Are Mental Health Screenings for Youth Worth the Risk?

Researchers shed light on the limitations of mental health screening instruments for youth that are increasingly being used in schools and medical settings.

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In an effort to increase support for children vulnerable to “psychiatric illness,” mental health screening assessments are now recommended by a wide range of regulatory agencies for adverse childhood experiences (ACEs), depression, anxiety, suicidality, etc. However, recent years have seen an increased intensity and zeal in the application of blanket screening policies, particularly related to depression and suicide risk.

In their commentary published last week in the Journal of the American Academy of Child & Adolescent Psychiatry, researchers Schuyler Henderson, Ruth Gerson, and Blake Phillips, offer a timely, critical perspective regarding the conflicting evidence for what constitutes “high risk,” and what can (and can’t) be done in response when risks are identified.

“The Joint Commission mandates a suicide assessment for patients ‘who exhibit suicidal behavior or who have screened positive for suicidal ideation’ followed by risk stratification: after ‘this assessment, patients should be classified as high, medium or low risk of suicide,’” they write. “But is suicide risk stratification in child psychiatry ready for prime time? Are we putting the risk assessment cart before the horse?”

Henderson, Gerson, and Phillips aren’t the first to identify patterns of alarmingly liberal efforts to detect psychosocial and behavioral dysfunction among youth by way of screening or risk assessment. In a 2014 Mad in America article entitled The Proactive Search for Mental Illness in Children, Bob Wipond explored screening and surveillance in clinical and, increasingly, school-based initiatives. He drew attention to the lack of evidence for a program in British Columbia called the Practice Support Program for Child and Youth Mental Health (PSP-CYMH), a joint initiative of the BC government’s Ministry of Health and the Doctors of BC.

In 2017, Jeanne Lenzer, Associate Editor for The BMJ, critiqued the US Preventive Services Task Force Recommendation Statement suggesting that all children and adults be routinely screened for depression, stating that “many guideline bodies would better serve clinical practice by making fewer recommendations: reflecting more of the uncertainty around treatment decisions. What we need are fewer recommendations and more high-quality evidence to base decisions on. Currently, we seem to be seeing the exact opposite.” Some of the complexities of the debate regarding screening were explored in a debate published in the Wall Street Journal.

In their report, Henderson, Gerson, and Phillis structure their insights by first addressing what may be implied by high risk (noting some variability in definitions and implications), exploring how risk-level determinations are made (risk stratification), pinpointing “the risk to risk”, and concluding with potential alternatives to the direction psychology and psychiatry are together moving.

High risk, they note, can mean any number of things, ranging from vulnerability to bullying, to low-SES, to potential for school failure. The authors suggest that determinations of risk level may be useful when reliably predictive of dangerous outcomes and when appropriately possible to link to effective care.

However, using suicide as a running example, they emphasize the lack of sophistication of tools currently available to predict accurately risk level, the absence of formalized systems in place to link children to support, the scarcity of empirically supported intervention initiatives even in communities where programs are available.

“Suicide screening instruments can be useful for guiding clinicians or others working with children and adolescents who might not otherwise know how to conduct a suicide risk assessment or even ask about suicidality,” they write. “However, these instruments do not necessarily add any value above the clinical standard of care for psychiatrists, either in risk stratification or in the prediction of suicidal behavior.”

Their exploration of risk level determinations highlights the often-murky nature of designations. Risk factors for suicide have been well established in research, but precision in prediction remains weak. Thus, distinctions between risk categories (e.g., high, medium, or low) may not provide the insight regulatory bodies imply. Differentiation between risk categories may be less clear cut than often assumed.

“Regulation can inspire and direct scientific advances, but it is nevertheless a problem when regulations are based on premature conviction about the evidence base.”

