Integrating Behavioral Health Early to Improve Pediatric Mental Health

As pediatric mental and behavioral health needs continue to rise nationwide, Cincinnati Children’s is reimagining how early care should begin—and developing best practices for how to integrate it. By embedding evidence-based screening, integrated behavioral health providers and community-aligned care models directly into the pediatric medical home, the health system is shifting mental health care upstream—creating a scalable, guideline-driven infrastructure that supports earlier identification, more easily accessed triage and more consistent referral pathways across care settings.

Rather than relying solely on specialty referral after symptoms escalate, Cincinnati Children’s has focused on building systemwide capacity to identify and address mental and behavioral health needs at multiple entry points, including primary care, ambulatory subspecialty clinics and community pediatric practices.

From National Guidelines to Systemwide Practice

Ten years ago, the U.S. Preventive Services Task Force (USPSTF) updated its guidelines to recommend routine screening for depression in all adolescents, ages 12 to 18, in primary care settings.

“That was a sentinel event,” says Emily Harris, MD, MPH, a child psychiatrist in the Division of Child and Adolescent Psychiatry and a board-certified pediatrician who has worked as a primary care pediatrician for over 10 years. “That change shifted pediatric primary care’s view to identifying mental health issues as one of their concerns.”

Cincinnati Children’s physician-hospital organization, Tri-State Child Health Services, recruited Harris to serve as the lead psychiatrist and content expert for a mental health work group dedicated to implementing routine screening for depression in primary care settings. Her work focused on developing a treatment algorithm and educational content to support clinicians’ capacity to manage patient responses to the screenings.

“The capacity of the PCP to address mental health concerns is an important aspect of safety and sustainability when integrating the depression and anxiety screening tools into primary care workflows,” Harris says. “The unique aspect was that a complex, multi-site organization partnered with Cincinnati Children’s expertise to strategize a standardized approach for initial assessment and management of common childhood conditions, catching concerns earlier in the course of illness presentation.”

Although it first launched a quality improvement project, the work evolved into an organizational expectation around 2018.

In 2022, Cincinnati Children’s expanded its universal screening approach across ambulatory subspecialty sites, says Martine Lamy, MD, PhD, a child psychiatrist in the Division of Child and Adolescent Psychiatry and associate chief of staff for mental health. That same year, the USPSTF issued its first recommendation for anxiety screening in children as young as 8 years old.

After a period of planning and education, Harris and her team launched a standardized anxiety screening protocol last year, again partnering with Tri-State Child Health Services to ensure uniform adoption across pediatric practices serving the region’s more than 250,000 children.

“Essentially, we took the national guidelines and amplified our efforts to ensure clinicians felt safe interpreting results and knew what to do next,” Harris says. “We knew it would be instrumental to give pediatricians without psychiatric training a clear strategy.”

Lamy underscores the innovation of aligning hospital-based pediatric primary care clinics and independent community practices around the same screening tools, referral thresholds and educational resources.

“How we’ve implemented it in different places may look slightly different, but the education, the guidelines for when to refer and the resources we provide to families are the same,” she says. “We’re delivering a consistent message across the system.”

Embedding depression and anxiety screening into the pediatric medical home has expanded what primary care clinicians feel prepared to manage, including initial assessment of suicidality.

The effects extend beyond traditional primary care. Ambulatory subspecialty clinics—including the Division of Sports Medicine—have incorporated anxiety and depression screening into their workflows.

Embedding Behavioral Health Providers Early in Childhood Care

This approach extends beyond screening to embedding behavioral health expertise directly into pediatric care teams.

Brea Lauer, PhD, a child psychologist in the Division of Behavioral Medicine and Clinical Psychology, is part of the Integrated Behavioral Health (IBH) program at Cincinnati Children’s Hopple Street Neighborhood Health Center. Launched in 2016, the hospital-based IBH program has since expanded to the Burnet Pediatric Primary Care (PPC) and Fairfield Primary Care clinics.

In these settings, pediatric psychologists meet with every patient and their parent or caregiver following the pediatrician visit, beginning at the 1-month well-child visit and continuing through age 5.

“We’re very integrated into our clinics,” Lauer says, noting that psychologists are included as a normal part of the visit for well-child checks and work closely with pediatricians. “We’re just part of the team.”

The goal is to introduce behavioral and developmental touchpoints early in life, identifying concerns before they escalate and normalizing behavioral health as a routine part of pediatric care. Psychologists use evidence-based strategies to develop patients’ emotional and behavioral health through interventions from a very young age. They also work to build relationships with families so that they can support them as they work toward goals for their child.

In addition, psychologists focus on practice transformation, working as a team with medical colleagues to incorporate trauma-informed and patient-centered care.

While the model was informed by HealthySteps—a national program supporting early childhood development for children ages 0 to 3—the Cincinnati Children’s hospital-based IBH framework differs in a critical way: Every child and family is seen, rather than requiring screening to access services.

Extending Integrated Behavioral Health into the Community

Building on the success in hospital-based clinics, Cincinnati Children’s launched Community Integrated Behavioral Health in two community practices at the end of 2019. Led by F. Lynne Merk, PhD, child psychologist in the Division of Behavioral Medicine and Clinical Psychology, the program is staffed by independently licensed social workers and professional clinical counselors, and serves patients from birth through young adulthood. Since 2019, the program has expanded to include 24 providers in 30 locations throughout the Greater Cincinnati region.

Unlike the hospital-based IBH program, the community model primarily delivers secondary prevention services. Social workers and counselors step in when a parent raises a behavioral concern or a pediatrician makes a recommendation.

When available, consultations may occur immediately following the pediatric visit or be scheduled for a day and time in the near future. During these encounters, clinicians provide psychoeducation, anticipatory guidance, evidence-based therapeutic interventions, crisis assessments and safety planning, and, when appropriate, referrals to specialty care. If a referral is made, families receive bridge support until specialty services are established.

“Our focus really is on access,” Merk says. “We want patients and families to get the right care at the right time, at the right dose and in a setting that’s convenient for them.”

Early data suggest that patients seen in pediatric primary care clinics with integrated behavioral health services are less likely to require emergency department visits or psychiatric admissions for behavioral health needs.

“We’re trying to capture things earlier in the pipeline, before they escalate,” Merk says. “And it appears to be working.”

Next Steps: Moving Prevention Even Further Upstream

Although Cincinnati Children’s already conducts more than 300,000 depression and suicide screenings annually across the health system, Lamy sees opportunities to move prevention even further upstream. One focus is building flexibility into services when data suggest certain school districts or neighborhoods may require additional mental and behavioral health support.

And Harris says, “We know intervening sooner—rather than waiting for diagnosis and referral—makes a huge difference, so we’re continuing to find ways to strengthen the care continuum earlier in the pediatric process.”

Meanwhile, Lauer and her colleagues are preparing to release a treatment manual later this year outlining the Cincinnati Children’s IBH model, including its theoretical underpinnings and operational logistics.

“Our goal is to share what we’ve learned with other hospitals and health systems,” she says. “We hope it can serve as a roadmap for organizations looking to build upstream behavioral health prevention into pediatric care.”

(Published March 2026)

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