A Response to Dr. Richard Friedman’s Defense of TeenScreen

A commentary by Richard Friedman, MD, [1] was published in December 28,
2006 issue of The New England Journal of Medicine in defense of TeenScreen,
Columbia University’s controversial mental screening questionnaire designed
to expand the pool of teenagers who are deemed mentally ill. Recently, close
to 50% of teens in a New York school who answered the TeenScreen
questionnaire were referred for psychiatric intervention. See:

Dr. Friedman is a clinical professor of psychiatry at Weill Medical College,
Cornell University. He is also a lecturer at Columbia University’s College
of Physicians and Surgeons. His commentary is peppered with sweeping
unsubstantiated statements such as:  “Before screening, Courtney was part of
a silent epidemic of mental illness among teenagers.”

Below Karen Effrem, MD, a pediatrician who serves on the board of Directors
of AHRP, offers a perspective quite different from that of Dr. Friedman.

Contact: Vera Hassner Sharav


I suspect that readers of the NEJM would have quite a different view or at
least serious questions about the process if they heard instead the story of
Aliah Gleason and other statistics that he omitted.

According to the published account [2], Aliah, 13 years old at the time,
underwent a psychiatric screening at her school in Texas under unclear
parental consent procedures.  The parents initially received a letter
several weeks after the screening stating that their daughter reported “not
experiencing a significant level of distress.”  Shortly after that, however,
a psychologist phoned her parents saying that Aliah had scored high on some
suicide rating and that she needed to be evaluated.  Her parents reluctantly
agreed to have her seen by a psychiatrist who did not admit her but referred
her for follow-up.  Six weeks after that, she was forcibly removed from
school by Child Protection and committed to the state mental hospital;
denied family contact for five months; forcibly medicated with twelve
different medications, including multiple atypical antipsychotics that are
not approved for use in this age group, many simultaneously and all without
parental consent; and physically restrained at least twenty-six times.

As vividly illustrated by the case of the Gleason family, as well as with
numerous situations associated with TeenScreen, parental rights are not
protected with screening.  Parental rights are routinely violated or
minimized by TeenScreen.  Despite Friedman’s claims of “explicit parental
consent,” one of David Shaffer’s research papers on TeenScreen lists passive
consent as the type of parental consent obtained. [3] The definition of
“passive consent” is that consent is assumed unless parents actively work to
exclude their children.  In addition, in one place in the TeenScreen
training manual programs are asked how many parents give passive versus
active consent. [4] On another page, the forms ask if they will use “active
consent, waiver of consent, or no consent at all.” [5]  Finally, the
TeenScreen Newsletter trains their programs to avoid compliance with the
federal Protection of Pupil Rights Amendment governing parental consent for
non-emergency surveys and screenings. [6] This is in direct
contradistinction to the intent of the Garrett Lee Smith Memorial Act’s
stated intention of preferring programs that require active parental
consent. [7]

Friedman minimizes the import of the impartial US Preventative Services Task
Force report on screening for suicide which said in part, “There is no
evidence that screening for suicide risk reduces suicide attempts or
mortality, there is limited evidence on the accuracy of screening tools to
identify suicide risk, there is insufficient evidence that treatment of
those at high risk reduces suicide attempts or mortality.” [8] So, even if
screening were accurate, as will be discussed below, there is no evidence
that current treatments are able to reduce the number of attempts or
mortality from suicide.

Friedman also discusses the low specificity of TeenScreen as if it is of
little significance, but in fact Schaffer admits that positive predictive
value (PPV) of TeenScreen is a dismal sixteen percent. [9] Any other
screening procedure would not even be considered with a PPV that low.

According to TeenScreen 55,000 students were screened.  Of those, one third,
or 18,150, screened positive and one half of those screening positive, or
9075, were referred for treatment.  If one applies Shaffer’s admitted 84%
false positive rate to the 18,150 who screened positive, 15, 246 were false
positives.  That could easily include all of the 9075 students that were
referred for treatment.  If one then applies new data cited at the 2006
meeting of the American Academy of Child and Adolescent Psychiatry that 59%
of children and adolescents with depression are treated with
anti-depressants [10] then 5354 students falsely and dangerously received
antidepressants just from that one screening program.

