Pediatric Mental Health

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 encouraging 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 challenges and increasing access to 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).

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

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):

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.

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:

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

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).

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)

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 is the 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 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 from 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 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.

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).

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 who 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. Children/adolescents who are currently having suicidal ideation or have a plan and/or possible intent to follow through 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.

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):

• 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.

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 age-appropriate limits
• 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

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.

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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• 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.
• Bellazaire, A. (2018). Health report: Preventing and mitigating the effects of adverse childhood experiences. National Conference of State Legislatures. Visit Source.
• Benton, T., Njoroge, W., & Ng, W. (2022). Sounding the alarm for children's mental health during the COVID-19 pandemic. Journal of the American Medical Association (JAMA) Pediatrics. 176(4). Visit Source.
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• Centers for Disease Control and Prevention. (CDC). (2020). Morbidity and Mortality Weekly Report: Youth Risk Behavior Surveillance 2019. Visit Source.
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• Centers for Disease Control and Prevention. (CDC). (2022b). Fast facts: Preventing adverse childhood experiences. Visit Source. 
• Dalabih, A., Bennett, E., Javier, J., & Pediatric Policy Council. (2022). The COVID-19 pandemic and pediatric mental health: Advocating for improved access and recognition. Pediatric Research. 91: 1018-1020. Visit Source.
• Delphin-Rittmon, M. (2022). LGBTQIA+ youth—Like all Americans, they deserve evidence-based care. Substance Abuse and Mental Health Services Administration. (SAMHSA). Visit Source.
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• Edi Putra, G., & Dendup, T. (2022). Health and behavioural outcomes of bullying victimisation among Indonesian adolescent students: Findings from the 2015 Global School-based Student Health Survey. Psychology, Health, & Medicine, 27:3, 513-527. Visit Source.
• Finlay-Jones, A., Strauss, P., Perry, Y., Waters, Z., Gilbey, D., Windred, M., Murdoch, A., Pugh, C., Ohan, J., & Lin, A. (2021). Group mindful self-compassion training to improve mental health outcomes for LGBTQIA+ young adults: Rationale and protocol for a randomized controlled trial. Contemporary Clinical Trials. 102. Visit Source.
• Integrative Life Center. (2021). What are the 10 adverse childhood experiences? Visit Source.
• Johnson, J., Harris, E., Spitzer, R., & Williams, J. (2002). The patient health questionnaire for adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients. Journal of Adolescent Health, 30(3), 196-204. Visit Source.
• Korczak, D., Madigan, S., & Vaillancourt, T. (2022). Data divide—Disentangling the role of the COVID-19 pandemic on child mental health and well-being. Journal of the American Medical Association (JAMA) Pediatrics. 176(7): 635-636. Visit Source.
• Kuper, L. (2022). Mental health in LGBTQ youth. Children's Health. Visit Source.
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• Melnyk, B., & Lusk, P. (2022). A practical guide to child and adolescent mental health screening, evidence-based assessment, intervention, and health promotion. (3rd Ed.) Springer Publishing Company: New York, NY. Visit Source.
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• Riddle, M. (2019). Pediatric psychopharmacology for primary care (2nd ed.). American Academy of Pediatrics.
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• Samji, H., Wu, J., Ladak, A., Vossen, C., Stewart, E., Dove, N., Long, D., & Snell, G. (2021). Review: Mental health impacts of the COVID-19 pandemic on children and youth—A systematic review. Child and Adolescent Mental Health. 27(2): 173-189. Visit Source.
• Sheridan, D., Gruising, S., Marshall, R., Lin, A., Hughes, A., Hendrickson, R., & Horowitz, B. (2022). Changes in suicidal ingestion among preadolescent children from 2000 to 2020. Journal of the American Medical Association (JAMA) Pediatrics. 176(6): 604-606. Visit Source.
• Sigurdson, J. (2019). Doctoral theses: Long-term effects of bullying in adolescence. Visit Source.
• The Trevor Project. (2020). National survey on LGBTQ youth mental health 2020. Visit Source.
• Williams, S., Schneider, M., Wornell, C., & Langhinrichsen-Rohling, J. (2018). Student's Perceptions of School Safety: It Is Not Just About Being Bullied. Journal of School Nursing, 34(4), 319–330. Visit Source.