Screening tests in children and adolescents

INTRODUCTION — The schedule of and recommendations for common screening tests in children in the United States will be reviewed here. The specific diseases and conditions are discussed separately.

OVERVIEW

General principles — Screening is defined as testing for disease in an individual or population that appears to be healthy [1]. The goal of screening is to identify children who are at increased risk of disease and warrant additional testing.

The following characteristics of a disease render it a good candidate for screening [1]:

●Substantial morbidity or mortality occurs if the disease is untreated

●The prevalence warrants testing in an apparently healthy population

●The existence of a preclinical phase is detectable by the test

●A cost-effective treatment is available

●Preclinical detection of disease provides some benefit (eg, improved prognosis, ease of treatment, decreased risk of transmission to others)

Screening tests for diseases conducive to screening should [1,2]:

●Be easy to perform and interpret

●Measure something directly related to the disease

●Have low risk, morbidity, and cost

●Be highly sensitive and specific

Adverse effects of screening that must be weighed against the potential benefits include [2,3]:

●False-positive test results must be followed up

●False-negative test results may delay diagnosis

●The cost of the screening program may compete with the cost of diagnosis, treatment, or primary prevention efforts

Adverse effects of screening are discussed separately. (See "Evidence-based approach to prevention", section on 'Unintended consequences of screening'.)

Test characteristics — In choosing an appropriate screening test, the sensitivity, specificity, and predictive value of the test must be considered [2,3]. These concepts are depicted in the classic 2 x 2 table (table 1). (See "Glossary of common biostatistical and epidemiological terms".)

●Sensitivity – Proportion of individuals who have the disease and have a positive test result.

●Specificity – Proportion of individuals who do not have the disease and have a negative test result.

The best screening tests have a high sensitivity (few false negatives) so that individuals who have the disease are identified by the screening test. A test that has a high specificity (few false positives) is also desired so that individuals are not erroneously labeled as having disease when they are disease free. (See "Evidence-based approach to prevention", section on 'Performance of screening tests'.)

In addition to sensitivity and specificity, interpretation of test results also depends upon the test's predictive value:

●Positive-predictive value – The proportion of patients with a positive test that have the disease.

●Negative-predictive value – The proportion of patients with a negative test that do not have disease.

The predictive values (and the proportion of positive and negative evaluations that can be expected) depend upon the prevalence of a disease within a population. Thus, for given values of sensitivity and specificity, a patient with a positive test is more likely to truly have the disease if the patient belongs to a population with a high prevalence of the disease (figure 1). (See "Glossary of common biostatistical and epidemiological terms".)

Types of screening — There are two types of screening programs:

●Universal (or population) screening refers to the screening of every individual within a population

●Selective (targeted or risk-based) screening refers to the screening of individuals for whom there is reason to believe that the screening may be positive

Selective screening increases the positive predictive value of a test by increasing the prevalence of the disease in the population that is screened (figure 1).

Screening guidelines — In pediatric practice, screening is routinely performed for a number of conditions, as discussed below. For most of these conditions, there is a lack of direct evidence from randomized controlled trials supporting the beneficial effects of screening and/or quantifying the potential benefits and harms. The lack of evidence does not necessarily mean that screening is not beneficial, only that it has not yet been adequately tested.

When deciding whether screening should be performed, the potential benefits and harms of screening must be considered. The balance between risks and benefits varies depending upon the condition, the clinical circumstances of the child and family, the availability of resources, and the values that patients (or patients' caregivers) place on the potential benefits and harms [4].

For many conditions, screening is regulated by local, state, or federal policies. In addition, recommendations regarding screening for various conditions are made by several professional groups and updated periodically. In the United States, these groups include:

●The American Academy of Pediatrics and Bright Futures [5-7]

●The American Academy of Family Physicians [8]

●The United States Preventive Services Task Force

●The Centers for Disease Control and Prevention

Recommendations regarding screening vary from country to country. The information below focuses on screening in the United States. A discussion of screening recommendations for other countries is beyond the scope of this topic review. Policies for individual countries may be available online (eg, United Kingdom, Canada).

State mandates for school screening — Within the United States, each state has its own mandates for school health screening. Most states require schools to assess students' vision and hearing at specific ages. In addition, some states require screening for oral health problems, elevated body mass index, type 2 diabetes, asthma, or scoliosis. The National Association of State Boards of Education provides information regarding state-specific mandates for school health screening.

