The American Academy of Pediatrics issued updated guidelines this year, recommending that youth ages 12 and over should be screened for depression every year by pediatricians and primary care physicians. But simply identifying the problem doesn’t address service gaps that may prevent young people from receiving the support they need.
Counseling@NYU sat down with Anil Chacko, associate professor of counseling psychology at NYU Steinhardt, whose research focuses on treatment of disruptive behavior disorders for at-risk youth, to discuss the importance of mental health screenings for young people and the challenges many families face accessing mental health services.
How might mental illness affect young people differently than other age groups?
Mental illness is going to have a significant impact on the key relationships that a young person has in their lives, with parents, siblings, and friends, as well as with teachers and classmates.
The kinds of mental health illnesses that are common in childhood include things like ADHD, conduct problems, learning disabilities, depression, anxiety, and other disorders. Many individuals diagnosed with these disorders continue to have these diagnoses as they get older. There are several epidemiological studies of adults with mental health difficulties like depression and anxiety, and the vast majority can trace at least some beginnings of these challenges to childhood. Childhood is a particularly important time for the development of some onset problems.
Do you think yearly mental health screenings would be beneficial for youth?
I certainly think so. Much like any other area of functioning in young people, there’s change. Change is typical, but it isn’t always necessarily positive and heading in the right direction. Mental health is a process that develops, changes and, for many individuals, is stable or gets better. But for some, it doesn’t go so well. Screening periodically is important just like in other areas to ensure that we catch kids who may be struggling with mental health issues and provide them with the kind of support they need. I think young people — and adults — should be screened or have some kind of check-in yearly around these mental health concerns. Screenings would have to use psychometrically valid, brief measures with high ability to identify people who would then meet diagnosis or benefit from treatment.
What are some of the barriers to youth being appropriately diagnosed with mental illness or mental health challenges?
The challenge is making sure they have access to providers who conduct evidence-based assessments. It is critical to ensure that there is a very good assessment, which also can be challenging if you’re not going to a specialist who can provide evidence-based assessments.
Obviously there are individual-level barriers for kids. As they get older, there’s concern from families about stigma around mental health. Also, there are systemic issues in terms of just how to navigate a system, identify an appropriate provider, and then ensure that provider utilizes evidence-based assessments. Those are probably the biggest barriers right now to accurate and effective diagnosis.
What kinds of barriers exist for young people seeking treatment?
The waiting list for mental health services is pretty long in general. Finding a provider who does evidence-based treatments is also a particular challenge. There are financial issues that are barriers as well. Being a practicing psychologist myself, I know that many families will seek services through our center, and we don’t take their insurance or we’re out of pocket, and that’s obviously a pretty significant financial burden for families. Insurance complicates things in terms of availability. Research over the last 10 years has really been trying to address how to create availability and access through technology or using paraprofessionals or laypeople.
What are the dangers for young people if they either are not being diagnosed or not getting treatment?
There’s a trajectory that’s set when kids who are struggling with social, emotional, and behavioral issues are left untreated or undiagnosed. Those problems simply don’t disappear. Coupled with other stressors such as poverty or poor peer relationships, they just get worse and they lead to a whole set of bad outcomes for kids. Treatment can certainly help. But I think it’s really important to differentiate between just getting any old treatment and getting treatment that has a pretty solid research base to it.
Do you think there’s any difference in how people perceive using medication versus using more of a counseling approach, particularly when you’re talking about children?
I think a lot of it does depend on the rationale given for the behavior from parents and key adults such as teachers. If a parent is thinking that this is just the way the child is and it’s not a function of the environment or things that are going on, they may attribute the child’s behavior to a biological reason and prioritize a biological approach to treatment, such as medication. And then there are obviously other kinds of families, who may see the problem as a response to stressors or believe that the behavior is caused by other things going on with the child such as the way they interact with peers. The family may prioritize non-medication approaches to treatment, such as counseling or therapy. But it certainly varies from family to family, and it varies by diagnosis.
What needs to happen beyond just a yearly mental health screening to meet the mental health needs of young people?
A thoughtful service delivery model integrates screening with getting people quickly into assessment and having treatment options readily available. If there isn’t one, then I think screening could potentially do more harm than good. For example, if you’re screened as having a possible high risk for something and then a pediatrician says, “Well, that’s not something I’m trained in, and I don’t really know if there’s anyone who can see you right away, maybe in two months,” that’s not a good outcome.
Integrated screening, assessment, and treatment needs to be very broad and include a school counselor, social worker, psychologist, psychiatrist, developmental pediatricians, and community folks to really address an often large, unmet need. Integrated care and mental health screenings can make a big difference. Pediatricians are trusted by families, and it makes a lot of sense for a pediatrician to screen, but the back-end work has to be in place. Otherwise identifying a problem and then not having any resources to help is just not a very good situation for kids and families.