Integrating Behavioral Health and Developmental Screening

Integrating behavioral health screening and developmental screening and surveillance into routine well-child visits can help clinicians identify and address issues that threaten a child’s optimal development. Without such screenings, some important conditions may be missed and significant disparities in outcomes may be more likely.

According to the CDC, one in six children ages 2-8 have a mental, behavioral, or developmental disorder. Key risk factors for a child having such a condition include lower socioeconomic status, prematurity, low birth weight, and lower level of mother’s education. Exposure to adverse childhood experiences (ACEs) such as racism, abuse, neglect, and parental mental health problems may also increase the risk of developing these conditions.

Conducting regular developmental screening using a standardized screening tool at the 9th, 18th, and 30th month, and 4th and 5th year well-child visits is the American Academy of Pediatrics’ recommended practice for the pediatric community. The available data on screening rates suggest, however, that these screenings are happening with less than ideal frequency. A national survey of parents found that 27.1% of children under 5 received development screening in 2016. New York State’s screening rate was 15.1%.

At the same time, access to early intervention (EI) services and infant and early childhood mental health services is limited. A recent joint report from Advocates for Children and Citizens Committee for Children of New York found one in four EI-eligible children in New York State had to wait for services. In Bronx County, nearly 40% of EI eligible services did not receive them by the legally mandated 30-day deadline.

Challenges to Integrating Behavioral Health and Developmental Screening and Support

Despite being committed to comprehensive screening of their patients, clinicians have found it difficult to incorporate into their regular practice. Some commonly encountered challenges are listed below.

1. Administering a screening and referral program can overwhelm a busy pediatric practice unless a streamlined workflow has been developed, including integration of screening and referral results into electronic medical records.  

2. Not all developmental screening tools include questions about the child’s socio-emotional development, an important component of screening.

3. Regulatory, workforce, and payment barriers can hinder effective integration of behavioral health services within primary care, especially for sites in need of dual licensure from the New York State Department of Health and the New York State Office of Mental Health. 

4. Although progress is underway, New York State does not yet include the national developmental screening measure as part of its Quality Assessment and Reporting Requirements, thus complicating performance tracking.

5. As with addressing unmet social needs, referring a patient and family externally for developmental or behavioral health services is no guarantee of access. Barriers may include:

• Too few providers of a service to meet the community’s needs (for example, in New York State there are about two child psychiatrists per 10,000 children)
• Scheduling, transportation, or safety conditions that make it difficult for patients to reach services
• Distrust that makes parents reluctant to share information with health and other service providers

Strategies for Integrating Screenings and Support at the Practice

Below are some strategies to help clinicians plan for and implement screening, surveillance, and family support workflows, and to help train pediatric care teams.

• Explore clinical and operational models for integrating behavioral health care into pediatric primary care, such as ZERO TO THREE's HealthySteps program, or the ambitious new federal demonstration project, Integrated Care for Kids (InCK).
• Identify and implement training tools to use with the pediatric care team.
• Recognize and understand the impacts of adverse childhood experiences (ACEs) and exposures to trauma as risk factors for healthy child development and mental health over the lifespan; consider screening parents for ACEs.
• Engage parents in developmental monitoring with parent-focused support resources:
  • CDC’s Learn the Signs. Act Early. Initiative
  • CDC Milestone Tracker App

Promising Approaches to Integrating Screening and Support for Behavioral Health and Child Development

Here are some examples of efforts taking place across New York to support child development and behavioral health through pediatric practice:

• Project TEACH NY from the New York State Office of Mental Health offers child health providers consultations and referrals to tele-psychiatry services, as well as guidelines for incorporating screening and treatment of behavioral health in the pediatric primary care settings
• HealthySteps, a national model for integrated care, pairs child development and behavior experts with pediatric care teams to ensure parents and providers have supports for children’s needs. Pediatric Behavioral Health Sciences at the Montefiore Medical Group expanded its HealthySteps program from one to twenty-one sites, becoming one of the largest integrated pediatric behavioral health sites in the nation. Subsequently, the New York State Office of Mental Health provided pilot financing to help other pediatric practices across the state adopt HealthySteps. 
• Help Me Grow is a systems-based approach to connecting families to community resources and child development information. There are HelpMeGrow programs in Western New York and on Long Island.
• The 100 Schools Project is an example of how child health providers can explore collaboration with community organizations, particularly schools, on mental health promotion and prevention.
• Strong Children Wellness, a model that partners pediatric primary care practice with community-based organizations to provide on-site care at the CBO. 

Resources