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Identifying Mental Health and Substance Use Problems of Children and Adolescents: A Guide for Child-Serving Organizations Identifying Mental Health and Substance Use Problems of Children and Adolescents: A Guide for Child-Serving Organizations U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Mental Health Services Acknowledgments This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by Wendy Holt from DMA Health Strategies under contract number HHSP2233200500736P with SAMHSA, U.S. Department of Health and Human Services (HHS). Lisa Rubenstein served as the Government Project Officer. Disclaimer The views, opinions, and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. The non-Federal resources included in this document are not all-inclusive. Inclusion in the document does not constitute an endorsement by SAMHSA or HHS. Public Domain Notice All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be downloaded or ordered at http://store.samhsa.gov. Or call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). Recommended Citation Substance Abuse and Mental Health Services Administration. (2011). Identifying mental health and substance use problems of children and adolescents: A guide for child-serving organizations (HHS Publication No. SMA 12-4670). Rockville, MD: Author. Originating Office Office of Child, Adolescent, and Family Branch, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857 HHS Publication No. SMA 12-4670 Printed 2012 Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 About SAMHSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Purpose of the Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 About the Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Why Early Identification Is Important . . . . . . . . . . . . . . . . . . . . . . . . . 4 Organization of the Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chapter 1: Prevention and Early Identification of Children’s and Adolescents’ Mental Health and Substance Use Problems . . . . . . . . . . . . . . 7 The Importance of Social and Emotional Development . . . . . . . . . . . . . . . . 7 Prevention and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 2: Understanding the Identification Process and Tools . . . . . . . . . . . 13 The Value of Early Identification . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Developing an Effective Approach to Improve Identification and Access to Care . . . 15 Applying Basic Principles to the Design of an Early Identification and Access-to-Care Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Employing Sound Methods to Identify Children and Adolescents Who May Have a Mental Health or Substance Use Problem . . . . . . . . . . . . . 22 Determining Goals: Populations and Problems of Concern . . . . . . . . . . . . . 24 Selecting an Identification Method . . . . . . . . . . . . . . . . . . . . . . . . . 29 Considering the Cultures and Languages of the Groups Being Screened . . . . . . . 33 A Short List of Mental Health and Substance Use/Abuse Screening Tools for Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Chapter 3: Key Steps of Early Identification . . . . . . . . . . . . . . . . . . . . . 41 Obtaining Informed Parental Consent . . . . . . . . . . . . . . . . . . . . . . . 41 Obtaining the Assent of Children and Adolescents . . . . . . . . . . . . . . . . . 44 Sizing an Early Identification Program: Estimating the Number of Children and Adolescents Who Will Be Identified With Likely Problems . . . . . . . . . . . . . . 44 Ensuring Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Administering the Screen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Responding to Screening Results . . . . . . . . . . . . . . . . . . . . . . . . . 45 Communicating Results to Caregivers . . . . . . . . . . . . . . . . . . . . . . . 46 Communicating Results to Mature Minors and Young Adults . . . . . . . . . . . . 47 Contents iii Chapter 4: Partnering for Resources . . . . . . . . . . . . . . . . . . . . . . . . 49 Benefits of Partnering to Access Community Resources. . . . . . . . . . . . . . . 49 Potential Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Partnership Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Supplements These supplements build upon the foundational information in Chapters 1–4 and are not meant to stand alone. Supplement 1: Child Welfare . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 The Need for Mental Health and Substance Use Screening in Child Welfare Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Effective Implementation of Screening of Abused or Neglected Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . 63 Challenges in Child Welfare Settings . . . . . . . . . . . . . . . . . . . . . . . 66 Working With Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Assessing and Treating Foster Children and Adolescents . . . . . . . . . . . . . 70 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Supplement 2: Early Care and Education . . . . . . . . . . . . . . . . . . . . . 