Is Consent Active Or Passive

J Sch Wellness. Author manuscript; available in PMC 2009 Jul 21.

Published in final edited course as:

PMCID: PMC2713664

NIHMSID: NIHMS99261

Passive Versus Active Parental Consent: Implications for the Power of School-based Depression Screening to Reach Youth at Gamble

Maggie Chartier, MPH, MS, ^ane Ann Vander Stoep, PhD,^two Elizabeth McCauley, PhD,³ Jerald R. Herting, PhD,⁴ Melissa Tracy, BA,⁵ and James Lymp, PhD⁶

Maggie Chartier

¹Psychology, PGSP-Stanford Consortium, 247 San Carlos Ave, Redwood Urban center, CA ude.drofnats@dyspcpm (Maggie Chartier is the corresponding author.)

Ann Vander Stoep

²Departments of Psychiatry and Behavioral Sciences and Epidemiology, University of Washington, Seattle, WA

Elizabeth McCauley

³Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA

Jerald R. Herting

⁴Departments of Sociology and Psychosocial and Community Health, University of Washington, Seattle, WA

Melissa Tracy

⁵Department of Epidemiology, University of Washington, Seattle, WA

James Lymp

^viDepartment of Pediatrics, Academy of Washington, Seattle, WA

Abstract

Kid and boyish depression often become untreated with resulting adverse effects on academic success and healthy development. Depression screening can facilitate early on identification and timely referral to prevention and treatment programs. Carried out in school settings, universal screening tin can reduce disparities in service utilization by extending the reach of detection and intervention to children who otherwise accept limited admission. However, unless confidentiality and informed option are assured, benefits of universal screening may be offset past loss of individual rights. Implementation of a school-based depression screening program raises the controversial question of how to obtain informed parental consent. During implementation of a depression screening program in an urban schoolhouse district in the Pacific Northwest, the district's parental consent protocol changed from passive to active, providing a natural experiment to examine differences in participation nether these ii atmospheric condition. Compared to weather condition of parent information with option to actively refuse (passive consent), when children were required to accept written parental permission (active consent), participation was dramatically reduced (85% to 66%). In addition, under conditions of active consent, non-participation increased differentially amongst student subgroups with increased hazard for depression. Successful implementation of school-based mental health screening programs warrants a careful read of customs readiness and incorporation of outreach activities designed to increase understanding and interest amongst target groups within the community. Otherwise, requiring agile parental consent may have the unwanted event of reinforcing existing disparities in access to mental wellness services.

Literature Review

Although babyhood depression has been associated with poor school operation, failure to complete schoolhouse, drug use, and suicide (1–three), nearly children with major depressive disorder or sub-threshold depressive symptoms practice not receive treatment (4–6). School-based programs have great potential to reduce disparities in service utilization and health status by extending the achieve of constructive interventions to children who otherwise have limited admission to handling or preventive care (7–9). Many school-based programs that address boyish depression or suicide-take chances use universal or targeted screening to identify potential at risk students (vii,10–thirteen). There are a number of factors that brand depression an appropriate screening target. The prevalence among children is loftier (2.5–viii.iii%) (14), and inexpensive, accurate, and piece of cake to administer screening tools are available (15,16). Nigh chiefly, early intervention can exist beneficial (17–20). Early intervention is predicated upon early detection, and without active screening, detection of depression and other emotional health problems that manifest with internalizing symptoms is hard, especially in younger children (21). A recent report published in the American Journal of Preventive Medicine named low screening as among the pinnacle 25 preventive services offering the well-nigh wellness benefit for the wellness intendance dollar (22). Yet considerable backlash was generated by recommendations from the President's New Freedom Commission to implement universal mental health screening in public schools (9).

Equally illustrated in Figure 1, implementation of universal depression screening in a school setting is carried out within a complex contextual framework of developmental, upstanding, practical and legal considerations. Ethically, untreated and undiagnosed low and other emotional health conditions may accept critical implications for a child's development. Applied considerations include the degree to which the school district assistants, school board and community recognize the role that emotional health plays in successful schoolhouse performance. Other practical issues include the availability of local resources for the administration of screening tests and the provision of advisable follow-upwards intendance. Finally, legal questions take been raised by the public and the press regarding voluntary participation in screening, the dissemination and employ of screening results, and the interests and agendas of proponents and funders. Successful implementation of screening programs requires safeguards to clinch confidentiality and informed selection, without which programme benefits may be offset by loss of individual rights (23). Pivotal in debates about school-based screening is the issue of how parent and kid consent/assent are obtained.

