Universal Mental Health Screening in Pediatric Primary Care ...screening in pediatric primary care...

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Universal Mental Health Screening in PediatricPrimary Care: A Systematic Review

Lawrence S. Wissow, M.D., M.P.H., Jonathan Brown, Ph.D., Kate E. Fothergill, Ph.D., M.P.H.,Anne Gadomski, M.D., M.P.H., Karen Hacker, M.D.,

Peter Salmon, Ph.D., Rachel Zelkowitz, M.H.S.

Objective: Universal mental health screening in pediatric primary care is recommended, butstudies report slow uptake and low rates of patient follow-through after referral to specializedservices. This review examined possible explanations related to the process of screening,focusing on how parents and youth are engaged, and how providers evaluate and usescreening results. Method: A narrative synthesis was developed after a systematic review of3 databases (plus follow-up of citations, expert recommendations, and checks for multiplepublications about the same study). Searching identified 1,188 titles, and of these, 186 full-textarticles were reviewed. Two authors extracted data from 45 articles meeting inclusioncriteria. Results: Published studies report few details about how mental health screens wereadministered, including how clinicians explain their purpose or confidentiality, or whether helpwas provided for language, literacy, or disability problems. Although they were not addresseddirectly in the studies reviewed, uptake and detection rates appeared to vary with means ofadministration. Screening framed as universal, confidential, and intended to optimize attentionto patient concerns increased acceptability. Studies said little about how providers were taughtto explore screen results. Screening increased referrals, but many still followed negative screens,in some cases because of parent concerns apparently not reflected by screen results but possiblystemming from screen-prompted discussions. Conclusions: Little research has addressed theprocess of engaging patients in mental health screening in pediatric primary care or howclinicians can best use screening results. The literature does offer suggestions for better clinicalpractice and research that may lead to improvements in uptake and outcome. J. Am. Acad.Child Adolesc. Psychiatry, 2013;52(11):1134–1147. Key Words: mental health, patientengagement, pediatrics, primary care, screening

uch evidence points to a gap betweenthe prevalence of child and adolescent
M mental health problems and the amount
and timeliness of treatment received.1,2 Universalscreening in pediatric primary care has beenproposed as a way to detect and systematicallyaddress mental health care needs. Screening andinitial treatment of mental health problems arerecommended by the American Academy ofPediatrics’ Task Force on Mental Health, and the

This article is discussed in an editorial by Dr. Michael S. Jellinekon page 1131.

Clinical guidance is available at the end of this article.

Supplemental material cited in this article is available online.

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US Preventive Services Task Force recommendsscreening for adolescent depression.3,4 The 2010Patient Protection and Affordable Care Actmandates that commercial health plans offerdepression screening,5 and Medicaid’s Earlyand Periodic, Screening, Diagnosis, and Testing(EPSDT) requires mental health assessment ofall covered children.6 However, to date, screeningremains far from universal,7-9 and mental healthservice follow-up rates after a positive result arereported to be low.10-12 Although there are manypotential explanations for these disappointingresults, including difficulty coordinating withother screening initiatives,13 the mechanics ofand compensation for administration,14,15 andlimited availability of follow-up treatment,15-18

other explanations may involve how screeninghas been implemented.

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PEDIATRIC MENTAL HEALTH SCREENING

One set of potential difficulties with imple-mentation centers on how screens are presentedto youth and families. Universal mental healthscreening addresses conditions that are particu-larly stigmatized and subject to cultural variationin symptomatology, threshold for treatment, andeven legitimacy as diagnostic entities.19 Theappropriateness of mental health screening ingeneral medical settings may not be universallyaccepted by patients or even providers. In mentalhealth screening, respondents must activelycollaborate to disclose potentially sensitive in-formation,20 and must decide whether what theyare experiencing matches the questions andresponse categories on the screener.21,22 Ulti-mately, respondents can credibly assert the exis-tence of a problem even if the screen does notdetect it, or vice versa.

A second set of potential difficulties relates tothe way in which initial screening results are usedby front-line clinicians. Screening programschoose their initial tests and cut-points to balancethe risk of missing cases with the burden (on bothclinicians and patients) of subsequent assess-ments needed to confirm a diagnosis.23 Programsnormally include plans for these subsequent as-sessments and figure them into the effort neededfor implementation.24,25 Although many brief in-struments have been validated for detecting childmental health conditions,26-30 their psychometricproperties make them unsuitable for use as uni-versal screens without a deliberate follow-upstep. For example, the Pediatric SymptomChecklist (PSC), the Strengths and DifficultiesQuestionnaire (SDQ), and the Patient HealthQuestionnaire (PHQ) have positive predictivevalues of 50% or less at the prevalence ratesfound in well-child visits.31-34 The PSC and SDQhave negative predictive values of about 90% atwell-child visit prevalence rates, so even negativeresults may need at least brief validation of achild’s low-risk status. In addition, broad-bandinstruments such as the PSC and SDQ yieldonly a risk of having some disorder, requiringadditional steps to refine a working diagnosisbefore a treatment plan can be developed. ThePSC and SDQ have subscales that point toward aparticular group of problems, but these distinc-tions may not be reliable across populations.30,35

The purpose of this article is to review theavailable information about how families andyouth are currently engaged in mental healthscreening programs in primary care, and howproviders evaluate and use the information

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collected from screens. Improving the fit betweenscreening practices and the nature of mentalhealth screening could be one path towardimproving mental health screening outcomes.

METHODSearch StrategyPubMed, PsycInfo, and EMBASE were searched forstudies of universal mental health screening in pedi-atric primary care in developed countries. A researchlibrarian and an expert in systematic reviews wereconsulted on database selection and search termdevelopment. Terms were identified using each data-base’s controlled vocabulary and other key wordswithin 4 domains: mental health, children, primarycare, and screening. Three authors (K.F., L.W., andR.Z.) came to consensus on the final terms for eachdatabase. Searches combined these terms using “AND”

logic. In addition to the database searches, studies wereidentified through reviewing citations of key articles.No restrictions were placed on start date; the end datefor inclusion was through May 2012. Once a final set ofarticles had been selected, an additional hand searchwas made for articles related to the same studies thatmight contain additional information on the screens ortheir use.36

Study Selection and Data AbstractionThree authors (K.F., L.W., and R.Z.) developed selec-tion criteria with a broad view of primary care thatalso included studies of school-based services andlow-acuity services within pediatric emergencydepartments. A key criterion was that screening wasadministered systematically to patients attending pri-mary care visits. Psychometric validation studies andepidemiological studies were excluded. Studies of at-titudes toward screening were included as long as theparticipants had actually experienced screening andwere not responding to hypothetical scenarios. Studieswere excluded if they did not involve children or youthor examined only screening for substance abuse ordevelopmental delay. No exclusions were made basedon research design or language. One author (R.Z.)reviewed all titles and abstracts generated through theformal database searches according to these criteria.She then retrieved the full text for the selected articlesand formally coded each article for inclusion in thereview. In unclear cases, 2 or more authors reviewedthe article and reached consensus on whether toinclude it.

Data abstraction followed PRISMA guidelines.37

The extraction tool addressed the 2 main potentialproblems with screening implementation discussedabove. To gather information about approaches toengaging patients in the screening process, includingaddressing concerns about stigma, descriptions werenoted of by whom and how screens were presented to

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families, if and how issues of confidentiality werediscussed, and the type of assistance offered whilecompleting the screener. To gather information aboutplans for second-stage evaluation of screening results,descriptions were noted of how clinicians were taughtor supported in scoring instruments, interpretingresults, and using results in clinical decision making.Within these 2 major areas, sub-areas emerged duringanalysis. When present, data on how the factors stud-ied related to rates of participation in screening or tovisit process or outcome were also extracted. Eacharticle was initially abstracted by a single author andthen checked by a second author. When a single studywas represented by multiple articles, we merged in-formation from the different articles unless it wasexplicitly stated that methods differed across theelements of interest. No attempt was made to ratethe strength of study methods. The heterogeneity ofstudy designs and measures precluded a formal meta-analysis. The results presented here represent a narra-tive synthesis of the extracted data. The onlinesupplement to this article includes a sample searchstrategy from 1 of the databases (PubMed)

FIGURE 1 Literature search flow diagram.

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(Supplement 1, available online), detailed tables(Tables S1 and S2, available online) summarizingabstracted data, and the PRISMA checklist of thesearch process (Table S3, available online).

RESULTSInitial searches produced 1,263 titles of possiblerelevance (Figure 1). Of these, we screened the1,188 unique titles and abstracts. Review of thesetitles and abstracts, plus searches for articlespossibly related to those found to be in range,resulted in a preliminary review of 186 full-textarticles. The final narrative synthesis included45 articles describing 38 studies. The most com-mon reasons for exclusion after full-text reviewwere that the article was a review article withoutoriginal data (n ¼ 33) or an epidemiologic(n ¼ 32) or psychometric (n ¼ 29) study withoutinformation about clinical use. The 38 studiessynthesized spanned nearly 4 decades from1976 to 2012, although 31 studies (35 articles)





were published between 2002 and 2012. A totalof 25 took place in primary care settings, 6 inemergency departments, and 1 entirely andanother partly in school-based sites. One studywas conducted among children in foster care, and2 others among children receiving a variety ofambulatory services. One study was a survey ofparents who had used primary care services forchildren with mental healthproblems, andanothercompiled state data on primary care mental healthscreening.9,38 Of the 36 studies that described asingle screening program, 11 involved only screenscompleted by parents, whereas 22 includedscreening completed by youth themselves and 3 byeither parents or youth, depending on age.

Most (n ¼ 21) of the studies were observa-tional, examining either systematic or conve-nience samples of patients who underwentscreening. Nine conducted pre–post comparisonsof screening trials or programs.39-47 Two studiescompared different timing of feedback ofscreening results to providers,10,48 and 1 studycompared screening to providers asking the samequestions as part of the visit.49 One study waspart of a randomized trial of depression treat-ment, but all study participants were similarlyscreened.50 Only 1 study randomized parents tocomplete a screen versus usual care.51 Table 1presents a summary of the settings and in-struments used.52-75 Additional details about thepopulations and data elements extracted arepresented in Tables S1 and S2, available online.

Engaging Parents and Youth in the ScreeningProcessWho Presents Screening to Parents and Youth?Different types of staff were used to introduceand administer mental health screening, but noconsensus emerged on who is best suited for thisrole. There was no evidence that parents or youthwere given a choice about who would administerthe screening tool. Among studies that did notemploy temporary research assistants for the task(n ¼ 21), 13 reported screens being introduced byadministrative staff (e.g., “front desk personnel”)before visits.8,10-12,32,40,44,48,57,61,63-65 Seven re-ported that screens were given to families bynurses or specially trained aides.41,47,56,59,60,69,72

One study incorporated screening questions intothe prompts given to primary care providers byan electronic medical record system.46 Only 1study, in an emergency department, asked fam-ilies who they thought should best introducemental health screening to eligible patients. In



that study, respondents believed that screensshould be introduced by clinicians, and only afterthere had been time to build a level of rapportsuited to a sensitive topic.45 In another emergencydepartment study, most youth said they werecomfortable with being asked by a nurse aboutsuicidality.54

Explaining the Purpose and Processes of Screen-ing. Little is described about how the purposeor processes of mental health screening areexplained to parents or youth. Examples from thestudies include having an appointment clerk tellparents that “optional mental health screening” isavailable at no cost,65 having a staff member saythat clinicians are interested in how youth arefeeling,50 and saying that a “mood questionnaire”is being given to all new patients.74 One studytold parents the clinic was “including questionsabout children’s emotion and behavior as part oftheir pediatric visit.”34 In another, a nurse askedparents to complete the socioemotional scales ofthe Ages and Stages Questionnaire for their childand presented them with a letter (in English orSpanish) explaining its purpose (the contents ofthe letter are not described in the publishedreport).56 The most elaborate framing wasdescribed in a study conducted in an emergencydepartment.60 A slide show introduced screeningusing “adolescents’ own words about how adepressed teenager might feel.” The slides alsodescribed what would happen if a screen werescored positive.

