Universal mental health screening in pediatrics: toward better knowing, treating, or referring.

creening for treatable conditions has long been a hallmark of pediatrics. Screening S starts before birth with in utero ultrasounds looking for congenital abnormalities, after birth with a heel prick for metabolic disorders, and in the primary care office with growth charts, specific developmental questions, hematocrits, urine dipsticks, and vision and hearing tests. Although psychosocial screening is far less common, the rate of positive findings is usually much higher than with any of the aforementioned traditional tests. I use the broader term psychosocial disorders or dysfunction rather than psychiatric disorder because pediatricians routinely face many questions that are not specifically defined in the DSM-5 and are defined quite differently in primary care in more everyday terms, such as problems in school, parenting, peer relationships, activities, or mood. These concerns might meet criteria for formal psychiatric diagnoses or they might not because they are framed as descriptions of dysfunction in day-to-day life that impairs the trajectory of the child’s development. Many issues with considerable impact—divorce, school failure, intense sibling rivalry, and poverty—may result in a positive screen result or parental concern and are important to explore before focusing on a formal psychiatric diagnosis. How common is psychosocial dysfunction? Of course this depends on the definition and threshold for dysfunction. Mild anxiety and depression are common but often result in little or no impairment over time. A rigorous definition of severity or dysfunction requires information and subjective judgment based on an interview. The literature typically cites 10% or 12% of children as having psychosocial issues sufficient to impair functioning. I suggest this could be several percentages lower if the level of