Position Statement 41: Early Identification of Mental Health Issues in Young People

Policy

Early identification, accurate diagnosis and effective treatment of mental health or substance use conditions1 in school-aged young people can alleviate enormous suffering and heartbreak and help young people to benefit from their education and to lead productive lives. No one contests that state and federal systems that serve young people like juvenile justice and child welfare need to engage in comprehensive screening, but several states have sought to ban mental health screening in schools. Mental Health America (MHA) opposes such legislation because it compromises the responsibilities of the schools under federal law to provide an education to all young people, regardless of disability, compromises the schools' obligation to identify and address significant impediments to learning of all kinds, discriminates against young people with emotional or behavioral difficulties, and risks constraining free communication by teachers and counselors to parents, which is essential to early identification and effective treatment of mental health and substance use conditions. Whenever warning signs are observed, parents should be counseled to see their primary care physician or a mental health professional concerning their child's need for mental or other health care.2

Of even greater potential importance, MHA believes that primary health care providers should be encouraged to identify signs of mental health or substance use issues at the earliest possible time. This position is endorsed by the American Academy of Pediatrics and (for depression) the United States Preventive Services Task Force.3

For early identification to have any value, public and private resources must be available to assure effective treatment. Reliable early identification of health problems in schools and primary care settings and effective, nondiscriminatory treatment can help to address a young person’s needs before they lead to greater academic or social problems, including suicide or self-mutilation, substance use, school suspension, dropping out, expulsion or involvement with the juvenile justice system.

Public education is needed to assure that parents, friends, teachers, school officials and primary care physicians and other health care providers can identify the early signs of mental health and substance use problems so that young people can receive the help that they need in a timely manner.

Background

Mental health problems affect one in five young people at any given time, and about two-thirds of all young people with mental health problems are not getting the help they need.4 5 6Research shows that early intervention can prevent significant mental health problems from developing. 7 8 Epidemiological research confirms the relationship between mental health issues and suicide or self-mutilation, substance abuse, suspension, dropping out, expulsion and involvement with the juvenile justice system.9 10 The research also shows that effective treatment can reduce the risk of such consequences.11 12

President Bush's 2003 New Freedom Commission on Mental Health proposed in its goal that: "In a transformed mental health system, the early detection of mental health problems in children and adults - - through routine and comprehensive testing and screening - - will be an expected and typical occurrence." The report emphasized early intervention in low-stigma settings like physicians' offices and schools, but much work remains to be done.

Primary care physicians and other health care providers are the "first line of defense" in identifying signs of mental health problems because they routinely see young people and their families and because confidentiality is assured. Research should be expanded to assure the availability of reliable, culturally and linguistically competent early identification and diagnostic tools. Primary care providers need to be trained in their use, and public and private resources need to be made available to assure that comprehensive treatment, individualized to the needs of the child and family, is available on a nondiscriminatory basis.

Recent collaborative efforts of pediatricians and mental health professionals have led to improved early identification efforts in Massachusetts, Vermont, Minnesota and New York. These efforts have enhanced access to timely and appropriate child psychiatric evaluations, consultation and treatment. MHA particularly applauds such efforts, which join forces with the primary health care system to promote the early identification of mental health issues in young people.

Although schools are required to identify all mental and other health impediments to learning under the federal Rehabilitation Act and Individuals with Disabilities Education Improvement Act, including mental health issues, screening for emotional or behavioral difficulties in schools has proven to be highly controversial and politicized. The concerns regarding school-based screening include fears of stigma, liability and cost, issues of mis-diagnosis and coercion of parents by school personnel, and deep concerns about over-medication of children. In addition, issues of cultural and racial bias are a significant concern among people of color. The development of reliable and culturally and linguistically appropriate screening tools remains an urgent priority.13

MHA acknowledges these challenges of mental health screening. However, with appropriate safeguards, MHA supports well-designed pre-school-based and school-based screening programs. Because teachers, school psychologists, social workers and other counselors have extended contact with children on a daily basis, they are often in a position to recognize early patterns of behavior that pose a risk for a child’s academic, social, emotional or behavioral functioning. While teachers and other school administrators are not and should not become diagnosticians, their candid communication with the family is vital in promoting students' well being, including their mental health. Where any health problems are noted, their concerns should be shared with the parents in a timely manner. In this regard mental health problems should be treated no differently than other health-related concerns. School personnel should be trained to recognize the early warning signs of mental health and substance use conditions and to know the appropriate actions to take in notifying parents and in protecting the rights and privacy of young people.

Accordingly, MHA opposes interference with the proper role of teachers and counselors in communicating with parents concerning the behavior and needs of their children. Schools and other community institutions and voluntary associations should encourage teachers and counselors to communicate regularly with parents concerning their child, including counseling the parents to consult with their primary care provider or a mental health professional if any sign of significant physical illness or mental health or substance use condition is apparent. In so doing, it is important that the risk of stigma be avoided by maintaining confidentiality and communicating in a clear and culturally competent manner. It is essential that parents not feel in any way coerced to seek treatment or to medicate their child.

