Healthy Kids Check: Lack of transparency and misplaced faith in the benefits of screening

In May 2011, the Australian Government announced an ‘evidence-based mental health and wellbeing check’ for 3- and 4-year-old children (Department of Health and Ageing (DoHA), 2011b). This was part of a package of mental health reforms closely linked to the appointment of Australia’s first Minister for Mental Health and Ageing, Mark Butler, in September 2010. The new health check will be incorporated into the existing Healthy Kids Check (HKC) for 4-year-olds (DoHA, 2010), which will be reconfigured to include 3-year-olds.

In June 2012, a newspaper report about the HKC created considerable controversy (Frances, 2012b; Stark, 2012). Informed discussion has been hampered by the lack of detailed information about what is planned, and when and how it will be implemented. This information is crucial to allay the concerns of parents and health and welfare workers. Furthermore, the main response from the Government has been to criticise any criticism and to deny that the check has anything to do with mental health or psychiatric diagnosis, rather than to clearly explain the nature and content of the check.

In this paper, we first discuss major discrepancies between the original announcements and the current claims about the proposed revised HKC. We go on to highlight uncertainties and contradictions in the current rhetoric. Then we discuss problems with screening more generally that have resulted in a significant shift away from routine population screening in medicine more broadly in recent years. Finally, preschool education and parenting programs, for which there is a stronger evidence base, are briefly discussed.

Unexplained change of direction

Contrary to criticism that it is ‘misleading and alarmist’ to describe the HKC as a ‘mental illness check for toddlers’ (Newman, 2012), it is clear that the initial intent was to assess mental health and identify mental disorder. The May 2011 budget announcement stated: ‘The Government will establish an Expert Group to advise on the inclusion of an evidence-based mental health and wellbeing check as part of the current Healthy Kids Check for three and four year old children’ and ‘Internationally renowned experts are telling us there is a growing body of evidence showing that you can identify kids with (or at risk of) conduct disorders [a diagnostic term in child psychiatry] or poor development very early – from 3 years old’ (DoHA, 2011b). In a Department of Human Services submission to the Standing Committee on Education and Employment Inquiry into mental health and workforce participation, the health and wellbeing check for 3-year-olds is cited amongst initiatives ‘Strengthening the focus on the mental health needs of children, families and youth’, with a specific ‘aim to identify the signs of mental illness early’ (Department of Education, Employment and Workplace Relations, Department of Health and Ageing, and Department of Families, Housing, Community Services and Indigenous Affairs, 2011: 37). In September 2011, an expert group in ‘child mental health’ was established to advise on:

• the design and use of the health check

• mapping child mental health services nationally for inclusion in the National Health Call Centre Network

• a training resource for health professionals (DoHA, 2011a).

Recently, however, advocates of the HKC have denied that it will assess mental health. We would be more reassured by this claim if it were not undermined by the denial that it was ever intended to. Minister Butler stated, ‘it’s not screening for mental health issues’ (Butler, 2012), and his Senior Media Adviser claimed, ‘The Government has never called it a “mental health check”. This language was adopted by tabloid newspapers’ (O’Halloran, 29 June 2012, personal communication). When provided with a Government document (DoHA, 2011b) that used the term ‘mental health and wellbeing check’, along with a number of other phrases consistent with the intent of early detection of mental disorder, the Adviser responded, ‘my minister has never called it a “mental health check”’ (O’Halloran, 29 June 2012, personal communication). However, a joint ministerial statement on Minister Butler’s website refers to ‘Helping to detect potential mental health problems in the early years’ and ‘identify emerging mental health problems early’ (Roxon et al., 2011).

Professor Frank Oberklaid, chair of the expert group, in spite of having stated that the HKC look at internalising disorders [another diagnostic term in child psychiatry] (Stark, 2012), said ‘it was wrong to see the Healthy Kids Check as a mental health check on children. The public and academic outcry about the check had been misinformed and there was “zero” danger of it resulting in overmedication or psychiatric labelling of children’ (Dunlevy, 2012). However, since New Zealand introduced a similar check, prescription rates of antidepressant and stimulant drugs are reported to have risen markedly (TVNZ, 2012). Although correlation does not prove causation, it is worrying that this occurred, and it demonstrates a need for research on the likely effects of implementation.

