Earthquake exposure, adverse childhood experiences, and psychosocial functioning in Chilean children: A longitudinal study.

The impact of an 8.8 magnitude Chilean earthquake on elementary school students' psychosocial functioning was assessed along with exposure to adverse childhood experiences (ACEs). Skills for Life, a national school-based mental health program in Chile, routinely assesses first- and third-grade students' psychosocial functioning and classroom adaptation. Students (N = 19,627) were screened before (2009) and after (2011) the 2010 earthquake with parent- and teacher-report measures and with a parent-report of four ACEs (family psychopathology, child chronic illness, family social isolation, father absence). Earthquake exposure was categorized as mild, moderate, or severe for Chile's 15 regions. Multilevel models analyzed the unadjusted and adjusted impacts of earthquake exposure and ACEs on functioning while clustering for school- and district-level effects. In covariate-adjusted models, earthquake exposure and three ACEs were significantly associated with worsened psychosocial functioning; earthquake exposure and all four ACEs were significantly associated with worsened classroom adaptation. New family psychopathology, B = 1.90, p < .001; chronic illness, B = 2.25, p < .001; and severe earthquake impact, B = 1.29, p < .001, held the strongest negative effects on psychosocial well-being. Moderate, B = 3.04, p = .011, and severe earthquake exposure, B = 2.53, p = .047, and new family psychopathology, B = 1.99, p < .001, were associated with the worst classroom functioning 1-year postdisaster. Findings suggest that both exogenous and home-based stressors can have significant consequences for children's psychosocial functioning and classroom adaptation, and routine screening helps quantify how individual students are affected by chronic versus acute stressors.

Recognizing Adolescent Depression with Parent- and Youth-Report Screens in Pediatric Primary Care.

OBJECTIVES: To compare the use of the parent-report Pediatric Symptom Checklist (PSC-17P) and youth-report Patient Health Questionnaire-9 Modified for Teens (PHQ-9M) in compliance with recent quality standards for adolescent depression screening. STUDY DESIGN: Parents of 5411 pediatric outpatients (11.0-17.9 years old) completed the PSC-17P, which contains scales that assign categorical risk for overall (PSC-17P-OVR), internalizing (PSC-17P-INT), externalizing (PSC-17P-EXT), and attention (PSC-17P-ATT) problems. Adolescents completed the PHQ-9M, which assesses depressive symptoms. Both forms were completed online within 24 hours of each other before pediatric well-child visits. RESULTS: A total of 9.9% of patients (n = 535) were at risk on the PSC-17P-OVR, 14.3% (n = 775) were at risk on the PSC-17P-INT, and 17.0% (n = 992) were at risk on either or both scales (PSC-17P-OVR and/or PSC-17P-INT). Using the PHQ-9M cut-off score of 10 (moderate-very severe depression), an additional 2.4% (n = 131) were classified as at risk, with 66.8% (n = 263) of all PHQ-9M positives (n = 394) also coded as at risk by the PSC-17P-OVR and/or PSC-17P-INT scales. Using a PHQ-9M cut-off score of 15 (severe-very severe depression), only 29 patients (21.8% of the PHQ-9M positives) not identified by the PSC-17P-OVR and/or PSC-17P-INT were classified as being at risk. CONCLUSIONS: The combined PSC-17P-OVR and/or PSC-17P-INT scales identified 17% of adolescents as at risk for depression, including about two-thirds to three-quarters of adolescents classified as at risk on the PHQ-9M. These findings support using the PSC-17P to meet quality standards for depression as well as overall screening in pediatrics. Primary care clinicians can add the PHQ-9M to identify additional adolescents who may self-report depressive symptoms.

Using a Brief Parent-Report Measure to Track Outcomes for Children and Teens with ADHD.

The Pediatric Symptom Checklist (PSC) is a widely used, parent-completed measure of children's emotional and behavioral functioning. Previous research has shown that the PSC and its subscales are responsive to patient progress over the course of psychiatric treatment. In this naturalistic study, parents and clinicians of 1736 patients aged 17 or younger completed standardized measures at intake and 3-month follow-up appointments. We assessed the 5-item PSC Attention Subscale (PSC-AS) as a longitudinal measure of attention-related symptoms in routine outpatient psychiatry treatment. Secondarily, we compared PSC-AS scores with clinician-reported diagnoses, psychomotor excitation symptoms, and overall functioning. Change scores on the PSC-AS were larger among patients with ADHD diagnoses than those with non-ADHD diagnoses. Comparisons between PSC-AS scores and clinician reports also showed acceptable levels of agreement. Given its effectiveness in tracking attention-related symptoms, the PSC may be particularly useful as a quality assurance or treatment outcome measure for clinicians treating ADHD.

