nami.org. AccessedMarch 1, 2010

39. Children and Adults With Attention Deficit/Hyperactivity Disorder Web site. Availableat: www.chadd.org. Accessed March 1, 2010

40. National Association of Pediatric NursePractitioners Web site. Available at: www.napnap.org. Accessed March 1, 2010

41. National Federation of Families for Chil-dren’s Mental Health Web site. Available at:www.ffcmh.org. Accessed March 1, 2010

42. Substance Abuse and Mental Health Ser-vices Administration Web site. Available at:www.samhsa.gov. Accessed March 1, 2010

43. The Compassionate Friends Web site. Avail-able at: www.compassionatefriends.org.Accessed March 1, 2010

44. Foy JM, Earls MF. A process for developingcommunity consensus regarding the diag-nosis and management of attention-deficit/hyperactivity disorder. Pediatrics. 2005;115(1). Available at: www.pediatrics.org/cgi/content/full/115/1/e97

45. Barbarin OA. Mental health screening ofpreschool children: validity and reliability ofABLE. Am J Orthopsychiatry. 2007;77(3):402–418

46. Knight JR, Sherritt L, Shrier LA, Harris SK,Chang G. Validity of the CRAFFT substanceabuse screening test among adolescentclinic patients. Arch Pediatr Adolesc Med.2002;156(6):607–614

47. American Academy of Pediatrics, Commit-tee on Quality Improvement, Subcommitteeon Attention-Deficit/Hyperactivity Disorder.Clinical practice guideline: diagnosis andevaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics.2000;105(5):1158–1170

48. American Academy of Pediatrics, Subcom-mittee on Attention-Deficit/HyperactivityDisorder, Committee on Quality Improve-ment. Clinical practice guideline: treatment

of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics.2001;108(4):1033–1044

49. Zuckerbrot RA, Cheung AH, Jensen PS,Stein RE, Laraque D; GLAD-PC SteeringGroup. Guidelines for Adolescent Depres-sion in Primary Care (GLAD-PC): I. Identi-fication, assessment, and initial manage-ment. Pediatrics. 2007;120(5). Available at:www.pediatrics.org/cgi/content/full/120/5/e1299

50. Cheung AH, Zuckerbrot RA, Jensen PS, Gha-lib K, Laraque D, Stein RE; GLAD-PC SteeringGroup. Guidelines for Adolescent Depres-sion in Primary Care (GLAD-PC): II. Treat-ment and ongoing management [publishedcorrection appears in Pediatrics. 2008;121(1):227]. Pediatrics. 2007;120(5). Avail-able at: www.pediatrics.org/cgi/content/full/120/5/e1313

51. Schur SB, Sikich L, Findling RL, et al. Treat-ment recommendations for the use of anti-psychotics for aggressive youth (TRAAY).Part I: a review. J Am Acad Child AdolescPsychiatry. 2003;42(2):132–144

52. Pappadopulos E, Macintyre JC, Crismon ML,et al. Treatment recommendations for theuse of antipsychotics for aggressive youth(TRAAY). Part II. J Am Acad Child AdolescPsychiatry. 2003;42(2):145–161

53. American Academy of Child and AdolescentPsychiatry. Practice parameter for the as-sessment and treatment of children and ad-olescents with anxiety disorders. J AmAcad Child Adolesc Psychiatry. 2007;46(2):267–283. Available at: www.aacap.org/galleries/PracticeParameters/JAACAP�Anxiety�2007.pdf. AccessedMarch 1, 2010

54. American Academy of Child and AdolescentPsychiatry. Practice parameters. Available at:www.aacap.org/cs/root/member�information/practice�information/practice�parameters/practice�parameters. AccessedMarch 1, 2010

55. Hughes CW, Emslie GJ, Crismon ML, et al;Texas Consensus Conference Panel on Med-ication Treatment of Childhood Major De-pressive Disorder. Texas Children’s Medica-tion Algorithm Project: update from TexasConsensus Conference Panel on MedicationTreatment of Childhood Major DepressiveDisorder. J Am Acad Child Adolesc Psychia-try. 2007;46(6):667–686

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