Inadequate information about the content and evidence base of the check

Ongoing debate and speculation are being fuelled by the lack of information about the content of both the health check and the training resource for health professionals. Nor has it been explained what evidence there is to support the initiative, despite repeated claims that the health check is ‘evidence-based’.

In a doorstop interview in June 2012 (Butler, 2012), Minister Butler reported that the high-level expert group had already spent ‘some months’ working to ‘get the design of that tool precisely right’. Yet no information is forthcoming about this instrument. In the following days, Professor Oberklaid was quoted as saying the check would involve checking the child’s progress against ‘a validated instrument of child development’, but he did not specify what instrument (Dunlevy, 2012). On the same day, Professor Lyn Littlefield, executive director of the Australian Psychological Society and a member of the expert group, seemed to contradict that, saying on Sydney ABC local radio that the questionnaire would be a composite including questions taken from existing instruments.

As the term mental health has disappeared from the Government’s discussion of the HKC, it has mostly been replaced by ‘social and emotional wellbeing’ and ‘social and emotional development’. For example, ‘it’s not screening for mental health issues, its [sic] screening to make sure that their social and emotional development is tracking as we hope and expect it will be’ (Butler, 2012).

Social and emotional wellbeing and development are broad terms that can have relatively positive connotations. Social and emotional development includes ‘the ability to identify and understand one’s feelings, accurately read and comprehend emotional states in others, manage strong emotions and their expression, regulate one’s behaviour, develop empathy for others, and establish and sustain relationships’ (Australian Institute of Health and Welfare, 2009: 60).

However, historically, social and emotional wellbeing (SEWB) has tended to be a euphemism for problems, including mental health problems:

Applied research on SEWB has not generally been concerned with the whole child or young person. If we consider a genealogy of ideas, it could be argued that research in SEWB has often involved observation of a set of individual behaviours that are seen as socially problematic, such as disruptive behaviour at school, or drug use or other risky behaviour, which has in turn been associated with observation of another set of problems, for example hyperactivity, low self-esteem, anxiety or depression. In the course of this research, a range of largely negative indicators of SEWB have been proposed, measuring for example actual behaviours, or states of mental health (Hamilton and Redmond, 2010: 6).

Furthermore, wellbeing manifests differently according to ‘culture, temperament and individual differences’ (Hamilton and Redmond, 2010). This raises concerns about how a universal screening instrument will perform with children from different backgrounds and life situations.

It is not reassuring to clinicians or families that, having announced a mental health check, its advocates contradicted this by saying it is not mental health, but not adequately explaining what it actually is, and why it has changed direction. If it is genuinely evidence-based, and if there is nothing for people to be worried about, it is unclear why a discussion paper, apparently prepared by Professor Oberklaid for Butler’s Mental Health Expert Working Group, has not been released to help allay professional concerns and public anxiety. We have not had a response to repeated requests that we have made to Minister Butler’s office to see the document.

Misplaced faith in the benefits of screening

Regardless of the unresolved debate about whether or not the HKC will screen for mental health problems, there are broader issues related to screening that have also not been adequately explained, and it is not clear to what extent they have been considered, let alone addressed.

For any health screening exercise to be justified, certain conditions must be met, including:

• A screening tool must be available that validly identifies the target problem with a high level of specificity and sensitivity. Those screened in must be far more likely to develop disease than those screened out (Viera, 2011). Even a small reduction in specificity will result in huge numbers of false positives.

• Interventions must be widely and equitably available to those who screen positive, which when targeted to people with ‘pre-disease’, effectively reduces the likelihood of developing disorders.

• The overall benefits to the population of intervening must outweigh the harms, factoring in those individuals who receive the intervention who have received false positive diagnoses.

