AAP updates guidance on screening for mental, emotional, and behavioral problems in children

AAP updates guidance on screening for mental, emotional, and behavioral problems in children | Image Credit: © tadamichi - stock.adobe.com.

The American Academy of Pediatrics (AAP) has released updated clinical guidance on screening for mental, emotional, and behavioral (MEB) problems in children, reflecting rising prevalence, persistent gaps in detection, and the growing mental health crisis among youth.¹

MEB problems are common, affecting an estimated 13% to 20% of children in the United States at any given time, with an additional 19% experiencing symptoms that cause impairment but do not meet diagnostic thresholds.^2,3 Between 37% and 39% of children are diagnosed with an MEB disorder by age 16, most often disruptive behavior problems, attention-deficit/hyperactivity disorder (ADHD), anxiety, and mood disorders.

“Between 23% and 61% of children with an MEB problem diagnosis at one point will have an MEB problem diagnosis in the future, although it is not always the same diagnosis,” the report states.

The COVID-19 pandemic amplified these concerns. More than 140,000 children lost a primary or secondary caregiver, while emergency visits for suicidal ideation rose substantially, particularly among adolescent girls. Suicide is now the second leading cause of death among youth 10 to 14 years of age and the third leading cause in those aged 15 to 24.

Updates to screening recommendations

The new clinical report expands recommendations outlined in prior AAP policies, including the 2019 “Mental Health Competencies for Pediatric Practice” and the Bright Futures “Recommendations for Preventive Pediatric Health Care.”

Screening is recommended to begin in infancy. Caregiver-focused screening for postpartum depression starts within the first month of life, while child-focused MEB screening begins at 6 months and continues at 12, 24, and 36 months, alternating with developmental and autism screenings.

After age 3, annual MEB screening is recommended at preventive visits. “Because of the enduring nature of MEB problems detected early … it is recommended that MEB screening be conducted at the 6-, 12-, 24-, and 36-month health supervision visits … After age 3, screening should occur yearly at routine health supervision visits,” the report notes.

Additional guidance includes:

• Anxiety screening annually for children aged 8 to 18 years.
• Depression and suicide risk screening beginning at age 12, with earlier suicide screening as clinically indicated.
• Substance use assessments yearly after age 11.

Screening tools and challenges

The report emphasizes the use of standardized, validated tools to minimize bias and improve detection. While no single instrument is suitable across all ages and diagnoses, caregiver questionnaires, child self-reports, and domain-specific tools (eg, for ADHD or depression) are available and should be tailored to patient populations.

Despite progress, barriers persist. Pediatric primary care clinicians (PPCCs) report limited time, lack of training, workforce shortages, and inadequate referral resources. “The failure rate to detect MEB problems ranges from 14% to 40%, moderated by the degree of family distress or known family history risk factors,” the authors wrote.

Children from racially and ethnically diverse backgrounds, non–English-speaking families, and those with disabilities remain disproportionately underserved due to cultural, language, and structural barriers.

Responding to positive screens

A positive screen should lead to further evaluation of severity, impact on functioning, and co-occurring factors such as social drivers of health (SDOH). The report highlights the importance of discussing findings with families, observing caregiver-child interactions, and considering trauma-informed approaches.

“The initial step to addressing any identified MEB problem is building a therapeutic alliance with children and families using a trauma-informed approach when appropriate,” the report states.

Referral pathways vary by community resources, but the report notes that telepsychiatry and integrated behavioral health services in pediatric practices are promising models for improving access.

Emphasis on resilience and systemic support

Beyond screening, the AAP encourages pediatricians to foster resilience and protective factors, such as positive parenting, supportive relationships, and access to early education. The report also underscores the need for advocacy to ensure appropriate reimbursement for screening and treatment, address disparities, and expand the mental health workforce.

“Promoting optimal child development and well-being includes assessing MEB problems in the context of the family and the community,” the authors conclude.

References:

1. Weitzman C, Guevara J, Curtin M, et al. Promoting Optimal Development: Screening for Mental Health, Emotional, and Behavioral Problems: Clinical Report. PEDIATRICS. Published online August 25, 2025. doi:https://doi.org/10.1542/peds.2025-073172
2. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and Development of Psychiatric Disorders in Childhood and Adolescence. Archives of General Psychiatry. 2003;60(8):837-844. doi:https://doi.org/10.1001/archpsyc.60.8.837
3. US Department of Health and Human Services, US Department of Education, US Department of Justice. Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. US Department of Health and Human Services; 2000.