Mental health screening of adolescents in pediatric practice

Principles for Primary Care Screening in the Context of Population Health

A key component of primary care pediatrics is health promotion through screening: applying a test or procedure to detect a previously unrecognized disease or disease risk. How do we decide whether to screen? In 1965, Wilson and Jungner published an influential set of screening principles focused on the health problem's importance, the screening tool's performance, and the evidence for treatment efficacy. However, if we want realistic estimates of the population effects of routine screening, we must also account for the health care system's real-world functioning and disparities in care. We offer revised principles to guide discussions about routine screening in the primary care setting. We add to Wilson and Jungner's principles: 1. A focus on life course epidemiology and its consequences for population health, 2. A need to screen for the early stages of chronic health problems, 3. A concern for screening's acceptability to providers and the community, 4. A recommendation for estimating the uncertainty in benefits and harms in evaluating screening, 5. Inclusion of systematic plans for population data collection and monitoring, and 6. Recognition that achieving population health improvement requires a high-performing system with sufficient throughput and monitoring to deliver accessible, affordable, and effective care, especially for the groups experiencing the greatest inequities in access. Above all, instead of assuming best practices in treatment delivery and monitoring after screening, we argue for realism about the health care system functioning in routine practice.

Rating Scales for Behavioral Health Screening System Within Pediatric Primary Care

Barriers to conducting standardized behavioral health screening within pediatric primary care settings include engaging youth and families, limited time available for this activity, and difficulties related to obtaining behavioral health consultation and treatment from specialists. Child and adolescent psychiatrists may assist pediatric primary care practices with engaging youth and families around screening by assisting with identifying rating scales that have good psychometric characteristics across multiple languages and are validated in diverse samples and available within the public domain. Additionally, they may partner with pediatric primary care professionals to assist with optimizing screening workflows and linkage to specialized services.

Self-produced audio-visual animation introduction alleviates preoperative anxiety in pediatric strabismus surgery: a randomized controlled study

Background

Hospital anxiety caused by strabismus surgery has an unpleasant and disturbing feeling for both children and their parents. This study aimed to determine the effect of viewing a self-produced audio-visual animation introduction on preoperative anxiety and emergence agitation of pediatric patients undergoing strabismus surgery.

Methods

In this prospective randomized study, 1 hundred children scheduled for strabismus surgery with aged 3 ~ 6 years. The children were randomly divided into 2 groups (n = 50 for each), Group A: using a self-produced audio-visual animation introduction; Group C: controlled group without audio-visual animation introduction. Children’s preoperative anxiety was determined by the modified Yale Preoperative Anxiety Scale (mYPAS) at different time points: the night before surgery(T1), at pre-anesthetic holding room(T2), and just before anesthesia induction(T3). The Spielberger State-Trait Anxiety Inventory (STAI) was used to record the anxiety of parents at T1,T2 and T3. The incidence and the degree of emergence agitation were recorded.

Results

The mYPAS scores at T2 and T3 were higher than T1(p < 0.05) in both groups. The average score of mYPAS in Group A was significantly lower than in Group C at T2 and T3(p < 0.05). The STAI scores in Group A at T2 and T3 were significantly lower than in Group C(p < 0.05). The incidence of agitation in Group A was lower than that in Group C(p < 0.05).

Conclusions

Based on the findings, viewing a self-produced audio-visual animation can effectively alleviate the preoperative anxiety for both children and their parents in pediatric strabismus surgery, and it was effective for reducing emergence agitation as well.

Trial registration

The trial was prospectively registered before patient enrollment at Chinese Clinical Trial Registry (Clinical Trial Number: ChiCTR1900025116, Date: 08/12/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01922-6.

Experiences of General Practitioners and Practice Support Staff Using a Health and Lifestyle Screening App in Primary Health Care: Implementation Case Study

Background

Technology-based screening of young people for mental health disorders and health compromising behaviors in general practice increases the disclosure of sensitive health issues and improves patient-centered care. However, few studies investigate how general practitioners (GPs) and practice support staff (receptionists and practice managers) integrate screening technology into their routine work, including the problems that arise and how the staff surmount them.

Objective

The aim of this study was to investigate the implementation of a health and lifestyle screening app, Check Up GP, for young people aged 14 to 25 years attending an Australian general practice.

Methods

We conducted an in-depth implementation case study of Check Up GP in one general practice clinic, with methodology informed by action research. Semistructured interviews and focus groups were conducted with GPs and support staff at the end of the implementation period. Data were thematically analyzed and mapped to normalization process theory constructs. We also analyzed the number of times we supported staff, the location where young people completed Check Up GP, and whether they felt they had sufficient privacy and received a text messaging (short message service, SMS) link at the time of taking their appointment.