Even if one is more conservative, and assumed that all 16% of the true
positives (2,904) of those screened for suicide were in the group of 9,075
referred for treatment, that would leave 6,171 (9,075 – 2,904 or 68%)
improperly referred for treatment and if 59% of those received
anti-depressants, 3,640 children and adolescents still improperly received
antidepressants from one screening program.

Either scenario raises grave concerns.  These antidepressants are under
Black Box Warnings for suicidal ideation in children and adolescents. [11]
David Shaffer and colleagues from Columbia have admitted “in children and
adolescents (aged 6-18 years), antidepressant drug treatment was
significantly associated with suicide attempts (OR, 1.52; 95% CI, 1.12-2.07
[263 cases and 1241 controls]) and suicide deaths (OR, 15.62; 95% CI,
1.65-infinity [8 cases and 39 controls]).” [12] With the possible exception
of fluoxetine, there is no evidence of efficacy of these medications in the
treatment of pediatric depression. [13] To expose thousands of young people
to these ineffective and dangerous medications needlessly is medically and
ethically unconscionable.

The following excerpts from Thomas Woodward’s testimony at the September 13,
2004 FDA hearing [14] on antidepressants  eloquently illustrate the tragic
consequences and very real dangers of further expanding TeenScreen and
programs like it:

“My name is Tom Woodward.  My wife Kathy and I had four
children.  Julie, the oldest of our children, took her life on July 22,
Julie was a gentle and beautiful young girl – she was only
17.  She was deeply loved and is sorely missed by all that knew her.
Julie was a normal teenager dealing with normal teenage
issues — she had no history of self-harm or suicide.
She was prescribed Zoloft and we were told that it was
‘safe, very mild, extremely effective’ and ‘essential to her feeling
Seven days after taking her first Zoloft tablet Julie hung
herself in the garage of our home.  We’ve since learned that Julie began
experiencing akathisia almost immediately after taking the first pill.
Julie never harmed herself in her 17 years – the only
variable was 7 days of Zoloft.  We are certain that Zoloft killed our
daughter. The problems associated with these drugs are particularly
frightening in light of the Bush Administration’s ‘New Freedom Initiative’ –
a program designed to subject every school age child in this country to
psychological testing.”


[1] Friedman, R. (12/28/06) Uncovering an Epidemic – Screening for Mental
Illness in Teens NEJM Vol. 355, No. 26 pp. 2717-2719
[2] Waters, Rob (2005) Medicating Aliah Mother Jones Magazine
FOR YOUNG ADULTS. http://www.afsp.org/education/shaff_pc.htm
[4] Columbia University TeenScreen Program (2003) Site Development Workbook
– Universal Screening Model, page 45
[5] Columbia University TeenScreen Program (2003) Site Development Workbook
– Universal Screening Model, page 70
[6] Columbia University TeenScreen Program (Fall 2003 ) TeenScreen News
http://www.antidepressantsfacts.com/TeenScreen-crimin.pdf , which says, “If
the screening will be given to all students, as opposed to some, it becomes
part of the curriculum and no longer requires active parental consent (i.e.,
if all ninth graders will be screened as a matter of policy, it is
considered part of the curriculum).”
[7] PL 108-355 Sec. 520E(c)(14) which says “preferred programs” will “obtain
informed written consent from a parent or legal guardian of an at-risk child
before involving the child in a youth suicide early intervention and
prevention program.”
[8] US Preventative Services Task Force
[9] Shaffer, D. et al. (2004). The Columbia Suicide Screen: Validity and
Reliability of a Screen for Youth Suicide and Prevention. Journal of the
American Academy of Child and Adolescent Psychiatry, 43(1), 71-79; p. 77
[10] Robinson, LM et. al. (2006) Poster session at the 2006 meeting of the
American Academy of Child And Adolescent Psychiatry as reported in Brunk,, D
(12/06) “Diagnoses of Depression Doubled in a Decade” Pediatric News
[11] FDA CDER (10/15/04) Labeling Change Request Letter for Antidepressant
[12] Olfson, M and Shaffer D (2006) Antidepressant Drug Therapy and Suicide
in Severely Depressed Children and Adults Archives of General Psychiatry 63:
[13] Jureidini, J et. al. (4/10/04) Efficacy and safety of antidepressants
for children and adolescents British Medical Journal 328:879-883
[14] Woodward, Tom (9/13/04)