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Pediatric Mental Health

1.5 Contact Hours including 1.5 Advanced Pharmacology Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
This course will be updated or discontinued on or before Friday, December 13, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will know how to identify the major mental health conditions and needs of pediatric patients.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Describe the components of a Mental Status Examination (MSE).
  2. Explain Adverse Childhood Experiences (ACEs) and how they impact children/adolescents.
  3. List the risk factors of pediatric mental health disorders.
  4. Describe the purpose of screening tools for pediatric mental health.
  5. Identify the assessment, diagnosis, management, and treatment of anxiety disorders.
  6. Identify the assessment, diagnosis, management, and treatment of depressive disorders.
  7. Determine the methods of prevention for pediatric mental health conditions.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Alyssa King (Nurse Planner, DNP, APRN, CPNP-PC, CLC)

Introduction

Mental health in childhood consists of obtaining developmental milestones, emotional milestones, learning social skills, and adapting to situations when problems arise. It includes feeling good about oneself, creating, and sustaining healthy relationships with others, and being able to react and adapt as challenges present themselves (American Academy of Pediatrics [AAP], n.d.). Both physical and mental health affect how children act, think, and feel on the inside (American Psychological Association [APA], 2022a). Children who are mentally healthy maintain a positive quality of life and can function well in all settings: home, at school, and within their communities (Centers for Disease Control and Prevention [CDC], 2022a).

Mental disorders among children can be described as serious deviations in which children have historically behaved, learned, and dealt with their emotions (CDC, 2022a). Although many children go through periods of change that deviate from their "normal" behavior, persisting symptoms that interfere with their social functioning, academic performance, and home life may point toward a possible mental disorder (CDC, 2022a).

For adults with mental disorders, symptoms were often present, though sometimes not recognized or addressed, in their childhood or adolescence (National Institute of Health [NIH], 2019). Early identification, intervention, and treatment of mental health disorders are vital to ensuring that children are able to experience healthy growth both physically and developmentally (AAP, n.d.).

Public Health Emergency: Pediatric Mental Health

In October 2021, the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Children's Hospital Association (CHA) made a declaration of a national emergency in child and adolescent mental health (AAP-AACAP-CHA, 2021). This declaration mentioned the COVID-19 pandemic, inequities that result from structural racism, and the issue of racial justice itself as the main reasons for the soaring rates of mental health issues among children, adolescents, and families (AAP-AACAP-CHA, 2021). Prior to the pandemic, the rates of childhood mental health issues and suicide had already risen significantly between 2010 and 2020, with suicide becoming the second leading cause of death for young individuals ages 10 to 24 (AAP-AACAP-CHA, 2021). The pandemic has only worsened this crisis. As of the October 2021 declaration, more than 140,000 children in the United States had lost either a primary or secondary caregiver (AAP-AACAP-CHA, 2021). The United States has seen a substantial increase in the rates of pediatric depression, anxiety, loneliness, suicidality, and trauma (AAP-AACAP-CHA, 2021). The declaration was made with the intention of harnessing more awareness, educating about the need for improved access and quality of care in the pediatric mental health world, and to encourage policymakers and child and adolescent advocates in all areas of practice to fight for a list of priorities (AAP-AACAP-CHA, 2021). The recommendations that were made include (AAP-AACAP-CHA, 2021):

  • Addressing of challenges and increase access for psychiatric/mental health telemedicine services
  • Promotion of Trauma-Informed Care in all systems that serve children and families
  • Recruitment of underrepresented populations into mental health profession roles
  • Government funding for community-based behavioral health services
  • Development and strengthening of suicide prevention programs for children and adolescents
  • Expansion of acute care emergency room units to include stabilization units and/or step-down units to safely house and accommodate children and adolescents who present to the emergency rooms in mental health crises
  • Increasing federal funding specifically for mental health screening, diagnosis, and treatment for all children, adolescents, and families
  • Focusing on the importance of school-based mental health care
  • Encouraging renewed importance of primary care mental health services

As a result of this declaration, additional pediatric-focused organizations responded to this "call to action" with their own official statements about their own plans for mitigation moving forward. The National Association of Pediatric Nurse Practitioners (NAPNAP) also provided a statement calling on all pediatric nurse practitioners to ensure that each and every patient encounter with a child or adolescent includes a mental health status examination (National Association of Pediatric Nurse Practitioners [NAPNAP], 2021).

COVID-19 Impact on Pediatric Mental Health

The COVID-19 pandemic exposed and worsened the already quite prevalent pediatric mental health crisis globally (Dalabih et al., 2022).

Mental Health-Related Emergency Department Visit Statistics

The Centers for Disease Control and Prevention (CDC) published a Morbidity and Mortality Weekly Report (MMWR) in February 2022 that presented statistics on the pediatric emergency department visits that were associated with mental health conditions before and during COVID-19 (Radhakrishnan et al., 2022). According to this report, during the months of March to October 2020, among all emergency department visits, the number of mental health related visits increased by 24% among U.S. children ages 5 to 11 years and 31% for adolescents ages 12 to 17 years (Radhakrishnan et al., 2022). In addition, a recent meta-analysis concluded that 25% of children now experience clinically significant depressive symptoms (Korczak et al., 2022). It also reported that 20% of children experience clinically significant anxiety symptoms (Korczak et al., 2022).

Suicide Statistics

In regard to suicide, the Centers for Disease Control and Prevention reported a significant rise in 2021 in youth emergency department visits for suspected suicide attempts (Korczak et al., 2022). The CDC reported a 50.6% increase for girls and 3.7% increase for boys, compared with the rates from 2019 (Korczak et al., 2022). In addition, according to a national study regarding suicide, the number of children in the age group of 9-12 years who ingested some form of poisonous medication or substance in an effort to attempt suicide increased by 4.5 times from 2000 to 2020 compared to a 2.4-fold among the older adolescent age group (Sheridan et al., 2022).

Factors Associated with Pediatric Mental Health Crisis

What could all of this be in relation to? Upon the essential "shutdown" of the country and the world altogether, the lives of everyone, children and adolescents as well, were significantly impacted. With children and adolescents being in a critical stage of growth and development, they are and have been at an increased risk of negative mental health impacts (Samji et al., 2021). The following factors are attributed to being related to these aforementioned psychiatric statistics (Benton et al., 2022; Bussieres et al., 2021; Saggioro de Figueiredo et al., 2021):

  • Abrupt withdrawal from school
  • Lockdowns
  • Loss of structure
  • Social isolation
  • Parental neglect and/or abuse
  • Loss of community supports
  • Educational adaptations
  • The developmental level of a child not being able to understand pandemic/fear of pandemic
  • Decrease of unstructured play with peers (for socialization and brain development)
  • Increased screen time (concerns about language development long-term)
  • Lack of physical exercise being confined inside/not having recess/physical education at school
  • Absence of outdoor activities
  • Family financial distress
  • Parental stress due to layoffs or working from home
  • More time home alone with parents suffering from substance use or psychiatric disorders
  • Change in diet/unhealthy eating (some children get their most nutritious meals from school)
  • Increased domestic violence at home during lockdowns
  • Significant changes in sleep patterns/lack of sleep
  • Reinforced disparities in mental health burden for girls
  • Reinforced disparities in mental health burden in LGBTQIA+ youth
  • Reinforced disparities in mental health burden in racially and ethnically minoritized youth

