Universal School Mental Health Screening: Rights, Risks, and Alternatives

Section: Children’s Right to Health

Artin A. Mahdanian and Dainius Pūras

Abstract

In 2025, the US state of Illinois enacted a mandate for universal school-based mental health screening, marking a significant development in youth mental health policy and an important attempt to address governments’ obligation to promote children’s mental health. Using this legislation as a case study, this paper examines the evidence, potential benefits, risks, and ethical implications of universal screening within broader international approaches to school mental health. Screening may facilitate earlier identification of psychological distress and improve pathways to support, but evidence that questionnaire-based screening itself improves long-term health or educational outcomes remains limited. Potential concerns include false positives, over-identification and medicalization of normative distress, insufficient follow-up capacity, risks to privacy and confidentiality, and tensions involving children’s autonomy, participation, and evolving capacities. A rights-based approach requires moving beyond symptom detection to address equitable access to care and the social and educational determinants of mental health. We propose that screening remain universally available, voluntary, evidence based, and linked to appropriate assessment and care and that schools prioritize universal resilience- and skills-based psychoeducation, supportive environments, and whole-school mental health promotion. School mental health policy should ultimately be judged not by how many children are screened but by whether it advances their health, dignity, participation, development, and equitable access to support.

Introduction

In July 2025, the governor signed Senate Bill 1560, making Illinois the first US state to enact a law requiring schools to conduct annual mental health screening for students in grades three through twelve.[1] Implementation is scheduled for the 2027–2028 school year, with the Illinois State Board of Education tasked with providing detailed guidance by September 2026.[2] Screening will be offered at no cost to districts, using state-approved self-report tools, and parents retain the right to opt their children out. The law also ties into Illinois’s Behavioral Health Care and Ongoing Navigation (BEACON) portal, a statewide resource designed to link families with behavioral health supports.

Adolescent mental health remains a serious concern. In the 2023 Youth Risk Behavior Survey, 40% of high school students reported persistent sadness or hopelessness, 20% reported seriously considering suicide, and 9% reported a suicide attempt.[3] Peer-reviewed cohort studies corroborate and deepen this picture, documenting particularly high risk among Black adolescent girls.[4] In such a climate, the passage of Illinois’s bill represents a decisive political statement: that the mental health of children should be assessed systematically, not left to chance or crisis. The growing burden of mental health difficulties among children and adolescents is not only a public health and educational concern but also a human rights issue. International human rights standards recognize children’s rights to health, development, participation, and privacy, and they place positive obligations on states to create conditions that support healthy development and ensure timely and appropriate access to prevention, health promotion, and care.[5] Illinois’s legislation can therefore be understood as an important attempt to respond to these obligations. The central question is not whether governments should act to address youth mental health—they should—but whether universal school-based screening represents the most effective, proportionate, and rights-respecting means of doing so.

Illinois is not alone in experimenting with universal school-based screening. Other countries have piloted or debated similar measures.[6] In Australia, federal and state-level pilot projects, such as the online Smooth Sailing model and cluster trials, have implemented voluntary well-being screening tools in secondary schools.[7] Several European jurisdictions now incorporate structured psychosocial questionnaires such as the Strengths and Difficulties Questionnaire.[8] The Dominic Interactive has been integrated into school health surveillance systems, as seen in the School Children Mental Health in Europe project funded by the European Union and in national pilots in Sweden and Scotland.[9] In the United States, earlier initiatives such as Columbia University’s TeenScreen program sought to mainstream routine adolescent screening but ultimately collapsed under widespread criticism over the use of passive consent, high false-positive rates, and concerns about pathologizing normal youth behaviors.[10]

The Illinois law is a powerful message, but policy and outcomes are not necessarily the same. Whether this pathway empowers or constrains children remains uncertain. Against this background, the challenge is no longer simply whether universal screening can identify psychological distress earlier, but whether it advances children’s right to health in a manner that is evidence based, proportionate, and respectful of their dignity.[11] Globally, enthusiasm for school-based mental health initiatives has grown, reflecting wider recognition that schools are among the most accessible settings for reaching children and adolescents.[12] Yet implementation remains uneven, and systematic reviews continue to report mixed evidence regarding the effectiveness of universal screening programs and important uncertainties regarding their long-term impact.[13] At the same time, increasing attention has been paid to the ethical and human rights dimensions of school mental health policy, including children’s autonomy, confidentiality, participation in decisions affecting them; equitable access to follow-up care; and the broader social conditions that shape mental health.[14]

This narrative review critically examines the empirical evidence, ethical considerations, and human rights implications of universal school-based mental health screening. It argues that while early identification may contribute to improving access to support, a genuinely rights-based approach must extend beyond symptom detection to encompass meaningful consent, confidentiality, equitable access to care, and sustained investment in preventive, resilience-focused, and whole-school approaches that address the social determinants of mental health.

Methods

This paper adopts a structured narrative review combined with a normative human rights analysis to examine universal school-based mental health screening, using the 2025 Illinois legislation as a contemporary policy case study. We selected a narrative review methodology because the subject spans multiple disciplines, including psychiatry, public health, education, ethics, law, and human rights, and therefore requires the integration of heterogeneous forms of evidence.

