As of Monday, annual checkups for the nearly half a million Massachusetts children on Medicaid will carry a new requirement: Doctors must offer simple questionnaires to detect warning signs of possible mental health problems, from autism in toddlers to depression in teens.
The checklists vary by age but ask questions about children's behavior - whether they are spending more time alone, seeming to have less fun, having trouble sleeping - that are designed to trigger discussion between parents and doctors. The conversations may or may not lead to a referral to a specialist.
Over the last several years, such questionnaires have increasingly become the standard of care in pediatric practices, but - spurred by legal action - Massachusetts is jumping ahead of other states by requiring the screens for all its young Medicaid recipients.
The new requirement represents "a huge step forward in a direction that is a national trend," said Dr. Robin Adair, a University of Massachusetts Medical School pediatrician and screening specialist.
Supporters say the screening can catch issues earlier, before they develop into hard-to-manage crises.
Skeptics warn that more children could end up on heavy-duty medications that they don't really need.
"In a more perfect world, screening for mental illness amongst children would clearly be a good idea," said Dr. John Abramson, a clinical instructor at Harvard Medical School and author of "Overdosed America."
"But let's look at the realities of the world we live in," he said. "What happens is that there's a very quick translation of mental health symptoms into drug treatment."
Others wonder how Massachusetts' overburdened mental health system for children will handle the new patients the screening is expected to identify.
Already, children's psychiatrists and psychologists are often overbooked. Children with serious mental illness sometimes end up stuck in psychiatric hospitals for lack of mental health services in the community.
If, as expected, the new screening requirement turns up more children with mental health problems, "I do think it creates a potential additional access problem," said Dr. David DeMaso, chief of psychiatry at Children's Hospital Boston.
The new screening requirement stems from a lawsuit, Rosie D. v. Romney, that accused the state of falling down on its obligations to poor, mentally ill children. The federal judge in the case ruled in January 2006 that Massachusetts must improve its care, and the new requirement is the first step in the state's court-ordered remedy plan.
Families may decline the screening if they wish. If a screen turns up signs of potential trouble, it is also up to the family whether to pursue further help and an official diagnosis.
The new requirement applies to the 460,000 children and young adults covered by MassHealth, the state Medicaid program, at annual checkups from birth to age 21.
The state's private insurers generally already reimburse children's doctors for such written screens, and Medicaid will now pay $9.73 to cover the testing.
The majority of pediatricians still rely on conversational questions such as "How are you doing in school?" or "Does your child have friends?" But research shows that written questionnaires are more accurate at picking up potential problems.
The tests can also home in on children whose problems might otherwise be missed. According to national estimates, about 10 percent of children have some sort of significant psycho-social problem, from hyperactivity to anxiety to stress from living amid domestic violence.
"The earlier we intervene, the more impact we can have on brain development," DeMaso said.
The screening is not meant to produce a diagnosis, but rather to act as a "check engine light," calling attention to a potential problem, said Lisa Lambert, executive director of the Parent/Professional Advocacy League, which represents families with mentally ill children.
"If it lights up, you need to call your mechanic, find out what the problem is and if it needs to be repaired," she said.
One of the league's family support specialists, Kathy Hamelin of Fitchburg, said her own experience as the mother of an autistic son has convinced her that expanded early screening is one of the best things to come out of the Rosie D. case.
When her now 17-year-old son, Kevin, was a toddler, she said, he would scream and cry all the time, smash his head against the wall when frustrated, and flap his hands bizarrely. When she asked her pediatrician about the hand-flapping, he said, "That's nothing. That's just an excitement reflex and he'll outgrow it." In fact, she said, it is a classic autism trait. Kevin's diagnosis and treatment came only years later.
If the pediatrician had used an autism screening tool, it might have sounded an early alarm.
"Our family suffered tremendously because of this," she said, "and I just feel like if he had had early diagnosis, not only the pain and frustration we felt as overwhelmed parents would have been less, but we would have received early intervention," which "would have put him in a much better position than he is now."
As the routine screening gets underway, the state will be tracking how many children are tested and how many screens indicate a need for follow-up, said Emily Sherwood, who is overseeing the state's remedy for the Rosie D. case as director of its Children's Behavioral Health Interagency Initiatives. The state also plans to expand mental health services for children and make them more family friendly.
She said parents and clinicians may decide on a variety of responses to worrisome scores: to wait and watch a while. To handle the problems themselves. Or to seek a referral to a mental health specialist.
The screenings in doctors' offices "help us understand mental health as a part of health," she said. "It's really up to parents and primary care clinicians how they want to use this tool."
Medicaid law already requires that children be screened annually for various problems, such as hearing and vision loss, as well as for mental illness. This new requirement specifies the method of screening for mental health problems, asking clinicians to choose from among eight standard tools for the screening. Each screen is geared toward a target age; some look for specific problems, such as substance abuse and autism.
Research suggests that the screens will boost the number of children referred to mental health providers - but not overwhelmingly.
Dr. Karen Hacker, executive director of the Institute for Community Health at Cambridge Health Alliance, has used and researched mental health screening for four years, and has found that between 5 percent and 7 percent of children score high enough to cause concern. Other practices have found rates as high as 12 percent.
But, she pointed out, many of those children were already in counseling. Some families decided not to pursue further help, and of those who did, many did not show up at appointments. She has not seen a dramatic uptick in the use of psychiatric medications since the screens were added to routine care, she said, though she understands that is a cause for concern.
"We're going to have to see how this unfolds," she said.
Carey Goldberg can be reached at firstname.lastname@example.org.