Education During COVID-19

Children spend the majority of their childhoods in school. The reason for this is their inherent need for socialization, mental stimulation, physical activity, and structure integration in order to grow and develop properly. Because schools were forced to close, children were forced into social isolation with a new responsibility to learn from home. This requirement forced parents to home-school their children or assist them in their virtual schooling (Mahapatra & Sharma, 2020). This responsibility became an added burden for parents who were already grabbling with working from home, losing employment status, contributing to a financial crisis, and/or managing household chores and responsibilities (Mahapatra & Sharma, 2020). Depending on the child's developmental level, many younger children required more assistance in focusing, sitting still, focusing on their teacher, and getting their work done while having the distraction of the home environment readily available to them. Because of this, some children were not always able to stay on task and complete work, frustrating teachers who were trying to ensure that their students were ready for the next grade. Teachers and administrators had their own frustrations with teaching from home. Some topics/subjects are just meant to be learned in person. In addition, some teaching staff struggled with the technological requirements of the hastened virtual school process. That coupled with not always reliable cable or internet connections, there was only so much that all parties involved could do to ensure schoolwork and learning had been accomplished. These changes and added concerns lead to generalized frustration, anger, and burnout among caregivers, parents, teachers, and school administration (Mahapatra & Sharma, 2020).

Children with disabilities (CWD) were even more disadvantaged with the suspension of their vocational activities they had previously received in the schools (Mahapatra & Sharma, 2020). In addition, students in secondary and tertiary education settings dealt with their own major challenges and academic stress in relation to being able to graduate and/or having all of the skills and credits in order to do so (Mahapatra & Sharma, 2020). Children and adolescents also suffered from losing out on significant, long-awaited, coming-of-age events such as homecoming football games, prom, graduation festivities, and graduation ceremonies.

Long-Term COVID-19 Effects

The immediate effects of the COVID-19 pandemic on children and adolescents are scary and significant. However, the long-term effects, some of which we do not even know about yet, have the potential to be even more devastating without urgent action (Benton et al., 2022). One such recommended action is that of a systematic response that considers how historically marginalized populations of children/adolescents are affected differently by the pandemic, especially in terms of issues in accessing mental health services and/or virtual care, and what can be done to intervene and work to eliminate their barriers to care (Benton et al., 2022).

The great news is that much can be done to screen, manage, and treat pediatric mental health disorders. The major challenge is ensuring access to this care is available to all children and adolescents who need it (Benton et al., 2022).

One of the most important things we all can do to help mitigate the pediatric mental health national emergency is by educating ourselves about what to look out for. The next section of this course will go over the elements of a Mental Status Examination for a child/adolescent.

Mental Status Examination

Image 1: Mental Status Exam

photo of medical professional administering a mental status exam

A Mental Status Examination, or MSE, is an important part of a pediatric mental health evaluation. It is crucial that the patient's age and developmental level are considered when results from the MSE are interpreted (The Royal Children's Hospital Melbourne [RCH], 2018). The MSE is utilized to gain a thorough understanding of the patient's current state of psychological functioning in order to dictate the next step in this patient's care.

An MSE consists of (RCH, 2018):

  1. Appearance & Behavior:
    1. Physical appearance
    2. How does the child relates with parents and healthcare professional
    3. Activity level
  2. Speech
  3. Mood
  4. Affect
  5. Thought Processes:
    1. Speed of thought
    2. Form of thoughts
    3. Content of thoughts
  6. Perception
  7. Cognition:
    1. Level of consciousness
    2. General orientation
    3. Attention
    4. Memory
    5. Abilities
  8. Insight & Judgement

We will now review each of these components of the MSE in greater detail.

Appearance & Behavior

When assessing a child/adolescent in this domain, first consider their physical appearance. Questions to ask yourself include (RCH, 2018):

  • What gender are they?
  • What ethnicity are they?
  • How old are they?
  • What about their current level of cleanliness and grooming?
  • Is their current hair/clothing/makeup style kempt or unkempt?
  • Do they have any syndromic-type features?

Then, consider how the child is interacting with both their parents and you, the healthcare professional (RCH, 2018):

  • Are they making eye contact with you?
  • Are they making facial expressions?
  • Do they seem to be reacting to you in an overfamiliar way or showing defiance?
  • With adolescents, are they able to be easily separated from their parents when you desire to have a private discussion with just them?

As far as the child/adolescent's activity level, consider the following (RCH, 2018):

  • How is their overall coordination, that you are able to assess?
  • Do they appear to have a psychomotor agitation or slowing?
  • How is their posture?
  • Are they exhibiting any motor patterns such as tics, tremors, or other odd mannerisms?

Speech

When assessing speech as part of the MSE, take note of how fast they are talking, the fluency of their words, the volume of words, and their overall tone (RCH, 2018). For children/adolescents who are mute, take note of that too.

Mood

Assess the child/adolescent's general overall mood at this time. Do they appear happy, sad, angry, dysphoric, apprehensive, euphoric, or euthymic (not happy nor sad) (RCH, 2018)?

Affect

When assessing for their affect, you are looking for their current emotional state (RCH, 2018). Affect is displayed in emotional responses such as facial or vocal expressions (laughing), energy levels, and body movements (Drury, 2022). Take note if their affect seems to be congruent or incongruent with their mood, meaning the child/adolescent's affect does not match their mood. Mood/affect incongruence points to possibly negative sequelae.

Types of Affect include (Drury, 2022):

  1. Broad Affect= The normal response; A person having a wide range of emotions and reacting appropriately to both sad and happy situations.
  2. Restricted Affect= Dulled feelings or emotions, but still close to broad affect in their reaction to most circumstances.
  3. Blunted Affect= Emotions or expressions are less reactive than average.
  4. Flat Affect= This is a complete lack of expression, feeling, or emotion.
  5. Labile Affect= This is when a child/adolescent's expressions shift frequently and unpredictably.

Thought Processes

While assessing a child/adolescent's thought processes, first consider the speed of their thoughts (RCH, 2018):

  • Do they appear to have "poverty of thought" where they are talking and then suddenly stop for no reason?
  • Do they have "poverty of content" where they are talking plenty, but they really are not saying anything of value or saying way too much past making a point?
  • Do they seem to have racing thoughts?
  • Are they jumping from one topic or thought to another (flight of ideas)?

As far as thought processes form, are their thoughts logical and goal-directed? Or are they disordered, providing too much detail, not enough detail, or simply a jumble of words together that are not making any sense (word salad) (RCH, 2018)?

In reference to the content of their thoughts, is it easy to understand and straightforward? Or are their thoughts composed of obsessions, delusions, phobias, magical thinking, or thoughts of harm to themselves or others (RCH, 2018).

Perception

In terms of the child/adolescent's perception, are they possibly experiencing/describing altered bodily experiences such as depersonalization (their thoughts feel as if they are not theirs/ they feel like they are observing themselves outside of their body), illusions (distortion of the senses), or hallucinations (visual, auditory, tactile, or olfactory experiences that are not real) (RCH, 2018)?

