Adolescent Depression Screening: Exploring Barriers and Facilitators of Implementation in School Settings
Prevention and early detection of adolescent depression is a national health priority. Current guidelines recommend routine screening for depression in children and adolescents and subsequently linking those in need to additional evaluation and care. Early detection through school-based screening has considerable potential to identify at-risk adolescents for referral to effective therapeutic services but significant barriers stand in the way of widespread implementation and sustainment. Thus, successful implementation of adolescent depression screening in a school-based setting should prioritize: (1) establishing positive attitudes toward mental health and depression; (2) securing sufficient financial and human resources; and (3) tailoring screening systems to account for individual school context.
Rates of depression spike dramatically during adolescence. Despite broad scientific consensus that early detection and treatment are key to preventing negative, long-term effects of adolescent depression, current screening rates among this population remain extremely low. A broad review of key barriers and facilitators to school-based depression screening was conducted with the goal of informing policy and practice. This paper details key findings and recommendations from the review.
WHAT WE KNOW ABOUT ADOLESCENT DEPRESSION SCREENING IN SCHOOLS
Nationally, 15.7% of youth (ages 12-17) reported suffering at least one major depressive episode in the past year. Rates of depression spike dramatically during adolescence and is associated with a number of adverse outcomes, including suicide, educational and professional underachievement, and later psychopathology.
Adolescent Depression Screening in Schools
A broad scientific consensus has formed that early detection and treatment are key to preventing negative, long-term effects of adolescent depression. Major stakeholder groups, including mental health experts, medical associations, and mental health advocacy groups, advocate integrating depression screening in schools. The current guidelines of the U.S. Preventive Services Task Force recommend routine screening for depression in children and adolescents (ages 12-18) and suggest that this screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
The school setting is seen by many as an opportune environment in which to target all adolescents for screening, particularly students (a) with elevated symptoms of depression who may not have sought help yet or been identified as being symptomatic, (b) at risk of developing symptoms due to external stressors or internal vulnerabilities, (c) with sub-threshold symptoms of depression, and (d) who are asymptomatic but who may develop symptoms in the future. Accordingly, a growing number of states are in the process of adopting policies to institute school-wide screening. Despite broad support for school-based screening, legitimate concerns remain regarding the feasibility and potential unintended effects of implementing these programs. Below is a summary of the key barriers and facilitators to implementing school-based adolescent depression screening.
Mental Health Attitudes
Limited knowledge about the need for mental health services or the role of emotional health in academic performance was found to be associated with lower acceptability of depression screening by school personnel. Conversely, more knowledge was linked to greater acceptability. Other themes that impact acceptability include caregivers and staff mistrusting mental health interventions and the belief that schools over-emphasize testing and assessment. These fears bolster a more pragmatic concern that screening activities will take away from valuable instructional time, where state education guidelines continue to become increasingly restrictive.
Instrument or Process Reliability/Validity
At base, families and school staff care significantly about the reliability and validity of screeners and worry about the impact of either false positives or false negatives. Implementation studies consistently find little evidence to substantiate this concern. The majority of youth who screen positive for depression are confirmed to be true positive by follow-up assessment. Another major concern about screening instruments is the need to account for a variety of developmental, learning, and language levels.
Privacy, Stigma, Student Impact
A consistent objection to screening is the threat to student privacy and the challenge of maintaining confidentiality when conducting universal screening. Breeches of confidentiality are reportedly believed to expose the student to labeling and stigma, expressed by both school personnel and students. Few tangible examples of adverse events have been reported, but parent fears of stigma and confidentiality persist. Another variation on these fears involves the possible impact that screening results could have on student eligibility for school services, programs, or admissions.
Preferences for Tailored Approaches
Case studies and stakeholder surveys and interviews indicate a strong preference for screening systems that take local school context into account. For example, qualitative interviews of caregivers and school staff indicated a preference for a teacher training program over curriculum-based or universal and selective screening programs.
Consent Process and Student Engagement
Requirement of active consent (i.e., where the guardian must perform some act, such as providing a signature, that indicates positive endorsement for student participation) was mentioned as a key factor in lowering participation in screening. However, while active consent provides greater safeguards for family choice, it has been found to limit participation among the very high-risk and underserved youth who might benefit most from resources. When securing guardian permission or student engagement is unfeasible, some evidence suggests that alternative approaches such as teacher-rated universal screening may be successfully applied. Beyond consent issues, experts also caution that students may not have sufficient buy-in and might not participate honestly and fully.
Administrative/Organizational Resources and Support
Sufficient infrastructure and organizational resources needed to collect, manage, and interpret screening assessment data are consistently listed as primary feasibility concerns. In two-stage assessment processes, specialized mental health professionals are often incorporated, requiring additional resources. Thus, enlisting educators or school staff may be more efficient and less expensive, but participation rates and response validity could decline if the community suspects the staff have inadequate knowledge or students worry about privacy.