Using a Brief Parent-Report Measure to Track Outcomes for Children and Teens with Internalizing Disorders.

The Pediatric Symptom Checklist (PSC) is a widely-used, parent-completed measure of children's emotional and behavioral functioning. Previous research has shown that the PSC and its subscales are generally responsive to patient progress over the course of psychiatric treatment. In this naturalistic study, we examined the performance and utility of the five-item PSC Internalizing Subscale (PSC-IS) as an assessment of routine treatment in outpatient pediatric psychiatry. Parents and clinicians of 1,593 patients aged 17 or younger completed standardized measures at intake and three-month follow-up appointments. Comparisons between PSC-IS scores and clinician-reported diagnoses, internalizing symptoms, and overall functioning showed acceptable levels of agreement. Change scores on the PSC-IS were also larger among patients with internalizing diagnoses than those with non-internalizing diagnoses. As a brief measure of internalizing symptoms, the PSC may be particularly useful to mental health clinicians treating youth with depression and anxiety as a quality assurance or treatment outcome measure.

Mental health predicts better academic outcomes: a longitudinal study of elementary school students in Chile.

The world's largest school-based mental health program, Habilidades para la Vida [Skills for Life (SFL)], has been operating on a national scale in Chile for 15 years. SFL's activities include using standardized measures to screen elementary school students and providing preventive workshops to students at risk for mental health problems. This paper used SFL's data on 37,397 students who were in first grade in 2009 and third grade in 2011 to ascertain whether first grade mental health predicted subsequent academic achievement and whether remission of mental health problems predicted improved academic outcomes. Results showed that mental health was a significant predictor of future academic performance and that, overall, students whose mental health improved between first and third grade made better academic progress than students whose mental health did not improve or worsened. Our findings suggest that school-based mental health programs like SFL may help improve students' academic outcomes.

Outpatient Evaluations: The Electronic Medical Record Report.

Conducting a new patient evaluation is a core skill in the practice of child and adolescent psychiatry. For residents, the psychiatric evaluation of a child is a stressful transition point moving from general to a child psychiatric specialty requiring new knowledge and skills.

Identifying Children and Adolescents at Elevated Mental Health Risk Before and During COVID-19.

OBJECTIVE: To determine whether the prevalence of psychosocial risk in children and adolescents changed from before to during the COVID-19 pandemic and whether these changes differed by age group, sex, and season, based on a standardized psychosocial measure completed as a routine part of primary care. METHODS: Children and adolescents aged 5.5 to 17.9 years were screened with a parent report Pediatric Symptom Checklist-17 (PSC-17P) between November 2017 and June 2022. Changes in the prevalence of psychosocial risk (global, internalizing, externalizing, and attention scales) from before to during the pandemic were compared by age group, sex, and season. RESULTS: In a sample of 459,767 health supervision visits, the prevalence of PSC-17P global, internalizing, and attention risk worsened significantly from before to during the pandemic, especially among female adolescents (ages 12.0-17.9). For a pediatrician seeing a hypothetical sample of 1000 adolescent girls, the expected number at risk would have increased from 103 to 131 on the global scale (26.6% increase), from 189 to 231 on the internalizing subscale (22.0% increase), and from 60 to 82 on the attention subscale (35.7% increase). Seasonality had a large effect, with significantly lower PSC-17P risk in the summer every year. CONCLUSION: Data from a large, national sample of pediatric visits suggested that global, internalizing, and attention concerns increased slightly overall from before to during the COVID-19 pandemic, with different patterns by age group and sex. Adolescent girls showed substantially increased global, internalizing, and attention problems. These increases support the need for further research and additional individual and system-level interventions.

Screening and Follow-Up Treatment Practices for Suicide Risk in Adolescent Primary Care: A Retrospective Chart Review.

Universal depression screening in adolescent primary care often encompasses questions about suicide risk. We conducted a retrospective chart review of well-child visits where adolescents (ages 13-17.9) had endorsed self-injurious thoughts and behaviors or suicidal ideation. The goal was to investigate primary care providers' follow-up actions, including documentation, further assessment, and referrals. Over 3-quarters of the progress notes showed evidence of further assessment, and two-thirds documented same-day actions, including mental health referrals, emergency department referrals, safety plans, medication changes, primary-care follow-up, and talking to parents. Actions varied by depression severity. Cases without interventions often had justifications. Owing to the variety of possible meanings and severity underlying positive screens, providers implemented an array of interventions, using clinical judgment to tailor actions to patients' individual needs and preferences. From these observations, we propose that standardized guidelines for suicide risk screening and follow-up should involve a clinical assessment and individualized treatment planning.

