Mental Health

Building Resiliency

As pediatricians, we often care for children that may have had exposures to neglect, maltreatment, family violence, family separation or extreme poverty. Over time, we see the negative consequences of these experiences on our patients in the form of poor academic success, substance abuse, and medical and mental health problems. These experiences are termed adverse childhood experiences or ACEs and it is estimated that about 60% of the adult population in the United States has experienced at least one ACE. Pediatricians should identify and attempt to prevent ACEs: we can support and coordinate efforts to build resilience in children by understanding the effect of toxic stress and providing early interventions and continuity in care.

The hallmark ACE study conducted in 1998 by the CDC and Kaiser Permanente in California categorized ACEs into three major categories: physical and emotional abuse, neglect and household dysfunction (e.g., parent with mental illness, substance abuse or experiencing separation or divorce). The study showed dramatic associations between ACEs and risky behavior, psychological illnesses, serious illness and even a lower life expectancy in the children.

In a child’s life, experiencing ACEs can lead to toxic stress. Toxic stress occurs when a child stays in a constant state of elevated stress. Often children have a caregiver to give them comfort during normal times of stress. In these cases, the levels of stress hormones will return to baseline. However, when no supportive caregiver can comfort the child, such as in cases of neglect, emotional or physical abuse, the child’s stress hormone level remains high.  This can affect other aspects of a child’s health and development.

The link between adverse childhood experiences and adult health and well-being has been well studied. We know that as the brain develops, more frequently used circuits are strengthened, while those that are not used can eventually fade away in a process called pruning. Stronger circuits are associated with higher-level functioning, improved memory, emotional and behavioral regulation and language. In children exposed to toxic stress, the circuits are weaker and fewer, especially in the areas of the brain dedicated to learning and reasoning. For example, the excessive stress activation shifts mental and physiological resources from long-term development to immediate survival.  This increases the task of vigilance at the expense of focused attention. Ultimately, poor coping habits and mental health problems can develop. We also know that the exposure to stress hormone increases systemic inflammation which contributes to a higher risk of cardiovascular disease and diabetes among other medical problems. Finally, evidence shows that the longer we wait to intervene, the more difficult it is to achieve healthy outcomes.

The concept of resiliency explains why some children overcome stress better than others. As pediatricians, understanding this concept can help us to build stronger individuals. Resiliency is thought to be related to a greater number of positive experiences compared to negative experiences. We know that a very important part of developing resilience is at least one stable and committed relationship with a supportive caregiver. Promoting regular physical exercise, stress-reduction exercises and promoting strong core life skills for both the child and the adult are additional ways pediatricians can promote resiliency.

Trauma-informed care involves prevention, recognition and response to trauma-related experiences. Early identification is an important first step. As pediatricians, we should consider ACEs-based screening questionnaires for every patient to assess the potential need for other services. The next step would be to link these patients with services such as social work, developmental therapies, or mental health support with experience in trauma. This is often the most difficult part in delivering trauma-informed care, so it is important to identify the resources available in the local area.

Finally, to address prevention, we should work with our families to reduce the stress of daily life, such as connecting them to resources like  food pantries or substance abuse programs. We should teach skills to families regarding parenting and safe dating practices. To promote strong relationships with other adult caregivers, we should be know of available after-school and mentoring programs. The overall goal should focus on changing the environment and behaviors in ways that will prevent ACEs from happening in the first place.  

Amisha Patel M.D.

Sources:
Fox  SE, Levitt  P, Nelson  CA  III.  How the timing and quality of early experiences influence the development of brain architecture.  Child Dev. 2010;81(1):28-40.

Felitti  VJ, Anda  RF, Nordenberg  D,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.  Am J Prev Med. 1998;14(4):245-258.

Shonkoff JP. Capitalizing on Advances in Science to Reduce the Health Consequences of Early Childhood Adversity. JAMA Pediatr. 2016;170(10):1003–1007. doi:10.1001/jamapediatrics.2016.1559

Kuehn BM. AAP: Toxic Stress Threatens Kids’ Long-term Health. JAMA. 2014;312(6):585–586. doi:10.1001/jama.2014.8737


Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE). http://www.cdc.gov.foyer.swmed.edu/violenceprevention/acestudy/index.html. Accessed February 5, 2020.

