Dr. Jellinek is Professor of Psychiatry and of Pediatrics, Harvard Medical School, Boston, and Chief Executive Officer, Community Network, Lahey Health System, Burlington, Massachusetts.

Michael S Jellinek, MD

Psychosocial issues are central to the care of adolescent patients. Pediatricians routinely discuss substance use, sexual health, and accident prevention with adolescents and are likely to see specific mental health concerns in about 20% of their patients. In light of rising suicide rates and the likely consequences of COVID-19, depression is an increasingly common concern. With limited access to mental health clinicians, individual pediatricians must manage patients’ mental health needs by enhancing their own skills, collocating mental health personnel in their practices, and building trusted referral networks.

Because psychosocial screening is now an expected part of pediatric primary care,

 this article focuses on screening adolescent patients, including choice of tools and follow-up of positive results.

Clinicians can download several well-validated, no-cost, and brief measures to screen for both broad and specific psychosocial concerns in their patients (Table).

One of the most common, broader screening measures, the Pediatric Symptom Checklist (PSC), has been endorsed by the National Quality Forum to assess both depression and overall psychosocial functioning, with 3 subscales reflecting internalizing, externalizing, and attention symptoms.

 The PSC is available in 35- and 17-item versions, in both parent and youth self- report versions, and in more than 30 languages.

Teenagers can also complete various diagnosis-specific measures. For example, the Patient Health Questionnaire Modified for Teenagers (PHQ-9M) is a 13-item screening tool for depression and suicide risk that uses language targeted toward adolescents. Generalized Anxiety Disorder-7 (GAD-7) is a 7-item self-report measure designed to identify and assess the severity of generalized anxiety disorder (not phobias or obsessive-compulsive disorders) using 

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

 The protocol Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) can be used to assess both substance use disorders and safety risks in patients aged 12 to 21 years—including those who do not endorse substance use—by asking about substance-related riding and driving, 2 leading causes of death in this age group.

The Guidelines for Adolescent Depression in Primary Care recommend annual screening (more frequently for those with higher-risk factors; eg, family history) for all adolescents 12 years and older using a validated screening tool that includes a depression measure.

Who should complete the questionnaire? Parents can provide better historical accuracy and add a mature perspective on a youth’s daily functioning. Adolescents often give more accurate insight into their internal emotional states, especially the subjective experience of depression or anxiety.

 Given the ease of administration, a best practice might be having both a parent- and a patient-completed screen, especially if integrated into the visit using an electronic patient portal.

Clinicians should discuss positive screens (eg, parent PSC, adolescent PHQ-9M) with the patient individually and then with their parent(s). Clinicians can ask about specific problems noted on the screenings, gather family history of emotional disorders, and assess by interview the adolescent’s daily functioning—school, family, friends, activities, and mood.

When a patient endorses suicidal ideation, clinicians should evaluate the severity of suicide risk. The Ask Suicide-Screening Questions (ASQ) approach recommends talking with the patient about factors such as the frequency of suicidal thoughts, previous attempts or self-injury, presence of a plan, substance use, bullying, family situation, access to means (especially guns and medication), and protective factors (eg, coping and problem-solving skills, meaningful relationships, reasons for living, and access to treatment).

 Because these issues can be difficult for teenagers to discuss, a valid assessment depends on a sense of trust and safety during the interview.

Although pediatricians and mental health clinicians are justified in feeling anxious when assessing suicidal risk because of the life-or-death concern, the expectation of accurately predicting suicidal behavior for any individual patient is unrealistic. Suicidal ideation is overwhelmingly more common than attempts, and there is, as yet, no reliable way to predict which patients with suicidal ideation will attempt or die by suicide. Still, these youths often have significant psychological distress and would likely benefit from additional assessment and a plan for managing suicidal ideation and treating their underlying psychosocial problems.

In addition to having a higher lifetime risk of suicide, adolescents struggling with psychosocial issues such as depressed mood, attentional difficulties, impulsivity, or anxiety

are more likely to have poorer physical health

 Rather than exclusively focusing on preventing imminent suicide, mental health screening is best viewed as a valuable opportunity to identify a vulnerable group of adolescents who merit follow-up with repeated screening, monitoring, and treatment planning in much the same way that pediatricians manage chronic physical illness. By advancing their own learning and with the help of more resources, primary care pediatricians can be well positioned to identify and help their adolescent patients burdened by mental health issues.

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8. National Institute of Mental Health. Ask Suicide-Screening Questions (ASQ) Toolkit. Accessed February 1, 2022. 

https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials

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Articles

For adolescent patients, psychosocial concerns can be an important part of care and routine validated screening can help pediatricians determine which patients may require extra care or even a specialist.

