Columbia University TeenScreen  Program

1. Columbia UniversityTeenScreen Program The Carmel Hill Center at the Division of Child & Adolescent Psychiatry Columbia University

2. Presentation Overview • What is the Columbia TeenScreen Program? • The problems of undiagnosed mental illness and suicide in youth • Support for mental health screening • How the TeenScreen Program works • NAMI Maine: A Case Study • How to become a TeenScreen site and support local screening efforts

3. What is the TeenScreen Program ? • National mental health screening program focused on: • Early identification of mental illness • Suicide prevention in youth • Linking those in need with further assessment • Goal: Provide all parents the opportunity for their teens to receive a voluntary mental health check-up • TeenScreen does not involve diagnosis or treatment • Community-based partnerships to develop screening • programs across the U.S. • Funded by private foundations, individuals and organizations

4. MentalIllness in Youth 10% of US children and adolescents suffer from a serious mental disorder that causes significant functional impairment at home, at school and with peers Twenty-one percent of US children ages 9 to 17 have a diagnosable mental or addictive disorder that causes at least minimal impairment In any given year, only 20% of children with mental disorders are identified and receive mental health services Half of all mood, anxiety, impulse-control and substance-use disorders start by age 14 Mental Health: A Report of the Surgeon General (1999) Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda (2000)Kessler et al., 2005

5. Prevalence of Mental DisordersU.S. Children and Adolescents Ages 9-17 14 13% 12 10 10.3% 8 6 6.2% 4 2 2% 0 Anxiety Disorders Disruptive Mood Disorders Substance Use Behavior Disorders Disorders Shaffer et al., 1996

6. Mental Health and Academic Achievement • 50% of children with serious emotional and behavioral disorders drop out of high school, compared to 30% of students with other disabilities (US Dept. of Education, 2001) • Students with mental illness have the highest drop out rate of any disability group (U.S. Dept. of Education, 2001) • Over half of the adolescents in the United States who fail to complete their secondary education have a diagnosable psychiatric disorder (Stoep et al., 2003)

7. Links Between Mental Illness and Suicide • 90% of teens who die by suicide suffer from a treatable mental illness at their time of death • Psychiatric symptoms developed more than a year prior to death in 63% of completed teen suicides • In only 4% of cases, psychiatric symptoms developed within the 3 months immediately prior to the suicide • Suicide is not the unpredictable event we once thought it was Shaffer et al. 1996

8. Risk Factors for Suicide MALE FEMALE Depression 50% 69% Antisocial 43% 24% Substance Abuse 38% 17% Anxiety 19% 48% Previous Attempts 28% 50% Girls attempt at much higher rates than boys (4:1) Boys die by suicide at much higher rates than girls (4:1) Risk factors for completed suicide: • 18- to 19-year olds* 60–67% 13% • 17- to 19-Year-olds 66% NA Brent et al., 1999; Shaffer et al., 1996

9. Secrecy: Disinhibition And Teen Suicidality Based on multiple published studies of teens and parents: • 85% do not reveal ideation • 30%–60% do not reveal past attempt to anyone • 90% of attempts unknown to parents Harkavy & Friedman 1987; Patton et al. 1997; Shaffer et al. (in preparation); Velez & Cohen 1988; Young & Zimmerman 1998

10. — U N I T E D S T A T E S, A G E S 15–19, 1964–2004 — TEEN SUICIDE RATES Rate per100,000 Year CDC 2006 (WISQARS) (reviewed 12/18/2006), Vital Statistics U.S. 1962–1978 E11

11. Support for Mental Health Screening

12. Conditions That Are Routinely Screened for In Youth PKU: affects less than 1% of children Lead Poisoning: affects 2% of children Scoliosis: affects less than 1% of children Hearing Problems: 1-2% of children have moderate to severe hearing loss Vision Problems: affects 15% of children American Academy of Family Physicians 1999; CDC 2003; National Center for Health Statistics, U.S. Department of Health and Human Services 2000; Windeler J. & Kobberling J., 1987

13. Why Should We Screen for Mental Illness and Suicide Risk? • Reliable screening tools that effectively identify at-risk teens are available • Mental illness is treatable • Most mentally ill and suicidal youth aren’t already being helped • There is ample time to intervene before a teen dies by suicide • No one else is asking teens these questions, but they will give us the answers

14. Mental Health Screening and The TeenScreen Program Are Effective • Screening in Mid-Adolescence Identifies: • Teens at risk for suicide • Teens who are depressed or suffering from other psychiatric disorders • Symptomatic teens who are not already in treatment or known by school personnel • At-risk teens who will make improvements in their academic functioning if referred for services post screening

