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. Author manuscript; available in PMC: 2024 Dec 1.
Published in final edited form as: J Child Health Care. 2023 Mar 14;28(4):700–714. doi: 10.1177/13674935231163362

Pediatric clinicians’ perspectives on assessing concerns about young children’s social-emotional wellbeing in primary care

James L Merle 1, Allison J Carroll 2, Nivedita Mohanty 3, Cady Berkel 4, Courtney Scherr 5, Matthew M Davis 6, Lauren S Wakschlag 7, Justin D Smith 1
PMCID: PMC10500037  NIHMSID: NIHMS1896101  PMID: 36916317

Abstract

We surveyed pediatric primary care clinicians working in Federally Qualified Health Centers about their perceptions of children’s social-emotional wellbeing. We identified clinician’s current methods for assessing social-emotional wellbeing in practices, perceived implementation barriers to providing behavioral health care, and interest in adopting a validated, low-burden developmentally sensitive parent-report instrument for screening for social-emotional wellbeing in young children. We surveyed 72 PCCs working in FQHCs from 9 US states. Analyses included examining central tendencies, correlations, analysis of variance, and group differences via t-tests. Average PCC perceptions of social-emotional wellbeing importance for overall health were statistically significantly higher than their confidence in providing care for common social-emotional wellbeing concerns (mean difference = 1.31, 95% CI = 1.13–1.49). PCCs expressed low satisfaction with currently available screening measures for identifying concerns in social-emotional wellbeing. Fewer than half of clinicians reported using any standardized parent-reported measure for identifying concerns in social-emotional wellbeing. Assessment methods and decision tools that improve clinician confidence concerning risk indications are needed, particularly at the critical early childhood period. Policymakers and payers ought to facilitate funding mechanisms that support pediatric PCCs in identifying early concerns in social-emotional wellbeing and providing referral guidance to evidence-based interventions to support parents and caregivers.

Keywords: Behavioral health, mental health, primary care, social-emotional, wellbeing

Introduction

In 2021, the US Surgeon General’s report indicated that one in five children and adolescents aged 3–17 years had a diagnosable mental or behavioral health condition in the United States (Stephenson, 2021). These problems often present early; approximately 13–27% of children 3–5 years have these conditions (Sheldrick et al., 2022). Pediatric wellbeing reflects healthy social-emotional development across multiple domains, including a child’s capacity to experience, manage, and express a full range of positive and negative emotions; develop close, satisfying relationships with others, and actively explore environments and learn (Laying the Foundation for Early Development: Infant and Early Childhood Mental Health, 2009). Social-emotional wellbeing—also termed “mental,” “behavioral,” or “psychosocial” health—encompasses internal emotion regulation and outward behavioral processes (Dodge et al., 2012).

Social-emotional wellbeing is linked to overall health status (Cree et al., 2018; Jones et al., 2015), and children who experience problems in social-emotional wellbeing are more likely to have externalizing and internalizing problems as well as poor functional outcomes including school dropout (Snyder and Dillow, 2015), later life substance abuse (Townsend et al., 2007), unemployment (Simmons, 2013), and obesity (Jones et al., 2015). This indicates a need for early and broad screening to identify concerns and evidence-based interventions to improve health and functioning and prevent downstream impairment. Accurate, early identification and intervention can moderate long-term consequences and save up to $100,000 per child in special education costs and other marked costs to society (National Research Council and Institute of Medicine, 2009).

Pediatric primary care clinicians (PCCs) (pediatricians, family medicine physicians, nurse practitioners, advanced practice providers) are often the first point of contact for concerns about social-emotional wellbeing (e.g., tantrums, attention problems, separation anxiety) in early childhood (Foy, 2018; Boat and Kelleher, 2020). The perceptions of pediatric PCCs regarding the importance of addressing concerns in social-emotional wellbeing, as well as their perceptions of self-efficacy and their professional role in the arena, are important determinants in the adoption and maintenance of evidence-based screening (Lyon and Bruns, 2019), which directly impacts early identification and intervention (Reding et al., 2014).

Pediatric PCCs largely agree that identifying concerns for children’s social-emotional wellbeing is part of their role responsibility (Davis et al., 2012; Stein et al., 2008), and roughly 80% believe that common mental health and behavior management problems should be referred to specialists (Heneghan et al., 2008). However, early studies found less than 15% of pediatricians reported confidence in successfully identifying and treating depression among children, a number that remained low in subsequent studies (Stein et al., 2008; Leaf et al., 2004). Nearly one in four pediatricians reported being uninterested in education concerning social-emotional wellbeing (Kramer et al., 2017). Although mental health monitoring and care is a core pediatric competency, the majority of pediatricians feel ill equipped to provide developmentally and culturally informed mental health care (Foy et al., 2019).

Despite agreement that identifying social-emotional concerns aligned with their role as pediatric PCCs, detection rates in pediatric primary care remain low (54%) (Centers for Disease Control and Prevention, 2018). Standardized parent-reported screening tools for social-emotional wellbeing are infrequently and inconsistently utilized in primary care (Boat and Kelleher, 2020; Allen et al., 2010), despite evidence that they improve rates of early identification (Barger et al., 2018). To illustrate this, when poorly constructed instruments, such as informal checklists, are used, only 30–40% of children are accurately identified (Glascoe, 2015). This number rises to 70% when standardized, valid and reliable instruments are administered (Glascoe, 2015). Even for children who are accurately identified early, time lags exist between when a child is identified with a social-emotional wellbeing concern and when they receive intervention, and half of children who are identified early do not ever receive care (Health resource and service administration, 2021; Whitney and Peterson, 2019; Sheldrick et al., 2011).