Cognition

When assessing the child/adolescent's cognition, first ask what their current level of consciousness is (alert, drowsy, delirium) (RCH, 2018).

Then, as far as their orientation, do they know who they are, where they are, and what the date is?

For their attention, are they able to focus on their conversation with you, or are they needing to be constantly redirected and highly distractable?

Regarding memory, are their immediate, short-term, and long-term memories intact?

For abilities, depending on their developmental level, do they have the appropriate level of higher thinking for their age (concrete to abstract understanding)?

Insight & Judgement

In reference to what you have assessed thus far, does the child/adolescent have "insight" or know about the current mental health deviations they might be experiencing (RCH, 2018)? Insight can range from being perfectly intact to partial or poor. Are they acknowledging there might be something wrong?

Judgement consists of the child/adolescent's problem-solving abilities in the context of their current psychological state (RCH, 2018). How is their decision-making in regard to their current mental status? Judgement can range from intact to impaired.

After conducting an MSE, you are then able to decide if this child/adolescent is in need of additional psychiatric services. When abnormal components are assessed and noted during the MSE, the child/adolescent should be referred to a mental health clinician (RCH, 2018). In the event that the results of the MSE point to a risk of immediate risk of harm to self or others or the presence of an acutely psychotic/agitated patient, immediate consultation with a mental health clinician should occur (RCH, 2018).

Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences, or ACEs, include events that are potentially traumatic. These events are those that occur from birth through about 17 years of age (CDC, 2022b).

ACEs can include all the following situations as listed in the following image:

graphic showing the adverse childhood experiences situations

This list, however, is not fully inclusive. Additional examples of ACEs include (CDC, 2022b; Integrative Life Center, 2021):

  • Experiencing violence or neglect
  • Experiencing physical, sexual, or emotional abuse
  • Witnessing violence occurring in the community
  • Having a family member attempt or die by suicide
  • Having a family member who has a mental health problem
  • Experiencing divorce/custody battles

ACEs Study

These ACEs have been shown to impact child/adolescents functioning, physical and mental health, and overall well-being (CDC, 2022b). These affects can be seen well into adulthood. In fact, the very first ACE study was conducted by the CDC and Kaiser Permanente from 1995 to 1997 (National Conference of State Legislatures [NCSL], 2021). Of the more than 17,000 adults surveyed about childhood experiences (including emotional, physical, and sexual abuse, neglect, and household dysfunctions of separation from a parent, substance use disorder, incarceration, violence, and/or mental illness), approximately two-thirds of respondents indicated a history of at least one ACE and more than 20% noted three or more (NCSL, 2021). As a result of this study, researchers identified a relationship between ACE exposure and an increased likelihood of negative behavioral effects and health issues, including heart disease and diabetes (NCSL, 2021). Since this original study, additional ACEs have been added to include familial death, economic hardship, unfair treatment due to race or ethnicity, and neighborhood violence (NCSL, 2021).

What are the Consequences of Exposure to ACEs?

As mentioned above, exposure to ACEs has been correlated with increased risk for certain behavioral issues and health conditions. Additional research has determined that ACE exposure increases a child's risk of obesity, autoimmune diseases, depression, and substance use disorders (NCSL, 2021).

A direct correlation has been noted:

The more ACEs one is exposed to, the greater the risk for negative effects.

But why? The underlying mechanism here is associated with the "toxic stress" that ACEs are said to exert their effects on health as well as growth and development (NCSL, 2021). Although some stress is normal and even essential to proper growth and learning, sustained chronic, toxic stress is damaging to both the body and to the brain (NCSL, 2021). This toxic stress can literally build up in the body, interfere with proper neural, hormonal, and immune development and ultimately alter DNA expression (NCSL, 2021). This change in DNA expression can result in lifelong effects on behavior, attention, decision-making abilities, and one's response to stress (NCSL, 2021).

How Can We Prevent the Effects of ACEs?

Because ACEs can have lifelong negative implications on the health and overall well-being of a child or adolescent, it is important that we do what can be done to prevent them and/or mitigate them once they have occurred.

The following strategies for prevention and mitigation have been presented by the National Conference of State Legislatures (2018) report after reviewing an extensive number of publications in the research done following the original ACE study (Bellazaire, 2018):

  • Achieving strong physical health: Obtaining adequate sleep, eating well, and participating in regular exercise.
  • Building resilience: Increasing positive parenting skills and creating safe, stable relationships in the home.
  • Incorporation of home visits: State-employed nurses, social workers, and teachers trained to visit family homes during pregnancy and early childhood to teach and provide support services.
  • Offering early childcare services: Expanding access to early childhood programs to bolster learning, social and emotional development, and the building of self-confidence.
  • Supporting the reduction of parental stress: Consider providing economic support, family-friendly workplaces, paid family and/or sick leave, and affordable housing.
  • Increasing mental health screening and treatment: Expand access to and coverage for comprehensive health and mental health services.

The CDC outlines these additional strategies for preventing ACEs altogether (CDC, 2022b):

Promoting social norms: Advertising public education campaigns, legislative approaches, and bystander approaches to teach and inform in a manner that helps to protect against violence and adversity.

  • Teaching vital skills: Prioritizing social-emotional learning, safe dating, healthy relationship building, family relationships, mentoring programs, and after-school programs.
  • Intervening early and often: Engaging children in primary care, family therapy when needed, individual therapy when needed, and family-centered treatment for households with someone suffering from a substance use disorder.

It is important to continue to raise awareness of ACEs to help either prevent them or work to prevent the long-term sequelae that result without adequate intervention (CDC, 2022b). The focus needs to be taken off the individual and, more so, shifted onto the community to help lessen the risk of ACEs and their effects. The more children and adolescents are able to reach their full potential, the more the communities these future adults will live in will benefit (CDC, 2022b).

Risk Factors

Mental health issues have officially surpassed those of a physical nature (asthma, diabetes) in children and adolescents (Melnyk & Lusk, 2022). This increased incidence is due to (Melnyk & Lusk, 2022):

  • Family dysfunction
  • Mental health stigma
  • Access to care for mental health services
  • Lack of screening
  • Genetics
  • Insufficient number of mental health professionals
  • The COVID-19 pandemic

The risk factors for mental health disorders in children and adolescents include (Melnyk & Lusk, 2022):

  • Poor self-esteem
  • Lack of coping skills
  • Learning disabilities/poor grades
  • Adverse Childhood Experiences (ACEs)
  • Social isolation
  • Bullying
  • LGBTQIA+ identification
  • Substance use
  • Behavior issues
  • Stressful home environment
  • Inconsistent caregivers
  • Parents with mental health disorders
  • Parental conflict (divorce, separation, abuse)
  • Altered parenting (controlling, avoidant, over-protective)

Substantial health disparities also exist, disproportionately affecting Hispanic and African American children (Melnyk & Lusk, 2022).