Results

A total of 4 GPs and 10 support staff at the clinic participated in the study, with all except 3 receptionists participating in the final interviews and focus groups. During the 2-month implementation period, the technology and administration of Check Up GP was iterated through 4 major quality improvement cycles in response to the needs of the staff. This resulted in a reduction in the average time taken to complete Check Up GP from 14 min to 10 min, improved SMS text messaging for young people, and a more consistent description of the app by receptionists to young people. In the first weeks of implementation, researchers needed to regularly support staff with the app’s administration; however, this support decreased over time, even as usage rose slightly. The majority of young people (73/87, 84%) completed Check Up GP in the waiting room, with less than half (35/80, 44%) having received an SMS from the clinic with a link to the tool. Participating staff valued Check Up GP, particularly its facilitation of youth-friendly practice. However, there was at first a lack of organizational systems and capacity to implement the app and also initially a reliance on researchers to facilitate the process.

Conclusions

The implementation of a screening app in the dynamic and time-restricted general practice setting presents a range of technical and administrative challenges. Successful implementation of a screening app is possible but requires adequate time and intensive facilitation. More resources, external to staff, are needed to drive and support sustainable technology innovation and implementation in general practice settings.

Suicide Screening in Primary Care: Use of an Electronic Screener to Assess Suicidality and Improve Provider Follow-Up for Adolescents

PURPOSE

The purpose of this study was to assess the feasibility of using an existing computer decision support system to screen adolescent patients for suicidality and provide follow-up guidance to clinicians in a primary care setting. Predictors of patient endorsement of suicidality and provider documentation of follow-up were examined.

METHODS

A prospective cohort study was conducted to examine the implementation of a CDSS that screened adolescent patients for suicidality and provided follow-up recommendations to providers. The intervention was implemented for patients aged 12-20 years in two primary care clinics in Indianapolis, Indiana.

RESULTS

The sample included 2,134 adolescent patients (51% female; 60% black; mean age = 14.6 years [standard deviation = 2.1]). Just over 6% of patients screened positive for suicidality. A positive endorsement of suicidality was more common among patients who were female, depressed, and seen by an adolescent-medicine board-certified provider as opposed to general pediatric provider. Providers documented follow-up action for 83% of patients who screened positive for suicidality. Documentation of follow-up action was correlated with clinic site and Hispanic race. The majority of patients who endorsed suicidality (71%) were deemed not actively suicidal after assessment by their provider.

CONCLUSIONS

Incorporating adolescent suicide screening and provider follow-up guidance into an existing computer decision support system in primary care is feasible and well utilized by providers. Female gender and depressive symptoms are consistently associated with suicidality among adolescents, although not all suicidal adolescents are depressed. Universal use of a multi-item suicide screener that assesses recency might more effectively identify suicidal adolescents.

Implementation of Depression Screening and Global Health Assessment in Pediatric Subspecialty Clinics

PURPOSE

Adolescents with chronic illness face greater risk of psychosocial difficulties, complicating disease management. Despite increased calls to screen for patient-reported outcomes, clinical implementation has lagged. Using quality improvement methods, this study aimed to investigate the feasibility of standardized screening for depression and assessment of global health and to determine recommended behavioral health follow-up, across three pediatric subspecialty clinics.

METHODS

A total of 109 patients aged 12-22 years (median = 16.6) who were attending outpatient visits for treatment of diabetes (80% type 1), inflammatory bowel disease, or cystic fibrosis completed the 9-item Patient Health Questionnaire (PHQ-9) depression and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health measures on electronic tablets. Patients screening positive on the PHQ-9 received same-day behavioral health assessment and regular phone check-ins to facilitate necessary follow-up care.

RESULTS

Overall, 89% of 122 identified patients completed screening during a 6-month window. Patients completed measures in a timely manner (within 3 minutes) without disruption to clinic flow, and they rated the process as easy, comfortable, and valuable. Depression scores varied across disease type. Patients rated lower global health relative to a previously assessed validation cohort. Depression and global health related significantly to certain medical outcomes. Fifteen percent of patients screened positive on the PHQ-9, of whom 50% confirmed attending behavioral health appointments within 6 months of screening.

CONCLUSIONS

A standardized depression and global health assessment protocol implemented across pediatric subspecialties was feasible and effective. Universal behavioral health screening for adolescents and young adults living with chronic disease is necessary to meet programmatic needs in pediatric subspecialty clinics.

Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? A systematic review

BACKGROUND

Adolescence and young adulthood are important developmental periods. Screening for health compromising behaviours and mental health disorders during routine primary care visits has the potential to assist clinicians to identify areas of concern and provide appropriate interventions. The objective of this systematic review is to investigate whether screening and subsequent interventions for multiple health compromising behaviours and mental health disorders in primary care settings improves the health outcomes of young people.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, literature searches were conducted in Medline, PsycINFO, Scopus and Cochrane Library databases (Prospero registration number CRD42013005828) using search terms representing four thematic concepts: primary care, young people, screening, and mental health and health compromising behaviour. To be eligible for inclusion, studies had to: include a measure of health outcome; include at least 75 % of participants aged under 25 years; use a screening tool that assessed more than one health domain; and be conducted within a primary care setting. Risk of bias was assessed using the Quality Rating Scale.

RESULTS

From 5051 articles identified, nine studies fulfilled the inclusion criteria and were reviewed: two randomised controlled trials (RCTs), one pilot RCT, two clustered RCTs, one randomised study with multiple intervention groups and no control group, one cluster RCT with two active arms, one longitudinal study and one pre-post study. Seven studies, including two RCTs and one clustered RCT, found positive changes in substance use, diet, sexual health or risky sexual behaviour, alcohol-related risky behaviour, social stress, stress management, helmet use, sleep and exercise. Of only two studies reporting on harms, one reported a negative health outcome of increased alcohol use.

CONCLUSIONS

There is some evidence that the use of screening and intervention with young people for mental health disorder or health compromising behaviours in clinical settings improves health outcomes. Along with other evidence that young people value discussions of health risks with their providers, these discussions should be part of the routine primary care of young people. Further quality studies are needed to strengthen this evidence.

Impact of pediatric mental health screening on clinical discussion and referral for services

OBJECTIVE

This study discusses the impact of mental health screening in pediatric primary care on the management of mental health concerns.

METHODS

Youth aged 11 years and their parents completed the Pediatric Symptom Checklist and chart reviews were used to gather information about discussion of mental health concerns and connection with mental health services. The study design was a post-intervention study with a concurrent comparison group of youth aged 12 years who were not offered a screening. The χ(2) or Fisher's exact tests and logistic regression were used to compare groups on outcome variables.

RESULTS

Parents who completed a mental health screening for their child were more likely to be referred and attend mental health services, attend a psychiatrist appointment, and discuss their concerns with the primary care provider compared with the comparison group.

CONCLUSIONS

Screening by parents improves detection of problems and fosters conversations with providers and subsequent connection with services.

Addressing the mental health needs of pregnant and parenting adolescents

Adolescent parenthood is associated with a range of adverse outcomes for young mothers, including mental health problems such as depression, substance abuse, and posttraumatic stress disorder. Teen mothers are also more likely to be impoverished and reside in communities and families that are socially and economically disadvantaged. These circumstances can adversely affect maternal mental health, parenting, and behavior outcomes for their children. In this report, we provide an overview of the mental health challenges associated with teen parenthood, barriers that often prevent teen mothers from seeking mental health services, and interventions for this vulnerable population that can be integrated into primary care services. Pediatricians in the primary care setting are in a unique position to address the mental health needs of adolescent parents because teens often turn to them first for assistance with emotional and behavioral concerns. Consequently, pediatricians can play a pivotal role in facilitating and encouraging teen parents' engagement in mental health treatment.

Universal mental health screening in pediatric primary care: a systematic review

OBJECTIVE

Universal mental health screening in pediatric primary care is recommended, but studies report slow uptake and low rates of patient follow-through after referral to specialized services. This review examined possible explanations related to the process of screening, focusing on how parents and youth are engaged, and how providers evaluate and use screening results.

METHOD

A narrative synthesis was developed after a systematic review of 3 databases (plus follow-up of citations, expert recommendations, and checks for multiple publications about the same study). Searching identified 1,188 titles, and of these, 186 full-text articles were reviewed. Two authors extracted data from 45 articles meeting inclusion criteria.

RESULTS

Published studies report few details about how mental health screens were administered, including how clinicians explain their purpose or confidentiality, or whether help was provided for language, literacy, or disability problems. Although they were not addressed directly in the studies reviewed, uptake and detection rates appeared to vary with means of administration. Screening framed as universal, confidential, and intended to optimize attention to patient concerns increased acceptability. Studies said little about how providers were taught to explore screen results. Screening increased referrals, but many still followed negative screens, in some cases because of parent concerns apparently not reflected by screen results but possibly stemming from screen-prompted discussions.

CONCLUSIONS

Little research has addressed the process of engaging patients in mental health screening in pediatric primary care or how clinicians can best use screening results. The literature does offer suggestions for better clinical practice and research that may lead to improvements in uptake and outcome.

A randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk

BACKGROUND

In pediatric emergency departments (EDs), adolescents at risk for suicide often escape detection and successful referral for outpatient mental health care.

