Jane Mendle, PhD’s research at Cornell University in Ithaca, New York, investigating the long-term psychological effects of early puberty has significant implications for our practices as pediatric nurse practitioners—and for all healthcare providers. Dr Mendle’s work is presented by Ms. Nierengarten in her April 2018 Contemporary Pediatrics article, “Early puberty in girls has long-term psychological effects.” The article reviews Dr Mendle’s prospective study which explored the correlation of onset of puberty and symptoms of depression. Her study findings revealed that 25% of girls who began menarche at 8 years of age had evidence of depression during their adolescent years, and 20% of those experiencing depression had it continue into young adulthood.
Dr Mendle’s research provides insightful information that can be directly applied to clinical practice to improve the recognition and time to treatment for depression in school-age children, adolescents, and young adult women, as well as the infants and young children of these women. The first step is to re-think the current practice for timing and age of screening for depression in primary care settings. Current recommendations for screening for depression call for it during the adolescent years in which the Personal Health Questionnaires (PHQ-2 and PHQ-9) are routinely administered at annual health maintenance visits and episodic visits.
However, based on Dr. Mendle’s research findings, practitioners must consider a change to screening all females for depression beginning at the onset of menses, especially when onset is at 8 years of age. Currently, screening for depression in children is not a standard of practice in primary care centers, most likely based on the lack of valid and reliable tools that screen for depression in children that can be easily administered by primary care providers. Specific depression screening tools for depression are lacking for school-aged children, or only contain a few questions embedded within a tool the results of which may show evidence of cognitive, emotional, or behavioral problems, such as the Pediatric Symptom Checklist (www.brightfutures.org). Clearly, it is time to conduct research studies to develop valid and reliable screening tools for depression in school-aged children that can easily be administered in primary care settings.
The maternal linkage?
On March 21, 2018, at the annual conference of the National Association of Pediatric Nurse Practitioners (NAPNAP) held in Chicago, Illinois, I gave a presentation entitled, “Assessing Infant Behavioral and Emotional Health: Preventing Life-Long Adverse Outcomes.” I discussed the research evidence showing a relationship between postpartum depression and the need for early recognition of symptoms for impaired emotional development in infants being raised by mothers with unrecognized and/or untreated depression. Has there been an unrecognized relationship between the early onset of puberty and an increase prevalence of maternal postpartum depression, leading to adverse infant emotional development? Current guidance by the American Academy of Pediatrics (www.aap.org) recommends administering the Edinburgh Postnatal Depression Scale (EPDS) in pediatric practices to detect postpartum depression in women whose infants are aged younger than 6 months. Although we should implement this recommendation, we must also ask the mother, “At what age did you begin menstruating?” This may alert us about a possible increased incidence of depression.
Change at the policy level
Depression is a major problem throughout the lifespan. Early identification and treatment of depression is critical to assuring healthy growth and development throughout the pediatric, adolescent, and young adult populations. Nurse practitioners—and all pediatric healthcare providers—can play a critical role in changing practice policies both at the micro-and macro-systems levels to include depression screening. If screening reveals the need, then referral to treatment should be policy. The burden of depression for the individual, the family, and society will only be tackled by screening and early referral to treatment. If we take the lead on implementing these practices within the primary care setting, we can foster improved behavioral and mental health outcomes.
American Academy of Pediatrics. Maternal depression screening. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/documents/maternaldepressionscreeningguidance.pdf
Bright Futures. Pediatric symptom checklist. www.brightgutures.org Retrieved from https://brightfutures.aap.org/Bright Futures Documents/Pediatric Systems Checklist (PSC-35).pdf