Back to Bayes-ics: Improving Universal Screening Decisions by Quantifying Uncertainty

Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment. To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation. This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools. In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9. The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year. A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity. In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern. ClinicalTrials.gov identifier: NCT03716869.

This preliminary study was designed to evaluate the outcomes of iterative teacher trainings for social/emotional/behavioral (SEB) screening in schools. Three separate and successive trainings were completed with adjustments made based on the previous training. We examined the level of accuracy in SEB screener knowledge and data-based decision-making (DBDM) teachers had after training. Additionally, we examined assessment items for patterns in performance on SEB screener knowledge and DBDM after training. Training 1 included 18 preservice teachers, who had greater than chance-level performance on screener knowledge and DBDM at posttest. Training 2 included 16 preservice teachers and Training 3 included 36 in-service teachers. Changes in pre- to posttest performance from these trainings indicated that there was an increase in screener knowledge and DBDM with large effect sizes. An examination of SEB knowledge and DBDM items indicated regular areas of strengths and deficits for the teacher after receiving the training. Implications for adjusting the training procedures and delivery, and examining teacher needs related to SEB screening knowledge and DBDM are discussed.

In the United States, 20% of youth experience social, emotional, and behavioral (SEB) problems. Despite this, very few of these youth with mental health concerns are identified or receive services. This is unfortunate because most mental health problems respond well to intervention and prevention efforts. One promising method for helping to identify youth who would benefit from mental health support is universal SEB screening in schools. Universal screening can be used within a multi-tiered framework of prevention and intervention to identify youth at risk early and to increase access to services. The purpose of this chapter is to discuss the use of universal SEB screening in schools that can be scaled up and utilized with school-based problems solving teams. We will also describe the process for scaling up screening efforts to prevent and intervene with student mental health issues. Lastly, we will describe lessons learned from a large-scale project using universal SEB screening over the past 5 years and efforts to use these lessons to inform future practices.KeywordsPreventionUniversal screeningMental health

Navigating academic demands in middle and high school may be particularly challenging for youth experiencing emotional and behavioral difficulties, and screening practices are a necessary first step in identifying youth in need of services. The goal of this study was to inform efficient universal screening practices in secondary schools by comparing 3 common methods of screening, including self- and teacher report on the Strengths and Difficulties Questionnaire, and grade point average (GPA) to indicate moderate and high levels of risk. Participants were 2,350 secondary students (47% female; 94% non-Hispanic White) and their teachers in 1 socioeconomically diverse school district. Using the moderate-risk criteria, there was low agreement among methods, and almost half the sample (46%) was identified as at risk by at least 1 of the 3 methods, indicating that responding to the needs of students who cross this liberal cutoff may not be feasible given school resources. Using the high-risk criteria reduced the agreement among screening measures. Self-report identified the most students as high risk and was more sensitive to teacher-rated concerns than the converse. If students were uniquely identified by teacher report, teachers rated them at high levels of risk, and predominant concerns were related to conduct problems. GPA captured few students with self- or teacher-rated internalizing or externalizing difficulties. Implications for universal screening within secondary schools are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Universal screening is increasingly becoming part of prevention and early intervention best practice in schools. Although the number of schools engaging in universal screening has increased over the past decade, emotional and behavioral problems are often their primary focus. Problem-focused screening, however, does not address positive contributions to mental health and is useful for only a small percentage of students. Conversely, the information obtained when assessing for strengths is relevant for all students. The inclusion of a strength-based approach in school-based universal mental health screening serves to broaden educators’ understanding of mental health and can inform reactive and proactive interventions that address problems and enhance strengths. This article discusses the knowledge and skills needed to implement universal complete mental health screening, that is, screening that assesses for students’ strengths and problems. A detailed description of complete mental health screening is provided, followed by a step-by-step implementation guide with specific considerations for practitioners who wish to engage in complete mental health screening as part of comprehensive efforts to promote the well-being of all students. Finally, the process of complete mental health screening is illustrated with a case example.

