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In 2007 in Massachusetts, a settlement of a class-action lawsuit on behalf of Medicaid beneficiaries mandated that primary care practices perform developmental, behavioral, and mental health screening using formal tools. The aim of this study was to assess perspectives from providers and practice staff about implementing developmental and mental health screening in response to the judicial ruling.In this qualitative study, semistructured interviews were conducted with 18 physicians and staff from 11 pediatric and medicine-pediatric primary care practices in Eastern Massachusetts between April 2009 and November 2010. Using an interview guide, data on barriers and facilitators to implementing developmental and mental health screening, how practices selected tools, and what processes or changes made screening routine were collected. Clinicians were asked how screening changed the quality and/or content of well-child care visits. Interviews were transcribed and coded. Overarching themes were generated using thematic analysis.Participants were motivated to comply with the mandate, and most practices reported implementing routine screening for developmental and mental health problems over several months. Although certain aspects of screening were endorsed, many perceived that screening added little to quality of care, primarily because tools lacked sensitivity and specialty resources were too scarce to address concerns adequately. Practices' receptivity to change and physicians' sense of duty to comply facilitated implementation. No practice developed processes specifically to track and follow-up abnormal results.Implementation of mandated developmental and mental health screening could be facilitated by providing assistance with practice change, improving the quality of screening tools, and assuring adequate referral resources.