By Colleen Fitzpatrick

Field leaders combat opposition; say screening will help youths Mental health screening.

To most professionals in the behavioral health field, those words signify a progressive practice embraced by the nation's top thinkers about mental health policy. Routine screening of the nation's young people for depression and other disorders or problem behaviors can lead to a range of positive out-comes with lifelong effects, from enhanced learning abilities and improved classroom performance to aversion of suicide, supporters say.

To other people, the same three words arouse fears around the stigma that might attach to a child or family as a result of the screening. Some opponents argue that the practice could encroach on territory that belongs to parents. Among a few, the phrase conjures images of "Stepford children," children who act increasingly alike as variations in behaviors are weeded out, largely through the use of medication urged by pharmaceutical companies and the "mental health industry."

Though mental health screening has been occurring for a few years in communities and schools nationwide, the debate bubbled forth last year onto the state and national stages.

In Illinois, which was considering sweeping reforms to its child mental health system, a draft preliminary plan sparked controversy with its recommendations to screen all pregnant women for depression and to "ensure that all children receive periodic social and emotional develop-mental screens." A subsequent draft version clarified the voluntary nature of proposed screening programs.

And last fall, mental health screening received a limited airing in Congress, when U.S. Rep. Ron E. Paul (R.-Texas) introduced an amendment to the Department of Health and Human Services (HHS) appropriations bill to prohibit the use of federal money for mental health screening programs. The amendment was overwhelmingly defeated on the House floor; 315 lawmakers voted against it. But 95 did vote "yes."

Paul then introduced the "Let Parents Raise Their Kids Act of 2004" (H.R. 5236) in an attempt to achieve his goal. The bill argues that mental health screening programs, if mandatory, "could lead to the increased over-medication of children," and could violate privacy and stigmatize families on the basis of their political, religious and social beliefs. Mental health advocates seethe at some of the 16 findings listed in Paul's bill, including that "parents are already being coerced to put their children on psychiatric medications and some children are dying because of it." Some advocates last fall questioned the need to publicly respond to such assertions, as well as those of anti-screening groups such as the Citizens Commission on Human Rights (CCHR), a self-described "mental health watchdog established by the Church of Scientology in 1969." In the end, advocates decided they could not afford simply to wait and hope that the controversy would blow over. Taking that approach might prove to be to the mental health field what presidential candidate John Kerry's early inaction to the Swift Boat Veterans for Truth assertions was to his chances for success, says Bill Emmet, coordinator of the Campaign for Mental Health Reform. Dooming, in other words. And for the mental health field, that could mean putting federal money for programs at stake. The Campaign for Mental Health Reform, a coalition of 16 mental health advocacy and policy organizations, released a statement in November in support of screening. The six-paragraph statement is "a pretty significant achievement," Emmet says. "We got a broad cross-section of the mental health advocacy organizations to agree to stand behind a short statement we feel was necessary in light of so much hysteria based in misconceptions ... and the threat that that would pose to programs we care about," including some $44 million in federal State Incentive Grants. Emmet, who also serves as project director with the National Association of State Mental Health Program Directors (NASMHPD), continues: "Left unanswered, people begin to believe the mental health commission recommendations are about the things that [screening opponents] are talking about. They're not. They're about a common-sense approach to mental health. It's very important to answer the wild assertions regardless of how they've developed."

Momentum on issue

The crosscurrents are likely to strengthen in the months ahead. Some forces, such as a new federal suicide-prevention law and private entities that are expanding screening efforts nationwide, are propelling the movement forward. Other forces are at work to hold back the effort, including organized anti-psychiatry groups and recent questions about a link between some antidepressants and suicides among young people, along with increasing scrutiny and public suspicion of the federal drug-regulatory process and the motivations of pharmaceutical companies. The screening debate has roots in the 2003 report of the President's New Freedom Commission on Mental Health, the only such report in a quarter-century. One of the report's six goals (Goal 4: Early Mental Health Screening, Assessment, and Referral to Services are Common Practice) observes, "If the system does not appropriately screen and treat" childhood disorders early they "may persist and lead to a downward spiral of school failure, poor employment opportunities, and poverty in adulthood. No other illnesses damage so many children so severely." Four recommendations accompany the goal. They include calls for screening across a person's lifetime, and for improving and expanding school mental health pro-grams. The commission report states, "While schools are primarily concerned with education, mental health is essential to learning as well as to social and emotional development. Because of this important interplay between emotional health and school success, schools must be partners in the mental health care of our children."

