Medicaid's mandatory mental health screenings ID 14,000 at-risk children

Massachusetts' new court-ordered mental health screening and intervention program led to 220,000 more children being given screenings, and 14,000 more children being identified as behaviorally and emotionally at risk, according to a recent study1.

Researchers from MassGeneral Hospital for Children in Boston looked at Medicaid well child visits from 2008 and 2009 that included behavioral health screens mandated by the Children's Behavioral Health Initiative (CBHI). The researchers demonstrated a significant increase in referrals for mental health evaluations for children with Medicaid during the same time period.

In 2006, Massachusetts lost a class action lawsuit brought by advocates arguing that the state lacked comprehensive and well-organized services for the mental health needs of children, notes Michael Jellinek, MD, chief of child psychiatry at Massachusetts General Hospital. The judge ordered that the Medicaid program provide a full spectrum of services for children beginning in July 2009, including behavioral health screening, he explains.

"The deeper reason this is important is probably over 10% of children have substantial emotional problems," says Dr. Jellinek. While pediatricians recognize some of these problems, many go unrecognized or are recognized only after the problem has already gotten more serious, he says.

For instance, a depressed adolescent could receive therapy and/or medication before he or she suffers years of negative effects, says Dr. Jellinek, or a younger child with attention deficit disorder could be treated before having problems in school.

Children are now screened for various mental health issues depending on their age, such as autism in the first couple years of life and substance abuse in adolescence, he says, and all children ages four to 16 are screened using a one-page pediatric symptom checklist.

Dr. Jellinek, who developed the checklist, says that its purpose is to alert the pediatrician that the child or adolescent is not functioning well, either with friends, in school, or in the family, and that there is a problem in this area that needs further exploration.

"Pediatricians are identifying children they didn't know about," he says. "The first step is to find them."

Tests not widely used

After mandatory screening was implemented, says Dr. Jellinek, the percentage of children on Medicaid who were screened went from just a few percent to almost half. "The study demonstrates that although everybody knew these kids had problems, until there was training and a court order and some reimbursement, these tests were not very widely used," he says.

To date, 24,000 children have been identified as being at risk, says Dr. Jellinek, and would likely not have been identified prior to implementing mandatory screening. Some of these patients may be treated by pediatricians, some may be sent for mental health evaluations, and some don't follow through, he says.

"It's still not perfect. Not all kids that screen positive get sufficient attention," he says. "We're not there yet, but it's better than when we weren't screening anyone."

Available providers would have been overwhelmed if all of the children who screened positive were referred, says Dr. Jellinek, but in fact, not all seek treatment. "We need to beef up the options that parents have, but alerting parents that there is a problem is an important first step," he says.

Contact Dr. Jellinek at (617) 726-2711 or


1.Kuhlthau K, Jellinek M, White G, et al. Increases in behavioral health screening in pediatric care for Massachusetts Medicaid patients. Arch Pediatr Adolesc Med 2011; 165(7):660-664.