Parental Preferences for Mental Health Screening of Youths From a Multinational Survey

This survey study conducted in 19 English-speaking countries investigates parents’ and caregivers’ comfort with and preferences for pediatric mental health screening assessments.


Introduction
The growing prevalence and burden of mental health disorders in pediatric populations 1 have made clear the need for improved detection of mental disorders. [2][3][4] In particular, early identification of youth mental disorders via universal screening is an increasingly actionable solution with the potential to minimize the severity and progression of illness, mediate long-term impairment, and increase access to care, [5][6][7][8][9] especially for common problems such as depression and anxiety. 10,11 A growing amount of literature has drawn attention to primary health care settings 2,12,13 as a natural point of integration, noting both the breadth of screenings already included in well-child visits and the reality that most mental health difficulties are first discussed with primary care practitioners (PCPs). [14][15][16] Consistent with these notions, work has found that mental health referrals from PCPs are preferred and result in a higher follow-up rate compared with referrals from other parties. 17 Accordingly, experts, health care systems, and local governments are increasingly promoting and building infrastructures to deploy mental health screening in primary care settings. 10,11,[18][19][20][21][22][23][24] However, it is also important to maximize the acceptability of screening. To date, much of the work around preferences for and acceptability of screening has focused on medical staff. [25][26][27][28] In this study, we focused on the attitudes of parents and caregivers, which require careful attention to optimize implementation of screening.
Preliminary findings suggest that parents are generally supportive of pediatric mental health screening, [29][30][31][32][33] although preferences exist. For example, studies have proposed that both parents and medical staff prefer mental health screening to occur during annual, routine visits. 27,34 While some studies have found that parents prefer to review their child's screening results with staff members who have medical expertise, 35,36 there is variability based on the content of the screening instrument. 33 Although 1 study showed relatively high acceptance rates of screening instrument topics (75%-85%), certain topics had significantly lower acceptance rates (eg, 50.4%), and percentages of acceptance appeared to substantially differ according to the topic. 33 Attitudes toward a growing number of mental health topics are being assessed in the literature (eg, suicidality, 28,33,37,38 substance use, 27,33 firearms, 29,33,39 depression, 25,28,33,40 attention-deficit/hyperactivity disorder, 25,40 anxiety, 25,40 and gender identity 32 ) although typically in isolation of one another, 27,28,32,37,41 precluding a comprehensive picture. 25,29,33,40 Additionally, previous studies 25, [27][28][29]32,37,38,40,41 often focused on the attitudes of patients and medical staff rather than parents and caregivers; they rarely studied the impact of the report option for the topic in question (eg, parent-report or a child self-report questionnaire). This is important because understanding parents' comfort levels with mental health topics is essential for the development of effective screening procedures. In addition, parental acceptance of screening is likely to differ depending on whether they or their child is having the conversation. 35 Furthermore, some researchers have identified the limits of solely relying on parent comments as a proxy for different types of problematic behavior in a child. [42][43][44] Prior studies suggest that an individual's country of residence may influence perceptions of mental disorders, in part due to cultural differences related to stigma and knowledge about resources for mental health. 45,46 There is limited knowledge regarding parents' comfort levels and preferences toward screening methods and content across international samples.
The present study examined comfort levels and preferences of parents and caregivers toward mental health screening in pediatric primary care settings using a novel survey that incorporated previous questionnaires and research along with input from experts and was administered to parents and caregivers from different English-speaking countries to assess general views of pediatric screening, methods, content, and report options (parent-report vs child self-report). Preferences were compared across countries to examine factors associated with parental preferences, comfort levels, and acceptability.

Participant Recruitment
Data for this survey study were collected from July 11 to 14, 2021, through Prolific Academic, 47 an online, crowdsourced survey recruitment service open to participants aged 18 years or older and available in most Organization for Economic Co-operation and Development countries. Prolific Academic participants have been shown to be more sociodemographically diverse and provide higher-quality data compared with participants of similar data collection platforms. 48 We requested samples from the US, the UK, Canada, and 16 other European and/or English-speaking countries (Australia, Austria, Belgium, Czech Republic, Denmark, France, Germany, Greece, Hungary, Ireland, Israel, Italy, the Netherlands, New Zealand, Poland, and Spain), which were grouped due to an insufficient number of parent samples on the platform. Prolific Academic participants were required to be fluent in English, be a parent or caregiver to 1 or more children (aged 5-21 years), and report about their oldest child in the study age range still living at home. There were no additional inclusion or exclusion criteria. Participants received $3 as compensation for a 15-minute survey. All data on Prolific Academic were collected anonymously after participants agreed to the terms of service; therefore, no additional informed consent was required. Approval and oversight were provided by the Advarra institutional review board. We followed the American Association for Public Opinion Research (AAPOR) reporting guideline.