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Framework for Implementation of Universal Depression Screening in Center Schools

In full general, minors (legally defined as any person under the historic period of 18 in 47 states (24) are required to have parental permission to receive medical treatment. However, a child tin be considered a minor in the eyes of the police force, but withal be immune to consent for specific health services in a limited number of situations. Although ages vary by state, minors in almost states may consent to reproductive wellness care (related to sexual assault, rape, pregnancy and STD services), HIV testing and counseling, mental health care, and drug or alcohol related services without parental notification (24). Boonstra, et. al have emphasized the importance of providing these types of confidential services to adolescents, since minors tend not to seek services for such sensitive health concerns, if they must notify their parents (25).

At present, consent for students to participate in schoolhouse-based emotional health programs is obtained using dissimilar approaches, as dictated by the schoolhouse district in which the plan is being implemented (8,9,12–14,29,36–37). The pick of approach is generally based on a district's interpretation of the Protection of Student Rights Human action (PPRA), put into effect by the federal regime in the 1970s. The PPRA states that, "No educatee shall be required … to submit to a survey, analysis or evaluation that reveals data apropos … mental or psychological issues of the student or the pupil'southward family unit" (28). The Act states that these stipulations "do not apply to any concrete examination or screening that is permitted or required by an applicable Land law, including physical examinations or screening that are permitted without parental notification." How this Act is to be applied with regard to low screening or when students are asked questions about "feeling unhappy" or "thinking that bad things would happen" is open up to interpretation.

Districts may determine to implement school-based health programs nether conditions of passive parental consent, in which parents are provided with information and given the selection to decline, or active parental consent, in which written parental permission is required before the child can participate. Under passive consent, parental non-response is interpreted every bit consent, whereas under agile consent, not-response is interpreted as reject.

Studies that compare participation rates under differing weather condition have shown that requiring active consent lowers student participation (29,30) and systematically excludes specific demographic and high risk groups (31–33). For case, in a trial of a gang prevention program delivered to middle-school students recruited from 18 schools across the U.Southward., agile parental consent protocols affected student participation differentially with respect to race, parental education, family unit structure, and parental level of school commitment (31). Another study found that use of active parental consent for participation in a survey of adolescent alcohol utilize led to differential under-representation of target groups of adolescents at high risk for drinking (33). While these studies demonstrated that use of active consent led to systematic exclusion of students at risk of disruptive behavior problems from programs that target these weather, little is known as to whether participation in programs targeting internalizing problems would exist similarly affected.

Reported hither are the results of a natural experiment that afforded an opportunity to examine participation in a schoolhouse-based low screening and early on intervention program nether differing consent procedures. Midway through implementation, a change in school district policy altered requirements for student participation from passive to active parental consent. This paper addresses the questions of how the requirement of active parental consent affected overall plan participation and whether it led to differential exclusion of children who were at increased take a chance for depression.

Methods

Subjects

Written report setting

Universal depression screening was conducted by the University of Washington's (UW) Developmental Pathways Project (DPP) in 6^thursday course classrooms in 4 public middle schools in the Seattle School District, during the fall semesters of 2002 and 2003. Students who screened positive for depression risk were evaluated at schoolhouse by a child mental wellness professional person who worked with students and parents to facilitate referrals to school and customs-based programs.

A full of 1,000–1,100 vi^th grade students are enrolled annually across the four schools which are located in distinct geographic and demographic areas of the city. With respect to race, ethnicity and socioeconomic status, students in participating schools were representative of students throughout the commune. All 6^th course students enrolled when the screening program was offered were eligible for participation unless a disabling condition precluded their agreement and completion of the questionnaire. A more than extensive give-and-take of the larger project and methodology is presented elsewhere (34). Report methods and recruitment strategies were approved past the University of Washington Man Subjects Review Committee and the Director of the Part of Research, Evaluation and Cess of the Seattle Public Schools.

Conditions of the natural experiment

Due to a conclusion by the Seattle School District legal counsel, the passive parental consent protocol employed during implementation of screening in 2002 was changed in 2003 to an agile protocol requiring written parental permission for participation.