Concerted policy changes within the American Academy of Pediatrics (American Academy of Child and Adolescent Psychiatry CoHCAaE, 2009) and implementation efforts (Lipkin et al., 2020b; Dougherty et al., 2015) over the past quarter century have increased the use of evidence-based screening practices for early identification among children birth–5 years in primary care settings from 23% in 2002 (Sand et al., 2005) to 63% in 2016 (Lipkin et al., 2020a). Still, systematic social-emotional screening remains rare (Allen et al., 2010). Further improvements are needed, and gaps remain in settings serving the most vulnerable youth, such as Federally Qualified Health Centers (FQHCs) (Health resource and service administration, 2021; Whitney and Peterson, 2019). Indeed, screening practices for social-emotional problems in primary care can be challenging due to time constraints, lack of provider experience, training, and self-efficacy, and poor or no reimbursement (Kramer et al., 2017; Horwitz et al., 2015). Further, parents of minoritized children tend be less trusting of medical care in general and mental health treatment more so (Boat and Kelleher, 2020). Nevertheless, continuing to improve screening rates, particularly for clinicians who serve socially and economically marginalized populations, is crucial for reducing health inequities in early assessment and intervention (Williams and Cooper, 2019).

Gaps in the literature

Primary care remains a vital setting to bridge the current gaps in early identification and intervention for social-emotional wellbeing concerns despite the noted challenges (Boat, 2015). Although prior studies have identified barriers, few have assessed pediatric PCCs’ perceptions of currently available screening and assessment methods for identifying social-emotional wellbeing, and fewer still have taken the next step of identifying implementation strategies—the actions taken and supports provided to enhance adoption, implementation, and sustainability of evidence-based tools and interventions (Powell et al., 2019)—needed to ensure wide-scale adoption in pediatric clinical practice. Numerous implementation strategies have been developed and tested, including providing ongoing training and consultation in social-emotional wellbeing and integrating quality screening tools into pediatric practice procedures and workflows (Powell et al., 2015).

Pediatric PCCs’ comfort, familiarity, and perceived need to reliably identify common social-emotional wellbeing concerns prior to age 5 has been low, and scant research has been conducted among clinicians working with children in FQHCs. FQHCs are supported by federal funding and provide culturally responsive, community-based medical, social, oral health, and behavioral services for more than 29 million medically underserved, low economic status populations across the U.S. (Health resource and service administration, 2021). Living in poverty increases the risk for both medical problems and problems in social-emotional wellbeing (Cree et al., 2018), and inequities in rates of care and access to services for social-emotional wellbeing are correlated with families with lower socio-economic status (Foy, 2018; Cree et al., 2018; Beck et al., 2016). Thus, FQHCs can play a vital role in early detection and management among infants and young children if equipped with the needed skills, tools and resources (Wakschlag et al., 2019).

Aims

This survey study of pediatric PCCs working in FQHCs sought to (a) extend research on pediatric PCCs’ perspectives of and their perceived confidence in identifying and intervening on young children’s social-emotional wellbeing; (b) assess methods for and satisfaction with screening for social-emotional wellbeing in children birth–5 years; (c) elucidate barriers associated with identifying and addressing social-emotional wellbeing concerns; and (d) assess pediatric clinicians’ interest in adopting validated, low-burden tools for systematically screening social-emotional wellbeing in infants, toddlers, and young children—when brain and behavior are most responsive to intervention. This study also examined potential differences by clinician type (i.e., pediatricians, family physicians, nurse practitioners and physician assistants), years of clinical experience, and the state in which they practice.

Method

Recruitment procedures and measures

This study was part of a team science initiative, the Mental Health, Earlier Partnership (Wakschlag et al., 2022), designed to translate developmental science to primary care for earlier identification and intervention for social-emotional wellbeing during the first 5 years of life. All procedures were approved by the Northwestern University Institutional Review Board. The survey was developed in collaboration with eight practicing pediatric PCCs. The first version was then piloted with two other pediatric PCCs who provided feedback on the items. Recruitment occurred via direct email invitation from the research team at AllianceChicago, a health center-controlled network, to clinical leadership at practice sites. Leadership then emailed the invitations to pediatric clinicians who care for infants and young children. The invitation included a hyperlink to a REDCap survey. Participants provided online consent prior to survey initiation. The survey took approximately 15–20 min and respondents received a $20 gift card. The inclusion criteria were being a PCC in an FQHC. Exclusion criteria were seeing only adult patients. The survey was hosted by Northwestern University and co-author AJC had access to the REDCap database. Additional information about the survey methodology and recruitment is available from the corresponding author.

