Discussing Depression and Suicide in the Media

Avicii (Tim Bergling), Chester Bennington, Kate Spade, Mark Salling, Robin Williams, Anthony Bourdain: All names in media for the unfortunate fame of recent suicides. Similarly, TV shows such as “13 Reasons Why” (released to Netflix in 2017) and pop songs like “1-800-273-8255” by Logic (featuring Alessia Cara and Khalid), shed light on the persistent and ever growing issue of adolescent depression and suicide. There has been heated national debate regarding the effect media has on perpetuating suicidal thoughts versus raising awareness. Whether by parental choice or not, the discussion of mental health and self-harm has made its presence known to the public eye of children with these big names of Hollywood and pop culture. Just as it is important to address gun violence covered by media, pediatricians and parents must take strong roles in approaching the sensitive subject of depression. Suicide is itself a very private matter, however more recently it has become publicized, glorified, and often shamed. In light of these portrayals, it is crucial to remember it for what it is: a mental health illness.

According the CDC 2018 Vital signs, suicide rates across ages continue to rise with a significant jump by 30% from 1996 to present, in half the US states [1]. Suicide remains the 3rd leading cause of death in children 10-14 years of age, and (since 2016) the 2nd leading cause of death in adolescents 15-24 years of age. Looking state specifically, Texas falls in the range of 19-30% increase in suicide rates. Fortunately, amongst adolescents, attempt rates and health injury caused by suicide attempts, remains relatively stable between 2013-2015, according to Youth Risk Behavior Survey [2]. The disappointing reality exists that even under the watchful eye of healthcare providers, 77% of those who complete suicide have been seen by a primary care provider, and 40% have been seen by an emergency care provider in the year leading up to their suicide [3].

What can be done? And how do we intervene? Initial screenings are not only welcomed by adolescent patients [4] but also effective in providing a backbone for further follow up [5]. Systematic tracking of endorsed suicidality, with formulas/surveys such as the PHQ-9, help to quantify mental health and to make screening easier for the providers.

For parents and pediatricians alike, anticipatory guidance during adolescent well child exams or sports physicals can serve as a time to review key topics such as:

  • Warning signs of depression:
    • social withdrawal, loss of interest in prior hobbies, hopeless talk, extreme or labile emotions/mood swings, verbal outcries on social media
  • Open communication:
    • encouraging parent-teen relationships, providing attention and empathy before patient outcries (http://www.bethe1to.com/), avoiding shame, expressing concern about the patient
  • Access to guns/medications/drugs at home:
    • removing adult (or child) medications that can be abused, removing and locking away guns (4-10x higher likelihood of suicide in households with gun access) [6]
  • Cyberbullying:
    • Limiting social media use, monitoring internet searches on suicide (more than 5 hours of internet use daily associated with higher rates of suicide) [7]
  • When to escalate and who to reach out to with concerns:

By initiating a conversation early on with parents and adolescents alike, pediatric providers may alter the perspective on mental health. Pop culture media is not required to uphold the ethics of beneficence or non-maleficence. Ultimately, it is the responsibility of the pediatrician and the community at large to invest in the future of its young adults. We can do this by advocating for improved funding (in light of budget cuts to mental health services), and perpetuating positive and open dialogue early on regarding mental health and depression.

~Alisha Wang, MD



[1] Suicide Rising Across the US: https://www.cdc.gov/vitalsigns/suicide/

[2] Trends in the Prevalence of Suicide-related Behavior: https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trends/2015_us_suicide_trend_yrbs.pdf

[3] Parkland Leads Way Nationally with Innovative Suicide Screening Program: https://www.parklandhospital.com/phhs/news-and-updates/parkland-leads-way-nationally-with-innovative-suic-769.aspx

[4] To Ask or Not to Ask? Opinions of Pediatric Medical Inpatients about Suicide Risk Screening in the Hospital. Journal of Pediatrics. Mar 2016. https://www.jpeds.com/article/S0022-3476(15)01464-X/pdf

[5] Suicide Screening in Primary Care: Use of an Electronic Screener to Assess Suicidality and Improve Provider Follow-Up for Adolescents. Journal of Adolescent Health. Feb 2018. https://www.jahonline.org/article/S1054-139X(17)30466-4/fulltext