Instruments

A screening questionnaire was administered to students under the supervision of trained DPP field staff. Bones demographic and family information was collected on the first page followed by 30 items from the Mood and Feeling Questionnaire (MFQ) (35) for xi–18 twelvemonth olds, which has been well validated in customs samples (36). MFQ questions were developed based on criteria for major depression and dysthymia in children in the Diagnostic and Statistical Manual (37). The MFQ covers affective, melancholic, vegetative, cognitive and suicidal aspects of depression as specified by DSM-III-R criteria in the two weeks prior to taking the survey. Three questions regarding suicide were removed due to their sensitive nature and the informality of a classroom setting.

Sources of Data for the Present Study

Information from the DPP screening questionnaire were used in the present written report, from which a measurement of depression-vulnerability was derived based on an MFQ score of 20 or greater. Response values for missing MFQ items were imputed by assigning missing items the boilerplate value of all the completed MFQ items for that particular student. Additional information on all students was obtained from schoolhouse records and included gender, race/ethnicity (from parent written report to schoolhouse) and plan (regular education, gifted, Early Language Learner (ELL), and Special Education).

Procedures

The modify from passive to active parental consent necessitated the use of somewhat unlike recruitment strategies. The unique and mutual recruitment elements across the two study years are described below.

Recruitment strategies consistent beyond both years

In both years, written assent was obtained from students. Colorful screening posters specific to each school were placed in classrooms and hallways. Every attempt was fabricated include students in ELL) and Special Education classrooms. A brief paragraph describing the projection was translated into the primary non-English languages (e.g. Spanish, Somali, Vietnamese, Tagalog, Chinese) spoken by families at each school and was sent to parents. The project contracted with linguistic communication interpreters to phone non-English-speaking parents and address their questions. During the 2 weeks post-obit official screening twenty-four hour period, project staff returned to the school and fabricated three attempts to screen students who had been absent-minded.

Year ane (2002): "Passive" consent, parental data with selection to reject

2 weeks prior to the initial screening day an introductory letter of the alphabet from the school chief and an information canvas was sent home to parents of all eligible students. Parents who did not desire their children to participate in screening were asked to return a self-addressed postcard included with the data parcel. Ane week prior to screening day, DPP staff hosted a sixth grade associates or presentations to half dozen^thursday grade homerooms to announce the upcoming screening day and provide an opportunity for students to inquire questions.

Yr ii (2003): "Active" consent, parental information with written parental permission

A letter of introduction from the school main, an information sheet and a parental consent form were included in the school enrollment packets. Each yr these packets are sent to parents of all students in the commune and comprise mandatory emergency contact information that must be updated and returned during the first calendar week of the school yr. In each of the four schools, study investigators attended the virtually important PTA meeting of the year or equivalent (e.g. 6^th grade back to school dark) in which they introduced the screening project to parents and described the opportunity for students to participate. DPP besides placed announcements in school newsletters.

To discourage non-response, students who returned their consent form, regardless of the parent's response (consent or decline), received a small prize. The calendar week prior to screening day, DPP staff visited homerooms to redistribute parental consent forms and answer questions. All students who returned parental consent forms by screening twenty-four hours, regardless of response, were entered in a raffle for a larger prize. The weekend prior to screening DPP staff made phone calls to all parents who had non withal responded.

Data Analyses

A Chi-foursquare exam was used to compare the proportion of students who participated in the depression screening program across the two written report years. Adjacent, a serial of analytic steps were taken to address the question of whether, under conditions of active consent, students with loftier depression run a risk were selectively excluded from participation. Inside gender, racial, school, schoolhouse program subgroups of students, the proportion decline in participation from 2002 to 2003 and the proportion of positive screens in 2002 were calculated, to assess whether subgroups that experienced a marked decline in participation also had a high proportion of positive screens. Second, incorporating data from students screened in 2002, logistic regression analyses were used to fit an equation that would predict each student's probability of screening positive on the basis of her/his gender, race/ethnicity, school, and educational program. Finally, with the resulting equation the mean predicted probability of screening positive for depression among 2003 non-respondents, participants, and declines was calculated. I-fashion assay of variance was conducted to test for significant differences amid these subgroups.