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Let’s talk about mass shootings

Mass shootings receive substantial media coverage and capture the public’s attention for days, even weeks. The United States has witnessed more than 290 mass shootings in 2019 so far [1]. Even more worrisome, the number of school shootings in the U.S. far exceeds that of several other high-income nations, even after accounting for population size [2]. Over the past decade, there were at least 180 shootings and 356 victims at K-12 schools across the U.S., 43 incidents this year alone [3]. They happened in big cities and in small towns, at homecoming games and during art class. Shootings have become a part of daily conversation around kids, in places that used to be considered “safe”, and the real cost of this crisis to the youth remains unknown. Pediatricians need to advocate and raise awareness that this generation may be facing increased levels of stress, decreased perception of safety, and higher prevalence of depression and anxiety than previous generations. We need to encourage routine screening for mental health problems in well-child visits, as well as empower parents with resources on how to approach conversations about this sensitive topic and how to manage their kids’ exposure to the media during catastrophic events.

Limited research has begun to elucidate the short-term direct and indirect effects of mass shootings on survivors and the broader community. Individual responses of survivors can include anxiety, depression, PTSS, grief, sleep problems, anger, demoralization, catastrophic thinking, and somatization symptoms [4]. Moreover, media coverage of mass shootings and their aftermath reaches far beyond the affected communities to the entire nation and beyond. As shown in the aftermath of the September 11 terrorist attacks (9/11), such indirect exposure can have mental health consequences. For example, in the National Epidemiologic Survey of Alcohol and Related Conditions, indirect exposure to 9/11 through the media was associated with increased risk for mood, anxiety, substance use disorders, and PTSD, relative to no reported 9/11 exposure [5]. Children may similarly associate schools with tragedy, violence and death, and they must go there daily.   

In the span of two weeks in March 2019, two students who survived the mass shooting that occurred in February 2018 at Marjory Stoneman Douglas High School in Parkland, Florida, died by suicide. Drawing direct individual-level causal connections between mass shootings and suicide deaths cannot be done with certainty; however, these deaths painfully underscore the potential long-lasting consequences of gun violence, mass shootings specifically [4]. 

Pediatricians have a responsibility to acknowledge the magnitude of the problem and urge that appropriate research be done to better understand the influence of direct and indirect exposure to mass shootings on the mental and physical health, social functioning and development in the pediatric population. We can also  bring this topic up in our health visits, especially right after a mass shooting with broad media coverage or one close to our area of practice. In Texas, two mass shootings with broad media coverage have occurred in the past month. We can start with a simple question about mood and anxiety in our well visits. This can offer a teaching opportunity for patients and their families and identify those who may benefit from other resources or therapies.

Fear, insecurity and anxiety can be transmitted to children from adults around them, even if they don’t fully understand the situation. This is why it is crucial that pediatricians educate parents and other members of the community that work directly with children (such as teachers) about the importance of having “the talk about mass shootings.”  It can be done appropriately with 4 basic steps: (1) initiate the conversation, (2) answer their questions, (3) correct any misconceptions and (4) limit media exposure. 

To find more information on how to have a conversation with children about shootings according to age group, visit the following resources:

Elisa Geraldino, MD

References

  1. Gun Violence Archive. https://www.gunviolencearchive.org
  2. School Shootings in the U.S.: What Is the State of Evidence?AliRowhani-RahbarM.D., M.P.H., Ph.D.abCaitlinMoeM.S.ahttps://doi.org/10.1016/j.jadohealth.2019.03.016
  3. CNN. 10 years of School Shootings. https://www.cnn.com/interactive/2019/07/us/ten-years-of-school-shootings-trnd/
  4. Rowhani-Rahbar A, Zatzick DF, Rivara FP. Long-lasting Consequences of Gun Violence and Mass Shootings. JAMA. Published online April 12, 2019321(18):1765–1766. doi:10.1001/jama.2019.5063 https://jamanetwork-com.foyer.swmed.edu/journals/jama/fullarticle/2731087?resultClick=1
  5. Lowe, S. R., & Galea, S. (2017). The Mental Health Consequences of Mass Shootings. Trauma, Violence, & Abuse, 18(1), 62–82. https://doi.org/10.1177/1524838015591572

E-cigarettes: the pediatrician’s role in an epidemic

The Surgeon General issued an advisory to warn about the rising use of vaping in minors (middle and high school children). E-cigarettes were introduced to the US market in the mid-2000s, and the market has expanded rapidly. In 2011, only 5% of high schoolers had used or experimented with them at some point, but only 4 years later in 2015, that percentage had grown to 13% of middle school and 39% of high schoolers. Because the use of electronic delivery systems for nicotine is a rising danger, pediatricians should include a routine discussion with teenagers as part of patient visits.