Study Design and Measures
The survey used for the present study was based on feedback from PCPs and mental health experts and from extensive reviews of prior studies exploring attitudes and preferences toward and/or barriers to mental health screening in youth populations (eTable in Supplement 1). The survey included 5 parts: background and demographics, willingness to discuss mental health, screening administration method, screening benefits and feedback, and parental comfort with screening topics (eAppendix in Supplement 1).

Background and Demographics
Participants were asked about their own and their child's age, race and ethnicity, and gender identity.
Race and ethnicity were included in the study to produce descriptive statistics of the sample characteristics; categories included American Indian/Alaska Native, Black/African American, Caribbean, East Asian/Pacific Islander, Latino/Latina/Latinx or Hispanic, Middle Eastern/North African, South/Southeast Asian, and White, with additional options for those who preferred to not answer, whose race or ethnicity was not listed, or who identified as 2 or more races and ethnicities.
Additional questions addressed the family's history of mental illness and frequency of physician visits.

Willingness to Discuss Mental Health
Respondents were asked to rate their agreement with 15 statements about mental health and learning disorders on a 6-point Likert scale (disagree [1] to agree [6]). The 15 statements assessed willingness for discussions (eg, "I am willing/able to discuss mental health with my child," "I am willing/able to talk about my child's learning difficulties with my family") and perceptions of mental health (eg, "It should be equally easy to talk about both mental health and physical health").

Screening Administration Method
Participants were asked 7 questions to assess their preferred mental health screening setting. One item queried the desired frequency of screening (monthly, quarterly, annually, or never). Five items assessed the preferred screening setting (eg, in the health care office, at the annual well-child visit only, or at home during a telehealth visit) on a 6-point Likert scale (disagree [1] to agree [6]). One multiselection checkbox item assessed participants' preference regarding with which staff member (physician, nurse, other health care practitioner, office staff, social worker, psychologist, counselor, teacher, or other) they would like to discuss their child's mental health issues.

Screening Benefits and Feedback
Four items assessed participants' opinions regarding the possible benefits of mental health screening. The listed benefits were "early detection of problems," "early intervention," "learning more about my child," and "other." Participants rated their agreement with each benefit on a 6-point Likert scale (disagree [1] to agree [6]) and then were offered a free-response option to suggest additional benefits. Four items assessed participants' preferences toward who completes the screening assessment and their preference for receiving results and feedback.

Parental Comfort With Screening Topics
Participants' comfort levels with 21 topics were assessed as a parent-report option and as a child selfreport option. Topics included depression, autism, suicidality, neurodevelopmental disorders, firearms, gender identity, and social media use. Comfort levels were rated on a 6-point Likert scale, with 6 indicating highest comfort.

Statistical Analysis
Analyses were conducted from November 2021 to November 2022. Statistical analyses were conducted using R, version 2022.02.2 + 485 (packages lme4 49 and stats 50 ) (R Project for Statistical Computing). Descriptive statistics were determined for survey sections prior to more advanced analyses being conducted. For all analyses, a 2-sided statistical significance cutoff of P < .05 was applied. Benjamini-Hochberg correction 51 was applied as appropriate. Linear and mixed-effects multivariate regression models were conducted to explore whether certain variables or interactions of variables were associated with parental comfort levels as a random variable.

Sample Characteristics
Of 1200 survey responses requested, data were collected from 1136 participants (94.7%). Thirty-five of the 1136 participants (3.1%) completed only 70% to 85% of the survey. We excluded 164 participants, 22 of whom did not report their child's age and 142 of whom had children outside the age range of our inclusion criteria.  (Figure 1). Figure 1 shows the slight variances that were observed by country. Screening contexts and topics were assessed on a 6-point Likert scale. Participants' country of residence and the child's age were accounted for in the regressions. As shown in Figure 3 and Figure 4, parental comfort levels with 21 screening topics differed by the topic and by the report option (parent-report vs child self-report  anxiety also being significantly associated with the child's age. Over 90% of participants agreed (Ն4 on 6-point Likert scale) that "early detection of problems," "early intervention," and "to learn more about my child" were benefits from mental health screening. Other reported benefits included better "access [to] mental health resources," "awareness of signs to watch for," ability "to accommodate/support my child," "management of symptoms," and "prevention of problems."

