Screening for mental disorders in children and adolescents

For many academics and researchers, the debate is over: The use of mental health screening questionnaires in a routine fashion in primary care offices greatly increases the detection of mental disorders among children and adolescents.  With such information, the American Academy of Pediatrics, Bright Futures, the US Preventive Services Task Force and others have weighed in.  Screening is the order of the day, at least for adolescent depression.  The remaining questions for the researchers have to do with finding the screening questionnaires with the best sensitivity and specificity that are short enough to be practical for physicians and patients.

However, primary care clinicians in all but the most sophisticated practices understand from experience that providing a medical home to children and adolescents identified by screening as having a possible mental disorder requires more than simple identification and that doing so can be challenging.  Effective screening demands additional assessment, appropriate choice of treatment for the detected condition, communication/engagement with the family and sometimes referral and follow-up with specialists.

Such complex, multi-step processes have the potential to break down.  Patients identified through a screening questionnaire as possibly at risk for a mental disorder may not end up receiving the care they need either because the subsequent diagnosis is incorrect, the wrong treatment is chosen, the family rejects the recommendation for care because of stigma or financial burden, or specialty care is not available.   Thus, several studies of screening and follow-up suggest that favorable clinical outcomes require more than paper and pencil screening in a waiting room. Primary care clinicians need the support of a system that improves the availability and access of mental health for appropriate referral and that acknowledges issues of provider payment for providing mental health services in primary care.

These challenges are not inconsequential, but there is progress being made including efforts by some physicians to collaborate with behavioral health professionals to increase the chances that patients referred for specialty care actually make it there and engage in services.

We have made great strides on the primary care/mental health screening issue over the past decade.  Our next challenge is to devote as much energy to addressing the day-to-day challenges that primary care clinicians face as they work to provide their adolescent patients with the mental health care they need and deserve.

Kelly J. Kelleher is Vice President for Community Health and Services Research at Nationwide Children’s Hospital in Columbus and is Physician Advisor for Teen Screen National Center for Mental Health Check-ups at Columbia University.

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  • Rob Lindeman

    “Patients identified through a screening questionnaire as possibly at risk for a mental disorder may not end up receiving the care they need either because the subsequent diagnosis is incorrect, the wrong treatment is chosen, the family rejects the recommendation for care because of stigma or financial burden, or specialty care is not available”
    I’m astonished that you failed to mention the major drawback of screening tests, i.e., that they are highly sensitive and have relatively low positive predictive values.  That is to say that even good screens have substantial false-positive rates.  In this case, many children and adolescents who don’t believe they have mental illness will be led to believe that they do.  The downsides are enormous.

  • http://twitter.com/knasky knasky

    Pygmalion effect:  form of self-fulfilling prophecy, and, in this respect, people with poor expectations internalize their negative label, and those with positive labels succeed accordingly (source: Wikipedia).

    We’re over-screening, IMHO, especially in mental health. In the military, we’re coming up with epidemic-sounding numbers because of the gross misuse of–and inappropriate interpretation of–screening instruments. Look hard enough for pathology, make the ‘criteria’ fuzzy enough, and you’ll eventually find all the pathology you want. Then, quite often, the treatment pathologizes normalcy, and we’re suddenly in the business of reinforcing negative labels, and the self-fulfilling prophesy is realized. And here’s the worst part: as the patient (they’re a “patient” now, you see) is diagnosed, we get all self-congratulatory about our screening efforts, and the positive feedback loop continues (See? Screening is great!)