Screening adolescents for psychosocial concerns

As a result of COVID-19, isolation, interpersonal tensions, losses of loved ones, barriers to extended family supports, poverty, job insecurity, and lack of socialization with other children and teens have been a cumulative and interactive burden for communities throughout the United States and elsewhere. The bell-shaped curve demonstrating the distribution of psychosocial disorders in our population has shifted to the right, meaning that the prevalence and severity of a wide range of problems have increased.

Anxiety and depression were already common disorders among teenagers and adolescents, who are especially sensitive to the layered consequences of COVID-19. There is growing concern that the pandemic has added to the rising rate of adolescent suicide and that any increase in depression will also increase the number of adolescents with suicidal ideation.

Now that the pandemic is being brought under better control and schools are reopening, the structure of school, activities, and social relationships will likely help some adolescents feel less depressed and anxious. Many psychologists have hypothesized, however, that the byproducts of COVID-19 (ie, persistent isolation during quarantine, financial strain, and sickness or death in the family) will have lasting effects on adolescent mental health. These effects may be further exacerbated by the stresses related to reestablishing social relationships, shifting from remote school to the intensity of a classroom, and facing the burden of “catching up” on their academic work and testing (particularly for students with higher support needs and/or those without adequate access to technology over the past year). Because adolescence is a time of such rapid change, every year marks a further blossoming of identity and concomitant stresses, and this second year of COVID-19 dramatically increases the need to assess the psychosocial functioning of adolescents.

How should pediatricians in primary care approach the recognition and management of psychosocial concerns in adolescents who are facing the usual developmental challenges intensified by COVID-19? How should pediatricians assess severity and whether additional primary care management or referral is appropriate? How should they frame their role in adolescent suicidal ideation and suicide prevention? What is the role of primary care follow-up?

Although parent observations and questions about their child’s mental well-being are always useful in encouraging recognition during a pediatric office visit, parents may not have the awareness or comfort to discuss potential problems in this setting, especially at an early point in adolescent psychosocial disorders. Screening all adolescents for general psychosocial problems and/or depression3 is the recommended and effective approach to recognition and is now a quality standard of the American Academy of Pediatrics, Medicaid, and the US Preventive Services Task Force, paralleling screening for growth and health indicators (eg, hematocrit, urine). Screening has been facilitated by electronic medical record (EMR) systems that allow parents and teenagers to complete screens online or on electronic devices, then automatically score and post the information in the EMR prior to the visit.

For broad psychosocial screening as well as depression screening, the Pediatric Symptom Checklist (PSC) is a validated, approved, and widely used questionnaire.

 Available at no cost and in more than 30 languages, it is most often completed by parents (although there is also a youth-completed version), and its simple scoring system can be found on the following website: 

https://www.massgeneral.org/psychiatry/treatments-and-services/pediatricsymptom-checklist/bibliography

. Parents can complete the questionnaire in about 3 minutes, and the EMR will report the results as an overall score reflecting psychosocial functioning at home, in school, with peers, and at activities. In addition, 3 subscale scores note risk of depression/anxiety, attention problems, and difficulties with conduct. The pediatrician can see the scores in the EMR to assess if any are positive and, later, assess trends over time with repeated administrations of the PSC.

Adolescent depression is common and has multiple consequences, including poor school performance, substance use, risk-taking behavior, low self-esteem, and suicide risk.

 Preliminary research suggests that the pandemic is substantially affecting youth mental well-being and depression, with 43.7% of Chinese adolescents reporting mild to severe depression,

 46% of young people in Latin America and the Caribbean reporting lower motivation to engage in their favorite activities,

 and 46% of US parents noticing a new or worsened mental health condition in their teenagers since the start of the COVID-19 pandemic.

 Rising percentages of psychosocial distress indicate a pressing need to accurately identify and help adolescents with depression. Given that adolescent depression, especially early in the course, can be very private, with symptoms remaining unexpressed to others, the Patient Health Questionnaire (PHQ-9) is a useful youth-reported screening tool that focuses specifically on depression.

PHQ-9 scores reflect severity of depression, and its ninth question asks about frequency of suicidal ideation.

Pediatricians could use both the parent-reported PSC and the youth-reported PHQ-9 to obtain a broad picture of overall psychosocial functioning and a more detailed view of depression. The use of both screens yields a range of 15% to 20% of teenagers identifying as positive on 1 or both measures. Most adolescents who screen positive would have indications of depression and anxiety, but about two-thirds will also have other issues related to attention, family problems, and relationships.