15. Widespread Support for Screening and TeenScreen • President Bush’s New Freedom Commission on Mental Health • Garrett Lee Smith Memorial Act • New York’s Clinic Plus Program • State suicide prevention plans • 34 National Health and education organizations • Suicide Prevention Resource Center • Parents • Teens

16. Presidential Support for Screening - New Freedom Commission on Mental Health - • Early detection and treatment of mental disorders can result in a substantially shorter and less disabling course of illness • Schools are in a key position to identify mental health problems and provide a link to appropriate services • Strong mental health programs in schools can attend to the health and behavioral concerns of students, reduce unnecessary pain and suffering, and help ensure academic achievement • The Columbia University TeenScreen Program is highlighted as a model screening program for youth The President’s New Freedom Commission on Mental Health (July, 2003)

17. Federal Support for Screening“Garrett Lee Smith Memorial Act” • Signed into law on October 21, 2004 • Authorizes $82 million over 3 years for the development of youth suicide prevention and intervention programs • 37 grants totaling $9.7 million awarded for FY 2005 to go towards the development and implementation of youth suicide prevention programs • Grants totaling over $14 million awarded in 2006 to 19 states and tribes to support statewide and tribal activities to develop and implement youth suicide prevention and early intervention strategies • $2.3 million in GLS funds were also awarded in September 2006 to assist colleges and universities in their efforts to prevent suicide and to enhance mental health services for students • Seven states (AZ, NV, NY, ID, WI, OH and MT) and one American Indian Tribe (Standing Rock Sioux) will implement TeenScreen with these funds

18. Federal Support for Screening GrowsSAMHSA and DOE SAMHSA: Adolescents at Risk Grants • Almost $2 million for school districts, tribes and non-profits • Awardees include TeenScreen sites in Tulsa, OK and Washington, DC DOE Integration of Schools and Mental Health Systems Grants • $5 million grant program to increase student access to mental health care through innovative approaches • Awardees include TeenScreen sites in Alhambra, CA and Amityville, NY

19. New York State 2006 – 2007 OMH Screening Initiative $33,000,000 Allocated for Children and Family Clinic-Plus Goal: With parent consent and youth assent, to increase the number of at-risk children and adolescents screened, assessed and treated for serious emotional disturbance. Up to 400,000 children screened Up to 76,000 children assessed Up to 36,000 additional children admitted to clinic services Up to 22,400 children receiving in-home treatment services Services will be provided through combination of 100% state aid and Medicaid rate enhancements.

20. State Suicide Prevention Plans • There are 34 state plans that encourage mental health screening as a means to prevent suicide • Of these 34, 5 states specifically mention TeenScreen as a model screening program (FL, IA, NE, NY, VT)

21. American Academy of Child and Adolescent Psychiatry American Association for Marriage and Family Therapy American Federation of Teachers American Managed Behavioral Healthcare Association American Mental Health Counselors Association American Psychiatric Association American Psychological Association Anxiety Disorders Association of America Bazelon Center for Mental Health Law Child and Adolescent Bipolar Foundation Children and Adolescents with Attention- Deficit/Hyperactivity Disorder Consumer Organizing and Networking Technical Assistance Center Depression and Bipolar Support Alliance Federation of Families for Children’s Mental Health Girls and Boys Town International Association of Psychosocial Rehabilitation Services International Society of Psychiatric-Mental Health Nurses National Alliance for the Mentally Ill National Association of County Behavioral Health Directors National Association of School Nurses National Association of School Psychologists National Association of Secondary School Principals National Association of State Mental Health Program Directors National Council for Community Behavioral Healthcare National Education Association National Empowerment Center National Mental Health Association National Mental Health Consumers’ Self-Help Clearinghouse President’s New Freedom Commission on Mental Health School Social Work Association of America Suicide Prevention Advocacy Network USA Tara National Association for Personality Disorders Tourette Syndrome Association United States Conference of Catholic Bishops National Support for Screening- Youth Screening Supporters - July 2006

23. TeenScreen History 1991: Pilot Study 1995: Public Service Screening Projects 1998: Follow-Up Study 1999: National TeenScreen Program Pilot 2003: National TeenScreen Program Launch

24. Columbia University TeenScreen Program Screening Sites 450 Active Sites 43 States and Washington, DC

25. Potential Screening Settings • Schools • School-Based Health Centers • Doctors’ Offices • Clinics • Drop-In Centers • Shelters • Residential Treatment Facilities • Juvenile Justice Settings

