Aware that mental illness generally begins early in life and that four teenagers commit suicide every day, several organizations and agencies are stepping up efforts to expand voluntary mental health screening and suicide prevention initiatives for youth--but they are doing so in the face of stigma and vocal opposition.
Aware that mental illness generally begins early in life and that four teen-agers commit suicide every day, several organizations and agencies are stepping up efforts to expand voluntary mental health screening and suicide prevention initiatives for youth-but they are doing so in the face of stigma and vocal opposition.
Child psychiatrist Kenneth Duckworth, MD, speaking on behalf of the Campaign for Mental Health Reform, a national partnership of organizations representing the mentally ill, their families, service providers and many others, said at a Congressional briefing last year, "We strongly believe that voluntary mental health screen with parental consent and involvement can have a huge benefit for youth at risk of mental and emotional disorders" (Duckworth, 2005).
Yet, these efforts are being met with resistance by opponents who claim screening will lead to the "labeling" and "drugging" of children and interference with parental rights.
Well informed about the controversies, child psychiatrist Steven Adelsheim, MD, former director of and now consultant to New Mexico's school mental health program, told Psychiatric Times that voluntary mental health screening programs are critical for safety and suicide prevention.
Suicide among teenagers is a national problem, he pointed out. It is the third leading cause of death among teen-agers. In 2002 (the latest year for which data is available), 1,531 children 15 to 19 years of age, and 260 between 10 and 14 years of age committed suicide (Center for Disease Control and Prevention, 2005). New Mexico, Adelsheim said, has the fifth highest rate of teen suicide in the country. Last year, the New Mexico Department of Health was among 14 state-sponsored youth suicide prevention and early interventions selected to receive an estimated $400,000 each in federal funding from the Substance Abuse and Mental Health Services Administration (SAMHSA). The grants were made possible by the Garrett Lee Smith Memorial Act (SAMHSA, 2005).
New Mexico's challenge with regard to youth suicide is outlined in the 2003 New Mexico Youth Risk and Resiliency Survey, which involved 103 of 191 high schools in the state and 11% of the high school students. Researchers found that nearly 31.9% felt so sad and hopeless almost every day for two or more weeks in a row that they stopped doing their usual activities; 20.7% seriously considered attempting suicide, 14.4% attempted suicide one or more times in 2003, and 7.5% indicated that their attempt required medical attention by a doctor or nurse (New Mexico Department of Health, 2004). For comparison, 16.9% of a national sample of 15,000 high school students surveyed the same year reported they have seriously considered attempting suicide, 8.5% have actually attempted it one or more times during a year and 2.9% needed medical attention (Centers for Disease Control, 2004).
Since many mental health disorders, such as anxiety and impulsive control disorders, begin in childhood or adolescence, it is wise to identify them early to avoid treatment delays, said Adelsheim, also associate professor of psychiatry, family/community medicine and pediatrics at the University of New Mexico Health Sciences Center.
He pointed to research [National Comorbidity Survey Replication reports] published last year in Archives of General Psychiatry that indicated half of the individuals who develop a mental health disorder in their lifetimes exhibit symptoms before age 14 and three-quarters by age 24 years (Kessler et al., 2005). What's more, those same reports revealed a substantial delay in the time from illness onset to the time people get treated (e.g., delays of six to eight years for mood disorders and nine to 23 years for anxiety disorders) (Wang et al., 2005).
"So it seems to me that being able to identify kids at risk early and then linking them early to services will decrease the chronicity of illness and will decrease the seriousness of other risk factors that might develop, such as violence, suicide, teen pregnancy and/or substance abuse problems," Adelsheim said. "When we are looking at depression and other mental health conditions, there is real value in identifying these problems early, getting kids services and getting them back on track in school."
Mental health problems that go undetected and untreated frequently persist, leading to educational ramifications as well, he added. A child who is very depressed or has other mental health problems that go untreated isn't going to learn or become a productive citizen.
A vocal opponent of the early detection concept is Rep. Ron Paul (R-Texas), a physician, who in 2004 and 2005 introduced legislation to prohibit the use of federal funds for a "universal or mandatory mental health screening program," arguing that it negates parental rights, encourages overmedication of children and is unsupported by evidence that it decreases suicide attempts. Paul's legislation (which did not pass) was backed by some anti-psychiatry and conservative political organizations, including Concerned Women for America, Gun Owners of America and the Eagle Forum. Paul's legislation particularly sought to prevent grants to states to implement recommendations of the President's New Freedom Commission on Mental Health.