[6] With Suicide Now Teens’ Second-Leading Cause of Death, Pediatricians Urged to Ask About Its Risks. AAP. Jun 2016. https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/With-suicide-Now-Teens%E2%80%99-Second-Leading-Cause-of-Death-Pediatricians-Urged-to-Ask-About-its-Risks.aspx

[7] Suicide and Suicide Attempts in Adolescents. AAP. Jun 2016. http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420


Parental Responsibility to Regulate Screen Time for Children

In 2016, the American Academy of Pediatrics (AAP) revised screen time guidelines for children. The previous guidelines advised no screen time for kids less than 2, and no more than 2 hours in front of the TV for kids over the age of 2. With the advent of smart phones and tablets making screen time and Internet access nearly ubiquitous, many pediatricians and other professionals felt the AAP was long overdue in revising screen time guidelines to be more appropriate for current and future generations of children. Newly revised 2016 guidelines were broken down into four basic age groups with added flexibility to customize screen time to fit the needs of the individual child, as follows:

  • For infants less than 18 months of age:
    • Parents should avoid use of screen media other than video chatting.
  • For infants 18 to 24 months of age:
    • If desired, parent should choose high-qualityprogramming, and watch with children to help them understand what they’re seeing.
  • For toddlers 2 to 5 years of age:
    • Parents should limit screen use to 1 hour per day of high-quality
    • Parents should co-view media with children to help them understand what they are seeing and apply it to the world around them.
  • For children 6 years of age and older:
    • Place consistent limitson the time spent using media, and the types of media, and make sure media does not take the place of adequate sleep, physical activity and other behaviors essential to health.

These new guidelines recognize that visual media can be an important tool for development and educationwhen properly utilized. The problem is that many parents do not properly adhere to these guidelines. Contrary to what some may believe, these guidelines do not relax the parameters for screen time. Rather, these guidelines call for increasedparental investmentin actively regulating their child’s media consumption. Examples of inappropriate screen time, at times even commonly witnessed directly by pediatricians in clinic, include some the following:

  • Parents using video streaming on mobile devices as a means of distracting their infants or children.
  • Parents not adequately supervising screen time.
  • Parents failing to set consistent limits on media use.
  • Parents or children choosing to view poor quality programming with little educational benefit.

Adverse effects of unregulated screen time are well understood to include the following: obesity, sleep problems, problematic internet use (e.g. gaming disorders), negative effects on school performance, risky behaviors (e.g. substance abuse, inappropriate sexual behaviors), sexting, piracy, predators and cyber bullying.

Given the common adverse effects of unregulated media use, it is important to recognize that the above guidelines do not indicate AAP’s endorsement of screen time as a primary learning activity. The AAP recommends that parents prioritize creative, unplugged playtimefor infants and toddlers. The amount of daily screen time for older children depends on the child and family, but children should prioritize productive time over entertainment time.

The AAP provides an important but underutilized tool online that helps families build their own custom Family Media Plan (see link below). Pediatricians who wish to emphasize the importance of regulated screen time should consider providing this resource to families in their clinics. The plan provides a customizable template that includes setting important boundaries in the development of healthy screen time behavior.

Lastly, a quote from Bill Watterson, arguably one of the most creative minds of the late 1980s-early 1990s who is known for his authorship of Calvin & Hobbes, helps reinforce the importance of alternatives to screen time:

“We’re not really taught how to recreate constructively. We need to do more than find diversions; we need to restore and expand ourselves. Our idea of relaxing is all too often to plop down in front of the television set [or internet] and let its pandering idiocy liquefy our brains. Shutting off the thought process is not rejuvenating; the mind is like a car battery—it recharges by running.”

Alex J. Foy, MD


Sources and Resources:

Build Your Own Family Media Plan


10 Tips for Becoming a More Active Family


Children and Adolescents and Digital Media


Constantly Connected: Adverse Effects of Media on Children & Teens


Obesity and Food Insecurity: A Dichotomy in the Current State of Nutrition in America

Nutrition plays a vital role in growth, behavioral and cognitive development, reproductive health, and long-term health maintenance.  Pediatric is arguably the most vulnerable population to the affect of food availability. In the early stages of childhood, appropriate nourishment can facilitate growth, cognitive and motor development. In school age children, it can facilitate or hinder academic success, and set up a foundation for a lifetime of healthy lifestyle or predispose a child to multiple chronic morbidities such as fatty liver disease, diabetes, and hypertension. In their teenage years, poor nutrition can lead to infertility, either through anovulation from malnourishment or PCOS from obesity.


