Welcome to the training on Behavioral Health: Screening and Intervention provided by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).
Notes: For purposes of this module,
- The term “serious emotional disturbance” (SED) is used to describe a range of mental, emotional, and behavioral disorders.
- The term “children” refers to children and adolescents ages birth through 20 years.
- The term “parent” includes guardians and caregivers.
- References and links mentioned in this module can be found in the Appendix of Resources.
The goal of this module is to equip Texas Health Steps providers and other interested health-care professionals to follow state requirements and best practices for psychosocial and behavioral health screening, diagnosis, and ongoing management in the primary care setting.
Texas Health Steps providers and other interested health-care professionals.
Specific Learning Objectives
After completing the activities of this module, you will be able to:
- Specify risk factors and diagnostic criteria for common forms of serious emotional disturbance.
- Apply the requirements of the Texas Health Steps Periodicity Schedule to conduct age-appropriate mental health screening for children and adolescents from birth through 20 years using approved tools.
- Integrate age-appropriate anticipatory guidance and evidence-based prevention strategies into clinical practice.
- Summarize the primary care provider’s role in coordinating care for children and adolescents with behavioral health disorders.
Please note this module expires on 6/21/2021.
This module was released on 6/21/2018.
Continuing Medical Education
The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians.
The Texas Department of State Health Services, Continuing Education Service designates this enduring material for a maximum of 1.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Nursing Education.
The Texas Department of State Health Services, Continuing Education Service under sponsor number CS3065 has been approved by the Texas State Board of Social Worker Examiners to offer continuing education contact hours to social workers. The approved status of The Texas Department of State Health Services, Continuing Education Service expires annually on December 31. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Social Work Education.
Certificate of Attendance
The Texas Department of State Health Services, Continuing Education Service has designated 1.50 hour(s) for attendance.
One of the requirements of continuing education is disclosure of the following information to the learner:
- Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
- Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
- Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
- Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
- Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).
The following are policies and definitions of terms related to continuing education disclosure:
The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.
All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.
Glossary of Terms
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.
Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.
Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).
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- Ask Suicide-Screening Questions (ASQ) Toolkit: Free resource that can help primary care providers identify youth at risk for suicide. From the National Institute of Mental Health (NIMH).
- Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. (2017). From the American Academy of Pediatrics (AAP).
- Facts for Families Guide: Information on a host of mental health-related topics. From the American Academy of Child & Adolescent Psychiatry (AACAP).
- Guideline for Prescribing Opioids for Chronic Pain: Recommendations for prescribing opioid pain medication for patients 18 and older in primary care settings. From the Centers for Disease Control and Prevention (CDC).
- healthychildren.org: Resources to support parents and promote positive parenting, including a Family Life section. From the AAP.
- Medications for mental health disorders: Learn more about commonly used medications for specific mental health disorders. From the NIMH.
- MentalHealth.gov: Resources for mental health issues, including the basics, what to look for, talking about mental health, and how to get help. From the U.S. Department of Health and Human Services.
- Mental Health Rating Scales:
- CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) Behavioral health screening tool recommended by the AAP Committee on Substance Abuse for adolescents ages 20 and younger. CRAFFT consists of a series of six questions to simultaneously screen for those at high risk for alcohol and other drug use disorders. The responses indicate whether a longer conversation about the use, frequency, and other risks and consequences is warranted.
- Patient Health Questionnaire (PHQ-9) Multipurpose instrument for screening, diagnosing, and measuring the severity of depression. The PHQ-9 is completed by the patient and scored by the clinician. The questionnaire can be administered repeatedly to reflect improvement or worsening in response to treatment.
- Pediatric Symptom Checklist (PSC) Psychosocial screen to improve the recognition of cognitive, emotional, and behavioral problems in children ages 4 to 16. The PSC consists of 35 items that are rated never, sometimes, or often. A “positive” score indicates the need for further evaluation and/or intervention. Youth-reported and parent-completed versions are available.
