Thursday, January 24, 2008

A New Child Mental Health System: What's all the screening about?

Here we are, three weeks into the era of improved mental health screening.  So far, the world hasn't ended and I don't think that anyone has lost their rights.  Today, however, my faith in some of the instruments was tested.
  • I saw a teenager who is barely passing high school, with multiple suspensions and some evidence of alcohol abuse in the past month, currently grounded by his parents for staying out overnight without knowledge or consent.  Her Y-PSC was 20 (within normal limits) and her CRAFFT was not worrisome.  I, on the other hand, remain quite concerned that she is at risk and recommended that he see a counselor.  After much discussion, he agreed to stop by and visit the school counselor.  
Lesson learned:  Screening does not obviate a thorough history.  As Peabody said long ago, the secret of caring for patients is to care for the patient.
  • Parents of a 2 year old dutifully completed the PEDS as completely normal, and then told me about thier concerns regarding expressive language delay, after which I made a referral to EI.  The PEDS, however, was scored negative.  I asked them why they have checked "no concerns" on the PEDS under language development, and they told me that they were not really "concerned", but were a little different.
Lesson learned:  Screening questions can't capture nuance of language.  Listening can.
  • Two patients were brought to their EPSDT visits by non-custodial relatives, one of whom answered the questions despite a real lack of real knowledge of what was happening in his life and the other of whom wouldn't complete the form despite a fairly good knowledge of what was going on.
Lesson learned:  Screening is only as good as the information we bring to the table.

While I still believe that screening for children's mental health problems is a good idea, the instruments thems really are, at best, an opening into the system.  The system still has its problems.  More on that later.

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