Abstract
Introduction
Childhood mental illness detection and treatment are concerns on both national and global levels. 1 The prevalence of behavioral health problems in US children is approximately 12% to 27% 2 and has been increasing over the past 3 decades. 3 Multiple studies have demonstrated that pediatricians substantially underidentify children with behavioral health problems,4-6 but identification improves with the use of screening tools.2,7-9 Early detection of and intervention for social and emotional problems are as important for school preparation as cognitive and language development. 10
The American Academy of Pediatrics Task Force on Mental Health emphasizes the importance of routine periodic mental health screening of children and their families.11,12 A number of validated pediatric mental health instruments are available,2,11,13,14 including the Ages and Stages Questionnaire: Social–Emotional (ASQ:SE). 15
Few studies describe the results of mental health screening in children younger than 3 years. 9 No previous studies have described the utility of a mailed mental health screening tool with a management protocol delivered by registered nurses for children who have abnormal screening results.
Study aims are to describe
the frequency of children 30 months old who did not pass the ASQ:SE when administered by mail,
a registered nurse–developmental screening coordinator (DSC) led management protocol for children with elevated scores on the ASQ:SE, and
outcomes of children who received contact from the DSC after concerns were identified through ASQ:SE screening.
Methods
Study Setting
The project was a prospective cohort study conducted at an academic center–based primary care practice consisting of 4 locations in Rochester and Kasson, Minnesota. The Mayo Clinic Institutional Review Board deemed this study a quality improvement project not requiring institutional review board approval.
Standard well-child care at the study site for children between 4 months and 6 years of age included recommended use of the Child Development Review, which contains open-ended mental health screening questions. 16 No standardized mental health screening occurred at point of care or by mail prior to this study.
Screening Tool
The ASQ:SE is a validated, caregiver-completed pediatric mental health screening tool. 15 Completed in an average of 10 to 15 minutes, it screens for mental health developmental delays, including self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people. The ASQ:SE has a reported sensitivity of 78% and specificity of 95%. 17
Protocol
Between October 1, 2010, and February 28, 2011, the ASQ:SE, along with a stamped return envelope, was mailed to children who receive primary care at the study site when they turned 30 months old. When returned, questionnaires were scored by DSCs; 2 registered nurses sharing a full-time position who manage the interpretation, documentation, referral process, and communication with all caregivers and clinicians for children receiving developmental or behavioral screening at the study site.
When children received a failing score greater than 57 or when concerns were identified on the open-ended questions of the ASQ:SE, the DSC called the children’s caregivers to review the concerning responses. When children scored at or below 57 and no other concerns were documented on the ASQ:SE, caregivers were mailed a letter reporting the passing result.
Depending on the type and severity of the concerns identified, as interpreted by the DSC, a referral was made to Early Intervention Services, the child’s primary care clinician, a clinician trained in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood Program (DC:0-3), 18 or directly to psychiatric services (Figure 1). A total of 8 clinicians (4 pediatric and 4 family medicine) at the study site were trained during 2 days by a DC:0-3 training–certified child psychologist.
Management protocol for children who do not pass the ASQ:SE screening.
Evaluation
For children contacted by the DSC for not passing the ASQ:SE or for concerning caregiver comments on the screen, the follow-up plan and short-term clinical outcomes were obtained from the electronic medical record or from local Early Intervention agencies. During the last month of the study, the demographic characteristics of race and insurance type were recorded for all children who received ASQ:SE screening.
Statistical Analysis
Statistical analysis was completed using JMP software version 9.0 (SAS Institute, Inc, Cary, NC). Demographic variables of gender, race, and insurance type were obtained from the medical record and analyzed for an association with the ASQ:SE completion rate using the Pearson χ2 test, with a P value of less than .05 considered statistically significant.
Results
Between October 2010 and February 2011, ASQ:SE questionnaires were mailed to 870 families. Of these screening questionnaires, 507 (58.3%) were returned, and 6 children (0.7%) were referred to early intervention or pediatric subspecialty services as a result of the screening process.