26. Principles of Quality Screening Programs • Screening must always be voluntary • Approval to conduct screening must be obtained from appropriate leadership • Staff must be qualified and trained • Confidentiality must be protected • Parents of identified youth must be informed of the results and offered assistance with securing an appointment for further evaluation

27. The Screening Process Debriefing NoReferral Middle and High School Age Youth Parent Consent and Participant Assent Screening Questionnaire Clinical Interview Parent Notification, Referral and Case Management

28. Staffing a TeenScreen Program Staff Roles: • Screener(s) • Mental Health Professional(s) for Clinical Interview • Case Manager(s) Sample Staffing Models: • Single Staff Model • Internal Team Model • External Team Model • Combination Model Anyone can organize a TeenScreen Program, BUT… teachers, school administrators, educational staff, and parents cannot implement the program

29. Parent Consent and Participant Assent • Parent consent and participant assent are always required • TeenScreen requires active written consent for every school that implements the program • Assent form is signed by participants before screening begins • Teens can refuse participation even if parent consent is granted

30. Screening Questionnaires Columbia Health Screen (CHS) - Suicide risk screen Diagnostic Predictive Scales (DPS) - Multi-disorder screen

31. CHS Overview 14-item, 10-minute, self-completion, paper-and-pencil survey for suicide risk Appropriate for 11-18 year-olds 6th grade reading level Trained layperson can administer and score Assesses for symptoms of depression, anxiety, substance abuse, suicide ideation and past attempts Highlights those who might be at risk and screens out those who are not Available in English and Spanish 33% positive rate

33. DPS Overview 52-item, 10 minute, self-completion mental health screen Appropriate for 11-18 year-olds Computer-based with spoken questions Trained layperson can administer and score Automatic reporting of screening results English and Spanish versions available 20-33% positive rate

34. The DPS Screens For: Social Phobia Generalized Anxiety Panic attacks Obsessions and Compulsions Depression • Suicide ideation (past month) • Suicide attempts (past year) Alcohol Abuse/Dependence Marijuana Abuse/Dependence Other Substances Abuse/Dependence

35. In the last 3 months….. Has there been a time when nothing was fun and you just weren’t interested in anything?

36. Clinical Interview 20-30 minute interview Conducted by a qualified mental health professional Review results of the screen and explore the indicated problem area(s) further Assess level of impairment resulting from symptoms endorsed on the screening questionnaire. Decide if referral for a complete evaluation is appropriate Does not represent a clinical diagnosis

37. Parent Notification and Case Management • Notify parents of screening results • Inform parents of recommendations for further evaluation • Educate parents about their children’s symptoms • Connect families with appropriate evaluation services

38. Protecting Confidentiality • ID numbers instead of names used • ID log kept separate from screening files • Documents stored in separate locked filing cabinets • Results not shared with educational staff or included in academic records • Release of information signed by parents to release files to third parties

39. What Columbia Requires From Prospective TeenScreen Sites • Quality screening plan with the ability to screen, interview, refer and case manage participants • Follow program protocols, policies and practices • Annual aggregate screening info and feedback, and participation in quality assurance activities • Shared commitment to the goal of routine mental health screening

40. A Case Study TeenScreen at NAMI Maine

41. Background on Maine Population of Maine=1,321,505 Population of NYC=8,104,079 Population of Chicago=2,862,244

42. Suicide Rates (per 100,000) for Maine, Northeast, and the U.S.1983-2003, All Ages, Age-Adjusted

43. Age-Specific Suicide Rates (per 100,000) Maine, 1983-2003 Trailing 5-Year Averages, Ages 10 to 34

44. NAMI & TeenScreen • Statewide systems and school knowledge and contacts • Consistent with mission • Expands and enhances child and adolescent programming • Comfort and experience with Advocacy

45. Gathering Statewide Support for TeenScreen • Maine Youth Suicide Prevention Program Strategic Plan • State Strategic Plan—National Association of State Mental Health Directors • Collaborations with Providers, schools, families of children with mental illness and communities

46. Support from Schools Awareness of the school hierarchy: • Superintendent • School Board • Principal • Staff

47. Financial Support • State and Federal funding—collaborate with suicide prevention programs; mental health authority; Department of Education, Health and Human Services, Public Health, SAMHSA • Private funding—look at suicide prevention; services for children with mental illness; prevention programs

48. Opportunities/Lessons Learned • Maine Department of Health and Human Services; Office of Rural Health • 1x grant of $40,000 • Aetna Regional Grant • 1 year grant $30,000

49. Lessons Learned

50. Office of Rural Health, Maine Department of Health and Human Services • BE PREPARED • Have a statewide view • Collaborate with leaders in several areas • Promote your program • Know your budget