Some practices have relied on the parent-reported PSC and used the PHQ-9 only if the parents report a high internalizing score on the PSC; however, the PSC alone would miss those adolescents who are functioning well outwardly, but privately feel depressed. Some practices give only the PHQ-9 or the youth-reported PSC, and these will miss the parent’s historical knowledge and more accurate assessment of the teenager’s overall functioning. Based on our recent research, we recommend that primary care practices use both the parent-reported PSC and the youth-reported PHQ-9 for routine psychosocial screening.

Next steps for patients who screen positive on the PSC and PHQ-9

About 25% of those teenagers scoring positive will be identified only by the overall score of the parent’s PSC and may have positive subscale scores in attention or conduct problems. As with any PSC positive score, most pediatricians look at answers marked “often” (such as “Often does not listen to rules”) to confirm that the parents sense difficulty in daily functioning, and try to define the problem further when talking to the teenager. Some of these problems, such as attention-related or divorce-related issues, will be known to the pediatrician from previous visits and require less time to evaluate.

New issues will need to be assessed for severity and a decision made whether to offer guidance, schedule follow-up visits to track the problem, or, if serious, refer for a full mental health evaluation. Practices are collaborating, or increasingly colocating, with social workers and psychologists who can provide access to mental health services onsite.

Among the teenagers with a positive screen on the parent-reported PSC, approximately 75% will also have a positive internalizing score, and most of these teenagers will also have a positive PHQ-9 score for depression.13 The score on the PHQ-9 defines depression severity: 0 to 4 (none), 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe). Most scores are moderate or lower, with only about 3% of teenagers scoring in the moderately severe or severe range. Adolescents have variations in mood and on any given day, their scores may vary from mild to moderate, or moderate to severe. It is meaningful for the pediatrician to review scores and note changes from prior visits.

With these positive indications, the pediatrician should do a brief assessment of the depression and its severity, and the risk of suicide. Teenagers developmentally are often not comfortable being open and forthright with adults. The pediatrician must use clinical skill (tone, posture, taking time, listening) to create a sense of trust and connectedness with the adolescent such that sufficient honest information can be gathered to ascertain the severity and risks of the depression.

Framing an approach to suicide ideation and prevention

Pediatricians are understandably anxious given the rising rates (and the horror) of a teenager dying by suicide or a depressed teenager taking risks, such as drunk driving, that results in a death called an “accident.” The clinical dilemma arises from the rarity of these events and their lack of predictability. Preliminary research has suggested increased rates of youth suicide attempts during the pandemic compared with 2019,

 but it is still too soon to fully assess the impact of the pandemic on adolescent suicide rates.

Among adolescents, deaths by suicide occur at a rate of approximately 10 in 100,000, annually.

 Based on the results of prior research in an older adolescent and adult population, it is likely that these 10 adolescents would have varied responses to question 9 of the PHQ-9, with some endorsing suicidal thoughts frequently but others endorsing no suicidal thoughts.

 Although accidents, some related to risk taking and illnesses, would have contributed to some more deaths, overwhelmingly most of the 100,000 cohort would be alive. We will discuss risk factors, but our current state of knowledge cannot predict which individual will commit a suicidal act or take a harmful risk, or when.

With these statistics and our lack of knowledge, pediatricians cannot (except in unusual circumstances) expect that they will prevent suicide either immediately or over the next 2 years. Suicidal ideation, depression, and positive parent-reported PSC scores are all alerts that a teenager is in emotional distress. They are more vulnerable to problems in school, family, or with peers, and to substance use, psychiatric disorders, and emotional suffering. Rather than focusing on immediate suicide prevention, the PSC and PHQ-9 select a population of teenagers who have “enduring vulnerability.”

 The screening interview is the first step in assessing the severity of this vulnerability and making recommendations.

This vulnerability is chronic, and just as with any chronic condition, the pediatrician provides appropriate follow-up and tracking. It is likely that half of teenagers who are identified as positive by the PSC and PHQ-9 will improve, and on repeat screening over time, will move from the positive to the negative score range or be at much lower risk. The remaining half, approximately 7% to 10% of all teenagers, will have more chronic or enduring vulnerability and will need ongoing follow-up and efforts to optimize helpful interventions.

Pediatricians should base referral decisions on their severity assessment and comfort level. Usually pediatricians are skillful in sensing the scale and complexity of a psychosocial issue and should refer for mental health evaluation. In general, if the PHQ-9 is positive in the range of moderate or above, and thoughts of death and suicide are frequent, timely referral is indicated to an experienced psychologist or psychiatrist. In less severe circumstances, the pediatrician can make recommendations concerning immediate stressors, suggest lifestyle changes

 (exercise, adequate sleep, meditation, activities that support self-esteem, tutoring, summer programs, etc), and offer guidance to both parents and the teenager. If specific depression treatment is indicated, referral for cognitive behavior therapy

 is a sound additional step. An increasing number of pediatricians are comfortable using first-line antidepressants to treat depression and anxiety. The evidence for the use of medication is stronger in more severe cases than in mild ones.