Children are entirely dependent on their caretakers for appropriate nutrition in the most crucial stages of their lives. In America, 16 million children currently live in food-insecure households, and more than one third of children and adolescents are overweight or obese. While obesity touches all colors, genders, and social-economic backgrounds in America, African Americans, Hispanics, and children from households with lower education level are especially affected.


Obesity is usually thought of as a disease of excess, however, there’s a positive correlation between poverty and obesity. According to a study of over 28,000 low-income children in the Massachusetts WIC program, children in food-insecure households have 22 percent greater odds of childhood obesity compared to their food-secure counterparts.  Though initially counterintuitive, several factors explain this relationship: lack of access to healthy food, greater exposure to obesity-promoting products, cycle of starvation and overeating, few opportunities for physical activities, high level of stress, depression, and anxiety, and limited access to healthcare.


Currently, several nutritional assistance programs such as WIC, Food Bank, and SNAP target low-income, food insecure populations. However, while these programs might address the issue of food insecurity and cycle of overeating and starvation, the types of food provided might contribute to obesity. For example, WIC provides 128 oz of fruit juice monthly to children ages 1-4, which is the maximum amount recommended by the AAP, food banks provide soda, juice, chips and other sugary snacks, and SNAP allows soft drinks, candy, cookies, ice cream, and cake to be purchased using monthly SNAP allowance. While the AAP’s policy statement in June 2017 does allow up to 3 oz of juice a day for 1-3 years old toddlers, it states that “fruit juice …has no essential role in healthy, balanced diets of children” and calls for pediatricians’ support to “reduce the consumption of fruit juice…by toddlers and young children already exposed to juice, including through…WIC.”


While we concentrate our efforts in providing assistance to food-insecure families, it is important to be mindful of the other phenomenon that tends to coexist with poverty and food insecurity: obesity.  When families are provided with juice, soda, and other non-nutritious food as part of their food package, it can be confusing and difficult to choose to consume only nutritious food. It is crucial for healthcare providers and nutritionists to counsel patients on healthy food choices, especially in families with limited access to resources and education.


Several resources can help families learn more about healthy food choices:






Phinga Do, MD












Food Insecurity and the Pediatrician’s Role in Fighting Hunger


In the United States hunger remains a problem with far reaching consequences especially when it affects our youngest members of society. Though many would argue that food is one of our most basic human needs, it is something many United States families at times must go without. (more…)

Heat Stroke in High School Football Players: A Lack of Regulation Placing Children at Risk

At the start of every school year, thousands of high school athletes come in excited to hit the field.  Unfortunately, heat related death in high school sports, especially high school football, remains a real risk due to lack of regulations and safeguards in place.  However, these injuries and deaths are entirely preventable by proper practices.  Pediatricians have a duty and an opportunity to protect these athletes from environments and circumstances that put them at increased risk for heat stroke and death.


SNAP: The Supplemental Nutrition Assistance Program and Its Future

When we come home every evening to join our friends and families for dinner, many of us seldom worry about whether we will have food on the table. For millions of Americans, however, hunger is a very real difficulty as they struggle to feed both themselves and their children. As part of the effort to combat hunger in the United States, physicians should support the continued funding of SNAP, a program implemented by the federal government to answer the challenge of food insecurity.

Since the 1960s, the Supplemental Nutrition Assistance Program, or SNAP, has provided eligible, low-income individuals and families with benefits for food at eligible retail stores. Formerly known as food stamps, this federal program assisted nearly 45 million individuals in 2017, especially households with children, elderly, and disabled persons. Eligibility for SNAP is limited to people with gross incomes up to 130% of the federal poverty line. Families are provided with monthly electronic debit cards to purchase groceries at authorized retailers.

In 2015, SNAP helped 4.6 million Americans rise above the poverty line, including 2 million children. The program also reduced the prevalence of food insecurity by as much as 30%. It also supports the economy; for every $1 billion added to SNAP funding, approximately 18,000 new jobs are created.

