Who is Responsible?
The American Academy of Pediatrics (AAP) expects pediatricians to screen for mental health problems at each annual visit. However, some pediatricians completing residencies in recent years have stated they are not comfortable with managing mental health issues and have requested additional training. In 2007, 183 internal medicine-pediatric residents reported their training and skills to be lower for adolescents than adults in mental issues and only fair or poor for children on some mental health care tasks (Melgar et al., 2008). Specific areas of weakness for treating children with mental health issues were prescribing antipsychotic, anxiolytic, and antidepressant medications and treating substance abuse. A survey found that of 305 pediatricians surveyed, only 1 in 3 co-managed mental health issues. Completion of additional developmental pediatric behavioral rotations of four weeks made them more likely to co-manage these issues (Green et al., 2016).
Members of the Association of Pediatric Nurse Practitioner Faculty (AFPNP) recognized that some pediatric nurse practitioners (PNPs) were uncomfortable with managing mental health issues (Dimarco & Melnyk, 2009), and began providing continuing education and conference topics on many of the same issues the physicians had identified (Melnyk et al., 2009). This led the National Association of Pediatric Nurse Practitioners (NAPNAP) to publish a position statement on the integration of mental health care in primary care and to actively advocate that public and professional attention focus on this need (NAPNAP Executive Board, 2013). NAPNAP's Development, Be havioral and Mental Health Special Interest Group was developed to investigate and conduct research. The Pediatric Nursing Certification Board developed a Pediatric Primary Care Mental Health Specialist (PHMS) certification for advanced practice registered nurses (Hawkins-Walsh & Van Cleve, 2019). More than 500 APRNs now are now PMHS certified. PMHS certificants may also practice with psychiatric mental health nurse practitioners or child adolescent psychiatric and mental health clinical nurse specialists.
The United States Preventive Services Task Force (USPSTF) (2019b) provides an online listing of the recommended activities by age group. However, they have no recommendations for screening children for mental health issues. They suggest screening adolescents aged 12 to 18 years for depression and drug and alcohol use. An Electronic Preventive Services Selector (USPSTF, 2019a) allows a clinician to personalize recommendations by including the person's age, sex, and use of tobacco or alcohol. Obesity screening was the only additional recommendation for children and adolescents (Jonovitch & Alpert-Gillis, 2014).
Several organizations describe tools for screening for mental health issues on their websites (see Table 1 for web addresses; links to a selection of commonly used tools can be found in Figure 1). For example, the Society for Adolescent Health and Medicine Services Association (SAMHSA) (2014) lists multiple tools for mental health screening for adolescents. The most familiar resource to pediatric-focused clinicians is Bright Futures (Hagan et al., 2017). Frequently used Bright Futures' tools include the Pediatric Symptom Checklist and Surveillance Questions. Another popular screening tool is the American Medical Association's (AMA) 1982 Guide lines for Adolescent Prevention Services (GAPS). GAPS include Home, Education, Activities, Drugs, Sexuality, Suicide/Depression, and Safety (HEADSSS). Positive items are followed up with discussion of issues in the clinical setting and possible referral.
The AAP website lists multiple screening and assessment tools for primary care by purpose and age group. Some are more suited for developmental, behavioral, or mental health, respectively. The psychometric properties and cost and accessibility are also included in the tables found at the AAP website, along with references. The Strength and Differences Questionnaire has been translated into 40 different languages for ages 3 to 17 years, takes 10 minutes to administer, and is freely accessible. The Early Childhood Screening Assessment takes 15 minutes to administer for ages 18 to 60 months for behavioral and emotional development and is readily accessed.
Some instruments found in the AAP resource table are for parent mental health, and others for parent or teacher ratings of child behavior. Tools to screen for parental abuse, depression, or violence are listed. Many are accessible at no cost, and some are proprietary or require licensing or training. This author suggests consulting the tables and locating the literature and references available for choosing a tool. Networking with other practices or agencies might help narrow down to the most appropriate tools for a particular setting.
The Runaway & Homeless Youth and Relationship Violence Toolkit from the Family and Youth Services Bureau is composed of items relevant to homeless or runaway youth. TeenMentalHealth.org offers several tools created by various experts and researchers. These are intended to diagnose and treat mental disorders in youth. Diagnosis-specific screening tools are available from Mental Health America, as well as from Youth and Parent Screens for Mental Health. A curriculum guide for mental health in high school as well as pamphlets to help teens understand mental illness in their parents are available. These can be found on the website under the heading for Health Professionals.
In addition to mental health screening tools, SAMHSA (2014) has an extensive list of screening tools for alcohol, drug, and tobacco use in adolescents. These include tools from the National Institute on Alcohol Abuse and Alcoholism and a tool for screening for drug abuse in a general medical center. The Drug Abuse Screen Test (DAST-20) from the Centre for Addiction and Mental Health is widely used.
Curtis and colleagues (2019) discussed training nurse practitioners on the Screening, Brief Intervention, and Referral to Treatment tool on conventional and mobile app methods. Participants found the alcohol and drug-screening tool, including the mobile app, acceptable and effective. The samples of nurses (n = 22) trained and the post-implementation focus group (n = 14) were small, but such initiatives may help others screen with less difficulty.
