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.

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…)

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

 

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…)