Research by the USDA Economic Research Service has found strong correlations suggesting that food insecurity increases the risk of adverse health outcomes and leads to higher healthcare costs. In 2017, food-insecure households spent 45% more on medical care compared to food-secure households. These people had a higher prevalence of heart disease and diabetes, and were more likely to be non-adherent to their medications. Conversely, SNAP participants were healthier and incurred about $1,400 less in medical costs over a year than other low-income individuals. Additionally, children with access to SNAP have improved long-term health, with lower risks of obesity, heart disease, and diabetes.

While SNAP fights to ensure that no American goes hungry, it also encourages work through specific requirements for able-bodied adults without dependents, or ABAWDs. Through the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, non-disabled individuals between the ages of 18 and 49 can only get SNAP for 3 months in 36 months unless they work 80 hours per month, participate in a qualifying educational or training activity, or do unpaid work through special State-approved programs. While the USDA’s Food and Nutrition Service determines its broad policy, states and counties manage its daily activities and administration. Many states request federal permission to waive these time limits due to local economic difficulties. These waivers have been crucial in assisting individuals who live in areas of particular hardship.

Currently SNAP is facing significant changes to its funding and structure. President Trump’s 2019 budget proposes cutting SNAP funding by over $213 billion over the next 10 years and restructuring how benefits are delivered. At least 4 million people would lose eligibility, and many others will have reduced benefits.

The biggest change is that the government will stop its partnership with over 260,000 retail stores around the country and instead provide government-purchased food boxes of nonperishable goods. This would mean that families would have less choice in their food, especially with fresh fruits and vegetables. Also, the states would be left to determine how these food boxes would be distributed and bear its costs.

Furthermore, a portion of these SNAP benefits would be withheld from households, and would ultimately affect 34 million people, or almost 90% of SNAP participants, in 2019. The proposal would also limit waivers for ABAWDs and increase the maximum age, which would severely impact those in high-unemployment areas, the elderly, and the disabled. Additionally, SNAP nutrition education funding would be eliminated, which would severely hinder the program’s goals for improved nutrition.

Proponents of these changes suggest that this will be an effective method of cutting government spending, while providing standardized meals for families. Concerns exist that SNAP creates “food stamp dependency” and increases the risk of childless and disability-free adults relying solely on SNAP benefits instead of working. Some studies by organizations such as the Foundation for Government Accountability report that many ABAWDs who left these programs after certain states renewed these time limits found work within 12 months and experienced a significant increase in their income. However, many studies have found that most people continue to work while remaining on SNAP, and that these waiver restrictions mostly affect people who live in areas without any available work.

While managing government spending is a perpetual aim for every Congress and President, the proposed changes to SNAP have the potential to negatively affect millions of American families, especially children. There would likely be an increase in health-related problems for individuals of all ages who relied on these benefits, which would lead to an increase in healthcare costs. It would also undermine previous efforts at promoting healthy nutrition habits and education. Improving savings in the national budget is a worthy goal, but not at the expense of pushing millions of people closer to hunger.

As physicians, we should make every possible effort to protect families and children from hunger. Please contact your local and federal representatives and encourage them to continue SNAP funding without restructuring the program or withholding SNAP benefits from those in need of assistance.

Vishnu Prathap, MD


Archambault, Josh. “Restoring Work Requirements: An Important Fix To America’s Food Stamp Crisis.” Forbes, Forbes Magazine, 11 Aug. 2015, www.forbes.com/sites/theapothecary/2015/08/11/restoring-work-requirements-an-important-fix-to-americas-food-stamp-crisis/#61d40681a20a.

Belluz, Julia. “45 Million Americans Rely on Food Stamps. Trump Wants to Gut the Program.” Vox, Vox, 23 May 2017, www.vox.com/policy-and-politics/2017/5/23/15675892/food-stamps-snap-evidence-health-poverty-hunger.

Carlson, S, and B Keith-Jennings. “SNAP Is Linked with Improved Nutritional Outcomes and Lower Health Care Costs.” Center on Budget and Policy Priorities, 17 Jan. 2018, www.cbpp.org/research/food-assistance/snap-is-linked-with-improved-nutritional-outcomes-and-lower-health-care.

Ingram, J, and N Horton. “How Kansas’ Welfare Reform Is Lifting Americans Out of Poverty Work.” The Foundation for Government Accountability, 16 Feb. 2016, https://thefga.org/research/report-the-power-of-work-how-kansas-welfare-reform-is-lifting-americans-out-of-poverty.