Screening Tools

Both early detection and appropriate evidence-based intervention are vital for children and adolescents with mental health conditions (Melnyk & Lusk, 2022). Each and every face-to-face meeting with a child or adolescent is an excellent opportunity to assess and screen for a possible mental health condition (Melnyk & Lusk, 2022). While screening tools are extremely useful in identifying the "red flags," it is important to note that no screening tool should replace a developmentally appropriate and comprehensive clinical evaluation (Melnyk & Lusk, 2022).

Most screening tools come in the form of questionnaires meant to assist us in collecting information from our patients and their parents. These questionnaires can be completed in the waiting room while families are waiting to see their provider or even during an appointment if things are discussed with the provider that would elicit a need for deeper evaluation. Many screening tools are available in multiple languages, namely Spanish. Once these questionnaires are completed, the healthcare professional is able to review the answers, calculate a final "total" or "score," and then assess that score against the key of that particular screening tool. The results of the screening tool are then able to guide the provider in what additional steps to take, if any are necessary. These steps can include referring to a higher level of care, prioritizing therapy, the need for pharmacological intervention, or a "watch and wait" approach that would include follow-up in the future for at-risk behaviors (Melnyk & Lusk, 2022).

While this list is not fully inclusive due to the sheer magnitude of screening tools available, here are several examples of screening tools/questionnaires that are commonly used with children and adolescents to assess for mental health concerns (Melnyk & Lusk, 2022):

  • Pediatric Symptom Checklist by Jellinek & Murphy (General mental health)
  • Home, Education, Activities, Drugs, Sexuality, and Suicide/Depression Assessment (HEADSS) by Goldrenring & Cohen (General mental health)
  • KySS Assessment Questions for Parents by Melnyk & Lusk (of older infants and toddlers, of preschool children, of school-age children and teens) (General mental health)
  • Guidelines for Adolescent Preventative Services (GAPS) by the National Association of Pediatric Nurse Practitioners (NAPNAP) (General mental health guidelines assessment)
  • Generalized Anxiety Disorder-7 (GAD-7) (Generalized Anxiety Disorder)
  • Patient Health Questionnaire-9 (PHQ-9) Modified for Teens (Adolescent Depression)
  • Patient Health Questionnaire-2 (PHQ-2) (Depression)
  • The Ask Suicide Questions (ASQ) Tool (Suicide risk)

Diagnosing Mental Health Disorders

A reliable diagnosis of mental health disorders is crucial in guiding the proper evidence-based treatment for pediatric patients (Melnyk & Lusk, 2022). Pediatric mental health conditions are diagnosed with the same source utilized for adults. This valuable and fully inclusive diagnostic criteria tool is the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5). This manual recently (March 2022) saw its' most recent update, now the DSM-5-TR. The DSM-5-TR was written with the involvement of over 200 experts in the field by the American Psychiatric Association (APA) (American Psychological Association [APA], 2022b). Integrated diagnostic criteria include symptoms, time frames of symptoms, behaviors, cognitive functions, personality traits, physical signs, prevalence, risk and prognostic factors, differential diagnoses, and comorbidities (APA, 2022c; Melnyk & Lusk, 2022). The important thing to remember is that in order for a condition to be a diagnosed disorder within the DSM-5-TR, the issue must result in an alteration in the child/adolescent's ability to function properly and cause distress.

Also included in the DSM-5-TR are International Classification of Diseases (ICD)-10 codes for assigning diagnoses (Melnyk & Lusk, 2022). Some of the most common ICD-10 codes and diagnoses for the child and adolescent population include (APA, 2022c; Melnyk & Lusk, 2022):

  • F41.9 → Anxiety state: unspecified
  • F41.1 → Generalized anxiety disorder
  • F48.9 → Suicide ideation
  • F33.0 → Major depressive disorder, recurrent mild
  • F31 → Bipolar disorder, unspecified
  • F43.22 → Adjustment disorder with anxious mood
  • F43.10 → Post-traumatic stress disorder, unspecified
  • F90.0 → Attention deficit hyperactivity disorder, inattentive
  • F90.2 → Attention deficit hyperactivity disorder, combined type
  • F84.0 → Autism
  • F99 → Mental disorder, not otherwise specified

It is vital that caution is taken when diagnosing a child or adolescent with a psychiatric disorder (Melnyk & Lusk, 2022). Stigma and labeling can create additional issues and bothersome burdens on families, especially if the diagnosis is incorrect (Melnyk & Lusk, 2022). On the other hand, making a timely diagnosis is also able to assist families in getting the support they need to begin the process of getting their child the appropriate access to comprehensive interventions in hopes of obtaining more positive outcomes long-term (Melnyk & Lusk, 2022).

Very specific to pediatrics is the reality that feedback from multiple sources will be solicited in order to fully assess the child or adolescent (Melnyk & Lusk, 2022). These additional sources can include parents, babysitters, teachers, or daycare staff (Melnyk & Lusk, 2022).

Because of the sheer number of pediatric mental health diagnoses, this course will focus on the disorder areas that are currently most prevalent and most commonly seen in light of the pediatric mental health national crisis.

Anxiety Disorders

Anxiety disorders are the most common mental health issues in children and adolescents (Melnyk & Lusk, 2022). While some level of worry and anxiety is essential for proper growth and development, too much can be detrimental (Melnyk & Lusk, 2022). Children and adolescents who suffer with anxiety disorders experience anxiety that interferes with their daily functioning, generally both at school and at home (Melnyk & Lusk, 2022). Anxiety disorders can ultimately impact the child's cognition, ability to regulate their emotions, and their overall behavior as well (Melnyk & Lusk, 2022). It is recommended that anxiety disorders be screened for at every well-child visit (Melnyk & Lusk, 2022). The important thing to remember, as mentioned above, is that in order for something to be a diagnosed disorder within the DSM-5-TR, the issue must result in an alteration in the child/adolescent's ability to function properly and cause distress.

Common Diagnoses

Common anxiety-related disorders include (APA, 2022c; Melnyk & Lusk, 2022):

  1. Separation Anxiety Disorder:
    1. Non-developmentally appropriate excessive fear related to separating from individuals to which the child/adolescent is attached
  2. Social Anxiety Disorder:
    1. Fear associated with social or performance activities
  3. Panic Disorder:
    1. Recurrent, unexpected panic attacks (racing heart, chest pain, shaking, shortness of breath, nausea, stomachache, feeling a loss of control)
  4. Generalized Anxiety Disorder (GAD):
    1. Excessive worry in a variety of settings lasting for at least 6 months
  5. Obsessive-Compulsive Disorder (OCD):
    1. The presence of obsessions (unwanted thoughts) and compulsions (actions that are repetitive that help the individual to lower their anxiety; ex. Handwashing, checking locks on doors, counting)

Assessment

It is important to be able to recognize the signs of anxiety/stress in children and adolescents. Often, when anxiety is severe, children and adolescents can show regressive behaviors (Melnyk & Lusk, 2022). Regressive behavior is when children show signs of an earlier stage of development. For example, a preschool-aged child could start sucking their thumb again when they have not done so in a while. The action of regression takes place because these behaviors are a source of comfort and security that worked for them in the past.

