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Behavioral-Developmental Health Screening and Response for Adolescents (Ages 12-17) in Pediatric Primary Care

Purpose

The purpose of this brief is to support pediatric and family medicine care teams in adapting their practices to better meet the needs of adolescents (ages 12-17) and their families by implementing behavioral-developmental health screening and response.

Definition

Behavioral-developmental health screening and response is an approach to pediatric primary care in which care teams administer screenings to identify behavioral health conditions (e.g., depression, anxiety, and substance use disorders), adversity (e.g., trauma and abuse), and health-related social needs (e.g., homelessness and food insecurity) and provide targeted interventions, referrals (if needed), and close follow-ups.

Adolescence is a period of profound transformation, marked by unique challenges that can significantly impact well-being. Adolescents experience hormonal shifts during puberty that trigger synaptic pruning, myelination, and neurotransmitter changes in the brain and can contribute to dangerous or risky behavior.1–6 They also navigate increased independence and autonomy, explore their identity, and develop their views and attitudes toward peers, friends, partner relationships, and issues of safety and violence.7,8 Compounding these changes, almost all (95%) adolescents (ages 13–17) use a social media platform, which can increase the risk of depression, anxiety, body image issues, and bullying—especially for girls.9–12

 

The effects of adverse childhood experiences (ACEs), such as abuse, neglect, violence, and parental substance abuse, may become more pronounced during adolescence and manifest as developmental delays, learning disabilities, behavioral health conditions, behavioral problems, and physical health issues.13–18 Having unmet health-related social needs, such as lack of access to healthy food or housing insecurity during childhood, can also contribute to psychosocial problems like depression, anxiety, substance use, and bullying during adolescence.19–21

 

Many adolescents struggle with behavioral health issues, and the rates are increasing.22–24 In 2022, 20% of adolescents reported at least one major depressive episode in the past year (up from 8.1% in 2009), 21% reported symptoms of anxiety, and 560 per 100,000 reported an eating disorder (up from 112 per 100,000 in 2017).24–26 Suicide is the second leading cause of death among adolescents ages 12-17, and drug overdose deaths (driven by fentanyl) are a growing issue.24,27

 

Given the significant developmental, social, and behavioral health challenges adolescents face, it is important for pediatric primary care teams to move beyond a focus on physical health and infectious disease by implementing behavioral-developmental health screening and response. While there isn't yet a large body of research evaluating a fully standardized and comprehensive behavioral-developmental health screening and response approach for age groups (i.e., ages 12 to 17), individual types of screening and interventions addressing social, emotional, and behavioral health have demonstrated feasibility and effectiveness for improving adolescent behavioral health outcomes and increasing resilience.28–33 By administering screenings, pediatric and family medicine providers can effectively identify adolescents with unmet behavioral health, developmental, and health-related social needs, enabling the provision of timely and targeted interventions, appropriate referrals, and close follow-up to improve outcomes.29–31

At its core, behavioral-developmental health screening and response involves screening to identify social, emotional, and behavioral health needs and providing appropriate evidence-based targeted interventions, referrals (if needed), and close follow-up. Although there is evidence that systematically addressing social, emotional, and behavioral health needs in adolescents leads to better outcomes, this approach to care is still developing, and there is considerable heterogeneity across different programs.34 However, there are numerous programs that implement behavioral-developmental health screening and response models with children ages 0-5, providing data on how effective interventions can be structured.35–37 Table 1 (below) takes the common components identified in programs for ages 0-5 and applies them to adolescents ages 12-17, providing a list of relevant activities for each component. This list serves as a reference for understanding potential activities when implementing behavioral-developmental health screening and response models but is not meant to be prescriptive or exhaustive.

