Children are once again caught in the cross-hairs of a political firefight. This time, the issue is the President’s New
Freedom Commission’s (NFC) final report on mental health. In its 2003 report, Achieving
the Promise: Transforming
Mental Health Care in America, the NFC calls for providing mental health screenings to children in a variety of
settings—including primary health clinics and schools—to ensure early detection and intervention.
Yet, since the report was released,
several state legislators and U.S. Rep.
Ron Paul, R-Texas, have proposed
legislation to prohibit mental health
screening of children in schools. In
Alaska, for example, the proposed
legislation would not only block
screening but would forbid school
personnel from discussing mental
health issues or recommending that
parents consult a mental health
Rep. Paul’s bill, which received 90 votes
in the last congressional session, cites
concerns expressed by anti-mental
health groups that the call for “universal
screening” is a plot “spawned by the
pharmaceutical industry” to medicate
America’s children. However, the report
doesn’t call for the “universal screening”
of all children and stresses that the
main goal of screening is the early
intervention of mental health problems,
which can halt the progression of
disorders and prevent recurrences later.
So what exactly is mental health
Screening commonly refers to the use of
one or more brief, structured
questionnaires that can help assess the
possibility that a person has a mental
health problem. Mental health
screening tools are not diagnostic tools.
They are designed to answer two basic
questions: Does the person have signs or
symptoms of a mental health problem?
If so, should this person be referred to a
mental health professional for an
Although mental health professionals
usually administer these screens, they
may be administered by trained nonmental
health staff from other agencies.
Most screens are designed to be fairly
brief processes, usually 15 to 30
minutes. Clearly, any efforts to formally
screen a child should be done by a welltrained
and qualified person.
To be sure, mental health screenings
present several challenges. First, there
are many screening tools available, but
they have not all been equally wellresearched.
In addition, their validity on
diverse cultural groups has not been
well-established. These two facts mean
that the tools may result in over- or
under-referrals for mental health
assessment. The degree of subjectivity
in the tools may also increase the
vulnerability of some cultural groups
through bias in administration and
A separate issue lies in the use of
screening tools in school settings.
While the NFC does not take a position
on who should administer screens in
schools, it does note that: “Every day
more than 52 million students attend
over 114,000 schools in the U.S. When
combined with the 6 million adults
working at those schools, almost onefifth
of the population passes through
the nation’s schools on any given weekday.” This means that mental health
problems are most likely to be noted in
schools. And, left untreated, they will
hamper a child’s ability to learn.
Can Do to Promote “Early
Identification” Programs in Their Communities
- Monitor their states for potential legislation that would
limit efforts to engage in early identification.
Proactively engage with schools in developing early
identification programs with strong privacy and rights
- Provide primary care providers with educational
opportunities on mental health screening.
- Engage with the state mental health authority on
developing and promoting early identification programs
and the support services needed once problems are
- Educate legislators on the needs and benefits of early
identification of mental health problems in children.
There is also considerable concern regarding
the potential for screenings to violate a
child’s privacy and stigmatize him or her.
Especially in school settings, care must be
taken to ensure that privacy is maintained.
And we’ve all heard concerns regarding
potential coercion by schools. Stories
abound of parents being told that their child
must be medicated to remain in school or
that because he or she has a mental illness,
they must be transferred. In the end, there
remains the perennial question of what to
do once you have identified a potential
mental health problem. Where are the
resources to help the child?
Any effort at early identification and
treatment of mental health problems in
school settings must take these concerns
seriously and work to address them. Because
the word “screening” evokes such strong
emotional reactions, NMHA prefers the
phrase “early identification.” Although this
is partly semantics, early identification is a
broader frame, allowing for a variety of
approaches, including alternatives to
While there is considerable debate about
the use of screening, the consequences of
failing to identify and treat emotional
disturbances in children are clear. Left
unidentified and untreated, children are at
risk for academic failure, suspension or
expulsion for behavior problems, and
involvement in the juvenile justice or
corrections systems. As we all know,
children from diverse backgrounds who
have mental health problems are particularly
at risk, because they are the least likely to
receive appropriate care and are
disproportionately overrepresented in our
nation’s juvenile justice facilities. Failure to
identify and address problems early also
increases the risk of a variety of negative
outcomes for all children, including suicide.