Identifying and responding to depression in adolescents in primary care: A quality improvement response.

The American Academy of Pediatrics (AAP) recommends adolescent depression screening and subsequent follow-up for those scoring at-risk. The current study assessed the outcomes of a Quality Improvement (QI) project that implemented these guidelines during annual well-child visits in a network of pediatric practices. This project used a two-stage screening process. First, adolescents were screened with the Pediatric Symptom Checklist (PSC-17). Second, adolescents who screened at-risk on the PSC-17 were asked to complete the Patient Health Questionnaire (PHQ-9). QI-participating providers received training on how to categorize the severity of their patient's depression based on PHQ-9 cut-off scores and clinical interview, and to implement and document appropriate options for follow-up. Patients in the QI group were significantly more likely to be screened with both the PSC-17 (93.8% vs. 89.1%, p < .001) and the PHQ-9 (54.8% vs. 16.4%, p < .001) compared to those in the non-QI group. Of the 80 adolescents in the QI group at-risk on the PSC-17 and with a completed PHQ-9, 65 (81.3%) received at least one type of referral for mental health, ranging from behavioral health services to lifestyle interventions. Findings support the feasibility of adolescent depression screening and referrals within pediatric primary care.

To screen or not to screen: Are we asking the right question? In response to considering de-implementation of universal perinatal depression screening.

This Editorial is a response to the Canadian Task Force on Preventive Health Care's recent recommendation "against instrument-based depression screening using a questionnaire with cut-off score to distinguish 'screen positive' and 'screen negative' administered to all individuals during pregnancy and the postpartum period (up to 1 year after childbirth)." While we acknowledge the gaps and limitations in research on perinatal mental health screening, we have concerns regarding the potential impact of a recommendation against screening and for "de-implementation" of existing perinatal depression screening practices, particularly if there is not careful attention to the specificity as well as limitations of the recommendation, or if there are not clear alternative systems put in place to support the detection of perinatal depression. In this manuscript, we highlight some of our key concerns and suggest considerations for perinatal mental health practitioners and researchers.

The Relationship Between First-Grade Psychosocial Functioning and Educational Outcomes through Eighth Grade in a Large Sample of Chilean Youth.

BACKGROUND: The association between early childhood psychosocial problems and poorer educational outcomes is well-documented, but the extent to which this association persists is less understood. The current study assessed the correlations between first-grade psychosocial functioning and educational outcomes through eighth grade in a large longitudinal sample of Chilean students. METHODS: The Pediatric Symptom Checklist-Chilean (PSC-CL) and Teacher Observation of Classroom Adaptation Re-Revised (TOCA-RR) assessed psychosocial functioning for 9736 students who were screened four times from first through eighth grade through the Skills for Life program. Adjusted linear mixed effects models assessed the association between first grade PSC-CL and TOCA-RR risk and third, sixth, and eighth grade GPA and school attendance. RESULTS: First-grade PSC-CL and TOCA-RR risk both significantly predicted lower third, sixth, and eighth grade GPAs; all p < .001. The relationships between first-grade psychosocial functioning and later school attendance rates were less consistent but still significant at certain time points. CONCLUSIONS: First-grade psychosocial risk was persistently associated with lower academic performance in a longitudinal sample of Chilean students followed through elementary and middle school. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Early school-based psychosocial screening and follow-up interventions have the potential to improve students' long-term educational outcomes.

Implementation and Outcomes of a National School-Based Mental Health Program for Middle School Students in Chile.

Background: Chile's national school-based mental health program, Skills for Life (SFL), has demonstrated effectiveness in improving behavioral and academic outcomes in first- through third-grade students. The current study assessed the feasibility and outcomes of SFL's program for sixth- through eighth-grade students. Methods: We assessed the percentage of students who participated in the program and longitudinal changes on teacher-reported Teacher Observation of Classroom Adaptation Re-Revised (TOCA-RR) scores, youth-reported Pediatric Symptom Checklist-Chile (PSC-Y-CL) scores, grade-point average, and school attendance from sixth to eighth grade (2016-2018) for SFL's workshop intervention. Linear mixed effects models analyzed the association between outcome variables and workshop attendance. Results: Of the 30,649 sixth graders who attended the 754 participating schools in 2016, 28,204 (92.0%) were screened with the TOCA-RR. Of the 1829 students who screened at risk, 1344 had available workshop data for seventh grade, with 86.9% of them participating in most (≥ 7) workshop sessions. Workshop attendance was significantly associated with improvements in school attendance and peer relationships (a TOCA-RR subscale) in eighth grade. Conclusions: With high rates of behavioral health screening and workshop attendance, this study demonstrated the feasibility of implementing SFL's middle school program on a national scale. Higher workshop attendance by at-risk students was associated with better school attendance and peer relationships in eighth grade, as well as better but not significantly different outcomes on other measures (e.g., teacher-rated school performance and aggressive behavior in the classroom). Overall, these findings provide preliminary evidence of the feasibility and benefits of SFL's middle school program.