There are several key differences to note in behavioral-developmental health screening and response for adolescents compared to children. For adolescents, the American Academy of Pediatrics (AAP) recommends that clinicians:

  • Maintain relationships with families and patients to help patients develop autonomy in healthcare decision-making.38
  • Provide developmentally appropriate care that protects adolescent confidentiality in the health care billing and insurance claims process in compliance with state and federal laws.39,40
  • Communicate and collaborate with schools, when possible, to determine whether patients are utilizing school-based behavioral and developmental health services and facilitate coordination of care, if so.41

Table 1. Behavioral-Developmental Health Screening and Response Common Components Adapted for Adolescents Ages 12-17

#

Common Components 

Relevant Activities 

1

Trauma-informed approach

2

Two-generation approach

  • Maintaining confidentiality and respecting adolescent autonomy while balancing family involvement.
  • Considering the adolescent perspective and ensuring they have a voice in decisions that impact them.
  • Building parents/caregivers as a resource by supporting parental/caregiver health and parenting skills when feasible.
  • Offering to facilitate communication between adolescent patients and their parents/caregivers to discuss sensitive topics.

3

Provider/staff training

  • Offering general education on adolescent-specific risk factors and behavioral health conditions.
  • Training to provide staff with skills to provide anticipatory guidance, administer screening tools in a trauma-informed and validated manner, conduct age-appropriate targeted interventions, connect to community resources, or use data for quality improvement.

4

Anticipatory guidance

  • Providing age-appropriate anticipatory guidance to patients and their families on topics relevant to adolescent development, such as puberty, sexual and reproductive health, healthy relationships, peer pressure, bullying, social media use, and behavioral health.
  • Building resiliency and addressing emotional regulation, stress management, coping skills, communication skills, conflict resolution, and decision-making.
  • Encouraging open communication and addressing common concerns and anxieties.

5

Parent/ caregiver education

  • Providing education and resources to parents/caregivers on adolescent development, communication, and behavioral health.
  • Emphasizing the importance of developing safe, stable, and nurturing relationships and providing a supportive home environment.

6

Team-based care

  • Employing integrated behavioral health clinician(s) to provide accessible low-barrier care.
  • Coordinating care with or providing clinical services or consultation for school-based health centers.
  • Ensuring seamless communication and information sharing among all care team members, particularly warm handoffs between primary care clinicians and behavioral health providers.
  • Supporting connection to ongoing behavioral health resources.

7

Standard workflows for screening and response

  • Conducting screening in a standardized and validated manner to identify recent trauma, family stressors, behavioral health symptomology, and health-related social needs in the context of cumulative adversity.
  • Developing workflows for providing appropriate tailored interventions, care coordination, and community connections.
  • Ensuring confidentiality is considered in all aspects of care, including the screening questionnaires, physical exam, communication, treatment planning, billing, and insurance claims.

8

Connection to community resources

  • Establishing partnerships and referral pathways to connect adolescents with school-based health centers and teen-focused organizations, behavioral health services, social services, and support groups.
  • Using school-based programs as an important referral resource, especially for resiliency-based training and management support.
  • Offering care coordination and navigation.
  • Following up with families to ensure resources are accessed.

9

Data utilization

  • Designing data reports to track the rates of screening, positive risk identified, and interventions provided.
  • Establishing data-driven quality assurance and improvement initiatives.
  • Designing actionable patient registries to identify and track patients and families who need additional support and close follow-up.
  • Adhering to state health information sharing and blocking regulations pertinent to adolescent health care.

How a practice or health system chooses to implement behavioral-developmental health screening and response is flexible and customizable based on available resources in the practice and community, staff expertise, and specific organizational goals. The programs listed below illustrate how the components and relevant activities can be implemented and demonstrate the feasibility of this approach.