We conducted a targeted literature search between September and December 2025 using PubMed, PsycINFO, Embase, and Scopus, which we updated in August 2026 to identify newly published evidence and literature. We also manually searched reference lists of key publications to identify additional relevant literature. Searches combined controlled vocabulary and free-text terms. Representative search strategies included combinations of (“school mental health” OR “school-based mental health”) AND (screening OR “universal screening”) AND (adolescent OR student), together with terms relating to false positives, overdiagnosis, medicalization, resilience, social-emotional learning, mental health literacy, privacy, consent, human rights, the right to health, children’s rights, ethics, and mental health policy. We conducted additional targeted searches for international human rights documents and policy reports.

The review prioritized peer-reviewed empirical studies, systematic reviews, meta-analyses, clinical practice guidelines, major policy documents, human rights reports, and influential theoretical literature published in English. We selected sources on the basis of their methodological quality, conceptual relevance, and contribution to contemporary debates concerning the benefits, risks, ethical implications, and policy alternatives related to universal school-based mental health screening. Given the policy focus of the review, publications and documents from the past 10 years were preferentially included.

We reviewed the literature iteratively and organized findings into recurring theme domains concerning the rationale for screening, potential benefits, possible harms, implementation challenges, human rights considerations, and policy alternatives. Given the narrative rather than systematic nature of the review, we did not perform formal independent coding or inter-rater reliability procedures. We then reviewed and refined the thematic structure and interpretation. This analytical approach allowed us to consider empirical evidence regarding effectiveness and implementation alongside broader ethical and human rights obligations relevant to school mental health policy.

Results

Before examining the specific benefits that supporters highlight or the cautions that critics raise, it is important to outline the general rationale underpinning universal screening. Screening tools are not diagnostic instruments and are not intended to establish psychiatric diagnoses. Rather, they function as brief indicators of potential concern that require further contextual and multi-source evaluation. Proponents argue that these initiatives are more than screening checklists; they represent a deliberate shift toward treating mental health as an integral component of public education.[15] The intention is not to diagnose or label every child but to create a culture where emotional well-being is monitored as routinely as physical health, reducing stigma and normalizing help-seeking.[16]

Although questionnaire-based screening instruments are intended to function as preliminary case-finding tools, their implementation does not always reflect this ideal. In routine clinical and educational practice, positive screening results may be interpreted as evidence of a psychiatric condition before a comprehensive clinical assessment has been conducted.[17] Brief symptom-based questionnaires can identify individuals with elevated symptoms, but a positive screening result does not establish a psychiatric diagnosis and requires appropriate clinical assessment. For example, at the conventional cut-off score of 10 or higher on the Patient Health Questionnaire-9 (PHQ-9), a widely used depression screening questionnaire, approximately half of positive screens may represent false positives in some adult primary-care populations.[18] Observational evidence has also associated office use of brief depression measures, particularly the PHQ-9, with depression diagnosis and antidepressant prescribing among some adult patients unlikely to have major depression, raising concerns about potential overdiagnosis and overtreatment.[19] Consequently, the distinction between screening and diagnosis must remain explicit throughout any school-based mental health program, with positive results serving merely as an indication for further professional assessment rather than as evidence of a mental health condition.[20]

Promise and potential

Advocates emphasize several interconnected potential benefits of universal school mental health screening, such as earlier recognition of distress, improved mental health care access, the integration of mental health into the daily life of schools, and the generation of system-wide data to inform policy and resource allocation.[21]

Early identification and prevention. Many young people with significant mental health symptoms never receive help until crises erupt.[22] Universal screening may reduce this “silent suffering” by identifying risks before they become deep-rooted.[23] The US Preventive Services Task Force recommends routine screening for depression and anxiety in children and adolescents within clinical settings, providing policy makers with a medical analog for extending such practices into schools.[24] Conceptual work emphasizes that universal screening is a critical step toward early identification and prevention.[25] Broader public health analyses likewise show that most children with mental health problems do not access timely services, underscoring the appeal of school-based screening.[26] Evidence from pilot programs suggests that early intervention can translate into tangible academic and social benefits, as well as stronger social-emotional skills.[27] School-based pilot studies, such as the Australian Smooth Sailing project, have shown improvements in help-seeking and functioning, and reviews highlight that early school interventions are associated with improved academic performance and reduced absenteeism.[28]

Nevertheless, the value of early identification depends not simply on detecting symptoms but on demonstrating that screening ultimately improves meaningful health and educational outcomes. Population screening is best justified when early detection is followed by interventions that measurably improve outcomes while producing benefits that outweigh potential harms. This principle applies equally to mental health screening, where the objective should not be the identification of larger numbers of students with elevated questionnaire scores but improved long-term well-being, functioning, and access to effective care.

Mental health care access. Another argument for universal screening is that it may improve equity in the identification of children experiencing psychological distress; however, equity cannot be reduced to detection alone. A rights-based understanding of equity requires that identification be accompanied by equitable access to comprehensive assessment, timely intervention, and appropriate follow-up care.[29] Experience from other school health programs demonstrates that screening alone does not necessarily reduce disparities if referral pathways are weak or services remain inaccessible. Consequently, universal screening should be understood as only one component of an equitable mental health system.

