What’s the best way to screen for child mental health issues?

There’s a delicate balance between avoiding stigmatising kids and identifying those who need early help. Seema Krishnakum/Flickr, CC BY-NC-SA

Early childhood screening has been suggested as a way to identify and treat kids at risk of developing childhood mental health issues. But finding the right tool for such screening poses major challenges.

The most recent Australian National Survey of Mental Health and Well-Being reported that 14% of children and adolescents experience mental health problems at any single point in time. Many of these children and adolescents don’t receive professional help.

Mental problems are distressing for children and their families, and they negatively impact child development, learning at school and relationships with peers. Many such problems begin in childhood and persist into adolescence and adulthood.

Interventions that can prevent the onset of problems, or effectively treat them in early development, have the potential to provide benefits across the lifespan.

The right intervention

A major challenge for early interventions is knowing who should be provided with help. One group, for example, would be people who have problems that are likely to persist in the absence of professional support. There are two kinds of such interventions.

The first is a universal intervention, known as such because it’s provided to everyone in the population. Universal interventions avoid stigmatisation and have the potential to benefit a large number of people. But they are costly to deliver and the benefit to individuals is often relatively small.

The second type is targeted and provided to those identified as having early signs of problems or those who belong to a particular group at high risk of developing problems.

The advantage of targeted interventions is that they focus on fewer people and have the potential to be more cost-effective than universal interventions.

But an essential prerequisite for targeted interventions is accurately identifying (through some kind of screening program) those people who will develop problems in the future or have problems that will persist without professional support.

Piggybacking physical health

In 2008, Australia implemented a Healthy Kids Check program to encourage early identification of “lifestyle risk factors and physical health issues” in four-year-old children. And in 2011, it was proposed the program be expanded to include screening for early signs of mental health problems.

The goal of this expansion was to make better use of targeted interventions to help ensure that children are healthy, fit, and ready to learn when they start school.

This focus on screening for early signs of mental health problems caused controversy among medical professionals, within academic circles and the general community. There were calls for better quality information about the accuracy of early screening before the expansion of the program.

As a general rule, public health screening programs should only be undertaken if there are effective interventions available for people who screen positive. In the case of targeted interventions, the level of screening accuracy required is influenced by the nature of the intervention.

If it’s expensive and stigmatising, then a high level of accuracy is important because treatment resources will be wasted and people may be falsely labelled as being at risk for future problems.

If the costs of an intervention are low, it’s not intrusive or stigmatising, and has the potential to benefit people without problems, on the other hand, then a lower level of accuracy is acceptable.

In the case of childhood mental health problems, there are only limited treatment resources available and there’s a real risk of stigmatisation so a high level of accuracy is vital. We decided to look into the accuracy of one screening approach that might be used in the expanded Healthy Kids Check.

Assessing screening accuracy

We used data from the Longitudinal Study of Australian Children to assess the accuracy of information obtained from parents when children were aged between four and five to identify those who had teacher-reported mental health problems at age six to seven.

We found three-quarters of children who were identified by their parents as having problems didn’t have teacher-reported mental health problems at age six to seven. Clearly, a one-off questionnaire completed by parents is inadequate for identifying the majority of children who subsequently experience mental health problems.

Currently, identification of mental health issues in general practice relies on clinical judgement and the extent to which parents alert doctors to the presence of such problems. But there’s substantial evidence that many children with problems are overlooked.

We think combining parent-report questionnaires with the clinical skills of doctors who can re-assess children over time and build relationships with families, may improve our ability to identify children who could benefit from targeted interventions. And that’s good for everyone.