Mental and Behavioral Health Screening at Preventive Visits: Opportunities for Follow-Up of Patients Who are Nonadherent with the Next Preventive Visit Karen A. Hacker, MD, MPH, Lisa N. Arsenault, PhD, Sandra Williams, SM, and Ann M. DiGirolamo, PhD, MPH Objectives To determine the type of subsequent care received by children nonadherent with their next preventive visit and whether behavioral factors predict use of emergency or acute care in this population. Study design Data on 1703 children (4-16 years) screened at a preventive visit with the Pediatric Symptom Checklist (PSC)/Youth-PSC were examined to determine subsequent preventive care adherence (10-18 months later). Then, nonadherent children were monitored to determine whether they returned to their medical home for acute care, delayed preventive care, or visited the emergency department (ED). Multivariate analyses were con- ducted to determine whether demographic and behavioral factors predicted return to either acute care or ED care site. Results Of the 461 children who were nonadherent with a second preventive care visit, most (85%) subsequently returned for acute, emergency, or delayed preventive care in the same medical system. Predictors of acute care or ED use included behavioral health risk characteristics (positive PSC, counseling, referral, parental concern), as well as adolescent age, self-pay and public insurance status, and living in lower socioeconomic communities. Conclusions Pediatricians should consider acute care or ED visits as opportunities for mental health screening follow-up, and intervention in populations at high risk who miss preventive care. (J Pediatr 2011;158:666-71). A recent Institute of Medicine report on preventing mental, emotional, and behavioral disorders in young people called for increased attention to mental health promotion for children at risk. 1 Behavioral health screening at the annual pre- ventive care visit is currently recommended by the American Academy of Pediatrics and mandated as part of the Med- icaid Early Periodic Screening Diagnosis and Treatment requirements. 2,3 Recently, the use of behavioral health screening tools at the annual visit has increased, with some states mandating their use for Medicaid populations. 4,5 Preventive visits offer good opportunities for screening given that they are generally longer than acute care visits and can accommodate anticipatory guid- ance and assessment in areas ranging from diet and nutrition to behavioral health. 6 Although screening during preventive care is recommended, there is little information available about whether this is the best time to screen. For example, should behavioral screening be done annually or more frequently, and if this is the only time in which mental health is addressed, which children will be missed? Studies have shown high variability in preventive care adher- ence, with rates ranging from 81% of infants to only 32% of adolescents. 1,3 Risk factors associated with poor preventive care include low socioeconomic status, adolescent age, lack of insurance, parental mental health, and being a racial or ethnic mi- nority. 1,3,7,8 In addition, there are a host of risk factors associated with missing outpatient appointments for both adolescents and adults, which include history of missing appointments, 9 transportation issues, 10 lack of a regular provider, 11 and poor psy- chological condition. 12 Finally, in our longitudinal study of children who were screened for behavioral health at two consecutive preventive visits with the Pediatric Symptom Checklist (PSC), children who were nonadherent with the second preventive care visit were significantly more likely to have had positive scores and to have been referred for mental health care at their initial visits than children who adhered to preventive care. 13 As a follow-up to our prior study and to improve behavioral health screening recommendations, our aims were to (1) de- termine whether nonadherent children maintained their relationship with their medical home and returned for acute or emer- gency care, thus offering additional opportunities for mental health follow-up; (2) determine what demographic and behavioral From the Institute for Community Health, Cambridge Health Alliance (K.H., L.A., S.W., A.D.), and Harvard Medical School (K.H.), Cambridge, MA Supported in part by a grant through The Integrated Health and Behavioral Health Care for Children, Adoles- cents, and Their Families grant program in HRSA’s Ma- ternal and Child Health Bureau. The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2011 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2010.09.059 CHA Cambridge Health Alliance CI Confidence interval ED Emergency department MH Mental health OR Odds ratio PSC Pediatric Symptom Checklist SES Socioeconomic status Y-PSC Youth Pediatric Symptom Checklist 666