No studies compared the success of differentmeans of explanation; however, parent and youthwillingness to be screened varied among studiesthat presented screening as optional or universal.A study that invited families to completescreening materials online before visits reportedthat only 9% did so.64 In a study in which regis-tration staff asked parents if they would be in-terested in screening, only about 45% accepted.65

In an emergency department study, nurses ortechnicians, “at any time during the adoles-cent patient’s assessment,” used a laminatedpamphlet to describe the purpose of screeningand ask for the adolescent’s participation;65% agreed to be screened.59 In contrast, sys-tematically presenting screening to patients orfamilies as a routine part of health maintenancevisits resulted in a higher rate of completion(85%–95%).11,41,61,62,74 Youth in 1 emergencydepartment study said they preferred universalscreening to avoid the feeling of being “targeted”as having a mental health problem.45

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TABLE 1 Summary of Included Articles and Studies

StudyFirst Author,

Year, Reference Setting Instrument RespondentFraming toPatient

YouthConfidentiality Accommodation Scoring

Second-StageEvaluation

1 Applegate200339

PC PSC Parent only Not stated Parent only Not stated PCP with training PCP decides

2 Asarnow200550;Asarnow200952; Wells201253

PC Items from CIDIand CES-D

Youth “Interested inhow youthfeeling”

Self-administered;no further detail

English only Study staff PCP supported bycare manager

3 Ballard 201254;Horowitz201055

ED SIQ Youth Not stated Self-administered;answers sharedif concern forsafety

English only Not stated On-site MH staffevaluatepositives

4 Berger-Jenkins201240

PC Initial question for“concerns”then PSC

Parent Not stated Parent only English andSpanish

Nurse PCP decides;brief training

5 Briggs 201256 PC ASQ-SE Parent Letter given toparent

Parent only English andSpanish, canask for help

Psychologist On-sitepsychologistevaluatespositives

6 Chisolm 200857 PC Health eTouch Youth Not stated Tablet withsafeguards;told clinicianwill see results

Not stated;literacy aproblem

Automatic Referralinformationfor þ items;automatic emailto suicide team

7 Chisolm 200910 PC Health eTouch Youth Not stated Same as study 6 Not stated Automatic Same as Study 68 Stevens 200848 PC Health eTouch Youth Not stated Same as study 6 Not stated Automatic Same as Study 69 Gardner 201032 PC Health eTouch Youth Not stated Same as study 6 Not stated Automatic PCP option to

discuss withon-site SW

10 Diamond201032

PC BHS Youth Not stated Not stated Not stated Automatic PCP decides

11 Fein 201059 ED BHS Youth Pamphlet andslide showexplainpurpose

Introductionexplains limitsofconfidentiality

English only butcould be audioassisted

Automatic “Routine care”with consultavailable

12 Pailler 200945,60 ED BHS Youth Same as study 11 Same as study 11 Same as study 11 Automatic Same as study 11

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TABLE 1 Continued

StudyFirst Author,




13 Gall 200061 School HC PSC withadditionalquestions

Youth Not stated Not stated Not stated Not stated Refer positivescreens

14 Garrison 199262 PC Custom survey Parent only Not stated; askedif willing toshare with PCP

Parent only English andSpanish

PCP PCP decides

15 Gruttadero201138

PC N/A N/A Parents feelgiving screenpositive frame

N/A N/A N/A N/A

16 Hacker 200611 PC PSC Parent or youth Not stated Youth do inwaiting area

Multiplelanguages

PCP scores PCPs told torefer þ orparent concern

17 Hacker 200912 PC PSC Parent or youth Not stated Same as study 16 Multiplelanguages

PCP scores Same asStudy 16

18 Hartung 201063 PC Primary Care MHScreener

Parent Not stated Parent only Parent only Not scored; itemby item review

Training onsymptomclusters, follow-up probes

19 Hayutin 200951 PC andGI clinic

PSC Parent Parents givenhandout aboutinterpretation

Parent only Not stated Some parentsself-scored

PCP got 5-minutetraining oninterpretingresults

20 Horwitz 200864 PC CHADIS system Parent Not stated Parent only Not stated Automatic Guidance for þitems; PCP’shad 30-mintraining

21 Husky 201165 PC DPS-8 Youth Not stated Disclosure ifdanger

Not stated Automatic PCP decides

22 Jee 201141 PC forfoster care

SDQ Youth and fosterparents

Not stated Not stated English only Not scored tillafter visit

Provider reviewsitems, on-siteSW can help

23 Jellinek 199966;Wasserman199967;Kelleher199768

PC PSC Parents Not stated Parent only Not stated Not stated PCPs not givenresults

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TABLE 1 Continued

StudyFirst Author,




24 John 200769 Outpatientpediatricclinics

Short Mood andFeelingQuestionnaire

Youth Not stated Not stated Not stated Automatic Prompts forcounseling

25 King 200970 ED Multiple Youth Not stated Notify parent if“high risk”

English only Research staff Not stated

26 King 201271 ED Multiple Youth Not stated Some youth toldstaff memberwill reviewresults

English only,readinglevel <6.1

Research staff Not stated

27 Kuhlthau 20119 Multiple(claims data)

Multiple Parent or youth Not known Not known Not known Not known Not known

28 Metz 197672 PC Multiphasic visit Parent Not known Parent only Not known;administeredby staff

Clinical staff PCP givendetailedsummary aftervisit

29 Murphy 199642;Pagano199673

School clinicsand PC

PSC with functionquestions

Parent Voluntary, reasonexplained

Parent only Initially none,then givenorally in Englishor Spanish

Not stated PCP could referregardless ofscore

30 Navon 200134 PC PSC Parent Desire to includeemotions andbehavior,voluntary

Parent only Bilingualresearchassistant

Research staff PCP decides,could bringto MDT

31 Olson 200543 PC Health TeenScreener

Youth Not stated Tablet withsafeguards

Not stated Automatic 2-hr training ininterviewingand motivation

32 Olson 200944 PC Health TeenScreener

Youth Not stated Tablet withsafeguards

Not stated Automatic Areas of teenreadiness tochangehighlighted

33 Schubiner199449

PC Safe TimesQuestionnaire

Youth Learning howadolescents areinterviewed

Not stated Not stated PCP scores Training ininterviewing,risk categories,psychometricsof screen

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TABLE 1 Continued

StudyFirst Author,




34 Smith 199074 PC STAI, CDI Youth Moodquestionnairefor all newpatients

Not stated Not stated Not stated Received resultsafter initialassessment

35 Williams 201175 ED DPS Youth Short orientationto computer

Headphones andaudio assisted

Audio assisted,English only

Automatic Managed by on-site SW

36 Wintersteen201046

PC Custom survey, 2stage, in EMRtemplate

Youth Part ofpsychosocialpart of visit

Not stated Not stated Not applicable 90-min trainingon responseto suicidality;on-site SWfor help

37 Zuckerbrot20068

PC ColumbiaDepressionScreen andoption to useDISC module

Youth Not stated Confidentialplace tocomplete

Not stated (frontdesk staffassistedsometimes)

Part automatic,part PCP

Some PCPtraining and listof referralresources

38 Rausch 201247 PC ColumbiaDepressionScale

Youth Not stated Not stated English andSpanishinstruments

PCP scored “Briefintroductionto adolescentdepression”and scoringguide; referpositives

Note: CDI ¼ Children’s Depression Inventory; CES-D ¼ Center for Epidemiologic Studies Depression Scale; DPS ¼ Diagnostic Predictive Scales; ED ¼ Emergency Department; EMR ¼ electronic medical record;MH ¼ Mental Health; PC ¼ Primary Care; PCP ¼ Primary Care Provider; PSC ¼ Pediatric Symptom Checklist; SDQ ¼ Strengths and Difficulties Questionnaire; STAI ¼ State-Trait Anxiety Inventory.

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Statements About Confidentiality. Most studies(n ¼ 18 of 27) in which youth were given screensdid not state how confidentiality was explained.Those that didusedvarying language. Two studiesof suicide screening in an emergency departmenttold teens that clinicians and parents wouldbe informed of results that indicated a concern forsafety.55,70 Two studies of more comprehensivescreening, 1 in an outpatient setting and 1 inan emergency department, told teens that theirresults would remain confidential unless therewas evidence of danger to self or others, abuse, orsignificant functional impairment.60,65 In 4 studies,youth were told explicitly that their healthcare provider would see the results.10,32,48,57 Onestudy said only that clinical staff had explainedthe “standard limits of confidentiality.”59

There was evidence that youth valuedknowing whether their responses would beconfidential. One study of a computerized,broad-band primary care mental health screenerfor youth 11 to 20 years of age found that a beliefthat data would remain private and would beused only for health care was positively corre-lated with satisfaction with use of the screen.57 InPailler et al.’s emergency department study,youth also said they wanted to know about theextent of confidentiality around their results.45

Another study found that youth completing ascreen on a hand-held device preferred itto paper because they believed it was morelikely to preserve the confidentiality of theirresponses.44 One study suggested that someyouth might change their answers to screensbased on who would talk with them about re-sults.71 Youth from low-income families, whentold a research staff member would meet withthem to review results, reported, on average,lower scores on a suicide risk instrument thandid those who were told they would not have thereview. Higher-income youth did not demon-strate this difference, and it is not clear whetherthe same effect would be seen if the review hadinvolved a nurse, doctor, or social worker.

Privacy for Youth During Administration.Providing privacy during the completion of ascreen is another aspect of assuring confidenti-ality and increasing disclosure. Most studiesinvolving youth did not discuss privacy, and 1study suggested that it could be difficult toassure, at least in an emergency department.In that study, parents gave consent for only 60%of eligible youth to be screened. The secondmost common reason for parents declining

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consent was unwillingness to leave the roomwhile the youth completed the screen.55 Anotheremergency department study used computer-assisted administration with headphones, offer-ing the possibility of private responses eventhough others might be present.60,75 Three pri-mary care studies offered youth a “confidentialspace” to complete the screen.8,65,74 Some studiesusing computerized screens noted the advantagethat responses could no longer be seen once theywere entered.43,76

Assistance With Completion. Little is knownabout the best strategies for conducting screeningin primary care when families come from varyingcultural, language, or literacy backgrounds. Eightof the studies reviewed excluded families that didnot speak English;41,50,54,59,70,71,74,75 many others(n ¼ 20) did not state the language in whichscreening was administered. Only 3 studies re-ported that parents or youth were able to ask forassistance when completing screens,34,42,56 and 1computer-administered screen had an option thatallowed the respondent to listen to the questionsas they were presented.59,60

Two studies provided insight into the impactof helping families who have problems withlanguage or literacy. One, which used the PSCwith Latino families, found a high rate ofincomplete forms when the instrument was self-administered.42,73 After a switch to oral admin-istration, completion rates improved, and theproportion “positive” increased among parents ofchildren more than 5 years of age (it stayed thesame for younger children). The study was notable to determine what about oral administrationhad been helpful; the authors speculated thatovercoming inability to read the written form,greater confidence in disclosing the informationverbally, or the ability of the person adminis-tering the screen to explain unfamiliar terms, mayhave contributed. In another study with a high(70%) completion rate and a culturally heteroge-neous population (screening forms in 6 lan-guages), language and literacy issues werethought to be among the reasons why someforms were not completed.12

Attitudes Toward Screening and Screening Uptake.In addition to valuing statements about universaland confidential processes, as noted above,studies found that youth and parents valuescreening as a means to improve treatment. In 1study, youth rated screening more highly if theybelieved that it would help them communicatewith their provider and receive better care.57





Other reasons for endorsing screening includedthe hope for better linkage to services54 andincreasing the likelihood of having one’s concernsaddressed during the visit.44 In a survey of par-ents of children with mental health problems,screening was seen by the parents as an oppor-tunity for doctors to signal that mental healthproblems beyond common concerns such asattention-deficit/hyperactivity disorder (ADHD)were appropriate for discussion in primary care.38

Evaluation and Use of Screening ResultsScoring Screening Instruments. Only 6 studiesstated or implied that providers were taught howto score the screens used,8,11,12,39,47,49 and only 1stated explicitly that providers were taught that ascreen could have variable and low predictivevalues depending on the cut-point used.8 In 20studies, screens were scored by a computer,research assistant, or co-located mental healthprovider.10,34,40,43-45,48,50,51,56-59,64,65,70-72,75 Onestudy had providers review the screen duringthe visit but not score it formally until afterward.41

Another suggested that providers not score thescreen at any time, but rather follow up on indi-vidual positive items and assess for functionalimpairment before considering a referral.63 Severalstudies did not describe how screens were scored.

