Mental health disorders in children are a public health issue due to the early onset, prevalence, and impact of these disorders (1). Mental health disorders have become increasingly prevalent among youth, with an estimate of 13-20% of school-aged children experiencing a mental disorder each year (2). A mental health disorder is defined as a serious deviation in the way children may learn, behave, or handle their emotions, and while the onset often occurs in childhood, its impacts may reach far into adulthood (3). It leads to a negative effect on a child’s development, preventing them from reaching necessary milestones (1). About 1 in 5 children meet the criteria for psychiatric disorders with impairment, with the most common mental health disorders including ADHD, anxiety, and depression (4). In addition, these disorders commonly occur together—for example, 3 in 4 children with depression have anxiety as well, and 1 in 2 children with depression have behavior problems (5). Coupled with the natural stress that children face from the demands of life, as well as the variation in services offered, it is critical for children to get the treatment they need as soon as possible (6).Not only do mental health disorders affect children and the way they learn, but the total cost of these disorders is around $247 billion annually. Additionally, suicide, which has been shown to be due to the interaction of mental health disorders with other factors, was the second leading cause of death among children 12-17 (2). Considering these factors, it’s clear that mental health in children needs to be further addressed.

Early detection and treatment coupled with ongoing assessment and monitoring is considered the best practice for mental health in children (7). Currently, some estimate that less 50% of children and adolescents with a mental health disorder have received needed services. In fact, one study showed that only 59.3% of anxiety problems and 53.5% of those with behavioral problems received treatment (1). Additionally, the average delay between the initial appearance of symptoms and the treatment or intervention is 11 years (8). These problems are partly because current mental health services are typically reactive rather than proactive, meaning that often students are overlooked and not screened for mental health disorders until the symptoms have noticeably impacted them or others in some way (6). This causes many children to lack a clear diagnosis and in turn the care needed.           

Schools are a key stakeholder in mental health services—often school behavioral health programs are the primary source of services for youth (6). In fact, 70% of youth who access mental health care do so within or in conjunction with schools (7). However, within schools, there is still under-identification, unmet needs, and a low quality of care. There is regular screening for physical health, but typically mental health concerns are only addressed after they have become noticeable (9). Externalized behaviors then are most often addressed, while thos with mental health disorders who internalize their associated behaviors are overlooked. Many students would benefit from schools providing a general mental health screening to all students before referring or assessing their eligibility for services. Currently, less than 15% of schools systematically evaluate the mental health needs of their student population (6). Yet at the same time, a survey of superintendents across the country showed that students’ behavioral health needs were the top concern (9). This shows there is a need for a way to address mental health disorders in children that utilizes the close relationship with the schools they attend.

            In order to help address the public health concern of mental health disorders in school-aged children, an essential first step is the implementation of universal screening procedures to assess all students for early signs of disorders. The urgency of a universal screening is already recognized and supported by the National Association of School Psychologists (9). Because schools are such a critical place for reaching youth with mental health issues, screening all children for these disorders should be a priority. Currently, childhood mental health disorders are “not typically the sole focus of federal public health surveillance but are included within systems that address multiple health issues” (2). Essentially, the only general screening in place for mental health in children is “as needed” or done within a random sample for research, rather than for the child’s benefit. There needs to be a clear effort to address childhood mental health and this can be done with screening students in schools. This would be the initial screening of all students, followed by steps to later identify those at risk, assess more specifically, and provide early intervention (6).

            Mental health screenings for all students would help bridge the gap between symptoms and the needed intervention (8). Typically, addressing mental health is done by relying on teacher nomination or school data like grades or attendance, which are more focused on the students that are externalizing their behavior or mental health disorder (9). Universal screening would allow for a more proactive approach, making sure more students are identified. This identification could lead to a reduced need for more intensive or specialized treatments due to earlier recognition of mental disorders in students (10). Because it would be within schools and rely on key stakeholders within those schools, it would also familiarize more staff members with the indicators of mental health disorders, which could be further applied throughout the year.

Universal mental health screenings would also provide increased information about the prevalence of mental disorders to inform future policy and resource allocation through the data collection that could occur. This is especially important because currently, the only source of data collection concerning childhood mental disorders is from various random sampling conducted by groups like the CDC. This data is limited considering the fact that it is only done through things like telephone surveys or a random sampling of only 14 selected sites (2).  Many schools are already implementing programs or tools to help them better screen their students, and screenings could be adjusted slightly to focus on what is most prevalent to specific schools or districts—for example, internalizing mental health concerns vs. externalizing (11). Screening in schools would also increase the collaboration between school and community providers, resulting in increased access for all children. Additionally, a universal screening would most likely normalize mental health disorders and provide a safer environment where students feel more comfortable with and understanding of these disorders (11). Schools are already an important resource in treating mental health disorders and implementing screenings would promote student success and provide access for all students (10).

