Mental Health

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

 

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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…)

Mental Health and Our School System

It is a common sentiment in the pediatric community that our current health care system does not meet the needs of the 1 in 5 children in the United States with a diagnosable mental health disorder. There is a current bill in Congress that speaks to this very problem: The Mental Health in Schools Act of 2013. This bill would require a comprehensive school mental health program that would assist children in dealing with trauma and stress and would encourage community partnerships among education systems and mental health and substance use disorder services and other agencies. (more…)

AAP supports increased funding for pediatric mental health services

The AAP responds to a request from the Senate Finance Committee regarding our nation’s mental health system.

In the wake of the tragic shootings at Sandy Hook Elementary School in Newtown, CT, the Administration and Congress are looking for ways to improve our nation’s mental health system. Exposure to violence causes toxic stress in childhood, which can have long-term negative effects on children. Managing adult mental health disorders begins with ensuring that children have access to quality mental health services. (more…)