Public health benefits. Universal mental health screening can be seen as analogous to vision or hearing checks: a first-level signal that further evaluation may be needed. Within this framing, mental health becomes a normalized part of school health, reducing stigma and embedding support into daily education.[30] Therefore, the screening should be used only as a basis for referral for further specialized evaluation.

Data and systems planning. Beyond individual benefits, universal screening offers a population-level perspective: Districts can use aggregated data to allocate resources strategically and identify regions where unmet needs are greatest, consistent with preventive medicine’s aspiration to reshape systems and support individuals.[31] In addition to monitoring symptom prevalence, data systems should also identify contextual and structural factors, including poverty, bullying, discrimination, adverse childhood experiences, and school climate, that shape children’s mental health and may guide preventive interventions beyond individual clinical referral.[32]

Critiques and concerns

Critics caution that due to the nature of mental health conditions, universal screening may contribute to a culture of labeling under certain conditions.[33] Schools might shift from spaces of growth into institutions of monitoring, where children’s inner lives might be reduced to data points.[34] This tension between care and control echoes broader critiques of institutional oversight of subjectivity.[35] Population screening is fundamentally different from clinical care because it is applied to large numbers of asymptomatic individuals, many of whom would never develop the condition being sought. As Sir Muir Gray, one of the architects of the United Kingdom’s National Screening Committee, famously observed, “All screening programmes do harm. Some do good as well and, of these, some do more good than harm at reasonable cost.”[36]

This principle has become a cornerstone of modern screening policy, reminding policy makers that the ethical justification for any screening program lies not in its ability to detect more cases but in demonstrating that its overall benefits clearly outweigh its inevitable harms.[37] Notably, recommendations regarding questionnaire-based mental health screening differ across countries. A review by Brett Thombs and colleagues of recommendation statements from three major national guideline organizations found that the US Preventive Services Task Force was more likely to recommend screening, whereas the Canadian Task Force on Preventive Health Care and the UK National Screening Committee were more likely to recommend against it. The authors attributed these differences partly to differing interpretations of indirect evidence and approaches to potential harms and resource use; importantly, none of the recommendations identified randomized trials providing direct evidence that screening itself improved health outcomes.[38]

These concerns also resonate with Michel Foucault’s concept of biopower, whereby institutions increasingly govern populations through surveillance, measurement, and normalization rather than overt coercion.[39] From this perspective, routine mental health questionnaires may function as subtle technologies of governance, encouraging children to interpret their emotional lives through institutional categories and risk scores. While proponents view this as early intervention, critics argue that such practices may inadvertently expand the boundaries of psychiatric oversight into ordinary developmental experiences.[40]

The ethical tension therefore concerns how systems can distinguish supportive identification from forms of routinized monitoring that, when poorly contextualized, may reduce complex experiences to institutional categories and risk scores. Reducing human complexity to scores and thresholds may inadvertently erode the very qualities of resilience, autonomy, and the capacity to make meaning that education is meant to cultivate. While most screeners rely on frequency-based self-report items rather than intimate disclosures, the repeated querying of emotional states may still shape how young people come to understand and narrate their distress.

False positives. In low-prevalence conditions, even reliable instruments can produce substantial numbers of false-positive results, raising the risk of unnecessary referrals and interventions.[41] A recent systematic review and quantitative synthesis of a widely used school-based universal social, emotional, and behavioral screener found considerable variability in classification accuracy, with specificity ranging from 0.77 to 0.95 and positive predictive values from 0.19 to 0.74 across studies.[42] Even if considered statistically acceptable, these rates may have important ethical and system-level implications when screening is applied to large populations of students. More broadly, Lisa Cosgrove and colleagues have questioned the assumption that increased detection through routine questionnaire screening necessarily translates into improved outcomes, arguing that potential harms, overtreatment, opportunity costs, and resource consumption must also be considered when evaluating screening policy.[43]

When evaluating any screening program, sensitivity and specificity are fundamental considerations. High sensitivity increases the likelihood of identifying children with genuine difficulties, whereas high specificity reduces the number of children without the condition who screen positive. Importantly, when the prevalence of the condition being screened for is relatively low, even a reasonably sensitive and specific instrument may generate a substantial number of false-positive results relative to true positives.[44] Consequently, implementation decisions should consider not only the statistical performance of screening tools but also the downstream consequences of unnecessary referrals, labeling, anxiety, opportunity costs, and diversion of already limited clinical resources.

Psychiatry itself, as it currently stands, is an evolving science at the crossroads of medicine, psychology, philosophy, and sociology, yet it remains marked by diagnostic limitations.[45] Symptom-based classifications, while useful, fail to capture the complexities of function, context, and meaning.[46] Diagnostic systems are often symptom-driven, privileging checklists of behaviors and moods while neglecting the broader context of distress, resilience, and function.[47] This can flatten the richness of human experience into narrow categories that may not fully capture whether a child is truly suffering, impaired, or simply passing through the turbulence of growth and existence.