Other signs of anxiety in younger children include (Melnyk & Lusk, 2022):

  • Temper tantrums
  • Distress around new people
  • Difficulty separating from parents/caregivers
  • Nightmares
  • Restlessness
  • Clinging behaviors

Signs of anxiety in older children include (Melnyk & Lusk, 2022):

  • Issues concentrating in school
  • Sleeping problems
  • Restlessness
  • Constant worrying
  • Physical complaints (stomachache, headache)
  • Avoidance of school/activities
  • Anger

When assessing for an anxiety disorder, it is helpful to ask questions like the following (Melnyk & Lusk, 2022):

  • Is there any family history of anxiety disorders within your family?
  • What impact do the anxiety symptoms have on the child's functioning (ability to go to school, grades, participate in curricular activities, sleep, appetite)?
  • What situations bring the anxiety on?
  • What helps to relieve the anxiety?
  • How is home-life?
  • What is your relationship like with your child?
  • How long have these symptoms been around?
  • Has your child experienced any traumatic events?
  • Describe the severity of the anxiety experienced.

Screening Tools

As mentioned above, the most common screening tool for Generalized Anxiety Disorders in children and adolescents is that of the Generalized Anxiety Disorder-7 (GAD-7). This tool is a self-assessment questionnaire that has 7 items, measuring the severity of those 7 items depending on how often they occur. This tool is available in the public domain, so no permission is required to reproduce or distribute it (Melnyk & Lusk, 2022).

The GAD-7 is available below:

Generalized Anziety Disorder 7-item (GAD-7) scale
Over the last 2 weeks, how often have you been bothered by the following problems?Not at all sureSeveral daysOver half the daysNearly every day
1. Feeling nervous, anxious, or on edge0123
2. Not being able to stop or control worrying0123
3. Worrying too much about different things0123
4. Trouble relaxing0123
5. Being so restless that it's hard to sit still0123
6. Becoming easily annoyed or irritable0123
7. Feeling afraid as if something awful might happen0123
Add the score of reach column++++
Total Score (add your column scores) =

When scoring the GAD-7:

  • 0-5= Mild Anxiety
  • 6-10= Moderate Anxiety
  • 11-15= Severe Anxiety

Any score of 10 or greater warrants further evaluation.

Other screening tools for anxiety disorders in children and adolescents include (Melnyk & Lusk, 2022; Rapp et al., 2016):

  • Screen for Child Anxiety Related Disorders (SCARED)
  • The State-Trait Anxiety Inventory for Children (STAIC)
  • KySS Worries Questionnaire
  • Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)

Management

Management of anxiety disorders includes regular screening, thorough assessment, and comprehensive evaluation in order to diagnose clinically significant anxiety as early as possible (Melnyk & Lusk, 2022).

The following are management tools that are commonly used and recommended to treat and manage anxiety disorders in children and adolescents (Melnyk & Lusk, 2022):

  • Promote good sleep hygiene (bedtime at the same time each night, "wind-down" routine, no caffeine or electronics before bed, avoid a television being in the child/adolescent's bedroom)
  • Encourage daily exercise
  • Maintain a daily routine with as much structure as possible
  • Encourage the consumption of healthy foods in all food groups
  • Determine stressors and work to either lessen or eliminate them
  • Cognitive-Behavioral Therapy (CBT)
  • Psychotherapy/Talk therapy
  • Limit caffeine
  • Work on coping skills (breathing exercises, mindfulness, meditation, positive self-talk, listening to music, journaling)
  • Family interventions, if needed (talk to parents about their own anxieties, refer them for their own psychiatric support if needed)
  • For young children, only provide answers to questions they are asking and do not overwhelm them with detail
  • Avoid exposure to scary images or news broadcasts for young children
  • Share developmentally-appropriate explanations to children when stressful events occur
  • Provide/encourage pharmacological intervention for moderate to severe anxiety

Pharmacological Treatment for Anxiety Disorders in Children/Adolescents

In cases in which anxiety is severe or not being fully managed with psychotherapy and other management techniques, it is beneficial to add in a form of pharmacological therapy (Melnyk & Lusk, 2022). The first-line treatment for anxiety disorders in children and adolescents is Selective Serotonin Reuptake Inhibitors (SSRIs). Although known for their anti-depressant use, SSRIs are quite effective in treating anxiety in children and adolescents (Melnyk & Lusk, 2022). SSRIs work by blocking the reuptake of serotonin, allowing for higher levels of serotonin, the mood neurotransmitter, to be in the brain (Melnyk & Lusk, 2022). When this happens, symptoms of anxiety lessen.

SSRIs are non-addictive and well-tolerated among this population (Melnyk & Lusk, 2022). Examples include Citalopram (Celexa®), Escitalopram (Lexapro®), Fluoxetine (Prozac®), Paroxetine (Paxil®), and Sertraline (Zoloft®) (Melnyk & Lusk, 2022). The most common side effects to explain to families and to watch for include upset stomach or nausea. These occur because one of the main sites of serotonin receptors is in the stomach. When serotonin levels increase in the brain, they also increase in the stomach. These side effects generally subside within the first few days once the body acclimates to higher levels of serotonin in the gut. It is important to note that SSRIs do contain a "Black Box Warning" of the possibility of suicidal ideation (Melnyk & Lusk, 2022). In addition, it is important to teach patients and families that SSRIs do not immediately stop or reduce symptoms. It is a gradual process as serotonin levels increase, which often takes between 4 to 6 weeks.

In the event SSRIs are not successful in mitigating symptoms, second-line options include Venlafaxine (Effexor) and benzodiazepines (Melnyk & Lusk, 2022). A non-benzodiazepine, Buspirone (Buspar), is also available as a first-line treatment for Generalized Anxiety Disorder in children and adolescents (Melnyk & Lusk, 2022).

Depressive Disorders

Depressive disorders affect 5% of children and between 10 to 20% of adolescents, more commonly in females (3 times as often as in males) (Melnyk & Lusk, 2022). It is estimated that about 40 to 70% of children and adolescents who have depression also have other mental health comorbidities (anxiety disorders, substance use, attention deficit hyperactivity disorder [ADHD], and conduct disorders) (Melnyk & Lusk, 2022).

Common Diagnoses

A common feature of depressive disorders is the presence of sad or irritable mood, which is also associated with physical and cognitive changes that interfere with normal functioning of the child or adolescent (Melnyk & Lusk, 2022).

Common depression-related disorders include (APA, 2022c):

  1. Major Depressive Disorder (MDD):
    1. Symptoms listed above as well as loss of interest in activities, weight loss or gain, increased or decreased appetite, increased or decreased need for sleep, fatigue, feelings of guilt, worthlessness, and/or helplessness, thoughts of death and/or suicide
    2. Symptoms for at least 2 consecutive weeks
  2. Persistent Depressive Disorder (Dysthymia):
    1. Persistent depressive symptoms for at least a year
  3. Disruptive Mood Dysregulation Disorder:
    1. The presence of recurrent, severe temper tantrums, verbal or behavioral, that are not proportionate to the situation at hand.
    2. ≥ 3 outbursts per week for ≥ 1 year

Assessment

The presentation of depressive signs and symptoms varies with the age of the child.