Participants responded to questions using a 4-point Likert-type survey. The survey assessed PCCs’ perceptions of the importance of social-emotional wellbeing for overall pediatric health, perceived confidence in managing social-emotional wellbeing, barriers to intervention, current methods for screening for social-emotional wellbeing in their practices, and interest in adopting a brief transdiagnostic parent-report screener for social-emotional wellbeing. A complete list of survey items and anchors are displayed in Table 2. For questions 2, and 6–10, age was queried separately in three groups (age birth–<2, age 2–<3, age 3–5).

Table 2.

Descriptive statistics of survey questions.

Question n Mdn IQR
1. How important do you think social-emotional wellbeing is to pediatric health? (1 Not at all important–4 Very important) 72 4 0
2. How likely do you think it is that poor social-emotional wellbeing in young children will result in long-term impairments in health and functioning at school age and beyond (please rate this below for young children of different ages) (1 Not at all likely–4 Highly likely) — — —
 a. Infants (0–<2 years) 72 4 1
 b. Toddlers (2– <3 years) 72 4 0
 c. Preschoolers (3–5 years) 72 4 0
3. Below are presenting concerns that may interfere with young children’s social-emotional wellbeing. Please rate the frequency of these presenting problems in your practice.
(1 Not at all common–4 Very common)		 — — —
 a. Fussiness/hard to soothe 72 3 1
 b. Tantrums 72 3 1
 c. Excessive crying 72 2 1
 d. Irritability 72 2 1
 e. Hard to manage 72 3 2
 f. Low self-control 71 3 2
 g. Family/Parenting stress 70 4 1
 h. Other 9 4 2
4. How well equipped do you feel to address the most common concerns related to children’s social-emotional wellbeing in your practice? (1 Not at all equipped–4 Very equipped) 71 3 2
5. Rate the extent to which the following are barriers to identifying and addressing concerns about social-emotional wellbeing in your practice (1 Not at all—4 Very much). Lack of… — — —
 a. EHR-based decision support tool for determining when to worry about young children’s social-emotional wellbeing 72 2 2
 b. Valid, low-burden, parent-report tool for screening/assessing social-emotional wellbeing in this age group 72 3 1
 c. Confidence in providing guidance about problems in social-emotional wellbeing in this age group 72 2 1
 d. Age-appropriate materials/resources for parents to access 72 3 2
 e. Readily available intervention resources to refer to parents 72 3 1
6. Rate the extent to which you agree with this statement: An EHR-integrated tool to aid practices in screening/assessing for risk for social-emotional wellbeing in infants and children is needed in primary care. Please rate this below for young children of different ages. (1 Strongly disagree–4 Strongly agree) — — —
 a. Infants (0–<2 years) 69 3 1
 b. Toddlers (2– <3 years) 71 3 1
 c. Preschoolers (3–5 years) 70 3 1
7. How satisfied are you with the screening/assessment in use in your clinic for social-emotional wellbeing in infants and young children? Please rate your satisfaction below for young children of different ages. (1 Very dissatisfied–4 Very satisfied) — — —
 a. Infants (0–<2 years) 55 2 1
 b. Toddlers (2– <3 years) 57 2 1
 c. Preschoolers (3–5 years) 57 2 1
 d. We do not have any screening/assessment for social and emotional wellbeing of children 5 years of age and younger 28 2 2
8. How burdensome is it for you and your medical staff to screen/assess social-emotional wellbeing in infants and young children in your practice? Please rate this below for young children of different ages. (1 Very burdensome–4 Not at all burdensome) — — —
 a. Infants (0–<2 years) 58 3    1.75
 b. Toddlers (2–<3 years) 60 3 2
 c. Preschoolers (3–5 years) 60 3 1
 d. We do not have any screening/assessment for social and emotional wellbeing of children under aged 5 years and younger 23 2 2
9. If your practice were to introduce a validated, low-burden, parent-report tool for screening/assessing social-emotional wellbeing in infants and young children to aid you, how likely would you use it in routine care? Please rate this below for young children of different ages. (1 Not at all likely–4 Highly likely) — — —
 a. Infants (0–<2 years) 72 4 1
 b. Toddlers (2–<3 years) 72 4 1
 c. Preschoolers (3–5 years) 69 4 1
10. Please rate your overall interest in adopting a validated, low-burden, parent-report tool for screening/assessing social-emotional wellbeing in infants and young children in your primary care practice. Please rate this below for young children of different ages. (1 Not at all interested– 4 Very interested) — — —
 a. Infants (0–<2 years) 71 4 1
 b. Toddlers (2– <3 years) 72 4 1
 c. Preschoolers (3–5 years) 70 4 1
n % —
11. How does your practice currently screen/assess social-emotional wellbeing in children aged 5 years and younger? — — —
 a. Clinical examination/observation 60 84% —
 b. Standardized parent interview 22 31% —
 c. Standardized observation of child/parent-child 22 31% —
 d. Parent-report surveys 32 45% —
 e. Computerized testing of the child   1   2% —
 f. Developmental testing of the child 21 29% —
 g. Other   1   2% —
 h. My practice does not screen/assess social-emotional wellbeing in children aged 5 years and younger   4   6% —
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Note: EHR = Electronic Health Record; Sample size: N = 82, Valid N = 72.