Recent theoretical work has also questioned whether widespread mental health awareness campaigns and routine questionnaire-based screening may unintentionally encourage some young people to interpret transient and developmentally normative emotional experiences as evidence of mental health conditions. Foulkes and Andrews have termed this the “prevalence inflation hypothesis,” proposing that increased awareness may alter symptom interpretation and self-concept in ways that contribute to higher reported rates of mental health problems.[48] Although this hypothesis remains to be tested empirically, it raises important questions regarding the potential unintended consequences of universal screening initiatives and reinforces the need for careful interpretation of questionnaire findings within their developmental and social context.

In this sense, universal screening has the potential to magnify the imperfections of our frameworks: What was meant as an act of early care may instead accelerate the medicalization of the normal existential struggles inherent to the human condition.[49] These philosophical and ethical concerns translate into concrete risks in practice, particularly through false positives.

Capacity gaps. Countries at all income levels, as well as many US states, including Illinois, already face acute shortages of school mental health professionals and psychiatrists.[50] The American Academy of Child and Adolescent Psychiatry reports that most states fall far below recommended workforce levels, and national data confirm persistent gaps in child mental health service provision.[51] If thousands of new “at risk” students are flagged without sufficient services, the initiative could become an exercise in frustration, raising expectations without relief. This gap between identification and intervention remains one of the deepest fissures in school mental health policy. From a human rights perspective, identifying children with unmet mental health needs without ensuring timely access to appropriate services risks creating an appearance of action while failing to fulfill the substantive right to health.

Privacy and autonomy. In the United States, school health records fall under the Family Educational Rights and Privacy Act rather than the Health Insurance Portability and Accountability Act, an important distinction that many parents are unaware of.[52] Some fear that confidential disclosures could be mishandled or even used against them. Although confidentiality is essential for protecting students’ privacy, it must also be balanced against children’s evolving autonomy and their right to participate in decisions affecting their own health.

Universal screening treads close to paternalism in ethics and philosophy, presuming authority over the interiority of students’ minds. International human rights standards increasingly recognize that children should not be viewed merely as passive recipients of protection but as individuals whose views deserve appropriate consideration according to their age, maturity, and decision-making capacity. In the context of school-based mental health screening, this raises important questions regarding whether students should be asked for meaningful assent or consent before participating, how their preferences should be respected, and under what circumstances parental consent or refusal should be decisive.

These questions become particularly complex during adolescence, when many jurisdictions recognize varying degrees of independent decision-making capacity for certain health services, including mental health care. Situations may arise in which an adolescent wishes to participate in screening or seek psychological support despite parental objections, while the converse may also occur, where parents consent to screening but the adolescent does not wish to participate. Such scenarios illustrate that universal screening involves not only public health considerations but also competing rights and interests relating to autonomy, parental responsibility, confidentiality, and the child’s evolving capacities. Although legal approaches differ across jurisdictions, programs should incorporate transparent procedures that respect children’s developing autonomy while ensuring appropriate safeguards and family involvement where necessary.

Meaningful participation also extends beyond individual consent. A rights-based approach encourages children and adolescents to contribute to the design, implementation, and evaluation of school mental health initiatives, ensuring that programs reflect their lived experiences, cultural contexts, and perceived needs.[53] Such participation may improve trust, reduce stigma, and enhance the acceptability of mental health services while helping avoid interventions that are experienced as coercive, intrusive, or disconnected from students’ everyday realities. Consequently, safeguarding confidentiality, respecting autonomy, and promoting meaningful participation should be regarded as integral components of any school-based mental health program rather than as secondary ethical considerations.

Cultural and developmental sensitivity. Mental health does not present uniformly across cultures, developmental stages, or social contexts. Screening instruments developed and validated in one population may not accurately capture how psychological distress is expressed in another, potentially leading to both under-identification and over-identification of students from diverse cultural or linguistic backgrounds.[54] Adolescence itself is also a period of rapid emotional, cognitive, and social development, during which fluctuations in mood, identity, and behavior are often normative. Distinguishing transient developmental experiences from clinically significant psychological conditions therefore remains challenging when relying on brief self-report questionnaires alone. Although studies generally suggest that screening itself causes little or no direct psychological harm, these concerns underscore the importance of interpreting screening results within their developmental, cultural, and social context rather than viewing questionnaire scores as objective indicators of mental health conditions.[55]

Historical lessons.The experience of the TeenScreen National Center in the United States illustrates that the success of school-based mental health initiatives depends not only on scientific validity but also on public trust, transparency, and respect for the rights of children and families.[56] Although it was introduced to improve early identification of mental health difficulties, concerns regarding passive parental consent, confidentiality, potential over-identification, and insufficient community engagement contributed to widespread public controversy and the program’s eventual discontinuation.[57] While Illinois’s legislation differs in several important respects, including its opt-out provisions and broader legislative framework, the experience highlights the importance of ensuring that universal screening programs are implemented with clear safeguards for informed participation, privacy, meaningful communication with families, and adequate access to follow-up services. Failure to address these may undermine public confidence even where the underlying objectives are widely supported.