What will be of help in dealing with mental health requirements at baseline, and with heightened needs post COVID-19? First, psychosocial screening should be a routine process, just like taking vital signs. Second, follow-up should be consistent, to assess the trajectory of any issue, especially depression, and gain a deeper understanding of the patient. Third, have mental health experts accessible and ideally integrated into pediatric practice, working closely with clinicians to improve access and quality. In the near future, the use of artificial intelligence and large data sets derived from EMRs will hopefully facilitate the discovery of history and behavior patterns that provide more specific guidance for treatment, especially medication.

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The long-term impact of COVID-19 on mental health may not be known for years, but right now it's vital to assess mental health in teenagers to help them get the help they may require.

Assessing COVID-19’s impact: Adolescent psychosocial functioning and suicidal ideation in outpatient pediatric practice

Parents can be very confused and worried about the behavior of their adolescent children. The worries are exacerbated by real risks as adolescents venture into real world demands and exposure to substance use.

Teenagers can be much less predictable than grade school-aged children. They can be very dependent, like younger children, and then fiercely independent. They can be friends with a peer group parents consider appropriate and, weeks later, befriend a clique that is disreputable or delinquent. A teenager can cry on a parent’s shoulder one night and be distant, even rejecting, the next morning. They can talk about going to graduate school and then, without appreciating the discontinuity, discuss dropping out or casually considering far-fetched careers such as being a rock star, with little understanding of the demands or odds against success those choices carry.

Parents will ask pediatricians to make sense of their teenagers’ behavior and seek advice. They describe these behavioral changes and wonder which path their teenager will follow. Is today’s behavior transient or permanent? Should a parent be supportive, unconditionally accepting, demanding, critical, or impose tough love? Can the pediatrician predict future behavior or provide any reassurance that teenagers will straighten out?

This article aims to provide the pediatrician with a framework for understanding adolescent behavior. Psychology is but one lens through which to view adolescent development, but before highlighting this perspective it is important to note some other lenses that have major impact:

 All the physical, sexual, and hormonal changes, plus the secondary psychological effects of the rate of change, variations in growth compared to peers, etc. Puberty includes mental development with variability in brain regions that affect judgment, impulsivity, and emotional vulnerability.

 Intellectual ability and movement from concrete to abstract reasoning, appreciation of nuance, and a restless readiness to invest emotionally and intellectually in philosophy, religion, politics, etc.

 Family history and myths embedded in cultural/religious traditions and expectations.

 The impact of privilege, poverty, schooling, and neighborhood (eg, gangs).

Young people do not move in a linear fashion from childhood to adolescence. Typical adolescent development is characterized by moving forward toward adulthood and moving back toward childhood in cycles or a pendulum motion.

 However, the back-and-forth movement from more childish to more adult functioning is governed by emotions, which results in an even-uneven momentum. Sometimes the pendulum swings quite far back to a toddler-like tantrum, and can also move toward adult behavior demonstrating a work ethic in dealing with a complex interpersonal situation in a very mature manner, or even being parental in soothing a stressed father, mother, or sibling. All these movements are typical and to be expected.

This momentum is governed by puberty, expectations, relationships, culture, and cognitive and emotional development. The short-term retreats into childish behavior allow for a respite, an easing of stress, and some new energy generated by an argument (clean up your room) or nurturance (I made your favorite dinner). After some time in childhood, the teenager is ready to meet the next challenge; for example, recovering from a rejection (by a friend) or defeat (not getting the desired role in a school play) to try again going forth more autonomously.

Two underlying factors add to the intensity of feelings for all concerned: loss and self-image. Of course, adolescence brings wonderful opportunities, excitement, and is eagerly anticipated by late childhood. There will be much to accomplish; however, feelings of loss play a powerful role for parents and teenagers. For parents, time with a school-aged child seems endless, comfortable, not as complex. At 13 or 14 years, academic work gets more serious, independent, and relevant to college hopes. Time becomes finite and imaginable—4 or fewer years until they leave for college. Adolescents take risks autonomously, can keep secrets, choose and discard friends on their own, and can give up previously valued pursuits such as a sport or musical instrument.

After 10 years of childhood intimacy, something is lost with the onset of puberty that can never be recovered. Arguments about bedtime or curfew, when to do homework, use of cell phones, and what to wear often reflect parental attempts to maintain control, to limit a sense of loss and the teenager’s swing toward autonomy.