Office of Research and Analysis. “Food and Nutrition Service.”Food and Nutrition Service, United States Department of Agriculture, Apr. 2012. https://fns-prod.azureedge.net/sites/default/files/BuildingHealthyAmerica.pdf.

Rector, Robert, and Vijay Menon. “SNAP Reform Act Offers Sound Basis for Welfare Policy.” The Heritage Foundation, 9 Jan. 2018, www.heritage.org/hunger-and-food-programs/report/snap-reform-act-offers-sound-basis-welfare-policy.

Rosenbaum, D, et al. “President’s Budget Would Cut Food Assistance for Millions and Radically Restructure SNAP.” Center on Budget and Policy Priorities, 15 Feb. 2018, www.cbpp.org/research/food-assistance/presidents-budget-would-cut-food-assistance-for-millions-and-radically.

“Supplemental Nutrition Assistance Program (SNAP): Able Bodied Adults Without Dependents.” Food and Nutrition Service, United States Department of Agriculture, 26 Feb. 2018,www.fns.usda.gov/snap/able-bodied-adults-without-dependents-abawds.

“Understanding SNAP, the Supplemental Nutrition Assistance Program, Formerly Food Stamps.” Feeding America, 2018, www.feedingamerica.org/take-action/advocate/federal-hunger-relief-programs/supplemental-nutrition-assistance-program.html?referrer=http%3A%2F%2Fwww.feedingamerica.org%2Ftake-action%2Fadvocate%2Ffarm-bill.html.

Cyberbullying: A Pediatrician’s Role in the Digital Age

Due to the recent explosion of hand-held technology over the past 2 decades, a new form of bullying has emerged called “Cyberbullying”. This type of bullying utilizes electronic means of communication such as text messaging, email, websites, or social media (Facebook, Twitter, etc.) to victimize and cause a power imbalance between peers. Pediatricians should identify signs of cyberbullying and provide appropriate anticipatory guidance and resources to both parents and patients.


Firearm Safety Considerations in the Pediatric Population

Recent tragedies in Las Vegas, Nevada, and Parkland, Florida have returned the topic of firearm safety to the forefront of societal and political discourse. Children and adolescents are particularly affected by firearm violence. The latest population data is sobering – nearly 12 firearm deaths per day in the United States in children ages 0-21 years old. The American Academy of Pediatrics (AAP) continues to call for legislative action to reduce the incidence of firearm-related violence. Initiatives championed by the AAP include: (1) banning assault-style weaponry, (2) banning Internet sale of firearms, and (3) requiring background checks prior to purchase of a firearm, to name a few.

How can pediatricians work to promote safety in their patient population? Efforts on both a political front through advocacy and on a personal scale via anticipatory guidance during well child examinations can create societal and individual change to improve the health and safety of all children.


  • Nearly 1 in 5 deaths in American youth under-20 is firearm-related.
  • Merely the presence of firearms in the home increases the risk of suicide among adolescents. The risk is even worse if the gun is kept loaded.
  • A study of personal firearm storage revealed:
    • 21.7% of subjects kept their firearms loaded when stored at home
    • 31.5% of subjects stored their firearms in unlocked locations
    • 8.3% of subjects kept their firearms loaded AND stored in unlocked locations
  • More than 75% of guns used in suicide attempts and unintentional injures of children ages 0-19 were stored in the residence of the victim, a relative, or a friend.
  • Children as young as 3-years old can produce enough squeezing pressure to pull a trigger on a loaded gun


  • The most effective measure to prevent firearm violence is the absence of firearms in the home.
  • Stricter regulations regarding access and purchasing of firearms
  • Better storage of weapons including trigger locks and locked storage boxes
  • Mechanistic alterations to make firing a weapon more difficult for children, such as increasing trigger pressures


  • Advocacy
    • Send correspondence to your local state legislator to share your views on firearm safety and the need for stricter control of access and storage
      • The AAP has resources to find the contact information for your state legislators and a draft email here.
    • Engage with local schools and media to offer your experience and expertise.
      • The AAP has developed talking points regarding firearm violence in the pediatric population that can be found here.
    • The AAP recommends pediatricians address firearm safety as part of routine anticipatory guidance for families with children of all ages.
  • Anticipatory Guidance
    • Always asked about firearms in the home. Where are they stored? Are they locked? Who has access?
    • Inform families that the safest homes are those without guns.
    • For homes with firearms, encourage families to take practice safe storage – store guns and ammunition separately and in locked containers.
    • Encourage removal of firearms in homes with adolescents, especially if there is a history of mood disorders, substance abuse and/or a history of suicide attempts.
    • Encourage parents to ask if there is a gun in the house before sending children to play at a friends’ home.

