Should the Way We Screen Children for Health Concerns Change?

In a 2021 paper, a group of doctors and researchers sought to determine how effective universal depression screening in primary care was on adolescent mental health. The maximum positive effect would be 100% of depressed adolescents receiving effective treatment.

Through 100,000 simulations, the authors found the median positive effect was only 4.2%. If there is such a small impact over an entire population, wouldn’t primary care providers’ time be more efficiently spent on other matters with potentially greater positive effect? At the very least, shouldn’t we spend less time talking about the actual screening tools and more time improving access to primary and specialty care?

That is one of the great debates with universal screening, says Kelly Kelleher, MD, an author of that 2021 publication. So many individual screens (physical and mental) have been suggested that it’s impossible for a primary care provider to perform them all. The process from screening to diagnosis to treatment to good outcome can break down at any point for nearly any reason – a family’s financial situation, the accessibility of care, the quality of the care received.

Some screens may have such little impact on overall population health that they don’t make sense to perform.

The most well-known principles for routine universal screening were first published in 1965. Dr. Kelleher, vice president of Community Health at Nationwide Children’s Hospital, and his colleagues are now suggesting they be updated to reflect the real world.

“The original list has lasted for more than 50 years, and it is great as far as it goes,” says Dr. Kelleher, who is also a principal investigator in the Center for Child Health Equity and Outcomes Research in the Abigail Wexner Research Institute at Nationwide Children’s. “But it assumes we live in an ideal world. We do not. In our actual world, some children who need screening and care the most do not receive it. Some screenings are done poorly, or the screening tools themselves are not very accurate. Some families resist the results of screenings. Our new principles address those issues with a population health lens.”

The new screening principles are presented in a recent paper in Academic Pediatrics:

1. Screening program design for children and adolescents and assessment of health outcomes should consider the burden and life-course epidemiology of the conditions under consideration.
2. Screening aims to improve population health, guided by the values of inclusion, equity, and efficiency, in addition to patient health.
3. Screening must be acceptable to participants, health professionals, and the community.
4. Screening tests should be fit for the purpose of improving population health in the context of the primary care setting.
5. Determining the net benefit of screening should reflect effectiveness in routine health system performance at each care process stage.
6. Plans for and evaluations of screening programs should estimate the uncertainty in program costs and benefits.
7. There should be a credible plan to evaluate the local screening program’s benefits and harms and its acceptability to the system’s patients, providers, and community.

The newly suggested principles raise the minimum standard for when a screening should be considered. The 1965 principles “focused on the importance of the health problem, the screening tool’s performance and the efficacy of a treatment,” in the words of the authors of the new principles. That’s a focus on what can happen.

The new principles focus on what actually does happen.

It’s important to note that these new principles apply to universal screenings, or what should happen for every child in a primary care setting, says Kelleher. If a parent notices that a child is having difficulty hearing, or a teacher remarks on a child’s significant change in behavior, a primary care provider (or appropriate professional) should then assess the child. A parent’s or teacher’s specific concern for a specific child is substantially different from the standards for a universal screen, says Kelleher.

“Universal screening is an effort to help all kids – every single child in a population, not just those who regularly go to the doctor, or those who have insurance, or those in stable family situations,” he says. “That’s how we should measure success. Our new principles reflect that. Our goal should be to do all the good we can, and we need to realistic about how to best achieve that goal.”

Published July 2024