There is a similar underlying sense of loss for the teenager. Although explicitly desperate to be more independent, the teenager also knows that except for short periods it is impossible to reverse development, to fully go home. There is a longing at times for the more dependent days but spending any length of time back in childhood is uncomfortable, a sense of disease often remedied by a rapid pendulum swing toward adulthood sometimes facilitated by an irritable outburst.

To leave home (metaphorically) with a sense of certainty requires an enormous boost of self-confidence on the part of the teenager, a certainty that the adolescent can handle any situation, become a doctor, a lawyer, or both, or can make the varsity team or senior orchestra. Parental attempts to provide a realistic framework to deflate (and protect) the teenager’s unreasonable expectations are seen as insulting and even ignorant. Like an explorer boasting of leaving home base for uncharted territory, this burst of confidence is normal and necessary rocket fuel to energize a journey to adolescent lands never experienced before puberty. This fuel also provides a false sense of safety or even infallibility, which adds to the lure and danger of risk-taking behavior. All these dynamics are expected and essential.

Younger teenagers will begin to form a more intense relationship with some adult outside the home. It may be a relative or neighbor, the parent of a friend, a teacher in an area of strength (piano, math), or a coach of a sport. At this age the teenager may spend more or as much time as possible at the neighbor’s house or go to school early to be with the teacher. The nature of this attachment will be deeper than to anyone other than parents. Some parents will wonder why their 12- or 13-year-old is so devoted to someone who has not raised them and is not that different in parental/adult approach or values. This is a safe first step away from the parents while still holding on quite intensely to another adult prior to the next step which is a major commitment to peer relationships. This movement is often more of a sign of a close parental relationship and evolving an identity than rejecting the parents.

Usually after this investment in a nonparent adult relationship, a young teenager’s peers become increasingly meaningful.

 The peers’ opinions about clothing, style, and relationships gain importance. It is normal for the peer group to change, sometimes quite suddenly and radically, from an academic group to a sports group to, alarmingly, a more alienated group with use of substances or disdain for school. These shifts in group allegiances are part of trying on temporary identities to see which aspects may fit and which swing toward or away from parental acceptance and traditions.

Early in the shift to nonparental adults and peer groups, many teenagers experience a crush—a moment when their sexual and personal attraction to another teen is so strong that the opportunity to catch sight of this new, critically meaningful peer is enough to sidestep a parent’s rule. Although this crush may not last long and may be one-sided, it is a moment that some believe signals the true psychological beginning of adolescence.

By mid-adolescence there are key adults including a coach, teacher, or adviser, as well as several peer groups that have been explored and tested as aspects of an emerging identity. These relationships have been augmented by videos, chats, social media, and thousands of text and image communications between an inner circle of peers and a huge number of others influencing the teenager.

By later adolescence, identity begins to solidify, though still plastic, and choices are about college and tentative career aspirations. More intimate interpersonal relationships supplement or at times supplant peer groups. Toward the end of adolescence, development evolves into a firmer concept of “what my 20s will be like.”

As the teenager experiences puberty, family expectations, school demands, and peer acceptance and rejection, the stress can be overwhelming. The only solution is to retreat, grieve, deflect, and reframe. The pendulum that has been in the zone of facing all these demands swings back and the adolescent may find solace with an intense investment in 1 peer group or activity to the exclusion of all else, a desperate leaving of the circumstances by running away or turning to drug use, or retreating by picking fights or seeking parental comfort.

Time spent being childish is moving against the tide of puberty, mastery, and development. The temporary comfort for normal adolescents will become increasing uncomfortable and they will begin to swing back—sometimes with irritability, sometimes with maturity. These swings are often microscopic, such as not caring about a difficult exam and afterward being able to move on with care (preparing better after a poor grade).

Retreating for too long can signal a more serious pathological break in development, the pendulum being stuck in behaviors that block progression and are self-perpetuating, such as addiction, premature or promiscuous sexuality, or serious violation of parental rules. These situations can make the teenager feel they have no way home. For one of every few thousand teenagers in high school, the effort to reach adulthood feels hopeless, substance use and/or impulsivity impair judgment, and/or there is a biologic vulnerability to depression, all of which may tragically result in suicide. Further, under these stressors, some teenagers will have suicidal ideation and a smaller subset attempt suicide.

The parental worries about adolescents vividly stick in our minds compared to the good outcomes that are much more common. For the vast majority of teenagers, the pendulum swings are not as severe. Support systems at home and school, or the collective wisdom/judgment of peers are all adequate to the task, and movement to adulthood is mostly successful.

The adolescent patient eliciting parental concern is an individual with a temperament, personality, level of self-esteem, and strengths and weaknesses. When asked to evaluate the mental health of your patient, you are being given a parentally edited snapshot. The snapshot that brings the teenage patient to your attention is often an argument or a high-risk behavior that is an accurate reflection of that moment but is only 1 frame of a 10-year-long movie that starts from finding a school locker or having a crush and ends with graduating college.

