Introduction
Mental health is a key component of overall well-being. Adolescents often experience gradual changes in their mental health, which can go unnoticed and undiagnosed. The aims of this study were as follows: (1) to assess the feasibility of implementing mental health screening for adolescent patients in the orthodontic setting and (2) to examine the difference between guardian and patient responses.
Methods
The Pediatric Symptom Checklist (PSC), a questionnaire used to identify emotional and behavioral issues, was employed as a screening tool in the orthodontic setting. Participants included children aged 12-17 years and their legal guardians. Measures of feasibility included the following: survey acceptance rate, survey completion rate and duration, and patient and guardian responses to questions related to the importance of screening and willingness to participate again. Analysis of overall and subscale checklist scores, as well as concordance between patient and guardian responses, was used to assess the difference in checklist responses.
Results
A total of 100 orthodontic patients and their legal guardians completed a modified version of the PSC in an average of 3-4 minutes. Overall, 14% patients had scores ≥15, indicating significant problems with emotion and behavior, compared with just 2% guardians. There was a significant difference between the mean PSC score for participants (8.22) and guardians (5.45) ( P <0.01). Concordance of responses between participant and guardian was low to moderate for many factors on the PSC.
Conclusions
Screening for mental health in the orthodontic setting is easily implemented and can help identify patients who require additional support and intervention.
Highlights
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Patients scored significantly higher on mental health assessments than guardians.
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There is low to moderate agreement between patients and guardians on mental health responses.
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Participants have a high acceptance of mental health screening in the orthodontic setting.
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Most participants agree on the importance of mental health screening.
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Mental health screening is feasible in orthodontics.
Mental health is an overarching term to describe one’s emotional, psychological, and social well-being. Physical health and mental health are inextricably linked and often interdependent. Although the exact cause of mental health disorders remains unclear, many factors, such as trauma, illness, genetics, or substance abuse, have been noted to influence the onset and progression of the disease. ,,, The Surgeon General of the United States recently stated that mental health is the defining public health crisis of our time.
Mental health, such as physical health, may change throughout different periods in life. Being able to gauge one’s mental health, such as recognizing a physical injury, is important for long-term well-being. Although older patients may be able to self-assess their mental health status, children and adolescents may not be as keenly aware of the issues that affect them because of poor mental health literacy. Children also mature rapidly, and disturbances in their mental health may go unrecognized and, consequently, untreated.
Youth were recently isolated because of a global pandemic during a critical period in their growth and may not have developed proper social skills or healthy coping mechanisms. This is worrisome as research demonstrates a strong association between social isolation and mental health issues. Although the digital universe may have allowed access to a plethora of information and social networks during this time, excessive use of social media has been correlated with a variety of mental health disorders.
Although forming meaningful connections in a virtual setting can be challenging, interactions in a home environment often foster deeper relationships and are important for a child’s well-being. However, family dynamics have changed over the last few decades. Guardians are more likely to be employed outside the home than in the past because of changes in work patterns, family dynamics, and financial needs. The ability to foster sufficient interactions for family bonding may be limited, and therefore, guardians may not be aware of their child’s mental health status.
The prevalence of poor mental health is increasing. The most recent National Questionnaire on Drug Use and Health indicates that approximately 20% of adults have a mental illness, with a greater proclivity towards females and young adults. Importantly, youth are equally impacted by poor mental health. The National Institute of Mental Health, a division of the National Institutes of Health, reported that approximately 20% meet the criteria for a mental disorder, but only a fraction of those youth are identified as needing assistance. ,, As such, identifying mental health disorders in youth will allow the focus to shift from treatment later in life to early intervention, allowing potential for improved adaptive functioning long-term. ,
Comprehensive mental health screenings are not standard in pediatric primary care. , Pediatricians typically see their patients annually for wellness examinations; however, in the absence of illness, pediatricians have relatively little contact otherwise and limited opportunities to evaluate for mental health issues. On the other hand, orthodontists see their patients every 4-6 weeks for close monitoring of treatment. This frequent interaction makes orthodontic appointments an ideal opportunity to screen for mental health issues, positioning orthodontics as a prime specialty for such screenings. Furthermore, in contrast to other medical and dental specialty visits, patients are not seen for an acute illness to be addressed at each orthodontic visit. This allows for a broader discussion between the orthodontist and patient. However, studies involving mental health and orthodontics are limited. Most studies focus on the effect of orthodontic treatment on mental health and well-being. ,,, Some studies address the management of patients with mental illness in the orthodontic setting. , To our knowledge, no study has explored the feasibility of screening for mental health in orthodontic patients.
With the plethora of benefits and the absence of focused research on the subject, this study’s primary aim was to assess the feasibility of implementing mental health screening for adolescent patients in the orthodontic setting. The secondary aim was to examine the difference between caregiver and patient responses to determine how well guardians are aware of their child’s mental health.