Opponents of screening have taken the commission report's recommendations to mean that a government move is afoot to declare mental health screening mandatory and universal. A weekly column by U.S. Rep. Paul titled "Forcing Kids into a Mental Health Ghetto" and posted on his website states that the report urges "forced mental health screening for every child in America." That's just one example of the misrepresentations being perpetuated, advocates say. Ralph Ibson, J.D., vice president of government affairs at the National Mental Health Association (NMHA), which is a member of the Campaign for Mental Health Reform, says, "Clearly, the issue has never been mandatory, universal mental health screening, which no one has pro-posed. An issue of real concern, however, is whether opinion leaders and policymakers will succumb to a campaign that seeks to single out mental health as a `radioactive' issue that must be regulated through federal law, as some have proposed."

Screening supporters say it is unconscionable not to use the tools available to identify emotional problems in children early on, and to alleviate the problems with treatment and supports. "What is the ethical responsibility?" says James McDonough, director of the Florida Office of Drug Control, which is assisting counties, school districts and youth programs in Florida that are interested in screening. "Is it more ethically responsible to adopt an ostrich-like approach or to know [about problems] and to offer services and advice?"

E. Clarke Ross, D.I A., chief executive of Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), echoes that sentiment. "If you're content with suicide rates for teens and children, if you're comfortable in allowing children to kill themselves every year and fail academically and for a number of them to drop out [of school], then you can continue not having mental health screening and not having programs for children with emotional, behavioral and mental disorders."

Ross and McDonough also observe that failing to treat emotional or behavioral disorders early results in an invitation to far too many young people into the juvenile justice system.

Where, when should screening occur?

Many advocates say the ideal setting for screening is in doctors' offices and clinics, integrated with primary healthcare. "Whoever is doing screening for general public health should involve mental health screening," says Ross, whose organization also is a member of the Campaign for Mental Health Reform.

The issue grows more complicated when the role of schools is considered, Ross acknowledges. Schools are "responsible for maximizing learning opportunities for all children. ... Screening them is a way of trying to more effectively identify emotional and behavioral problems where those problems are interfering with learning," he says. The alternative, he adds, is to "wait until problems become so severe and significant that it highly disrupts the learning both for the individual and the class."

But don't tools already exist in schools to identify children with behavioral problems? Theoretically yes, say some screening supporters. Good school systems have psychologists, nurses and guidance counselors in place, along with procedures for addressing behavioral problems. But many schools don't have the money or personnel to operate according to that ideal.

Some advocates liken mental health screening to the decades-old practice of offering vaccinations and other-wise checking children in schools for vision and hearing problems, scoliosis and other physical health disorders.

But Daniel Fisher, M.D., Ph.D., a practicing psychiatrist who served as a mental health consumer representative on the New Freedom Commission, disagrees with that assessment. "It's very different from physical health because the causes are so much more complex," he says. "Unlike vision and hearing, which are located exclusively within the child, [behavioral and emotional problems] have much more to do with the interactions between the child and the social system."

Fisher is executive director of the consumer-run National Empowerment Center, which also is a campaign member. He supports screening for children in distress, but views it as "not a first step but almost a last step."

One danger is that screening could lead to "too narrow a definition of what the problem is; you don't get the full picture. You miss the person's relation to their larger environment," Fisher says. For example, there may be too many children in a classroom, and a child might need more attention or intellectual challenge. Teachers might not be taking a child's learning style into account. Or the child may have nutrition needs.

"There's no question that a child in distress needs help, but it should be provided in a comprehensive fashion, in a collaborative fashion ... with wraparound services," Fisher says. "Viewing mental illness through a narrow lens of symptoms does not enable people to meet life's challenges — vocationally, emotionally or residentially."