Almost nothing is harder than seeing an upset, difficult, or depressed adolescent and fully understanding their personal struggles, helping parents reflect on their own behavior, advising how to help their teenager, and predicting the future trajectory. Putting the snapshot into perspective means asking about preadolescent development and seeing whether any patterns or trauma are continuing to affect the pendulum movements.

Threads of current loss, failed hopes, and peer and parental relationships can be followed from the current crisis back to earlier times to assess whether development proceeded as expected. Is the behavior designed to distant the parents? How is the adolescent functioning in school, at home, in activities? Do they have hope? Are they connected to friends, religion, school, or activities? Are they depressed or addicted to a substance?

The pediatrician can take all this into account and humbly recommend some steps to meet the adolescent where they are and provide suggestions to move the pendulum toward a developmental trajectory. These suggestions could include parental advice on providing more support/structure or allowing more autonomy, reframing a situation to recommend options (talking to a teacher or guidance counselor to deal with an academic problem), reframing the adolescent’s perspective, offering a follow-up appointment sooner to continue the discussion, or, if needed, a mental health referral. Sometimes sharing a similar situation from a previous patient or from one’s own experience can provide an option or hope.

Much of the pediatrician’s insight will be based on the quality of the relationship between the teenager and this known, respected, nonparental adult. Building the relationship at ages 10, 11, and 12 years is helpful. Creating a safe, kind, respectful setting is a major step and listening with empathy and tolerance will often lead to a readiness by the adolescent to listen.

1. Diekema DS. Adolescent brain development and medical decision-making. 

. 2020;146(suppl 1):S18-S24. doi:10.1542/peds.2020-0818F

Inventing Ourselves: The Secret Life of the Teenage Brain

3. Rageliene T. Links of adolescents identity development and relationship with peers: a systematic literature review. 

4. Blos P. The second individuation process of adolescence.

. 1967;22:162-186. doi:10.1080/00797308.1967.11822595

A teenager’s day-to-day behavior can vary greatly. Here are some tips in understanding and navigating this challenging time.

 

Helping parents cope with adolescent behavior

As the weather gets warmer and we are increasingly liberated from COVID-19 constraints, accident prevention should become a high priority. As pediatricians, we appropriately focus on physical measures like helmets for biking or skateboarding, seat belts when in cars, and self-locking fences and gates around pools. Less often do we consider psychosocial issues that could significantly affect the risk for injury from accidents.

For younger children, drowning (about 1000 deaths per year) and unintentional gunshots (about 3000 firearm-related injuries) are the most common accidents.

 Both types of events happen quickly. Pools should have proper fences and gates. Guns should have trigger locks with ammunition stored and locked in a separate site. In addition, pediatricians should ask about potential stressors that could distract parents. Are the parents supervising several young children at the same time? Is there an elderly or ill parent who needs constant attention in the home? Is there family conflict that has resulted in distractions? Is there substance abuse, especially alcohol, that has interfered with childcare? These questions can seem hard to ask, but if, for example, the pediatrician starts by inquiring about access to a pool and then notes the dangers of drowning, these questions will be seen as caring and not critical.

Given an adolescent’s less-developed sense of judgment and often heightened self-confidence, teenagers don’t often stop to ask, “should I take this risk?” Children and adolescents with short attention spans, impulsivity, and depression are at increased risk, because these conditions further impair judgment and result in less consideration about safety. Pediatricians can assess a teenager’s behavior and judgment, and then have a frank conversation about potential decisions that youth may have to make. What kind of dangerous behaviors have they seen among peers? How do they decide how much to drink at a party? How rigorous are they about drinking and being a passenger or driving themselves? Will their friends watch out for them? Do they have good judgment? If they tend toward depression, do they ever think about taking a risk and not really caring about the consequences? Of course, parents have the major role in accident prevention. Pediatricians can ask how parents see their children reacting to safety measures. Do they accept seat belts and helmets, and how do their children assess risks? Have parents reviewed various scenarios for when their children and teenagers are on their own, such as with friends in a park, at a pool, at a party? Have there been forthright conversations about being vulnerable when drunk and how parents will react to a call for help if that call avoids a dangerous situation? What kind of risks did the parents take as teenagers? What behaviors do they demonstrate with alcohol or when driving? What parents do as role models far outweighs what they say.

Summer is a good time to prioritize accident prevention. Send out some information electronically prior to a visit, have some materials in the waiting room, and pick a question or 2 to ask during visits with your patients as the weather gets warmer.