Material and methods
The study population comprised 100 patients and their legal guardians at the Montefiore Medical Center Orthodontic Residency Program in the Bronx, New York. The institutional review board of the Albert Einstein College of Medicine approved this study (institutional review board No. 2023-15281).
The study subjects included patients aged 12-17 years (the typical age of adolescent patients seen in the orthodontic setting) and their legal guardians. They were asked to complete a modified Pediatric Symptom Checklist (PSC). The purpose of the questionnaire was explained to the patient and legal guardian, either in the waiting room or while awaiting treatment in the operatory, by the study coordinator. The informed consent forms and questionnaires were provided in English or Spanish, based on patient and guardian preference. The participants were provided with a QR code that connected them to the questionnaire. Participants then accessed the questionnaire using their mobile devices. Patients without cellular internet access were able to use the free clinic Wi-Fi to gain connection. Patients and guardians had different QR codes to ensure the collected data was separated for analysis.
The PSC is a validated and widely used screening questionnaire that covers a broad range of potential emotional and behavioral problems in youth. There is a 17-question version of the PSC that is translated into many different languages, including English and Spanish. ,,,, Each question offers 3 possible answers, weighted at 0, 1, or 2 points. The scores for each of the 17 items are then summed to produce a total score ranging 0-34. These 17 questions were grouped into 3 subscales: attention problems, internalizing problems (anxiety and depression), and externalizing problems (conduct). A total overall score of ≥15 on the PSC has been found to suggest significant difficulties with emotion and behavior. , Scores of ≥7 for the attention and externalizing problem subscales, as well as ≥5 for the internalizing problem subscale, are considered above the cut-off for suggesting difficulties.
Before beginning the survey, patients and guardians were advised not to discuss the questionnaire and instructed to ask the survey administrator should any questions arose. Survey participants were informed that the questionnaire related to their life in general and not specifically to their orthodontic treatment. Guardians were informed to answer questions about the patient as they deemed most appropriate. Patients and their guardians had the option to discontinue answering the questionnaire once started if they desired. After the questionnaires were completed, a screen with the composite score appeared. The overall results were reviewed with the patient and their legal guardian.
For scores <15, the legal guardian was provided with a form listing mental health resources to bring awareness and availability of additional services if ever needed. When the scores reported by the patient or legal guardian were ≥15, suggesting impairment in emotional or behavioral functioning, the legal guardian was informed. They were advised of the need to see a mental health professional if the patient was not already doing so. Local mental health resources were provided, and any questions were answered.
The inclusion criteria for the study required participants aged 12-17 years to be able to read and write in English or Spanish and be capable of completing a questionnaire. Exclusion criteria included those with craniofacial anomalies, such as cleft lip and palate, as those patients are not routinely seen in general orthodontic practice, which was the focus and area of interest for this study. Risks of completing the questionnaire included triggering psychological stress. The benefits of the study included identifying significant mental health conditions in orthodontic patients for earlier intervention and the possibility of expanding the use of this screening tool in orthodontic practice.
Measures of feasibility included the following: survey acceptance rate, survey completion rate and duration, and patient and guardian responses to questions related to the importance of screening and willingness to participate again. Analysis of overall and subscale checklist scores, as well as concordance between patient and guardian responses, was used to assess the difference in checklist responses and determine how well guardians are aware of their child’s mental health.
Statistical analysis
Descriptive statistics were calculated for demographic variables to report the frequency and proportion of participants’ age, race, and sex. Average and standard deviations (SDs) were computed for continuous variables, such as age, the duration of survey completion in seconds, and scores from both patient and guardian surveys.
Bivariate analyses were conducted to compare mean scores between patients and guardians using an independent-samples t test. Cross-tabulations were used to compare the responses of guardians and patients for categorical variables related to emotional and behavioral health. In addition, the concordance between guardian and patient responses was assessed using percentage agreement for the same set of variables. Further bivariate analyses using the Fisher Exact test were performed for patient survey items, such as “feels sad,” “worries a lot,” “distracted easily,” and other behavioral indicators.
Alpha was set at 0.05, and data analysis was performed using Stata (version 18.0; Stata Corporation, College Station, Tex). Survey responses were collected and stored using Qualtrics (Qualtrics, Provo, Utah), a software that assists in building and distributing surveys as well as collecting responses ( Qualtrics XM: The Leading Experience Management Software ). Resident investigator, principal investigator, study personnel, and biostatistician all had access to the questionnaire responses.
Results
A total of 100 patients and 100 legal guardians completed the questionnaire ( Table I ). The average age of patients was 13.72 years with an SD of 1.52 years. The gender of patients was split almost equally, with 51 females and 49 males participating. Most patients were Hispanic and Latino, comprising 70% of the survey participants. Although patients from the entire age range of the study population were represented (12-17 years), most patients were between the ages of 12-14 years.
