indepth

Volume 27, Issue 463

March 20, 2006

MENTAL HEALTH SCREENING FOR KIDS: A MOVEMENT IN THE MAKING?

By Anna C. Spencer

In keeping with the trend towards prevention and primary-care, some state legislators and others want the nation’s youth to be screened for possible mental illness.

According to the 1999 U.S. Surgeon General’s report on mental health, nearly 4 million children and adolescents suffer from a serious mental illness that significantly impairs their functioning at home, at school and with peers. That said, only 20 percent of these children are ever identified and receive mental health services.

Suicide is the third leading cause of death among youth aged 15 to 24, and research shows that over 90 percent of youth who commit suicide have a mental illness. Moreover, close to 50 percent of students with mental illness age 14 and older drop out of high school, and many youth with mental illness end up in juvenile detention facilities: 65 percent of boys and 75 percent of girls in the juvenile justice system have a mental illness.

“We know very well about the extent of mental illness among kids and how failing to identify and treat these disorders can derail the lives of these kids,” said Darcy Gruttadaro, director of the Child and Adolescent Action Center at the National Alliance on Mental Illness (NAMI). Nevertheless, “as a nation, we’ve done a very poor job of identifying children who have serious mental health needs.” But that may be beginning to change.

In April 2002, President Bush established the New Freedom Commission on Mental Health to identify policies to improve coordination of treatments and services for adults and children with serious mental illness and emotional problems. In its final report, released in July 2003, the Commission included as one of its goals increasing the early detection of mental illness among children and young adults, by expanding screening in primary-care settings and schools.

Meeting Resistance

From birth on, children are routinely screened by physicians and school systems to ensure they are reaching physical and developmental milestones. Screening questionnaires offer a quick picture of a child’s well-being, identifying those who may require additional assessment and follow-up care.

But if vision, hearing, blood lead levels and language development are all regularly tested, emotional and social development are often left out of the picture. Mental health advocates, physician groups and school health officials all argue that children and adolescents should be routinely screened for mental illness. Those who might need treatment could then be further assessed and, if need be, treated. Research shows that early detection, assessment and links to treatment can prevent mental health problems from worsening.

A study in the British Journal of Psychiatry in 2002 found that children who do not receive treatment for depression and conduct disorders continue to have these problems in adulthood, use more health-care services as adults, and have higher health-care costs than other adults. Children with untreated mental illness also are more likely to experience school failure, have poor employment status and live in poverty as adults.

Mental health screening can be an “extremely helpful tool,” said Minnesota Rep. Mindy Greiling. There is a “huge range of what is normal during childhood and adolescence,” and mental health exams can “either affirm a nagging feeling a parent has that something is wrong or assure [parents] that everything is normal.”

But if advocates strongly support mental health screening, others oppose adding yet another assessment to the list of exams that children undergo. Some argue that children’s mental health should be handled by the family, not the school or state, and others add that such screening is based, at best, on shaky science – they fear that mental health testing will incorrectly label healthy children as mentally ill.

“This widespread net-casting doesn’t make any sense, and nobody benefits from screening,” said Dr. Karen Effrem of EdAction, a nonprofit consumer protection group. Effrem argues that mental health diagnoses are based on a subjective process and, as a result, “any screening tool designed to pick up these subjective measures is inherently flawed.”

Effrem said she supports suicide prevention efforts, but she believes that screening for mental health problems in high schools overstates the normal and generally temporary traumas teens experience. As a result, “kids are funneled into long-term counseling and/or drug therapy,” neither of which has been proven to be effective in children or adolescents, she said. “There is very little evidence that psychotropic medications work in children, yet we continue to overmedicate [them],” Effrem said. “It’s dangerous.”

Greiling said she understands the vehement opposition to mental health screening. American culture is “hush-hush” about mental illness, she noted, arguing that’s all the more reason for talking openly about normal social and emotional development and evaluating it on a regular basis. Mental health screening is a “critically important part of ensuring the overall welfare of children,” Greiling asserted. “In the end, it’s more damaging not to help kids than it is to screen them.”

A number of states are considering following the recommendations of the New Freedom Commission report by implementing mental health screenings for children and adolescents. In 2005 the Minnesota Legislature considered a bill that would have expanded pre-school screening to include a “socio-emotional development” component. The bill didn’t pass, but Rep. Greiling is pursuing her agenda by planning to convene a group of legislators in April to discuss mental illness. “We need a critical mass of lawmakers who understand mental illness, as well as the benefits of early screening,” she said.

In 2003, Illinois passed the Children's Mental Health Act, which called for the development of a Children's Mental Health Plan. The plan includes short- and long-term recommendations on how Illinois can improve the coordination of prevention, early intervention and treatment services for children at risk for mental illness from birth to age 18. The plan also proposes increasing the number of “periodic social and emotional development screens” a child receives, as part of regular medical check-ups and in school settings.

A Model Program for Adolescents

Recognized as a model program by the National Freedom Commission, Columbia University’s “TeenScreen” program is designed to identify youth who may be at risk for suicide or are suffering from an untreated mental illness. The program, which was developed in 1991, currently is used in 42 states in over 450 schools (see map). While each site operates independently, they all adhere to the national program’s implementation standards and requirements.

TeenScreen provides consultation, screening materials, software, training and technical assistance free to qualifying schools and communities. In return, partners are expected to screen at least 200 youth per year and to ensure that a licensed mental health professional (at the school or in the community) is available to provide immediate counseling and referral services for the youth at greatest risk.

The program requires that screening be voluntary for students and that parental consent be obtained. TeenScreen also strongly recommends that parental consent be “active” rather than “passive.” This means that parents must sign a consent form and students must return the form prior to answering the screening questionnaire. Roughly 90 percent of TeenScreen programs obtain consent this way. Passive consent would mean that information was sent home to parents, but students were not required to return a signed form to participate. Teens also must agree to participate, and they are given the right to refuse to answer any question.

While TeenScreen has been proliferating in high schools across the country in recent years, the program has also met strong resistance in some quarters. “There has been a lot of misinformation about the program out there,” said Leslie McGuire, director of TeenScreen. “First, this is not universal or mandatory screening. Kids are not being coerced into taking the TeenScreen questionnaire because we absolutely require parental consent, and teens must also agree to participate.”

In addition, during the screening process, participants are never labeled with any sort of mental illness. “We’re not in the business of diagnosing teenagers, we simply identify kids who may require a more in-depth evaluation,” McGuire said. And in the end, parents decide how to proceed with the information. “We don’t advocate for any type of treatment or endorse one medication over the other. Our primary goal is simply to see that the kids who need help get it.”

McGuire points to research that “clearly demonstrates” TeenScreen is highly effective in identifying kids who may be at risk for suicide or have other mental health problems. In a study of 2,000 high school students who participated in TeenScreen, 74 percent of students who were contemplating suicide and 50 percent of students who had made a prior suicide attempt were not previously known to be having problems by school personnel. In addition, 69 percent of students who had symptoms of depression were also undetected. “The questionnaire offers students a confidential and safe way to share information that they might not otherwise be able to share with their parents or school personnel,” McGuire said.

Research shows that exposing kids to information about suicide and asking them questions about the topic does not make them any more likely to contemplate or attempt suicide, or cause them undue distress. A study in the April 2005 issue of the Journal of the American Medical Association showed that depressed teens and previous suicide attempters who are screened are less distressed and suicidal than depressed teens and previous suicide attempters who are not screened.

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MENTAL HEALTH SCREENING FOR KIDS: A MOVEMENT IN THE MAKING?

Meeting Resistance

A Model Program for Adolescents

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