≥ 92% of participants will know how to identify the major mental health conditions and needs of pediatric patients.
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.
≥ 92% of participants will know how to identify the major mental health conditions and needs of pediatric patients.
After completing this continuing education course, the participant will be able to:
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.).
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):
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).
The COVID-19 pandemic exposed and worsened the already quite prevalent pediatric mental health crisis globally (Dalabih et al., 2022).
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).
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).
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):
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.
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.
Image 1: 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):
We will now review each of these components of the MSE in greater detail.
When assessing a child/adolescent in this domain, first consider their physical appearance. Questions to ask yourself include (RCH, 2018):
Then, consider how the child is interacting with both their parents and you, the healthcare professional (RCH, 2018):
As far as the child/adolescent's activity level, consider the following (RCH, 2018):
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.
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)?
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):
While assessing a child/adolescent's thought processes, first consider the speed of their thoughts (RCH, 2018):
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).
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)?
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)?
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, 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:
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).
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).
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):
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.
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).
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):
Substantial health disparities also exist, disproportionately affecting Hispanic and African American children (Melnyk & Lusk, 2022).
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):
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):
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.
Common anxiety-related disorders include (APA, 2022c; Melnyk & Lusk, 2022):
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):
Signs of anxiety in older children include (Melnyk & Lusk, 2022):
When assessing for an anxiety disorder, it is helpful to ask questions like the following (Melnyk & Lusk, 2022):
The GAD-7 is available below:
|Over the last 2 weeks, how often have you been bothered by the following problems?||Not at all sure||Several days||Over half the days||Nearly every day|
|1. Feeling nervous, anxious, or on edge||0||1||2||3|
|2. Not being able to stop or control worrying||0||1||2||3|
|3. Worrying too much about different things||0||1||2||3|
|4. Trouble relaxing||0||1||2||3|
|5. Being so restless that it's hard to sit still||0||1||2||3|
|6. Becoming easily annoyed or irritable||0||1||2||3|
|7. Feeling afraid as if something awful might happen||0||1||2||3|
|Add the score of reach column||+||+||+||+|
|Total Score (add your column scores) =|
When scoring the GAD-7:
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):
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):
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 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).
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):
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):
The following are signs/symptoms of depressive disorders among toddlers and preschool-age children (Melnyk & Lusk, 2022):
The following are signs/symptoms of depressive disorders among adolescents (Melnyk & Lusk, 2022):
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:
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 current recommendations for the management of depressive disorders in children and adolescents are (Melnyk & Lusk, 2022):
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.
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):
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:
It is also helpful to become familiar with the other options of outreach in your area to share with children/adolescents and their families.
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.
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):
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.
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):
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 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):
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):
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):
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.
Work to prevent mental health disorders should occur at all levels: primary, secondary, and tertiary (Melnyk & Lusk, 2022):
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:
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.
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.
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.
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.
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!
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.