Table I
Subject characteristics (N = 100)
| Characteristics | Percentage (%) | |
|---|---|---|
| Mean age (SD, range) in years | 13.73 (1.52, 12-17) | |
| 12 | 25 | |
| 13 | 28 | |
| 14 | 20 | |
| 15 | 9 | |
| 16 | 12 | |
| 17 | 6 | |
| Sex | ||
| Male | 49 | |
| Female | 51 | |
| Race | ||
| White | 7 | |
| Black or African American | 14 | |
| Hispanic or Latino | 70 | |
| Other | 9 |
Of those approached to participate, only 5 guardians declined, resulting in a response rate of 95% (100/105) ( Table II ). The survey completion rate was 100%. All participants had mobile devices that could access the questionnaire via the QR code. Survey completion time varied between patients and guardians. Mean patient duration was 3 minutes 5 seconds (SD = 3 minutes 13 seconds), as compared with mean guardian duration of 4 minutes 5 seconds (SD = 2 minutes 22 seconds). The median (50th percentile) survey completion duration for patients (2 minutes 11 seconds) and guardians (3 minutes 18 seconds) was less than their respective mean durations.
Table II
Feasibility measures (N = 100)
| Response rate (%) | 95.24 | |
|---|---|---|
| Completion rate (%) | 100 | |
| Patient | Guardian | |
| Duration (minutes:seconds) | ||
| Mean (SD) | 3:05 (3:13) | 4:05 (2:22) |
| Median | 2:11 | 3:18 |
| Receptivity (%) | ||
| Do you think that screening for mental health in the orthodontic setting is important? | 61 | 60 |
| Would you feel comfortable taking this survey again at future orthodontic appointments? | 87 | 71 |
Most patients and guardians thought that screening for mental health in the orthodontic setting was important (61% and 60%, respectively). The results showed that patients and guardians were willing to complete the questionnaire again at future appointments (87% and 71%, respectively).
Each patient factor on the checklist was analyzed, and concordance, as measured by percent agreement, between patient and guardian was determined ( Table III ). Most factors exhibited low to moderate agreement. The lowest percent agreement included the factors “distracted easily” (37%) and “worries a lot” (42%), whereas the highest included “takes things that do not belong to them” (84%) and “fights with other children” (81%). The patient and guardian responses for the following 8 factors were statistically significantly associated: “is down on self,” “worries a lot,” “daydreams too much,” “fights with other children,” “does not understand other people’s feelings,” “teases others,” “blames others for his or her troubles,” and “refuses to share.”
Table III
PSC questionnaire responses and concordance measures (N = 100)
| Never | Sometimes | Always | Percent agreement (%) | P value | |||||
|---|---|---|---|---|---|---|---|---|---|
| Patient | Guardian | Patient | Guardian | Patient | Guardian | ||||
| Internalizing subscale | 1. Feels sad, unhappy | 36 | 59 | 63 | 32 | 1 | 9 | 51 | 0.17 |
| 2. Feels hopeless | 72 | 92 | 25 | 8 | 3 | 0 | 72 | 0.38 | |
| 3. Is down on self | 52 | 78 | 42 | 21 | 6 | 1 | 60 | 0.03 | |
| 4. Worries a lot | 39 | 53 | 49 | 44 | 12 | 3 | 42 | 0.049 | |
| 5. Seems to be having less fun | 61 | 78 | 36 | 21 | 3 | 1 | 64 | 0.08 | |
| Attention subscale | 6. Fidgety, unable to sit still | 43 | 79 | 40 | 17 | 17 | 4 | 46 | 0.14 |
| 7. Daydreams too much | 44 | 80 | 39 | 19 | 17 | 1 | 48 | 0.04 | |
| 8. Distracted easily | 31 | 55 | 50 | 40 | 19 | 5 | 37 | 0.95 | |
| 9. Has trouble concentrating | 40 | 60 | 50 | 36 | 10 | 4 | 46 | 0.25 | |
| 10. Acts as if driven by motor | 80 | 60 | 15 | 23 | 5 | 17 | 58 | 0.09 | |
| Externalizing subscale | 11. Fights with other children | 80 | 88 | 16 | 11 | 4 | 1 | 81 | <0.01 |
| 12. Does not listen to rules | 71 | 47 | 24 | 38 | 5 | 15 | 51 | 0.08 | |
| 13. Does not understand other people’s feelings | 63 | 66 | 27 | 20 | 10 | 14 | 52 | 0.02 | |
| 14. Teases others | 64 | 79 | 34 | 20 | 2 | 1 | 65 | 0.01 | |
| 15. Blames others for his/her troubles | 75 | 82 | 24 | 17 | 1 | 1 | 74 | 0.03 | |
| 16. Refuses to share | 63 | 80 | 35 | 20 | 2 | 0 | 63 | 0.02 | |
| 17. Takes things that do not belong to him/her | 84 | 94 | 13 | 6 | 3 | 0 | 84 | 0.06 | |
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