  • Barbara Bush Children’s Hospital and Tufts University School of Medicine ACEs and Resiliency Program: This model involves team-based primary care, which screens and responds to trauma, family stressors, adolescent behavioral health symptomology, and health-related social needs. An integrated behavioral health therapist delivers evidence-based prevention and treatment services and provides referrals to community supports to address health-related social needs and build resiliency for families and individual patients (ages 0 to 21). Within one year, the Barbara Bush Children’s Hospital and Tufts University School of Medicine ACEs and Resiliency Program achieved an 88.46% trauma screening completion rate across 14 pediatric primary care practices, increased the rate of identified post-traumatic symptomology from 16.3% to 57.1%, and connected 46.5% of previously unconnected patients with post-traumatic stress disorder symptomology to behavioral health resources.42
  • The Bayview Child Health Center-Center for Youth Wellness Integrated Pediatric Care Model: This model involves team-based care where medical assistants screen children and adolescents (ages 0 to 19) for exposure to ACEs and toxic stress upon check-in for routine visits in the pediatric setting. Pediatricians share relevant information about stress and its effects on health and development, ask about symptoms associated with toxic stress, and provide anticipatory guidance or referral to integrated care based on the screening results and behavioral-developmental health symptomology. Upon referral, care coordinators provide home visits and targeted education to families to enhance understanding and coping strategies and provide trauma-informed, evidence-based therapies in collaboration with community partners.
  • The Children’s Hospital of Philadelphia (CHOP) Center for Violence Prevention Growing Resilience in Teens (GRIT) Program: This team-based program proactively addresses trauma for youth and adolescents (ages 8 to 17) who are patients at two CHOP Primary Care Center locations. The pediatric primary care providers screen children and families to identify trauma exposure, post-traumatic stress symptoms, depression, anxiety, suicidality, and health-related social needs and provide direct referrals to peer-support groups; home, school, or community-based case management support; or a comprehensive trauma-informed behavioral health assessment. From July 2021 to August 2022, the CHOP GRIT Program team completed 125 assessments, connecting 32 youths with trauma-focused cognitive behavioral therapy and 93 youths with case management support and assistance.43 The GRIT team communicates closely with the providers and social workers to ensure an integrated, coordinated plan for each family. The GRIT program also receives referrals from after-school programs in West and Southwest Philadelphia and provides peer-support groups in some of these schools.

1. Set Goals and Get Ready.

Initiating behavioral-developmental health screening and response for adolescents ages 12-17 requires careful planning and preparation. It’s important to establish clear objectives and proactively address the unique challenges of working with this age group. Consider the following:

  • How will you reduce barriers to care for adolescents? Adolescents are less likely than younger children to complete a well-child visit.44–48 They most often cite financial strains (e.g., high care costs, lack of insurance, and prior authorization issues), system and structural issues (e.g., medication shortages, limited clinic space, disparate health technology, long wait times, and lack of coordinated care), communication challenges, and care navigation issues as barriers to care.49 Your practice can implement team-based care and partner with community-based organizations that provide insurance navigation, financial assistance, and interpretation services. Your practice can also try opening before or closing after traditional work hours and partnering with school-based providers and health centers to increase the availability and space for appointments.

  • What are the state and federal laws around adolescent autonomy, privacy, and confidentiality? Adolescents have greater autonomy and legal rights regarding privacy and confidentiality. Your practice can conduct a thorough review of state and federal laws (e.g., the Health Insurance Portability and Accountability Act (or HIPAA) and state-specific minor consent laws) or consult with legal counsel to determine which services adolescents can consent to on their own and which ones require parental consent.

  • How will you, in compliance with state and federal laws, respect adolescent autonomy in decision-making regarding their care and the sharing of their health information? Your practice can use a shared decision-making approach to empower adolescents to actively participate in their care. You can ensure that they have opportunities for private conversations with providers, away from parents or guardians, during which you can clearly explain consent procedures and emphasize their right to make informed decisions.

  • What communication protocols will you establish among care teams, staff, and families to ensure appropriate information sharing while maintaining confidentiality? Your practice can provide written policies and educational resources for providers and staff outlining adolescent rights to autonomy, privacy, and confidentiality, including a list of services adolescents can consent to independently. You can also provide regular training to all staff on these laws and policies, as well as how to document autonomy and consent in the adolescent's medical record.

  • How will you identify and respond to families with adolescents overdue for a well-child visit or who did not attend a scheduled behavioral health appointment? Your practice can use patient registries to identify and track outreach to families with adolescents overdue for a well-child or acute visit. You can use auto-dialers, phone calls, text messages, emails, direct mailers, and direct messages in patient portals to remind families of upcoming or overdue visits or even convert acute visits to well-child visits or vice versa.

TIP: Create initial aim statements.