- Mental Health Screening and Assessment Tools for Primary Care: Table of mental health screening and assessment tools, summarizing their psychometric testing properties, cultural considerations, costs, and references. From the AAP.
- Patient-Reported Outcomes Measurement Information System (PROMIS): Set of freely available validated measures of physical, mental, and social well-being. From the National Institutes of Health (NIH).
- Postpartum Depression Kit: Free resource for the screening, diagnosis, and treatment of PPD. From the Texas Health and Human Services Commission (HHSC).
- Postpartum Depression Screening Tools: Validated for use in PPD patients and available online. From Texas Health Steps.
- Standardized Assessment Tools: Free repository of available standardized tools to assess mental and physical conditions. From the National Cancer Institute (NCI).
- Suicide Prevention Mobile Apps: Download the free ASK about Suicide and Hope Box apps. From the Texas Suicide Prevention Council.
Texas Mental Health Programs and Services
- Children’s Health Insurance Program (CHIP): Designed for low-income families who lack access to health insurance and don’t qualify for Medicaid.
- Early Childhood Services (ECI): Diagnosis of a disability or developmental delay, including autism spectrum disorder (ASD), qualifies a child for ECI services through age 35 months. To refer families for services, use the online form developed by ECI and the Texas Pediatric Society. Families can also contact the ECI program by calling the Texas HHSC Office of the Ombudsman at 877-787-8999, choose a language, and then select Option 3.
- Mental Health First Aid (MHFA): Learn more about training and class availability from Texas local mental health authorities (LMHAs) and local behavioral health authorities (LBHAs).
- Texas Council of Community Centers: Community Mental Health Services for adults and children is administered through 39 local mental health authorities (LMHAs) throughout the state. Visit the group’s website for a map showing service areas and a listing of center addresses and contact information for mental health authorities (LMHAs).
- Texas Education Agency (TEA): In Texas, school district Preschool Programs for Children with Disabilities (PPCD) provide special education and related services for eligible children ages 3 through 5 with disabilities. Eligible children may receive PPCD services in a variety of places.
- Texas Health and Human Services Commission (HHSC): Plays a major role in the funding and oversight of publicly funded mental health care, including coverage for mental health services for children through Medicaid and CHIP.
- Texas Health Steps: The Texas Health Steps Periodicity Schedule, Child Health Clinical Health Records, Anticipatory Guidance, and other information and forms for health-care providers are available on the Texas Health Steps Provider Information web page.
- Texas Medicaid: Delivered and managed through a variety of providers, including STAR Medicaid, STAR+PLUS Medicaid and STAR Kids managed care programs, and Medicaid fee-for-service programs.
- Texas Medicaid & Healthcare Partnership (TMHP): Information for Medicaid providers, including the Texas Medicaid Provider Procedures Manual (TMPPM).
- Texas Mental Health and Substance Abuse Division (MHSA): Oversees the mental health system in Texas.
Ahmedani, B. K., Simon, G. E., Stewart, C., Beck, A., Waitzfelder, B. E., Rossom, R., & Solberg, L. I. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870–877.
American Academy of Child & Adolescent Psychiatry (AACAP):
- A guide to building collaborative mental health care partnerships in pediatric primary care. (2010).
- Han, B., Compton, W. M., Blanco, C., Colpe, L., Huang, L., & McKeon, R. (2017). National trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults. Journal of the American Academy of Child & Adolescent Psychiatry, 57(1), 20–27: e2.
- Merikangas, K. R., He, J., Burstein, M., Swanson, S., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2011). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989.
- Panic disorder in children and adolescents. (2013).
- Schizophrenia. (2013).
- Workforce issues. (2016).
- Workforce maps by state. (2015).
American Academy of Pediatrics (AAP):
- 10 things parents can do to prevent suicide. (2015). Committee on Psychosocial Aspects of Child and Family Health.
- Addressing early childhood emotional and behavioral problems. (2016).
- Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. (2017).
- Calzo, J. P., Sonneville, K. R., Scherer, E. A., Jackson, B., & Austin, S. B. (2016). Gender conformity and use of laxatives and muscle-building products in adolescents and young adults. Pediatrics, 138(2): e20154073.
- Children’s hospitals admissions for suicidal thoughts, actions double during past decade. (2017). AAP News.
- Council on Injury, Violence, and Poison Prevention Executive Committee. (2012, reaffirmed December 2016). Policy statement: Firearm-related injuries affecting the pediatric population. Pediatrics, 130(5).
- Fortuna, R. J., Robbins, B. W., Caiola, E., Joynt, M., & Halterman, J. S. (2010). Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics, 126(6), 1108–1116.
- Fowler, K. A., Dahlberg, L. L., Haileyesus, T., Gutierrez, C., & Bacon, S. (2017). Childhood Firearm Injuries in the United States. Pediatrics, June 2017, e20163486.
- How emotional and behavioral disorders are treated. (2015).
- Kulig, J. W. & Committee on Substance Abuse. (2005). Tobacco, alcohol, and other drugs: The role of the pediatrician in prevention, identification, and management of substance abuse. Pediatrics, 115(3).
- Mental health initiatives.
- Mojtabai, R., Olfson, M., & Han, B. (2016). National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics, 138(6).
- Study: Gunfire kills or injures more than 7,000 children per year. (2017).
American College of Obstetricians and Gynecologists (ACOG). (2013). Postpartum Depression: When does postpartum depression occur?
American College of Pediatricians (ACP). Marijuana use: Detrimental to youth. (2017).
American Psychiatric Association (APA):
- Duckworth, K. (2015). Understanding Mental Disorders: Your Guide to DSM-5. American Psychiatric Publishing.
- Knoll, J. L. & Annas, G. D. (2016). Mass Shootings and Mental Illness. American Psychiatric Association Publishing.
- What are disruptive, impulse-control and conduct disorders? (2018).
- What is mental illness? (2015).
American Psychological Association. (n.d.). Children’s mental health.
American Society of Addiction Medicine. (2016). Opioid addiction facts & figures.
Anxiety and Depression Association of America. (2015). Childhood anxiety disorders.
Bartlett, J. (2014). Childhood-onset schizophrenia: What do we really know? Health Psychology and Behavioral Medicine, 2(1), 735–747.
Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., Downey, M. M., Jackson, K., Fernandez, T., & Mandell, D. S. (2015). Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cognitive Behavioral Practice, 22(1), 5–19.
Bergink, V., Rasgon, N., & Wisner, K. L. (2016). Postpartum psychosis: Madness, mania, and melancholia in motherhood. The American Journal of Psychiatry, 173(12), 1179–1188.
- Child and adolescent psychiatry and mental health (compilation of articles).
- Merten, E. C., Cwik, J. C., Margraf, J., & Schneider, S. (2017). Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child and Adolescent Psychiatry and Mental Health, 11(5).
Boston University, Center for Anxiety & Related Disorders. (n.d.). Specific phobias in children and adolescents.
Brady Center to Prevent Gun Violence. (2015). The truth about suicide & guns.
Centers for Disease Control and Prevention (CDC):
- Adolescent health. (2017).
- Attention-deficit/hyperactivity disorder (ADHD): Other concerns & conditions. (2018).
- Autism spectrum disorder. (2017).
- Data and statistics: Mental, behavioral, and developmental health of children aged 2–8 years. (2017).
- Depression among women. (2017).
- Guideline for prescribing opioids for chronic pain. (2017).
- Mental health of children aged 3–17 years. (2017).
- QuickStats: Percentage of children and adolescents aged 4–17 years with serious emotional or behavioral difficulties, by poverty status and sex — National Health Interview Survey, 2011–2014. (2015). Morbidity and Mortality Weekly Report, 64(46), 1303.
- Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016). Increases in drug and opioid-involved overdose deaths — United States, 2010–2015. Morbidity and Mortality Weekly Report, 65(50–51), 1445–1452.
- Smoking and tobacco use. (2017).
- Suicide among youth. (2017).
- Youth Risk Behavior Surveillance, United States. (2015).
- Youth violence: Risk and protective factors. (2017).
Child Mind Institute:
- Children’s Mental Health Report. (2016).
- Conduct disorder basics. (n.d.).
- How anxiety leads to disruptive behavior. (n.d.).
Colino, S. (2016). The hidden risks of eating disorders in guys. U.S. News & World Report, November 23.
Diamond, G. S., Herres, J. L., Krauthamer Ewing, E. S., Atte, T. O., Scott, S. W., Wintersteen, M. B., & Gallop, R. J. (2017). Comprehensive screening for suicide risk in primary care. American Journal of Preventive Medicine, 53(1), 48–54.
Fristad, M. A., Verducci, J. S., Walters, K., & Young, M. E. (2009). Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry, 66(9), 1013–1021.
Gochman, P., Miller, R., & Rapoport, J. L. (2011). Childhood-onset schizophrenia: The challenge of diagnosis. Current Psychiatry Report, 13(5), 321–322.
Interdepartmental Serious Mental Illness Coordinating Committee. (2017). ISMICC report to congress. The way forward: Federal action for a system that works for all people living with SMI and SED and their families and caregivers.
Kaplan, Y. C., Keskin-Arslan, E., Acar, S., & Sozmen, K. (2017). Maternal SSRI discontinuation, use, psychiatric disorder and the risk of autism in children: A meta-analysis of cohort studies. British Journal of Clinical Pharmacology, 83(12), 1298–2806.
Lebel, C., Walton, M., Letourneau, N., Giesbrecht, G. F., Kaplan, B. J., & Dewey, D. (2016). Prepartum and postpartum maternal depressive symptoms are related to children’s brain structure in preschool. Biological Psychiatry, 80(11).
Meadows Mental Health Policy Institute and Texas Conference of Urban Counties. (2016). Texas mental health landscape.
Mental Health America:
- Mental health information. (n.d.).
- Conduct disorder. (n.d.).
- The state of mental health in America. (2017).
Merck Manual. (2017). Overview of mental disorders in children and adolescents.
Munir, K. M. (2016). The co-occurrence of mental disorders in children and adolescents with intellectual disability/intellectual developmental disorder. Current Opinion in Psychiatry, 29(2), 95–102.
National Alliance on Mental Illness (NAMI):
National Association of Anorexia Nervosa and Associated Disorders (ANAD). (n.d.). Eating disorder statistics.
National Council for Behavioral Health (NCBH):
- Congressional briefing highlights children’s mental health. (2017).
- Mental Health First Aid. (n.d.).
National Eating Disorders Association (NEDA). (n.d.). Binge eating disorder: Overview and statistics.
National Institute for Health Care Management (NIHCM). (2009). Issue paper: Strategies to support the integration of mental health into pediatric primary care.
National Institute of Mental Health (NIMH):
- Autism spectrum disorder. (2017).
- Bipolar disorder. (2016).
- Child and adolescent mental health. (2017).
- Eating disorders. (2017).
- Intramural researchers develop suicide risk screening toolkit for medical settings. (2018). Science Update.
- Major depression. (2017).
- Mental illness. (2017).
- National survey confirms that youth are disproportionately affected by mental disorders. (2010). Science Update.
- Pediatrics-based brief therapy outdoes referral for youths with anxiety and depression. (2017). Science Update.
- Postpartum depression facts. (n.d.).
- Schizophrenia. (2017).
- Symptoms outdo diagnoses in predicting bipolar disorder in at-risk youth. (2016). Science Update.
- Treatment of children with mental illness. (2009).
National Institute on Drug Abuse (NIDA):
- Principles of drug addiction treatment: A research-based guide. (2018).
- Trends and statistics. (2017).