Discussion

Illinois’s legislation represents a legitimate and important attempt to address the growing burden of mental health difficulties among children and adolescents and to improve access to timely support. From both a public health and a human rights perspective, governments have a positive obligation to promote children’s mental health and to ensure that appropriate services are available to those in need. The question, therefore, is not whether governments should act but whether universal school-based mental health screening, as currently implemented, constitutes the most effective, proportionate, and rights-respecting means of fulfilling these obligations.

The evidence reviewed in this paper suggests that universal screening offers important potential benefits, including earlier identification of students experiencing psychological distress, increased opportunities for intervention, and greater awareness of unmet mental health needs. However, these benefits are accompanied by important scientific, ethical, and practical challenges, including false-positive results, over-identification, concerns regarding privacy and autonomy, limitations in referral capacity, and uncertainty regarding long-term effectiveness. A rights-based approach therefore requires more than balancing benefits against harms; it requires ensuring that policies respect children’s dignity, participation, confidentiality, evolving autonomy, and equitable access to appropriate follow-up care, as well as the broader social conditions that influence mental health.[58] Universal screening should be viewed as one possible component of a comprehensive school mental health strategy rather than a solution.

The following recommendations seek to preserve the potential benefits of early identification while ensuring that school mental health policy remains scientifically sound, ethically robust, and consistent with a human rights-based approach to children’s mental health.[59] We seek to strengthen the availability, accessibility, acceptability, and quality of school mental health services while respecting children’s rights and ensuring that screening remains proportionate to the available evidence.

• Ensure universal availability, not universal compulsion. Mental health screening should be universally available so that every student who wishes to participate, or whose family seeks assessment, can access appropriate services without unnecessary barriers.[60] However, universal availability should not be equated with universal participation. An opt-in model—or, at a minimum, a transparent and meaningful opt-out process—better respects children’s evolving autonomy, parental responsibilities, and the principles of informed participation. Unlike vision or hearing screening, mental health assessment concerns highly personal experiences, emotions, identity, and relationships that cannot be fully captured through questionnaire-based instruments alone.[61] Consequently, any population-based screening program should be grounded in a rights-based framework that safeguards dignity, confidentiality, voluntary participation, and meaningful access to follow-up care rather than prioritizing screening uptake as an end in itself.[62]

• Strengthen infrastructure before scale-up.Screening without adequate referral capacity is ethically questionable and medically unhelpful.[63] Any jurisdiction implementing universal screening must ensure that adequate school counselors, psychologists, and community clinicians are available to respond. Investment in workforce development, partnerships with community clinics, and telehealth integration are essential.

• Guard privacy and data integrity. Robust safeguards must protect student information. Parents and students should be clearly informed about what is collected, who sees it, and how it is used. Without trust in confidentiality, screening risks doing more harm than good.[64]

• Maintain ongoing evaluation and transparency. Implementation should be accompanied by rigorous evaluation. Independent researchers should assess both outcomes and unintended consequences. Regular public reporting can sustain trust and ensure that policy adapts to evidence.[65]

Adopting a human rights framework for school mental health

International human rights law recognizes that children are entitled to the highest attainable standard of physical and mental health and that governments have positive obligations to create conditions that promote healthy development and provide appropriate support when difficulties arise. Human rights principles suggest that school mental health programs should not only seek to improve health outcomes but also respect children’s rights. The right to health extends beyond access to medical treatment. This broader understanding of the right to health has also been emphasized by the United Nations, especially in the 2017 report of the Special Rapporteur, which notes that mental health policy should move beyond an excessively biomedical model focused primarily on diagnosis and symptom reduction toward approaches that recognize human rights and the social determinants of mental health.[66] Rather than locating distress exclusively within individuals, the report emphasizes that mental health is profoundly influenced by the environments in which people live, learn, work, and develop and that governments should prioritize policies that strengthen these. This perspective does not reject clinical care or early identification; instead, it situates them within a broader rights-based framework that seeks to empower individuals.

Such an approach is particularly relevant in schools, where the goals of education should encompass academic achievement, healthy development, social participation, and well-being. A rights-based school mental health system should therefore be judged not only by the number of students screened or referred for assessment but also by whether it promotes children’s overall rights and well-being. Children and adolescents should also have opportunities to contribute to the design, implementation, and evaluation of school mental health programs. A rights-based approach also recognizes that mental health is shaped by factors extending well beyond the individual child; poverty, unstable housing, discrimination, racism, bullying, family adversity, exposure to violence, and poor school connectedness all have substantial negative impacts on children’s psychological well-being. Viewed through this framework, universal school mental health screening should be understood as one possible component of a broader system of care.