Create initial aim statements to describe what you would like to achieve from your efforts. Aim statements can provide common language and shared understanding for garnering buy-in and support; guidance for selecting screening tools, workflows, and referral pathways; justification for staff, budget, and other resource allocation; and measurable targets for tracking progress and evaluating effectiveness. To get started, consider this aim statement worksheet (PDF – 215 KB) or the formula and examples below.

By [DEADLINE], we will [OUTCOME/ACTION] for [INTENDED POPULATION] by [GOAL] (as measured by [DATA SOURCE]).

  • Example #1: Increase the proportion of adolescents aged 12-17 who receive screening for depression with the Patient Health Questionnaire (PHQ) for Adolescents (PHQ-A) during their annual well-child visits by [percentage] within [timeframe].
  • Example #2: Increase the number of adolescents aged 12-17 with a Pediatric Symptom Checklist-17 (PSC-17) score >15 who receive timely referrals to appropriate behavioral health services when needed by [percentage] within [timeframe].
  • Example #3: Increase the percentage of adolescents aged 12-17 with a PRAPARE® score > 0 who receive an appropriate community referral by [percentage] within [timeframe].

Once you have considered key challenges and set initial aims, develop a realistic timeline for implementation. Pick a start date and work backward from there, building in time to garner support from leadership and clinical and administrative staff and prepare adolescents and families in your practice or system.

2. Redesign the Pediatric Care Team and Foster School-Based Partnerships.

AAP recommends that pediatric practices use a strengths-based approach in the care of adolescents that promotes safe, stable, and nurturing relationships and builds resiliency.50 Safe, stable, and nurturing relationships with parents, caregivers, family, peers, and teachers, along with other positive childhood experiences, act as protective factors for adolescents. Safe, stable, and nurturing relationships promote healthy development and positive health outcomes for adolescents throughout their lives by buffering adversity and building resiliency.51–56 Adolescents with higher levels of resiliency report having fewer mental health problems.57

 

AAP also recommends that pediatric practices address adolescent behavioral health and developmental concerns by implementing a patient-centered, adolescent medical home model with coordinated or integrated behavioral health care.38 In addition, AAP recommends, when possible, that pediatric providers communicate and coordinate with schools and school-based health centers to provide adolescents with access to a medical home.41 About 96% of public schools offer some form of mental health services—they may have a licensed clinical social worker or psychologist located in the school or school-based health center—however, understaffing can limit the reach of these services.58,59 

Behavioral Health Interventions in Pediatric Primary Care Settings

Pediatric primary care practices can use integrated behavioral health, like Barbara Bush Children’s Hospital and Tufts University School of Medicine ACEs and Resiliency Program, as a foundation to implement behavioral-developmental health screening and response. To integrate behavioral health, pediatric primary care practices can 1) provide behavioral health training to the care team, 2) coordinate behavioral health care using web-based or telephone consultation, 3) co-locate behavioral health clinicians within primary care, or 4) implement integrated or other team-based care approaches like collaborative care or patient-centered medical homes.60–63

 

Table 2 in the Evidence of Effectiveness section summarizes statistically significant outcomes data for children and adolescents receiving integrated behavioral health care in pediatric primary care practices. As outlined in the table, integrated behavioral health models, especially those that include team-based care and target adolescents with positive screenings, have demonstrated effectiveness in improving behavioral health outcomes for adolescents in pediatric primary care settings.

 

If you have the resources and opportunity, consider expanding the care team to help distribute new roles and responsibilities. The most common roles added to pediatric care teams working with adolescents include:

  • Care managers or coordinators: Provide anticipatory guidance, parenting coaching, and adolescent development support; conduct intake and screening processes; facilitate referrals and communication with school-based health centers and school-based resiliency-building programs; connect families with community resources; and/or provide care coordination and follow-up.64
  • Behavioral health clinicians (e.g., psychologists, professional counselors, marriage and family therapists, and clinical social workers): Provide evidence-based treatments that reduce the negative effects of trauma and increase resilience for adolescents via telehealth or onsite in pediatric primary care practices, school-based health centers, or school-based settings, including:65
Partnerships with School-Based Settings