The following are signs/symptoms of depressive disorders among infants (Melnyk & Lusk, 2022):

  • Issues with feedings
  • Lack of eye contact
  • Irritability
  • Sleep issues
  • Apathy

The following are signs/symptoms of depressive disorders among toddlers and preschool-age children (Melnyk & Lusk, 2022):

  • Excessive number and severity of tantrums
  • Behavioral issues at home and/or school
  • Aggressive tendencies
  • Irritability
  • Regressive behaviors

The following are signs/symptoms of depressive disorders among school-age children (Melnyk & Lusk, 2022):

  • Impulsivity
  • Anhedonia (loss of pleasure in things once loved)
  • Sleep issues
  • Sadness
  • Irritability
  • Physical complaints (stomachache, headache)
  • Acting out in school

The following are signs/symptoms of depressive disorders among adolescents (Melnyk & Lusk, 2022):

  • Sadness
  • Anger
  • Withdrawn behavior
  • Anhedonia
  • Self-hatred
  • Sleep issues
  • Appetite changes
  • Inability to concentrate
  • Substance use

Screening Tools

The most common screening tool for depression in children aged 13 and older is the Patient Health Questionnaire-9 (PHQ-9) Modified for Teens (Melnyk & Lusk, 2022). This questionnaire is composed of 9 questions and is directly based on the DSM-5 diagnostic criteria for depression (Melnyk & Lusk, 2022). This tool is available in the public domain, so no permission is required to reproduce or distribute it (Melnyk & Lusk, 2022).

The main components of the PHQ-9 Modified for Teens that ask questions according to the diagnostic criteria of depression and are modified in a way best understood by adolescents include symptom evaluation of mood, pleasure in doing things, sleep, appetite, energy levels, concentration, and thoughts of hurting oneself (Johnson et al., 2002; Melnyk & Lusk, 2022).

The directions of this modified PHQ-9 have the adolescent answer each question with either: (0) Not at all, (1) Several days, (2) More than half the days, or (3) Nearly every day when considering the past two weeks.

When scoring the PHQ-9 Modified for Teens:

  • 0-4= No or Minimal Depression
  • 5-9= Mild Depression
  • 10-14= Moderate Depression
  • 15-19= Moderately Severe Depression
  • 20-27= Severe Depression

All positive answers to the final question regarding suicide must be followed by a clinical evaluation as soon as possible. An italicized disclaimer is made at the bottom of the questionnaire that tells the adolescent that if they are having thoughts of feeling that things would be better off if they were no longer alive or if they are having thoughts of hurting themselves, they should tell their doctor, go to a hospital emergency room, or call 911 immediately (Johnson et al., 2002; Melnyk & Lusk, 2022).

Other screening tools for depressive disorders in children and adolescents include (Melnyk & Lusk, 2022):

  • The Center for Epidemiological Studies Depression Scale (CES-DC) for Children
  • The Patient Health Questionnaire-2 (PHQ-2)

Management

The most important part of a depression evaluation is assessing for suicidal ideation (Melnyk & Lusk, 2022). A child or adolescent having current suicidal ideation must be immediately evaluated and stabilized before anything else is done.

The current recommendations for the management of depressive disorders in children and adolescents are (Melnyk & Lusk, 2022):

  • Families must be educated and counseled about depression and the treatment options.
  • Children and adolescents should be told that if they disclose plans of hurting themselves, their parents will legally need to be notified.
  • Families and the medical team must come up with a plan of treatment for the child/adolescent with specific and measurable goals.
  • A safety plan must be developed (emergency communication in the event of needing a crisis, putting away guns/knives/sharp objects/medications safely away from child/adolescent).
  • Psychotherapy/talk therapy.
  • Encourage exercise, healthy diet.
  • Cognitive-Behavioral Therapy (CBT).
  • Psychopharmacological agents as needed.

Pharmacological Treatment for Depressive Disorders in Children/Adolescents

Pharmacological intervention for depressive disorders, namely anti-depressants, should be reserved for moderate to severe depression (Melnyk & Lusk, 2022). These are most helpful when taken in conjunction with psychotherapy/CBT with a therapist (Melnyk & Lusk, 2022).

According to past research, 50 to 60% of children and adolescents who suffer from depression have a positive response to anti-depressants (Riddle, 2019). Just as with anxiety disorders, SSRIs are the first-line treatment for depressive disorders. Therefore, the same information about these medications provided above applies here as well.

Suicidal Ideation

For any child or adolescent who screens positive for depression or has made self-harming comments should also be evaluated for suicidal ideation (Melnyk & Lusk, 2022).

When assessing for suicidal ideation, make sure to ALWAYS ask (Melnyk & Lusk, 2022):

  • Have you been having suicidal thoughts/thoughts about hurting yourself?
  • Have you ever tried to kill yourself?
  • Are you having feelings about wanting to kill yourself right now?
  • How long have you felt this way?
  • Do you have a plan for ending your life?
  • Do you have intent to act out your plan?

The suicide warning signs include (Melnyk & Lusk, 2022):

  • Change in behavior
  • Giving away personal affects
  • Having no hope for the future
  • Being preoccupied with the thought of death
  • Major life changes/crises

After asking questions like the ones above, low risk children/adolescents are those that are not currently/actively having suicidal thoughts. If they have in the past, are having passive suicidal thoughts (often think about just not wanting to wake up, wanting to be hit by a car, etc.), or are struggling with on/off suicidal thoughts but without a current plan and intent, these children/adolescents require the mobilization of social supports, a psychiatric evaluation, and the development of a safety plan, if one is not already drafted. For children/adolescents who are currently having suicidal ideation or have a plan and/or possible intent to follow-through, they are considered high risk. High risk patients necessitate a call to a national crisis line, a call to 911, and/or direct transportation to an emergency department (Melnyk & Lusk, 2022). Depending on the child/adolescent's current condition, other options include outpatient counseling, inpatient hospitalization, or residential programs for short-term stays (Melnyk & Lusk, 2022).

The National Suicide Lifeline number was recently (July 2022) updated to be a shorter, easier-to-remember number. For any child or adolescent with depression and/or a history of suicidal ideation (or for any adults as well, it is vital that the following information is shared with them and their families:

24/7 Suicide and Crisis Lifeline: Call or Text "988"

It is also helpful to become familiar with the other options of outreach in your area to share with children/adolescents and their families.

Evidence-Based Interventions

Depending on the specific mental health condition, certain evidence-based interventions are available for treating and managing pediatric mental health diagnoses. With the assistance of screening tools, the pediatric mental health clinical team can decide which routes are the most beneficial for each specific child or adolescent. While many medications are available and FDA-approved for use in children and adolescents for specific conditions, medication alone is not usually completely effective in treating a mental health disorder (Melnyk & Lusk, 2022). What is recommended is often a trial of psychotherapy first. Then if medication is desired to be added to the treatment regimen, a combination of medication and therapy/counseling is what has been shown to lead to the best outcomes (Melnyk & Lusk, 2022).

