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Implementation of preventive behavioral and mental health recommendations for children and adolescents in primary care

Key Questions May 2, 2023
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In response to the worsening crisis in mental and behavioral health among children and adolescents in the US, AHRQ identified the need for an evidence review to inform the implementation of preventive behavioral health interventions for children and adolescents as part of primary care. Several groups currently recommend screening children and adolescents for mental wellbeing and behavioral health disorders including depression, suicidality and anxiety as screening has shown some evidence of effectiveness.1 However, implementation of preventive interventions is less than ideal2 and perhaps uncommon. Low implementation rates may be related to the low actionability of the recommendations3 amid the competing demands of other recommended, evidence-based interventions during a relatively brief primary care visit. Access to care-either because of insurance and cost hurdles or the lack of pediatric-trained mental health providers may also be playing a role as referral rates vary widely after screening. Furthermore, how best to engage patients and families around mental health concerns and the implementation of services is unclear.4   

Thus, we propose conducting a systematic review to identify implementation strategies that are effective for achieving recommended preventive behavioral health services. This review could  be used by health systems to support implementation efforts and by funding agencies to inform future research funding.

KQ 1. What are the effectiveness and harms of strategies to implement preventive behavioral and mental health interventions including screening in outpatient healthcare settings for children and adolescents?

       1a. Do characteristics of the practice, patient and caregiver population, or strategy modify effectiveness and harms?



Primary care practices providing health care to people 18 years and younger

  • Practice characteristics: type of setting, type of practice/providers, structure, size, readiness for implementation, use of HIT, population served
  •  (e.g., insurance mix, patient/family age, gender/sex, race/ethnicity, SES)


Content of Interventions Provided (note that these are not the interventions being compared in the review)

  • Recommended behavioral health screenings, such as screening for ACEs, anxiety, and depression
  • General or specific instruments
  • Screening of patients or family members



Strategies to implement preventive behavioral health screening as described by the EPOC taxonomy5 (some examples provided)

  • How, when and where healthcare is delivered
  • Who provides healthcare/support
  • Healthcare coordination and management of care
  • Information and communication technology
  • Interventions targeted at healthcare providers or systems
  • Financial Arrangements (insurance, incentives)
  • Governance (organization, health care professional)


  • Strategy characteristics: complexity, number of components, Intensity/frequency/duration, etc.


Other implementation strategy, no implementation strategy


Implementation outcomes

  • Acceptability
  • Adoption
  • Appropriateness
  • Cost
  • Feasibility
  • Fidelity
  • Penetration
  • Sustainability
  • Rate of follow-up/ referral

Health outcomes

  • Satisfaction/patient experience
  • Mental health symptoms/diagnoses
  • Functional status
  • Quality of life
  • Service utilization
  • Adverse outcomes


  • Cost
  • Clinician burnout
  • Opportunity cost
  • Lack of follow-through/ lack of therapists or other professionals




Outpatient Setting (including pre-visit, during encounter with clinician, waiting room)

ACE= adverse childhood experience; EPOC = Effective Practice and Organisation of Care; SES=socioeconomic status.

  1. Webb, M.J., Kauer, S.D., Ozer, E.M. et al. Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? A systematic review. BMC Fam Pract 17, 104 (2016). https://doi.org/10.1186/s12875-016-0504-1
  2. Charach A, Mohammadzadeh F, Belanger SA, Easson A, Lipman EL, McLennan JD, Parkin P, Szatmari P. Identification of Preschool Children with Mental Health Problems in Primary Care: Systematic Review and Meta-analysis. J Can Acad Child Adolesc Psychiatry. 2020 May;29(2):76-105. Epub 2020 May 1. PMID: 32405310; PMCID: PMC7213917.
  3. Finnell SME, Stanton JL1, Downs SM. Actionable recommendations in the bright futures child health supervision guidelines. Appl Clin Inf 2014; 5: 651–659. http://dx.doi.org/10.4338/ACI-2014-02-RA-0012
  4. Wissow LS, Brown J, Fothergill KE, Gadomski A, Hacker K, Salmon P, Zelkowitz R. Universal mental health screening in pediatric primary care: a systematic review. J Am Acad Child Adolesc Psychiatry. 2013 Nov;52(11):1134-1147.e23. doi: 10.1016/j.jaac.2013.08.013. Epub 2013 Aug 30. Erratum in: J Am Acad Child Adolesc Psychiatry. 2014 Mar;53(3):382. PMID: 24157388; PMCID: PMC3942871.
  5. Effective Practice and Organisation of Care (EPOC). EPOC Taxonomy; 2015. epoc.cochrane.org/epoc-taxonomy (accessed 2/13/2023)

Project Timeline

Implementation of Preventive Behavioral Health Screening for Children in Primary Care

May 1, 2023
Topic Initiated
May 2, 2023
Key Questions
Page last reviewed May 2023
Page originally created May 2023

Internet Citation: Key Questions: Implementation of preventive behavioral and mental health recommendations for children and adolescents in primary care. Content last reviewed May 2023. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.

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