Screening Infants Through Adolescents for Social/Emotional/Behavioral Problems in a Pediatric Network.

OBJECTIVE: To assess changes in screening completion in a diverse, 7-clinic network after making annual screening for social/emotional/behavioral (SEB) problems the standard of care for all infant through late adolescent-aged patients and rolling out a fully automated screening system tied to the electronic medical record and patient portal. METHODS: In 2017, the Massachusetts General Hospital made SEB screening using the age-appropriate version of the Pediatric Symptom Checklist the standard of care in its pediatric clinics for all patients aged 2.0 months to 17.9 years. Billing records identified all well-child visits between January 1, 2016 and December 31, 2019. For each visit, claims were searched for billing for an SEB screen and the electronic data warehouse was queried for an electronically administered screen. A random sample of charts was reviewed for other evidence of screening. Chi-square analyses and generalized estimating equations assessed differences in screening over time and across demographic groups. RESULTS: Screening completion (billing and/or electronic) significantly increased from 2016 (37.2%) through 2019 (2017 [46.2%] vs 2018 [66.8%] vs 2019 [70.9%]; χ2 (3) =112652.33, P < .001), with an even higher prevalence found after chart reviews. Most clinics achieved screening levels above 90% by the end of 2019. Differences among demographic groups were small and dependent on whether data were aggregated at the clinic or system level. CONCLUSIONS: Following adoption of a best-practice policy and implementation of an electronic system, SEB screening increased in all age groups and clinics. Findings demonstrate that the AAP recommendation for routine psychosocial assessment is feasible and sustainable.

Using brief clinician and parent measures to track outcomes in outpatient child psychiatry: longer term follow-up and comparative effectiveness.

BACKGROUND: This study explored the feasibility and validity of using brief clinician- and parent-rated measures routinely over 6 months in outpatient child psychiatry. METHOD: All patients under 18 years of age seen for intake in the Child Psychiatry Clinic from 1 August 2007 through 31 July 2010 were eligible for inclusion in the study. Data were collected at intake for 1033 patients and at 3- and 6-month follow-up. RESULTS: ANOVA for repeated measures showed statistically significant improvements in total and subscale scores on all three measures (Brief Psychiatric Rating Scale for Children, Children's Global Assessment Scale, and Pediatric Symptom Checklist) at both second and third assessments. CONCLUSION: The fact that both broadband and narrowband scales showed significant improvements over the first 6 months of care establishes the possibility that these measures could be used in experimental designs studying comparative effectiveness.

Back to Basics: Lifestyle Interventions for Adolescent Depression.

LEARNING OBJECTIVES: After completing this activity, practitioners will be better able to:• Discuss and better understand the recently adopted screening standards for adolescents with depression and the potential advantages of using "lifestyle medicine"• Set up a process for providing effective interventions for the increased number of patients with adolescent depression• Design or update their toolbox of treatment options for adolescents with depression based on the new literature and increased demand. ABSTRACT: Recently adopted quality standards recommend that pediatricians screen adolescents for depression and that they document follow-up plans for those who screen positive. As a result of these new recommendations, pediatricians and other pediatric providers, as well as psychiatrists and other mental health professionals, may face an increasing number of referrals and a growing need for effective interventions for adolescent depression. Given the widely acknowledged scarcity of traditional mental health resources, the current study reviewed the rapidly expanding array of evidence-based, but nontraditional, interventions applicable to outpatient pediatric and mental health care settings. Many of these interventions come from a lifestyle medicine framework. Lifestyle medicine interventions are congruent with the cultures of pediatrics and outpatient psychiatry, and offer additional evidence-based tools for providers managing adolescent depression. These interventions can be implemented individually or within group or community settings, and may be used in conjunction with more common interventions such as psychotherapy or psychotropic medications.

Suicidal Ideation in Adolescents: Understanding Results from Screening with the PHQ-9M and the PSC-17P.