The dangers of vaping have been suspected by the medical community since its introduction, and evidence is accumulating to validate those fears. Evidence does support the suspicion that nicotine predisposes the adolescent brain to more severe tobacco addictions. Biological studies (animal models and human population data) indicate that the teenage brain is more susceptible to addictions–earlier exposure leads to stronger addictions and increased likelihood of experimenting with other substances. Thus, the fear that nicotine delivery systems are a bridge (rather than just an alternative) to more serious tobacco addictions is validated by the data so far.

Conversely, it is also true that electronic nicotine systems can help current smokers wean the nicotine addiction. However, from a public standpoint, this could be far outweighed by the number of younger non-smokers who are led to develop a habit they might have otherwise avoided. The solvents and flavors in e-cigarettes are not benign either. While they are safer (by current estimates) than traditional tobacco smoke, they do cause inflammation of the airways. For example, two common additives (diacetyl and acetyl propionyl) have been shown to cause popcorn lung/bronchiolitis obliterans. Like other consumable additives, the FDA has long considered them safe for ingestion, but the aerosolized form can still cause damage to lung tissue.

The toxicity of nicotine itself forms the most obvious risk to young people. First of all, nicotine has been shown to irreversibly decrease attention and processing speed and to increase the fear response mechanism. In other words, teenage nicotine exposure will impair memory and attention span for life and increase the likelihood of anxiety and depression. This risk decreases when exposure is delayed until adulthood, so the teenage years represent a critical window.

Second, nicotine is very toxic in utero. It increases the risk of SIDS, hearing impairment, language delays, ADHD, and possibly obesity. It may begins disrupting the normal development of brain circuitry as early as 5 weeks gestation, and even secondhand exposure to vaping can result in significant serum nicotine levels. These facts should be strongly emphasized to adolescent girls who may wish to be mothers someday, as well as to anyone who lives in proximity to women of childbearing age.

Finally, nicotine has long been known to acutely increase heart rate and blood pressure. Its long-term cardiovascular consequences are still unknown. Other nicotine-replacement  systems (nicotine patches, etc) have not been shown to cause cardiovascular toxicity, but the prolonged, irregular doses from vaping have not yet been sufficiently studied.

This is a prominent issue among young people in our country independent of racial or economic demographics, and pediatricians should give it a proportionate level of attention. Parents should be informed of its dangers during well child visits and given data about the specific risks. Given its prevalence, this should be a routine topic of anticipatory guidance for middle-school children and older. Also, local governments and schools should be encouraged to aggressively regulate teenage access to these devices and limit marketing to that audience. Evidence shows that regulation does prevent a large fraction of teenage vaping, and pediatricians should play an active role in voicing the importance of this legislation. As health care providers, we have the opportunity now to intervene in our communities and forestall some of the long-term consequences of this new epidemic among young people in our country.   

Natasha Varughese, MD

E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. US Health and Human Services 2016.

Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check. Levy DT, et al. Tob Control 2018;0:1–7

The impact of local regulation on reasons for electronic cigarette use among Southern California young adults. Hong H, et al. Addictive Behaviors, 2018 (ahead of print).

Sports: Healthy Competition vs Performance Anxiety

With school back in full swing, kids are joining their friends and classmates in school sports. Sports can be a great way for growing children to develop fine and gross motor skills. However, it can also be an area of stress and pressure to perform. (more…)

Let’s Talk About Bullying
Bullying Picturehttps://www.istockphoto.com/photo/girl-crying-gm518118234-89841353

It is the first month of school for many of our children out there which can be a very exciting time. For many parents, it means their house is a little quieter in the day and the return to a normal routine. For children it means a new pencils, a fun backpack, seeing their friends every day, and a fresh start. However, this time of year can also lead to anxiety and the fear of not “fitting in”. For some children, it can also mean bullying. It is vital that pediatricians and parents understand what bullying is as well as what to look for and what to do if a child is affected by bullying.