Data analytic approach

Data were analyzed in R, v.4.1.1 (R Core Team, 2021). Correlations, central tendencies, analysis of variance, and t-tests were conducted. When statistically significant group differences were found (at the a = .05 level), Cohen’s d was calculated as an effect size estimate (Lakens, 2013). When running multiple comparisons, Bonferroni adjustments were be made to control the Type 1 error rate. If differences in clinician type were statistically significant, a post-hoc Tukey’s HSD test was conducted. Missing data among variables of interest was 14%, and item-level deletion was used for missingness when conducting analyses. Missing data was assumed to be missing at random. Consistent with prior research, we hypothesize that clinicians will perceive social-emotional wellbeing as important to physical health (Kramer et al., 2017), and we also hypothesize that they will not feel highly equipped to address social-emotional wellbeing in practice given this trend in similar healthcare settings (Horwitz et al., 2015). Given that our sample is among PCCs practicing within FQHCs who serve racial/ethnically diverse, low-income patients, we anticipate that respondents will identify unique barriers, such as having a lack of readily available resources that perfectly match patient needs. Given that the network of FQHCs we recruited from is based in Illinois and this likely to have a high proportion of respondents from this state, we compared Illinois respondents to all other states to examine potential state/regional differences.

Results

Table 1 provides participant demographics and sample statistics. Data from 72 participants were used in the analyses as 10 respondents started the survey but discontinued before completing the items of interest to the current study. Pediatric clinicians, including pediatricians (n = 36), family physicians (n = 11), nurse practitioners (n = 15), and physician assistants (n = 10), in FQHCs from nine US states, 69% from Illinois (1–7 providers each in California, Hawaii, Iowa, Indiana, Kentucky, Michigan, North Carolina, New York), participated. Illinois has greater representation given the number of FQHCs in the state within the AllianceChicago network. Respondents reported a median of 8.5 years (IQR = 11.75) of experience.

Table 1.

Sample Characteristics (N = 72).

n (%) or M (SD)
Sex
 Female   58 (81%)
 Male   13 (18%)
Provider type
 Pediatrician   36 (50%)
 Nurse practitioner   15 (21%)
 Family physician   11 (15%)
 Physician assistant   10 (14%)
Number of years in practice    10.9 (8.6)
Percentage of time treating
 Infants/Toddlers (birth–2 years)    24.6 (13.9)
 Preschoolers (3–5 years)   21 (9.1)
 School age (6–12 years)    21.3 (9.5)
 Adolescents (13–17 years)    21.4 (13.6)
State
 California      1 (1%)
 Hawaii      7 (10%)
 Iowa      2 (3%)
 Illinois       50 (69%)
 Indiana      2 (3%)
 Kentucky      2 (3%)
 Michigan      1 (1%)
 North Carolina      2 (3%)
 New York      5 (7%)
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See Table 2 for descriptive statistics from survey items. Overall, PCCs rated social-emotional wellbeing as “very important” to pediatric health (Mdn = 4, IQR = 0)). Across the age group categories (birth-5 years) respondents rated poor social-emotional wellbeing in young children as “somewhat likely” to “highly likely” to result in long-term impairments (Mdn = 4, IQR = .33)), with ratings statistically significantly higher for preschoolers (ages 3–5) compared to infants/toddlers (ages birth–2), t (100.9) = 3.19, (mean difference = 2.6, 95% CI = 0.09–.43, d = 0.53). Given typical interpretations of Cohen’s d—small (d = 0.2), medium (d = 0.5), and large (d = 0.8)—this was a medium effect. PCCs rated themselves between “somewhat unequipped” to “somewhat equipped” (Mdn = 3, IQR = 1) to address common concerns related to children’s social-emotional wellbeing. On average, there was a statistically significant discrepancy between mean PCC ratings of the importance of children’s social-emotional wellbeing compared to their level of confidence in feeling equipped to address it in primary care, t (87.95) = 14.75, mean difference = 1.31, 95% CI = 1.13–1.49). There were no statistically significant differences for any survey questions by PCC type. Providers in Illinois rated statistically significantly higher than providers from other states that poor social-emotional wellbeing in toddlers (children aged 2–<3) was more likely to result in long-term impairments in health and functioning F (1,69) = 4.93, p = .029, adj. R2 = .05, standardized estimate = 0.11).

Barriers to identifying and addressing social-emotional wellbeing

On average, PCCs rated each of the barriers above a two or “somewhat of a barrier.” The highest rated barrier to identifying and addressing concerns in social-emotional wellbeing was having readily available intervention resources to provide parents (Mdn = 3, IQR = 1). Number of years practicing was negatively (std.est. = −0.35) associated with the degree to which PCCs’ confidence was a barrier in providing guidance to caregivers about social-emotional wellbeing concerns (F (1,70) = 10.06, p = .002, adj. R2 = .11). This indicates that less experienced PCCs rated their lack of confidence as a greater barrier than more experienced clinicians. Years practicing were also positively (std.est. = 0.24) associated with reporting access to intervention resources as a barrier (F (1,70) = 5.4, p = .02, adj. R2 = .06), indicating that more experienced clinicians perceived a lack of available resources as a greater barrier than those with less experience. Practitioners from Illinois rated that screening/assessing for social-emotional wellbeing among toddlers (aged 2–<3; F (1,57) = 6.12, p = .016, adj. R2 = .08) and preschoolers (aged 3–5; F (1,57) = 7.72, p = .007, adj. R2 = .10) was less burdensome compared to providers from other states (std.est. = −0.28 and −0.32, respectively). Although less so for Illinois, it was promising that most respondents indicated that assessing for social-emotional wellbeing was not very burdensome across age groups (Mdn = 3, IQR = 1).