Henderson, Gerson, and Phillis reject the assumption regulatory agencies promote that there is no harm in screening, citing evidence of low sensitivity of some popular tools in identifying need, a lack of adequate programming illuminating the unethical nature of identifying risk without opportunity for appropriate intervention, and impractical protocol for intervention when supports are available. They write:

“If we are to be serious about addressing risk, we do know what to begin to do. Rather than algorithmic responses demanding services that may not be available or even indicated, public health measures instead should begin by restricting access to lethal means, mitigating risk factors on a population level, and enhancing broad access to care.”

The authors emphasize the potential value in tighter regulation of weapons, substances, and potentially dangerous medication alongside a movement towards a system valuing youth safety over adult convenience. Further, efforts to promote community and inclusion at a school level could potentially mitigate risk for depression among youth. Psychoeducation for children and families and an emphasis on connectedness are evidence-based practices that could also impact change.

Henderson, Gerson, and Phillis make a compelling case that without the enhancement of broad access of supportive services, and widespread acknowledgment of the importance of context even the best screening tools would have minimal practical value. They conclude:

“We should not forget, as advocates for child and family mental health, that every time we talk about children at risk, we need to think about why adults are putting children at risk and what we should actually be doing about it.”

 

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Henderson, S. W., Gerson, R., & Phillips, B. (2019). What Is “High Risk” and What Are We Actually Supposed to Do About It? Journal of the American Academy of Child & Adolescent Psychiatry, 58(6), 561-564. (Link)

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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19 COMMENTS

  1. Mental health screenings create “patients”, they don’t help people keep themselves out of the system. They are the perfect tool to use against groups of people that are considered to be less desirable than WASPS. This is the perfect tool to use against any group that the system fears.

    In the 1970’s, when the riots were taking place in the large cities of this country, more young African American men ended up in psychiatric institutions with labels of paranoid schizophrenic than you could shake a stick at. African American men are still the group that gets this label more than any other. When the country watched the Olympics held in Mexico City in real time and watched those two, young, African American sprinters (I think that they were track and field athletes) stand on the winners’ podium and slowly raise their black gloved fists in the air during the national anthem you could feel a collective wave of shock go through the room you were watching this in.

    When First Nations children (Native Americans) refused to give up their language and culture in the boarding schools (many of them run by Christian organizations) they were beaten and humiliated. When and if this didn’t work walla, they were sent to the asylums just especially created for the First Nations peoples through the wonderful generosity of the United States government and they were labeled as insane. They were often held for years there and guess what? They got to do work for the institution, without pay, just like they were expected to work at the boarding schools without pay.

    Do I think that these screenings are a good thing for children? Absolutely not. They are just one more example of the drug companies and psychiatry widening their net in order to trap as many people as possible. If they were really serious about helping children with high ACE scores they’d do something about the trauma being done all through this country on so many levels to children. They would pay attention to children when these kids tell someone that they’re being sexually abused by a family member or friend of the family. They will do something about the abusive foster child system that tends to drug the kids in their care rather than actually trying to understand what causes “bad” behavior. They will actually begin admitting that trauma is widespread against children in our society and then they’ll go about doing something about it.

    These screenings are a joke.

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  2. Well, for students 9th Grade and up, you could give them annual Hoffer/Osmond Diagnostic (HOD) Tests or Experiential World Inventories, both of which concentrate on inner experiences of the test subject, and one of which (the HOD) has a sub-set that suggest inquiries about suicide. I’m sure your professional readers will brush them off, as Hoffer and Osmond were Black Princes from the Dark Side of psychiatry (according to mainstream psychiatry), but I had an interesting experience while reviewing a group of old protocols I’d accumulated from numerous individuals. I had seven “suicide HODs” from several hundred tests, and the takers of six had made attempts (86%).