Results

Of the one,011 enrolled students who were eligible to participate in screening in the autumn of 2002, the parents of 69 (6.eight%) declined to allow their children to participate; 58 students (5.vii%) declined participation; 12 (ane.ii%) were absent on screening day and on the subsequent make-up days; and xi(1.i%) of students were excluded because their parents did not receive the notification letter of the alphabet and therefore had no opportunity to turn down. A total of 861 (85.ii%) eligible students participated. Of the ane,021 students eligible for screening in 2003, the parents of 215 (21.i%) declined to let their children to participate, sixteen students (i.6%) declined participation; and 117 (11.5%) parents did not return a permission form. A total of 672 (65.viii%) eligible students participated. A significantly lower proportion of students participated under atmospheric condition of active than under weather of passive consent (65.8% vs. 85.ii%; p < 0.001).

As shown in Table 1, the magnitude of reject in participation and the proportion of students who screened positive for depression differed by educatee race/ethnicity, by schoolhouse, and by educational programme. The subgroups with the highest proportion of positive screeners in Year ane tended to be those with the greatest pass up in participation in Yr ii. For example, in Yr 1 African American students were significantly more likely than Caucasian students to screen positive for low (OR = 2.09; 95% CI = i.18 – 3.70) and experienced a disproportionately greater reject in participation from Year 1 to Twelvemonth ii (a decrease of 30.1% amongst African American students, compared to a decrease of 9.eight% amongst Caucasian students).

Table one

Screening Participation and Low Screening Status, by Schoolhouse, Educational Program, Gender, and Race/Ethnicity, and Year (2002 & 2003).

	SCREENING PARTICIPATION					DEPRESSION Status

	2002		2003			2002		2003
	Northward	% of eligible students screened	Due north	% of eligible students screened	modify in % participation	N	% screening positive for depression ^a	N	% screening positive for depression ^a

Total	861	85.2	672	65.8	−19.4	118	13.7	99	14.seven

Schoolhouse
A	188	lxxx.3	137	57.iii	−23	17	9.0	39	28.5
B	350	85.4	311	77.2	−8.2	38	10.9	28	9
C	126	88.1	78	54.5	−33.half-dozen	27	21.4	11	14.i
D	197	87.nine	146	61.six	−26.3	36	18.three	21	14.4

Educational program
Regular	594	83.iv	478	63.8	−19.6	79	thirteen.three	71	fourteen.9
Gifted	98	89.nine	83	76.9	−13	3	3.1	12	xiv.5
ESL	71	91	45	69.2	−21.8	14	nineteen.7	v	eleven.1
SBD ^b	10	90.ix	vii	77.8	−13.one	3	30	i	14.3
Other special education	88	87.1	59	64.8	−22.3	19	21.6	ten	16.9

Gender
Female	394	84.ii	329	66.6	−17.6	56	14.2	54	16.4
Male	467	86	343	65	−21	62	13.iii	45	13.1

Race/ethnicity
Caucasian	340	87.half-dozen	297	78.4	−9.2	32	9.four	29	9.viii
African American	225	83.six	139	53.5	−30.1	43	19.1	41	29.v
Asian/Pacific Islander	206	83.4	149	59.4	−24	33	16	18	12.one
Hispanic	77	86.five	69	64.5	−22	eight	10.4	x	14.five
Native American/ Alaska Native	xiii	72.ii	17	lxx.8	−1.4	2	15.4	1	5.ix

As shown in Figure 2, compared to other Twelvemonth ii participants and non-participants, the predicted probability of screening positive for depression was significantly college for students who in Year ii were excluded from participation due to non-response (F = 4.844, df = three, p = 0.002).

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Predicted Probability of Depression, by Consent Status, 2003

^* Percent predicted to score 20 or college on the MFQ (and 95% confidence intervals) based on school, educational plan, gender, and race/ethnicity.

Give-and-take

This natural experiment demonstrated that participation in a depression screening program fell markedly under conditions of active, as compared to passive parental consent, and that the pass up in participation was non equivalent beyond subgroups of students or across schools. Nether conditions of active consent, participation by groups of students with a higher likelihood of screening positive for low was differentially reduced. These findings are consistent with other research showing differential exclusion of high gamble students when active parental permission is required for participation in school-based programs (31–33).

