One in five adolescents in the U.S. suffers from developmental, mental or behavioral health illnesses, according to the National Association of Pediatric Nurse Practitioners.
To avoid serious, adverse outcomes, it is crucial these illnesses be detected early by pediatric nurse practitioners and pediatric-focused APRNs and pediatric nurses.
Dawn Garzon Maaks, PhD, CPNP-PC, PMHS, FAANP, president of NAPNAP, shared with us about what the organization is doing to help children with mental health issues and support those who provide care to affected youth and their families.
Garzon Maaks is a professor at the College of Nursing at Washington State University in Vancouver. She also is a fellow of the American Association of Nurse Practitioners and an advocate for advanced practice pediatric-focused nurses.
Q: Self-harm and bullying are concerning issues in adolescent mental health. How do pediatric nurse practitioners screen for them and help parents become more aware?
All children get bullied at least once and, unfortunately, many see bullying as something that just happens. Sustained bullying can cause traumatic stress and may be considered an adverse childhood experience.
This non-trivial bullying is hard to detect. Often survivors do not report what is happening because they are afraid they will get into trouble or the bully will actually escalate their behavior.
Bullying and self-harm are much more common now than in past generations. Technology keeps us socially interconnected no matter where we are.
Research tells us social media and technology use that is excessive or inappropriate actually increases the risk of anxiety and stress. Self-harm is usually not a suicidal behavior but rather a symptom of overwhelming mental pain.
Pediatric nurse practitioners and other APRNs who care for our youth must talk about these issues as part of routine anticipatory guidance. We have to ensure we do good skin and mental health assessments as part of wellness care or any time symptoms have the potential to be stress related.
Parents need to learn that bullying is not a rite of passage and that self-injury and risk-taking can be subtle.
Q: What other adolescent mental health issues should pediatric care practitioners be aware of and what resources are available to them?
We need to assess for adverse childhood experiences and all children, especially those older than 11, must be screened for anxiety and depression. Suicide is the second leading cause of death for people 10 to 24 years of age and, in some states like Utah, it is the leading cause of death. We lose thousands of children each year to suicide.
Of course, substance abuse is another critical issue that must be screened for. Unfortunately, just telling young people to say no doesn’t work.
NAPNAP’s Developmental Behavioral and Mental Health special interest group has an amazing website full of provider resources on a wealth of mental health issues, and they have a great resource for parents on how to raise a healthy teenager.
Other good sources for more information include the Substance Abuse and Mental Health Administration’s Adverse Childhood Experiences website and the National Institute on Drug Abuse’s adolescent substance abuse screening page.
Q: How do you recommend pediatric nurse practitioners screen for these issues in adolescent patients?
Children ages 11 and older should be screened annually for depression and substance use. I personally recommend including anxiety screening as part of wellness care, given the increase in anxiety rates.
The Developmental Behavioral and Mental Health special interest group’s resources listed previously are great and include links to a number of screening tools for each condition. From ADHD to eating disorders to anxiety and autism, these passionate advocates have valuable references for anyone looking for pediatric developmental, behavioral or mental health information.
It is best to use standardized tools that really get to significant symptoms and not over identify or under identify issues. Of course, it helps to separate older children from their parents, if they are willing to do so, to maintain confidentiality and remove the fear of getting into trouble.
Q: What are some intervention strategies for at-risk adolescents, namely, those who have been bullied, have performed acts of self-harm or have attempted suicide?
The most important thing is to perform good quality wellness care. When we do expedited older child and adolescent well visits, we miss many of the subtle signs that tell us kids are struggling.
I like to ask kids if anyone has ever made them feel unsafe. It is an open-ended question that lets them steer the conversation.
Look at your patients’ skin! Of course, you should preserve modesty, but if you do not get them into underwear and robe, you will never notice wounds hidden under bulky clothing.
Suicidal ideation is real. It is important to ask your patients if they have ever thought of harming themselves or others.
If they say yes, ask open-ended questions to find out when this occurred. If recent, ask if it consisted of only thoughts or if there was a plan involved.
The key is to have in place how you will refer out, if needed, prior to finding a child in crisis. We prepare for how we will deal with a medical emergency in practice. It is equally important to think about how we will deal with a mental health emergency.
Q: As an organization, what is NAPNAP doing to educate their members about adolescent mental health?
We have our NAPNAP Partners for Vulnerable Youth that is in its second year of dealing with the issue of child trafficking. Our aim is to educate providers about human trafficking and give them resources on how to help these kids.
Our Developmental Behavioral and Mental Health special interest group is passionate and engaged, and our Adolescent Health Care and School-based Health Services special interest groups provide members with resources and opportunities to network and address these and other critical issues.
We support the pediatric primary care mental health specialist role and published an official statement on pediatric mental health and violence in September.
We have members who serve as content experts to federal and professional organizations who seek, like us, to keep kids healthy in body and mind.
Each year our national conference includes several behavioral and mental health sessions or mini-tracks. We invite pediatric nurse practitioners, FNPs and other providers to join us for our next conference March 7-10, 2019, in New Orleans.
Providers can find behavioral and mental health education on our online education system or at our specialty symposia hosted in the summer and fall. Clinical practice resources also can be found in our For Providers channel.
Take these courses on adolescents’ mental health issues!
(1 contact hr)
The North American Nursing Diagnosis Association defines self-mutilation as the \\”deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension.\\” Self-injurious behavior can have serious consequences for the person and elicit feelings of helplessness from caregivers. This module will provide the knowledge to dispel the mystery and promote effective treatment for people who engage in self-injurious behavior. It informs readers about the disease, causes, assessment and treatments.
Helping Children Who Are Being Teased and Bullied
(1 contact hr)
Surveys have shown that about 20% to 28% of American youths (middle school and high school age) report being bullied. Research studies have shown that those who are chronically teased or bullied can suffer short- and long-term psychological consequences and physical problems. This educational activity will help you to distinguish between being teased and bullied and to present effective strategies to help youths, families, and school personnel prevent or respond to harsh teasing or bullying.
Sorting Out Mood Disorders in Children and Adolescents
(1 contact hr)
This continuing education module highlights mood disorders (also called affective disorders) that are diagnosed in childhood and adolescence. Bipolar and depressive disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition:DSM-5 are discussed, including disruptive mood dysregulation disorder, which appeared for the first time in the DSM-5. Identifying and diagnosing childhood mood disorders requires special knowledge and skill. Children and adolescents with mood disorders present differently than adults with mood disorders. Mental health professionals who work with children must possess a child-centric understanding of mood disorders to identify problems, provide proper treatment, or refer to the appropriate discipline.