Exploring Initial Screening Results With Fami-lies. The studies reviewed provide little guidanceon how providers should explain and confirmscreening results with families. Only 2 studiessaid explicitly that providers were trainedeither to ask follow-up questions about specificpositive answers63 or to validate the resultsthrough further questioning.8 Some appeared toassume that clinicians would be recommendingfurther care for those with positive screen re-sults.34,42,47,53,54 One explicitly said that childrenwho scored positive (on the PSC) should bereferred to a co-located social worker unless theywere already receiving mental health care.11

Although some providers received a degree oftraining on diagnosis and management ofthe conditions targeted in the screens8,46,49,64 orhad some degree of access to a mental healthconsultant,11,32,41,56,59 others received only briefinstruction,47 in 1 case as little as a few minutes.51

Other providers were simply instructed to follow“routine practice” or use results in whatever waythey believed was clinically indicated39,40,59,60,72

or as an “adjunct to their clinical judgment.”34

One study provided more general trainingin motivational interviewing, patient-centered



counseling, and developing action plansregarding issues that might come up as a result ofscreening.43 Three computerized screening sys-tems provided prompts or referral resourceskeyed to particular positive answers, but except in1 case64 theredidnot appear tobe trainingprovidedon use of the prompts.10,32,48,57,69

Screening Follow-Up. Reported referral ratesprovide some clues to how providers usescreening results to make clinical decisions.Whether parents were also asked more generallyabout mental health concerns influenced therelationship of screening results to follow-upplans. In 1 study, the overall referral rate forchildren who were PSC positive was 75% versus5% for children who were negative. However,among children whose parents said they hadmental health concerns about their child, referralrates for PSC-positive and -negative childrenwere very similar (94% and 72%, respectively).11

In a study of adolescents that used a differentoutcome measure,10 16% of those with positivescreens had at least 1 mental health visit in thefollow-up observation period, compared to 5% ofthose who screened negative. However, the rela-tionship of receiving follow-up services to apositive screen was seen for depression and sui-cidal thoughts, but not for substance problems.This study also involved a comparison of youthwhose providers received screening results at thetime of the visit or after a delay. Receipt of resultsat the time of the visit led to increased providerrates of recognition of youth mental healthproblems48 but not to subsequent differences inservice use. Thus, it was not clear whether thedifference in use related to increased providerreferrals or to screened youth being motivated toseek mental health services. Even youth whoscreened negative had more use than youth whohad not been screened (although the comparisongroup was not randomized).

Four studies, when viewed together, couldsuggest that more elaborate screens offeringdiagnostic support may allow providers to bemore discerning about follow-up processescompared to brief screens that yield only anoverall risk status. Three studies using the briefPSC reported that about 70% or more of thosewith a positive result received a referral.11,42,61 Incontrast, in a study using the Depressive Psy-chopathology Scale (DPS-8; an 84-item comput-erized instrument covering suicide, social phobia,panic attacks, generalized anxiety, obsessive-compulsive disorder, depression, and substance

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abuse),65 45% of those positive received a referral.Three of these studies (2 PSC and the DPS-8study) were carried out in settings with inte-grated or co-located behavioral health services,although they differed in the age range of thechildren/youth involved and in whether parentswere asked if they had concerns.

Two studies found that although positivescreens greatly increased the likelihood ofreferral, a large proportion of the mental healthreferrals made from primary care ultimately werefor children who had screened negative. InHacker et al.’s study using the PSC,11 61% ofmental health referrals were for children withnegative screens. In the study with youth usingthe DPS-8,65 11 (46%) of the total 24 with mentalhealth follow-up plans were screen negative.Screening may thus prompt parents or youth toprovide information during the visit even if theydid not reveal it in their responses to the screenitself. In 2 studies using computerized screenswith summary reports, screened youth reportedthat the process had reduced the chance that 1 oftheir concerns would not be discussed.43,44

Screening may also prompt providers to askadditional questions (beyond those on the screen)even when they are not explicitly trained to do so.Some providers reported that screening had hel-ped them better plan visits and focus on topicsthat were most relevant to patients.32,43,44 In astudy that made audio recordings of visits beforeand after screening was introduced, screeningincreased the number of discussions of behavioralissues, and this was not related to the screeningscore.39 One study randomized providers to usethe PSC scored either by parents or by a staffassistant.51 After the visit, parents reported on theextent to which PSC items had been discussedwith their child’s doctor. Screening (compared toa nonscreened control group) increased discus-sions regardless of who scored the PSC, but staffscoring increased the extent to which providersraised topics rather than parents. Parent scoringdid not impact the extent to which parents initi-ated discussions, but it was positively correlatedwith their satisfaction that PSC-related issues hadbeen sufficiently discussed.

DISCUSSIONFor mental health screening to succeed, re-spondents must be willing to divulge potentiallysensitive information and agree to its meaningand validity. This review found that current use

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in primary care, at least as reflected in the contentsof published reports, places little emphasis onsteps that would make this possible. Publishedreports give little explanation of how the purposeof screening is explained or what youth aretold about who will have access to the informa-tion. Assistance with completion or accommoda-tion for language differences, hearing or visionimpairment, or limited literacy is not usuallydescribed, and there are only inconsistent reportsof attention to privacy during the screening pro-cess. However, although systematic comparisonamong studies is not possible, there is some evi-dence that attention to these factors influencesattitudes toward screening and rates of uptake.

The literature also provides little insight intohow clinicians evaluate initial screening resultsand use them to make clinical decisions.Although some programs paired screening withtraining or facilitated access to consultation andevaluation, the plans described for manyassumed either that clinicians already knew whatto do with the information or that all patientswho screened positive should be referred forevaluation or treatment from a specialist. Only2 articles said explicitly that the psychometricsof the screens that they used had been explainedto providers, and that providers were trainedeither to ask follow-up questions or in some wayvalidate the screen results.8,63 In the absence ofskills to interpret results, and especially whenusing instruments that do not explicitly helpdifferentiate among possible mental healthproblems, busy clinicians may opt to refer allpositive screens (or cases with parental concerns).Such a policy could overwhelm limited mentalhealth resources with large numbers of appoint-ments, many of which might not be kept. Infact, 1 study noted that the cut-point on itsdepression screen had to be adjusted upwardbecause primary care and behavioral health pro-viders could not handle the volume of cases beingidentified.48 One of the reviewed articles—perhaps because it was evaluating a new instru-ment—provides a possible model for what pro-viders should know if they are to use existingscreening tools. Hartung et al.63 trained providershow to decide when follow-up questions werewarranted, suggested general probes to getfurther information, and underscored thatassessing impairment was a necessary step beforeconsidering a referral.

Other guidance can be drawn from the studiesabout possible ways to address problems with




Clinical Guidance

� The literature suggests that screening can have apositive effect on parent, youth, and primary careprovider willingness to discuss mental health issues.

� There is a suggestion in published studies thatparents and youth favor screening that is framed asuniversal, confidential, and designed to improvecommunication with their primary care provider, butthere remain many questions about how screeningcan best be presented in primary care settings.

� Screening may have unpredictable and potentiallyundesired impacts for patients and systems in theabsence of support for clinical decision making,first-line treatment, and linkage to specialty care.Factors that promote effective screening—attentionto informing patients about clinical goals, usingaccessible terms, and discussing confidentiality—are also important aspects of any care that is sub-sequently offered.

� Mental health professionals working with primarycare providers may want to inquire about the extentto which their colleagues have been trained tointerpret screening results. If asked for informal orformal consultation based on screening findings(positive or negative), it could be important to askhow the screen was administered, what otherinformation has been gathered, and how thecombined information has led to a desire forconsultation or referral.


engagement. The few studies that asked foundthat both patients and providers found screeninguseful as a way to more efficiently and acceptablyinitiate discussions of mental health problemsand be responsive to patient concerns.32,38,43,44

The studies reviewed suggest that families andyouth are likely to feel positive about screeningthat is framed as universal, intended to optimizeattention to their concerns, and designed toaddress common but sensitive issues in athoughtful and confidential manner. As has beenfound in other settings, computerized screeningwas well accepted and may prove to be aneffective way of efficiently administering screensthat offer more decision support, overcome liter-acy barriers, and create a greater sense of confi-dentiality.77,78 Studies of general medical carehave also found that youth asked to disclosesensitive concerns are responsive to assurancesabout confidentiality.79 These considerationsapply not just to screening but also to engagingparents, children, and youth in any service towhich they are subsequently referred.38,45 Mentalhealth problems can be chronic or recur across thelifespan, and negative experiences may make anindividual reluctant to seek services when theyare needed at a time in the future.

All of our observations regarding the rela-tionship of engagement and evaluation toscreening uptake or follow-up are best taken asjumping-off points for further study; we did notconduct a formal meta-analysis, and none of thestudies reviewed were designed to explore theseissues. The scanty information provided in moststudies about engagement and evaluation stepsdoes not necessarily mean that they wereneglected by investigators, but could reflect aform of publication bias. Investigators or editorsmay see these details as unrelated to outcomesand thus less important to report than otherstudy details. In addition, the inclusion ofstudies from school and low-acuity emergencysettings goes beyond the usual definition ofprimary care, although it reflects the ways inwhich many children and youth receive generalmedical services. The strongest conclusionthat can be drawn from this review is that theexisting literature on pediatric mental healthscreening processes for patient engagement andprovider use is very limited. Key issues such ashow to present screeners in ways that are notpotentially damaging to therapeutic relation-ships (e.g., intrusive, culturally inappropriate,



not confidential), or how to help providers makevalid use of screening results, have not receivedsystematic study.

The large number of screen-negative childrenreferred in some studies poses an importantquestion for planning follow-up services. We donot know whether these referrals represent false-negative results (which could be caused by failureto disclose information on the screen itself, amisadjustment of the cut-off point, or the overallprocess prompting disclosure of concerns notcovered on the screen), or, less optimistically, anoversensitization to mental health concernsprompted by using the screen. New research onmental health screening in primary care shouldat the very least provide details about howscreening is framed to patients and how pro-viders are taught to use results; ideally it shouldstudy variations in these aspects of the processwithin the context of a clear vision of the clinicalgoals desired. &

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11

WISSOW et al.

Accepted August 27, 2013.

Drs. Wissow, Brown, and Fothergill, and Ms. Zelkowitz are with theJohns Hopkins School of Public Health. Dr. Gadomski is with theBassett Research Institute. Dr. Hacker is with Cambridge Health Alli-ance. Dr. Salmon is with the University of Liverpool.

This work was supported by the National Institute of Mental Health(NIMH) grant P20 MH 086048.

The authors gratefully acknowledge the guidance of Andrea Villanti,Ph.D., and Donna Hesson, M.L.S., of the Johns Hopkins School ofPublic Health for guidance with systematic literature review methods.

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46 www.jaacap.org

Disclosure: Drs. Wissow, Brown, Fothergill, Gadomski, Hacker, andSalmon, and Ms. Zelkowitz report no biomedical financial interests orpotential conflicts of interest.

Correspondence to Larry Wissow, M.D., M.P.H., Johns HopkinsSchool of Public Health, 703 Hampton House, 624 N. Broadway,Baltimore, MD 21205; e-mail: [email protected]

0890-8567/$36.00/ª2013 American Academy of Child andAdolescent Psychiatry

http://dx.doi.org/10.1016/j.jaac.2013.08.013

REFERENCES
1. Kataoka SH, Zhang L, Wells KB. Unmet need for mental health
care among U.S. children: variation by ethnicity and insurancestatus. Am J Psychiatry. 2002;159:1548-1555.