On the basis of publicly available information, the mental health check for 3-year-olds has not been shown to meet any of these criteria. But such screening will turn up psychiatric cases; research shows that in this age group, case ascertainment studies using ‘validated questionnaires’ find that about 7–16% of children attract psychiatric diagnoses (Gudmundsson et al., 2012). However, the implications of such diagnoses for any need for professional intervention are unclear, and there is no evidence to suggest that 10% of toddlers would be better off for having been diagnosed. And even if they were, there are not sufficient trained clinicians to meet their needs. Although clinical psychologists’ training includes some work with children, few psychologists have advanced skills and experience in infant mental health. Similarly, few paediatricians have specialist training in infant mental health.

Professor Oberklaid and a colleague have posted an email on a paediatric list-serve, declaring that ‘The expert group are aware of all of the issues in relation to screening, including labelling, resource implications etc that have been raised by colleagues. This is NOT a mental health screening process, is NOT designed to make psychiatric diagnoses, and has no danger of increasing the number of children on drugs!’. Unfortunately, in the absence of information about what the screen will consist of, and evidence to support its use, his statement does not reassure.

In medicine more broadly, established screening regimes are being questioned and downgraded (Schwartz and Woloshin, 2012), because harms and costs frequently outweigh benefits, and because of opportunity costs. In the US, the Choosing Wisely campaign, run by nine specialty societies (including the American College of Physicians, the American Society of Clinical Oncology, and the American Gastroenterological Association), has published lists of ‘Five things physicians and patients should question’ (Choosing Wisely, 2012), urging caution about many screening and diagnostic tests and medical interventions. The US Preventive Services Task Force (USPSTF) recommends not conducting prostate-specific antigen (PSA) testing for prostate cancer (USPSTF, 2011), nor routine mammography for women aged 40–49 (nor teaching patient self-examination at any age) (USPSTF, 2009a), nor spirometry for chronic obstructive pulmonary disease (USPSTF, 2009b). Harris (2011) notes that, ‘With few exceptions, the contribution of screening to improving the health of the public is small’, with less benefit and greater harms than has been realised.

The enthusiasm for the HKC is clearly influenced by assumptions that early diagnosis and intervention are always appropriate. However, the current state of knowledge and understanding falls well short of that required to justify the implementation of the HKC. Emeritus Professor Allen Frances has argued that at most it should be undertaken as a research study, with parents giving fully informed consent (Frances, 2012a). The following steps would need to be followed before population-wide intervention.

• Clear specification of what is the target problem.

• Development of a tool aimed to detect the target problem.

• Validation of that tool in a representative population.

• Development and/or identification of a range of interventions that can be applied when the problem is detected.

• Piloting of the screening process in a representative population.

• Evaluation of the pilot project, including the viability of responding equitably to ‘screened-in’ cases.

• Up-scaling of interventions as required to meet projected population demand.

In contrast, there is strong evidence of the social and economic benefits of preschool education and parenting programs, particularly for economically disadvantaged children (Heckman et al., 2006). These programs promote the cognitive, psychological, and social–emotional development and wellbeing of all participants, rather than seeking to identify deficits in (and potentially stigmatise) a minority of individuals. However, by engaging with children and parents, they facilitate identification of a broad range of challenges and problems (including, but not limited to, physical and mental health problems) at an early stage. Ideally, these programs are delivered on a universal basis, either within the entire population or within disadvantaged communities (Karoly et al., 2005: 134–135), with additional support available for children and families identified as likely to benefit.

Conclusion

The inclusion of mental illness or social and emotion wellbeing in the Healthy Kids Check is well intentioned but insufficiently thought through in terms of not only its public health impact, but also its public acceptability. The change in rhetoric from mental illness to social and emotional development/wellbeing, coupled with the dearth of explanation, suggests planning on the run.

It is not enough to say that a health check is ‘evidence-based’ without publicising the evidence. When this is combined with unexplained back-peddling about the nature and purpose of the check, it is not only legitimate but also necessary for concerned health professionals to question the appropriateness of the initiative.

Clearly, both the Government and the community are keen to promote psychological, social, and emotional wellbeing among young children, helping them to ‘develop resilience and learn life skills that support them to participate fully in society as they grow up’ (DoHA, 2011b). This can be more appropriately and effectively achieved by strengthening the provision of early childhood services to the community than by resource-intensive screening with potentially harmful unintended consequences.