Outside of primary care settings, schools are the most common healthcare service setting for children and adolescents.66 Several studies have assessed the implementation of evidence-based approaches for increasing resilience and addressing behavioral health symptomology for adolescents in school-based settings. These interventions typically involve psychoeducational techniques, cognitive-behavioral therapy, problem-solving therapy, mindfulness and target cognitive competence, problem-solving/decision-making, cooperation and communication skills, and coping mechanisms.67 Table 3 in the Evidence of Effectiveness section summarizes statistically significant outcomes data for adolescents participating in resiliency-based interventions or receiving integrated behavioral health care in school-based settings. As outlined in the table, these resiliency-based interventions in school-based settings, particularly those involving cognitive behavioral therapy and multicomponent approaches, have demonstrated effectiveness in increasing adolescent resiliency. They have also demonstrated effectiveness in improving adolescent behavioral health outcomes, specifically illicit substance use and internalizing problems.

School-based health centers and school-based resiliency programs can be vital extensions of the pediatric care team. Similar to the team-based model of the Children’s Hospital of Philadelphia GRIT Program, you can establish formal agreements and clear communication channels with these school-based health centers and resiliency programs, coordinate screening efforts with them, and develop care pathways where adolescents identified in the primary care setting can be seamlessly referred to and receive services in them (and vice versa). You can use this online school-based health center map to find your community’s participating school districts and school-based health centers.

TIP: Implement warm handoffs/same day visits.

Warm handoffs within the Primary Care Behavioral Health model of care between pediatric care team members have been associated with increased first appointment show rates, improved patient engagement, fewer no-shows, fewer cancelations, shorter time between referral and initial scheduled behavioral health visit, and more total behavioral health visits.68–70

TIP: Huddle as a team to prepare for the day.

Example discussion topics for your huddle can include increasing the use of the PHQ screening tool for behavioral health follow-up visits, identifying patients who may need an additional reminder call or transportation support, and identifying patients who may benefit from a warm handoff or collaborative visits with a behavioral health clinician.

TIP: Up-train your team.

If you are unable to expand your care team to address gaps in knowledge, skills, and experience, up-train them instead. Clinical and administrative staff can be trained to support health-related social needs through referrals and connection tracking. Primary care providers can receive additional training (see examples listed below) to conduct resiliency-building and behavioral health interventions for adolescents.

Sample Targeted Intervention Trainings for Providers

3. Conduct Training and Education.

Conduct foundational training and education to increase staff and provider understanding of trauma-informed care and how the unique experiences of adolescence can significantly impact brain development, risk-taking, and subsequent long-term health.

Sample Foundational Trainings for Providers

TIP: Provide trauma-informed scripts to your team.

Trauma-informed language builds a sense of safety and trust through transparency, choice, and collaboration. The sample script excerpts below use the word “all” to prevent families from feeling singled out. The statements explain why the provider and patient are rooming alone and using questionnaires and have a choice embedded in them.   

Sample Trauma-Informed Script Excerpts for Clinical Rooming Staff
  1. For parents: “We start all visits with adolescents alone if they’re comfortable with that and then bring in the parents afterward. It gives us a chance to get to know the adolescent as an individual a bit better. I will come and get you as soon as we are done and before the provider comes in. Is that okay with you?”
  2. For adolescents: “We ask all patients your age to complete written questionnaires. It helps us to better understand how you are doing so that we can offer the best care. I can give it to you to complete on your own. Your provider will then review your answers with you. Does that work for you?”

You can create scripts for your practice using the examples in the following guides:

4. Adopt Validated Screening Tools and Standardized Workflows.

Select the screening tools and workflows your care team, including any school-based partners, will use to identify adolescents and families who have experienced trauma and behavioral health symptomology and have unmet health-related social needs, such as transportation, housing, or food insecurity.

 

You can use this screening tool finder or the sample list below to identify validated screening tools for behavioral, social, and emotional health, child development, and health-related social needs for adolescents ages 12-17.71 When implementing a new screening tool, examine its validation process and align your workflow as closely as possible to the validated methodology for each tool you choose to use. For example, the PHQ-A, PSC-17, and the Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) screening tool are all validated as self-completed written screeners for adolescents. 