2. Kramer T, Garralda ME. Psychiatric disorders in adolescents inprimary care. Br J Psychiatry. 1998;173:508-513.

3. Committee on Psychosocial Aspects of Child and Family Healthand Task Force on Mental Health. Policy statement—the future ofpediatrics: mental health competencies for pediatric primary care.Pediatrics. 2009;124:410-421.

4. US Preventive Services Task Force. Screening and treatment formajor depressive disorder in children and adolescents: US Pre-ventive Services Task Force Recommendation Statement. Pediat-rics. 2009;123:1223-1228.

5. Preventive regulations, 2010 Patient Protection andAffordableCareAct. Public Law 111— 148. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148). Accessed December 24, 2012.

6. Semansky R, Koyanagi C, Vandivort-Warren R. Behavioral healthscreening policies in Medicaid programs nationwide. PsychiatrServices. 2003;54:736-739.

7. Olson AL, Kemper KJ, Kelleher KJ, Hammond CS, Zuckerman BS,Dietrich AJ. Primary care pediatricians’ roles and perceived re-sponsibilities in the identification and management of maternaldepression. Pediatrics. 2002;110:1169-1176.

8. Zuckerbrot RA, Jensen P. Improving recognition of adolescentdepression in primary care. Arch Pediatr Adolesc Med. 2006;160:694-704.

9. Kuhlthau K, Jellinek M, White G, VanCleave J, Simons J,Murphy M. Increases in behavioral health screening in pediatriccare for Massachusetts Medicaid patients. Arch Pediatr AdolescMed. 2011;165:660-664.

10. Chisolm D, Klima J, Gardner W, Kelleher K. Adolescent behav-ioral risk screening and use of health services. Admin Policy MentHealth. 2009;36:374-380.

11. Hacker K, Myagmarjav E, Harris V, Suglia S, Weidner D, Link D.Mental health screening in pediatric practice: factors related topositive screens and the contribution of parental/personalconcern. Pediatrics. 2006;126:1896-1906.

12. Hacker KA, Williams S, Myagmarjav E, Cabral H, Murphy M.Persistence and change in pediatric symptom checklist scores over10 to 18 months. Acad Pediatr. 2009;9:270-277.

13. Norlin C, Crawford M, Bell C, Sheng X, Stein M. Delivery of well-child care: a look inside the door. Acad Pediatr. 2011;11:18-26.

14. Earls MF, Hay SS. Setting the stage for success: implementation ofdevelopmental and behavioral screening and surveillance in pri-mary care practice—the North Carolina Assuring Better ChildHealth and Development (ABCD) project. Pediatrics. 2006;118:e183.

15. Weitzman C, Leventhal JM. Screening for behavioral healthproblems in primary care. Curr Opin Pediatr. 2006;18:641-648.

16. Brent DA. Screens and doors: the management of adolescentdepression in primary care. Arch Pediatr Adolesc Med. 2006;160:755-756.

17. Richardson LP, Lewis CW, Casey-Goldstein M, McCauley E,Katon W. Pediatric primary care providers and adolescentdepression: a qualitative study of barriers to treatment and theeffect of the black box warning. J Adolesc Health. 2007;40:433-439.

18. Sanci L, Lewis D, Patton G. Detecting emotional disorders in youngpeople in primary care. Curr Opin Psychiatr. 2010;23:318-323.

19. Canino G, Alegria M. Psychiatric diagnosis—is it universal orrelative to culture? J Child Psychol Psychiatry. 2008;49:237-250.

20. Maynard DW, Freese J, Schaeffer NC. Requests, blocking moves,and rational (inter)action in survey introductions. Am Sociol Rev.2010;75:791-798.

21. Warnecke RB, Johnson TP, Chavez N, et al. Improving questionwording in surveys of culturally diverse populations. Ann Epi-demiol. 1997;7:334-342.

22. Bradburn NM, Rips LJ, Shevell SK. Answering autobiographicalquestions: the impact of memory and inference on surveys. Sci-ence. 1987;236:157-161.

23. Gordis L. Epidemiology. Philadelphia: Saunders; 2004.24. Klabunde CN, Lanier D, Breslau ES, et al. Improving colorectal

cancer screening in primary care practice: innovative strategiesand future directions. J Gen Intern Med. 2007;22:1195-1205.

25. Wagner EH, Austin BT, Von Korff M. Organizing care for patientswith chronic illness. Milbank Q. 1996;74:511-544.

26. Williams SB, O’Connor E, Eder M, Whitlock E. Screening for childand adolescent depression in primary care settings: a systematicreview for the U.S. Preventive Services Task Force. U.S. PreventiveServices Task Force Evidence Syntheses, formerly Systematic Ev-idence Reviews. 2009. Report No. 09-05130-EF-1.

27. Carter AS, Briggs-Gowan MJ, Davis NO. Assessment of youngchildren’s social-emotional development and psychopathology:recent advances and recommendations for practice. J Child Psy-chol Psychiatry. 2004;45:109-134.

28. Gilbody S, House A, Sheldon T. Screening and case finding in-struments for depression (review). Cochrane Database Syst Rev.2005;(4):CD002792.

29. Gilbody S, Sheldon T, House A. Screening and case-finding in-struments for depression: a meta-analysis. Can Med Assoc J. 2008;178:997-1003.

30. Simonian SJ. Screening and identification in pediatric primarycare. Behav Modif. 2006;30:114-131.

31. Richardson LP, McCauley E, Grossman DC, et al. Evaluation of thePatient Health Questionnaire-9 item for detecting major depres-sion among adolescents. Pediatrics. 2010;126:1117-1123.

32. Gardner W, Klima J, Chisolm D, et al. Screening, triage, andreferral of patients who report suicidal thought during a primarycare visit. Pediatrics. 2010;125:945-952.

33. Goodman R. Psychometric properties of the strengths and diffi-culties questionnaire. J Am Acad Child Adolesc Psychiatry. 2001;40:1337-1345.

34. Navon M, Nelson D, Pagano M, Murphy M. Use of the pediatricsymptom checklist in strategies to improve behavioral health care.Psychiatr Services. 2001;52:800-804.

35. Kostanecka A, Power T, Clarke A, Watkins M, Hausman CL,Blum NJ. Behavioral health screening in urban primary care set-tings: construct validity of the PSC-17. J Dev Behav Pediatr. 2008;29:124-128.

36. Greenhalgh T, Peacock R. Effectiveness and efficiency of searchmethods in systematic reviews of complex evidence: audit ofprimary sources. Br Med J. 2005;331:1064-1065.

37. Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group.Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.

38. Gruttadaro D, Markey D. The family experience with primary carephysicians and staff: a report by the National Alliance on MentalIllness. May 2011. Arlington, VA: National Alliance on MentalIllness.

39. Applegate H, Kelley ML, Applegate BW, Jayasinghe IK,Venters CL. Clinical case study: pediatric residents’ discussions of

OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY


mailto:[email protected]

http://dx.doi.org/10.1016/j.jaac.2013.08.013

http://www.gpo.gov/fdsys/pkg/PLAW-111publ148

http://www.gpo.gov/fdsys/pkg/PLAW-111publ148



and interventions for children’s behavioral and emotional prob-lems. J Pediatr Psychol. 2003;28:315-321.

40. Berger-Jenkins E, McCord M, Gallagher T, Olfson M. Effect ofroutine mental health screening in a low-resource pediatric pri-mary care population. Clin Pediatr. 2012;51:359-365.

41. Jee SH, Halterman JS, Szilagyi M, Conn A, Alpert-Gillis L,Szilagyi PG. Use of a brief standardized screening instrument in aprimary care setting to enhance detection of social-emotionalproblems among youth in foster care. Acad Pediatr. 2011;11:409-413.

42. Murphy JM, Ichinose C, Hicks RC, et al. Utility of the PediatricSymptom Checklist as a psychosocial screen to meet the federalEarly and Periodic Screening, Diagnosis, and Treatment (EPSDT)standards: a pilot study. J Pediatr. 1996;129:864-869.

43. Olson AL, Gaffney CA, Hedberg VA, et al. The Healthy Teenproject: tools to enhance adolescent health counseling. Ann FamMed. 2005;3(Suppl 2):S63-S65.

44. Olson AL, Gaffney CA, Hedberg VA, Gladstone GR. Use ofinexpensive technology to enhance adolescent health screeningand counseling. Arch Pediatr Adolesc Med. 2009;163:172-177.

45. Pailler ME, Cronholm PF, Barg FK, Wintersteen MB, Diamond GS,Fein JA. Patients’ and caregivers’ beliefs about depressionscreening and referral in the emergency department. PediatrEmerg Care. 2009;25:721-727.

46. Wintersteen MB. Standardized screening for suicidal adolescentsin primary care. Pediatrics. 2010;125:938-944.

47. Rausch J, Hametz P, Zuckerbrot R, Rausch W, Soren K. Screeningfor depression in urban Latino adolescents. Clin Pediatr (Phila).2012;51:964-971.

48. Stevens J, Kelleher KJ, Gardner W, et al. Trial of computerizedscreening for adolescent behavioral concerns. Pediatrics. 2008;121:1099-1105.

49. Schubiner H, Tzelepis A, Wright K, Podany E. The clinical utility ofthe Safe Times Questionnaire. J Adolesc Health. 1994;15:374-382.

50. Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a qualityimprovement intervention for adolescent depression in primary careclinics: a randomized controlled trial. JAMA. 2005;293:311-319.

51. Hayutin LG, Reed-Knight B, Blount RL, Lewis J, McCormick ML.Increasing parent-pediatrician communication about children’spsychosocial problems. J Pediatr Psychol. 2009;34:1155-1164.

52. Asarnow JR, Jaycox LH, Tang L, et al. Long-term benefits of short-term quality improvement interventions for depressed youths inprimary care. Am J Psychiatry. 2009;166:1002-1010.

53. Wells KB, Tang L, Carlson GA, Asarnow JR. Treatment of youthdepression in primary care under usual practice conditions:observational findings from youth partners in care. J Child Ado-lesc Psychopharmacol. 2012;22:80-90.

54. Ballard ED, Bosk A, Snyder D, et al. Patients’ opinions about sui-cide screening in a pediatric emergency department. PediatrEmerg Care. 2012;28:34-38.

55. Horowitz L, Ballard E, Teach S, et al. Feasibility of screening pa-tients with nonpsychiatric complaints for suicide risk in a pediatricemergency department: a good time to talk? Pediatr Emerg Care.2010;26:787-792.

56. Briggs RD, Stettler EM, Silver EJ, et al. Social-emotional screeningfor infants and toddlers in primary care. Pediatrics. 2012;129:e377.

57. Chisolm DJ, Gardner W, Julian T, Kelleher KJ. Adolescent satis-faction with computer-assisted behavioural risk screening in pri-mary care. Child Adolesc Ment Health. 2008;13:163-168.

58. Diamond G, Levy S, Bevans K, et al. Development, validation, andutility of Internet-based, behavioral health screen for adolescents.Pediatrics. 2010;126:e163.

59. Fein JA, Pailler ME, Barg FK, et al. Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinicalstaff in the pediatric emergency department. Arch Pediatr AdolescMed. 2010;164:1112-1117.

60. Pailler ME, Fein JA. Computerized behavioral health screening inthe emergency department. Pediatr Ann. 2009;38:156-160.



61. Gall G, Pagano ME, Desmond MS, Perrin JM, Murphy JM. Utilityof psychosocial screening at a school-based health center. J SchHealth. 2000;70:292-298.

62. Garrison WT, Bailey EN, Garb J, Ecker B, Spencer P, Sigelman D.Interactions between parents and pediatric primary care physi-cians about children’s mental health. Hosp Commun Psychiatry.1992;43:489-493.

63. Hartung CM, Lefler EK. Preliminary examination of a new mentalhealth screener in a pediatric sample. J Pediatr Health Care. 2010;24:168-175.

64. Horwitz SM, Hoagwood KE, Garner A, et al. No technologicalinnovation is a panacea: a case series in quality improvement forprimary care mental health services. Clin Pediatr (Phila). 2008;47:685-692.

65. Husky M, Miller K, McGuire L, Flynn L, Olfson M. Mental healthscreening of adolescents in pediatric practice. J Behav Health StudRes. 2011;38:159-169.

66. Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM,Kelleher KJ. Use of the pediatric symptom checklist to screen forpsychosocial problems in pediatric primary care: a nationalfeasibility study. Arch Pediatr Adolesc Med. 1999;153:254-260.

67. Wasserman RC, Kelleher KJ, Bocian A, et al. Identification ofattentional and hyperactivity problems in primary care: a reportfrom pediatric research in office settings and the ambulatorysentinel practice network. Pediatrics. 1999;103:e38.

68. Kelleher KJ, Childs GE, Wasserman RC, McInerny TK,Nutting PA, Gardner WP. Insurance status and recognition ofpsychosocial problems. A report from the pediatric research inoffice settings and the ambulatory sentinel practice networks.Arch Pediatr Adolesc Med. 1997;151:1109-1115.

69. John R, Buschman P, Chaszar M, Honig J, Mendonca E, Bakken S.Development and evaluation of a PDA-based decision supportsystem for pediatric depression screening. Stud Health TechnolInform. 2007;129:1382-1386.

70. King CA, O’Mara RM, Hayward CN, Cunningham RM. Adoles-cent suicide risk screening in the emergency department. AcadEmerg Med. 2009;16:1234-1241.

71. King CA, Hill RM, Wynne HA, Cunningham RM. Adolescentsuicide risk screening: the effect of communication about type offollow-up on adolescents’ screening responses. J Clin Child Ado-lesc Psychol. 2012;41:508-515.

72. Metz JR, Allen CM, Barr G, Shinefield H. A pediatric screeningexamination for psychosocial problems. Pediatrics. 1976;58:595-606.

73. Pagano M, Murphy JM, Pedersen M, et al. Screening for psycho-social problems in 4-5-year-olds during routine EPSDT examina-tions: validity and reliability in a Mexican-American sample. ClinPediatr (Phila). 1996;35:139-146.

74. Smith MS, Mitchell J, McCauley EA, Calderon R. Screening foranxiety and depression in an adolescent clinic. Pediatrics. 1990;85:262-266.

75. Williams JR, Ho ML, Grupp-Phelan J. The acceptability of mentalhealth screening in a pediatric emergency department. PediatrEmerg Care. 2011;27:611-615.

76. Julian TW, Kelleher K, Julian DA, Chisolm D. Using technology toenhance prevention services for children in primary care. J PrimPrev. 2007;28:155-165.

77. Turner CF, Ku L, Rogers SM, Lindberg LD, Pleck JH,Sonenstein FL. Adolescent sexual behavior, drug use, andviolence: increased reporting with computer survey technology.Science. 1998;280:867-873.

78. Newman JC, Des Jarlais DC, Turner CF, Gribble J, Cooley P,Paone D. The differential effects of face-to-face and computerinterview modes. Am J Public Health. 2002;92:294-297.

79. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influenceof physician confidentiality assurances on adolescents’ willingnessto disclose information and seek future health care. A randomizedcontrolled trial. JAMA. 1997;278:1029-1034.

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SUPPLEMENT 1

Sample Search Strategy (PubMed)Mental Health. “Mental Health”[majr] OR “mentalhealth”[tiab] OR “mental illness”[tiab] OR “Anxi-ety Disorders”[Mesh] OR “Anxiety, Separa-tion”[Mesh] OR “Attention Deficit and DisruptiveBehavior Disorders”[Mesh] OR “Depressive Dis-order/classification”[Mesh] OR “Depressive Dis-order/diagnosis”[Mesh] OR “Substance-RelatedDisorders/classification”[Mesh] OR “Substance-Related Disorders/diagnosis”[Mesh] OR “Self-Injurious Behavior/classification”[Mesh] OR“Self-Injurious Behavior/diagnosis”[Mesh] OR“anxiety”[tiab] OR “depression”[tiab] OR “atten-tion deficit”[tiab])

Youth. “Child”[Mesh] OR “Adolescent”[Mesh])OR “Minors”[Mesh] OR “adolescen*”[tiab] OR“teen*”[tiab] OR “youth”[tiab] OR “children”[tiab]

Primary care. Primary Health Care“[Mesh] OR“Adolescent Medicine”[Mesh]) OR “GeneralPractice”[Mesh] OR “Pediatrics”[Mesh] OR“General Practitioners”[Mesh] OR “Physicians,

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Family”[Mesh] OR “Physicians, Primary Care”[Mesh] OR “primary care”[tiab] OR “pedia-tric*”[tiab] OR “paediatric*”[tiab]

Screening. “Screen*”[tiab] OR “mass screening”[MeSH:noexp] OR “questionnaires”[Majr] OR“Risk Assessment”[Mesh:noexp]

Key domains are listed above in bold. Domainswere joined using the Boolean operator “AND.”Due to the high number of search hits, we addedthe following exclusion terms to the PubMedsearch, using the Boolean operator “NOT”EXCLUSIONS

NOT (“developmental disabilities”[MeSH] OR“developmental disabilities”[tiab] OR “autism”

[tiab] OR “asthma”[MeSH] OR “asthma”[tiab] OR“obesity”[MeSH Terms] OR “obesity”[tiab] OR“chronic pain”[tiab] OR “cancer”[tiab] OR “car-diac”[tiab] OR “diabetes”[tiab] OR “epilepsy”[tiab]OR “infection”[tiab] OR “oral”[tiab] OR “dental”[tiab] OR “allergy”[tiab] OR “hypertension”[tiab]OR “inflammatory bowel disease”[tiab] OR“congenital”[tiab] OR “arthritis”[tiab] OR“musculoskeletal”[tiab])




TABLE S1 Study Setting, Instruments, Scoring, Follow-Up, and Clinical Impact of Screening

First Author, Year,and Referencea Setting and Population Instrument

Who Scores andTraining in Scoring

Follow-up to Screen andTraining or Assistance

With Follow-up Impact on VisitImpact on Referrals

and Use

Applegate 20031 Residents (4); 52patients age 6e16 ycoming for WCC

PSC with or withoutparent handout

Residents taught “how touse and score.” Taughtabout importance ofintervention

Resident decides how touse results and handouts

Increased behavioraldiscussions but not relatedto PSC score; authorsspeculated residents didnot use screener to identifychildren needing moreintervention

No increase inbehavioralinterventions frombaseline

Asarnow 20052;Asarnow 20093;Wells 20124

4,002 youth 13e21 yscreened, 418enrolled and thenrandomized, range ofprimary care settings

Set of items fordepression/ dysthymiafrom CIDI and CES-D

Study staff (enrolledpatients randomized tousual care or QIintervention fordepression)

In QI condition caremanager of PhD levelclinician supported PCPwith evaluation, patienteducation, treatment,referral; usual care PCPstrained on evaluationand treatment

No difference in satisfactionwith mental health carebetween QI and usualcare group

QI group patients hadfewer depressionsymptoms at follow-up

Ballard 20125;Horowitz 20106

Convenience sample of156 ED ages 10e21 y

15 or 30 item versionof Suicidal IdeationQuestionnaire

Not stated On-site ED psychiatric staffevaluate positive resultswhile patient waits forED provider

Those requiring psychiatricevaluation did not havelonger visits

Not stated

Berger-Jenkins20127

229 children 5e12 y inprimary care

Initial screening questionabout concerns; ifpositive get PSC-17

Nurse scores and putson chart

Providers introduced toPSC and rationale forscoring; encouraged touse own judgment aboutresults; on-site MHconsultant 1 day/week

Increase in chart notes re:MH concerns but nochange in proportion withMH diagnosis

Referrals decreased

Briggs 20128 3,169 children 6e36mo in primary care

ASQ-SE given a 6-monthintervals

Psychologist scores Positive screens givento co-locatedpsychologist, whoconsults with PCP abouttreatment

Not stated MH intervention reducedsubsequent scores

Chisolmb 20089 1,021 youth 11e20 y inprimary care

Health eTouchbehavioral risk screen(computerized)

Scored electronically,positive results andindividual items givento provider

No discussion of providertraining or assistance

Not stated Not applicable

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TABLE S1 Continued





and Use

Chisolmb 200913 996 youth 11e20 y inprimary care


Scored electronically,positive results andindividual items givento provider(randomized to getimmediate versusdelayed)

No discussion of providertraining or assistance

Not stated Increased use of medicaland MH services overnext 6 mo; positivescreen increaseddepression care (vs.negative screen) butsubstance careunrelated to screenresult

Stevensb 200814 878 youth 11e20 y inprimary care


Scored electronically,positive results andindividual items givento provider(randomized to getimmediate versusdelayed).

Increased cut-off duringstudy when providers“overwhelmed.”

No discussion of providertraining

Increased providerrecognition of behavioraland substance concerns inimmediate vs. delayedresults, but even withimmediate feedback 45%of youth with concernsmissed by PCPs

Not applicable

Gardnerb 201015 1,547 youth 11e20 y inprimary care

Health eTouchbehavioral risk screen;this article focuses onsuicide screen, PHQ-A

Scored electronically,positive results andindividual items givento provider (usuallybefore visit) andsuicideprevention team

PCP not trained; hadoption of discussingresults with family orreferring to on-site socialworker and suicideprevention team;assistance withscheduling follow-upMH visit

Social workers spoke to98% of those with SI; PCProle not discussed

65% of those referred forMH follow-up receivedit in next 6 months

Diamond 201016 415 youth 12e21 y inprimary care

Behavioral HealthScreen

Scored electronically,PCP receives printoutwith scaled scores bydomain

Those with behavioralneed “referredappropriately;” nodiscussion of training(though instrumentdesigned to “focusclinical conversationsabout risk”

Providers thought BHS usefulfor facilitating visit,planning conduct of visit,guiding follow-upquestions

Not applicable

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Fein 201017 857 youth 14e18 yin ED

Behavioral HealthScreen-ED

Scored electronically,ED provider receivesprintout with scaledscores by domain

Clinical staff followed“routine care” whichcould include SW orpsychiatric consult;training not discussed

Increased identification ofpatients with psychiatricillness

Increased ED-based SWand psychiatricassessments

Pailler 200918,19 Pilot: Youth 14e18 y inED, number not stated

Interviews pre-pilot: 60non-acute ED patients12e18 y and parents

Behavioral HealthScreen-ED

Scored electronically,ED provider receivesprintout with scaledscores

Nurses and EDtechnicians received on-site training; other EDstaff made aware.Providers instructed to“follow their routinecare” of positivescreens; consultationavailable. Database ofreferral resources

Not discussed Mentions comparison ofpatient outcomes andreferrals before andafter implementationbut does notprovide data

Gall 2000 20 383 youth 13e18 y inschool-based healthcenter

PSC-Y plus additionalquestions, including,“Do you haveemotional orbehavioral problemsfor which youwant help?”