1. Brady United. Key statistics. Accessed May 1, 2021. https:

With the joy of summer and easing of some COVID-19 restrictions, children and families are eager to be outdoors and active. Sadly, accidents, many of which are preventable, are a leading cause of morbidity and mortality in children and teenagers.

Preventing summer accidents

When I started my pediatric residency, I knew my long-term career goal was to be a child and adolescent psychiatrist. I very much appreciated that the pediatric residency built my core identity as a physician, capable of caring medically for children whether in an intensive care unit or in primary care. However, my natural bent was to always include the psychosocial aspects of care and to ask more psychologically oriented questions after the necessary medical information was gathered, for example, when admitting a child to the hospital. When I went to my primary care clinic, I, of course, completed all the usual screening and vital sign measures. Height, weight, urine screening for infection and diabetes, as well as traditional vital signs were done at every visit. In infants and toddlers, developmental issues such as sitting, walking, first words, and toilet training were well noted. However, through working in both an academic and community clinic setting, I was increasingly convinced that there were psychosocial concerns unaddressed and not recognized by any available screening approach.

Most supervising attendings would ask 1 or 2 questions about school or friendships that had a ‘hit or miss’ quality. The director of the clinic was wonderfully intuitive and almost magically sensed which children needed a mini-psychiatric review. However, at the time, there was no training requirement in behavioral pediatrics and even the rotations now instituted could not train someone to select children in a primary care setting without some screening mechanism. Overall, the recognition of emotional problems in pediatrics was highly variable, and the research conducted in the late 1970s indicated that the identification of emotional problems in pediatric primary care was well below expectations set by epidemiological studies.

 I wondered if there could be a short, valid screening questionnaire that could fit into the flow of a busy clinic and identify children in need of further pediatric evaluation and potential mental health referral.

I knew the time pressure and workflow in primary care practice. Any screening process, like a urine dipstick or blood pressure, had to be brief, take no more than 3 or 4 minutes to administer and score, and not clog up the waiting room that had been built to accommodate the typical flow of patients. The screen had to be understandable and readily accepted by parents and teenagers and, if possible, one form had to be applicable to a broad age range. The front desk had enough paper to deal with (electronic records were still 30 years in the future) that there could not be different screening forms by age, gender, or other demographic factors. Using the metaphor of a urine dipstick, the screening had to be simple with one form on one shelf. Given the economics of practice, the screen had to be free to administer and score and potentially be reimbursable like other routine procedures.

1. What issues or problems should a set of screening questions identify?

As a psychiatrist, I was trained to look for sets of symptoms that met criteria for a disorder—a system better suited to adults than to children, given the complexities of development and family considerations. Pediatricians were not familiar with lists of symptoms, with a certain number of symptoms needed for a diagnosis, independent of family or developmental history, and with a diagnostic result of more than one mental health diagnosis. A child diagnosed with major depression from the psychiatric perspective could be 11 or 16 years of age, could have a strong family history of depression suggesting a largely biological etiology, or could be trying to cope with divorcing parents, bullying at school, an alcoholic, abusive father, or a family’s food insecurity. Many pediatricians had no experience with this psychiatric diagnostic approach, were uncomfortable with one or more diagnoses not grounded in an etiology, and/or found it of limited use in communicating with parents or colleagues.

Rather than lists of symptoms, pediatricians start by asking how old is the child and how are they functioning with friends, school, activities, in family life? What is the status of the child’s mood and self-esteem? Given the strong reluctance to use the psychiatric symptom-based approach, to be broadly accepted, psychosocial screening in primary care would have to be based on understandable questions regarding daily functioning. A child’s daily functioning is an expression of their strengths and stressors. A child’s functioning is the common pathway for the influences of genetics, their psychological development, social determinants of health, coping abilities, and resilience. In the context of the epidemiology of childhood psychosocial issues, a screen will find 10%-15% of all 4-16-year-old children “positive,” meaning the pediatricians should include assessing the child further as part of the pediatric visit.

The questionnaire items reflect difficulties in psychosocial functioning with the goal of coming to a score that reflects risk versus non-risk. The first version of the screening tool had 35 questions for parents to rate their child’s problems as occurring “never,” “sometimes,” and “often.” Naming the screening questionnaire, “The Pediatric Symptom Checklist” (PSC) emphasized that a child’s psychosocial functioning was a core and routine part of pediatric healthcare. The PSC was freely available with no charge for the tool, its use, or scoring. More than a decade after initial validation, some colleagues found that groups of questions on the PSC clustered together and could reliably identify risk in 3 different domains: externalizing, internalizing, and attention problems in a shorter 17-item format of the PSC.

