In 2011, the Australian Government announced plans to change the voluntary Healthy Kids Check (HKCheck) during 2012–2013,1 by lowering the age of screening to children aged 3 years and incorporating elements of social and emotional wellbeing. The HKCheck will be conducted by general practitioners, practice nurses and Aboriginal health workers, and will cost about $11 million over 5 years.2

The Expert Working Group developing the HKCheck has not made public what the check comprises and what screening will be involved. While the first media release focused on 3-year-olds and “social and emotional development”, the most recent release (March 2013) announced that the expanded HKCheck will be phased in initially in eight Medicare Local areas in 2013, and the target group will be children aged from 3 to 5 years.3

It is not clear from the latest media release if social and emotional development will be included, and whether the HKCheck will identify “at-risk” families (ie, those with risk factors for children with psychological, conduct and behavioural problems) or whether it will identify risk factors for childhood psychiatric disorders. One aim of a population screening program, such as the HKCheck, is to ensure support for children by identifying and referring families to an appropriate health professional for an in-depth assessment and appropriate intervention (if initial primary health screening finds children who potentially would benefit from this).

Conducting population screening raises a number of complex issues. We will discuss the potential health benefits and risks of population social–emotional screening of children 3–4 years of age, and propose options based on currently available evidence. The first 3 years of life are crucial in terms of neurodevelopment — trauma, stress and/or attachment disruption may have adverse effects on brain and psychological development.4 Early adversity is associated with a range of later difficulties in multiple domains in life, including development and psychiatric disorders;4 however, this important topic is beyond the scope of our article.

Social and emotional wellbeing in early childhood is defined as a “young child’s capacity to experience, regulate and express emotions, form close and secure relationships, and explore the environment and learn . . . these capacities [are] best accomplished within the context of the caregiving environment that includes family, community and cultural expectations . . .”.5 This definition implies that promoting children’s social and emotional wellbeing means alleviating current distress and suffering; enhancing social and emotional competence; establishing and sustaining positive developmental trajectories; and taking a holistic approach rather than concentrating just on the child.

Population screening aims to accurately and inexpensively identify children in need of a more comprehensive social–emotional assessment. Screening instruments used for widespread detection should be brief; easy to administer, score and interpret; of acceptable reliability and validity; and able to provide information that is both developmentally appropriate and clinically useful. Recommended levels for specificity and sensitivity are greater than 80%. There is a need for a balance between identifying a sufficient proportion of “cases” to effectively improve early detection, while minimising false positives.6 Risks of screening include over-medicalising (ie, inter-preting normal and individual variation or transient disturbances as psychopathological conditions); not identifying relationship disturbances; and labelling (with the associated stigma). Finally, screening is potentially very costly.

Currently, there are a number of clinical instruments that examine social and emotional development in 3-year-olds.

• The one-page Pediatric Symptom Checklist, for use by paediatricians, is a brief assessment from parental reporting of dysfunction in major areas of a child’s daily life. A positive score suggests the need for further evaluation by a qualified mental health worker. This instrument has a specificity of 68% and a sensitivity of 95% when compared with clinicians’ ratings of children’s psychosocial dysfunction.7

• The Child Behavior Checklist (CBCL/1.5-5) for ages
  1–5 years has good reliability and validity, but is lengthy (99 items).8 It is not a screening instrument, but is used as part of a comprehensive assessment by experienced clinicians.

• The 11-item Brief Infant–Toddler Social and Emotional Assessment (BITSEA) assesses social–emotional abilities, such as empathy, prosocial behaviours and compliance,
  up to age 36 months and takes about 10 minutes to complete.9 Research has shown that its internal consistency and inter-rater reliability are marginal.10

• The Ages and Stages Questionnaire – Social Emotional (ASQ-SE) is a comprehensive tool for screening possible delays in social–emotional and developmental functioning in children. It takes 15 minutes to complete and its sensitivity has been found to be 71%–85%.11

• Parents’ Evaluation of Developmental Status (PEDS) is a brief screening tool for developmental and behavioural screening and ongoing surveillance of children from birth through to 8 years of age. Summary psychometric figures are sensitivity 86% and specificity 74%. However, only two specific questions concern mental health issues, and its validity testing (that it measures what it purports to measure) is mainly derived from overall development and not specifically social–emotional development.12

While the BITSEA and ASQ-SE were developed as clinical screening tools, they were not designed for large-scale population screening. These instruments may be used in a number of clinical settings, although they are most easily applied where time is not an issue and by those who have in-depth knowledge of child development (eg, staff of child health clinics). The CBCL/1.5-5, the BITSEA and the ASQ-SE need to be purchased and require training to score.