Score recorded inmedical record; whoscores not stated

No mention of training.Students with positivescreen who asked forreferral received one.Agreement with MCO toprovide referrals

Not discussed Positive score stronglyassociated withreferral (81% ofpositives versus 8% ofnegatives); referralrelated to laterdecreased absencesand tardiness

Garrison 199221 1,378 well-child visits tourban primary careclinic and 3 privatepractices; 327 casesin which parent raisedpsychosocial concern

1-page bilingual surveywith demographics,parent concerns,indication of desire totalk to PCP

Placed in chart afterparent completes it;evidently even if parentdid not wish to discusswith PCP

No mention of training; inurban setting more oftenasked patients to returnfor further discussion; inprivate practice gavereassurance andguidance

Providers did not addressconcern in 35% of visitswhere parent had concernand wanted to talk aboutit. Parents with fewerconcerns more likely tohave them discussed

Medicaid families morelikely to be referred

Gruttadero 201122 554 family respondentsof Web-based surveyof caregivers ofchildren and youthwith mental illness

Survey of experienceswith primary careproviders

Not applicable Not applicable Not applicable Not applicable

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Hacker 200623 1,668 youth 4 y/11 moto 19 y at well visits inprimary care

PSC or PSC-Y plusadditional questionsabout parent concerns

Provider scores oncevisit has begun

Providers instructed todiscuss results withfamily; make handoff toco-located SW inperson. Children whoscore positive and notalready in care, andthose negative butparent has concern, arereferred, but providercan refer anyone ifdesired

Not described Number of MH referralsdoubled from yearbefore screening; ofthose referred, 41%had positive PSC

Hacker 200924 1,033 youth 4 y/11 moto 19 y at well visits inprimary care who hadmore than 1 screenover time

PSC or PSC-Y plusadditional questionsabout parent concerns

Provider scores oncevisit has begun

Same as Hacker 2006 Not described Referral of youth at indexvisit associated withdrop in PSC score atfollow-up but notrelated to whetherreferralappointment kept

Hartung 201025 328 children 3e12 y inprimary care

Primary Care MHScreener

Instrument not scored—PCP to review items

Need impairment tojustify referral; no strictcut-off score

PCPs trained:-items matching particularsymptom clusters

-look for often or very oftenitems

-criteria for asking follow-up questions

-general probes asking forexamples and relatedfunctional problems

-referral list

Not described (articlefocuses on psychometrics)

Not described (articlefocuses onpsychometrics)

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Hayutin 200926 174 children aged 4e16 y in primary careand pediatric GI clinic

PSC Parents randomized(according to theirprovider) to no screen,to score screenthemselves, or to havenurse or medicalassistant score

Providers told that purposeof study was to evaluatewaiting-roomintervention to increasecommunication aboutemotional andbehavioral problems;providers received 5-mintraining and writteninstructions oninterpretation of PSC

Screening increaseddiscussion of psychosocialissues among those withhigher scores, regardlessof who scores; staffscoring associated withmore physician initiationof discussion; parentscoring associated withhigher ratings of “enough”discussion

No impact of screeningon referrals (ratevery low)

Horwitz 200827 376 families of childrenup to age 8 yscheduled for well carein primary care

“CHADIS” system ofmultiple (23) screenerson-line plus asking forranked concerns

Computer scored 30-min session onepidemiology anddiagnosis. Systemincludes on-linematerials for providersand families.

Too time consuming forprovider, better forassistant; not alwaysaware that screeningcompleted; providers didnot find on-line materialuseful

Not applicable

Husky 201128 483 youth 13e17 ycoming for well care inprimary care

DPS-8 Computer-generatedsummary of disorderand total scores

No information abouttraining or preparationof providers, butprovider review“privately withadolescent” isrecognized as secondstage of screen

Not described. Screening regardless ofoutcome resulted inmore MH andpediatric follow-up, butpositive screen moreso; doubled proportionthought to need care

Jee 201129 195 youth 11e17 y infoster care

SDQ Not formally scoreduntil after visit

Providers review SDQduring visit; training notdiscussed; SW availableto make referrals

Doubled detection rate ofsocial-emotional problemsfrom 27 to 54%

Not known

Jellinek 199930

Wasserman199931

21,065 youth aged 4e15 y in primary carepracticeebasedresearch networks

PSC Not stated who scores Training video forpractices but details notprovided

Not stated, providers didnot have access to PSCresults

Not stated

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Kelleher 199732 10,250 youth ages 4e15 in primary carepractice-basedresearch networks

PSC Not stated who scores Training video forpractices but details notprovided

Not stated and providersdid not have access toPSC, but in independentreport providers agreedwith positive PSC 54% ofthe time. Agreement morelikely if provider identifiedthe patient as their own

Not stated

John 200733 124 youth 8e18 yselected by nursingstudents in a variety ofambulatory pediatricsettings

Short Mood and FeelingQuestionnaire andfour additionalquestions on PDAsystem (PDA-DSS)

Not stated whether PDAscores instrument

Discussion suggests needfor additional training onhow to share results withpatients and developtherapeutic relationship;PDA-DSS does includesome teaching and“counselinginterventions”

Not stated Not stated

King 200934 295 youth aged 13e17y at ED

Multiple instruments fordepression, SI, alcoholabuse as initial screenand 4 others forsecond stage

Screening administeredand scored byresearch staff andinforms ED physician

Article focuses on validityand utility vs. priordiagnosis

Not applicable 54% of those positive forSI had come for otherreasons (MH andmedical); 56 of thosepositive already intreatment

King 201235 245 youth aged 13e17y at ED

Multiple instruments fordepression, SI, alcoholabuse

Screening administeredand scored byresearch staff

Article focuses on whethertelling youth that a staffmember will review theresults influencesanswers

Not applicable Not applicable

Kuhlthau 201136 Claims data forMassachusettsMedicaid pre- andpostmandatory MHscreening inprimary care

Not specified Not specified Not specified Not specified 25% increase in numberof children withbehavioral healthevaluations

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Metz 197637 983 youth 4e16 y inprimary care

“Multiphasic” visitaddressing severalaspects ofpsychosocial anddevelopmental risk

All instrumentsadministered by aidesand scored

PCP provided withsummary of results listingpast diagnoses, testfailures, parent concernsbut since PCP visit not onsame day not clear ifthere is additionalcontact; follow-up at PCPdiscretion;supplementarycounseling available

PCPs said it was useful 4% of screen patientswere “new cases”(57% of thoseidentified as at risk)

Murphy 199638 379 youth 6e16 y atschool-based andneighborhood primaryhealth care centers

PSC with additionalquestions aboutfunction, mental healthcare, demographics

Not specified Not specified but PCPscould refer youthregardless of score;additional questionabout function includedon form but use notstated

37% of those positive notreferred (reasons notknown but 36% of notreferred positives hadprior care)

Referrals for mentalhealth care increased6-fold; 69% of referralshad positive screen

Pagano 199639 117 children 4e5 y atschool-based andneighborhood primarycare centers

PSC with additionalquestions aboutfunction, mental healthcare, demographics

Not specified Questions added to PSCabout functioning to helpclinicians assess needfor referral

Not stated Parents who believedchild needed help orwanted services morelikely to be positive(14%) vs. others (1%)

Navon 200140 570 children andadolescents 2e18 y inurban primary carecenters

PSC Scored by RA PCP told to use results as“adjunct to their clinicaljudgment. indicator ofneed for furtherservices.”Multidisciplinary teammeeting at PC sitediscussed programissues and individualcases. Not clear whetherall providers attended

Not stated Of sub-sample ofpositives reviewed byteam (25), 5 found tobe OK, 4/20 withneed not previouslyidentified

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Olson 200541 165 adolescents in 6rural primary carepractices

90-item Healthy Teenscreener basedon GAPS

PCPs involved in screenand follow-up plandevelopment over 4“PDSA” cycles; in usescored by computerwith summary

2-h training onmotivationalinterviewing, goalsetting, action plans,patient-centeredcounseling; authorsconcluded that moretraining would havebeen helpful as wouldhave been handouts

PCPs found it hard todevelop action plansexcept when teen hadspecific concern; thought itwould be better to useaction plans for thosealready engaged; alloweduse of time for counselingrather than data gathering

Not applicable

Olson 200942 1,052 youth 11e19 y in5 rural primary carepractices

90-item Healthy Teenscreener based onGAPS (younger andolder teen versions)

Computer scores; PCPcan see printed reportor scan all answerselectronically

PCPs involved indevelopment had role indeciding about cut-offs;otherwise training notspecified.

Part of screener assessesteen readiness tochange; these resultshighlighted for PCP

PCPs found screen helpedtarget most at risk andthose interested in change;helped better use time invisit, though trouble if toomany risks presented atonce and forced toprioritize

Not applicable

Schubiner 199443 152 youth/youngadults, 14e23 y, inprimary care

Safe TimesQuestionnaire

In intervention arm PCPreviews and scoresscreen

Training on preventivehealth screening andgeneral guidelines forinterviewing and healtheducation, use ofmnemonic to rememberrisk categories,psychometrics ofscreener

Videotape assessmentcompared visits with andwithout screener: screenervisits shorter by 4 min (lesstime in assessment) but noincrease ininformation time

Not applicable

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Smith 199044 205 youth 10e17 y;urban hospital primarycare clinic

STAI, CDI Not stated who scoresinstrument

Providers had to assesspatient and developprovision diagnosisbefore receivingscreening results; useunexpectedly positivescreen to explorepsychosocial history.MH assessmentavailable in clinic.

15% of patients hadelevated screens but werenot identified as havingMH problem by PCP

Not applicable

Williams 201145 399 youth 4e18 ycoming to ED

DPS Computer scored ED physicians not involvedunless “urgent mentalhealth concern”detected; in that casefacilitated a referral. On-site SW

�97% of nurse andphysician providers notbothered by screening

Not applicable

Wintersteen 201046 1,415 youth 12e18 y in3 urban primary careclinics

Two stage screen withtotal 8 questions

Not formally scored;questions asked aspart of PCP’s interviewof patient

90-min training on youthsuicide, includingepidemiology, risk andprotective factors,assessment,management. SW inclinic to make referrals

Increased 3-fold rate ofinquiry about SI;increased rate ofidentifying SI

Increased rate of referralto MH

Zuckerbrot 200647 734 youth 13e17 y athealth maintenancevisit or sick visit atsuburban primary carepractice

Columbia DepressionScale and depressionmodule of DISC-IV asoptional second stage

DISC is computerscored; Providersscored CDS. Providerstaught how to useinstruments and cut-offs; training includeddiscussion ofpredictive values atvarious cut-off values

Clinicians “educated”about adolescent andhow use score incombination ofassessment of positivesymptoms; had option touse clinical interview orDISC as second-stagescreen; also received listof referral resources

Providers reported lowburden to use CDS butDISC harder; interested incontinuing use of CDS butmixed opinions of DISC;overall more comfortableassessing depression;CDS helpful for openingdiscussion

Not applicable

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Rausch 201248 636 youth mean age16.6 y seen in 3primary care practices

CDS Reviewed and scored byprovider. Separatescoring sheet indicatedcutoffs and hadcheckbox forsuicidality or need foremergency treatment

Providers and support staffgot “brief introduction”to adolescentdepression, instrument;consider referral is anycurrent or previoussuicidal thoughts, scoreabove cut-off, or otherconcern

Providers reported higherlevel of confidence foridentifying and managingdepression and believedyouth had greater comfortlevel; 37% of providersthought too burdensomefor sick visit

12.6% of those screenedreceived referral formental health service;did not seem to be anincrease from pre-screening, but notmeasured

Note: Note: CDI ¼ Children’s Depression Inventory; CDS ¼ Columbia Depression Scale; CES-D ¼ Center for Epidemiologic Studies Depression Scale; DISC ¼ Diagnostic Interview Schedule for Children; DPS ¼ DiagnosticPredictive Scales; ED ¼ Emergency Department; exam ¼ examining; MH ¼ Mental Health; PC ¼ Primary Care; PCP ¼ Primary Care Provider; PDA ¼ personal digital assistant; PDA-DSS ¼ personal digital assistantebased decision support system; PSC ¼ Pediatric Symptom Checklist; SDQ ¼ Strengths and Difficulties Questionnaire; STAI ¼ State-Trait Anxiety Inventory.aList of articles in alphabetical order by first author except where a series of articles discussed distinct studies carried out by the same group.bInvolve similar populations using the same electronic screening system. An article describing the system but not reporting on a particular study (Julian 200710) describes features related to confidentiality during

administration and decision assistance for the primary care provider (suggested preventive services and referrals, real-time monitoring of results by a suicide prevention team) that are not mentioned in the reports of the 4studies. In addition, Stevens 200911describes a trial of enhanced telephone follow-up of a subset of youth who screened positive using the system, and Stevens 201012 describes readiness to change among a subsetwho screened positive for substance use. Neither of these articles provides additional details relevant to the focus of the review.