Toward a rights-based model of school mental health

Taken together, the evidence and human rights considerations discussed above suggest that universal screening is best understood as one component of a comprehensive school mental health system rather than its organizing principle. Its value depends on the validity of the screening process, the availability of appropriate follow-up services, and its integration within a broader preventive and promotive framework that addresses both individual needs and the social and educational conditions shaping mental health.[67] A rights-based approach therefore requires attention to early identification, as well as to interventions that strengthen students’ capacities, supportive relationships, school environments, and opportunities for healthy development.[68]

There is a substantial empirical literature supporting such an approach. Meta‑analyses of resilience‑focused and social‑emotional learning programs show consistent, if modest, improvements in emotional symptoms, behavior, and academic performance at the population level.[69] For example, Joseph Durlak and colleagues’ landmark review of 213 universal social-emotional learning programs found benefits for social‑emotional skills, conduct problems, and grades, and later resilience‑focused syntheses reported meaningful reductions in depressive and internalizing symptoms and general distress.[70] While effects are not large, they are reliable across diverse settings.[71]

Prevention‑oriented reviews specific to depression and anxiety reach similar conclusions. School‑based curricula drawing on cognitive behavioral therapy can reduce symptoms at post‑intervention, with effects that sustain with booster sessions or high‑fidelity implementation.[72] This suggests that resilience education should be treated as a core skill set rather than a one‑off lesson block.[73] It also cautions against over‑claiming: Universal programs are not a panacea, but they can shift risk distributions in a favorable direction when integrated into ordinary schooling with adequate teacher training and system support.

Importantly, universal psychoeducation need not depend primarily on scarce mental health professionals. Evidence-based curricula can be integrated into ordinary school programming and delivered by appropriately trained teachers and school staff, with mental health professionals providing consultation, supervision, and higher-tier intervention when required. This tiered approach reserves scarce specialist resources for students with greater needs while allowing preventive competencies to reach the wider student population. Global guidance aligns with this trajectory; the Helping Adolescents Thrive guidelines issued by the World Health Organization and UNICEF recommend promotive and preventive psychosocial interventions in schools, including life‑skills education, problem‑solving training, and parent and carer components, delivered with attention to cultural context and safeguarding.[74] These recommendations explicitly prioritize strengthening competencies and environments that support well-being.

Two clarifications are important for a balanced, evidence‑based case. First, mental health literacy programs reliably improve knowledge, reduce stigma, and increase help‑seeking intentions, but their direct effects on mental well-being are inconsistent.[75] Mental health literacy should therefore be coupled with skills practice (e.g., cognitive restructuring, behavioral activation, and stress management) rather than knowledge alone.[76] Second, not all universal lessons work as intended. The large My Resilience in Adolescence cluster‑randomized trial found that mindfulness training delivered at scale did not outperform usual provision for adolescent mental health outcomes, underscoring that effectiveness depends on program content, fidelity, and context.[77] These cautions support, rather than weaken, a resilience‑first policy: Schools should adopt evidence‑supported, developmentally appropriate curricula with teacher training, supervision, and continuous evaluation, rather than mandating blanket symptom screening.

This broader perspective is consistent with contemporary international frameworks for school health, which increasingly emphasize whole-school approaches integrating health promotion, prevention, early support, family engagement, and attention to the wider determinants of health. Within such models, screening serves a supportive rather than dominant role. The foundation of school mental health becomes the creation of safe, inclusive, and psychologically supportive learning environments, accompanied by universal psychoeducation, social-emotional learning, resilience-building, anti-bullying initiatives, teacher training, and accessible pathways to care for students requiring additional assessment or intervention. Such an approach recognizes that promoting children’s mental health requires strengthening both individual capacities and the educational and social environments in which those capacities develop.

Conclusion

As a narrative review, this paper is intended to provide an integrative analysis rather than a systematic synthesis of all available evidence. Consequently, conclusions should be interpreted in light of the strengths and limitations, including the possibility of publication bias and selective reporting despite the structured search strategy employed. The ambition behind universal school-based mental health screening is both understandable and commendable. Governments have a responsibility to protect and promote children’s mental health, to reduce barriers to care, and to ensure that young people experiencing psychological distress are identified and supported as early as possible. Illinois’s legislation reflects these important objectives. The question is therefore not whether governments should act but whether universal screening alone can fulfill these responsibilities in a manner that is evidence based, proportionate, and consistent with children’s rights.

The evidence suggests that universal screening alone cannot fulfill these responsibilities. While it may facilitate earlier identification of some students who would otherwise remain unnoticed, it needs to be complemented by accessible services, meaningful consent, confidentiality, participation, and educational environments that actively promote mental well-being. Screening should therefore be understood as one component of a comprehensive, rights-based school mental health strategy rather than its defining feature. Universal resilience- and skills-based psychoeducation, supportive school climates, attention to social determinants, and timely access to appropriate assessment and care are likely to provide a more sustainable and equitable foundation for improving children’s mental health.

Ultimately, the goal of school mental health policy should extend beyond just identifying psychological symptoms to creating conditions in which children and adolescents can thrive, asking both how many students are screened and whether young people experience greater dignity, autonomy, participation, belonging, and resilience. If implemented within such a framework, Illinois’s legislation should be viewed not as the final destination of school mental health reform but as an opportunity.

Artin A. Mahdanian, MD, FRCPC, FAPA, is an independent scholar based in Washington, DC, United States, practicing in the Washington metropolitan area, United States, and in Quebec, Canada.

Dainius Pūras, MD, is a professor of psychiatry at Vilnius University, Lithuania, and a former United Nations Special Rapporteur on the right to health.