In summary, none of these tools meets all requirements for a brief population screen of children’s social–emotional development.

The same clustering of symptoms seen in 3-year-olds also occurs in older children and adolescents, and these symptom clusters are associated with socioemotional impairment, including social problems or a negative impact on the family. Studies using available validated instruments and clinical assessment have found the most prevalent clusters to be anxiety disorders, attention deficit hyperactivity disorder (ADHD), depressive disorder and behavioural difficulties.13 Kowalenko notes a range of prevalence figures of 7%–26%, reflecting the need for caution in interpreting these data and for further research.13 Another population study reported prevalence rates of impairment of 7%–11% (Diagnostic and statistical manual of mental disorders [DSM-IV]) in children entering school.14

Some problem behaviours and symptoms in early childhood are not transient. Typically, research in this area involves measuring internalising (eg, anxiety15) and/or externalising (eg, aggression15) symptoms, or specific symptoms, including attention problems15 and post-traumatic stress disorder.16 In general, studies suggest moderate continuity of symptoms (although most studies are not continued into adolescence), and there can be a change in symptom presentation over time.17 Children who frequently engage in externalising or internalising problem behaviours are at greater risk of a range of negative long-term outcomes, including dropping out of school and incarceration.18,19 A repeated finding is that elevated aggression persists from the age of 3 years to middle childhood. Currently, there is no research showing screening results at 3 years being predictive of specific psychopathological conditions in adulthood.20

Risk factors identified for symptom clusters in 3-year-olds are similar to those in older children.21 For example, there is evidence of long-term implications of early impairment, including that caused by parental mental health problems.4 Relatively few empirical studies have quantified the long-term predictive strength of these risk factors, when measured at, or near, the age of school entry. The moderating and mediating variables (eg, family factors, socioeconomic status) associated with the persistence of difficulties are typically not included in current screening measures.

Waiting to screen, identify and intervene may leave children “at risk” and miss opportunities for early intervention, prevention and improved trajectories, resulting in loss of both health and future economic benefits.22 Psychosocial problems are increasingly difficult to change or correct at an older age, but a meta-analysis has demonstrated the effectiveness of intervention in early childhood.23 However, similar to older children, younger children generally do not receive interventions because the problems remain undetected.24 From a broader perspective, identifying high-risk or symptomatic young children, and providing accurate prevalence estimates, would enable appropriate funding for the health and educational services necessary to support these children and their families.

As well as the previously noted risks, there are challenges in terms of both GPs using screening instruments and parents attending services offered.25 While there is research highlighting some of the short-term and longer-term problems in at-risk groups, developmental psychopathology is complex and it may not be possible to design a screening tool that can accurately identify young children who will develop disorders in the future.

Emotional and behavioural symptoms in young children are a final common pathway produced by multiple possible aetiologies requiring individual treatment planning. It is currently unclear which domains a screening instrument should include.

Evidence-based early intervention programs have often involved economically disadvantaged families. While there are well researched early intervention programs, some programs were shown not to be beneficial and, until further evidence is available, some scepticism remains about the universal application of early intervention programs.5 Is it better to have a population-based approach to treatment that does not need screening, or screening that leads to more targeted interventions? Further research is needed.

Children identified as being in need of more assessment may overwhelm currently available Australian health care resources. Jureidini and Raven note that interventions must be widely and equitably available to those who screen positive and, when targeted to those with “pre-disease”, should effectively reduce the likelihood of developing disorders.26

Given current knowledge, two fundamental steps are needed. First, we need to invest in methodologically robust, longitudinal population studies, starting before birth, which include risk factors and multiple outcome parameters. This information combined with that from the Australian Early Development Index (a population tool used in the first year of school, measuring five domains of children’s development)27 would provide much needed data on norms for Australian 3-year-olds to assist service planning.

Second, rather than spending money on screening that lacks an evidence base, a logical first step would be to develop a population-based screening instrument. One possible strategy would be to modify existing instruments to make them briefer. Alternatively, we could design a new instrument following best practice, after a comprehensive review of the existing literature, and obtain expert advice to ascertain which domains to include (infant, infant–parent interaction, family interaction). Then factor analysis and psychometric testing could be used to validate a brief population-screening version. Finally, its applicability in broader contexts could be assessed, including in different cultures.

Despite good intentions, further research and planning are needed before starting large-scale, population social–emotional screening of 3-year-old children in Australia.

Someone once told me that during his life, Winston Churchill would often refer to his depression as a “black dog” — a vile, loathsome creature that would shadow every decision and thought in his mind. But to me,
it was not just a dog, but something more sinister and predatory.