COMMON SCREENING TESTS IN PEDIATRICS

Newborn genetic and metabolic screen — Screening newborns for genetic and metabolic disease is discussed separately. (See "Overview of newborn screening".)

Newborn bilirubin screening — In the United States, a systematic approach to screening for hyperbilirubinemia is recommended for all term and late preterm infants. Newborn hyperbilirubinemia screening is discussed separately. (See "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening".)

Critical congenital heart disease — We agree with recommendations to screen all newborns for critical congenital heart disease using pulse oximetry. The screening procedure, criteria for a positive screen, and assessment of infants with a positive screen are discussed separately. (See "Newborn screening for critical congenital heart disease using pulse oximetry".)

Hearing screen — Hearing loss in newborns and young children may be associated with delays in speech, language, and cognitive development. Causes of hearing loss in children are discussed separately. (See "Hearing loss in children: Etiology".)

Newborns — Newborn hearing screening is discussed separately. (See "Screening the newborn for hearing loss".)

Infants and children — We suggest a hearing risk assessment at all health maintenance visits and periodic hearing screening for all children between 4 and 21 years of age, in agreement with the American Academy of Pediatrics (AAP)/Bright Futures guidelines [5,6]. Hearing screening for infants, children, and adolescents is discussed separately. (See "Hearing loss in children: Screening and evaluation".)

Vision screen — Vision screening throughout childhood and adolescence helps to detect amblyopia, strabismus, and defects in visual acuity (table 2). It is discussed separately. (See "Vision screening and assessment in infants and children", section on 'Vision screening'.)

Developmental screening — The AAP/Bright Futures guidelines recommend developmental screening at 9, 18, and 30 months of age and screening for autism spectrum disorder at 18 and 24 months of age [5,6]. Developmental surveillance is recommended at all other preventive health visits. Developmental screening is discussed separately. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to screening' and "Autism spectrum disorder in children and adolescents: Surveillance and screening in primary care", section on 'Approach to ASD surveillance and screening'.)

Behavioral/social/emotional screening — The AAP/Bright Futures guidelines recommend behavioral, social, and emotional screening at each health maintenance visit [5,6]. Behavioral, social, and emotional screening is discussed separately. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to screening'.)

Iron deficiency — The AAP/Bright Futures guidelines recommend risk assessment for iron deficiency anemia at four months of age and measurement of hemoglobin or hematocrit at 12 months of age [5]. They also suggest repeat risk assessment at 15, 18, 24, 30, and 36 months of age and annually thereafter. The risk assessment at four months of age includes history of prematurity or low birth weight, and diet (ie, use of low-iron formula or not receiving iron-fortified formula) [9,10]. Risk assessment after one year of age includes questions about socioeconomic status, limited access to food, diets low in iron (eg, vegetarian diet), exposure to lead, and excessive menstrual bleeding (for females who are menstruating) [9,10]. The AAFP and USPSTF found insufficient evidence to recommend for or against routine screening for iron deficiency anemia in asymptomatic children aged 6 to 24 months [8,11].

Screening for iron deficiency in infants, children, and adolescents is discussed separately. (See "Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis", section on 'Screening recommendations' and "Iron requirements and iron deficiency in adolescents", section on 'Screening'.)

Lead poisoning

Background — In October 2021, the Centers for Disease Control and Prevention (CDC) lowered the population-based blood lead reference value from 5 mcg/dL (0.24 micromol/L) to 3.5 mcg/dL (0.17 micromol/L) [12]. The 2021 reference value is based on the 97.5^th percentile of the blood lead level (BLL) distribution among children age one to five years in the National Health and Nutrition Examination Surveys from 2015-2016 and 2017-2018.

The use of a reference value rather than a threshold for toxicity or level of concern was initiated in 2012 to underscore the absence of a specific threshold for lead's irreversible neurodevelopmental effects and to emphasize primary prevention [13,14]. The CDC Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) recommends that clinicians educate families about prevention of lead exposure and provide environmental assessments to identify sources of lead exposure before testing children for lead poisoning. Blood lead screening remains necessary to identify children for whom primary prevention is unsuccessful [15].

The goal of primary prevention is to minimize the neurodevelopmental effects of lead poisoning through source control and early detection. (See "Childhood lead poisoning: Clinical manifestations and diagnosis" and "Childhood lead poisoning: Exposure and prevention".)