 

The tools listed below are available in multiple languages to support an equitable model for all patients. Please note that, for this age group, the PHQ-A and Patient Health Questionnaire-9 (PHQ-9) are superior to the Patient Health Questionnaire-2 (PHQ-2), especially regarding suicidality, and are useful for supporting diagnosis and tracking intervention response.72–76 As such, the PHQ-2 is not listed. 

Validated Screening Tools for Adolescents Ages 12-17

Depression

Anxiety

Substance Use

Suicidality

Behavioral, Social, and Emotional Health Screening Tools

Health-Related Social Needs

Trauma

Also, consider confidentiality when planning the screening workflow. You can, for example, implement a workflow where adolescents complete written screening tools alone in the exam room. Be sure to also implement workflows that support ongoing close follow-up for adolescents with positive behavioral health screenings. You can:

  • Emphasize that they have their follow-up appointment scheduled prior to leaving the office.
  • Conduct targeted outreach to adolescents who did not attend the scheduled well-child visit or behavioral health appointment.
  • Use medication refills and other calls to the practice to review if follow-up is needed.

5. Identify Community Resources.

Identify, if you haven't already the government and community programs available to help you meet the needs of the adolescents and families you serve. Your pediatric primary care practice or health system will not be able to address every need identified during screening. Establishing direct relationships with programs in schools and other community-based settings can further facilitate successful connections for families.

For example, your care team can screen for transportation barriers. If a patient and their family screen positive, they can:

  • Provide materials on the available public transportation options.
  • Offer assistance with completing applications for transportation assistance programs, vehicle donation programs, reduced transit fare programs, and free or subsidized passes/vouchers for trains, buses, rideshares, and taxis.
  • Provide referrals to community resources.
  • Purchase passes for buses, taxis, or rideshares using funds from the practice’s budget, grants, or other external sources.

You can use this online school-based health map to find the school districts and school-based health centers in your community. You can also use this online social care database or 211 to find local community resources, including:

  • Case management programs
  • Behavioral health providers
  • Crisis support services
  • Childcare agencies
  • Basic needs assistance
  • Legal assistance
  • Peer support
  • Health and social services programs

6. Align the Electronic Health Record System to Support Workflows, Data Collection, and Quality Improvement.

Both medical and behavioral health staff need to be able to access information seamlessly and securely to support coordinated and collaborative care. Any existing silos among clinicians and limitations in the electronic health record (EHR) can significantly hinder this crucial information flow. Work with care team members and your information technology staff or vendor to conduct a thorough assessment of current information-sharing practices and identify barriers within the EHR that prevent integrated access to medical and behavioral health records among staff.

Partner with your information technology staff or vendor to develop EHR models capable of aligning workflow and data reports. Additionally, creating structured data fields early on can support the creation of essential EHR reports for tracking the rates of screening, positive risks identified, and interventions provided. Where appropriate and with strict adherence to privacy regulations, explore opportunities for securely sharing relevant data (e.g., screening results and progress in interventions) to improve care coordination and outcomes with school-based health centers and other external partners. Plan to conduct regular assessments of your EHR with your technology staff or vendor to identify and troubleshoot points of vulnerability in which adolescent confidentiality and privacy may be compromised if appropriate safeguards are not put in place.

Your care team, practice, or health system can create and use data registries and data reports to support implementing quality improvement methodologies for behavioral health screening and response—such as the Plan-Do-Study-Act (PDSA) cycle—and the data can also be used to create patient registries that provide increased support and connections for patients and families with higher risk, symptomology, barriers, and adversity. Other potential areas to examine during routine quality improvement activities include screening methods, medication prescribing, referral rates, referral connection, treatment adherence, patient satisfaction, and behavioral health remission rates.

TIP: Track metrics across time for all patients.

The reporting examples below move beyond examining PHQ-A or PHQ-9 screening rates to also reporting rates of PHQ-A or PHQ-9 scores greater than or equal to (> or >=) 10 over time and rates of follow-up plans and other targeted interventions.

Figure 1. Rates of PHQ-A or PHQ-9 Scores ≥10

Figure 2. Rates of Follow-Up Plans and Other Targeted Interventions

TIP: Closely track patients with identified risks.