Presenting concerns interfering with young children’s social-emotional wellbeing

Among the concerns rated, all were above a two or “somewhat common” on average, indicating that they all were related to social-emotional wellbeing to some extent. Interestingly, the highest rated concern interfering with social-emotional wellbeing was family/parenting stress (Mdn = 4, IQR = 1). Other factors, including tantrums (Mdn = 3, IQR = 1), excessive crying (Mdn = 2, IQR = 1) and irritability (Mdn = 2, IQR = 1), were all rated >2 or “somewhat common” indicating providers perceived them to be related to young children’s social-emotional wellbeing. No statistically significant differences emerged by clinician type, years of experience, or when comparing Illinois to the other states.

Screening methods

The most common screening methods for social-emotional wellbeing were clinical examination/observation (84%) followed by parent surveys (45%) (responses were not mutually exclusive). Respondents rated their satisfaction with current social-emotional wellbeing screening methods among children birth–5 years in their clinics between “somewhat dissatisfied” and “somewhat satisfied” (Mdn = 2, IQR = 1). They also rated that they would be “somewhat interested” to “highly interested” (Mdn = 4, IQR = 1) in adopting a validated, low-burden parent-report tool for assessing social-emotional wellbeing in infants and young children birth–5 years.

Discussion

The results of the survey of pediatric PCCs achieved our aims of adding to and addressing gaps in the literature concerning social-emotional health of children birth–5 years in primary care. Consistent with prior research (Kramer et al., 2017), pediatric PCCs reported social-emotional wellbeing as an important overall health indicator and that behavioral health services are in high need. However, these findings were discrepant with respondents’ perceived low confidence in addressing such concerns, and a number of barriers for risk identification and intervention were reported. This finding of perceived lack of confidence has also been shown in earlier research conducted between 2004 and 2013) (Horwitz et al., 2015), indicating a persistent challenge. Lack of confidence in addressing social-emotional concerns may be linked to lack of explicit training in developmentally informed care (Foy et al., 2019), with their general dissatisfaction with and minimal usage of current screening tools and poor access to effective interventions. Moreover, it is likely that FQHCs face unique barriers at various socio-ecological levels influencing their confidence and self-efficacy, and constraining the consistent use of evidence-based practices to identify and intervene early among young children with concerns in social-emotional wellbeing (Nakamura et al., 2019)

These findings underscore the need for better training, tools for identification and an increase in the availability of intervention resources to which families can be referred. PCCs reported greater perceived risk of impairment among children ages 3–5 years experiencing social-emotional wellbeing concerns compared to risk occurring between ages birth–<2 years, which may imply perceptions that social-emotional wellbeing concerns before age three are transient and do not warrant intervention, or that currently available assessment methods are simply unreliable. It could also indicate a need for education and training on the impairing consequences of early warning indicators evident in the first years of life. Research shows an increased risk of impairment when behavior problems are evident prior to age three (Smith et al., 2014), and interventions are effective at reducing the likelihood that early risk leads to mental health problems later in childhood (Smith et al., 2019). This suggests that a “watch and wait” approach should be replaced with “identify and act” earlier in development (Wakschlag et al., 2022).

Though pediatric PCCs indicated that social-emotional wellbeing is important to overall health, low confidence in screening and intervening undermines potential population health benefits of existing evidence-based tools and services. Even for more experienced and confident providers, a lack of available resources was rated as a barrier to screening and providing indicated care to families. Since pediatric PCCs are often the initial contact for children and their families in receiving preventive care and navigating health services, it is imperative that they have the tools to accurately identify children in need of intervention and support services. Referral barriers in the literature include limited access to affordable or age-appropriate intervention resources, poor communication between primary care and mental health services, and low referral follow-through rates (Davis et al., 2012). FQHCs experience these and additional barriers due to limited resources within the FQHC and in the communities in which they operate (Nakamura et al., 2019; Boat and Kelleher, 2020).

Although pediatric PCCs in this study were dissatisfied with existing screening methods for social-emotional wellbeing, they did not find screening and assessing for social and emotional wellbeing overly burdensome and were interested in adopting an EHR-integrated tool, which is consistent in existing literature on preferred modality for universal screening in healthcare settings (Goplerud and McPherson, 2015). Because health inequities persist in a cascading pattern among marginalized populations and families with lower socio-economic status (Cree et al., 2018; Foy, 2018), the need for innovations that promote the consistent use of screening tools with high reliability and validity is even more urgent among practitioners within FQHCs, along with training in culturally informed care strategies that reduce identification and referral bias and drive equitable implementation (Smith et al., 2021; Sheldrick et al., 2022) of evidence-based interventions will be key.

