Mental health screening tools for kids are 30 years out of date

Suicide is the second leading cause of death among children aged 10 to 14 in the U.S. That’s evidence of a systemic failure in identifying and addressing mental health concerns in young people.

Compounding the problem is the average delay of 11 years between the onset of a mental health condition and its diagnosis. Think about it: a child exhibiting signs of mental health challenges at age 6 may not receive proper diagnosis or treatment until age 17. This delay means that some children spend their formative years with unaddressed mental health struggles that often lead to risky choices and other potentially harmful experiences.

The crux of the issue lies in the limitations of current mental health screening tools, particularly the outdated Pediatric Symptom Checklist (PSC), which was developed in the late 1980s and remains a commonly used survey to assess mental health. The PSC is used to broadly evaluate anxiety, depression, ADHD and internalizing or externalizing behaviors. It is not meant to diagnose these conditions. Instead, it is often used to assess if a child might have a mental health condition and, if it appears so, can be used to refer the child to a therapist for further evaluation.

The PSC is a paper-based set of 35 questions that parents fill out (or children themselves, once they’re 12). Like much of the pediatric health care system, the PSC has failed to adapt to modern knowledge and technology. The result? It’s harder than it needs to be to identify kids who are suffering, as well as track trends and implement timely interventions.

These are profound constraints. The PSC and the nine-item Patient Health Questionnaire (PHQ9), a diagnostic survey introduced in the early 1990s by Pfizer to help primary care doctors assess depression and prescribe Zoloft, are blunt instruments, offering simplistic scoring systems with no nuance. The PHQ9, which was originally intended for use with adults but is often used by pediatricians, relies on nine statements of symptoms that one can choose to agree or disagree with. Participants say how often they experience particular symptoms: “not at all (0),” “several days (1),” “more than half the days (2)” or “nearly every day (3).” Scores of 5, 10, 15 and 20 represent respective cut points for mild, moderate, moderately severe and severe depression.

The PSC, with 35 data points, follows a similar format of symptoms and level of agreement. It triggers a referral to a therapist only with a score of 28; nothing happens with a score of 27 or below.

Both these tools also fail to account for multiple or simultaneous mental health conditions, such as depression and suicidal ideation or anxiety and obsessive-compulsive disorder. This is a crucial aspect in understanding the complex mental health landscape.

I’ve seen firsthand the limitations of these tools, especially the PSC. As the founder and CEO of futuresTHRIVE, a mental health technology company, for the past four years I have participated in studies centered on children’s mental health screening (checking seemingly healthy children for hidden warnings about mental health issues). Children often grapple with understanding parts of the questionnaire, like when the PSC asks them if they “act as if driven like a motor.” (Do adults even understand what this means?) They are also easily distracted by the paper and pencil they are given to answer the questions, as these almost always lead to doodling. The evident disconnect between the currently available tools and the authentic experiences of children shows the need for a significant overhaul in approaching youth mental health screening.

Health care practitioners also deserve better tools. The American Academy of Pediatrics (AAP) points out that many pediatricians don’t feel equipped to address mental health concerns during their 15-minute patient visits. Despite their eagerness to provide mental health care, the current way of collecting information — whether verbally or paper-based — is not sustainable and clearly not working. These methods make pre-visit screening challenging, adding to the difficulty of identifying and addressing mental health concerns in children. A recent CDC report also reveals a significant gap in how children’s mental health is tracked.

Technology can fill in some of the gaps by allowing parents and children to complete questionnaires online before visiting a practitioner. Through AI, technology can also collect more information about specific mental health conditions, risk factors and more — all at the same time, in a less biased way — as well as collect nonverbal communication, like emotion and voices changes. By using AI, my company has created powerful analyses through aggregating a variety of factors, giving practitioners a more complete information set — one that is more closely aligned with the AAP’s recommendations — about the relevant measures in a child’s life. This also offers a more complete picture of the child. Other companies in the field are focused on diagnosing depression through voice biomarkers and concentrate their research on youths over age 18.

To create better mental health screening for young people, all health care practitioners who work with children must first ensure that they pose the right questions at the appropriate times and in suitable formats for those of different ages. Questions regarding the frequency, intensity and consequences of specific feelings, along with surrounding contextual factors, can paint a more detailed picture of mental health.

Consider this question: “On a scale of 1 to 5, with 5 being the happiest, how happy are you?” If a child indicates that his or her happiness level is low, an interactive questionnaire can follow up with: “What makes you happy? If one thing would make you happier, what would it be?” This is much more effective than today’s standard, whereby a child simply indicates that he or she feels sad “never,” “sometimes” or “often.”

New tools can also probe into coping mechanisms and support systems and how these evolve over time. More open-ended and context-aware questions would also be valuable. For example, in response to the question, “Have any of your peers ever said or done anything that hurt you?” a clinician can ask, “What happened? What did you do?” In this way, screening tools can be developed that not only pinpoint potential root causes of mental health conditions but also offer insights into individuals’ distinct narratives. Harnessing technology makes it possible to move away from standardized approaches toward more personalized and adaptive models.

Machine learning algorithms can track individual responses over time, identifying unique patterns and trends, just like practitioners do for height and weight. AI specifically serves as a sophisticated tool that goes beyond traditional screening methods, as algorithms possess the ability to recognize subtle patterns in responses and behaviors that may go unnoticed through traditional observation. These nuanced analyses, when reviewed in aggregate, also contribute significantly to our understanding of the complex and multifaceted nature of a community’s mental health, without adding more work for doctors.

AI can also enable interactive experiences for the child. Unlike static assessments, such as the PSC, AI provides real-time analysis and adaptation for caregivers and practitioners that can lead to early intervention. As individuals interact with the tool, the AI algorithms dynamically adjust, providing immediate insights into the child’s health.

Of course, technology has its limitations. Given the complex and unique nature of mental health, finding the right treatment path must still involve the practitioner and family members. But technology can arm practitioners with important details to help guide the path toward appropriate and timely treatment. Making the screening process easier and more effective also means it can be done more often. Accruing years of data about the qualities of a child’s mental health helps identify potentially worrisome patterns. And technology can help children before an official diagnosis is even made. Practitioners can use the information they learn to help kids improve their mental health through getting more sleep, exercising regularly, eating healthier foods and avoiding certain stressful situations.

While the harrowing statistics on child suicide paint a bleak picture of childhood development, adding updated screening tools to provide early warning signs of mental health issues opens the door for hopeful outcomes. Arming practitioners with modern, easy-to-use mental health screening tools and comprehensive real-time data will help them to better partner with patients and their families to give children the help that they need and deserve at the earliest possible moment.

Wendy Ward is the founder and CEO of futuresTHRIVE, a company creating tools for the early identification and tracking of pediatric mental health problems.

If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.