The example risk registry below is based on completed PHQ-A screening tools with a score greater than or equal to 10. Providers or trained clinical staff can use such information to consider: Who are the patients with elevated PHQ-A scores? Do they have an upcoming appointment? Have they been connected to community resources? Is the PHQ-A score improving? Was suicidality present? A well-designed report can support rapid chart review and focused patient outreach to increase connection to treatment and resources.

Figure 3. Risk Registry for Patients with PHQ-A or PHQ-9 Scores >10 

Next Primary Care Visit

Recall Date

Pos. PHQ Date

PHQ Score

SI

Last PHQ Date

Last PHQ Score

SI

Interventions

3/25/24

5/3/25

1/20/25

19

Y

2/26/25

12

N

Beh Health Ref, Med Rx

1/29/25


 

1/10/25

14

N

1/10/25

14

N


 


 


 

12/17/24

22

Y

2/10/24

19

Y

Beh Health Ref, Med Rx

3/4/25


 

12/10/25

12

Y

12/10/25

12

Y


 


 

4/4/25

11/19/25

12

N

1/12/25

8

N

Med Rx


 

6/12/25

11/10/25

18

Y

1/8/25

3

N

Med RX

  • Adolescents ages 12-17 are facing a significant behavioral health crisis, evidenced by rising rates of depression, anxiety, eating disorders, and suicidality. Implementing behavioral-developmental health screening and response in pediatric primary care and family medicine can address the complex behavioral and developmental needs of adolescents through proactive screening for behavioral health conditions, adversity, and health-related social needs, followed by resiliency-building and behavioral health interventions, and referrals to community supports and close follow-up if needed.
  • Comprehensive behavioral-developmental health screening and response has been shown to work for children ages 0-5. While there isn't yet a large body of research evaluating a fully standardized and comprehensive behavioral-developmental health screening and response approach for ages 12 to 17, evidence demonstrates the feasibility of implementing its components for adolescents in pediatric primary care and school settings. Existing programs have achieved high screening rates and have connected youth to necessary behavioral health resources and support.
  • There is also moderate research evidence supporting universal screening for depression, anxiety, and intimate partner violence among adolescents. Resiliency-building and behavioral health interventions in pediatric primary care settings have demonstrated effectiveness in improving adolescent behavioral health outcomes better than treatment as usual, particularly when delivered via collaborative care. Resiliency-building and behavioral health interventions in school-based settings have also demonstrated effectiveness in increasing adolescent resilience and improving behavioral health outcomes, including illicit substance use and internalizing problems.
  • Pediatric and family medicine practices and health systems can implement behavioral-developmental health screening and response for adolescents by identifying and setting practice goals; redesigning the care team; creating a training and education plan for the care team; adopting standardized tools and workflows; identifying school-based and other community resources; and aligning electronic health records to support workflows, data collection, and quality improvement.

Table 2. Meta-Analyses on Integrated Behavioral Health Models in Pediatric Primary Care Practices

Study

Description

Sample

Outcomes Data for Children and Adolescents

Hostutler et al. (2024)33

Meta-analysis of randomized clinical trials (RCTs) and quasi-experimental studies of integrated behavioral health.


 

27 studies involving 6,879 children and adolescents (ages 0-21) and their caregivers met the study eligibility criteria.

A small overall effect size (SMD = 0.19, 95% CI, 0.11–0.27; p < 0.001) for integrated primary care to usual or enhanced usual care.

No statistically significant differences between treatment and prevention trials [Qm(1) = 1.07; p = 30].

Similar effectiveness between co-located and integrated models [Qm(1) = 0.01; p = 0.92].

Asarnow et al. (2015)28

Meta-analysis of randomized clinical trials (RCTs) of integrated behavioral health.

Note: Most (86%) of the studies included in this meta-analysis had a follow-up period of 6 months.

31 studies with 35 intervention-control comparisons. 13,129 participants aged 1-21 met the study eligibility criteria.


 


 

A significant advantage for integrated care interventions relative to usual care on behavioral health outcomes for up to 20 months (d = 0.32; 95% CI, 0.21–0.44; p < 0.001).

