Unanswered Questions in New Mental Health Screening Program for Children

An article presents new screening tools for pediatric depression and anxiety—but fails to answer its own questions about efficacy

Peter Simons
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An article, just published in the Journal of Pediatric Health Care, presents two new mental health screening instruments intended to be used by pediatric primary care (PPC) providers in their work with children. The researchers conducted a study comparing the two approaches: paper-based screening questionnaires vs. computerized screening questionnaires. However, they also posed questions about the utility of the screening process in general. According to the authors, the real challenge is “how to address mental health problems once they are identified.” They write:

“PPC providers largely lack the training and resources to provide mental health treatment when indicated, mental health services providers in the community are scarce or have long waiting lists, and communication between PPC providers and mental health professionals for consultation or co-management of patients’ symptoms seldom happens.”

That is, screening may identify children’s mental health problems, such as anxiety and depression. However, it cannot help pediatricians effectively treat concerns which lie outside of their specialty. Likewise, screening does not help pediatricians connect children to mental health services when there are no services available.

Photo Credit: Pixabay

The authors suggest that one solution to this dilemma is “task shifting”—improving the ability of pediatricians to work with mental health concerns. Thus, their screening program included algorithms that provided recommendations to providers regarding how to treat the identified mental health concerns:

“The algorithms also guided PPC providers to connect all children with positive screening and assessment results to a community mental health provider. Other recommendations included considering medication (a selective serotonin reuptake inhibitor titration schedule was included in the toolkit) or referring to a psychiatrist for a medication evaluation, establishing a patient safety plan, and using one of several informational handouts to provide education about depression and/or anxiety to the patient and family and to discuss goals and options for treatment.”

In summary, the algorithms provided the pediatrician with the following options: refer the child to a specialist, prescribe a SSRI, or provide the child and family with handouts about depression and anxiety. It is unclear how these interventions would improve outcomes, even if the screening program identified mental health concerns that would not normally be detected. After all, the authors previously discussed long wait times and the unavailability of mental health specialists as their primary reason for increasing mental health care from pediatricians.

However, the researchers’ study focuses on improving screening alone, rather than improving the education of pediatricians or increasing the burden of specialty work on pediatricians. The research does not address whether “task shifting” would be appropriate or successful. However, the authors do note that “PPC providers expressed frustration over time constraints placed on well-child visits and their ability to address a myriad of health topics efficiently, effectively, and within the time allotted.”

Although the researchers compared the two screening interventions (paper-based screening questionnaires vs. computerized questionnaires), they did not compare the outcomes of the screening. In both cases, the screening questionnaire was given to approximately 50% of the children who were already identified as having potential mental health concerns. Thus, the research may be limited by the fact that the questionnaire was not implemented as a true screening, but rather used as a diagnostic tool.

After children scored positive on the initial screening, the algorithm indicated that they should be moved to “next-level assessment” and complete another screening tool. At that time, at least a third of the children who had screened positive were then “ruled out”—meaning they did not score positive on the next level assessment.

Again, the authors did not compare outcomes, and there was no control group— so it is not possible to speak to whether either of these screening approaches resulted in improvements in clinical care.

While there is substantial evidence that screening for medical conditions (such as cancer) significantly improves outcomes, it is not clear that screening for mental health concerns is associated with improved outcome. In studies that directly tested mental health screening outcomes using randomized, controlled trials, the screening group did not improve significantly compared to the group that was not screened.

The Canadian guidelines and the guidelines of the United Kingdom reflect this evidence—they both recommend against screening for mental health concerns. They report that the harm of overdiagnosis and overmedication for people experiencing mild situational mental health concerns may outweigh the uncertain benefits of screening. In fact, one study estimated that 80% of positive depression screening results are actually false positives—people who do not have depression but were identified by the questionnaire as meeting the criteria.

The United States Preventive Services Task Force (USPSTF), in contrast, recommends screening for depression in both adults and adolescents. The USPSTF argues that because screening can identify mental health concerns, and because there exist effective interventions for mental health concerns, screening, therefore, may be associated with improved outcomes.

The authors of this study present a computerized screening solution as a way of expanding identification of depression and anxiety in children. However, they bring up questions about the role of pediatricians, as well as the efficacy of screening for mental health concerns— as there is no direct evidence of benefit.

 

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Honigfeld, L., Macary, S. J., & Grasso, D. J. (2017). A clinical care algorithmic toolkit for promoting screening and next-level assessment of pediatric depression and anxiety in primary care. J Pediatr Health Care, 31(3), e15-e23. (Link)

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Peter Simons
MIA Research News Team: Peter Simons comes from a background in the humanities where he studied English, philosophy, and art. Now working on his PhD in Counseling Psychology, his recent research has focused on conflicts of interest in the psychopharmaceutical research literature, the use of antipsychotic medications in the treatment of depression, and the general philosophical and sociopolitical implications of psychiatric taxonomy in diagnosis and treatment.

17 COMMENTS

  1. We don’t need no education
    We don’t need no thought control
    No dark sarcasm in the classroom
    Teachers leave them kids alone
    Hey! Teacher! Leave us kids alone!
    All in all you’re just another brick in the wall.
    All in all you’re just another brick in the wall.

    To the tune of “Another Brick in the Wall (Part 2)”, Pink imagines a surrealistically oppressive school system in which children are put into a meat grinder.