Additionally, in several states across the United States, legislation has been introduced that prohibits mental health screening of children in schools, prohibits school personnel from recommending psychotropic drugs for children and limits the ability of school personnel to make recommendations or even have dialog with parents about behavioral health diagnoses, according to the National Mental Health Association (2005). States with such legislation have included: Alaska, Florida, Georgia, New Mexico, New Hampshire, New York, Pennsylvania, Tennessee, Utah and Vermont. In both Utah and Florida, the legislation was passed by the legislature but vetoed by the governors.
Much of the controversy over mental health screening stems from an endorsement of the practice by the President's New Freedom Commission on Mental Health. While the commission has been accused of calling for mandatory screening without parental consent, Michael F. Hogan, PhD, director of the Ohio Department of Mental Health and chairman of the commission, in a 2004 letter to the Washington Times, said:
The commission did not call for mandatory universal mental-health screening for all children. I am at a loss to explain why this misrepresentation persists, since it is at odds with the plain language of our report to the president. ... [T]he commission proposed broad screening only in settings where many children are known to have untreated behavioral problems. Beyond this, the commission promoted programs that provide voluntary screening only with parental consent.
A SAMSHA backgrounder recently pointed out that the Administration does not support mandatory screening nor screening of children without parental consent.
One of the model screening programs identified in the New Freedom report was TeenScreen, created by Columbia University in New York City, under the leadership of David Shaffer, MD, director of the Division of Child and Adolescent Psychiatry at Columbia University. It has become the most widely used mental health screening program for teen-agers, with more than 450 active screening sites in 43 states. According to data from the Suicide Prevention Resource Center, seven of 41 states that currently have suicide prevention plans specifically mention TeenScreen by name: New York, Florida, Iowa, Nebraska, New Mexico, Oregon and Vermont. Additionally, TeenScreen has trained individuals to conduct screenings in Panama, South Korea, Colombia and Australia.
"For 2005, based on the projections we get back from our sites, we think approximately 122,000 kids [in the United States] were offered the screening, and about 55,000 actually did the screening," Leslie McGuire, MSW, director of Columbia University's TeenScreen Program, said in an interview with Psychiatric Times. Since the program's initiation in 1999, McGuire estimated that 100,000 teen-agers have been screened. About 16% to 17% of those screened received a referral for a complete mental health evaluation.
"Our ultimate goal is to make mental health checkups available to all American teens," said McGuire. "I don't mean that every kid should be screened, but that this should be something that is available for our kids just like other health screenings are."
Laurie Flynn, executive director of the Carmel Hill Center for Early Diagnosis and Treatment, which oversees the TeenScreen Program, and executive director of TeenScreen, likened TeenScreen to an early warning system. We are very eager, she said, to find those youngsters who may be at risk for serious psychiatric disorders, to identify those youngsters and alert their families so they can make the best decisions about further assessment and appropriate treatment.
The issue of youth suicide prevention is personal to Flynn; her daughter made a suicide attempt during her senior year of high school.
"Certainly having the experience as a parent of dealing with a youngster, who suddenly became depressed and suicidal, was stunning and certainly galvanizing. I never experienced anything as terrifying and for which I felt quite as unprepared," she told Psychiatric Times, adding that she wished a program like TeenScreen had been in place when her daughter's illness struck.
The TeenScreen program uses scientifically validated questionnaires to help identify teen-agers at risk. Currently, sites have the option of picking between three different screens:
All of the screening instruments, which take between eight and 10 minutes to complete, were developed and tested at Columbia University.
"We know those screens and the research base for those screens well, and we are able to provide specific training in how to use them, and how to interpret the results," Flynn said.
Typically, we bring the folks to New York, and they will spend one full day in a training session at Columbia. Sometimes, we go out to a site, if we are training a lot of people at once, Flynn added. Recently, TeenScreen hosted its first conference. More than 200 attendees received updates on research and were able to share information on techniques that are effective in screening and suicide prevention.
Currently, the TeenScreen Program offers its screening instruments, materials, software, training and consultation services at no cost.
"We have never had any sponsorship other than private philanthropy here at Columbia, which has been useful in the wake of these erroneous allegations that we are somehow promoting one or another kind of treatment. ... Because, in fact, we never have, we don't and that's not our role," Flynn said.
There are several ways that communities can make mental health screening available to youngsters and their families, at minimal cost, according to Flynn.
Sometimes, there is a school health clinic, and the screening becomes part of the health checkup process.
Sometimes, the staff of a community mental health center will come into a school or community site and provide the screening to youngsters. Sometimes, a local mental health association will have a contract with the school district to provide the service.
"We've worked with the State Department of Education in Iowa, Office of Drug Control in Florida, with a student assistance program in the schools in Pennsylvania ...wherever there is energy and interest," Flynn added.
Flynn emphasized that the screenings are voluntary and require parental consent and involvement.