OBJECTIVE: The objective of the study was to help pediatricians understand and respond to suicidal ideation (SI) in adolescents based on data from 2 widely used screening measures that assessed SI and other psychosocial vulnerabilities in a large, national sample. METHODS: Adolescents (ages 11-17 years) completed the Patient Health Questionnaire Modified for Teenagers (PHQ-9M) using the Comprehensive Health and Decision Information System software before their well-child visits. Question 9 asks about past 2-week SI. Their parents filled out the Pediatric Symptom Checklist (PSC-17P), which screens for a broad range of psychosocial problems. Chi-square analyses and one-way analysis of variances assessed the relationship between SI and psychosocial problems. RESULTS: Among 5411 adolescents, 266 (4.9%) reported SI at least several days in the past 2 weeks. Among adolescents with SI, 187 (70.3%) reported moderate to very severe depression on the PHQ-9M (≥10), 68.1% were at risk on at least 1 PSC-17P problem subscale, 59.7% on the PSC-17P internalizing scale, 42.9% on PSC-17P overall, 20.6% on PSC-17P externalizing, and 18.5% on PSC-17P attention. Within the subsample endorsing SI nearly all days, 35.7% had a former suicide attempt. CONCLUSION: The PHQ-9M identifies a clinically heterogeneous subset of approximately 5% of adolescents who report occasional to frequent SI. The PSC-17P corroborates their high degree of overall risk and offers additional information that can help pediatricians assess clinical severity and range of psychosocial problems. Given our limited knowledge of how to predict and prevent an individual adolescent's suicide, the focus of screening should be to identify and help the subset of patients with chronic psychosocial vulnerability of any type.

Mental health matters in elementary school: first-grade screening predicts fourth grade achievement test scores.

The objective of the study was to evaluate whether mental health problems identified through screens administered in first grade are related to poorer academic achievement test scores in the fourth grade. The government of Chile uses brief teacher- and parent-completed measures [Teacher Observation of Classroom Adaptation-Revised (TOCA-RR) and Pediatric Symptom Checklist (PSC-Cl)] to screen for mental health problems in about one-fifth of the country's elementary schools. In fourth grade, students take the national achievement tests (SIMCE) of language, mathematics and science. This study examined whether mental health problems identified through either or both screens predicted achievement test scores after controlling for student and family risk factors. A total of 17,252 students had complete first grade teacher forms and these were matched with fourth grade SIMCE data for 11,185 students, 7,903 of whom also had complete parent form data from the first grade. Students at risk on either the TOCA-RR or the PSC-Cl or both performed significantly worse on all SIMCE subtests. Even after controlling for covariates and adjusting for missing data, students with mental health problems on one screen in first grade had fourth grade achievement scores that were 14-18 points (~1/3 SD) lower than students screened as not at risk. Students at risk on both screens had scores that were on average 33 points lower than students at risk on either screen. Mental health problems in first grade were one of the strongest predictors of lower achievement test scores 3 years later, supporting the premise that for children mental health matters in the real world.

Validation of the Pediatric Symptom Checklist in HIV-infected Batswana.

OBJECTIVE: To determine the validity of the Pediatric Symptom Checklist (PSC), a brief measure of psychosocial health, for screening HIV+ Batswana children. METHOD: Setswana versions of the parent and child PSC were administered to 509 HIV+ Batswana children (age 8-16) and their parents/guardians. Test properties were evaluated and cut-off scores were derived using receiver operating characteristic curve analysis. Scores on the parent-completed PSC and the child-completed PSC-Y were compared to parental and clinic staff reports of concern about the child's psychosocial health and to scores on the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scale. RESULTS: The Setswana PSC has high internal consistency (Cronbach's alpha 0.87 for the parent-completed version). Comparing PSC scores to parental reports of concern and child-reported depression symptoms, a cut-off score of 20 on the PSC and PSC-Y maximised the sensitivity and specificity. CONCLUSIONS: The PSC performed well in Setswana-speaking children and is a promising screening tool for paediatric psychosocial problems in busy clinical settings. Screening with the PSC may allow for early detection and treatment of psychosocial problems. This is likely to be of particular value for HIV+ children for whom HIV treatment non-adherence may result from untreated psychosocial dysfunction.

Attachments: The Pediatric Symptom Checklist: A Bridge to Child and Adolescent Psychiatry From Pediatrics.

During my residency training in pediatrics and child/adolescent psychiatry (1973-1979), I wondered how pediatricians would identify children with psychosocial problems. Some behavioral problems were obvious because the school or parent had raised a concern. Most pediatricians would ask 1 or 2 psychosocial questions, and some, attuned to emotional issues, would identify children based on their clinical impressions. However, the few studies that had been done at the time indicated that the rates of psychosocial problems identified in pediatric primary care were far lower than predicted by epidemiological studies. Therefore, I began the work to create a screening questionnaire.