Findings from this study have implications for policy, such as recommendations for universal screening for broad-based social-emotional risk at younger ages. The U.S. Preventive Services Task Force, for example, has only endorsed screening for depression among adolescents (ages 13–17) (Zallman et al., 2017). Endorsing screening for younger children, and on transdiagnostic risk indicators, rather than narrow-band disorders, that are responsive to evidence-based interventions (Smith et al., 2019) would trigger changes in reimbursement and new quality metrics that could help to routinize this practice. By extension, with increased focus on early social-emotional wellbeing, states and federal agencies could allocate funding to provide much-needed evidence-based interventions.

Limitations

Importantly, this study represents the view of pediatric PCCs serving populations that are often excluded from research (Duma et al., 2018; Terry, 2020). However, the sample was relatively small (N = 72) and uneven across clinician type. While most respondents practiced in FQHCs located in Illinois (n = 50), it is unclear the reasons for the two differences found in expectations for problems to persist when concerns are identifiable in toddlerhood and the lower perceived burden of screening for social-emotional wellbeing in toddlers and preschoolers compared with respondents from other states. A deeper dive into factors not assessed in this survey is needed to understand the reasons for these minor observed differences. A larger sample could also clarify if this was an artifact of this relatively small sample. We did not see any differences by clinician type, which is possibly due to power considerations, though findings may also indicate homogeneity within FQHCs. Finally measuring individual perceptions through Likert scales leave participants susceptible to response biases, such as social desirability, which can lead to inflated estimates (Kreitchmann et al., 2019).

Future directions

Future research should include a larger sample with sufficient representation of clinician types and collect qualitative data to understand differences due to distinctive interests and training experiences that could potentially lead to differences in role expectations (Stein et al., 2008; Leaf et al., 2004). Future research is also needed that elucidates additional individual- and organizational-level barriers to better understand the practical implications of the issues reported on this survey (Siu, 2016). Finally, implementation strategies, such as EHR-integrated tools that reduce burden should be developed and tested to support clinicians and ultimately create opportunities for greater access among patients and feasibility for pediatric practices and clinicians (Wakschlag et al., 2022).

Implications for practice

This study identifies key individual-level determinants that may elucidate a path toward reducing the research-to-practice gap of universal social-emotional wellbeing screening in pediatric primary care. System barriers also inhibit practice change even when individual clinicians desire practice change. Policy and implementation efforts have improved early identification and intervention rates (Lipkin et al., 2020a; American Academy of Child and Adolescent Psychiatry, 2009), though there is a continued need for research that identifies multilevel barriers to implementation and addresses them with strategies to increase equitable implementation and sustained use of evidence-based practices in primary care will ultimately yield better outcomes for children and families in need. Bolstering early identification and prevention of mental health problems is a vital step towards addressing the burgeoning mental health crisis, as earlier onset problems are most likely to become severe and persistent (Stephenson, 2021).

Conclusions

Primary care is often the first point of contact where common concerns in children’s social-emotional wellbeing are encountered by a trained professional (Robinson and Reiter, 2007). Although primary care has been identified as an appropriate setting to identify and address common social-emotional wellbeing concerns, previous literature and the current study show that there is wide variability in pediatric PCCs’ ability and capacity to incorporate standardized tools and confidence in identifying and treating children birth–5 years. EHR-integrated tools and other implementation strategies will be needed to support clinicians to bridge the research-practice gap and provide greater access to families in need of social-emotional and behavioral health services.

Acknowledgments

We gratefully acknowledge the contributions of our many MHE-P collaborators.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by grants 2018-68001-27550 (USDA; MPIs Berkel and Smith), MH121877 and MH107652 (PI Wakschlag), and Pilot Grant from the Division of Health Systems Innovation and Research, Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah (awarded to JDS); with support from Northwestern University Institute for Innovations in Developmental Sciences and Telethon Kids Institute; Northwestern University Primary Care Practice-Based (NP3) Research Program funded in part by a Clinical and Translational Science Award (CTSA) grant from the National Institutes of Health (UL1TR001422); and National Institute of Health training postdoctoral slot to JLM (NLM; T15LM007124).

Abbreviations

PCC

Pediatric primary care clinicians

FQHC

Federally Qualified Health Center

Footnotes

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.