    Pink Floyd came out with The Wall in 1979 before they rolled out mass drugging for school children. Before 1980, the drugging of children on a massive scale was unheard of, even unimaginable. What most people could not envisage, however, was well within the imaginative scope of marketing departments of drug companies. In 1987, when ADHD made its debut in the American Psychiatric Association’s diagnostic manual (DSM-III-R), the authors estimated that only 1 in 33 children had the condition. Today, one in eight American children is diagnosed with attention deficit hyperactivity disorder (ADHD).

    The authors of this study present a computerized screening solution as a way of e x p a n d i n g identification of depression and anxiety in children…

    All in all you’re just another algorithm in – the – machine, in – the – machine

    It’s just sick it really is.

    • I know I don’t even know how to comment anymore this is so absurd and ridiculous. I tried to be cleaver with my stupid Pink Floyd comment but really.

      Do we really need a computerized mental health analyzer to “detect” if a kid is anxious or depressed about something ?

      Computerized screening solution as a way of e-x-p-a-n-d-i-n-g identification of depression and anxiety in children…

      “After children scored positive on the initial screening, the algorithm indicated that they should be moved to “next-level assessment” and complete another screening tool.”

      Leave them kids alone ! With your effing algorithms, we are humans at least some of us still are and we say things to each other such as how are you feeling ?

      This is absurdity, the algorithm indicated…. 40 years ago this could have been a dystopian future movie plot with the computerized mental health detector for children and the brain chemical drugs.

      • The algorithm referred to in this article makes it out to be more elegant than it really is. It has nothing to do with computers. Presribing algorithms are nothing more than charts of unbelievable simplicity developed by drug companies with no scientific merit whatsoever. They would be more aptly named ‘Psychiatry for Dummies’. If you saw the playbook used by some psychiatrists, a practice condoned by their guild, you would be stunned by the colossal waste of spending four years at medical college for anyone who bases his/her practice on following anything as ridiculous as a prescribing algorithm authored by a drug manufacturer. I’m embarrassed just thinking about it. An auto mechanic and a plumber has more integrity.

        • “If you saw the playbook used by some psychiatrists, a practice condoned by their guild, you would be stunned by the colossal waste of spending four years at medical college for anyone who bases his/her practice on following anything as ridiculous as a prescribing algorithm authored by a drug manufacturer.”

          Madmom,

          I was similarly stunned when I went to a psychiatrist for advice, and finally (after failing to get anything useful from him) asked how he knew when people are crazy. “By their behavior,” he solemnly told me.

          By how people ACT? Wow, I always thought they had some kind of secret scientific way of knowing this, not just using common sense like the rest of us! I’m like you, I wondered why he needed four years of medical school. Needless to say, I never went back.

        • A computer could literally do a better job. At least it would be consistent and not influenced by drug company inducements, and could be programmed to actually tell you about the potential side effects and alternative options. Most psychiatrists seem to provide negative “added value” to the process.

    • Yes. More teens drugged with SSRIs means more mass shootings. More mass shootings mean more draconian legislation pushed through by Murphy the Merciless and his ilk. This enables Pharma-Psychiatry hucksters to push these drugs on everyone. This leads more mass shootings. More draconian laws. More drugs.

      Ah. The Psychiatric Circle of Death. 😛

    • You don’t have to read or post, Pat. You’ve already said you’re leaving like three times. Is there something in this article that throws you over the edge? You do realize, don’t you, that there is no evidence that any of the SSRIs work with kids under 12, and the one study showing only Prozac working with teens was considered badly flawed? Does this not concern you?

    • Me pat, the unethical psychiatrists don’t hang out here, since we have the science which proves the DSM is a classification system of the theorized “mental illnesses” that can be created with the psychiatric drugs, as opposed to real “genetic mental illnesses.” Thus we have the scientific proof their entire industry is based upon scientific fraud.

      Since you’re apparently a believer in the psychiatrists’ theorized DSM disorders, and psychiatrists, perhaps you’d be wiser to follow their lead, and personally choose to not frequent this website? No offense intended, just suggesting you follow those you believe in, and stop torturing yourself by continuing to frequent a website that is apparently one you don’t want to follow any longer, since you do have the free will to leave this website.

      And just curious, what does your idiotic breakdancing video have to due with “mental health,” other than when one is dealing with a psychiatric drug withdrawal induced super sensitivity mania, dancing is a good way to deal with such a “mania”?

  2. Children can not BE mentally ill. As mental illness is defined by behavior and children can not control their behavior as is why they are named children.

    “Because the mental diseases that supposedly afflict children are undeniably misbehaviors, and because the child mental patient is in an even more helpless position than the adult mental patient, child psychiatry is a doubly problematic enterprise.” “Child psychology and child psychiatry cannot be reformed. They must be abolished.” Szasz

    • I agree, the massive drugging of American children is appalling. We have an industry of adults defaming and torturing children with made up and scientifically invalid “mental illnesses” for profit. How sick can an adult get? “Child psychology and psychiatry can not be reformed. They must be abolished.” No doubt.

      But the globalist banking “elite” apparently have a penchant for pedophilia, and apparently control our government with such, so the psychiatric minion have chosen to cover up these unconscionable crimes against children for their money masters who create money out of nothing, and un-Constitutionally charge un-godly interest on such. Which, by the way, are even worse psychiatric crimes against humanity than were committed in Nazi Germany or Bolshevik led communist Russia. Oops, the wrong banking families took over the US monetary system.

  3. I suffered severe depression at age 7. Looking back, I think it stemmed from not fitting into the Special Behavioral School where I was shoved. The teacher and her aid kept shaming me for knowing too much. (Probably frustrated with not knowing how to handle a really smart kid with behavioral issues.) Then a bout with mono made it much, much worse.

    Thank God, we didn’t have as many drugs back then!