Not My Child: The Consideration of Stigma and Ethics in Child Mental Health Screening Policy (Week 2)

Chris’ mother, Jane, sits across from the school nurse in silence as the school nurse’s words sink in: “your son’s mental health screening showed symptoms of depression.” Jane thinks: that doesn’t make any sense, sure Chris has been a little moody lately and he hasn’t been hanging out with his friends as much or going to soccer practice but he’s becoming a teenager and isn’t that how teenagers just are? He’s just being a normal boy. Jane barely hears the school nurse over her own thoughts or the sinking sensation in her stomach “I recommend you take him to a doctor to be evaluated”. Jane’s stomach turns as she thinks: a doctor? An evaluation? Is it really that serious? It can’t be; my son is a normal kid, he’s not one of those kids who skulks around acting sullen and disgusted with the world. He’s not depressed. Not my child.

Hearing that your child might have a chronic illness is likely to be difficult whether it’s a condition that is labeled as physical or psychological but diagnoses of mental disorders tend to carry an extra weight created by stigma or misinformation. The images of people with mental illnesses created by media and works of fiction are usually inaccurate or exaggerated for entertainment value to the detriment of real people who live with these disorders. The resulting stigma creates ethical considerations that we as nurses should consider when developing policy for child mental health screening.

Longest describes ethical principles that should be weighed during the policy decision-making process; these include respect for autonomy and confidentiality, beneficence, and non-maleficence¹.

Autonomy: Based on Jane’s reaction she might choose not to take her son to a psychiatrist for evaluation and treatment. Should the school nurse respect the mother’s decision or intervene to get treatment for Chris? As nurses, we recognize the need to respect the autonomy of our patients; this autonomy must also be taken into consideration when developing policy. In the case of child mental health screening, we need to consider making the screening optional as well as making subsequent evaluation and treatment optional if symptoms of mental health disorders are noted. When stigma is potentially interfering with the decision making process for the parent or child it is our duty to inform and to try to break down the stigma but not to override their wishes.

Confidentiality: Stigma against people with mental disorders enhances the need for confidentiality. As discussed earlier portrayal of people with mental disorders in entertainment media tends to be exaggerated and it is not uncommon for them to be depicted as violent offenders such as in the case of movie trailers for the recently released movie, Split, and its depiction of a person with Disassociate Identity Disorder https://www.youtube.com/watch?v=84TouqfIsiI. In truth, a review by the Institute of Medicine found that people with mental illness contribute just a small to the overall rate of violence to the general population². While confidentiality is important no matter what type of screening is being preformed, the stigma of mental illness increases the necessity of protecting the confidentiality of students whose screening suggests the presence of a mental disorder and should be taken into consideration during policy development and deciding who should be informed when screening results are positive.

Beneficence/Non-Maleficence: The principles of beneficence and non-maleficence must also be taken into consideration when developing health policy. Policy should be created with consideration of how it will benefit those who the policy will affect while minimizing negative effects. In this case, the intention of policy should be to benefit those children who are shown to have symptoms of a mental disorder through screening by providing referral for evaluation and treatment as soon as possible to mitigate the effects of illness. Conversely, some proponents of screening promote it out of concern for school violence perpetrated by children with mental illnesses. This perspective needs to be addressed with education for the public to dispel myths about violence in persons with mental illness and confidentiality should be maintained for children diagnosed with a mental illness in order to minimize harm. This is the intent of the principle of non-maleficence. We must also keep in mind the costs entailed to the school in carrying out these screenings and to the parents in getting their child treatment.

We, as nurses, should promote policy for screening children for mental disorders that will promote the greatest benefit for these children while minimizing costs to the child, parents, and to the school.

Jane sits at her kitchen table in her home studying the list of psychiatrists the school nurse had given to her earlier that day. The school nurse had described the symptoms of depression and the potential consequences of leaving the depression untreated as she had given Jane this list. Some of those symptoms do sound like things I’ve seen in Chris lately. What if he is depressed? The school nurse says he could start to feel hopeless and give up on school. He could give up on his future. He could give up on life. Jane looks over the list again. As she picks up her cellphone a feeling of determination and resolve swells inside of her: Not my child.

¹Longest, B.B. (2010). Health policymaking in the United States (5^th ed.). Chicago, IL: Health Administration Press.

² Institute of Medicine (2006). Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: Institute of Medicine.