References

  1. Allen SG, Berry AD, Brewster JA, et al. (2010) Enhancing developmentally oriented primary care: an Illinois initiative to increase developmental screening in medical homes. Pediatrics 126(Suppl 3): S160–S164. [DOI] [PubMed] [Google Scholar]
  2. American Academy of Child and Adolescent Psychiatry CoHCAaE (2009) Improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics 123: 1248–1251. [DOI] [PubMed] [Google Scholar]
  3. Barger B, Rice C, Wolf R, et al. (2018) Better together: developmental screening and monitoring best identify children who need early intervention. Disability and Health Journal 11(3): 420–426. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Beck AF, Tschudy MM, Coker TR, et al. (2016) Determinants of health and pediatric primary care practices. Pediatrics 137(3): e20153673. [DOI] [PubMed] [Google Scholar]
  5. Boat TF (2015) Improving lifetime health by promoting behavioral health in children. JAMA 313(15): 1509–1510. [DOI] [PubMed] [Google Scholar]
  6. Boat TF and Kelleher KJ (2020) Fostering healthy mental, emotional, and behavioral development in child health care. JAMA Pediatrics 174(8): 745–746. [DOI] [PubMed] [Google Scholar]
  7. Centers for Disease Control and Prevention (2018) Developmental monitoring and screening. https://www.cdc.gov/ncbddd/childdevelopment/screening.html [Google Scholar]
  8. Cree RA, Bitsko RH, Robinson LR, et al. (2018) Health care, family and community factors associated with mental, behavioral, and developmetnal disorders and poverty among children aged 2-8 years — Unites States, 2016. Morbidity and Mortality Weekly Reoport 67: 113701383. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Davis DW, Honaker SM, Jones VF, et al. (2012) Identification and management of behavioral/mental health problems in primary care pediatrics: perceived strengths, challenges, and new delivery models. Clinical Pediatrics 51(10): 978–982. [DOI] [PubMed] [Google Scholar]
  10. Dodge R, Daly A, Huyton J, et al. (2012) The challenge of defining wellbeing. International Journal of Wellbeing 2(3): 222–235. [Google Scholar]
  11. Dougherty LR, Leppert KA, Merwin SM, et al. (2015) Advances and directions in preschool mental health research. Child Development Perspectives 9(1): 14–19. [Google Scholar]
  12. Duma N, Vera Aguilera J, Paludo J, et al. (2018) Representation of minorities and women in oncology clinical trials: review of the past 14 years. Journal of Oncology Practice 14(1): e1–e10. [DOI] [PubMed] [Google Scholar]
  13. Foy JM (2018) Promoting Mental Health in Children and Adolescents: Primary Care Practice and Advocacy . American Academy of Pediatrics. [Google Scholar]
  14. Foy JM, Green CM, Earls MF, et al. (2019) Mental health competencies for pediatric practice. Pediatrics 144(5): e20192757. [DOI] [PubMed] [Google Scholar]
  15. Glascoe FP (2015) Evidence-based early detection of developmental-behavioral problems in primary care: what to expect and how to do it. Journal of Pediatric Health Care 29(1): 46–53. [DOI] [PubMed] [Google Scholar]
  16. Goplerud E and McPherson T (2015) Implementation Barriers to and Facilitators of Screening, Brief Intervention, Referral, and Treatment (SBIRT) in Federally Qualified Health Centers (FQHCs). Report Prepared for the Office Of Disability, Aging And LongTerm Care Policy Office Of the Assistant Secretary For Planning And Evaluation. Washington, DC: US Department of Health and Human Services. [Google Scholar]
  17. Health Resource and Service Administration (2021) Health Center Program Impact and Growth. https://bphc.hrsa.gov/about/healthcenterprogram/index.html [Google Scholar]
  18. Heneghan A, Garner AS, Storfer-Isser A, et al. (2008) Pediatricians’ role in providing mental health care for children and adolescents: do pediatricians and child and adolescent psychiatrists agree? Journal of Developmental and Behavioral Pediatrics: JDBP 29(4): 262–269. [DOI] [PubMed] [Google Scholar]
  19. Horwitz SM, Storfer-Isser A, Kerker BD, et al. (2015) Barriers to the identification and management of psychosocial problems: changes from 2004 to 2013. Academic Pediatrics 15(6): 613–620. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Jones DE, Greenberg M and Crowley M (2015) Early social-emotional functioning and public health: the relationship between kindergarten social competence and future wellness. American Journal of Public Health 105(11): 2283–2290. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Kramer TL, Drummond KL, Curran GM, et al. (2017) Assessing culture and climate of federally qualified health centers: a plan for implementing behavioral health interventions. Journal of Health Care for the Poor and Underserved 28(3): 973–987. [DOI] [PubMed] [Google Scholar]
  22. Kreitchmann RS, Abad FJ, Ponsoda V, et al. (2019) Controlling for response biases in self-report scales: forced-choice vs. psychometric modeling of Likert items. Frontiers In Psychology 10: 2309. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Lakens D (2013) Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Frontiers in Psychology. 4: 863, DOI: 10.3389/fpsyg.2013.00863 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Infant and Early Childhood Mental Health (2009) Laying the Foundation for Early Development: Infant and Early Childhood Mental Health. Zero To Three. https://zero-to-three-review.herokuapp.com/resources/443-laying-the-foundation-for-early-development-infant-and-early-childhood-mental-health [Google Scholar]
  25. Leaf PJ, Owens PL, Leventhal JM, et al. (2004) Pediatricians’ training and identification and management of psychosocial problems. Clinical Pediatrics 43(4): 355–365. [DOI] [PubMed] [Google Scholar]
  26. Lipkin PH, Macias MM, Baer Chen B, et al. (2020a) Trends in pediatricians’ developmental screening: 2002–2016. Pediatrics 145(4): e20190851. [DOI] [PubMed] [Google Scholar]
  27. Lipkin PH, Macias MM and Norwood KW (2020b) Promoting optimal development: identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics 145(1): e20193449. [DOI] [PubMed] [Google Scholar]
