failure of the health care reimbursement system to compensate primary care providers for behavioral care has been an impediment to expansion of an engaged workforce. Greater capacity for behavioral evaluation and care is an unaddressed need in the United States. Training and support for individuals and programs that provide behavioral care, whether in the health care, social service, or education system, is a high-priority need.

Another barrier is the nature of many of the risk factors, such as poverty, violence, and other neighborhood-related stressors. Modifying these risk factors requires community action, which does not respond in a timely fashion to the needs of individual children. Interventions for population-wide risk factors often fall back on individually focused efforts that identify or build on protective factors, such as parental or other caregiver support in the home. Partnerships with schools can also address risk and protective factors from the individual or group perspective, for example, interventions for exposure to aggressive behaviors (Wilson and Lipsey, 2007).

  1. The cost of finding a case should be affordable, cost-effective, and reimbursable. As suggested from the discussion above, screening in the primary health care system can be carried out and reimbursed, as demonstrated by the program for Medicaid children mandated by the courts in the state of Massachusetts. A study of the costs of both developmental and behavioral screening for preschool-age children in a general pediatric practice estimated a per member, per month cost of $4 to $7, depending on the screening objectives and methods (Dobrez, LoSasso, et al., 2001). If effectiveness of screening for, detecting, and preventing cases of MEB disorders can be demonstrated, it is likely that screening in the primary health care setting will be cost-effective. Walker, Severson, and Seeley (2007) report positive outcomes associated with use of a behavioral screening tool paired with family and classroom interventions. No data were found for the cost of screening in school systems. It appears that the biggest economic barrier is not cost, but arriving at societal decisions about who will pay for screening and what the mechanisms for reimbursement of the cost will be.

  2. Screening can be population-based or targeted to at-risk groups or individuals. It should be longitudinally implemented, as risks and early signs or markers of evidence-based disorders may develop over time. Contrary to the experience with newborn screening for specific diseases, for which markers are not time-sensitive, risks and early signs or symptoms of MEB disorders may appear or be introduced over time. Therefore, screening for risk factors or the antecedents of these disorders is an ongoing process. The age at which screening should be initiated and the frequency with which it should be repeated have not been subjected to systematic study. These determinations will require judgments based on, among multiple factors,



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