Screening for Anxiety and Depression in Schools: Next Steps
By Ellen Hallsworth, Director, Bradley REACH
“How do we know if our children are struggling? And what do we do about it if they are?”
Screening for Anxiety and Depression in Schools: Next Steps
How do we know if our children are struggling? And what do we do about it if they are?
Since the pandemic shone a light on children and adolescents’ behavioral health, these questions are increasingly urgent for health care providers, educators and policy makers.
Screening for Anxiety, Depression and Suicidality
Last year, the US Preventive Services Task Force recommended that all children over the age of eight should be screened for anxiety, and that all children over age 12 should be screened for depression. In our webinar on screening in schools, we heard that the evidence for this recommendation is some of the most compelling, with fewest associated harms, that the Task Force has reviewed.
Yet implementing the recommendations creates logistical challenges. Overcoming these challenges is crucial to making screening a first step in improving behavioral health care. Who carries out screening? Where does it happen? How do we connect children who screen positive to appropriate follow-up care?
“Go Where the Kids Are”
At the New England Children’s Behavioral Health Network, we have heard again and again from stakeholders that a first step in improving access to high-quality care equitably is to “go where the kids are.” For most kids, much of the time, they are in school.
For this reason, there is a renewed impetus to deliver behavioral health services, including screening, in schools. As part of implementing the Bipartisan Safer Communities Act, CMS recently released guidance on improving access to health care for Medicaid and CHIP beneficiaries, including preventive care and behavioral health, in school settings. Connecticut’s Senator Murphy recently re-introduced legislation to strengthen mental health services in schools. In Rhode Island, Project AWARE funding from SAMHSA is providing training to educators to help them respond to behavioral health issues.
Next Steps
Our discussion in May highlighted issues that we should address in order to provide screening (and connections to follow up care) in schools effectively.
Logistics
Beyond the high-level recommendations on screening in schools and improved school-based care, schools are faced with a range of options for implementation. There is a range of models for providing screening and preventive services. For example, CHDI operates a Multi-Tiered Systems of Support model in schools in Connecticut. In Massachusetts, Mood Check has been working with schools to bring in external providers for screening. These tools and models all screen for different conditions (anxiety, depression, trauma, suicidality); schools need clarity about what they are screening for and why, including how screening tools address the needs of their student body.There are important questions about who does the screening, and about how to integrate screening with existing services in schools. Health care providers need to build strong partnerships with staff in schools, who often feed overburdened by increased responsibility for behavioral health, in addition to dealing with pandemic-related learning loss. Equally, we need to build connections not just between schools and specialist behavioral health care, but also between schools and primary care pediatricians, who (like schools) are struggling with the added burden of the behavioral health crisis.
Schools are also faced with challenges around how to get consent for screening and how to involve families, including how to engage them in next steps where there is a positive screen.
For school-based screening and preventive services to work, schools need support to become experts in evaluating the evidence and choosing screening tools that will work best for them.
What Happens Next?
Screening is not an end in itself; its value comes from connecting children and families to appropriate follow-up care. Mood Check’s experience in Massachusetts suggests that 10% of students report elevated symptoms of anxiety and 16% report elevated symptoms of depression. In an already overburdened care system, with severe workforce shortages regionally and nationally, ensuring that these children receive the right care presents a challenge.
What is the role for schools in helping families to navigate the complex system of behavioral health and find good, culturally appropriate care? Care coordinators can play an important role in ensuring a successful transition from a positive screen in schools to appointments with licensed providers. In the meantime, how can schools and their partners “hold” students who screen positive but are not yet able to access care?
A preventive approach is also crucial. Not all children who screen positive will require appointments with a psychologist or psychiatrist. By catching problems at an early stage, many children should be able to stay at the lowest level of the MTSS pyramid. In turn, this should enable providers to target care where it’s most acutely needed.
Health Disparities
Teachers and other professionals in schools know that behavioral health is intimately connected to the social determinants of health. Growing up in a family worried about homelessness or food insecurity is likely to induce and intensify anxiety. School-based providers need to see behavioral health through a wider health equity lens, rather than focusing on depression and anxiety in isolation. To address these challenges, just as it’s important for schools to connect students to follow-up clinical care, improving behavioral health will also likely require making connections to services that can address families’ basic needs. Whether this happens in schools or through external partners, this needs to be adequately and sustainably resourced.
Equity is also part of the picture when it comes to finding ongoing care. Even for patients with good insurance, network inadequacy can make it challenging to find providers, meaning that families with the resources to pay for services out of pocket have most access to care. For families who are underinsured, high co-pays and deductibles can make it close to impossible to find care that isn’t financially catastrophic. Payors have a role to play in reducing these barriers where possible.
Reimbursement
The US Preventive Services Task Force has a mandate not to consider payment mechanisms in its recommendations, ensuring they are based solely on the available evidence. Yet reimbursement is key for successful implementation. The current swath of grant funding for behavioral health in schools is welcome and much needed, but screening and providing preventive care in schools in the long-term will require sustainable funding mechanisms.
Medicaid is taking steps to make it easier to reimburse services in schools, but the administrative barriers remain high, and it’s challenging for schools to bill Medicaid and commercial payors.
Capitated funding models may make it easier to give schools the flexibility they need to provide services that are responsive to their students’ individual needs at a population and an individual level. Improving the evidence base for services provided in schools, and developing more sophisticated metrics of quality, would be an important underpinning for moving toward a more value-based system of reimbursement.
Ultimately, service provision in schools and beyond will follow the money.
Beacons for Behavioral Health
At the end of the event, a consensus emerged that providing children and families with better support will require a “revolution in the fabric of society.”
If schools are adequately resourced with the funding, staff, partners, and connections to the community they need, they can serve as beacons in the process of social change, searching for children and adolescents in need and connecting them to a continuum of care. Ensuring sufficient resourcing will take both sustained political will and collaboration across sectors.
We want to help move this agenda forward through network-building and advocacy. We intend to make school-based behavioral health services a theme of our work over the coming months. If you’d like to get involved, please contact… and sign up for our mailing list to hear about future events and projects in this space.
Watch our Webinar below, featuring:
Michael Silverstein, MD, MPH - Director, Hassenfeld Child Health Innovation Institute; George Hazard Crooker University Professor of Health Services, Policy, and Practice, Brown University; Vice-Chair, U.S. Preventive Services Task Force
Tracy R. Gladstone, PhD. - Associate Professor of Behavioral and Social Sciences, Hassenfeld Child Health Innovation Institute at Brown University; Senior Scholar & Research Advisor, Wellesley Centers for Women, Wellesley College
Jeana Bracey, PhD. - Associate Vice President of School and Community Initiatives, Child Health and Development Institute
[Moderator] Alice Forrester, PhD. - President & CEO, Clifford Beers Community Care Center