  28. Lyon AR and Bruns EJ (2019) User-centered redesign of evidence-based psychosocial interventions to enhance implementation—hospitable soil or better seeds? JAMA Psychiatry 76(1): 3–4. [DOI] [PubMed] [Google Scholar]
  29. Nakamura Y, Laberge M, Davis A, et al. (2019) Barriers and strategies for specialty care access through federally qualified health centers: a scoping review. Journal of Health Care for the Poor and Underserved 30(3): 910–933. [DOI] [PubMed] [Google Scholar]
  30. National Research Council and Institute of Medicine (2009) Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. Preventing Mental, Emotional, and Behavioral Disorders Among Young People. Washington DC: National Academies Press. [Google Scholar]
  31. Powell BJ, Fernandez ME, Williams NJ, et al. (2019) Enhancing the impact of implementation strategies in healthcare: a research agenda. Frontiers in Public Health 7: 3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Powell BJ, Waltz TJ, Chinman MJ, et al. (2015) A refined compilation of implementation strategies: results from the expert recommendations for implementing change (ERIC) project. Implementation Science 10: 21. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. R Core Team (2021) R: A Language and Environment for Statistical Computing. Austria: R foundation for statistical computing Vienna. [Google Scholar]
  34. Reding MEJ, Chorpita BF, Lau AS, et al. (2014) Providers’ attitudes toward evidence-based practices: Is it just about providers, or do practices matter, too? Administration and Policy in Mental Health 41(6): 767–776. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Robinson PJ and Reiter JT (2007) Behavioral Consultation and Primary Care: A Guide to Integrating Services. Springer. [Google Scholar]
  36. Sand N, Silverstein M, Glascoe FP, et al. (2005) Pediatricians’ reported practices regarding developmental screening: do guidelines work? do they help? Pediatrics 116(1): 174–179. [DOI] [PubMed] [Google Scholar]
  37. Sheldrick RC, Bair-Merritt MH, Durham MP, et al. (2022) Integrating pediatric universal behavioral health care at federally qualified health centers. Pediatrics 149(4): e2021051822. [DOI] [PubMed] [Google Scholar]
  38. Sheldrick RC, Merchant S and Perrin EC (2011) Identification of developmental-behavioral problems in primary care: a systematic review. Pediatrics 128(2): 356–363. [DOI] [PubMed] [Google Scholar]
  39. Simmons A (2013) Suspensions and expulsions contribute to school dropouts. Journal of Educational Controversy 7(1): 14. [Google Scholar]
  40. Siu AL (2016) US preventive services task force screening for depression in children and adolescents: U.S. preventive services task force recommendation statement. Annals of Internal Medicine 164(5): 360–366. [DOI] [PubMed] [Google Scholar]
  41. Smith JD, Davis P and Kho AN (2021) Community-driven health solutions on Chicago’s South side. Stanford Social Innovation Review 19(3): A27–A29. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Smith JD, Dishion TJ, Shaw DS, et al. (2014) Coercive family process and early-onset conduct problems from age 2 to school entry. Development and Psychopathology 26(4 Pt 1): 917–932. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Smith JD, Wakschlag L, Krogh-Jespersen S, et al. (2019) Dysregulated irritability as a window on young children’s psychiatric risk: transdiagnostic effects via the family check-up. Development and Psychopathology 31(5): 1887–1899. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Snyder TD and Dillow SA (2015) Digest of Education Statistics 2013. NCES 2015-011. National Center for Education Statistics. [Google Scholar]
  45. Stein REK, Horwitz SM, Storfer-Isser A, et al. (2008) Do pediatricians think they are responsible for identification and management of child mental health problems? results of the AAP periodic survey. Ambulatory Pediatrics 8(1): 11–17. [DOI] [PubMed] [Google Scholar]
  46. Stephenson J (2021) Surgeon general urges rapid, coordinated response to mental health crisis in US youth. JAMA Health Forum 2(12): e214995. [DOI] [PubMed] [Google Scholar]
  47. Terry M (2020) Pushing for more ethnic and racial diversity in clinical trials. https://www.biospace.com/article/pushing-for-more-ethnical-and-racial-diversity-in-clinical-trials/ [Google Scholar]
  48. Townsend L, Flisher AJ and King G (2007) A systematic review of the relationship between high school dropout and substance use. Clinical Child and Family Psychology Review 10(4): 295–317. [DOI] [PubMed] [Google Scholar]
  49. Wakschlag LS, Finlay-Jones A, MacNeiill LA, et al. (2022) Don’t get lost in translation: integrating developmental and implementation sciences to accelerate real-world impact on children’s development, health, and wellbeing. Frontiers in Public Health 10: 827412. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Wakschlag LS, Roberts MY, Flynn RM, et al. (2019) Future directions for early childhood prevention of mental disorders: a road map to mental health, earlier. Journal of Clinical Child and Adolescent Psychology 48(3): 539–554. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Whitney DG and Peterson MD (2019) US national and state-level prevalence of mental health disorders and disparities of mental health care use in children. JAMA Pediatrics 173(4): 389–391. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Williams DR and Cooper LA (2019) Reducing racial inequities in health: using what we already know to take action. International Journal of Environmental Research and Public Health 16(4): 606. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Zallman L, Joseph R, O’Brien C, et al. (2017) Does behavioral health integration improve primary care providers’ perceptions of health-care system functioning and their own knowledge? General Hospital Psychiatry 46: 88–93. [DOI] [PubMed] [Google Scholar]

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