Firearm violence is a huge issue that will constantly provoke heated debate and passionate rhetoric from all sides. As pediatricians, we can take simple steps to inform parents and help protect the most vulnerable population of our society.

D. Alan Potts, MD



Implementing Perinatal Depression Screening into the WCC

Problem: Texas enacted House Bill 2466, effective September 1, 2017, to provide Medicaid and child health plan coverage for maternal depression screening during an office visit for the child.  The purpose of this brief report is to inform clinicians of this coverage and urge Pediatricians to standardize the practice of perinatal screening during well child checks in the first year. 

Background: One out of every seven women experience depression during pregnancy or within one year of delivery, defined as “perinatal depression”.  This staggering statistic makes perinatal depression the most underdiagnosed obstetric complication in the United States.  If untreated, perinatal depression can have devastating consequences for the mother, their child, and their families.  Research has shown a higher incidence and risk for preterm birth, low birth weight, intrauterine growth restriction, pre-eclampsia, substance use during pregnancy, suicidality and infanticide.

  • Prevalence of perinatal depression is 2x greater in low-income women
  • Perinatal depression can threaten the initial mother-child relationship – i.e. attachment, bonding, breastfeeding
  • Perinatal depression can negatively affect all aspects of a child’s development – lower level of engagement, lower activity level, poor regulation, withdrawal

Last year the U.S. Congress enacted the “21st Century Cures Act”, which included the “Bringing Postpartum Depression Out of the Shadows Act of 2015”.  This law established and expanded pre-existing state funding for maternal depression screening and treatment in primary care settings. The goal was to provide doctors with the training and resources to complete screening, as well provide the follow up support and treatment therapies necessary.

In response to the new federal law, Texas passed the House Bill 2466.  Texas’ new law directs the state agency to develop rules for implementing the maternal depression screening and provide Medicaid coverage for it, regardless of whether the mother is also a recipient of Medicaid.

For guidance, clinicians can review the work done by leaders in Massachusetts to identify women facing perinatal depression and engaging them in appropriate therapies.  The Massachusetts Child Psychiatry Access Project (MCPAP) for Moms developed as a spinoff program of the successful MCPAP launched in 2005.  The original MCPAP was designed to help pediatricians manage pediatric psychiatric needs.  MCPAP for Moms provides three main services: https://www.mcpapformoms.org/

  1. Trainings and toolkits to assist Pediatricians in depressing screening, referral, medication discussions, and other treatment options
  2. Real-time psychiatric telephone consultation for providers caring for pregnant and post-partum women
  3. Networking opportunities with community-based resources to support pregnant and post-partum women

Recommendations/Takehome points: As Pediatricians, we are often the first to see a mother after she leaves the hospital.  We have a unique and important opportunity to identify those struggling with perinatal depression, and get them the help they need and deserve quickly.

  • Perinatal depression screening can be appropriately integrated at the 1, 2, 4, and 6 month visits for the child.
  • It can be as simple as two questions:

Over the past 2 weeks:

(1) Have you ever felt down, depressed, or hopeless?

(2) Have you felt little interest or pleasure in doing things?

  • Screening does not require the Pediatrician to treat the mother. It gives an opportunity to refer her to the appropriate resources.

Alison Kimura, MD, MPH



  1. http://www.legis.state.tx.us/billlookup/text.aspx?LegSess=85R&Bill=HB2466
  2. https://www.congress.gov/bill/114th-congress/senate-bill/2311?q=%7B%22search%22%3A%5B%22bringing+postpartum+depression%22%5D%7D&r=1
  3. https://www.congress.gov/bill/114th-congress/house-bill/34/actions
  4. https://www.mcpapformoms.org/
  5. http://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1003&context=parentandfamily
  6. Byatt, Nancy, et al. “Improving perinatal depression care: the Massachusetts Child Psychiatry Access Project for Moms.” General hospital psychiatry40 (2016): 12-17.
  7. Earls, Marian F., and Committee on Psychosocial Aspects of Child and Family Health. “Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.” Pediatrics5 (2010): 1032-1039.



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

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