Larger effects for treatment trials that targeted diagnoses and/or elevated symptoms (d = 0.42; 95% CI, 0.29–0.55; p < 0.001) relative to prevention trials (d = 0.07; 95% CI, -0.13–0.28; p = 0.49).

It was 66% more likely that a randomly selected youth would experience improved behavioral health outcomes with integrated care compared to usual care and 73% more likely with collaborative care compared to usual care. Both have a substantial advantage over usual care, though collaborative care had a higher likelihood (7 percentage points) of improved outcomes over general integrated care.

Note: Usual care denotes primary care treatment as usual. Enhanced usual care refers to referral to specialty treatment, brief advice from pediatric primary care providers, and educational materials. Integrated care includes collaborative care, co-location with minimal integration, or behavioral health training, consultation, or telehealth for pediatric primary care providers.

Table 3. Systematic Reviews and Meta-Analyses on Integrated Behavioral Health Models and Resiliency-Building Interventions in School-Based Settings

Study

Description

Sample

Outcomes Data for Children and Adolescents

Llistosella et al. (2023)77

A systematic review and meta-analysis of RCTs, cluster trials, quasi-experimental studies, and mixed methods studies.

27 studies in the systematic review and 16 in the meta-analysis. Participants were adolescents aged 10-19.

Resiliency-based interventions in school-based settings have been shown to increase adolescent resiliency, particularly cognitive behavioral therapy-focused interventions (SMD = 0.20; 95% CI, 0.06–0.34; n = 3) and multicomponent interventions [SMD = 1.45; 95% CI, 0.11–2.80; n = 4), for up to 8 weeks.

Only three studies in this meta-analysis looked at duration beyond 8 weeks, and no significant intervention effects were found in those studies.

Pinto et al. (2021)78

A systematic review and meta-analysis of RCTs.

17 studies in the systematic review and 13 in the meta-analysis. Participants were children aged <12 and adolescents aged 12–22.

Resiliency-based interventions in school-based settings show initial effectiveness in promoting child and adolescent resiliency (SMD = 0.48; 95% CI, 0.15–0.81; p = 0.02; n = 10) and continued effectiveness for up to 6 months (SMD = 0.12; 95% CI, -0.44–0.69; p = 0.02; n = 3).

Hodder et al. (2017)79

A systematic review and meta-analysis of RCTs.

19 studies in the systematic review with a total of 51,867 participants. Participants were children aged 5-9 and adolescents aged 10-18.

Universal resilience-focused interventions in the school setting reduced adolescent illicit substance use, not including tobacco or alcohol use (OR = 0.78, 95% CI, 0.6–0.93; p = 0.007; n = 10).

There was a significant intervention effect on adolescent illicit substance use, not including tobacco or alcohol use (OR = 0.84; 95% CI, 0.72 –0.99, p > 0.05; n = 7) at long-term follow-up (12 months).

Dray et al. (2017)67

A systematic review and meta-analysis of RCTs.

49 studies in the meta-analysis with 41,521 participants. Participants were children aged 5-9 and adolescents aged 11-18.

Universal resilience-focused interventions in the school setting reduced internalizing problems for adolescents (SMD = -0.19; 95% CI, -0.35 to -0.02; p = 0.03; n = 3).

There was also a significant intervention effect on internalizing problems for adolescents (SMD = -0.22; 95% CI, -0.42 to -0.02; p = .03; n = 2) at long-term follow-up (>12 months).

Knopf et al. (2016)80

A systematic review of quasi-experimental and observational studies.

46 studies in the systematic review evaluated onsite clinics serving urban, low-income, and racial or ethnic minority high school students.

The presence and/or use of a school-based health center was associated with:

  • Decreased alcohol use (-14.8%)
  • Decreased use of other illicit substances (-27.2%)
  • Decreased self-reported mental health problems (-5.7%)

Note: Only 9 of 46 studies assessed school-based health centers that provided mental health care.

Adolescent Autonomy, Confidentiality, and Privacy

Behavioral Health Screening and Response Models for Adolescents

Resiliency-Building and Behavioral Health Integration in Pediatric Care Settings

Resiliency-Building and Behavioral Health in School-Based Health Centers

Trauma-Informed Care for Adolescents

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