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J Am Acad Child Adolesc Psychiatry. 2018 Aug;57(8):603-609. doi: 10.1016/j.jaac.2018.04.017. Epub 2018 Jun 22.

Sequential Screening to Improve Behavioral Health Needs Detection in Primary Care.

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Medical College of Wisconsin, Milwaukee; Children's Hospital of Wisconsin, Milwaukee. Electronic address:
Medical College of Wisconsin, Milwaukee; Children's Hospital of Wisconsin, Milwaukee.



This study evaluates sequential screening to improve behavioral health needs detection, reduce unnecessary referrals, and discern adverse impacts (false negatives) for pediatric primary care populations.


Monte Carlo simulation methodology was used to generate performance data for six sequential screening programs based on known technical properties of three broadband behavioral health measures and general psychopathology base rate estimates in pediatric primary care. Descriptive statistics, least-squares power regression, and data visualization were used to compare performance across programs.


Ratio of reduced referrals to net false negatives was differentially affected by measure choice, administration order, and technical properties. Certain screening programs showed greater differences at lower base rates of psychopathology (approximately 12.8:1 ratio at 3% prevalence for SDQ-PSC [SDQ = Strengths and Difficulties Questionnaire, PSC = Pediatric Symptom Checklist] program), despite observed net sensitivity/specificity (0.47/0.97) that was comparable to other programs.


Sequential screening is a viable alternative to traditional single-measure behavioral health screening practices in primary care. However, stakeholders must be deliberate with instrument selection and implementation to maximize anticipated benefits and minimize costs. Closer examination of practical issues is necessary to further discern advantages of a screening workflow in pediatric primary care.


base rate fallacy; integrated behavioral health; primary care; screening; sequential screening


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