Bullying is an unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. This behavior is typically repeated over time. Bullying encompasses verbal abuse, social abuse, and physical abuse. Verbal abuse is writing or saying cruel things. It includes teasing, name-calling, threats, taunting, and inappropriate sexual comments. Social bullying is when someone hurts someone else’s reputation or relationships. It includes leaving someone out on purpose, spreading rumors about someone, telling other children not to be friends with someone, and embarrassing someone in public. This can include cyberbullying, which can take place through text messaging, social media websites, apps, e-mail, web forums, or multi-player online games. Cyberbullying has the potential to “go viral” and spread very quickly. Physical bullying involves hurting a person’s body or possessions. Both boys and girls can be a bully or be bullied.

The effects of bullying, both of the bullying and the bullied, can have long-term consequences. Kids who are bullied can experience depression and anxiety. These issues may persist into adulthood. They also can have an increased amount of health complaints and decreased academic achievement. In fact, children who are bullied are more likely to miss, skip, or drop out of school. Kids who bully others are more likely to abuse alcohol and other drugs in adolescence and as adults, get into fights, vandalize property, and drop out of school. They are also more likely to partake in early sexual activity, have criminal convictions as adults, and be abusive toward their romantic partners, spouses, or children as adults.

Due to all of these potential negative consequences, it is important for both pediatricians and parents to be able to recognize signs of both being bullied and bullying others. Only 40% of children notify an adult in times of bullying. Therefore, it is important for pediatricians and parents to ask kids about bullying with questions such as, “how are things going at school?” or “is anyone being picked on?”. Since not all children being bullied will exhibit physical signs, it is important for parents to look for many different signs and symptoms. These include unexplainable injuries, lost or destroyed clothing, books, electronics, or jewelry, frequent headaches or stomach aches, and changes in eating habits, like suddenly skipping meals or binge eating.

Other signs of bullying include difficulty sleeping or frequent nightmares, declining grades, loss of interest in schoolwork, or not wanting to go to school, sudden loss of friends or avoidance of social situations, feelings of helplessness or decreased self-esteem, and self-destructive behaviors such as running away from home, harming themselves, or talking about suicide. Signs that children are bullying others includes getting into physical or verbal fights, becoming increasingly aggressive, getting sent to the principal’s office or to detention frequently, having unexplained extra money or new belongings, blaming others for their problems, not accepting responsibility for their actions, and being competitive and worrying about their reputation or popularity.

Even after identifying that a child is being bullied or is a bully themselves, it is hard to know what to do. In the case of a child being bullied, one of the first steps is teaching children how to respond. It is important to teach children to look the bully in the eye, stand tall and stay calm, and to know when to walk away. Also teach your child to have them say firmly things such as “I don’t like what you are doing” or “Please do not talk to me that way”.  This will not be instinctive to most children so it is important to practice these skills so they feel more prepared when the time comes. Parents should also encourage their children to make friends with other children inside and outside of school. This can be done by encouraging children in activities that they are interested such as team sports, music groups, or other social clubs.

Another important thing to teach children is to know how to ask for help. Children should know that being bullied is not their fault and they should reach out to their teacher, school counselor, or school principal. Parents should talk with the school principal if the child is too scared to ask for help or if the child continues to be fearful or affected.  If the results from these conversations are not resulting in action on the school’s part, make a written request to the principal asking for a copy of the school district’s policies on reporting and investigating bullying.  Most school districts have procedures for parents and others to make written reports. Some states require schools to make investigations of reports of bullying. If the local campus is not responsive, make a written request to the school superintendent.

If a child is experiencing cyberbullying only a few actions need to be taken differently. First, don’t threaten to take away the child’s devices as this may seem as a punishment. Instead, if there is online evidence of the bullying, take and save a screenshot in order to report the bullying to the social media platforms in which the abuse happened as well the school or police if appropriate. Otherwise, support the child in the same ways as mentioned above.

It can also be a stressful situation as well if your child is bullying others. It is important to be consistent and set firm limits on a child’s aggressive behavior by using effective, nonphysical discipline such as loss of privileges. Another way to influence your child’s behavior is by being a positive role model and showing children they can communicate what they want without teasing, threatening, or hurting others. In addition to these measures, help children understand how bullying can hurt other children. Communication is also important in these situations and parents should be speaking with the school and other parents in order to try to find practical solutions to the bullying that is occurring.

