Computer-Assisted Methods to Screen for Mental Health and Addictive Disorders

There are nearly 40 million children in the U.S. who are 12 to 17 years old.  Nearly 8 million of these children have a diagnosable mental or addictive disorder. At the same time there is a scarcity of qualified mental health professionals who can screen and treat these children. As many as 5.6 million of these children are not being identified or receiving help. Mental health services are not historically a priority in the U.S. Adequate funding by Federal, State or private insurance for screening and treatment activities has not been available. The current estimated cost to thoroughly screen adolescents in America is between two and four billion dollars. There are not enough mental health professionals to conduct qualified screening.

Because of a scarcity of resources and qualified professionals there has been a great deal of research and professional interest since the 1990's in the use of computers to screen people for mental health problems. These approaches, by in large, hold promise as an efficient means to screen youth for mental and addictive disorders. There is also a wealth of research in man-computer interaction and the use of computers in behavioral and psychological assessment.

Paperny and Hedburg (1999) demonstrated that a computer can do a better job screening a person for health related issues and that computer assisted patient interviews can be less expensive and more reliable than face-to-face interviews.

There are two methods by which children can be screened using a computer system. The first method involves using computer systems that are designed to interview the child. This approach is referred to here as a computer-assisted child interview (CACI). The second method involves the use of a computer system that is designed to interview the parents of children or reliable observers. This system is referred to as a computer-assisted parent interview (CAPI). In this case, the  parents are informants.

Computer-Assisted Child Interviews (CACI)

In general, cooperative children are likely to answer questions administered by a computer and more so than those administered by a person. A computer-assisted child interview (CACI) is a self-report measure. Westen & Weinberger (2004) argue that self-report measures are useful provided the patient has adequate self-observation skill, clear memories and can accurately express their beliefs. They point out that self-observation is also subject to errors. The mind is sufficiently complex that it is difficult to minimize literacy and vocabulary requirements that are necessary to make diagnostic and predictive judgments. Obtaining information necessary to identify subtle mental health problems in children may not be accessible through self-report. As the questions become fewer and simple, the domain of potential corresponding disorders must become broad and general. As a result, a distinction must be made between screening and diagnosis.

CACI follows a general procedure that involves interview, information processing and follow-up. In order to use a computer assisted child interview, a child would normally sit in front of a computer, then read (or read and listen) to questions that are asked by the computer. The child responds to questions by clicking on the appropriate answer. When finished, the computer then processes the responses, generates a diagnosis or impression, and identifies any risks such as those of violence or suicide. The machine generated report is given to the sponsoring school, medical clinic or community mental health center for follow-up. The results are written for professional audiences and are not appropriate for children or parents to read. Professionals would normally conduct further evaluation of the child in question based on this report and then meet with parents. The process is sponsored or administered by a medical clinic or a school  in collaboration with mental health professionals or a community mental health agency.

CACI is based on the assumption that a child will be accurate and cooperative. If they aren’t, then the whole process is subject to bias and errors. The CACI approach relies on the child as the primary source of information and gives the responsibility for assessment and follow-up to physicians, schools, mental health professionals and public programs. Parents are involved in the process after a determination has been made that there is a mental health disorder or high risk problem. In some cases, the child may be involved in further evaluation and treatment before the parents are even aware there is a "concern" or a "problem."

A CACI, for children, has several logistical and professional challenges. Child interview approaches usually require parental cooperation or consent, scheduled appointments, dedicated computers and professionals, a facility to interview children, a follow-up procedure, a referral procedure, but most of all, children who will be honest, accurate and cooperative.

There are a number of advantages when using CACI. The greatest advantage is the ability of this approach to gather information directly from the child. This can be a particular advantage when parents are not involved with their child or they are not able to provide reliable information about their child's history and behavior. The CACI is very powerful intervention when children want help and parents might prevent public authorities from providing mental health services. 

A weakness when using CACI pertains to matters of informed consent, which as a legal and ethical matter, requires patients and subjects considering a diagnostic procedure, or treatment, to understand the risks and benefits so that they can make an informed decision. At what point children are deemed qualified to appreciate the risk is already defined by state laws. In order for CACI to be used on every child, legislation supporting CACI must be enacted that will bi-pass parental consent and involvement.

All treatment or diagnostic procedures carry a risk for harm. Such harm includes social stigma, self-harm and potential limitations on life, liberty and pursuit of happiness. As a matter of law, any professional or agency who does not provide informed consent, or limits individual freedom without due process, may be criminally responsible or civilly liable for any subsequent harm.