The beast followed me in the same way that a lapdog would follow its master, though there was no doubt of who was in charge. Behind every thought, decision and doubt in my mind, the black dog would be not too far away, waiting for a moment of weakness. Feeding off my shame, regret and self-loathing, its hunger knew no bounds and it could smell the fear that seeped from my skin.

For most of my adolescent years, that’s what it was like living with my depression. Every day was a new trial for me to fail and a new reason to undermine my existence. No matter what I did, no matter how hard I worked, I would always come home beaten and shamed. I was constantly making mistakes and no matter how trivial they were, I always punished myself. Every transgression I made was
a constant reminder of how worthless I was.

I never felt more alone than I did during those years. While my peers enjoyed themselves by going out, playing sports or singing in musicals, I spent my breaks eating my lunch alone. I always compared myself to them, asking myself why I couldn’t be like them. Each time, the conclusion was the same; it was because they were normal and I wasn’t. I felt there was something wrong with me, something I couldn’t fix. It was a period of time in which I felt my life was spinning out of control and my sanity was slowly unravelling.

The only thing keeping me alive was my desire to do medicine. Even before I met the black dog, becoming a doctor was all I ever wanted. To work in a craft that was centred around people and their ability to care. It was my calling in life and it was something that I needed to do. But most importantly, it allowed me to push past my depression and survive. No matter how hard things got, I had the strength to continue. I wanted desperately to speak to the school counsellor and confide in her all the pain and misery I was feeling. Maybe there was a cure. I owed it to myself to try. But what would happen if people found out that I was seeing her? What if my peers thought I was insane? The disgrace and humiliation I would feel if everyone knew would be too hard for me to handle. No, I decided. It was
my burden to bear and no one else needed to find out.

It wasn’t long before I tumbled. Months passed, the days became harder for me to bear and my depression deepened. As life continued and my peers moved forward, I was left behind, forgotten. It was as if everyone was in on a big secret that I was not privy to. The cruel isolation wreaked havoc on my self-esteem, pushing me further towards the brink of insanity. As my mind unravelled, my body ached with constant agony.

And then everything became too much. I felt numb and sick at the same time. Waves of nausea, spite and humiliation washed over me as all my mistakes flashed before my eyes. My breathing became laboured and what little tenacity I had left crumbled. I had finally convinced myself that I was a complete and utter failure. I wept. While I sobbed, I wondered what it was like to feel normal and why I lived a cursed life. I pleaded with the Almighty for sweet relief, one way or another. I didn’t care anymore, I just wanted out. As the depression took hold, I reached the chasm’s edge. One step and I would be committed forever. I asked a God I didn’t believe in to give me a break.

To this day, I am thankful for what happened next. After I confessed everything to the counsellor, she helped me realise that no matter how alone I felt, I had my family, my friends and the school to stand by me. That this unbearable agony
I was feeling was common. That people do care. It was something I needed to hear. I was quickly referred to a psychologist for further treatment and I began acceptance and commitment therapy, where I learnt how to acknowledge my faults and move on with my life. Just sharing my problems with someone else and feeling as if they cared was enough to relieve my grief. The pain and doubt that used to hound my every move had less of an impact now. With each session, I could feel the dog — my dog — being pushed further away until it was out of sight.

During the course of the next few months, I was able to complete my final year and secure an interview for medicine. As the date of my interview approached, I became nervous and anxious but I strengthened my resolve. It was my only chance to rectify what had happened to me and I wasn’t going to throw it away. When the day came, I gave it my all.
I talked about why I loved medicine and how I couldn’t see myself doing anything else. I showed them the passion I
had for the profession and the drive necessary to succeed. Afterwards, I was able to rest knowing that I did everything I could. My biggest fight was over.

One month later, I received a call that I had started to believe would never come. I was offered a place to study medicine. It was as if a burden was lifted off my chest. I finally had what I so dearly coveted. It made me realise that anything was possible. That I could live again. Despite being harder than anything I had ever done, studying medicine was the best thing that ever happened to me. I was no longer held back by the expectations that others had of me and was able to become whoever I wanted to be.

That said, I still needed to control my depression. At times, I could feel it edging back into my life and I fought to keep it in check. It was the little things, like new experiences and social pressure, that I struggled with. However, the hardest part was learning about depression at university. Learning about its causes and symptoms made me relive the trauma
I went through. But I always remembered what my life was like before medicine, and how grateful I am for my life now.

Despite my terrible ordeals, I feel that my depression has made me more empathetic. As I remember my clinical experience as a patient, I find it easier to understand what the patient is going through. This recognition allows me to identify with the patient and develop rapport. I know that the dog is not gone forever and I still have bad days. But for the first time in my life, I think I can handle it. I am ready for the next step and this time I’m not alone.