            However, there are drawbacks to universal mental health screenings being provided by schools. Some may feel that this screening violates the privacy of their students’ mental health and information associated (10). However, as previously mentioned, most children dealing with mental health disorders already receive treatment or interventions at school. Limited amount of resources warrants concern, especially if there is an increased number of referrals to providers for treatment as a result. It would also require stakeholders within the school to make this happen, which relies on willing collaboration of school administration and staff. Additionally, funding would most likely be needed to ensure the proper development and implementation of a screening program for all schools. While there are many free screening tools currently available, standardizing the format and creating a clear system for all schools to adopt would take time and resources.

While some schools already have some screening programs already in place, these may not be evidence-based or may produce too many errors in their results, especially if untrained school faculty are involved (10). It would require time to be taken away from direct instruction, but perhaps it could be coupled with the general health screenings that schools already require if needed. Regardless, it will take an increased amount of time at some level.  Some worry about the risk of overdiagnosis or stigmatization that may happen due to the broad screening methods that would be done (11). However, this screening would serve as a preliminary measure to then refer students who raise concerns, rather than an official diagnosis or treatment.

            Mental health screening is needed to better diagnose and treat children who need it. Schools provide a clear place for universal screenings to occur as many students access mental health resources there already. Because of this, it is worth considering the possibility of a universal health screening that could be implemented within schools to better diagnose and treat children with mental health disorders.  

Sources:

1. Ghandour, R., Sherman, L., Vladutiu, C., et al. Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children. Journal of Pediatrics; 206 (March 2019): 256-267. Accessed from https://www.jpeds.com/article/S0022-3476(18)31292-7/fulltext
2. Perou, R., Bitsko, R.H., Blumberg, S.J., Pastor, P., Ghandour, R.M., Gfroerer, J.C. et al. Mental health surveillance among children—United States, 2005-2011. Centers for Disease Control and Prevention. (Suppl)MMWR. 2013; 62: 1–35. Accessed from https://www.cdc.gov/mmwr/preview/mmwrhtml/su6202a1.htm?s_cid=su6202a1_w
3. Centers for Disease Control and Prevention. Key Findings: Children’s Mental Health Report. March 2019. Accessed fromhttps://www.cdc.gov/childrensmentalhealth/features/kf-childrens-mental-health-report.html
4. Carter, A., Wagmiller, R., Briggs-Gowan, M. Prevalence of DSM-IV Disorder in a Representative, Health Birth Cohort at School Entry: Sociodemographic Risks and Social Adaptation. J Am Acad Child Adolesc Psychiatry. 2010 Jul; 49(7): 686-698. Accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3166638/
5. Centers for Disease Control and Prevention. Data and Statistics. April 2019. Accessed from https://www.cdc.gov/childrensmentalhealth/data.html
6. Siceloff, E., Bradley, W., Flory, K. Universal Behavioral/Emotional Health Screening in Schools: Overview and Feasibility. Rep Emot Behav Disord Youth. 2017 Spring; 17(2): 32-38. Accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350819/
7. Connors, E., Arora, P., Curtis, L., Stephan, S. Evidence-Based Assessment in School Mental Health. Cognitive and Behavioral Practice. Feb 2015 22(1): 60-73. Accessed from https://www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/pii/S1077722914000509
8. National Alliance on Mental Illness. Mental Health Screening. 2020. Accessed from https://www.nami.org/learn-more/public-policy/mental-health-screening
9. Substance Abuse and Mental Health Services Administration. Ready, Set, Go, Review: Screening for Behavioral Health Risk in Schools. Rockville, MD: Office of the Chief Medical Officer, Substance Abuse and Mental Health Services Administration, 2019. https://www.samhsa.gov/sites/default/files/ready_set_go_review_mh_screening_in_schools_508.pdf
10. Center for Mental Health in Schools at UCLA. Screening Mental Health Problems in Schools. Mental Health in Schools Program and Policy Analysis. Accessed from http://smhp.psych.ucla.edu/pdfdocs/policyissues/mhscreeningissues.pdf
11. Goodman-Scott, E.; Donohue, P.; Betters-Bubon, J. The Case for Universal Mental Health Screening in Schools. American Counseling Association, 2019. Accessed from https://ct.counseling.org/2019/09/the-case-for-universal-mental-health-screening-in-schools/