A comment is warranted near a perplexing report finding. Despite the asymmetric reduction in participation in groups at increased take a chance of screening positive, the percentage of students who screened positive for depression did not, as might exist expected, decrease from Year 1 to Twelvemonth 2. Instead, it increased (though not significantly) from thirteen.7% to fourteen.seven%. At that place are two plausible explanations for this finding, neither of which tin can be substantiated with the data bachelor. One explanation is a cohort issue, (i.e., the 2003 6^th class cohort had worse emotional health than the 2002 6^thursday grade accomplice). The second explanation is a variation of "the ecological fallacy" in that, although subgroups of students at high gamble of depression showed a more precipitous reject in participation, individual students at adventure of depression within these subgroups may take selectively participated. The equivalence in the proportions of positive screens among participating students in Years 1 and 2 is consistent with Eaton, et. al.'s finding that despite general drops in participation under conditions of agile, as compared with passive parental consent, the prevalence of boyish risk behavior in surveyed students from 143 schools beyond the U.Southward. did not change (30).

This report of participation in a depression screening programme has a number of limitations. Parental attitudes towards emotional health screening and consent differ past state and school district such that these findings may have limited external validity. Also the internal validity of our findings is limited by the naturalistic (non-randomized) conditions under which the study was conducted. Factors other than the alter in consent procedure could accept influenced pupil participation betwixt the two years of the study. For example, there was a change in principals at Schools B and C which could have influenced schoolhouse policy and attitudes towards screening. School B, which did not experience a reject in participation, was exceptional for a number of reasons. School assistants and parents demonstrated a articulate interest in the issue of childhood depression. In 2003 the chief investigators were invited to lead a mental health workshop for all faculty and staff and to brand a presentation on adolescent emotional development at a well-attended 6^th Course Parent Night. A summary of these talks was published in the school newsletter. This experience underscores the importance of active efforts to foster community readiness, regardless of the requirements for parental consent.

In examining factors related to participation in screening and to emotional health status, the classification system used for race/ethnicity may have been besides rough, equally it fabricated distinct between immigrant and native-built-in families. Nearly 27% of students screened reported both parents being born exterior of the U.S. Combining African immigrants with native-built-in African Americans and Asian immigrants with native-built-in Asian Americans within the aforementioned racial categories may exist inappropriate. The emotional wellness status and likelihood of participation in emotional health screening of immigrants and non-immigrants of the same race is likely to differ (38).

Reasons for parental response or non-response were not assessed. Lack of information about and appreciation of the part of emotional health in academic performance, fear of stigma, mistrust of mental health interventions, and language barriers may have contributed to decisions or lack thereof. Only as unlike strategies may be needed to encourage participation among families from different races, additional targeted outreach is needed for families who are non native English speakers and for families from cultural groups that adhere to specific attributions almost and interventions for childhood emotional wellness problems.

In decision, implementation of school-based emotional health screening programs warrants careful consideration of customs readiness to use public health solutions to children's emotional health problems. Questions regarding consent procedures for emotional health screening in students, the use of screening results, and the interests and agendas of funders should exist addressed openly. School districts planning to implement mental health programs should be aware that requiring active parental consent may run at cross purposes to the goal of extending the reach of mental wellness care to underserved populations and may have the unwanted effect of reinforcing existing disparities in access to mental wellness services. Alternatives to active parental consent, such as an active/passive consent protocol take been proposed. This approach uses active consent during round one and passive consent in round two, assuasive students whose parents did not answer to choose to participate while assuasive parents who exercise not desire their children to participate multiple opportunities to pass up (39).

Increased sensation of how academic success "rests on a foundation of social-emotional competencies" (p. 303) (40) should exist fostered among children themselves, their parents, school administrators, and policy makers. Effective social marketing strategies that are tailored to the needs and attitudes mutual in specific cultural subgroups of the population and that engender interest amongst primal school leaders are critical to furthering this process. Child and adolescent depression are prevalent, and school-based programs accept dandy potential to address social and economic disparities in access to interventions designed to improve children's emotional wellness condition and academic success.

Acknowledgements

This written report was funded by R01-MH63711 from the National Institutes of Mental Wellness and Drug Corruption. The authors wish to thank the Seattle children and parents who participated in the Developmental Pathways Project.

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