As the prevalence of childhood lead poisoning declines, there has been a move from screening all children (universal screening) to targeted screening of children at increased risk [16,17]. The AAP/Bright Futures guidelines and the ACCLPP suggest that screening for lead poisoning should be done in accordance with federal, state, and local laws as applicable [5,6,13,15]. Information regarding state screening plans is available through the CDC. For children who live in states that do not have a state screening program in place, we suggest universal lead testing during the ages of peak exposure; the AAP/Bright Futures guidelines and the ACCLPP suggest universal lead testing for such children at ages 12 and 24 months [6,13,15]. (See "Childhood lead poisoning: Exposure and prevention".)

The USPSTF found insufficient evidence to assess the benefits and harms of screening for elevated BLLs in asymptomatic children ≤5 years of age [17,18]. They found no direct evidence from controlled studies that screening children resulted in improved health outcomes (eg, cognitive problems, behavior problems, learning disorders) [17]. For children with elevated BLL, they found conflicting or insufficient evidence regarding the effectiveness of early detection and intervention (eg, counseling, nutritional intervention, residential hazard control, chelation) in reducing BLLs.

Targeted testing — We agree with the AAP Council on Environmental Health suggestion for targeted testing for lead poisoning with BLL for children 12 to 24 months of age who live in communities or census block groups in the United States with one or more of the following [15,19]:

●Inadequate data on the prevalence of elevated BLLs

●≥25 percent of housing built before 1960

●≥5 percent of children 12 to 24 months of age with BLLs ≥5 mcg/dL (0.24 micromol/L)

In addition, children and adolescents ≤16 years of age who enter the United States as an immigrant, refugee, or international adoptee should be tested for blood lead concentration at the time of arrival (or at the initial pediatric health care visit if the results of the arrival test are not available) [16,20-22].

Lead testing should be repeated three to six months after initial testing in [20]:

●Children ≤6 years of age, regardless of initial test results

●Children age 7 to 16 years of age if initial BLL was ≥3.5 mcg/dL (0.17 micromol/L)

●Children >7 years of age who have a risk factor (eg, environmental exposure risk factor, sibling with BLL ≥3.5 mcg/dL [0.17 micromol/L]), regardless of initial test result

Lead risk assessment — The AAP/Bright Futures recommendations for preventive health care suggest that the risk for lead poisoning be assessed at 6, 9, 12, 18, and 24 months of age, and annually thereafter through six years of age [6]. The BLL should be checked if any risk is detected.

The risk of lead poisoning is increased in children who [15]:

●Live in or visit a home or child care facility with an identified lead hazard

●Live in or visit a home or child care facility that was built before 1978, but particularly before 1960, and is in poor repair or was renovated in the past six months [13,15]

Other exposures that may increase the risk of lead poisoning include folk remedies, certain types of ceramics, pewter cookware, and certain parental occupations (eg, smelting, soldering, auto body repair) or hobbies (table 3) [16,17]. Patient risk factors include inadequate nutrition, frequent hand-mouth activity, and developmental disabilities. Abused or neglected children also should be considered for blood lead testing [15]. (See "Childhood lead poisoning: Exposure and prevention" and "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'History'.)

Screening for and management of lead poisoning in pregnant and lactating women is discussed separately. (See "Lead exposure, toxicity, and poisoning in adults", section on 'Pregnancy and breastfeeding'.)

Measurement of BLL — Measurement of the BLL is the test for lead poisoning. The blood lead reference value (ie, 3.5 mcg/dL [0.17 micromol/L] is used to guide decisions about medical or environmental follow-up for individual children, recognizing that the accuracy of BLLs between 3.5 and 5 mcg/dL (0.17 and 0.24 micromol/L ) is uncertain because they may be within the variability of the test [12,23,24]. (See "Childhood lead poisoning: Management".)

The BLL may be measured on a capillary or venous blood sample. BLL measurement is discussed in detail separately. (See "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Lead levels'.)

Oral health screening — In accord with the AAP/Bright Futures guidelines, we suggest oral health risk assessment, including the need for fluoride supplementation, at six and nine months of age and referral to a dental home at one year of age or as soon thereafter as possible, if a dental home is available [5,6]. Oral health risk assessment should continue at 12, 18, 24, and 30 months and yearly from three to six years of age until a dental home is established. (See "Preventive dental care and counseling for infants and young children", section on 'Risk assessment'.)

