Pediatric Mental Health

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 a 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):

• 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

Children spend the majority of their childhoods in school. The reason for this is their inherent need for socialization, mental stimulation, physical activity, and structural 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 grappling 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 require 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 by the suspension of the vocational activities they had previously received in the schools (Mahapatra & Sharma, 2020). In addition, students in secondary and tertiary education settings deal 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.

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?

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 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.

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

• Do they appear to have a "poverty of thought" when 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)

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?

Judgment 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? Judgment 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).

These ACEs have been shown to impact child/adolescent functioning, physical and mental health, and overall well-being (CDC, 2022b). These effects 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 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):

• 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).

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)

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.

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:

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 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

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).

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 the 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

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

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)

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 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.

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).

Cadence is a 16-year-old in the 10th grade. She has been having difficulty focusing on schoolwork for the last six months. 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 the 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 initially talked to both Mom and Cadence 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 says 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 the mom get Cadence into therapy with a therapist who 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 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 explained that she has had a better appetite, has been sleeping 7 hours a night, can focus better in school, and has had much better grades in the last week. She denies any suicidal ideation, including passive thoughts.