Chelsea Day, MD

 

References:

American Academy of Pediatrics. Bullying and Cyberbullying. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Bullying-and-Cyberbullying.aspx. August 28th, 2018.

Healthy Children. Bullying: It’s Not Okay. https://www.healthychildr en.org/English/safety-prevention/at-play/Pages/Bullying-Its-Not-Ok.aspx. August 28th, 2018.

Healthy Children. Cyberbullying.https://www.healthychildren.org/English/family-life/Media/Pages/Cyberbullying.aspx. August 28th, 2018.

Stop Bullying. Warning Signs for Bullying. https://www.stopbullying.gov/at-risk/warning-signs/index.html. August 28th, 2018.

Adverse Childhood Experiences

The negative effects of adverse childhood experiences (ACEs) on the health and development of children have been well known in the field of pediatrics for a long time. This topic has recently come back into the public spotlight in the wake of the tragic separation of children from their parents at the southern border of the United States. Given these events, it is important to remind ourselves of the impact of such traumatic events on these children and on the countless other children within the United States who fall victim to similar stressors.

What is an Adverse Childhood Experience?

ACEs can be thought of as anything that causes toxic stress. As described by the Harvard Center on Childhood Development, toxic stress involves experiences of strong, frequent, and/or prolonged adversity that can negatively affect a child’s physical and mental health [1]. These stressful experiences are often worsened by poor social support systems for the child. The Kaiser ACE study looked at 3 types of adverse experience that could lead to toxic stress: abuse (emotional, physical, sexual), neglect, and household challenges (substance abuse, mental illness, violent treatment of partner, parental separation, or member of household sent to prison) [2].

What is the impact of ACEs?

The Kaiser ACE Study looked at surveys of over 17,000 people between 1995 and 1997 that asked questions regarding their childhood experiences, current health status, and behaviors [2]. Almost two-thirds of adults surveyed had at least one ACE, and more than one in five reported three or more ACEs. This study continues today through the Behavioral Risk Factor Surveillance System (BRFSS), which, as of 2014, has the participation of 14 states and the District of Columbia [3]. Most importantly these studies consistently show a dose-response relation between ACEs and negative health and well-being outcomes. This means the more ACEs you had as a child, the more likely you were to have negative outcomes as an adult, such as heart attack, stroke, diabetes, asthma, depression, disability, and unemployment. The Centers for Disease Control and Prevention (CDC) estimates that the lifetime costs associated with child maltreatment are about $124 billion [2].

What can we do to help as pediatricians and as citizens?

The American Academy of Pediatrics recommendations for alleviating childhood stressors focus on 3 major areas: identifying stressors, connecting to community resources, and advocacy [4,5].

As pediatricians, we often have insufficient time to spend with our patients and their families, but, as evidenced above, it is incredibly important that we make the identification of outside stressors an integral part of our social histories. Child safety, substance use, and sexual activity are generally well screened for, but parental health and societal barriers are less common screening questions. Some examples of important questions to include for parents and caregivers are [6]:

  • Food security: Are there times when you don’t have enough food?
  • Income: Do you ever have trouble making ends meet?
  • Housing: Is housing ever a problem for you?
  • Supplemental Child Care: Is your child in Head Start, preschool or other childhood programs? Are you pulled away from caring for your child too much by your job or other responsibilities?
  • Parental Mental Health: Do you take medication for a mental health condition or have you ever been diagnosed with one?

All questions should be posed in a non-judgmental way with an emphasis on the pediatrician’s ability to connect the family with helpful services. In an ideal world, we as pediatricians should be aware of the resources available to our patients’ families, but in reality our attention and time may be stretched too thin to accommodate such constantly-changing information. An incredibly helpful resource for families and pediatricians is 2-1-1. This is a nation-wide service provided by United Way to connect families with local resources such as food pantries, crisis centers, and housing support [7]. Families with identified problems can call 2-1-1 for assistance or www.211.org can be pulled up in the pediatrician’s office for directories of available resources in the area.