Discussion
The present study found that a majority of parents and caregivers were comfortable having their child screened for all mental health topics probed in the survey. However, several preferences were observed. First, participants expressed a preference for carrying out screenings on an annual basis-a model that fits well with that of general medical screenings in the primary care setting. Second, participants favored completing the screening assessment in health care offices rather than at home, although comfort levels for at-home screening were still relatively high. Third, there was a preference for having physicians and psychologists provide the interpretation of the findings, with notably lower comfort levels for reviewing results with social workers, general office staff, or teachers. Regarding Parents and caregivers were asked whether they were comfortable ("yes") or not comfortable ("no") with each type of staff member. screening content, we found that participants' comfort was dependent on screening content and report option (parent-report vs child self-report complete the screening assessments themselves, although they were still relatively comfortable with allowing their child to complete a self-report assessment, with their comfort increasing with the child's age. Finally, it is worth noting that our findings were not dependent on country, although some variation in overall comfort levels across countries was present. Beyond supporting the acceptability of pediatric mental health screening in primary care settings to parents, the present work also suggests potential areas for optimization in future efforts.

JAMA Network Open | Psychiatry
First, our findings suggest that home-based screenings can minimize workflow interruptions and time costs associated with screening 27,28,32,37,52 and are an acceptable solution for many parents. As web-based screening assessments become more widely available and are integrated into electronic health record systems, health care offices may consider this route of administration. This may also allow for increased frequency of screenings, as certain mental illnesses are known to fluctuate by season, 53 suggesting that annual screening may not be sufficient for all disorders. Future work should explore the best times of the year to screen youths and whether home-based screening can better capture some of these fluctuations. Second, parents and caregivers appeared less comfortable with direct screening of their children than via their own report. Although less concerning for the detection of externalizing disorders, such as attention-deficit/hyperactivity disorder, this can be problematic for the detection of internalizing disorders, such as anxiety and depression. Additional analyses aligned with the US Preventive Services Task Force's recommendation of child self-report screening beginning at age 12 years, 10 although future research is needed. Some participants expressed decreased comfort with assessment of key topics related to risk of harm (eg, suicidal ideation, substance use, and firearms). Increased efforts toward the education of parents about the potential benefits and risks of screening may help to increase comfort levels for more comprehensive screening processes.
Our finding of a preference for interpretation of screening assessment results by medical professionals may have implications for efforts focused on school-based screening. In particular, it suggests that school-based efforts may benefit from either having a medical or psychological professional on site to have these conversations periodically or transferring the screening results to the child's primary care clinicians for discussion with families. Implementing screenings in both primary care and school-based settings may then address concerns of time demands and other barriers from screening staff 24 in addition to improving identification and detection. Future work is needed to better understand how to support screening practices in these settings regarding education and training, management, and finances, with consideration of common business models and workflows of PCPs.

Limitations
Limitations of this study include a requirement that participants be fluent in English and have knowledge of and access to Prolific Academic, an online resource. These inclusion criteria prevented parents and caregivers with limited English skills and/or access to the English-based internet site from participating in the study. Inclusion of data from multiple countries suggests some level of generalizability of findings, although it does not exclude potential bias. To our knowledge, current research has not yet addressed cultural and geographic differences in openness to screen, interpret, and take action on pediatric mental health problems and behaviors. Previous studies have suggested that socioeconomic and demographic factors (eg, race and ethnicity and annual household income) may affect results. [54][55][56] Interestingly, the present study did not find an association between these factors and parental comfort levels; however, given the lack of racial and ethnic diversity in the present sample, this requires further study. A systematic review of previous studies noted a variety of changes to family life as a result of the COVID-19 pandemic. 57 Thus, another potential limitation arises from the pandemic occurring simultaneously with this survey, which may have influenced participation rates and responses.

Conclusions
In this survey study of parents and caregivers, there was cross-national parent and caregiver acceptability for mental health screening of their offspring, with preferences for follow-up with experts who can facilitate further evaluation or treatment. This study suggests the need to engage both professionals and the public who may benefit from screening and some of the key factors (eg, screening topics, child age, country of residence, and report option) that may enhance the development of future programs to detect and intervene in mental disorders in youths.