Please address correspondence to Artin A. Mahdanian. Email: drartin@outlook.com.

Competing interests: None declared.

Copyright © 2026 Mahdanian and Pūras. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/bync/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

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[13] A. Richter, M. Sjunnestrand, M. Romare Strandh, and H. Hasson, “Implementing School-Based Mental Health Services: A Scoping Review of the Literature Summarizing the Factors That Affect Implementation,” International Journal of Environmental Research and Public Health 19/6 (2022).

[14] A. Songco, D. A. Francis, E. A. McDermott, et al., “The Impact of Universal Mental Health Screening on Stigma in Primary Schools,” Child and Adolescent Psychiatry and Mental Health 19 (2025).

[15] N. Humphrey and M. Wigelsworth, “Making the Case for Universal School-Based Mental Health Screening,” Emotional and Behavioural Difficulties 21/1 (2016).

[16] Organisation for Economic Co-operation and Development, Promoting Good Mental Health in Children and Young Adults: Best Practices in Public Health (2025).

[17] E. Dowdy, M. Furlong, T. C. Raines, et al., “Enhancing School-Based Mental Health Services with a Preventive and Promotive Approach to Universal Screening for Complete Mental Health,” Journal of Educational and Psychological Consultation 25/2–3 (2015).

[18] B. Levis, A. Benedetti, and B. D. Thombs, “Accuracy of Patient Health Questionnaire-9 (PHQ-9) for Screening to Detect Major Depression: Individual Participant Data Meta-Analysis,” BMJ 365 (2019).

[19] A. Jerant, R. L. Kravitz, E. Fernandez y Garcia, et al., “Potential Antidepressant Overtreatment Associated with Office Use of Brief Depression Symptom Measures,” Journal of the American Board of Family Medicine 27/5 (2014).

[20] P. Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders (Johns Hopkins University Press, 2007).

[21] Dowdy et al. (see note 17).

[22] Verlenden et al. (see note 3).

[23] Cooper et al. (see note 4).

[24] US Preventive Services Task Force, “Screening for Anxiety in Children and Adolescents: US Preventive Services Task Force Recommendation Statement,” JAMA 328/14 (2022).

[25] Richter et al (see note 13).

[26] D. G. Whitney and M. D. Peterson, “US National and State-Level Prevalence of Mental Health Disorders and Disparities of Mental Health Care Use in Children,” JAMA Pediatrics 173/4 (2019).

[27] J. A. Durlak, R. P. Weissberg, A. B. Dymnicki, et al., “The Impact of Enhancing Students’ Social and Emotional Learning: A Meta-Analysis of School-Based Universal Interventions,” Child Development 82/1 (2011).

[28] O’Dea et al. (see note 6); M. Fazel, K. Hoagwood, S. Stephan, and T. Ford, “Mental Health Interventions in Schools 1: Mental Health Interventions in Schools in High-Income Countries,” Lancet Psychiatry 1/5 (2014).

[29] M. Alegría, M. Vallas, and A. J. Pumariega, “Racial and Ethnic Disparities in Pediatric Mental Health,” Child and Adolescent Psychiatric Clinics of North America 19/4 (2010).

[30] Humphrey and Wigelsworth (see note 15).

[31] Dowdy et al. (see note 17).

[32] Organisation for Economic Co-operation and Development (see note 16).

[33] Gorman (see note 12).

[34] Braund et al. (see note 7).

[35] N. S. Rose, Governing the Soul: The Shaping of the Private Self, 2nd edition, reprint (Free Association Books, 2005).

[36] Gray et al. (see note 11).

[37] R. M. Ewart, “Primum Non Nocere and the Quality of Evidence: Rethinking the Ethics of Screening,” Journal of the American Board of Family Practice 13/3 (2000).

[38] B. D. Thombs, N. Saadat, K. E. Riehm, et al., “Consistency and Sources of Divergence in Recommendations on Screening with Questionnaires for Presently Experienced Health Problems or Symptoms: A Comparison of Recommendations from the Canadian Task Force on Preventive Health Care, UK National Screening Committee, and US Preventive Services Task Force,” BMC Medicine 15 (2017).

[39] M. Foucault, The History of Sexuality, Volume 1: An Introduction (Penguin Books, 1990).

[40] Braund et al. (see note 7).

[41] Ibid.

[42] A. Goerdt, F. G. Miller, D. Dupuis, et al., “Validity Evidence of the Social, Academic, and Emotional Behavior Risk Screener–Teacher Rating Scale: A Systematic Review and Quantitative Synthesis,” Journal of School Psychology 110 (2025).

[43] L. Cosgrove, J. M. Karter, A. Vaswani, and B. D. Thombs, “Unexamined Assumptions and Unintended Consequences of Routine Screening for Depression,” Journal of Psychosomatic Research 109 (2018).

[44] Goerdt et al. (see note 42).

[45] Alegría et al. (see note 29).

[46] Rose (see note 35).

[47] Ewart (see note 37).

[48] L. Foulkes and J. L. Andrews, “Are Mental Health Awareness Efforts Contributing to the Rise in Reported Mental Health Problems? A Call to Test the Prevalence Inflation Hypothesis,” New Ideas in Psychology 69 (2023).