73 Mental Health in Infants and Young Children . . . . . . . . . . . . . . . . . . . 74 Identification of Social and Emotional Problems in Very Young Children . . . . . . 76 Working With Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Addressing Social and Emotional Problems in Very Young Children. . . . . . . . . 81 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Supplement 3: Family, Domestic Violence, and Runaway Shelters . . . . . . . . . 85 Mental Health and Substance Use Problems of Children and Adolescents in Shelters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Effective Identification of Mental Health and Substance Use Problems . . . . . . 87 Working With Children, Adolescents, and Families. . . . . . . . . . . . . . . . . 90 Assessing and Treating Youth in Shelters. . . . . . . . . . . . . . . . . . . . . 91 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Supplement 4: Juvenile Justice . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Mental Health and Substance Use Problems of Youths in the Juvenile Justice System . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Screening Youths in the Juvenile Justice System . . . . . . . . . . . . . . . . . 97 Working With Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Assessing and Treating Youths in the Juvenile Justice System . . . . . . . . . . . 105 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108 iv Identifying Mental Health and Substance Use Problems of Children and Adolescents Supplement 5: Mental Health and Substance Abuse Treatment for Co-occurring Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Incidence of Co-occurring Mental Health and Substance Abuse Disorders . . . . . 110 Screening Tools: A Valuable Component of a Comprehensive Mental Health or Substance Use Assessment . . . . . . . . . . . . . . . . . . . . . . . . . 112 Treating Youths With Co-occurring Disorders . . . . . . . . . . . . . . . . . . . 117 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117 Supplement 6: Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 The Role of Pediatric Primary Care in Promoting Healthy Mental Development . . . 120 Effective Methods of Identification . . . . . . . . . . . . . . . . . . . . . . . .121 Working With Children, Adolescents, and Families. . . . . . . . . . . . . . . . . 126 Follow-up and Referrals for Positive Screens . . . . . . . . . . . . . . . . . . . 127 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130 Supplement 7: Schools and Out-of-School Programs . . . . . . . . . . . . . . . . 131 How Children’s and Adolescents’ Mental Health Affects Their Ability to Learn . . . 132 Identification of Students’ Mental Health and Substance Use Problems . . . . . . 133 Partnering With Caregivers and Ensuring Confidentiality . . . . . . . . . . . . . . 140 Interventions for Identified Challenges . . . . . . . . . . . . . . . . . . . . . . 142 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Appendices Appendix A: Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . 149 Appendix B: Tool Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . 153 Adolescent Alcohol and Drug Involvement Scale (AADIS) . . . . . . . . . . . 154 Adolescent Drinking Index (ADI) . . . . . . . . . . . . . . . . . . . . . . . 155 Adolescent Obsessive-Compulsive Drinking Scale (A-OCDS). . . . . . . . . . 157 Ages & Stages Questionnaires: Social-Emotional (ASQ-SE) . . . . . . . . . . 158 Assessment of Substance Misuse in Adolescence (ASMA) . . . . . . . . . . 160 Brief Infant-Toddler Social and Emotional Assessment (BITSEA). . . . . . . . 161 CRAFFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163 DISC Predictive Scales (DPS) . . . . . . . . . . . . . . . . . . . . . . . . 165 Drug Abuse Screening Test–Adolescents (DAST-A) . . . . . . . . . . . . . . 167 Global Appraisal of Individual Needs–Short Screener (GAIN-SS) . . . . . . . . 168 Massachusetts Youth Screening Inventory, 2nd Edition (MAYSI-2) . . . . . . . 170 Pediatric Symptom Checklist (PSC-35) . . . . . . . . . . . . . . . . . . . . 172 Personal Experience Screening Questionnaire (PESQ) . . . . . . . . . . . . 174 Rutgers Alcohol Problem Index (RAPI) . . . . . . . . . . . . . . . . . . . . 176 Strengths and Difficulties Questionnaire (SDQ). . . . . . . . . . . . . . . . 178 Contents v Appendix C: Sample Parent Letter, Information Sheet, and Forms for Consent and Assent . . . . . . . . . . . . . . . . . . . . . . . . . 181 Sample Parent Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Sample Information Sheet . . . . . . . . . . . . . . . . . . . . . . . . . 183 Sample Parent Consent Form . . . . . . . . . . . . . . . . . . . . . . . . 185 Sample Youth Assent Form . . . . . . . . . . . . . . . . . . . . . . . . . 187 Appendix D: Principles Guiding Screening for Early Identification of Mental Health and Substance Use Problems in Children and Adolescents . . . 