ABSTRACTBackground: Screening, brief intervention, and referral to treatment (SBIRT) is recommended as a strategy to prevent or reduce adolescent substance use. Offering SBIRT in schools may provide an opportunity to reach adolescents not accessing primary care. The objective is to assess school nurses' attitudes and practices regarding adolescent SBIRT. Methods: The authors administered electronically and in person a questionnaire including 29 items on SBIRT attitudes and practices to school nurses registered for the Northeastern University's School Health Institute Summer Program in Massachusetts (N = 168). Survey questions were adapted from a questionnaire originally developed by the American Academy of Pediatrics. Results: One hundred and forty-four nurses completed the survey for a response rate of 85.7%. More than three quarters of the respondents (77.0%) were in favor of universal alcohol screening in schools. None of the respondents reported screening their students on a regular basis. More than half (64.4%) of nurses reported screening students; however, they did so only when they suspected alcohol use. During these instances, only 17.9% used a validated screening tool and almost all (98.2%) used face-to-face clinical interviews. When addressing alcohol use by a student, the large majority of respondents reported including the following recommended clinical strategies: asking about problems related to alcohol use (56.3%), explaining the harms of alcohol use (70.1%), and advising abstinence (73.6%). On average, respondents spend 5 to 10 minutes discussing alcohol use with their students. Conclusion: Survey respondents were supportive of universal alcohol screening in school, although few were doing so at the time. When respondents identified students using alcohol, their interventions were closely aligned with clinical recommendations for brief intervention. Implementation of SBIRT that focuses on standardized, annual screening has the potential to deliver high-quality care in this setting.

The use of data-based decision making (DBDM) in schools to drive educational improvement and success has been strongly promoted by educational experts and policymakers, yet very little is documented about the actual DBDM practices used in schools. This study examines DBDM practices in 25 middle schools through 80 standardized observations of data team meetings and through survey responses. DBDM practices in terms of structure, process, content, quality, and alignment between self-report and observation are described. Key findings include the following: (a) The average amount of time spent discussing an individual student was brief, less than 2 min; (b) on average, actionable decisions following discussions of behavior or reading issues were made 34% to 40% of the time; and (c) there was weak alignment on key topics between self-reported and observed DBDM practices. These findings underscore the need for additional studies of DBDM practices in school and of the impact of DBDM practices on important student outcomes.

Screening for amblyopia in primary care visits is recommended for young children, yet screening rates are poor. Although the prevalence of amblyopia is low (3%-5%) among young children, universal screening in schools and mandatory optometric examinations may improve vision care, but the cost-effectiveness of these vision testing strategies compared with the standard in primary care is unknown. To evaluate the relative cost-effectiveness of universal school screening and mandated optometric examinations compared with standard care vision screening in primary care visits in Toronto, Canada, with the aim of detecting and facilitating treatment of amblyopia and amblyopia risk factors from the Ontario government's perspective. An economic evaluation was conducted from July 2019 to May 2021 using a Markov model to compare 15-year costs and quality-adjusted life-years (QALYs) between school screening and optometric examination compared with primary care screening in Toronto, Canada. Parameters were derived from published literature, the Ontario Schedule of Benefits and Fees, and the Kindergarten Vision Testing Program. A hypothetical cohort of 25 000 children aged 3 to 5 years was simulated. It was assumed that children in the cohort had irreversible vision impairment if not diagnosed by an optometrist. In addition, incremental costs and outcomes of 0 were adjusted to favor the reference strategy. Vision testing programs were designed to detect amblyopia and amblyopia risk factors. For each strategy, the mean costs per child included the costs of screening, optometric examinations, and treatment. The mean health benefits (QALYs) gained were informed by the presence of vision impairment and the benefits of treatment. Incremental cost-effectiveness ratios were calculated for each alternative strategy relative to the standard primary care screening strategy as the additional cost required to achieve an additional QALY at a willingness-to-pay threshold of $50 000 Canadian dollars (CAD) ($37 690) per QALY gained. School screening relative to primary care screening yielded cost savings of CAD $84.09 (95% CI, CAD $82.22-$85.95) (US $63.38 [95% CI, US $61.97-$64.78]) per child and an incremental gain of 0.0004 (95% CI, -0.0047 to 0.0055) QALYs per child. Optometric examinations relative to primary care screening yielded cost savings of CAD $74.47 (95% CI, CAD $72.90-$76.03) (US $56.13 [95% CI, $54.95-$57.30]) per child and an incremental gain of 0.0508 (95% CI, 0.0455-0.0561) QALYs per child. At a willingness-to-pay threshold of CAD $50 000 (US $37 690) per QALY gained, school screening and optometric examinations were cost-effective relative to primary care screening in only 20% and 29% of iterations, respectively. In this study, because amblyopia prevalence is low among young children and most children in the hypothetical cohort had healthy vision, universal school screening and optometric examinations were not cost-effective relative to primary care screening for detecting amblyopia in young children in Toronto, Canada. The mean added health benefits of school screening and optometric examinations compared with primary care screening did not warrant the resources used.