For psychopharmacology, the general rule is that of "Start Low, Go Slow" (Melnyk & Lusk, 2022). It is also important to note that providers without in-depth psychopharmacology education and training should be very careful about prescribing any medications specifically for mental health disorders in children and adolescents (Melnyk & Lusk, 2022). Evidence-based management guidelines are available to be used for those in primary care. A great psychopharmacology textbook source is Riddle's 2019 Pediatric Psychopharmacology for Primary Care (2nd edition), developed by the American Academy of Pediatrics. Consultation with or referral to a child psychologist or a psychiatric-mental health nurse practitioner is always a good idea in times of uncertainty.

LGBTQIA+ Children/Adolescents

Lesbian, gay, bisexual, trans, queer or questioning, intersex, asexual, and other identities of gender and sexuality (LGBTQIA+) children and adolescents are at a significantly increased risk of mental health disorders as compared to their heterosexual, endosex (non-intersex), and cisgender (non-trans) peers (Finlay-Jones et al., 2021). Because of societal stressors and pressures, stigma, discrimination, and marginalization, LGBTQIA+ children and adolescents often suffer from a full range of mental health issues (Finlay-Jones et al., 2021). In addition, individuals who identify as LGBTQIA+ often face barriers to accessing health care services, including mental health services (Finlay-Jones et al., 2021). In fact, recent studies have found that 60% of trans and gender-diverse individuals felt detached from mainstream medical and mental health services (Finlay-Jones et al., 2021). Research has also shown that LGBTQIA+ children and adolescents consider suicide at a higher rate than heterosexual children and adolescents (Kuper, 2022).

The Trevor Project is a national survey on LGBTQ youth mental health. It was conducted to identify the exclusive challenges that LGBTQIA+ children and adolescents routinely face (Kuper, 2022). The results of this survey in 2020 included (The Trevor Project, 2020):

  • 40% of LGBTQ individuals considered attempting suicide
  • 68% of LGBTQ individuals reported symptoms of Generalized Anxiety Disorder
  • 48% of LGBTQ individuals stated that they engaged in self-harm
  • 46% of LGBTQ individuals desired to seek mental health services that they had been unable to yet secure
  • 29% of LGBTQ individuals have either been kicked out or ran away, experiencing homelessness
  • 33% of LGBTQ individuals have reported that they have been physically threatened or harmed due to their gender/sexual identity

LGBTQIA+ youth desire to be seen, heard, and affirmed (Kuper, 2022). When they feel comfortable talking to their families and friends, they are able to be themselves. When they are able to be themselves, the anxieties that surround their personal identities are able to be reduced.

How Can We Support LGBTQIA+ Children/Adolescents?

Offering your time and your willingness to listen is incredibly valuable. Your acceptance and validation can really make a difference in these children's and adolescents' lives. As a matter of fact, The Trevor Project determined that having support from anyone (family, friend, or even a special third-party person) can reduce suicide attempts from 22% to 13% (The Trevor Project, 2020).

A few strategies for supporting the mental health of LGBTQIA+ children and adolescents are (Kuper, 2020):

  • Educate yourself: It sends a positive message to LGBTQIA+ youth that you care if you are trying to learn more to understand.
  • Keep communication open: Let the child/adolescent know that you are always there to listen to them when they need you.
  • Demonstrate support: It is not "just a phase". Utilize their preferred pronouns and encourage them to share their identity when they are ready.
  • Community resources: Learn what the community resources are in your area and refer LGBTQIA+ individuals who require those services as needed.
  • Mental health professional assistance: If a child or adolescent is showing signs of a mental health disorder such as anxiety or depression, encourage them to see a mental health professional.

LGBTQIA+ are normal variations of human sexuality and identity. They are NOT mental health disorders. Affirming the normalcy of personal identities is one of the best actions friends, family, school personnel, and community leaders can take to work to improve the mental health of this pediatric population (Delphin-Rittmon, 2022).

Bullying

Bullying is defined as intentional and repetitive aggressive behaviors towards another person in which there is a real or perceived power imbalance present (Man et al., 2022). Forms of bullying include physical violence, verbal bullying, or cyberbullying (electronic bullying on forms of social media).

According to the most recent United States' High School Youth Risk Behavior Survey (YRBS) in 2019, 15.7% of students said that they were electronically bullied via either texting or other forms of social media. In addition, 19.5% of students said they were bullied on school property (CDC, 2020).

Children and adolescents who are bullied tend to be those who (Pigozi & Bartoli, 2016):

  • Are physically smaller than the aggressors
  • Have physical differences
  • Have developmental disabilities
  • Have intellectual disabilities
  • Have emotional disabilities
  • Demonstrate signs of low self-esteem
  • Demonstrate signs of low overall self-confidence

For decades bullying has been dismissed as a normal part of growing up. In the past, it was regarded without long-term effects (National Association of School Nurses [NASN], 2018). Research over the past few years has led to a more well-versed understanding of the very serious, life-long consequences that bullying can cause (NASN, 2018).

Common short-term signs and possible long-term chronic consequences of bullying in children and adolescents include (Edi Putra & Dendup, 2022; Sigurdson, 2019; Earnshaw et al., 2017):

  • Sleep disturbances
  • Irritable bowel disturbances
  • Headaches
  • Abdominal pain
  • Nausea
  • Sore throats
  • Palpitations
  • Recurrent upper respiratory infections (URIs)
  • Bedwetting (and other regression behaviors)
  • Decreased appetite
  • Fatigue

The effects, however, do not end at the physical signs and symptoms. As of the most recent studies, bullying also contributes to (Edi Putra & Dendup, 2022; Earnshaw et al., 2017):

  • Loneliness
  • Significant depressive symptoms
  • The emergence of anxiety disorders
  • Increased substance use (alcohol, smoking cigarettes, and illicit drugs)
  • Suicidal and/or homicidal ideation
  • Truancy
  • Physical fighting
  • Sedentary behavior

In addition to the psychological impact, bullying can also affect academic achievement and the overall potential of children/adolescents who have been bullied. Those who are bullied tend to have lessened educational success, increased behavioral issues in school and at home, increased absenteeism, and a higher rate of school dropout (Williams et al., 2018).

Due to the physical and emotional effects of bullying as well as the toll it can take on the mental health of the pediatric population, it is important to identify these children and adolescents early. If bullying occurs at school, ensure the school system is equipped with an anti-bullying protocol. For cyberbullying, close monitoring of social media platforms is necessary. It is also helpful to maintain open communication and ask questions about these things so children and adolescents feel more comfortable sharing what might happen to them.