Computer-Assisted Parent Interviews (CAPI)

Parents are obviously not trained or qualified to diagnose and treat their children. Training parents to identify and diagnose mental health problems is problematic and could be expensive as well as unrealistic. Instead of training parents to replace the role of a clinician, parents can be a valuable and reliable source of information. Instead of interviewing children, as is the case in a computer-assisted child interview (CACI), a computer-assisted parent interview (CAPI) gathers information from parents who serve as informants.

CAPI is based on the assumption that the report of parents (not the child) will be comprehensive, accurate and cooperative. If they aren’t, then the whole process is subject to bias and errors. The CAPI approach relies on one or more parents as the primary source of information and gives the responsibility for follow-up to the parents. Multi-informant procedures provide a greater measure of reliability, confidence in the results, validity and utility. In order to use this approach, parents must  be present and involved in their child's life so they have accurate information regarding their child's history, behavior and feelings.

There are a number of advantages and disadvantages that are apparent when using a CAPI.

Parent Involvement. CAPI is designed to involve parents in a computer-assisted interview process. The process simultaneously gathers information and serves as the first step toward intervention. Involvement can led to parental investment in both the process and subsequent decisions. Involvement can increase awareness, observation and interaction between parents and their child. Parent interaction over their respective responses and communication about their child can increase when two parents participate in the same interview process. Differences of opinion and possibly conflict may surface. The weakness in this approach is that some parents do not want to be involved in this process either because they wish to avoid conflict, don't care, don't believe it is important or do not trust the process. Clearly, parents who are not involved with their child, or do not want to participate in their care, can undermine this process.

Parent Education. A CAPI approach will expose parents to questions regarding their child that they may have never considered or noticed. Participation in a CAPI can educate and sensitize parents to potential behavior and emotional states that have a bearing on their decisions as parents. Parents who care about their child can learn more about certain behaviors and history that can be used to help them be more effective as parents. In some cases, parents will get to know their child better, pay closer attention and talk more with their child. Parents may even talk more with each other when they realize they do not know the answer to important questions or differ in their responses.

Parental Empowerment. A CAPI is designed get parents involved, increase awareness, provide information and educate parents. In effect, this approach empowers and puts parents in charge of subsequent decisions. Parent involvement, education and information empowers parents in a number of ways. Parents who are knowledgeable and credible are in a better position to advocate and make appropriate choices. Rather than relinquishing responsibility for parenting issues and treatment, parents become more involved.

The CAPI approach depends on a parent who must be qualified as a reliable informant. No appointment is necessary. Parents can screen their child at any time and re-evaluate their child if necessary. Physicians and mental health professionals do not need to schedule appointments for screenings, provide a place for an interview and they do not need to provide a computer or technical support to maintain and process information. In addition, health care professionals are not responsible for the results, nor are they obligated to provide intervention, treatment or referral services to children. The responsibility and right to seek help remains with parents. Depending on privacy issues, parents may be able to  use their own computer, a friends computer or a computer at a library, clinic or school. CAPI is based on a belief that parents not only have the responsibility but the right to advocate for additional screening, evaluation and treatment services based on what they believe is appropriate and necessary.

Some parents are not as involved with their children as much and they should. When absent parents are asked to screen their child using a CAPI, they are likely to discover that they need to get involved and pay more attention to their children. The CAPI approach is a much better approach than a CACI when children are likely to be dishonest, misleading and uncooperative.

Summary

Children can provide reliable information for screening purposes if they have adequate self-observation skills, clear memories and the ability to recognize and articulate their behavior and history. Computer-assisted child interviews (CACI) can be used to screen children who are voluntary, can make an informed decision and those who have parental support and confidence in the process.

At the same, many parents can be reliable informants. They have a wide observational base, can see what their children are doing, and they have information as to how their children  think and feel. Involved parents can provide a detailed history of their child.

Parents may not understand or appreciate the full significance of what they see and know, but they can be reliable informants. A CAPI approach can be used to screen children who are not willing to participate in the process and in cases where parents do not want their child screened using a CACI approach. Both approaches have merit. The approach used should depend on the child and their parents.

References

Mental Health: A Report of the Surgeon General.  Rockville, MD.: U.S. Department of health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institute of Mental Health, 1999.

Paperny, D. M., & Hedburg, V. (1999). Computer-assisted health counselor visits: A low cost model for comprehensive adolescent preventive services. Archives of Pediatric Adolescent Medicine, 153, 63-66. 

U.S. Public Health Service, Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. Washington, DC: Department of Health and Human Services, 2000.

Westen, D., & Weinberger J. (2004). When clinical description becomes statistical prediction. American Psychologist, 695-613.

Dated: December 12, 2008