Table 1 summarizes demographic characteristics of children screened in February 2011. Of 165 screens mailed, 91 questionnaires (55.2%) were returned. The majority of the patients who received screening were white (69.1%) and insured privately by institutional insurance provided to health system employees (57.6%).
Demographic Characteristics of Children Screened With the Ages and Stages Questionnaire: Social–Emotional Screen in February 2011.
Figure 2 presents the percentage of screens returned among insurance types and ethnicity groups. Caregivers of children with government insurance returned the ASQ:SE questionnaire 34.2% (13/38) of the time compared with caregivers of those who had private or institutional insurance (65.5% [76/116]; P < .001). The questionnaire return rate difference between white and non-white children was not statistically significant (P = .135).
Relationship between insurance type and ethnicity on mailed Ages and Stages Questionnaire: Social–Emotional screen return rates in February 2011.
Of 507 children with returned questionnaires, 21 (4.1%) had elevated scores on the questionnaire and 17 (3.4%) had concerning comments written on the form, thereby prompting phone follow-up from the DSC. Of children with elevated scores, 14 passed after a follow-up call, 4 were referred to mental health subspecialty pediatrics and did qualify for ongoing services, 2 were referred for mental health services but did not qualify, and 1 could not be reached for follow-up.
Discussion
Mental health screening for a general pediatric population by mail using the ASQ:SE can be implemented using a care management model. Our overall questionnaire return rate of 58% was suboptimal for comprehensive population screening, especially for children with government insurance.
Few previous studies have evaluated the prevalence of mental health disorders in a general pediatric population of children age 3 years and younger. In a randomized sample population of 210 children from the Copenhagen Child Birth Cohort, 16% of children had a mental health diagnosis. 19 In addition, few studies have reported results using the ASQ:SE instrument in primary care practice. One study in 159 children aged 6 months to 5.5 years reported that the ASQ:SE identified 24% as having a potential social– emotional problem whereas provider surveillance detected 4%. 9 In our cohort, 4.1% of children did not pass the standardized screening portion of the questionnaire. This low incidence is likely because of survey return selection bias and/or our patient population, which was primarily privately insured and children of health care employees.
Most pediatricians (85%) agree that they should be responsible for identifying behavioral management problems, 20 but even when reimbursement systems are in place for this health care service, only about half of children are screened at well-child visits. 21 Likely barriers to mental health screening include the large number of existing screening and anticipatory guidance tasks currently recommended at well-child visits 22 as well as difficulties managing the follow-up and referral process. Mental health screening outside of the clinic visit setting through a care management model or through community resources are potential alternative approaches and should be further explored in future studies.
In the United States, a shortage of access to mental health services exists, 7 and increasing primary care clinicians’ ability to evaluate and triage mental health concerns has the potential to improve this situation. The DC:0-3 is an instrument used to diagnose mental health disorders in children aged 0 to 5 years, 18 and this study shows that it may be feasible to teach primary care clinicians how to use this tool. Because of the small number of children who did not pass the ASQ:SE in this study cohort, the effectiveness of the clinician DC:0-3 training could not be evaluated. Future studies need to evaluate how to better train primary care residents and clinicians to diagnose and treat pediatric mental health problems.
Strengths of this study was implementation in a relatively enclosed health care setting with a unified medical record and the utilization of an established protocol for screening, interpretation, and initial care of children. A limitation is that the study population (mostly white and privately insured) may not be generalizable to other settings.
Future studies should evaluate the optimal timing and methods to administer standardized mental health screening questionnaires in patient populations that have different baseline prevalence levels of mental health concerns.
Conclusion
Implementation of mental health screening by mail with initial results managed by a registered nurse care manager can be successfully incorporated in primary care practice to standardize initial care of children determined to be at risk for mental health conditions. However, screens sent and returned through mail may not be the most effective method to comprehensively screen a primary care population. Screening electronically and implementing a backup screening system at point of care are potential areas of future study.
Footnotes
Acknowledgements
The authors thank developmental screening coordinator Paulette V. Rostad, RN, and Whitney L. Landsteiner, RN, for their aid in data collection as well as Sheila Nation for her help with the figure presentation.
Authors’ Note
The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was made possible by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH).”