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TABLE S2 Aspects of Screening Engagement

First Author, Year,and Referencea

Where and by WhomScreen Is Introduced

How Purpose IsExplained

Parent/YouthPreferences for

Framing (if Studied)Confidentiality

Procedures for YouthConfidentiality

Statements to Youth

Acceptance Rate ifAvailable andApplicable

Accommodation forLiteracy or Language

Applegate 20031 In waiting room(recruited andconsented by RA)

Not stated No change in parentsatisfaction preepost intervention

Parents only Not applicable Not applicable Not stated

Asarnow 20052;Asarnow 20093;Wells 20124

RA obtained consentfrom parent and youth

“Interested in how youthfeeling;” important totalk to provider aboutdifficulties includingstress or depression

Not stated Self-administered byyouth

Not stated 13% declined screen Limited to English

Ballard 20125;Horowitz 20106

Approached by studystaff member in ED butcompleted in exam room

Not directly stated butincluded desire to screenfor suicidal ideation

Most youth thought it“OK.” Some feltrelief. Minorityreported stress.Wanted providersto understand thembetter, identify risk,prevent harm,connect withresources

Youth administeredscreen alone inexam room

Youth told thatanswers would beshared withclinician andparents would benotified if concernfor safety

Parents could decideif medical patientswould bescreened; overallaccept rate 60%;reasons for declineincluded parent notwanting to leaveroom, too young tobe asked aboutsuicide, too ill to beasked

Excludeddevelopmentaldelay and non-English speakers

Berger-Jenkins20127

Given screen by frontdesk personnel at wellvisits

Not directly stated;screener asked a firstquestion about concernsfor behavior, mood, orlearning

Not studied Parents only Not applicable One-third of eligibleparents completedat least firstsurveillancequestion; reasonsfor not completingunknown

PSC in English andSpanish

Briggs 20128 Nursing staff gavescreener to parents inexam room

Letter provided reviewingpurpose of screening(details not stated)

Not studied Parents only Not applicable 64% of eligiblechildren screenedat least once(reasons notknown)

Screens in Englishand Spanish,family could ask forhelp withcompletion

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Chisolm 20089 Adolescents invited byclinic registration orresearch staff butparents had to provideconsent if <18 y old;completed on tablet inwaiting room

Not stated Perceived usefulnessand trust werepositively related toyouth satisfaction

Youth responds ontablet inwaiting area

Told clinician wouldsee results

Acceptance rate notstated; 9% did notcomplete after theyhad started

Not stated, butliteracy issuesstated as 1 of thereasons for non-participation

Chisolm 200913 Completed screen inwaiting room, howapproached not stated

Not stated Not studied Youth responds ontablet inwaiting area


25% of eligiblepopulationscreened

Not stated

Stevens 200814 Approached byregistration or researchstaff

Not stated Not studied Youth responds ontablet inwaiting area


Recruitment rate forregistration staffnot known; rangedfrom 60% to 95%among 3 RAs

Not stated

Gardner 201015 Approached byregistration or researchstaff

Not stated Not stated Youth responds ontablet inwaiting area


Recruitment rate forregistration staffnot known; rangedfrom 60% to 95%among 3 RAs

Not stated

Diamond 201016 Recruited by research staff Not stated Sub-sample ofadolescentresponders thoughtit helped duringappointment andfavored use infuture

Youth reply oncomputer; locationnot specified

Not stated Not applicable Not stated

Fein 201017 ED nurse or technicianasked adolescents aftertheir medical assessment

Used “tri-fold pamphlet”explaining purpose(details not stated) forrecruiting then “slideand audio show”explaining rationale

Not studied Family members“encouraged butnot forced” to leaveroom while youthuses computer

Introduction explains“standard limits ofconfidentiality”

65% acceptancerate for screeningbut overall only33% of eligiblescreened

Excluded non-Englishspeakers and thosewith hearing orvisual impairment;did offer option oflistening toquestions viaheadphones

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Statements to Youth



Pailler 200918,19 Presented by ED nurse ortechnician once patienthad initial assessment

Brochure explainedscreening initiative andbounds onconfidentiality (given tofamily as placed in examroom); introductory slideshow provided rationalefor screening andreviewed confidentiality

Parents wanted to beinvolved and givepermission; youthdid not want screento interfere withother concerns;wanted provider tobe sensitive andwanted to knowaboutconfidentiality;screen earlier toavoid “targeting;”wanted moreinformation aboutmeaning ofscreening results

Conducted inindividual patientrooms; option tolisten tointroduction onheadphones;nurses andtechniciansrequested parentsto give youthprivacy whilecompleting screen;results not printedto patient room

Adolescents couldrequestconfidentiality if nota threat to self orothers

About 20% ofeligible patientsscreened; slightdecrease afternurses notreminded;apparently relatedmostly to staffissues; proportionof familiesaccepting notstated

Option to use audioassistedadministration

Gall 200020 All youth attending school-based health centerasked as part ofregistration

Not stated Not studied Not stated Not stated 95% agreed tocomplete screen

Not stated

Garrison 199221 Given to all parents atwell-child visits; notstated by whom

Not stated, but parents areasked if they are willingto discuss results withpediatrician

Not studied Parent only Not applicable Proportion screenedfell over time from95% to 60%(attributed torepeat screening);of those statingconcerns, 37% didnot wish to discusswith pediatrician

Screen provided inEnglish andSpanish

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Gruttadero201122

Not applicable Not applicable Parents believe thatasking about MHat well visits helpsnormalize theseconcerns andcreate comfort

Not applicable Not applicable Note applicable Not applicable

Hacker 200623 Parents and youthcompleted screen inwaiting room, given byregistration staff atannual visit

Not stated In pilot phase parentswelcomed useof tool

Youth completedtheir own screenerin waiting area

Not stated No refusals in pilotphase; 85% ofeligible screened inimplementationphase; missingforms and literacyissues

Screening instrumentin 6 languages; 4%of screens invalidbecause ofexcessive missingitems

Hacker 200924 Parents and youthcompleted screen inwaiting room, given byregistration staff atannual visit

Not stated Not studied Youth completedtheir own screenerin waiting area

Not stated 70% of eligible hadinitial screening;not provided,literacy, language,lost form issues

Screening instrumentin 6 languages

Hartung 201025 Given to all parents at wellvisits by receptionist oron indicated basis ifparent or provider hadMH concern. Completedin waiting or exam room

Not stated Not studied Parent only Not applicable Not stated Not stated; readinglevel grade 8.8

Hayutin 200926 Parents approached inwaiting room by RA

“Study investigatingstrategies for improvingattention to psychosocialissues.” Parents alsogiven information aboutinterpreting scores andtold they could raiseconcerns regardless ofscore

Not studied Parent only Not applicable 80% agreed to be instudy

Not described

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Horwitz 200827 Introductory letter andreminded by phonebefore visit; onlinescreen completedat home

Not stated 53% thought thatanswering thequestions would beof some help indiscussingconcerns; 85%somewhat likely touse screen asecond time

Parent only Not applicable Overall 11%completion rate(range among 3sites 9%e19%);most did notremember letter,too busy, technicalissues

Not stated

Husky 201128 Parents offered screeningwhen call forappointment; told it isoptional but no cost,asked to come early ifinterested; nurse obtainsconsent

Not stated Youth completescomputerizedscreen alone inexam room; resultsreviewed privatelywith adolescent butinforms parent ifMH concern

Confidential except ifdanger to self orothers, abuse,“significantfunctionalimpairment”

45% completedscreening, withproportionaccepting varyingover time

Not stated

Jee 201129 Nurse gave form to youthin exam room whilewaiting for provider(also to foster parent ifpresent)

Not stated Not studied Youth may or maynot be alone inexam room

Not stated 92% of eligiblecompleted screen

Limited to Englishspeakers

Jellinek 199930;Wasserman199931

Parents approached inwaiting areas by clinicalpersonnel

Written consent obtainedbut framing not stated

Not studied Parent only Not applicable 97% of formsreceived forprocessingcomplete; ratesomewhat higher inmiddle and higherSES versus lower;overall acceptancerate not known

No exclusion criteriadescribed

Kelleher 199732 Parents enrolled byclinician

Written consent obtainedbut framing not stated

Not studied Parents only Not applicable >82% of eligiblechildrenparticipated

No exclusion criteriadescribed

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John 200733 Nursing students could usethe screen in anambulatory clinicalplacement; approachedchild or adolescent

Not stated Not studied Not stated Not stated One-third of eligibleencountersscreened; mostbarriers seemed tobe related tonursing studentconcerns aboutappropriateness ofscreening in ED,specialty, orprivate practicesetting and concernabout follow-up

Not stated (but mostof those screenedwere Hispanic orAfrican American)

King 200934 RAs obtained consent fromparent

Not stated Not studied Youth completedscreen alone

Parent and clinicianwould be notified ifscreen at“high risk”

61% agreed toparticipate

Excluded non Englishspeakers

King 2001235 RAs obtained consent fromparent

Not stated Not studied Youth completedscreen alone

Some youth told theirresults would bereviewed with themby a staff member

Lower income youthless likely to reportdepressionregardless ofreview status;lower income lesslikely to reportsuicidality if toldresults would bereviewed

Reading level variedfrom 0.2 to 6.1

Kuhlthau 201136 Not applicable (articlebased on Medicaidclaims for screening)

Not applicable Not studied Not known Not known Making screeningmandatory forMedicaid-enrolledchildren increasedproportion of visitswith screensto 54%

Not known

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Metz 197637 Screening takes place aspart of hour-long“multiphasic healthexamination” that isseparate fromsubsequent well visit

Not stated Not studied Children interviewedalone by an aidewithout parent ifchild willing toseparate

Not stated Parents of about halfof childrenidentified as “newcases” acceptedMH follow-upinterview; but three-quarters of parentsasking for interviewwere of childrenclassified aslow risk

Not known; tests andscalesadministered bytrainedparaprofessionals

Murphy 199638 Parent asked to fill outscreener in waitingroom; not stated wherescreening conductedonce items were readaloud to parents andrecord answers

Described as voluntary Not studied Parent only Not applicable Based on logsscreensadministered to 1/3 to ½ of eligibleparents; 90% ofthose approachedagreed

More positivescreens when readaloud versuswrittenadministration

English and Spanishforms available;during study notedthat parents haddifficulty with formsso changed to haveRA read the formsto all parents

Pagano 199639 Parent asked to fill outscreener in waitingroom; not stated wherescreening conductedonce items were readaloud to parents andrecord answers

Form explained reason forthe psychosocialscreening study (exactcontents not stated inarticle)

Not stated Parent only Parent only Acceptance rate notknown

No difference inpositive rate bymethod ofadministration(paper vs. oral)

English and Spanishforms available;during study notedthat parents haddifficulty with formsso changed to haveRA read the formsto all parents

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Navon 200140 All patients approached inwaiting area by RA

Clinic including questionsabout children’semotions and behavioras part of their pediatricvisit but voluntary; resultswould be put in child’srecord

Not studied Parent only Not applicable About 90% agreedto have childscreened

Bilingual RA

Olson 200541 Not stated; used as routinein participating practices

Not stated Youth said novelty ofPDA was engagingand preferred to“being grilled”;reported beingcandid and said itmade it easier todiscuss issues

Youth used PDA withsmall screen andanswers that“disappeared” soconfidentialitypossible eventhoughadministered inwaiting area

Not stated Not known Not stated

Olson 200942 Given to adolescentsduring healthmaintenance visits

Not stated Youth said screeningresulted in theirbeing listened tomore carefully, hadfewer unexploredconcerns, greaterbelief inconfidentiality

Youth used PDA inwaiting area as inOlson 2005

Not stated Not known Not stated

Schubiner 199443 Completed before visit Part of study wherepurpose stated aslearning howadolescents areinterviewed

Study comparedstructured interviewwith review of thescreener: reviewled to shorter visitand led to moreaccurate detectionof MH problems

Completed inwaiting room

Not stated Not stated (screeningpart of randomizedtrial)

Not stated

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Smith 199044 Consecutive adolescentclinic patients

“Mood questionnairegiven to all newpatients”

Not studied Not stated Not stated 90% of eligibleparticipated;mostly excluded bylanguage

Excluded non-Englishspeakers

Williams 201145 RAs approached familiesand obtained consent

Short orientation tocomputer program;framing not stated

Most parents andchildren thoughtscreeningacceptable butonly 61% thought ithelpful; minorityparents and thosewhose children hadMH problem morelikely to find ithelpful

Headphones andaudio-assistedadministration forconfidentiality

Not stated Not stated Excluded non-Englishspeakers

Wintersteen201046

Suicide questions builtinto EMR psychosocialtemplate

Framed by other questionsin psychosocial template

Not studied Not stated (part ofprimary care visit)

Not stated (part ofprimary care visit)

Adding item to EMRincreased rate ofinquiry from 37%to 82%

Not applicable

Zuckerbrot 200647 Front desk staff offeredinitial paper screen toall eligible youth

Not stated (but resultssuggest that front-deskstaff could provideinformation aboutprocess)

Not studied Taken to confidentialspace, sealedscreen aftercompletion

Not stated 53% of eligiblecompleted screens;reason for mostmissing not known;few recordedrefusals

Follow-up assessmentfound that front-desk staff neededtraining on how torespond to patientand parent queriesand concerns

36. Rausch201248

Given by medicalassistant

Not stated Not studied Not stated Not stated 92% of thoseapproachedagreed butassistants gavescreener to onlyabout 25% ofeligible

CDS available inEnglish andSpanish

Note: CDS ¼ Columbia Depression Scale; ED ¼ emergency department; EMR ¼ electronic medical record; exam ¼ examining; MH ¼ mental health; PDA ¼ personal digital assistant; PSC ¼ Pediatric Symptom Checklist;RA ¼ research assistant; SES ¼ socioeconomic status.aList of studies in alphabetical order by first author except where a series of articles discussed distinct studies carried out by the same group.