Fisher also raises issues of self-determination and control over treatment. "In a recovery-oriented system, how much children and individual families have control over the situation is very important."

As schools, communities and states set up screening programs, advocates strongly acknowledge the need for clear guidance and thorough discussion and written policies that address the qualifications of the individuals conducting the screening, and the procedures to protect the privacy and confidentiality rights of children and parents.

How will results be used?

Opponents' main concerns kick in once the screening results are in hand. One fear is that screening will lead to widespread medication use — in the absence of studies into pediatric prescribing practices.

They also point to the ongoing discussion of selective serotonin reuptake inhibitor (SSRI) antidepressants and the risk in adolescents of violent and suicidal behavior. The issue was widely debated last year amid deepening concerns among health professionals of all stripes (and the public) about the integrity of the Food and Drug Administration's (FDA's) role in assessing drug safety.

Fisher is wary of diagnosing a child according to the American Psychiatric Association's (APA's) Diagnostic and Statistical Manual of Mental Disorders. "You have to be very cautious about what this label could do and what the consequences would be for this child, for their future and also what the treatment would be. ... Once a problem is identified, there's inevitably referral for segregation."

Fisher continues, "Very frequently the treatment of choice becomes medication." Behavioral problems "often are the responsibility of the school system to address and I think school systems would prefer to have these problems medicalized."

The Alliance for Human Research Protection (AHRP) took similar concerns several steps further in a widely disseminated e-mail last fall. "The only beneficiaries of government-initiated screening for mental illness are the pharmaceutical industry, politicians whose campaigns the industry finances and the mental health provider industry — including psychiatrists, psychologists, medical institutions, social workers and 'advocacy' groups — all of whom have a vested interest in expanding their income-producing client base," the patient protection group wrote.

Supporters stress that screening does not produce a diagnosis, but rather is the first step in a process that includes further assessment, and treatment if appropriate. Users of one screening program, Columbia University's TeenScreen, report that about 15 percent of students who are tested are referred to mental health services.

Ratcheting up research

Adding to the debate is the lack of a robust body of research surrounding screening.

One study published last year in the American Journal of Public Health found that the SOS High School Suicide Prevention Program, a depression and suicide screening program, reduced suicide attempts by 40 percent among 2,100 students exposed to the program in Hartford, Conn., and Columbus, Ga., high schools. The program, offered by Screening for Mental Health, Inc., of Wellesley, Mass., is on the National Registry of Effective Programs maintained by the federal Substance Abuse and Mental Health Services Administration (SAMHSA).

TeenScreen, whose goal is to offer a free and voluntary mental health checkup to every student in the country before he or she graduates from high school, was singled out by the New Freedom Commission as a model program. Columbia researchers, including David Shaffer, M.D., chief of child and adolescent psychiatry and leader of the research effort to develop TeenScreen, have conducted a few screening-related studies. One published in the Journal of the American Academy of Child and Adolescent Psychiatry established the reliability of the program's screening instrument.

As the practice expands, so will the research. The nation's first youth suicide-prevention law, the Garrett Lee Smith Memorial Act, authorizes spending $82 million in federal money in the coming three years to support state efforts to create or expand youth suicide-prevention programs, and for evaluation.

Both TeenScreen and Screening for Mental Health have shifted their strategies this year. While continuing to work with individual schools or communities, the organizations also have targeted regional and statewide agencies in order to have a broader impact and attract public funding. Both also have new research planned or under way.

The chairman of the New Freedom Commission, Michael F. Hogan, Ph.D., says one intention of Goal 4 was to light a fire under the research community to provide better science-based guidance about the effectiveness of a host of practices and treatments in mental health. Hogan, director of the Ohio Department of Mental Health, says he believes the debate over screening will quiet down — but not before raging for a while longer.

"The current flap about screening is in my view a lot like the flap about SSRIs and teenage suicide in that I think in time it is going to be seen as silly," Hogan says. "But as we sit here today, it is tremendously unfortunate that the research community has not yet provided better guidance about the safety and effectiveness of medication. It's also unfortunate that in our schools, pediatric practices and our families we as a nation are unprepared to identify children with developing and potentially serious and even fatal disorders."