Tuberculosis — We agree with the AAP/Bright Futures guidelines suggesting tuberculosis risk assessment by one month of age, at ages 6, 12, and 24 months, and annually thereafter [5,6]. Tuberculosis terminology is evolving and inconsistent (table 4). Factors associated with increased risk of acquiring tuberculosis infection or progressing to tuberculosis disease are listed in the table (table 5). Testing for tuberculosis infection in children is discussed separately. (See "Tuberculosis infection (latent tuberculosis) in children", section on 'Diagnosis'.)

Urinalysis — The AAP no longer recommends a screening urinalysis for children [5,6,25,26].

Hypertension — We agree with the AAP/Bright Futures recommendations for hypertension screening [5,27].

●For children without risk factors or conditions associated with hypertension (table 6A-B), we measure blood pressure (BP) annually at health supervision visits, beginning at age three years.

●For children <3 years with risk factors for hypertension (table 6A), we measure BP at all health supervision visits.

●For children ≥3 years with risk factors for hypertension (table 6B), we measure BP at all health encounters.

For screening purposes in children <13 years, the threshold for additional evaluation is the 90^th percentile BP for age and sex for a child whose height is at the 5^th percentile (ie, the lowest 90^th percentile BP for age and sex), which minimizes false negatives [27]. For screening purposes in male and female adolescents ≥13 years of age, the threshold for additional evaluation is systolic BP ≥120 mmHg or diastolic BP ≥80 mmHg [27]. However, many clinicians have access to an electronic medical record (EMR) that automatically calculates the child's BP percentile for age, sex, and actual height.

●For clinicians who have access to an EMR that calculates the child's BP percentile according to age, sex, and height according to the 2017 AAP guidelines [27], children whose BP is >90^th percentile for age, sex, and height require further evaluation.

●For clinicians who do not have access to an EMR that calculates the child's BP percentile according to age, sex, and height according to the 2017 AAP guidelines [27], BP screening thresholds by age and sex are provided in the table (table 7). These values have a negative predictive value of >99 percent [28]. They should be used only for identification of children and adolescents who need further evaluation.

The diagnosis of hypertension is based upon the child's age, sex, and actual height percentile and requires additional evaluation. It is discussed separately. (See "Definition and diagnosis of hypertension in children and adolescents", section on 'Diagnosis'.)

Conditions that predispose to sudden cardiac death — Screening for conditions that predispose to sudden cardiac death is discussed separately. (See "Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) in children", section on 'Primary prevention of SCD'.)

Physical activity assessment — Assessment of physical activity and motor skill development is an important component of health supervision visits [29-31]. Physical activity and play improve physical (eg, cardiovascular, musculoskeletal) and mental health and well-being [29,32,33]. (See "Physical activity and strength training in children and adolescents: An overview", section on 'Physical activity'.)

Assessment of physical activity encompasses asking about duration, intensity, and type of activity in addition to assessment of age-appropriate fundamental movement skills (eg, throwing, catching, running, jumping, striking, kicking, skipping) [29].

Recommended physical activity levels vary with age [29,34,35]:

●0 through 11 months – Floor-based play several times per day; total of 30 minutes of tummy time while awake

●1 through 2 years – ≥3 hours per day (any intensity) including ≥30 minutes of activity that is planned and directed by an adult (eg, taking a walk in the neighborhood, playing in a playground)

●3 through 5 years – ≥3 hours per day of any activities that develop gross motor skills (eg, running, catching)

●≥6 years – ≥1 hours per day of moderate or vigorous aerobic activity, with ≥3 days per week of vigorous activity (eg, running, jumping rope, skating), muscle-strengthening activity (eg, climbing jungle gyms, push-ups, resistance training), and bone-strengthening activity (eg, jumping rope, running, skipping)

We provide information about the benefits of physical activity for all children, including those with special health care needs. (See "Physical activity and strength training in children and adolescents: An overview", section on 'Physical activity'.)

For children whose physical activity level is lower than recommended or whose fundamental movement skills are below what is typical for age (eg, poor kicking skills at age six years or jumping skills at age eight years [36]) and whose caregivers are interested, we also provide information and resources about promotion of physical activity. Structured at-home programs may improve motor skills [37].