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TABLE S3 PRISMA Checklist for Systematic Review

Topic title Item Page

Title 1 1134AbstractStructured summary 2 1134IntroductionRationale 3 1134Objectives 4 1134MethodProtocol 5 1135Eligibility 6 1135Information sources 7 1135Search 8 1135, Supplement 1 (available online)Study selection 9 1135Extraction process 10 1135e6Data items 11 Tables S1, Table S2 (available online)Bias in individual studies 12 Not assessedSummary measures 13 Not applicable—narrative reviewSynthesis of results 14 Narrative synthesisRisk of bias across studies 15 Not assessedAdditional analyses 16 Not applicableResultsStudy selection 17 1136Study characteristics 18 1136e8, Tables S1, Table S2 (available online)Risk of bias within studies 19 Not discussedResults of individual studies 20 Table 1, Tables S1, Table S2 (available online)Synthesis of results 21 1137e44Risk of bias across studies 22 Not assessedAdditional analyses 23 Not applicableDiscussionSummary of evidence 24 1144e5Limitations 25 1144e5Conclusions 26 1144e5Funding 27 1146

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SUPPLEMENTAL REFERENCES1. Applegate H, Kelley ML, Applegate BW, Jayasinghe IK,

Venters CL. Clinical case study: pediatric residents’ discussions ofand interventions for children’s behavioral and emotional prob-lems. J Pediatr Psychol. 2003;28:315-321.

2. Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a qualityimprovement intervention for adolescent depression in primarycare clinics: a randomized controlled trial. JAMA. 2005;293:311-319.

3. Asarnow JR, Jaycox LH, Tang L, et al. Long-term benefits of short-term quality improvement interventions for depressed youths inprimary care. Am J Psychiatry. 2009;166:1002-1010.

4. Wells KB, Tang L, Carlson GA, Asarnow JR. Treatment of youthdepression in primary care under usual practice conditions:observational findings from youth partners in care. J Child Ado-lesc Psychopharmacol. 2012;22:80-90.

5. Ballard ED, Bosk A, Snyder D, et al. Patients’ opinions about sui-cide screening in a pediatric emergency department. PediatrEmerg Care. 2012;28:34-38.

6. Horowitz L, Ballard E, Teach S, et al. Feasibility of screening pa-tients with nonpsychiatric complaints for suicide risk in a pediatricemergency department: a good time to talk? Pediatr Emerg Care.2010;26:787-792.

7. Berger-Jenkins E, McCord M, Gallagher T, Olfson M. Effect ofroutine mental health screening in a low-resource pediatric pri-mary care population. Clin Pediatr. 2012;51:359-365.

8. Briggs RD, Stettler EM, Silver EJ, et al. Social-emotional screeningfor infants and toddlers in primary care. Pediatrics. 2012;129:e377.

9. Chisolm DJ, Gardner W, Julian T, Kelleher KJ. Adolescentsatisfaction with computer-assisted behavioural risk screeningin primary care. Child Adolesc Ment Health. 2008;13:163-168.

10. Julian TW, Kelleher K, Julian DA, Chisolm D. Using technology toenhance prevention services for children in primary care. J PrimPrev. 2007;28:155-165.

11. Stevens J, Klima J, Chisolm D, Kelleher KJ. A trial of telephoneservices to increase adolescent utilization of health care for psy-chosocial problems. J Adolesc Health. 2009;45:564-570.

12. Stevens J, McGeehan J, Kelleher KJ. Readiness to change in ado-lescents screening positive for substance use in urban primary careclinics. J Child Adolesc Subst Abuse. 2010;19:99-107.

13. Chisolm D, Klima J, Gardner W, Kelleher K. Adolescent behav-ioral risk screening and use of health services. Admin Policy MentHealth. 2009;36:374-380.

14. Stevens J, Kelleher KJ, Gardner W, et al. Trial of computerizedscreening for adolescent behavioral concerns. Pediatrics. 2008;121:1099-1105.

15. Gardner W, Klima J, Chisolm D, et al. Screening, triage, andreferral of patients who report suicidal thought during a primarycare visit. Pediatrics. 2010;125:945-952.

16. Diamond G, Levy S, Bevans K, et al. Development, validation, andutility of Internet-based, behavioral health screen for adolescents.Pediatrics. 2010;126:e163.

17. Fein JA, Pailler ME, Barg FK, et al. Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinicalstaff in the pediatric emergency department. Arch Pediatr AdolescMed. 2010;164:1112-1117.

18. Pailler ME, Cronholm PF, Barg FK, Wintersteen MB, Diamond GS,Fein JA. Patients’ and caregivers’ beliefs about depressionscreening and referral in the emergency department. PediatrEmerg Care. 2009;25:721-727.

19. Pailler ME, Fein JA. Computerized behavioral health screening inthe emergency department. Pediatr Ann. 2009;38:156-160.

20. Gall G, Pagano ME, Desmond MS, Perrin JM, Murphy JM. Utilityof psychosocial screening at a school-based health center. J SchHealth. 2000;70:292-298.

21. Garrison WT, Bailey EN, Garb J, Ecker B, Spencer P, Sigelman D.Interactions between parents and pediatric primary care physi-cians about children’s mental health. Hosp Commun Psychiatry.1992;43:489-493.

22. Gruttadaro D, Markey D. The family experience with primary carephysicians and staff: a report by the National Alliance on MentalIllness. May 2011. Arlington, VA: National Alliance on MentalIllness.

23. Hacker K, Myagmarjav E, Harris V, Suglia S, Weidner D, Link D.Mental health screening in pediatric practice: factors related topositive screens and the contribution of parental/personalconcern. Pediatrics. 2006;126:1896-1906.

24. Hacker KA, Williams S, Myagmarjav E, Cabral H, Murphy M.Persistence and change in pediatric symptom checklist scores over10 to 18 months. Acad Pediatr. 2009;9:270-277.

25. Hartung CM, Lefler EK. Preliminary examination of a new mentalhealth screener in a pediatric sample. J Pediatr Health Care. 2010;24:168-175.

26. Hayutin LG, Reed-Knight B, Blount RL, Lewis J, McCormick ML.Increasing parent-pediatrician communication about children’spsychosocial problems. J Pediatr Psychol. 2009;34:1155-1164.

27. Horwitz SM, Hoagwood KE, Garner A, et al. No technologicalinnovation is a panacea: a case series in quality improvement forprimary care mental health services. Clin Pediatr (Phila). 2008;47:685-692.

28. Husky M, Miller K, McGuire L, Flynn L, Olfson M. Mental healthscreening of adolescents in pediatric practice. J Behav Health StudRes. 2011;38:159-169.

29. Jee SH, Halterman JS, Szilagyi M, Conn A, Alpert-Gillis L,Szilagyi PG. Use of a brief standardized screening instrument in aprimary care setting to enhance detection of social-emotionalproblems among youth in foster care. Acad Pediatr. 2011;11:409-413.

30. Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM,Kelleher KJ. Use of the pediatric symptom checklist to screenfor psychosocial problems in pediatric primary care: a na-tional feasibility study. Arch Pediatr Adolesc Med. 1999;153:254-260.

31. Wasserman RC, Kelleher KJ, Bocian A, et al. Identification ofattentional and hyperactivity problems in primary care: a reportfrom pediatric research in office settings and the ambulatorysentinel practice network. Pediatrics. 1999;103:e38.

32. Kelleher KJ, Childs GE, Wasserman RC, McInerny TK,Nutting PA, Gardner WP. Insurance status and recognition ofpsychosocial problems. A report from the pediatric research inoffice settings and the ambulatory sentinel practice networks.Arch Pediatr Adolesc Med. 1997;151:1109-1115.

33. John R, Buschman P, Chaszar M, Honig J, Mendonca E, Bakken S.Development and evaluation of a PDA-based decision supportsystem for pediatric depression screening. Stud Health TechnolInform. 2007;129:1382-1386.

34. King CA, O’Mara RM, Hayward CN, Cunningham RM. Adoles-cent suicide risk screening in the emergency department. AcadEmerg Med. 2009;16:1234-1241.

35. King CA, Hill RM, Wynne HA, Cunningham RM. Adolescentsuicide risk screening: the effect of communication about type offollow-up on adolescents’ screening responses. J Clin Child Ado-lesc Psychol. 2012;41:508-515.

36. Kuhlthau K, Jellinek M, White G, VanCleave J, Simons J,Murphy M. Increases in behavioral health screening in pediatriccare for Massachusetts Medicaid patients. Arch Pediatr AdolescMed. 2011;165:660-664.

37. Metz JR, Allen CM, Barr G, Shinefield H. A pediatric screeningexamination for psychosocial problems. Pediatrics. 1976;58:595-606.

38. Murphy JM, Ichinose C, Hicks RC, et al. Utility of the PediatricSymptom Checklist as a psychosocial screen to meet the federalEarly and Periodic Screening, Diagnosis, and Treatment (EPSDT)standards: a pilot study. J Pediatr. 1996;129:864-869.

39. Pagano M, Murphy JM, Pedersen M, et al. Screening for psycho-social problems in 4-5-year-olds during routine EPSDT examina-tions: validity and reliability in a Mexican-American sample. ClinPediatr (Phila). 1996;35:139-146.

40. Navon M, Nelson D, Pagano M, Murphy M. Use of the pediatricsymptom checklist in strategies to improve behavioral health care.Psychiatr Services. 2001;52:800-804.


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41. Olson AL, Gaffney CA, Hedberg VA, et al. The Healthy Teenproject: tools to enhance adolescent health counseling. Ann FamMed. 2005;3(Suppl 2):S63-S65.

42. Olson AL, Gaffney CA, Hedberg VA, Gladstone GR. Use ofinexpensive technology to enhance adolescent health screeningand counseling. Arch Pediatr Adolesc Med. 2009;163:172-177.

43. Schubiner H, Tzelepis A, Wright K, Podany E. The clinical utility ofthe Safe Times Questionnaire. J Adolesc Health. 1994;15:374-382.

44. Smith MS, Mitchell J, McCauley EA, Calderon R. Screening foranxiety and depression in an adolescent clinic. Pediatrics. 1990;85:262-266.

45. Williams JR, Ho ML, Grupp-Phelan J. The acceptability of mentalhealth screening in a pediatric emergency department. PediatrEmerg Care. 2011;27:611-615.

46. Wintersteen MB. Standardized screening for suicidal adolescentsin primary care. Pediatrics. 2010;125:938-944.

47. Zuckerbrot RA, Jensen P. Improving recognition of adolescentdepression in primary care. Arch Pediatr Adolesc Med. 2006;160:694-704.

48. Rausch J, Hametz P, Zuckerbrot R, Rausch W, Soren K. Screeningfor depression in urban Latino adolescents. Clin Pediatr (Phila).2012;51:964-971.


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