In light of concerning evidence that many young people with mental disorders are not receiving appropriate mental health intervention, school-based mental health screening has been advocated as one way to improve identification of at-risk youth. Despite having much promise, universal screening in schools remains a relatively uncommon practice internationally. Various barriers that deter school psychologists and counsellors from screening have been identified, including lack of resourcing to implement screening, lack of knowledge about the mechanics of how to carry out a screening program, and concern about how to manage the anticipated increased workload generated by following up identified students. In this practice-based paper we discuss a four-stage process that guides school psychologists and counsellors in the establishment of a school-based screening program, with specific reference to overcoming perceived barriers.

Research conducted to date has highlighted barriers to initial adoption of universal behavior screening in schools. However, little is known regarding the experiences of those implementing these procedures and there have been no studies conducted examining the experiences of educators in different stages of implementing various tiered systems of supports. Universal screening is foundational to a successful Comprehensive, Integrated Three-Tiered (Ci3T) model of prevention—an integrated tiered system addressing academics, behavior, and social and emotional well-being. Therefore, the perspectives of Ci3T Leadership Team members at different stages of Ci3T implementation were solicited through an online survey that sought to understand (1) current school-based screening practices and (2) individual beliefs regarding those practices. A total of 165 Ci3T Leadership Team members representing five school districts from three geographic regions across the United States, all of whom were participating in an Institute of Education Sciences Network grant examining integrated tiered systems, reported the screening procedures were generally well-understood and feasible to implement. At the same time, results highlighted continuing professional learning may be beneficial in the areas of: (1) integrating multiple sources of data (e.g., screening data with other data collected as regular school practices) and (2) using those multiple data sources to determine next steps for intervention. We discuss educational implications, limitations, and directions for future inquiry.

The main purpose of this study was to assess the current principals’ decision-making practice in government preparatory schools of West Shoa Zone, Oromia Regional State. To conduct this study, a quantitative research method particularly cross-sectional descriptive survey design was employed. A total of 233 respondents were included into the study. The data were collected through questionnaire, interview which was semi-structured, focus group discussion and document review. Data gathered through questionnaire were analyzed using percentage, frequency and chi-square. Data obtained through interview, focus group discussion and document review were qualitatively analyzed. The study revealed that the principals’ decisionmaking practice in participating stakeholders in most areas of principals’ decision-making practice of preparatory schools was unsatisfactory. Absence of participatory school leadership, lack of trust between stakeholders and principals were some of the factors that were found to have hindered principals’ decisionmaking practice in schools. It was, thus, concluded that stakeholders’ role in school decision-making was not given due attentions in preparatory schools under the study. This is likely to affect the overall activities of schools, in general, and decision-making practice, in particular. Based on the conclusion, consequently, it was recommended that woreda/district education office need to assign trained and experienced principals and train principals who can empower stakeholders to participate and improve the decision-making practices of schools.