Resources include:

●AAP Institute for Healthy Childhood Weight

●Sport for Life: Developing Physical Literacy: A Guide for Parents of Children ages 0 to 12

●Exercise is Medicine Prescription for Health (provides handouts to promote physical activity in children and adolescents)

Screening for dyslipidemia — Our approach to screening for dyslipidemia uses a combination of universal and selective screening based on age and cardiovascular risk factors (algorithm 1A-B). It is generally consistent with the recommendations of the United States National Heart, Lung, and Blood Institute, AAP, American Heart Association, and American College of Cardiology [38,39].

Screening for dyslipidemia is discussed separately. (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis".)

Sickle cell disease or trait — Screening for sickle cell disease or trait is routinely performed in the United States and many other countries. Screening for sickle cell disease has been part of newborn screening in all 50 states since 2006 [40]. Screening children and adolescents for sickle cell disease and sickle cell trait are discussed separately. (See "Diagnosis of sickle cell disorders", section on 'Newborn screening' and "Sickle cell trait", section on 'Screening'.)

Screening for sexually transmitted infections — Recommendations for screening sexually active adolescents for sexually transmitted infections vary with age, sex, and sexual behavior (table 8). (See "Screening for sexually transmitted infections", section on 'Screening recommendations'.)

Cervical dysplasia screening — For immunocompetent, asymptomatic, female adolescents, screening for cervical cancer usually begins no earlier than age 21 years. (See "Screening for cervical cancer in resource-rich settings", section on 'Screening in average-risk patients'.)

Nicotine, alcohol, and substance use — In accord with the AAP/Bright Futures guidelines, we suggest annual screening for tobacco, alcohol, and substance use, typically beginning at age 11 years [5,41-44]. Asking about tobacco, alcohol, and substance use provides an opportunity for positive reinforcement of nonuse and may be necessary for clinical care (eg, choice of medication) [45]. Prevention of smoking in children is discussed separately. (See "Prevention of smoking and vaping initiation in children and adolescents".)

The AAP encourages clinicians to begin discussing the dangers of drinking alcohol with patients as young as nine years of age [46]. Early initiation of this discussion is suggested because children begin to view alcohol positively between 9 and 13 years of age given the frequent exposure to alcohol advertising, because alcohol use is so common [47], and because early initiation is associated with increased risk of alcohol use disorder (AUD) [48-50]. In a multisite survey of 1193 rural adolescents, approximately 2 percent of those aged 12 through 14 years and 10 percent of those aged 15 through 20 years met the Diagnostic and Statistics Manual of Mental Disorders, 5^th edition (DSM-5) criteria for AUD, according to self-reported frequency and quantity of alcohol use and DSM-5 AUD symptoms [47].

Data from the 2019 Youth Risk Behavior Surveillance System indicate that among high school students in the United States [51,52]:

●Approximately 15 percent reported having their first drink of alcohol (more than a few sips) before they were 13 years old

●Approximately 8 percent reported having tried cigarette smoking (even one or two puffs) before they were 13 years old

●Approximately 6 percent reported having tried marijuana before they were 13 years old

Early alcohol and substance use has been associated with increased risk of unintentional injuries, motor vehicle crashes, unhealthy use and dependence during adulthood, and alcohol-related health and social problems during adulthood [44,53,54]. Binge drinking increases the risk of adverse outcomes [46]. (See "Substance use disorder in adolescents: Epidemiology, clinical features, assessment, and diagnosis", section on 'Clinical consequences'.)

Despite the lack of evidence to support the counseling of adolescents in the primary care setting against alcohol and substance use [55], the AAP/Bright Futures guidelines suggest risk assessment for alcohol and drug use yearly, typically beginning at age 11 years [5,42], although screening for alcohol use may begin as early as 9 years [46]. The USPSTF found insufficient evidence to assess the balance of benefits and harms of primary screening for and behavior counseling to prevent unhealthy alcohol use in adolescents <18 years of age [56]. The USPSTF also found insufficient evidence to assess the balance of benefits and harms of primary screening for unhealthy drug use in adolescents <18 years of age [57] or behavior counseling to prevent illicit drug use in children, adolescents, and young adults [58-60].

The AAP/Bright Futures guidelines suggest asking the adolescent directly about experimentation with or use of tobacco, alcohol, or drugs [5,42]. It is important to ask specifically about smokeless tobacco, electronic cigarettes, inhalants, anabolic steroids, and nonmedical use of prescription stimulants [61-63]. If substance use is reported, additional information is gathered regarding duration, amount, and frequency.