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  4. The key words are- “ as advocates of children and families mental health.”
    They should see and protest themselves as advocates for children and families.
    This idea had been around for a long, long time. Normal Schools actually highlighted social issues and some public school systems had Open Air Schools for medically fragile children with a nurse who did home visits and a physician and the surgeon currant health food of the day graham crackers and cream cheese.
    In the early 1980’s when child physical abuse was recognized but not sexual abuse there the beginnings of good hearted programs. Not that they were the best but essentially well meaning. They did not last because trauma and the concept of both macro and micro societal factors were never addressed.
    One local program was for identifying depression in teens. The father was a survivor but really really into the biopsych approach. It never got off the ground. Another was the idea of cutting in teens to teens. There was a more of a trigger event then solid help.
    It was like walking on the moon. So much was not understood and many tried things to quickly in ignorance.
    Not having access to the psych survivor history was a tragic and huge loss.
    There was much hidden from view.
    Title 1 reading programs incorporated both student and family support but the Social Work Staff were the first folks cut in school budget debacles.
    At that time, it was support and advocacy and never ever much about medication.
    This was also during the waves of desegregation and now looking back at the history of lynching I knew but honestly knew nothing about, no wonder kids did not want to go to school or the kids that did, the terror their families held in their hearts and heads.
    We the professionals and the government and the communities blew it big time and part of our suffering now as a nation is part and parcel of that tangled tragic history.
    Same for First Nation children who were forcibley moved to residential schools.
    I would like to think that psych survivors here and now can use our own tragic experiences to voice what so many children could and never did speak. We know.
    That maybe is true advocacy being a witness for not only ourselves and each other
    but all who encountered true abolition of human rights and dignity.
    It would be a door of hope if even beginning steps could be taken.

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  8. Label a bunch of shy, awkward , unhappy kids hopelessly defective.
    Force them to take a cocktail of mind altering drugs.
    Publicly parade them in front of others. Tell them how sick and crazy these kids are in order to lessen “stigma” through “education.”

    Good golly, what could possibly go wrong with this plan?
    It IS the perfect plan. Assuming the plan is grooming a criminal class through the educational system.

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  9. “Their exploration of risk level determinations highlights the often-murky nature of designations. Risk factors for suicide have been well established in research, but precision in prediction remains weak. Thus, distinctions between risk categories (e.g., high, medium, or low) may not provide the insight regulatory bodies imply. Differentiation between risk categories may be less clear cut than often assumed.”

    Risks factors for suicide are well established but there’s no precision in making predictions. In other words those factors don’t really apply and have more to do with something else, and you can be sure that whether or not someone is in the grasp of the mental health system is not listed as a factor, although I think that if you checked data that it increases the risk and is a major risk factor.

    Which seems to be a consistent story.

    Lets make a whole lot of people sick, and if something we’re doing helps some of them then we can ignore the basic truth that initially we made more people sick than we’re helping.

    Psychiatric drugs correlate with an epidemic, and they also cause extreme paranoia about the brain itself, as if it’s malfunctioning when expressing dissent, or sadness, or the kind of dream state called psychosis which is about as vital to society as dreaming, fiction, myth and why we would even have the ability to conceive of interactions in time.

    And psychiatric diagnosis allows a whole array of intelligence beyond the norm to be suppressed. From people dismissing another person because they are “crazy,” and what they are expressing are “symptoms.” to understandably insecure people being lied to about what’s going on with them and ending up being disabled for life. And all one has to do is instead of thinking someone is “crazy,” instead of going on about “mental health,” actually looking at what’s going on and really trying to understand it beyond the fear that it might expose something that takes you out of the comfort zone.

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  12. The cost of ~mental health~ screenings is that we are teaching people to cooperate in times when they should refuse.

    We should have cards people can carry which state a religious objection and give a web site and a number to call. Anyone who calls will be threatened with a lawsuit.

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  13. We should have discussions, and online and f2f training sessions, about how to refuse mental health screenings of all types. Basically just how to tell off psychotherapists.

    And remember, anytime a child is sent to a psychotherapist, that has to be considered as involuntary.

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  14. That they would get you in front of a psychotherapist, it is either voluntary, or it is because they already have some sort of power over you.

    And then as far as questionnaires, it is the same, they must have some sort of power over you.

    I feel that it is highly immoral to write or publish articles which are based on mental health questionnaires.

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