Mental Health Decision Making in Pediatric Primary Care: A Scoping Review.

BACKGROUND: Pediatric primary care providers (PCPs) play a central and growing role in identifying and addressing mental health problems (MHPs), yet the clinical-decision making processes are poorly understood. We reviewed the literature on PCP recognition, referral, and management of pediatric MHP to identify opportunities for future research related to diagnostic accuracy and mental health service delivery in primary care. METHODS: Scoping review methodology was used to examine the published research on PCP recognition, referral, and management decisions for pediatric MHPs. Data was organized by decision type and factors that influence decision making, including child characteristics, family characteristics, and clinician or practice context variables. RESULTS: Forty-five peer-reviewed studies were included. Compared to gold standard assessments and parent-reported questionnaires, PCPs consistently under-recognized MHPs. The decision to refer patients varied by disorder and was largely influenced by problem severity and parental disclosure. Management decisions were primarily shaped by disorder and clinician comfort level. Across decision domains, problem severity, parental engagement, clinician training, and practice context emerged as consistent determinants of PCP decision making. CONCLUSIONS: PCPs face persistent challenges in addressing pediatric mental health concerns. This review underscores many opportunities to improve outcomes and reduce inequities in primary care mental health service delivery. There is a need to improve accurate identification, clarify thresholds for referral, and strengthen PCP knowledge and confidence in addressing internalizing disorders and higher acuity concerns. Future research should explore sequential screening, targeted training, and integrated behavioral health approaches to support clinicians and improve systems.