Advocacy can be taken up by pediatricians and citizens alike. As a new pediatrician, I am already incredibly frustrated by the lack of resources and societal support for my patients and their families. It is so disheartening to see news like the tragic separation of children from their families at the border when the terrible effects of such adverse childhood experiences have been well known for so long. The takeaway message I would like to stress to any readers of this post is that childhood welfare is not partisan. Government funds will not be wasted on this issue, and children will not be made lazy by receiving assistance. Increased childhood welfare could alleviate many causes of ACEs which lead to suffering and wasted human potential on an incredible scale. I implore any readers to find an issue they feel passionately about, and look for ways to help. These may include registering to vote, writing your representatives, supporting child advocacy campaigns on social media, making donations or volunteering for local charities like food banks, shelters, or child care centers. For information on advocacy issue you may visit the websites below for more information.

https://www.aap.org/en-us/advocacy-and-policy/Pages/Advocacy-and-Policy.aspx

https://www.naeyc.org/resources/blog/support-and-advocate

https://www.cwla.org/our-work/advocacy/

http://childwelfaresparc.org/

 

Benjamin Masserano, MD

 

References

[1] https://developingchild.harvard.edu/science/key-concepts/toxic-stress/

[2] https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html

[3] https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

[4] http://pediatrics.aappublications.org/content/pediatrics/early/2011/12/21/peds.2011-2663.full.pdf

[5] http://pediatrics.aappublications.org/content/128/6/e1680

[6] http://pediatrics.aappublications.org/content/120/3/e734

[7] http://www.211.org/

Mental Health Screenings in Adolescent Care

The first week of October every year is designated as Mental Health Awareness Week in the United States – a pattern established by our Congress in 1990 to recognize the efforts of the National Alliance on Mental Illness (NAMI, www.nami.org) and increase awareness about mental health conditions. As we close out the end of Mental Health Awareness Week, I would like to focus on an important topic that sometimes ends up being overlooked or rushed through at a primary care visit: mental health screenings in the adolescent population.

According to results derived from a recent National Comorbidity Survey Replication, nearly 50% of all mental health conditions in the United States begin by age 14. Per data from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA), suicide is currently the second leading cause of death in adolescents; 18% of high school students nationwide reported having seriously considered attempting suicide (females > males), and at least 9% had attempted suicide one or more times. Identifying a possible mental health diagnosis early in life — such as depression, anxiety disorders, ADHD, eating disorders, or PTSD — can help save many individuals from life-altering consequences.

The American Academy of Pediatrics (AAP) recommends annual mental health screenings for adolescents starting at age 12. While state Medicaid provisions in Texas previously only allowed for one mental health screening, total, to be billed between the ages of 12 and 18 as part of an annual well-child exam, recent Texas legislation passed on September 1, 2017 (HB 1600) now allows Medicaid reimbursement for up to once-a-year mental health screenings with well-child exams from the ages of 12-18, which is an important step in the right direction.

Texas, however, is currently in the midst of a mental health workforce shortage, especially in child and adolescent psychiatry. Although legislative efforts to address this shortage within the state are in progress, it renders the pediatrician or primary care doctor’s duty to address mental health within adolescent well-child visits absolutely imperative at this moment.

Screening questions/tools that can be used in an adolescent primary care mental health screening can include, but are not limited to:

  • HEADDDSS Assessment:
    • Home – living situation, safety in the home, relationships with family
    • Education/Environment – address any learning/attention difficulties, friends and social circle, school and online bullying, social media (mis)use
    • Activities – hobbies, extracurriculars, jobs
    • Diet – include screening for disordered eating behaviors
    • Drugs:
      • Substance Use Screening Tool: CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble)
    • Depression/Suicidality:
      • Screening Tools: PHQ-2 (initial screen) + the more detailed PHQ-9
    • Sexual Activity/Sexuality/Sexual Abuse
  • Anxiety Screening Tool: SCARED (Screen for Child Anxiety-Related Emotional Disorders)
  • Trauma Screening Tool: CATS (Child-Adolescent Trauma Screen)
  • Pediatric Symptom Checklists (PSCs)

*Note: Mental health screenings for adolescents under Texas Medicaid must utilize at least 1 of the screening tools approved by Texas Health Steps, which includes the PSCs, the CRAFFT, and the PHQ-9.

For additional mental health information for patients, such as finding the closest behavioral health treatment centers, an excellent resource is the national SAMHSA website at https://www.samhsa.gov/treatment/index.aspx.