The AAP/Bright Futures guidelines suggest using the CRAFFT screen to identify problematic substance use. The CRAFFT screen is a brief screening tool that has been validated in the adolescent primary care setting [64,65]. The six CRAFFT screening questions are asked if the adolescent endorses drinking alcohol, smoking marijuana or hashish, or using any other substance to get high during the previous 12 months. The CRAFFT screening questions include:

●C(ar) – Have you ever ridden in a car driven by someone (including yourself) who was "high" or had been using alcohol or drugs?

●R(elax) – Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?

●A(lone) – Do you ever use alcohol or drugs while you are by yourself, alone?

●F(orget) – Do you ever forget things you did while using alcohol or drugs?

●F(riends) – Do your family or friends ever tell you that you should cut down on your drinking or drug use?

●T(rouble) – Have you ever gotten into trouble while you were using alcohol or drugs?

One point is scored for each "yes" answer. In a large, hospital-based adolescent clinic, a score of ≥2 had a sensitivity and specificity of 76 and 94 percent, respectively, for identifying problem use (use associated with adverse consequences), abuse (continued use despite harm), or dependence (associated with tolerance, withdrawal) [64]. Exploration of "yes" responses on the CRAFFT screen and of problems related to substance use may provide information that can be used in intervention [41]. In a multicenter observational study in 1573 Hispanic, Black, and White adolescents (12 through 18 years of age), the sensitivity and specificity of the CRAFFT screen were 98 percent (95% CI 91-100 percent) and 73 percent (95% CI 71-76 percent), respectively, for AUD and 88 percent (95% CI 83-92 percent) and 80 percent (95% CI 78-82 percent), respectively, for cannabis use disorder (using the Diagnostic Interview Schedule for Children Version IV as the reference standard) [66].

Other screening tools that can be administered by an interviewer or self-administered and are sensitive and specific in identifying substance use disorders (SUDs) as defined by the DSM-5 criteria include [41]:

●The Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) assesses the frequency of use during the past 30 days, 90 days, and year [67]. Cutoffs of ≥6 days for tobacco and ≥2 days for alcohol or marijuana correlated with problematic use. The BSTAD is available in the full text of reference [67].

●The Screening to Brief Intervention (S2BI) tool (available through the Massachusetts Child Psychiatry Access Program) assesses the frequency of tobacco, alcohol, marijuana, and other/illicit drug use in the past year [68]. It discriminates among clinically relevant use categories: no SUD ("once or twice"), mild or moderate SUD ("monthly"), and severe SUD ("weekly or more") [41].

Alcohol-only screening tools may be used if time does not permit full substance screening [46]. One such screen was developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in collaboration with the AAP (table 9) [69]. This screen focuses on friends drinking (an early warning signal and predictor of the patient's future drinking levels [70]) and frequency of drinking (a predictor of alcohol-related harm [71]). In a multicenter observational study in 1573 Hispanic, Black, and White adolescents (12 through 18 years of age), the sensitivity and specificity of the NIAAA/AAP screen were 87 percent (95% CI 76-94 percent) and 84 percent (95% CI 82-86 percent), respectively, for AUD (using the Diagnostic Interview Schedule for Children Version IV as the reference standard) [66]. A systematic review confirmed the accuracy of the NIAAA/AAP and other brief screening tools to detect AUD in adolescents, but the data were insufficient to determine whether such tools can detect unhealthy alcohol use [72].

The AAP clinical report provides additional information about screening, brief intervention, and referral to treatment [41]. The National Institute on Drug Abuse website provides resources related to addiction and offers access to screening tools for adolescent patients.

Smoking cessation and the diagnosis and management of alcohol use disorder and substance use disorder in adolescents are discussed separately. (See "Management of smoking and vaping cessation in adolescents" and "Substance use disorder in adolescents: Epidemiology, clinical features, assessment, and diagnosis" and "Substance use disorder in adolescents: Treatment overview".)

Depression and suicide risk screening — In accord with the Bright Futures/AAP, we suggest universal screening for depression and suicide risk annually from age 12 through 21 years [5,73]. We also suggest targeted screening for depression in children ≥10 years and adolescents at high risk of depression, including those:

●With a personal or family history of depression, bipolar disorder, suicidality, substance use, or other psychiatric illness

●With significant psychosocial stressors (eg, family crises, physical or sexual abuse, neglect, other trauma)

●With frequent somatic complaints

●Who are in foster care or have been adopted

Depression is an important risk factor for suicide, which is among the leading causes of death for children and adolescents.