[49] A. V. Horwitz, Creating Mental Illness (University of Chicago Press, 2003).

[50] B. M. Kuehn, “Lack of Adolescents’ Mental Health Care Is a Global Challenge,” JAMA 326/19 (2021).

[51] American Academy of Child and Adolescent Psychiatry, “Workforce Maps by State,” https://www.aacap.org/AACAP/Advocacy/Federal_and_State_Initiatives/Workforce_Maps/Home.aspx; R. Aggarwal, R. Balon, E. V. Beresin, et al., “Addressing Psychiatry Workforce Needs: Where Are We Now?,” Academic Psychiatry 46/4 (2022).

[52] US Department of Education and US Department of Health and Human Services, Joint Guidance on the Application of FERPA and HIPAA to Student Health Records (2019).

[53] A. Chinsen, A. Berg, S. Nielsen, et al., “Co-Design Methodologies to Develop Mental Health Interventions with Young People: A Systematic Review,” Lancet Child and Adolescent Health 9/6 (2025).

[54] L. J. Kirmayer, “Beyond the ‘New Cross-Cultural Psychiatry’: Cultural Biology, Discursive Psychology and the Ironies of Globalization,” Transcultural Psychiatry 43/1 (2006).

[55] C. R. DeCou and M. E. Schumann, “On the Iatrogenic Risk of Assessing Suicidality: A Meta-Analysis,” Suicide and Life-Threatening Behavior 48/5 (2018)

[56] Lenzer (see note 10).

[57] V. Sharav, “TeenScreen: ‘Under Intense Criticism Nationally,’” Alliance for Human Research Protection (March 14, 2006), https://ahrp.org/teenscreen-under-intense-criticism-nationally/.

[58] A. A. Mahdanian, “Between Belonging and Backlash: Rethinking Diversity, Equity and Inclusion in Mental Health,” Journal of Public Mental Health 25/1 (2026).

[59] A. A. Mahdanian, M. Laporta, N. Drew Bold, et al., “Human Rights in Mental Healthcare: A Review of Current Global Situation,” International Review of Psychiatry 35/2 (2023).

[60] Humphrey and Wigelsworth (see note 15).

[61] Rose (see note 35).

[62] Mahdanian et al. (see note 59).

[63] Whitney and Peterson (see note 26).

[64] US Department of Health and Human Services, “Does the HIPAA Privacy Rule Apply to an Elementary or Secondary School?,” https://www.hhs.gov/hipaa/for-professionals/faq/ferpa-and-hipaa/index.html.

[65] Richter et al. (see note 13).

[66] D. Pūras and P. Gooding, “Mental Health and Human Rights in the 21st Century,” World Psychiatry 18/1 (2019).

[67] K. Weare and M. Nind, “Mental Health Promotion and Problem Prevention in Schools: What Does the Evidence Say?,” Health Promotion International 26/Suppl 1 (2011).

[68] World Health Organization, Guidelines on Mental Health Promotive and Preventive Interventions for Adolescents: Helping Adolescents Thrive (2020).

[69] R. D. Taylor, E. Oberle, J. A. Durlak, and R. P. Weissberg, “Promoting Positive Youth Development Through School-Based Social and Emotional Learning Interventions: A Meta-Analysis of Follow-Up Effects,” Child Development 88/4 (2017).

[70] Durlak et al. (see note 27); J. Dray, J. Bowman, E. Campbell, et al., “Effectiveness of a Pragmatic School-Based Universal Intervention Targeting Student Resilience Protective Factors in Reducing Mental Health Problems in Adolescents,” Journal of Adolescence 57 (2017).

[71] J. Dray, J. Bowman, E. Campbell, et al., “Systematic Review of Universal Resilience-Focused Interventions Targeting Child and Adolescent Mental Health in the School Setting,” Journal of the American Academy of Child and Adolescent Psychiatry 56/10 (2017).

[72] E. A. Stockings, L. Degenhardt, T. Dobbins, et al., “Preventing Depression and Anxiety in Young People: A Review of the Joint Efficacy of Universal, Selective and Indicated Prevention,” Psychological Medicine 46/1 (2016).

[73] A. Werner-Seidler, S. Spanos, A. L. Calear, et al., “School-Based Depression and Anxiety Prevention Programs: An Updated Systematic Review and Meta-Analysis,” Clinical Psychology Review 89 (2021).

[74] World Health Organization (see note 68).

[75] Y. Wei, J. A. Hayden, S. Kutcher, et al., “The Effectiveness of School Mental Health Literacy Programs to Address Knowledge, Attitudes and Help Seeking Among Youth,” Early Intervention in Psychiatry 7/2 (2013).

[76] Ibid.

[77] W. Kuyken, S. Ball, C. Crane, et al., “Effectiveness and Cost-Effectiveness of Universal School-Based Mindfulness Training Compared with Normal School Provision in Reducing Risk of Mental Health Problems and Promoting Well-Being in Adolescence: The MYRIAD Cluster Randomised Controlled Trial,” Evidence-Based Mental Health 25/3 (2022).