Anita Verma, MD

References:
American Academy of Child and Adolescent Psychiatry. (2013). Child and Adolescent Psychiatry Workforce Crisis: Solutions to Improve Early Intervention and Access to Care. https://www.aacap.org/App_Themes/AACAP/docs/Advocacy/policy_resources/cap_workforce_crisis_201305.pdf
American Academy of Pediatrics. (2017). Recommendations for Preventative Pediatric Health Care. Bright Futures, 4th Ed. https://www.aap.org/en‐us/documents/periodicity_schedule.pdf
Centers for Disease Control and Prevention. (2016). Children’s Mental Health Report. CDC Features: Life Stages and Populations. https://www.cdc.gov/features/childrensmentalhealth/
Centers for Disease Control and Prevention. (2016). 1991-2015 High School Youth Risk Behavior Survey data. http://nccd.cdc.gov/YouthOnline/App/Default.aspx
Department of Health and Human Services, Office of Adolescent Health: Adolescent Mental Health Fact Sheets. https://www.hhs.gov/ash/oah/facts-and-stats/national-and-state-data-sheets/adolescent-mental-health-fact-sheets/texas/index.html
HB 1600: Relating to certain mental health screenings under the Texas Health Steps program. http://www.capitol.state.tx.us/BillLookup/Text.aspx?LegSess=85R&Bill=HB1600
Kessler R.C., et al. (2005). Lifetime Prevalence and Age of Onset Distributions of DSM‐IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62(6): 593‐602. https://www.ncbi.nlm.nih.gov/pubmed/15939837
Testimony of Pritesh Gandhi, MD, MPH, to the Texas House of Representatives Public Health Committee, in support of HB 1600, March 2017. Submitted on behalf of the Texas Pediatric Society, Texas Medical Association, and Texas Academy of Family Physicians. https://txpeds.org/sites/txpeds.org/files/documents/house-ph-hb1600-3-14-17.pdf

 

Addressing the violence in the news with children

Children are indirectly exposed to acts of violence and terrorism almost continuously via the media.  News media continually cycles global events onto screens in every household. The stress of witnessing a shooting is no longer limited to the bystanders and civilians caught on the scene, but is spread diffusely across state and national borders to viewers in their homes including children. Pediatricians can help children and their caretakers process these tragedies better.  

Exposure to such news stories can contribute to a stressful environment for the child. In recent years the AAP has focused on ‘toxic stress’ in a child’s life. Toxic stress has been defined as “the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships” (National Council of Science: Excessive stress disrupts the development of brain architecture). A growing body of evidence suggests that ecology and biology interact to effect development, i.e., the ecobiodevelopmental framework. In the case of toxic stress, a stressful ecology inculcates lasting detrimental effects in biology and behavior. It can lead to development of poor coping skills, unhealthy lifestyle choices, chronic cardiovascular diseases and serves to perpetuate health disparities to mention a few.

Opinions vary on the extent and significance of the effect of exposure to news media coverage of acts of terror and violence. Increasingly, after such an incident, many articles emerge suggesting how parents should talk to their children about violence. Unfortunately, many children do not have the “buffering protection afforded by stable, responsive relationships” with their parents. Parents themselves may face a difficult time coming to terms with the same tragedies. This gap can be bridged by the pediatrician, school and public policy.

Pediatricians can routinely screen for toxic stress. The AAP has put forward many helpful resources which advise parents on how to talk to their children regarding media violence, tragedies they may have witnessed, school shootings and disasters. Whenever such news is circulating, pediatricians can ask parents if they have trouble communicating with their children about it, expand on their anticipatory guidance using the pre-existing AAP guidelines and recommend appropriate resources to them.  Further, pediatricians in collaboration with mental health professionals can meet with parent-teacher associations to share how children are able to best process these events.

Schools can engage their own mental health services and counselors to have a discourse with children in an age-appropriate manner. In the absence of adequate resources, these sessions could be done in groups and limited to when the event is local.

Finally, state government officials can improve funding for mental health services for children and implement strategies to incentivize an increase in the mental health professionals catering to the pediatric population. Legislators can formulate guidelines for Social and Emotional Learning (SEL) curriculum for grades K-12 as exist for pre-kindergarten. As of December 2015, free-standing guidelines for Social and Emotional Learning exist only in the states of Illinois, West Virginia and Kansas. Bills proposing training of teachers and principals to address social and emotional development needs of students have been previously introduced in the U.S. House (H.R.850; H.R.497) and the U.S Senate (S.897) in 2015. In the same year, a bill (HB 3289) was also introduced in the Texas Legislature proposing formulation of a local school health advisory committee to address mental health concerns existing in school efforts and to make recommendations to the school district concerning the integration of social and emotional learning into the academic curriculum.