National Institutes of Health (NIH). (2015). Patient-Reported Outcomes Measurement Information System (PROMIS).
National Research Council-Institute of Medicine (NRC-IOM). (2009). Preventing mental, emotional, and behavioral disorders among young people. National Academies Press.
Office of the U.S. Surgeon General. (2018). The facts on e-cigarette use among youths and young adults.
Olfson, M., Druss, B. G., & Marcus, S. C. (2015). Trends in mental health care among children and adolescents. New England Journal of Medicine, 372, 2029–2038
Olfson, M., King, M., & Schoenbaum, M. (2015). Treatment of young people with antipsychotic medications in the United States. JAMA Psychiatry, 72(9), 867–74.
Ornoy, A. & Koren, G. (2017). Selective serotonin reuptake inhibitors during pregnancy: Do we have now more definite answers related to prenatal exposure? Birth Defects Research, 109(12), 898–908.
Ringeisen, H., Stambaugh, L., Bose, J., Casanueva, C., Hedden, S., Avenevoli, S., Blau, G., Canino, G., Carter, A., Colpe, L., Copeland, W. E., Fisher, P. W., Kaufman, J., Merikangas, K., Narrow, W., Stroul, B., & West, J. (2016). Measurement of childhood serious emotional disturbance: State of the science and issues for consideration. Journal of Emotional and Behavioral Disorders, 25(4), 195–210.
Schrobsdorff, S. (2016, November 16). There’s a startling increase in major depression among teens in the U.S. Time.
Shrivastava, A., Johnston, M., & Tsuang, M. (2011). Cannabis use and cognitive dysfunction. Indian Journal of Psychiatry, 53(3), 187–191.
Smink, F. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4), 406–414.
Society of Clinical Child & Adolescent Psychology. (2017). Therapy or medication?
Substance Abuse and Mental Health Services Administration (SAMHSA):
- Center for Behavioral Health Statistics and Quality. (2016). DSM-5 changes: Implications for child serious emotional disturbance (unpublished internal documentation).
- Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. (2017).
- Populations at risk for suicide. (2017).
- Substance use disorders. (2015).
Texas Department of Family and Protective Services (DFPS) and The University of Texas at Austin College of Pharmacy. (2016). Psychotropic medication utilization parameters for children and youth in foster care (5th version).
Texas Department of State Health Services (DSHS). Mental health services for children and adolescents. (2016).
Texas Health and Human Services Commission (HHSC):
- Community Resource Coordination Groups (CRCGs) of Texas handbook. (2016).
- Postpartum depression among women utilizing Texas Medicaid. (2016).
- Postpartum depression kit. (2017).
Texas System of Care:
- A better future for Texas children: The impact of System of Care. (n.d.).
- Achieving a Texas System of Care: Final evaluation report. (2018).
- Achieving well-being for children and youth. (2012). Brochure.
The Incredible Years. (n.d.).
The Nemours Foundation. (2018). Postpartum depression.
Tobin, E. T., Hulkower, R. L., & Kaminski, J. W. (2017). Behavioral health integration in pediatric primary care: Considerations and opportunities for policymakers, planners, and providers. Milbank Memorial Fund report.
U.S. Department of Health and Human Services:
- Adolescent mental health disorders. (2016).
- Agency for Healthcare Research and Quality (AHRQ). (2017). Behavioral and mental health.
- Office on Women’s Health. (2017). Depression during and after pregnancy.
Vo, M., Lau, J., & Rubinstein, M. (2016). Eating disorders in adolescent and young adult males: Presenting characteristics. Journal of Adolescent Health, 59(4), 397–400.
Wissow, L. S., van Ginneken, N., Chandna, J., & Rahman, A. (2016). Integrating children’s mental health into primary care. Pediatric Clinics of North America, 63(1), 97–113.
World Health Organization:
The medical definitions provided in this module were obtained or adapted from Merriam-Webster and the Mayo Clinic.