The National Institute of Mental Health provides information about the Ask Suicide-Screening Questions (ASQ) Information Sheet, a tool used widely to screen for suicide risk in youth. It is used in primary and acute care by asking five specific questions about suicidal wishes, ideation, attempts, and current thoughts about suicide. Brahmbhatt and colleagues (2019) developed a clinical pathway to address suicide risk in pediatric hospitals. They suggested using ASQ questions followed by safety assessment to determine if a full suicide risk assessment is needed.
There is little literature on screening for children younger than 12 years of age. The annual wellness checks using Bright Futures (Hagan et al., 2017) lists symptom guidelines. The table (found at https://screeningtime.org/star-center/#/screening-tools#top) is a shorter list of tools for various purposes, and gives ages and time required to be spent. The Strength and Difficulties Questionnaire is frequently used in clinical practice. Other tools, such as Ages and Stages for Developmental, Behavioral and Mental Health Screening are licensed or require fees and training. The Vanderbilt Diagnostic Rating Scales are widely used by teachers and parents to detect attention deficit/hyperactivity disorder (ADHD) in children. These instruments measure inattention, depression, anxiety, oppositional behavior, and other symptoms of ADHD and attention deficit disorder. All resources located recommend an interprofessional team approach to screening. Consultation with psychiatric mental health nurse practitioners, sociologists, and pediatric psychologists to identify tools and procedures is best.
Screening for ACES
A few articles about screening for ACEs or related topics were located. Chung and colleagues (2016) published major screening tools for social determinants of health in impoverished children and families. These are either free or copyrighted and require permission to use, and several are in multiple languages. Gadeberg and colleagues (2019) conducted a systematic review of screening and measurement tools, and discussed their use in refugee children and adolescents. Different tools, languages, and multicultural use are included. Their conclusions would be helpful in choosing instruments with this population. Blum and colleagues (2019) conducted a study attempting to identify ACEs related to depression and violent tendencies in adolescent participants as part of the Global Early Adolescent Study. Although many different tools are under development to screen for ACEs or relate them to other disorders, most rely on self-report or parent or guardian report to identify original problems. A basic personal and family intake history may be sufficient to find children who require additional screening and referral.
Horner and colleagues (2019) suggest that pediatric caregivers consider each episode of illness or accidental injury as a trauma when interviewing children and families. Thirty percent of injured children may develop PTSD (Horner et al., 2019), and previous stressors, such as divorce or financial instability, increase that likelihood. Horner and colleagues (2019) explain the principles of trauma-informed care (safety, choice, collaboration, trustworthiness, and empowerment), and in particular, trauma-focused mental health care, which encourages support and treatment to the whole person, rather than focusing on only treating individual symptoms or specific behaviors. Trauma-informed care is implemented by screening for trauma exposure and acknowledging effects of events, providing common coping strategies and referral to trauma-focused mental health therapy, and promoting effective treatments. Both the child and parent or caregiver should be included in targeted interventions by the provider's agency. Principles of trauma-informed care should be applied by each team member and employee in contact with the child and family.
Concerns initially expressed in many primary care, emergency, and specialty settings about lack of experience and knowledge of diagnosis and management of mental health issues can be alleviated if interprofessional teams are available in those settings. In some areas, specialty clinics and practices are available for immediate referral, although long waiting periods for appointments are common. Barriers may include lack of insurance coverage or refusing Medicaid for mental health issues. The literature contains a few instances where such teams are already established and provide care (Kimmel et al., 2017; Kolko et al., 2019). The integration of mental health specialists into a specialty setting or regular visits by specialists to primary care settings is recommended repeatedly in the literature. Caballero and colleagues (2019) suggested co-locating pediatric and mental health facilities to concentrate care and access to mental health providers who are in short supply in many parts of the United States and worldwide.
Relying on teamwork requires care. Chaffin and colleagues (2017) conducted a study of untreated behavioral problems in a group of 267 children aged 6 to 16 years during a well child visit. Caregivers completed either the questionnaire alone or the questionnaire plus some additional items. Seventy-three instruments were missing due to office error. The screener missed 35% of critical items. When we rely on team members to score tools, we should be supportive of the screener but review findings. Chaffin and colleagues (2017) suggest that when child self-report items differ from parent reports, the child report should be investigated.
Technology holds promise to support the lack of mental health providers. Aboujaoude and Salame (2016) reviewed computer applications available at the time for use in clinical settings. They looked at computerized cognitive behavioral therapy and online therapy, smart phone-based interventions and mobile therapy and symptom tracking, and virtual reality exposure therapy. Remote pharmacotherapy was one area that lacked study. Patients with ADHD and families continually struggle with requirements for prescription renewal. The authors concluded that children and adolescents are comfortable with digital platforms, and the lack of mental health providers may drive future development of these tools. At that time, there was little research, and they expressed a concern about the negative social focus on cyber bullying and "addiction" to video games and the Internet.
Mason and colleagues (2019) implemented an intervention group to alleviate stress after identifying 86 adolescents whose screening or history were positive. Participants' heart rate variability was recorded. They completed four questionnaires on their level of distress, anxiety, and stress. The intervention group was educated about the causes of stress and exercise and relaxation techniques. There were no significant differences in scores of the intervention and control groups, but information from the questionnaires showed that 11 teens tried to commit suicide. Stress, anxiety, and depression were significantly related. Of the 50 participants, 46 thought the intervention was helpful, and they felt more relaxed; 22 wanted to have additional sessions.
Pediatr Nurs. 2020;46(1):27-31. © 2020 Jannetti Publications, Inc.