"Nobody cares more about family privacy than I do, and nobody respects more of the role of families in mental health services and decision making than I do," said Flynn who served as executive director of the National Alliance for the Mentally Ill for 16 years.
She explained that both parental consent and participant assent is required before a youth can participant in the screening process.
"We have given our sites standard letters and forms and recommended models they can use and adapt. So, I think we have been an exemplary program in the use of consent," she said.
"We are about identifying potential for risks, alerting the parents, and then parents can choose what to do next. Parents need to be informed about their options, but we didn't want to look like we were coming with 'the solution,'" Flynn said.
McGuire explained the general process once a teen-ager screens positive on one of the TeenScreen instruments. The teen-ager immediately will have a clinical interview with a mental health professional to determine if they need a complete evaluation. If an evaluation is determined necessary, a TeenScreen case manager meets with the teen-ager and contacts the parents to inform them of the screening results and the clinician's recommendations. The issues are explained in detail.
"It is not enough to call up and say, 'We have screened "Leslie," and we think she's got depression and needs to be evaluated for that, good luck,'" said McGuire. "You need to explain what depression is, how it can impact the child and his or her functioning, what happens when depression is not treated and then offer the family assistance in finding a place where the child can be evaluated."
Families without insurance are given assistance in getting help through public programs.
In New Mexico, Adelsheim said that currently 14 different school districts around the state are using some version of TeenScreen at their school-based health centers. He expects that number to grow, since additional state funding is enabling the number of school-based health centers to grow from 34 to 68.
"We have been looking at the issue of how we are going to build more TeenScreen models across the school-based health centers throughout the state," said Adelsheim, who is now a consultant for New Mexico's Behavioral Health Purchasing Collaborative.
Work with TeenScreen in New Mexico began in 2001 through a collaborative relationship with the New Mexico Department of Health's Office of School Health and the University of New Mexico's Department of Psychiatry. As a pilot test, the TeenScreen Program began at five school-based health centers, one of which was in the Native American community of Acoma-Laguna. The pilot led to the stationing of a TeenScreen Program Western Regional Coordinator in Albuquerque, integration of the TeenScreen Program into several Robert Wood Johnson-funded research grants and the adoption of screening by several frontier schools.
In the state, Adelsheim explained, TeenScreen serves as a secondary screening tool after students are first identified as being at risk on a statewide initial information screen administered at school-based health centers.
"We really only train sites on the use of TeenScreen where we have had an adequate number of mental health providers on site to be available to provide services to the youth who ended up with a positive screen. So we haven't used it really in a broad-brush, universal approach," he said.
To assist school-based health centers in rural areas, Adelsheim said child psychiatrists from the University of New Mexico are visiting some areas one or two days a month, working with the schools and seeing some of the kids identified as being at risk for mental health problems or suicide. Also, a Telehealth project launched this year is enabling child psychiatrist consultants to provide backup consultations.
Nationally, questions have arisen as to the efficacy of voluntary mental health screenings for youth. A follow-up study of teens referred to treatment following screens found that the majority of youth identified as at risk got help. Parents reported that 47% of teens referred to a mental health professional received help within the first three months of the screening and that number grew over time. Six months after screening almost 60% had received assistance. In one survey of parents whose children were identified through TeenScreen, 72% reported that their child was doing very well or significantly improved after participating in the screening program and seeing a mental health professional (Center for Early Diagnosis and Treatment, 2004).
Currently, the TeenScreen Program is working on a multi-stage evaluation with a school district in the Midwest, according to McGuire. The school district has in-school mental health programs and the mental health team does a pretty good job of identifying kids who need help, she said. The number of kids identified by the mental health team was compared with the number of kids identified as being at risk with TeenScreen.
"The results are that TeenScreen identified 15 times the number of kids who need mental health services than did the in-school mental health program," said McGuire. "We are continuing to do research there. We are going to follow up the kids who are identified by both TeenScreen and by the in-school mental health program, and re-interview the kids and also their parents, hopefully this spring, to find out what happened to them. Did they go for mental health services? Was it helpful? What kind of services did they get?"
The researchers also will compare the teens that were referred and received mental health treatment to those who didn't seek out the services. Additionally, there are plans to offer screening to the same kids a year and a half later to see what happened. For example, are kids who screened negative the first time, now positive? Attention will also be given to attendance and academic outcomes.
On a personal level, Flynn is aware of teen-agers identified through TeenScreen who have gotten help and are doing well. She described a young African-American female who, at age 15, was very depressed and on the verge of dropping out of high school. The teen-ager was identified as being at risk through TeenScreen and received treatment. Now, she has completed high school and is midway through college.
After connecting to treatment, she was asked why she didn't tell someone she was in trouble and needed help. Flynn said her answer was very poignant and one she hears all the time: "Nobody ever asked me."
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