Prevention of Mental Health Issues

Work to prevent mental health disorders should occur at all levels: primary, secondary, and tertiary (Melnyk & Lusk, 2022):

  1. Primary Prevention:
    1. During pregnancy
    2. At birth
    3. Taking a family history of mental health disorders that the child might be at risk for
    4. Parental support, education, and anticipatory guidance of what is to come as far as developmental milestones, overall temperament, discipline, and what children need to be healthy and successful
  2. Secondary Prevention:
    1. During childhood
    2. Screening for mental health disorders
    3. Screening for mental health disorder comorbidities
  3. Tertiary Prevention:
    1. During childhood/adolescence/adulthood
    2. Continued screening for mental health disorders
    3. Assessing/screening for comorbidities
    4. Providing support, psychopharmacological treatment, education, and resources to treat the current condition and to prevent subsequent/additional mental health issues because of untreated/unmanaged current diagnoses

In pediatrics, working with the parent(s) or caregiver(s) is a big part in mitigating mental health issues when possible. As many mental health conditions stem from the relationship between the child/adolescent and their caregiver(s), parents should be educated and empowered to do what can be done to prevent possible mental health disorders (Melnyk & Lusk, 2022). Helpful parenting tips we can teach families include (Melnyk & Lusk, 2022):

  • Provide positive reinforcement/praise
  • Give specific praise ("You did an excellent job cleaning up your room!")
  • Set limits that are age-appropriate
  • Follow-through on set limits
  • Allow for and promote independent behaviors
  • Reward good behavior
  • Give gradual increases in chore responsibilities around the house as age increases
  • Give children the opportunity to make choices
  • Give children the opportunity to make mistakes
  • Assist children in problem-solving (identifying the problem, identifying the cause, coming up with solutions, choosing a solution, reflecting)
  • Model behavior you expect of your child
  • Make a habit of frequently communicating your expectations regarding behaviors
  • Meet your child's friends and the friend's parents
  • Reach out for support and guidance for stressful events in society or your child's life
  • Encourage daily physical activity and exercise
  • Encourage family activities
  • Encourage positive patterns of thinking/positive self-talk
  • Work with your child to learn how to control emotions/anger (identifying triggers, coming up with a plan to calm down like counting to 10 or doing some belly breathing)
  • Encourage being accessible to your children and always interested in what they have to say/what is on their mind
  • Allocate special one-on-one time to each child as often as you can
  • Stay vigilant in knowing where your child is, what they are doing, and what they are reading/watching/listening to

Resources

Because the topic "Pediatric Mental Health" is so broad and all-encompassing, it is not possible to cover all subtopics within this very important topic within the constraints of this singular course. For additional information for you, children, adolescents, and families, please use the following resources:

  • Information for Parents and Anxiety in Children and Teens: Visit Resource.
  • Information to Provide for School-Age Children and Teens About Stress and Anxiety: Visit Resource.
  • Information for Parents on How to Help Your Child/Teen Cope With Stressful Events or Uncertainty: Visit Resource.
  • Information to Provide for Helping Children, Teens, and Their Families Cope with War and/or Terrorism: Visit Resource.
  • National Institute of Mental Health (NIH) Child and Adolescent Mental Health: Visit Resource.
  • Medline Plus: Teen Mental Health: Visit Resource.
  • Centers for Disease Control and Prevention: Children's Mental Health: Visit Resource.
  • To find a therapist in your zip code, use: Visit Resource.
  • American Academy of Pediatrics: Mental Health Screening and Assessment Tools for Primary Care: Visit Resource.
  • American Academy of Child and Adolescent Psychiatry: Visit Resource.
  • American Psychological Association (APA): Children's Mental Health: Visit Resource.
  • American Academy of Pediatrics (AAP): Development and Behavior: Visit Resource.
  • Kids Health: Visit Resource.
  • National Association of Pediatric Nurse Practitioners (NAPNAP): Visit Resource.
  • The Trevor Project: LGBTQ Youth Mental Health: Visit Resource.

Case Study: Cadence

History of Present Illness

Cadence is a 16-year-old in the 10th grade. For the last six months, she has been having a hard time focusing on schoolwork. Her math teacher reached out to her mother to share that Cadence's grades have started to fall. Her mother notes that she has not been herself recently and is concerned because she often refuses to spend any time with the rest of the family, preferring to lock herself in her bedroom as soon as she gets home from school and through the rest of the evening. As Cadence's mother has suffered from depression in her past and is aware that depression can carry a genetic load among families, she decided to take her to see her own psychiatrist for an evaluation.

Assessment/Screening

During the clinical evaluation, the psychiatrist talked to both mom and Cadence together initially to ask about how life is currently going for Cadence. Cadence is quiet and will only nod in response to questions asked. Cadence's mother shares her concerns, and that Cadence's current condition is interfering with her life as she is no longer performing well in school. The psychiatrist then asks mom to step out so she can discuss things alone with Cadence.

Once alone, the psychiatrist begins to ask more questions about how Cadence has been feeling lately. Cadence starts to speak up a bit more. She explains that she has been really sad since breaking up with her boyfriend, she has not wanted to spend time with her family because they do not understand what she is going through, she has not had any appetite, she cannot focus on school, she does not really care to do well in school anymore, she does not enjoy activities with her friends like she used to, all she wants to do is sleep. No matter how much sleep she gets, her body is always tired. When asked about feelings of worthlessness or hopelessness, Cadence endorses these feelings. When asked about self-harm, Cadence denies having harmed herself recently or in the past. When asked about suicidal ideation, Cadence explains that sometimes she just hopes she will fall asleep and never wake up again. The psychiatrist confirms that she has no plan or intent for suicide.

Plan of Care

The psychiatrist brings mom back in, and they work on a plan together. The psychiatrist diagnoses Cadence with Major Depressive Disorder. Because the PHQ-9 Modified for Teens resulted in a score of 18, her current severity of depression is moderately severe. She recommends that mom get Cadence into therapy with a therapist that specializes in CBT. They all discuss a safety plan in the event that Cadence begins having more active suicidal thoughts. Because of the severity of her depressive symptoms, Cadence is started on an SSRI, Prozac, at the starting dose to hopefully help to curb her symptoms in the next 4 to 6 weeks. All side effects as well as the "Black Box" warning regarding increased suicidality for this age group were explained to both Cadence and her mother, and their questions were answered. A follow-up appointment was scheduled for one month from today to assess how the medication is helping and if the dosage needs to be adjusted. Cadence and her mother are told they can call the psychiatrist at any time should side effects be unbearable or if Cadence feels her symptoms are worsening.

Follow-Up Evaluation

In one month, Cadence sees her psychiatrist for her follow-up appointment. She tells her doctor that she is enjoying therapy much more than she thought she would. She explains that it is really nice having someone to talk to. She tells the psychiatrist that she is also starting to feel better. She had some nausea when she first started the Prozac, but it has subsided since week two. Cadence explains that she has had a better appetite, she has been sleeping 7 hours a night, she is able to focus better in school and her grades in the last week have been much better, and she denies any suicidal ideation, including passive thoughts.

Conclusion

Once a mental health problem is identified, the child or adolescent, as well as the family, require support and guidance in management and treatment. Remain vigilant for any signs of acute psychiatric emergency, especially those of suicidal ideation and/or plan/attempt. Mental health problems are treatable, often with much success!

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

  • American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, & Children's Hospital Association. (AAP-AACAP-CHA). (2021). AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. American Academy of Pediatrics. Visit Source.
  • American Academy of Pediatrics. (AAP). (n.d.) Initial approaches to addressing behavioral & emotional concerns in primary care. Visit Source.
  • American Psychological Association. (APA). (2022a). Children's mental health. Visit Source.
  • American Psychological Association. (APA). (2022b). About DSM-5-TR. Visit Source.
  • American Psychological Association. (APA). (2022c). Diagnostic and statistical manual of mental disorders (5th ed. Text Revision). (DSM-5-TR). American Psychological Association Publishing: Washington, D.C.
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