In nationwide surveys of high school students (2009 to 2019), the percentage of students who reported feeling so sad or hopeless every day for ≥2 weeks in a row that they stopped doing some usual activities increased from 26 to 37 percent [74]. Effective treatments for adolescent depression include medications (eg, selective serotonin reuptake inhibitors) and psychotherapy (cognitive behavioral therapy or interpersonal therapy). (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors", section on 'Epidemiology' and "Overview of prevention and treatment for pediatric depression", section on 'Acute treatment'.)

There is limited evidence to guide the choice of a depression screening tool [73]. A number of tools have been evaluated in primary care practice, including depression-specific tools, broader psychosocial tools, and combined tools for depression and other psychiatric disorders. Providers are encouraged to choose a tool that will work best for their practice, patients, and health organizations. They are also encouraged to screen for suicidality [75]. (See "Suicidal ideation and behavior in children and adolescents: Evaluation and management".)

The Patient Health Questionnaire-2 item screen (PHQ-2) has been validated in adolescents [76]. It consists of two questions [77]:

"Over the past two weeks, how often have you been bothered by any of the following problems:

●"Little interest or pleasure in doing things?"

●"Feeling down, depressed, or hopeless?"

The responses for each question include "not at all" (0 points); "several days" (1 point); "more than half the days" (2 points); and "nearly every day" (3 points). Adolescents with a score of ≥3 should undergo additional assessment for depressive disorder. In a primary care sample of 499 adolescents, a PHQ-2 score ≥3 had a sensitivity of 74 percent and specificity of 75 percent for detecting major depression according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition [76]. Some practices choose to use a cut-off of 2 to increase sensitivity, but this must be weighed against the potential extra workload and decrease in clinic efficiency related to the increased number of false positives identified with the lower cut-off [77]. (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Assessment'.)

Other validated depression screening tools for adolescents include the PHQ-9 Modified for Teens (in English or Spanish), the Kutcher Adolescent Depression Scale-6-item, and the Columbia Depression Scale (parent or teen version) [78-81]. These tools and scoring instructions are available in the Guidelines for Adolescent Depression in Primary Care Tool Kit [82]. In systematic reviews, the sensitivities of these tools ranged from 70 to 90 percent and specificities from 40 to 90 percent [73,83].

Studies in adult patients suggest that screening improves identification of depression (see "Screening for depression in adults", section on 'Improved detection'). Studies comparing outcomes among adolescents screened and not screened for depression are lacking [73,84]. However, in a randomized trial, adolescent patients with depressive symptoms who were identified in primary care and received six months of effective treatment (eg, psychotherapy and/or medication) had fewer depressive symptoms and improved mental health-related quality of life than those who received usual care [85].

The USPSTF recommends screening adolescents age 12 to 18 years for major depressive disorder [86,87]. They concluded that the evidence was insufficient to screen for major depressive disorder in younger children or to screen children and adolescents for suicidality.

Anxiety screening — Anxiety is characterized by excessive fear or worry that is associated with physical and emotional symptoms. Screening children and adolescents for anxiety is discussed separately. (See "Anxiety disorders in children and adolescents: Assessment and diagnosis", section on 'Screening and assessment'.)

Screening for poverty — We agree with the AAP recommendation to screen for poverty during health care visits [88]. Screening for basic social needs (eg, food, housing, utilities, transportation) may uncover both obvious and less apparent economic difficulties associated with adverse health outcomes, less preventive care, and increased use of emergency care services [89-98]. Providers can then link the families with available community services (eg, 2-1-1, a free and confidential helpline and website for people in North America) and/or provide high-quality written resources [99]. Although the accuracy of screening for poverty and other social determinants of health has not been proven [100], as one of multiple components of a comprehensive approach to patient and family engagement, screening may initiate a conversation about family concerns and priorities [101].

A variety of screening instruments may be used, including the single question: "Do you (ever) have difficulty making ends meet at the end of the month?" In a pilot study in a primary care practice, this question was 98 percent sensitive and 40 percent specific in identifying families with a need for community resources [102,103].

The Well-child Care Visit, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) survey instrument may prompt discussion of poverty-related topics and referral for community resources [104]; the survey instrument is available in the appendix of reference [104].

Other screens that may be used for specific needs include:

●Food – Endorsement of either of the following statements as often or sometimes true rather than never true is an accurate indication of food insecurity [105-108]:

•"Within the past 12 months we worried whether our food would run out before we got money to buy more."