The release of the fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5)1 classification system, scheduled for May 2013, will create controversy due to the expanded range of problems now classed as mental disorders. However, in our view, it is unlikely to improve clinical care. The ultimate test for any system of diagnosis is its clinical utility. That is, does it assist clinicians to improve their selection or sequencing of treatments and enable them to make more accurate prognostic statements in keeping with newer concepts and knowledge? We propose that a refinement to traditional diagnostic practice — clinical staging — is more likely to improve clinical care and inform future research into the causes of mental disorders.2–5 Further, clinical staging draws the practice of clinical psychiatry closer to general medicine, especially with regard to chronic disease management.

In the past century, a major challenge for psychiatry was a lack of international consensus on diagnostic categories. For many decades, DSM and other international systems strived to enhance the reliability of psychiatric diagnoses. Recent field trials for DSM-5 indicate that acceptable reliability remains elusive.6 However, even diagnostic categories with modest reliability have limited validity. A major weakness is that the diagnoses refer to “categorical phenotypes” that fail to address critical differences in clinical presentations associated with age of onset or stage or course of illness.2–5 Most criteria reinforce categories derived from observations of middle-aged people with long-established stable illnesses, who have often been treated extensively by specialised mental health services. Inevitably, these map poorly onto earlier, less specific clinical presentations seen in general outpatient, primary care or community settings. They also presuppose that independent causal pathways exist for each clinical phenotype — an assumption that is not supported by contemporary family, genetic, neurobiological or risk factor research.2,3

What are the alternatives? Twenty-first century health care places an increasing premium on personalised or stratified medicine, with the goal of delivering more tailored treatments. Consequently, there is increasing international support for applying the concepts of clinical staging, particularly for adolescents and young adults with significant mood or psychotic disorders.4,7 Given that 50% of major mental disorders begin between 15 and 25 years of age, a focus on enhanced care and novel clinical research during this critical developmental phase is a timely test of this framework.5,8,9

At its core, the clinical staging model recognises the full spectrum of illness experience. For example, for ischaemic heart disease, the staging model identifies individuals at risk (because of genetics, lifestyle or other risk factors), those with symptoms or related syndromes that suggest illness progression (eg, hypertension, metabolic syndrome) and those with overt evidence of cardiac disease (eg, angina). Further, treatments differ at each point on the illness continuum, with interventions with lower risk–benefit ratios being provided at earlier stages (ie, dietary change or increased exercise for the at-risk stage, and more complex medical treatments for later stages). In psychiatry, this approach also differentiates at-risk individuals (stage 0; eg, family history of severe mental disorders) from those with early subthreshold or attenuated syndromes (stage 1; eg, brief episodes of psychotic or hypomanic symptoms) from those meeting threshold diagnostic criteria (stage 2) or with established or persisting illness (stage 3). Importantly, staging suggests that disorders emerge via a limited set of overlapping and fluctuating symptom clusters (microphenotypes), some of which resolve, while others progress and stabilise into clinical presentations (macrophenotypes) that ultimately resemble more traditional diagnoses.2–5 The clinical staging model is compatible with clinical reality and can be tested for reliability, predictive validity and patterns of association with developmental epidemiology and neurobiological markers.7,10

For mental health, the critical challenge is to help all patients entering care by reducing symptoms, promoting recovery and quality of life, and preventing progression to premature death or further disability.8 The means for achieving these outcomes may be better assisted by clinical staging rather than by prematurely assigning categorical diagnoses to an evolving clinical profile. Also, rather than encouraging early use of medical interventions, the specific intent of staging models is to mimic the disease-management principles now widely applied in general medicine, which enable clinicians to target stage-appropriate interventions from early in the course of illness. Thus, for most young people entering care before the development of full-blown mood or psychotic disorders, the emphasis is on providing relevant information and psychological strategies (including e-mental health), reducing known risk factors (notably alcohol and/or substance misuse), minimising self-harm, promoting resilience, encouraging self-monitoring and reviewing longitudinal course.8 In future, low-risk, evidence-based neuroprotective strategies (which are behaviourally, psychologically or medically based) may also become available.

Clinical staging revolutionised general medical practice, focusing attention on the benefits of intervening earlier in the course of life-threatening illnesses. For clinical psychiatry, it could enable appropriate matching of the timing and intensity of interventions to the specific needs of help-seeking individuals. Also, staging sheds light on the evolution of symptom networks and syndromes,5 and enhances our chances of validating specific pathophysiological pathways and of introducing more objective measures of illness risk, onset and progression.2 In medicine, the successor of clinical staging was clinicopathological staging. In the future, we hope that clinical psychiatry will also be based on the combination of objective markers of illness course and enhanced clinical care.