Reviews and studies consistently point to gaps in the infrastructure required for appropriate screening follow-up. As intended, screening will identify a substantial number of young people with unmet needs. Thus, the more established the follow-up procedures are in a system, the more acceptable universal screening is viewed and the more likely that the program will be sustained.
Cost of Instruments, Personnel, and Responsibility for Follow-Up Services
The cost of screening instruments is a core concern for schools that typically are not allotted additional local or state monies for new screening programs. In addition to the financial costs associated with school-based screening implementation, parents and school staff also suggest an additional burden associated with the responsibility and legal risk that the school is accepting. Collaborative efforts between schools and mental health experts alleviate some school staff fears about feasibility even as long-term concerns about budget and ongoing training persist
The majority of school staff do not have prior training in mental health screening and for a variety of reasons may not wish to participate. Further, school personnel have varying degrees of experience in using data to plan, implement, evaluate, and sustain programs. Thus, inclusion of current school staff will require careful planning around initial training and continuing education.
Expansion of Staff Roles
A few studies highlight that mental health screening exceeds the typical roles of educators and school staff. Expanding these roles may have to be negotiated with union representatives and requires re-distribution of other roles to avoid placing additional burdens on the existing staff.
BARRIERS TO SCREENING
Unclear or Impractical Procedures
Multiple reports caution that lack of information and impractical procedures can impede successful screening. School professionals consistently express concerns that they will not be adequately prepared to administer screening and that new procedures will require new, uncompensated duties. Reports emphasize the need for whole-school awareness of procedures and processes, including information about where screening would take place, how one would participate, how the information would be used, and how the process would unfold afterward.
Mental Health Attitudes and Impact on Students
Several studies/reviews find that fear of stigma and negative effects on students from screening present critical barriers to implementation of screening guidelines. Specific concerns include how screening procedures will protect confidentiality, how staff will support students once they have been identified, and how debriefing will be conducted for students and families after assessment. Case studies and caregiver surveys support the efficacy of needs assessments with the local community to identify family beliefs about screening and mental health, as alternative value systems (e.g., preference to retain mental health discussions within the family or separate from academics) can limit participation
Differential Validity or Access for the Underserved
Many screening instruments have been normed on limited samples. Thus, concerns arise that bias may cause depression symptoms of some ethnic groups to be under-represented and others over-represented. Case studies have identified approaches to limit bias, but instrument selection should be chosen with the local community in mind.
Poor Follow-Up Services
Nearly every narrative review cited the need for an integrated service system to address the needs of identified students. The absence of any follow-up system sets the school up for potential liability or burdens the current school system to develop ad-hoc therapeutics. Further, any impression that follow-up services are unresponsive or require long wait times can also generate negative attitudes toward screening and impede future administrations.
FACILITATORS TO SCREENING
Positive Mental Health Attitudes
Awareness of mental health problems, their prevalence in youth, and their potential impact on development highly influences community attitudes toward integrated school-based programs. Surveys of caregivers and school staff suggest that understanding the relevance and effectiveness of screening as part of an effective response system is critical for securing community buy-in from relevant stakeholders, including students, caregivers, educators, and administrators.
Instrument Availability and Ease of Administration
Accessibility and affordability of instruments is key to implementation, as is having few requirements for specialized training to administer, score, and interpret results.
Established Relationships Between School and Families
Several studies described collaborative processes between schools, families, and outside experts that built promising screening and triage systems. Active collaboration acknowledges unique values and concerns of key stakeholders and allows for a prior and ongoing problem-solving that builds trust and confidence in professionals and the system. Successful screening approaches have also developed strong engagement strategies (e.g., motivational interviews, follow-up contact) to solicit and maintain participation.
Established Multi-Tiered System of Support
The majority of studies recommend incorporating screening into a systematic assessment and triage system that provides direct referral to follow-up services, such as those modeled by the approach taken in Multi-Tiered Systems of Support (MTSS). Within a comprehensive school-based system, screening could be used to prioritize triage, support an organized referral management system, and facilitate friendly hand-offs to maximize receipt of care.
Value to Stakeholders and Feedback Systems
The ultimate success of any screening system will rely on the perceived and actual value the program has for families and schools. Collaborative community engagement at the outset can help guarantee that stakeholders are engaged. Incorporating mechanisms to provide feedback (e.g., annual reports) to families and school personnel about the benefits to stakeholders of screening can also foster sustainable motivation and support.
TAKING ACTION: WHAT CAN STAKEHOLDERS DO?
The promise of school-based screening to optimize the accurate identification and treatment of adolescent depression remains. Several barriers and facilitators to school-based adolescent depression screening are presented here. Findings from this review shed light on several research-, practical- and policy-related implications.
Future research should include controlled experimental designs (e.g., randomly assigning schools to multiple screening processes) and collecting diverse follow-up outcomes (e.g., participation and follow-up rates, attitude surveys, organizational cost-effectiveness) from multiple stakeholder perspectives (e.g., student, caregiver, school, regional legislatures).
Practitioners will need to build implementation efforts through an iterative and collaborative process that involves relevant stakeholders and forges school-community partnerships.