OBJECTIVE

This study aimed to assess the effectiveness of a brief, ED-based mental health service engagement intervention to increase linkage to outpatient mental health services.

DESIGN/METHODS

Adolescents presenting to a pediatric ED who were not currently receiving mental health services were screened for suicide-related risk factors (Columbia Suicide Scale). If positive, youths were then screened for impairment, alcohol use, and depression. Those screening positive on the Columbia Suicide Scale and the alcohol, impairment, or depression screen were randomly assigned to the intervention (short motivational interview, barrier reduction, outpatient appointment established, reminders before scheduled appointment) or standard referral (telephone number for a mental health provider). Study groups were compared with respect to screen acceptability and outpatient mental health care linkage and change in depression symptoms at 60 days after the index ED visit.

RESULTS

A total of 204 families were enrolled. Overall, 24 adolescents (12%) screened positive for suicide risk factors and were randomized to the intervention (n = 11) or standard referral (n = 13) groups. The groups did not significantly differ on several measures of screen acceptability. As compared with the standard referral group (15.4%), the intervention group (63.6%) was significantly more likely to attend a mental health appointment during the follow-up period (Fisher exact test, P = 0.03). There was also a nonsignificant trend toward greater improvement of depressive symptoms in the intervention than standard referral group (t = 1.79, df = 18, P = 0.09).

CONCLUSIONS

When adolescents are identified in the ED with previously unrecognized mental health problems that increase suicide risk, a brief motivational and barrier-reducing intervention improves linkage to outpatient mental health services.

Depression screening and mental health outcomes in children and adolescents: a systematic review protocol

BACKGROUND

Depression is an important cause of disability among children and adolescents. Depression screening is one possible method for managing depression, and screening programs have been initiated in some school and medical settings. However, in 2005, the Canadian Task Force on Preventive Health Care and the United Kingdom National Institute of Clinical Excellence did not recommend depression screening among children and adolescents. By contrast, in 2009, the United States Preventive Services Task Force recommended that all adolescents, but not younger children, be screened for depression in medical settings with integrated depression management services, although no trials of screening were identified. The objectives of this systematic review are to evaluate in children and adolescents the accuracy of depression screening tools; depression treatment efficacy; whether depression screening improves depression outcomes; and potential harms related to depression interventions and screening.

METHODS/DESIGN

Data sources will include the bibliographic databases MEDLINE, Cochrane CENTRAL, PsycINFO, EMBASE, LILACS and Web of Science, supplemented by reference harvesting of eligible articles, relevant systematic reviews, relevant guidelines and recommendations, and selected journals, and by searches for unpublished studies. Eligible studies will report data for children and adolescents aged 6 to 18 years. Eligible diagnostic accuracy studies must compare a depression screening tool to a validated diagnostic interview for major depressive disorder and report diagnostic accuracy data. Eligible treatment studies must be randomized controlled trials of pharmacological, psychotherapeutic, or other depression treatments commonly available for children and adolescents in pediatric, primary-care, and family medicine settings. Eligible screening studies must be randomized controlled trials that compare depression outcomes between children or adolescents who underwent depression screening versus those who did not. Studies of harms will include randomized controlled trials and observational studies that evaluate harms from depression screening or treatment. Two investigators will independently review titles and abstracts, followed by full article review. Disagreements will be resolved by consensus. Two investigators will independently extract the data, with discrepancies resolved via consensus.

DISCUSSION

The proposed systematic review will determine whether there is sufficient evidence of benefits in excess of harms and costs to support screening for depression in childhood and adolescence.

Intimate partner violence, mental health disorders, and sexually transmitted infections: important screening opportunities for pediatric healthcare providers

PURPOSE OF REVIEW

This article addresses three critical areas where pediatric healthcare providers must employ effective screening techniques to ensure the best care for patients: intimate partner violence (IPV), mental health issues, and sexually transmitted infections (STIs).

RECENT FINDINGS

IPV is now recognized as an important issue impacting the health of children. While long-term outcomes secondary to positive screening results are not known, routine, sensitive questioning can identify at-risk children and help connect families to resources in the community. Routine use of validated screening tools for mental health disorders (MHDs) in the office setting is now recommended. STIs disproportionately affect adolescents and young adults, yet timely diagnosis is often challenging because infections are frequently asymptomatic and adolescents may not be forthcoming about risk-taking behaviors. There is significant opportunity for pediatricians to improve screening rates of adolescents.

SUMMARY

Screening is an essential aspect of healthcare for pediatricians. An understanding of current screening recommendations for IPV, MHDs, and STIs will assist providers in earlier detection of medical problems in their patients and will likely improve patient outcomes.