Youth Mental Health Screening and Linkage to Care
Abstract
HIGHLIGHTS
What Has Previously Worked in the United States?
Youth Screening Tools
Staged Assessment Approaches
Linkage-to-Care Efforts
Staged Linkage-to-Care Models
What Is Needed?
Developing Collaborative Efforts
Addressing Limitations to Screening
Barriers to Implementation of Linkage to Care
Addressing Barriers to Screening and Linkage to Care: Recommendations
Developing Collaborative Efforts
Challenge | Additional considerations |
---|---|
Screening and linkage to care | |
Collaborative efforts | The screening and linkage-to-care initiative will require building partnerships with care providers in many settings (e.g., school and medical settings and local health and mental health departments) across the United States. Once the screening process indicates that a youth would benefit from care at a level beyond online resources (see figure in the |
Workforce requirements | The initiative will require resources and staff to maintain the online portal, including updating educational content, linkage-to-care resources, mental health tools, and recommendations for care. |
Continuity of care | The initiative will need to address how to handle continuity-of-care issues, such as when youths move out of the area, or other interruptions to screening or linkage. Continuity of care will be especially important in school settings, where the screening and linkage process can be interrupted by the end of the school year. During the first stage of the proposed project, screening with an adapted first-stage screener will take place in sites that are already conducting screening; such sites will already have procedures for continuity of and linkage to care. Several strategies could be adopted, such as developing care navigator services and developing procedures for secure access to protected health information within the screening and linkage portal. |
Outreach and engagement | The initiative will require extensive efforts to inform and engage providers, the public, and relevant government agencies (see the |
Resources | Additional funding will be required to develop, host, and maintain an online portal for screening and mental health resources (e.g., educational materials, mental health tool kits, therapeutic tools, caregiver navigators, and recommendations for care); however, because routine psychosocial screening is now the standard of care in pediatrics and in many educational settings, some aspects of the initiative, including first-stage screening, could be launched with little extra cost if the newly developed screener were substituted for, or used to supplement, measures already in use in settings where screening is routinely conducted. In other settings, additional investment could be justified by the promise of early identification leading to potential prevention of functional impairment and of more serious mental health care needs, both of which will reduce future costs to the system. |
Ethics | The ethics of screening and linking to care in non–help-seeking contexts must be considered. It is possible that youths who meet thresholds for mental health concerns may experience distress from either unexpected results or the stigma associated with mental illness (36). However, the burden of untreated mental health concerns outweighs these concerns. A nationwide screening effort also may help reduce stigma. Regardless, continued advocacy for stigma reduction is needed. |
Setting | Several obstacles unique to each setting will be encountered. For example, in primary care, obstacles will include dealing with insurance, payment, and time constraints. For schools, unique constraints will include being bounded by the school year and added logistic hurdles in terms of coordinating with caregivers. |
Screener | |
Large age range | Validation will be required to ensure that any screener is adapted across different age ranges. For the first-stage screener, different versions may be required for different age groups (e.g., ages 10–12 years vs. 22–24 years). Some items, especially psychosis spectrum symptom items, may need to vary according to the age of the individual completing the screening (see more details about screening in the |
Consent | For youths ages <18, a parent or guardian will need to provide consent for screening. Consent in school settings will require logistic considerations different from those in medical settings. Although regulations vary widely from state to state and even among school districts, some secondary schools now ask parents to sign blanket consents that permit screening at any time during the school year. The screening program will also need to be sensitive to the complex challenges for youths in foster care. |
Incorporating multiple informants | Information from caregivers about a youth’s symptoms may also be needed to guide the process, particularly for younger individuals. Screening initiatives will ideally incorporate both youth and caregiver reports of mental health concerns. However, the addition and validation of caregiver reports and procedures would ideally occur once a first-stage screening tool is completed. These approaches may differ depending on the age range. Even for young adults completing screening measures, reports by caregivers or significant others could strengthen the screening and care linkage process. |
Privacy | It is important to consider issues related to privacy, including the issue of individuals who are unsure of confidentiality limits. Concerns can arise regarding whether responses can be shared with family members, school staff, or even law enforcement. These issues require upfront efforts to ensure privacy and a safe place to discuss symptoms, as well as discussions of confidentiality boundaries. Additionally, all screening data will need to be housed securely, such as in a HIPAA-compliant, cloud-based, online format. Protections would also need to be in place regarding access to any information on the online portal. Collaboration with one of the many companies that provide screening platforms that are fully secure and compliant will be an essential part of the initiative. |
Safety concerns | It is necessary to ensure that procedures are in place for addressing safety concerns (e.g., symptom acuity). It may be necessary to validate a screening measure with and without suicide-risk items. At least initially, screening with the new instrument will take place in locations that are already screening and that therefore have procedures and resources for handling safety concerns. As the initiative expands, procedures and staff will need to be in place for addressing mandated reporting issues, including reports of abuse and neglect and concerns regarding danger to self or others. Reporting requirements will vary by state. For immediate concerns about suicidal ideation and behavior, procedures will be required for contacting caregivers and linking to crisis resources. Protocols for secondary assessment of suicide and self-harm risk have been developed and shown to be feasible within diverse settings (33, 41). |
Inclusivity considerations | Tool development and validation procedures will need to address concerns and procedures for creating validated language translations, ensuring reasonable reading level of items, including audio capabilities, using culturally sensitive techniques, and identifying and screening individuals with intellectual and developmental disabilities (see more details about screening in the |
Logistic issues | Logistic hurdles will need to be addressed according to setting, system, and population variables. Ideally, school settings would initiate the screening process at least once per year during the school year, and medical settings would initiate the screening process at annual visits. Procedures will need to be in place to avoid youths’ completion of multiple assessments within short periods. |
Developing second-stage screening efforts | After developing a first-stage screening measure, second-stage screening would be determined and updated according to additional discussions and available science. Some second-stage assessments could be integrated into the online portal, although some second-stage interviews likely will require trained interviewers, necessitating recommendations for appropriate in-person assessments. |
Linkage to care | |
Lack of availableevidence-based care | The initiative will create recommendations regarding how to overcome issues of limited resources for addressing concerns, such as limited availability of specialty clinics for addressing psychosis spectrum symptoms in certain U.S. regions, especially rural settings (SAMHSA has funded 21 pilot sites recommending staged-care models for addressing these symptoms, although evidence for these models is still emerging). The increased use of telehealth during the pandemic indicates that telehealth may be a viable tool for improving access to care in rural, frontier, or other communities with limited mental health services, although telehealth use may involve overcoming licensure issues when conducted across state lines. Over time, the initiative may need to work with communities to organize training sessions to fill needs for evidence-based care. Furthermore, especially for youths experiencing mental health concerns without a diagnosable condition, there may be a paucity of evidence-based care. Evidence suggests that cognitive-behavioral therapy may mitigate such distress. Additional research will be required to develop other evidence-based care for subthreshold mental health concerns. |
Development of online resources | Online resources will be available for anyone accessing the online portal, but specific resource recommendations will be provided for individuals linked to tier 1 (mild symptoms) care on the basis of screening responses (see figure in the |
Logistic issues | Several additional logistic issues will need to be worked out as the program is piloted at each additional site, such as ensuring that telehealth options or providers that are geographically proximal are available to youths referred for services, supporting families with multiple youths in need of services, ensuring that wait times for care are not prohibitively long, and addressing reimbursement issues. |
Adapting Existing Screeners
Inclusion of Psychosis Spectrum Symptoms
Validation Efforts for the Adapted Screener
Developing a Screening and Linkage-to-Care Platform
Conclusions
Supplementary Material
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