189 Appendix E: References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 vi Identifying Mental Health and Substance Use Problems of Children and Adolescents Introduction Introduction The Promise of Early Identification “Childhood is an important time to prevent mental disorders and to promote healthy development, because many adult mental disorders have related antecedent problems in childhood. Thus, it is logical to try to intervene early in children’s lives before problems are established and become more refractory. The field of prevention has now developed to the point that reduction of risk, prevention of onset, and early intervention are realistic possibilities. Scientific methodologies in prevention are increasingly sophisticated, and the results from high-quality research trials are as credible as those in other areas of biomedical and psychosocial science. There is a growing recognition that prevention does work.…” —Surgeon General, U.S. Public Health Service1 “The earlier we recognize a child’s mental health needs, the sooner we can help. Early recognition and intervention can prevent years of disability and help children and families thrive. All parents should learn to recognize the signs and symptoms of mental health problems in early childhood; furthermore, they should seek help for their child’s mental health problems with the same urgency as any other health condition.” —Administrator, Substance Abuse and Mental Health Services Administration2 “…drugs change brains—and this can lead to addiction and other serious problems. So preventing early use of drugs or alcohol may reduce the risk of progressing to later abuse and addiction…. Research has shown that science-validated programs…can significantly reduce early use of tobacco, alcohol, and illicit drugs…. Discoveries in the science of addiction have led to advances in drug abuse treatment that help people stop abusing drugs and resume their productive lives.…” —National Institute on Drug Abuse, National Institute of Health3 Introduction 1 About SAMHSA The mission of the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the Department of Health and Human Services (HHS), is to reduce the impact of substance abuse and mental illness on America’s communities. SAMHSA, together with many partners, has demonstrated that prevention works, treatment is effective, and people recover from mental and substance abuse disorders. SAMHSA’s top priority is creating communities where individuals, families, schools, faith-based organizations, and workplaces take action to promote emotional health and reduce the likelihood of mental illness, substance abuse, including tobacco, and suicide. Purpose of the Guide This guide was created to promote the early identification of children and adolescents with mental health and substance use problems as well as to provide guidance, tools, and resources for early identification—including a compendium of the most developmentally, culturally, and environmentally appropriate screening instruments. SAMHSA developed the guide using the input of the members of the Federal/National Partnership* (FNP) Early Identification Workgroup, chaired by representatives from the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA). Workgroup members include representatives from the Administration for Children and The Federal Action Agenda Families, HHS; the Air Force, Department Includes a Call to Address of Defense; CDC, HHS; HRSA, HHS; Early Identification Indian Health Services, HHS; National SAMHSA’s Federal Partner Senior Institute on Drug Abuse, National Workgroup produced the publication Institutes of Health, HHS; Office on Transforming Mental Health Care in Disability, HHS; Office of Juvenile America: The Federal Action Agenda.4 Justice and Delinquency Prevention, One of the action steps identified in Department of Justice; Office of Safe the Federal Action Agenda is to “promote and Drug-Free Schools, Department of strategies to appropriately serve children Education (ED); Office of Special at risk for mental health problems in Education Programs, ED; and SAMHSA, high-risk service systems.” The Federal HHS. Individuals from these agencies Action Agenda calls for a Federal crossreviewed the guide to ensure that it agency group to assess the feasibility of accurately addresses the general implementing one or a combination of concerns and issues as well as the current screening instruments in the specific needs of children and systems serving these at-risk youths. adolescents targeted by their agency. * The Federal/National Partnership (FNP) is the abbreviated title for the Federal/National Partnership for Transforming Child and Family Mental Health and Substance Abuse Prevention and Treatment. The Early Identification Workgroup is one of three task groups of SAMHSA’s Federal Partner Senior Workgroup, which consists of agencies from the Departments of Health and Human Services, Education, Housing and Urban Development, Justice, Labor, Veterans Affairs, and Social Security Administration. 2 Identifying Mental Health and Substance Use Problems of Children and Adolescents