•"Within the past 12 months the food we bought just didn't last, and we didn't have money to get more."

In a validation study, endorsement of either of these statements was 97 percent sensitive and 83 percent specific in identifying food insecurity compared with the 18-item United States Department of Agriculture Household Food Security Survey, a research tool from which the questions were taken [106].

In a systematic review, household food insecurity was associated with behavioral, emotional, and developmental problems in children of all ages [109]. Children from families with food insecurity may warrant enhanced developmental/behavioral surveillance. (See "Developmental-behavioral surveillance and screening in primary care".)

The AAP and Food Research & Action Center have developed a toolkit to help clinician address food insecurity.

●Housing – Asking whether families have moved frequently in the past year or lived with another family for financial reasons helps to identify housing insecurity [110].

Screening for poverty may have unintended harms (eg, patient/family frustration if they have unrealistic expectations about the type or quality of resources and services that are available; patient/family feeling stigmatized if screening is limited to particular subgroups, etc) [111]. The risk of unintended harm can be minimized through care coordination, collaboration with service providers, involving the family in shared decision-making before making referrals, screening the entire practice population rather than subgroups (and explaining this screening strategy to families), and acknowledging and building on patient and family strengths.

Intimate partner violence — The process of asking about intimate partner violence is discussed separately. (See "Intimate partner violence: Childhood exposure", section on 'The process of asking about caregiver intimate partner violence' and "Adolescent relationship abuse including physical and sexual teen dating violence".)

SUMMARY AND RECOMMENDATIONS

●Definition and goal of screening – Screening is defined as testing for disease in an individual or population that appears to be healthy. The goal of screening is to identify children who are at increased risk of disease and warrant additional testing. (See 'Overview' above.)

●Lead poisoning – Screening for lead poisoning should be performed in accordance with state laws as applicable. (See 'Lead poisoning' above.)

●Oral health – We suggest oral health risk assessment beginning at six months of age and referral to a dental home at one year of age or as soon thereafter as possible (Grade 2C). (See 'Oral health screening' above and "Preventive dental care and counseling for infants and young children", section on 'Risk assessment'.)

●Tuberculosis – We agree with guidelines suggesting tuberculosis risk assessment (table 5) by 1 month of age, at ages 6, 12, and 24 months, and annually thereafter. (See 'Tuberculosis' above.)

●Hypertension – We screen children without risk factors or conditions associated with hypertension by measuring blood pressure annually at health supervision visits, beginning at age three years. For children <3 years with risk factors for hypertension (table 6A), we measure BP at all health supervision visits. For children ≥3 years with risk factors for hypertension (table 6B), we measure BP at all health encounters. (See 'Hypertension' above.)

●Alcohol, tobacco, and substance use – We suggest screening for alcohol, tobacco, and substance use annually, beginning at age 11 years (Grade 2C). (See 'Nicotine, alcohol, and substance use' above.)

●Depression – We suggest screening adolescents for depression annually, beginning at age 12 years (Grade 2B). (See 'Depression and suicide risk screening' above.)

●Poverty – Screening for poverty during health care visits may identify economic difficulties for which community services are available. (See 'Screening for poverty' above.)

●Other conditions – Screening for other conditions is discussed separately. These include:

•Genetic and metabolic disease (see "Overview of newborn screening")

•Hyperbilirubinemia (see "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening")

•Critical congenital heart disease (see "Newborn screening for critical congenital heart disease using pulse oximetry")

•Hearing loss (see "Screening the newborn for hearing loss" and "Hearing loss in children: Screening and evaluation")

•Vision screening (see "Vision screening and assessment in infants and children")

•Developmental and behavioral/social/emotional problems, including anxiety:

-(See "Developmental-behavioral surveillance and screening in primary care".)

-(See "Autism spectrum disorder in children and adolescents: Surveillance and screening in primary care".)

-(See "Anxiety disorders in children and adolescents: Assessment and diagnosis", section on 'Screening and assessment'.)

•Iron deficiency in infants and adolescents (see "Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis", section on 'Screening recommendations' and "Iron requirements and iron deficiency in adolescents", section on 'Screening')

•Dyslipidemia (see "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis")

•Sexually transmitted infections (see "Screening for sexually transmitted infections", section on 'Screening recommendations')

•Cervical cancer (see "Screening for cervical cancer in resource-rich settings")