Program managers, clinicians and people working in prevention services and other planning and policy-related aspects of children services have highlighted the need for more evidence-based practice with respect to screening and assessment of mental health and substance use–related problems. The need is probably even more pressing with children and adolescents than with adults given the evidence that early recognition and treatment of substance use (and probably mental disorders) can reduce the length and outcome of the individual's overall treatment trajectory.
There is considerable research and development under way in many parts of Canada with respect to screening for co-occurring mental health and substance use disorders among adults presenting to mental health or substance use services, as well as to health care services such as primary care. However, screening (and assessment) tools and processes that have been tested with an adult population will not necessarily work with adolescents and younger children.
This project was designed to produce research synthesis and advice that will help program managers and clinicians choose appropriate, well-validated, screening tools for this population.
From the outset the plan included a knowledge exchange focus1 that had three critical features:
- Close engagement of an Expert Advisory Committee made up of program managers and clinicians drawn from addiction, mental health and child and adolescent psychiatry, as well as mental health and addiction treatment system planners. The Advisory Committee's mandate included acilitating the link to regional and provincial program funders and policy-makers in Ontario. The Committee was closely engaged in the development of the specifications of the review and synthesis process. Members were consulted regularly to ensure the final product would meet the needs of end-users at multiple levels.
- A planned hand-off in Ontario to a provincial dissemination team and concurrent disorder champions. Some members of the research team are now serving as advisors to the dissemination team to support development and dissemination of a toolkit and other knowledge exchange activities.
- Development of a detailed technical report and this plain language summary. These two documents would also serve as a foundation for knowledge exchange activities at multiple levels and for multiple purposes in other jurisdictions outside Ontario.
Screening tool review
Before beginning the review of the screening tools, the team collected and considered background information on screening and assessment (e.g., the context of children and adolescent psychopathology, the distinction between screening and assessment, the importance of context in considering different tools and procedures and the different types of validation process that are used in construction of screening and assessment tools). Thus, the answer to the question about what tool(s) "works" is both highly context dependent and related to the goals and research procedures used by the developer. This makes the choice among different options challenging even with a technical summary of the tool's psychometric and other properties in hand.
Starting from a base of almost 3,500 abstracts and articles, and sifting and sorting through literally hundreds of screening and assessment tools and protocols, the team arrived at a subset of tools and studies for the more detailed review and "scoring." In the end, this was distilled to 33 articles and 20 different tools that were assessed in detail. A standard set of criteria was used for reporting the results of validation of diagnostic screening tools, followed by an overview of validity and reliability data with different populations and settings and applications in different cultural contexts. Tables 1 and 2 summarize the results for the 20 tools. A more detailed description of the methodology begins on page 67.
The report is a snapshot
It is important to view this summary as a "snapshot" of screening tools that exist now and as they stand up against the set of criteria that was imposed upon the search and synthesis process. The development of new tools, and improving the quality of data on existing tools, are ongoing processes of research and evaluation. Although some widely used, well-researched screening tools (e.g., the Massachusetts Youth Screening Instrument – Second version (MAYSI-2) did not meet the criteria for this project, we anticipate that research based on a diagnostic gold standard may be published in the near future. Similarly, relative newcomers to the field (e.g., the GAIN Short Screener) will no doubt be the subject of considerable research in the years to come.
Choice of criteria influences results
The final selection here is intimately tied to the various criteria and decisions made along the way. The team opted for an approach that not only allows for a meaningful comparison of the performance of various tools in a synthesis report such as this, but which also has the most meaning for the screening and assessment process itself. Other criteria would have led to a selection of different studies and undoubtedly different tools.
In the summary tables, "stakeholder enthusiasm" is summarized for the different options. This feedback was collected from the group of CD champions in Ontario. However, getting and incorporating feedback on the tools and other important features of screening and assessment of mental health and substance use disorders will undoubtedly be an ongoing process involving various types of end-users engaged in practice, policy and/or research.
1. This knowledge exchange component applied only to the Ontario arm of the project. Members of the Ontario Advisory Committee are identified in Appendix A. Each Canadian jurisdiction, including British Columbia, will ultimately be responsible for this second stage, which focuses on dissemination and knowledge exchange. Inter-provincial/territorial collaboration in the dissemination stage will be encouraged, as well as opportunities for joint evaluation and research.