Screening and Measurement
Primary care clinicians are taught to engage in a complex process of clinical reasoning to identify illness. This process is no different for mental health conditions.
In the clinical assessment tool kit is an understanding of the epidemiology of diagnoses, awarenss of the range of diagnostic candidates, and a host of available tests and knowledge of test characteristics.
Screening tools improve both the efficiency and comprehensiveness of the clinical encounter and are increasingly linked to value-based care. In this section we cover formalized screening procedures and tools used for specific disorders.
Evidence Based Assessment
Pediatricians think statistically and sequentially, adding assessment information, weighing dynamic factors, and applying a clinical decision making model.
The Evidence Based Assessment model provides clear steps to the process of prediciting, prescribing treatment, and tracking the progress.
Steps 1 and 2 in Evidence Based assessment is identifying the prevelance or base rate of disorders. This graph includes the common disorders, with data compiled from multiple sources (Breslau et al., 2017; Francés et al., 2022; Kessler et al., 2005; Merikangas et al., 2010; Patel et al., 2018; Solmi et al., 2021).
Step 3 of the Evidence Based Assessment Model should include weighing known risk factors that migth increase the liklihood of disorder. Family mental history is very important to ask about because of elevated genetic and correlated enviormental factors.
Parental history of any psychiatric diagnosis is associated with increased incidence rates of mental illness. Odds Ratios (OR) indicate elevated risk of disorder in youth with parents with history of illness. Reported OR for common disorders include ADHD (4-9 OR), Anxiety Disorder (2-6 +OR), and Depression (3-13 +OR) (Martin et al. 2018; Rappe et al 2012; Telman et al. 2017; Rice et al. 2012).
Step 4, 5, and 6 Typically, our team recommends using a broad mental health measure built to detect multiple conditions. If there is elevated concern, a targeted measure for a specific condition (e.g. anxiety, depression) would be employed. This is called sequential screening and it essentially zeros in on a subgroup of a population through a brief set of consecutive screens, reducing the likelihood of false positives and false negatives.
Next we'll identify measures and psychometric properties to support implementation in the pediatric practice.
Broad Measures
Broad measures screen for multiple mental health symptoms and are optimally employed as an initial measure that might detect possible concerns. Positive results should received subsequent targeted screening related to specific concerns.
Measure | Informant | Cut-offs | Sensitivity/Specificity |
Patient Symptom Checklist – 17 |
Total Score: ≥ 15 Internalizing: ≥ 5 Externalizing: ≥ 7 Attention: ≥ 7 |
Total Score: 73%/74% Internalizing: 52%/74% Externalizing: 62%/89% Attention: 59%/91% |
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Strengths and Difficulties Questionnaire (SDQ) |
Total Score: ≥ 15 Emotional (Anx): ≥ 5 Conduct (ODD): ≥ 3 Conduct (CD): ≥ 4 Inattention/HI: ≥ 6 |
Total Score: 81%/42% Emotional (Anx): 75%/51% Conduct (ODD): 84%/66% Conduct (CD): 89%/63% Inattention/HI: 95%/32% |
ADHD Tools
Here are freely available targeted measures developed to assess ADHD and Oppositional Defiant Disorder/Conduct Disorder
Measure | Informant | Cut-offs | Sensitivity/Specificity |
SNAP-IV Items: 26 Age: 6-18 |
ADHD IN: Parent > 2.56; Teacher > 1.78 ADHD H/I: Parent > 1.78; Teacher > 1.44 ADHD CT: Parent > 2.00; Teacher > 1.67 ODD: Parent > 1.38; Teacher > 1.88 Summed scale score, divided number of items in scale |
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NICHQ Vanderbilt Items: 55 (P), 44 (T) Age: 6-12 |
ADHD Combined: > 6 ODD Total: > 10 |
ADHD Combined: 67%/86% ODD Total: 88%/85% |
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Note: NICHQ Parent Vanderbilt positive cutoff requires 6 of 18 items on the Combined Inattention/Hyperactivity scale be recorded as 2 or 3 and at least one 4 or 5 rating on the performance scale |
Anxiety Tools
Targeted anxiety measures free for use.
Measure | Informant | Cut-offs | Sensitivity |
Screen for Child Anxiety and Related Disorders (SCARED) Items: 41 Age: 8-17 |
Total Score: ≥ 25 Panic: ≥ 7 GAD: ≥ 9 Separation Anx: ≥ 5 Social Anx: ≥ 8 School Avoidance: ≥ 3 |
Parent Total: 65%/99% Youth Total: 64%/92% |
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SPENCE Child Anxiety Items: 44 Age: 3-6; 8-15 |
T Score: ≥ 60 (T-Score, M = 50; SD 10) |
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Generalized Anxiety Disorder (GAD-7) Items: 7 Age: 12+ |
Total Score: ≥ 10 | ||
Patient Reported Outcomes Measurement System - Fixed Length Short Form (V2) Items: 8 Age: 5-17 |
Parent T-Score: ≥ 62 Youth T-Score: ≥ 63 (T-Score, M = 50; SD 10) |
Depression Tools
Here are targeted depression measures that are free for use.
Measure | Informant | Cut-offs | Sensitivity/Specificity |
Short Moods & Feelings Questionnaire (SMFQ) Items: 13 |
Total Score: ≥ 11 | Parent Total: 65%/99% Youth Total: 64%/92% |
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Patient Health Questionnaire Items: 9 |
T Score: ≥11 | 89.5%/77.5% | |
Patient Reported Outcomes Measurement System (PROMIS - Depression) Items: 8 (6) |
Parent T-Score: ≥ 60.5 (T-Score, M = 50; SD 10) |
Other Targeted Tools
Freely available targeted screening for primary care.
Measure | Informant | Domain | Cut-offs | Sensitivity/ Specificity |
Ask Suicide Questionnaire (ASQ -4) Items: 4 |
Suicidality | Any "Yes" response results in further assessment | 100%/87.9% |
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Columbia Suicide Severity Risk Scale (Primary Care) Items: 2+ |
Suicidality | Any "Yes" response results in further assessment | ||
CRAFFT 2.1 Items: 9 |
Substance Use/ Abuse |
T Score : ≥2 | Any substance use disorder: 76%/94% | |
Screening to Brief Intervention (S2BI) Items: 9 |
Substance Use/ Abuse |
Affirmative response to frequency in past year | Any substance use disorder: 90%/94% | |
Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) Items: 5+ |
Substance Use/Abuse | Risk of use of alcohol, tobacco, and marijuana |
≥6 days of tobacco use 95%/97% |
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Eating Attitudes Test-26 Items: 26 |
Disordered Eating | Total Score: ≥20 |
References
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