Adopting such a multi-pronged approach will better preserve the childhoods of the current generation and safeguard their adult lives as well.

References:

1.       National Scientific Council. Excessive stress disrupts the development of brain architecture. Journal of Children’s Services. 2014 Jun 10;9(2):143-53. Accessed July 11, 2016. URL: http://developingchild.harvard.edu/wp-content/uploads/2005/05/Stress_Disrupts_Architecture_Developing_Brain-1.pdf

2.       Shonkoff, J.P.; Garner, A.S. Technical Report: The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012. doi:10.1542/peds.2011-2663

3.       Committee on psychosocial aspects of child and family health, committee on early childhood, adoption, and dependent care, and section on developmental and behavioral pediatrics. AAP Policy Statement: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012. doi:10.1542/peds.2011-2662

4.       Busso, D.S.; McLaughlin, K.A.; Sheridan, M.A. Media exposure and sympathetic nervous system reactivity predict PTSD symptoms after the Boston marathon bombings. Depress Anxiety. 2014 July ; 31(7): 551–558. doi:10.1002/da.22282

5.       Marie Leiner, M.; Peinado, J.; Villanos, M.T.M.; Lopez, I.; Uribe, R.; Pathak, I. Mental and emotional health of children exposed to news media of threats and acts of terrorism: the cumulative and pervasive effects. Frontiers in Pediatrics. 2016. doi: 10.3389/fped.2016.00026

6.       Collaborative for Academic, Social and Emotional Learning. Identifying K-12 Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: https://pedsadvocacy.files.wordpress.com/2016/07/a46cb-state-scorecard-summary-table-for-k-12-12-16-15.pdf

7.       Collaborative for Academic, Social and Emotional Learning. Identifying Preschool Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: http://static1.squarespace.com/static/513f79f9e4b05ce7b70e9673/t/55df7c05e4b031d82f728c5d/1440709637809/preschool-table-8-27-15.pdf

8.       Texas Education Agency. Accessed July 9, 2016. URL: http://tea.texas.gov/index2.aspx?id=2147495508

 

Gohar Warraich, M.D.

 

Consciously Supporting Concussion Awareness

In recent years, public interest has increased surrounding concussions/mild traumatic brain injuries (MTBI). This is due in large part to the recent hypothesis that concussive forces from contact sports may be a risk factor for the development of chronic traumatic encephalopathy (CTE), a disease seen most often in former boxers and professional football players.

Research, legislation, and documentaries have sought to better define the incidence and risks of concussions, its relationship to these 2 diseases, and to increase public awareness of this issue. Currently, legislation is pending in both the U.S. House of Representatives and the Senate that has the potential to further achieve these goals by increasing general awareness about concussions and giving parents and youth the ability to make informed decisions about the sports in which they participate. We as pediatricians can advocate for the safety of our patients by contacting our local representatives and asking them to become cosponsors for the “SAFE PLAY Act” (H.R. 829).

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Child Trafficking: A Public Health Concern

Human trafficking is not only a global issue, but also a major public health concern within the United States. Studies suggest that up to half of trafficking victims seek medical attention at least once during their trafficking situation. This represents a large, often-missed opportunity for healthcare professionals to intervene. The injustices of human trafficking include forced labor, involuntary servitude, child soldiers, and sex trafficking. Some estimate that over 20 million men, women, and children are victims of human trafficking worldwide. [1] However, the scope of the problem is difficult to quantify, given the covert nature of the crime. The U.S. government no longer includes official estimates in its annual “Trafficking in Persons” reports. In 2004, the Department of Justice estimated that 14,500-17,500 trafficking victims were brought to the U.S. each year. [2] In addition to the victims brought illegally to this country, another 300,000+ youth within the U.S. are thought to be at risk of exploitation. [3]  As many as 80% of trafficking victims are female, and one-third to one-half are minors. [4] Cases of child trafficking have been confirmed in all 50 U.S. states over the last decade. [3]

Here’s what pediatricians can do to help: (more…)