Universal mental health screening (UMHS) in schools has strong potential to support early identification of mental health problems in young people. Despite likely benefits implementation remains low, with the lack of evidence regarding acceptability of screening to key stakeholders a contributing factor. We systematically assessed the current evidence base for acceptability of UMHS in schools and its status within key stakeholder groups. MEDLINE, Embase, PyschINFO, Education Research Complete, ASSIA, and Web of Knowledge were searched for relevant articles. All study types collecting acceptability UMHS in schools were included spanning three key stakeholder groups as informants. Articles were assessed for quality using the Mixed Methods Appraisal Tool with outcome data assessed via narrative synthesis and standardised scoring employing the Theoretical Framework for Acceptability Questionnaire. Our review identified 28 studies representing 11,854 informants providing acceptability data on universal mental health screening in schools. Quality of studies varied and designs heterogenous, with wide variation in how acceptability was defined and measured resulting in a weak evidence base. Only 8 studies employed validated acceptability measures. We found some evidence of moderate to high acceptability for all stakeholders, especially school staff, however overall data on acceptability is limited. Of particular concern is a paucity of acceptability data for young people, especially primary school pupils. Schools should consider assessing pupil perspectives on acceptability outside of screening to further understand drivers of non-participation and mitigate any risks of exacerbating health inequalities.

Behavioral and social-emotional challenges experienced in childhood are risk factors for negative educational and health outcomes. Universal social-emotional screening in schools has been identified as an effective approach to identifying children at risk for mental health and behavioral challenges and is congruent with tiered frameworks for data-based decision-making and mental health service delivery. Even so, implementation of screening in schools has been limited, and many schools continue to rely on office discipline referrals (ODRs) as a primary source for the identification of students needing support. This paper uses two case studies to illustrate key steps in the process of implementing universal screening. The case studies demonstrate a systematic approach to implementation and ways in which universal screening can be used to support multi-tiered systems of support (MTSS) initiatives, highlighting the importance of foundational planning using a multidisciplinary team of school personnel.

Screening in High Schools to Identify, Evaluate and Lower Depression (SHIELD) was a randomized clinical trial of school-based universal depression screening conducted with public high schools in Pennsylvania, United States. Screened adolescents were twice as likely to initiate depression treatment compared to peers who were not screened. The purpose of this qualitative study was to understand the experience of communities participating in universal screening via SHIELD. Semi-structured interviews were conducted with school staff (n = 11), parents (n = 4) and adolescents (n = 7) from April-October 2021. A codebook was developed with 20 % of audio transcripts coded for inter-rater reliability (staff k = 0.88, parents k = 0.90, adolescent k = 0.74). The two coders divided and individually coded remaining transcripts for thematic content analysis. Three themes were identified: 1) Depression screening was well-received; 2) The main challenge with screening was inadequate staffing to manage referrals; and 3) School staff suggested alternate formats and methods for future screening. In summary, school-based depression screening was well-received, but schools experienced challenges with staffing and resources to support identified adolescents and offered alternative suggestions for future screening. Schools interested in depression screening need education and capacity building focused on barriers and challenges with the process. Learning from staff who have realized this evidence-based practice in their respective districts will support next steps towards implementation.

To evaluate the effectiveness of adolescent suicide risk screening to increase initiation of mental health services via a secondary analysis using data from the SHIELD (Screening in High Schools to Identify, Evaluate and Lower Depression) randomized clinical trial, which evaluated school-based screening for major depressive disorder (MDD). Students in 14 Pennsylvania high schools were randomized by grade to either the usual school practice of targeted referral for behavior raising a concern for suicide risk or universal screening using the Patient Health Questionnaire-9 (PHQ-9), with any response >0 to item 9 regarding suicide risk considered positive. Students identified in either arm were referred to the Student Assistance Program (SAP), which is mandated in all Pennsylvania schools. The SAP determined follow-up. Study groups were compared using mixed-effects logistic regression. The participants comprised 12 909 students, with 6473 (50.1%) randomized to universal screening. The study group was 46% female and 43% Hispanic or non-Hispanic Black. Adolescents in the universal screening arm had 7.1-fold greater odds (95% CI, 5.7-8.8) of being identified as at risk for suicide, 7.8-fold greater odds (95% CI, 4.6-13.1) of follow-up needs, and 4.0-fold greater odds (95% CI, 2.0-7.9) of initiating mental health treatment. Although the PHQ-9 is a MDD screening tool, its use in universal screening increased identification and treatment initiation for adolescents at risk for suicide. This confirms the value of universal screening and suggests that a suicide-specific risk assessment would have even greater impact on treatment initiation for identified youth. ClinicalTrials.gov: NCT03716869.