Generally, a parent or legal guardian brings the child for the pediatric visit and is typically the person in the best position to assess the child’s functioning. The questionnaire reflects a parents’ perceptions and when considering the psychosocial functioning of a child, a parent is more like the umpire in a baseball game. A ball thrown by the pitcher is defined as a ball or strike by the umpire, and once defined, enters history as what the umpire indicated. Is a child more often alone, having fun, or not listening to rules? There are no objective counts, only a parents’ sense of the situation and that is why “often” scores are so relevant. The major area where parents’ perception is limited is with teenagers, when their thoughts are often private, and a related depressive mood may be hidden. A youth-completed version of the PSC has been developed and other instruments specific to adolescent depression such as the patient health questionnaire (PHQ-9 )are also available.

3. What is the clinical path of a primary care pediatrician if a screen is “positive”?

The goals for the clinician are to assess if the screen is a true positive (similarly to other positive screens, eg, repeating a higher than expected blood pressure), and, if deemed valid, assessing the level of severity and next steps. Questions answered “often” are a good starting point for the pediatrician to solicit the parent’s understanding, and to explore the impact of the behaviors on the child’s and family’s functioning. The next step is to have the pediatrician ask questions about other areas of functioning (school, friends, activities, family, and mood). Depending on these answers, it may be relevant to ask about family violence, any mental health treatment, family history of emotional disorders, and safety concerns (access to guns or dangerous adult medications). Usually, in about 15 minutes, pediatricians get a sense of whether this is a true positive, the general nature of the issue and the severity of impairment or suffering. Next steps might be to offer counseling, schedule a follow-up (“watchful waiting”), or refer to a mental health consultation. Repeat PSCs can be given at the appropriate interval to monitor watchful waiting or get some feedback on the course of treatment post referral. The PSC more than doubled both the recognition and referral rate for psychosocial dysfunction (See Figure).

Since its initial creation, over 35 years of research on the PSC in more than 200 studies has shown its validity and reliability in a wide range of settings,

 demonstrated that it is understood and well-accepted by parents and clinicians,

 is sensitive to the impact of social determinants of health and poverty on mental health,

 can be shortened from a 35- to a 17-item version, can be used in both a parent- and youngster-reported format,

 and that regular use of the PSC is associated with an increase in mental health treatment.

 The PSC is also used in specialty pediatric and mental health clinics, schools, Head Start, state agencies, and online.

In Massachusetts, the PSC was one of a handful of recommended screening questionnaires mandated by a Federal Court as part of a remedy to broaden mental health services for children with Medicaid.

 The PSC has been endorsed by the Massachusetts and California Medicaid programs, the American Academy of Pediatrics, and the National Quality Forum, both for overall screening and for screening adolescents for depression using its internalizing scale.

 The PSC is now included in many if not most US electronic medical record systems (EMR) including two of the most widely used (EPIC and Centricity).

Studies of the PSC in an EMR indicate that 70%-90% of children in large systems can be screened routinely, that pediatricians document their discussion of PSC scores in medical records, generally selecting the higher scoring children for mental health referral. The screen is now a routine feature of the visit and increases referrals for mental health services.

Many questions, however, still remain unanswered: Which children benefit the most from early recognition (those with the highest scores or those with lower levels of risk)? Can the PSC be used to track progress in treatment or highlight the need for more intensive treatment? What is the natural history of an individual’s scores over a decade or more of childhood and adolescence, how should outcomes in functioning be measured, and can the PSC be used more effectively to identify impending adolescent risk taking and suicidal behavior? The PSC is now widely used and is a major bridge between pediatric and mental health care. However, with the burden of mental health problems rising, especially during and post COVID, the bridge should be busier, better resourced, and refined by future research.

1. Gould MS, Wunsch-Hitzig R, Dohrenwend, B. Estimating the prevalence of childhood psychopathology: a critical review. 

2. Pediatric Symptom Checklist. Massachusetts General Hospital Website. 

https://www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptom-checklist

3. Gardner, W, Murphy, M, Childs, G, et al. (1999). The PSC-17: A brief pediatric symptom checklist with psychosocial problem subscales. A report from PROS and ASPN. 

4. Jellinek M, Murphy J. Screening for psychosocial disorders in pediatric practice. 

5. Murphy JM, Reede J, Jellinek MS, Bishop SJ. Screening for psychosocial dysfunction in inner-city children: further validation of the pediatric symptom checklist. 

6. Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM, Kelleher KJ. Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study

7. Arauz-Boudreau A, Riobueno-Naylor A, Haile H, et al. How an electronic medical record system facilitates and demonstrates effective psychosocial screening in pediatric primary care. 

8. Spencer AE, Baul TD, Sikov J, et al. The relationship between social risks and the mental health of school-age children in primary care. 

A good approach to knowing when a child needs referral for mental health evaluation, the Pediatric Symptom Checklist has evolved over the years to better screen children.