Action Steps

• MHA affiliates and advocates should encourage early identification and early intervention. Primary care physicians should be supported in identifying and getting treatment for mental health or substance use conditions.
• Affiliates should monitor compliance with EPSDT requirements for screening of young people. EPSDT is a mandatory set of services and benefits for all individuals under age 21 who are enrolled in Medicaid. Screening services to detect mental health conditions must be conducted at established, periodic intervals and whenever a problem is suspected. Consent decrees have been entered against several states that were not meeting their EPSDT obligations.14
• Affiliates should actively engage with their school districts to determine what efforts are underway to “screen” or promote early identification, and what programs are in place to provide appropriate services to young people with mental health or substance use conditions that prevent them from receiving full educational benefit from the general education program, as required by federal law. Getting and protecting required funding for screening and treatment is essential as schools face cutbacks.15
• Affiliates should help their school districts address issues of stigma, mis-diagnosis, coercion of parents by school personnel, over-medication or neglect of mental health needs of children, and cultural and racial bias in early identification programs.
• Affiliates can offer information and training to pediatricians and other primary care providers about early identification and screening.
• Affiliates can offer training sessions to parents and school personnel on appropriate early identification of children at risk, alternatives for getting help, and effective communication by school personnel.
• Affiliates should conduct legislative briefings in states where there are current efforts to enact legislation on mental health screening.
• Affiliates and advocates should encourage early identification and early intervention and should work to defeat any legislation that gets in the way of candid discussion of mental health and substance use issues.

Effective Peroid

The Mental Health America Board of Directors adopted this policy on December 4, 2010. It is reviewed as required by the Mental Health America Public Policy Committee

Expiration Date: December 31, 2015

1. ^{The term "mental health or substance use conditions" as used in this policy statement is intended to include the federal term "emotional or behavioral disturbance."}
2. ^{Early intervention in response to identified mental health or substance use conditions should be distinguished from mental health and sobriety promotion and prevention of mental health and substance use disorders, which are addressed separately in MHA Position Statement 48.}
3. ^{See http://www.aap.org/commpeds/dochs/mentalhealth/, http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm}
4. ^{U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General, Rockville, M.D., U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services and National Institutes of Health (1999). http://www.surgeongeneral.gov/library/mentalhealth/home.html}
5. ^{Shelton, D., “Emotional Disorders in Young Offenders” Journal of Nursing Scholarship 33(3):259 (2001).}
6. ^{Cicchetti, D., Rogosch, F.A., “Psychopathology as Risk for Adolescent Substance Use Disorders: A Developmental Psychopathology Perspective” Journal of Child Clinical Psychology 28(3):355-65 (1999).}
7. ^{Hurry, J., Storey, P., “Assessing Young People who Deliberately Harm Themselves” The British Journal of Psychiatry 176, 26-131 (2000).}
8. ^{Gall G., Pagano M.E., Desmond M.S., Perrin J.M., Murphy J.M., “Utility of Psychosocial Screening at a School-based Health Center” Journal of School Health 70:292-298 (2000).}
9. ^{Cicchetti, D., Rogosch, F.A., "Psychopathology as Risk for Adolescent Substance Use Disorders: a Developmental Psychopathology Perspective" Journal of Child Clinical Psychology 28(3):355-65.} 
10. ^{Brener N.D., Krug E., Simon T.R., Lowry R., “Trends in Suicidal Ideation and Behavior among High School Students in the United States, 1991-1997” Suicide and Life-Threatening Behavior 30(4):304-312 (2000).}
11. ^{Davis, C., Martin, G., Kosky, R,, O’Hanlon, A., Early Intervention in the Mental Health of Young People: a Literature Review (2000) Monograph published by The Australian Early Intervention Network for Mental Health in Young People.}
12. ^{Durlak, J.A., Wells, A.M., “Evaluation of Indicated Preventive Intervention (Secondary Prevention) Mental Health Programs for Children and Adolescents” American Journal of Community Psychology 26(5):775-802 (1998).}
13. ^{Feeney-Kettler, K.A., Kratochwill, T.R., Kaiser, A.P., Hemmeter, M.L., Kettler, R. J., “Screening Young Children's Risk for Mental Health Problems: A Review of Four Measures” Assessment for Effective Intervention 35(4):218-230(2010).}
14. ^{The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions are among the most specific in the Medicaid Act. See 42 U.S.C.§§ 1396a(a)(10)(A), 1396a(a)(43), 1396d(a)(4)(B), 1396d(r). Over the years, states have not adhered to these clearly articulated responsibilities, and litigation has resulted. EPSDT establishes a broad scope of benefits—all the services listed within the Medicaid Act at 42 U.S.C. § 1396d(a)—and a uniform medical necessity definition—services needed to “correct or ameliorate” the child’s physical or mental conditions. 42 U.S.C. §1396d(r)(5). Advocates are citing these broad treatment requirements to obtain coverage for a range of services that children need to live at home and in the community, including screening, rehabilitative services, case management, home health care, and personal care services. See, generally, “Medicaid EPSDT Litigation” (monograph), produced by Jane Perkins, National Health Law Program (October 2, 2009) http://www.acmhai.org/pdf/Jane_Perkins_-_EPSDT_Litigation.pdf}
15. ^{The Minnesota Association for Children’s Mental Health has prepared two exemplary toolkits for teachers: “Unlocking the Mysteries of Children’s Mental Health: An Introduction for Future Teachers,” Minnesota Association for Children’s Mental Health (Rev. Ed. 2004.) St. Paul, MN: Author and “A Teacher’s Guide to Children’s Mental Health,” Minnesota Association for Children’s Mental Health (2002) St. Paul, MN: Author. See http://www.macmh.org/macmh-publications/}