Impact of Wellness Policy Review, Wellness Council Activity, and Student Health Objectives on Overall School Wellness Climate.

BACKGROUND: The whole school, whole community, whole child (WSCC) model suggests wellness councils, ongoing review of wellness policy, and a plan for evaluating set objectives are some of the key features needed to support school wellness infrastructure. This study explored the relationship between implementation of these infrastructure features and overall school wellness environment assessment scores among a sampling of Pennsylvania schools. METHODS: The Healthy Champions program provides Pennsylvania schools an opportunity to self-assess their wellness environments across several school wellness topics. Staff enrolled their school in the program by completing a self-report electronic assessment. Enrollment data from the 2020/2021 program year were analyzed using the Kruskal-Wallis test and linear fixed model to identify the impact of varied implementation levels across 3 wellness infrastructure activities. Interactions between these variables and overall assessment score were also analyzed. RESULTS: Of the 645 Pennsylvania schools enrolled and analyzed, we observed higher mean wellness environment assessment scores (∆ 0.74 95% CI 0.40-1.07; p < 0.001) among schools that reported some frequency of all 3 wellness infrastructure activities, compared to schools that reported no frequency for the activities. IMPLICATIONS: Schools with existing policies and practices related to the 3 wellness infrastructure activities should consider the degree of implementation to best support overall wellness in their school setting. Additional research to explore implementation barriers and supports is needed. CONCLUSIONS: Analyses indicated that overall wellness environment assessment scores are impacted by implementation thresholds for wellness council meeting frequency, revision of wellness policy, and review of student health promotion objectives.

Evaluating the Impact of Aevidum on Mental Health Knowledge, Attitudes, and Help-Seeking Behaviors in High School Students: A Mixed-Methods Study.

PURPOSE: To compare Aevidum's school mental health curriculum vs the curriculum plus Aevidum clubs in a mixed-methods study including pre/post surveys, a randomized clinical trial, and qualitative interviews. DESIGN: Concurrent mixed-methods: Aim 1) pre-post surveys evaluated curriculum only vs curriculum plus club schools separately regarding changes in knowledge, help-seeking, and school culture; Aim 2) randomized clinical trial compared curriculum only to curriculum plus club schools; Aim 3) qualitative school staff interviews enhanced understanding of school culture changes. SETTING: Curriculum delivered to 9th graders at ten Pennsylvania high schools; 5 schools randomized to start clubs. SUBJECTS: Students (surveys), staff (interviews). INTERVENTION: Aevidum curriculum plus/minus club. MEASURES: Aim 1, mixed effects linear and logistic regression models for longitudinal data were used to analyze survey items at each time point. Aim 2, the same regression models were used, except models included a fixed-effect for group and group by time interaction effect. Aim 3, interviews were transcribed; a codebook was developed followed by thematic analysis. RESULTS: Pre-survey 2557 respondents; 49% female, 86% non-Hispanic white. Post-survey 737 (29% response rate). Aim 1, pre-post (Likert responses, larger numbers favorable) demonstrated increased student knowledge to identify depression (4.26 [4.19-4.33] to 4.59 [4.47-4.71], P < .001) and help a friend access support (4.30 [4.21-4.38] to 4.56 [4.40-4.71], P = .001). Help-seeking increased for phone helplines (1.61 [1.57-1.66] to 1.78 [1.70-1.86], P < .001), crisis textlines (1.60 [1.55-1.64] to 1.78 [1.70-1.86], P < .001), internet/websites (1.80 [1.75-1.85] to 1.99 [1.90-2.08], P < .001), school counselors (P = .005) and teachers (.013). Aim 2, no significant differences in knowledge, help-seeking or culture between curriculum only vs curriculum plus club schools. Aim 3, staff (n = 17) interviews supported reduced stigma and increased mental health referrals. CONCLUSIONS: Aevidum's curriculum improved mental health knowledge and help-seeking; adding the club did not significantly change responses. Staff identified positive school culture impacts. Limitations include the lower post-survey response.

Lessons Learned from an Academic Partnership to Review Pennsylvania Network for Student Assistance Services' Annual Survey.

INTRODUCTION: Pennsylvania's Student Assistance Program (SAP) began in the mid-1980s to address student barriers to academic success. SAP teams, groups of trained school and community professionals, review referrals, and connect students to services. State leadership conducts an annual SAP team survey, but capacity to evaluate data and affect change is limited. In 2020, leadership partnered with [institution name] to collaboratively review the survey data. METHODS: Frequencies and percentages were calculated. Open responses were coded. Logistic regression models evaluated the association between SAP team size, team meeting frequency, and team maintenance. RESULTS: The 2019 to 2020 survey had 1003 respondents. Median number of SAP team members was 8 (range 1-21). The majority (54%) indicated their SAP team met once per week/cycle for 30 to 90+ minutes. Larger teams met more often. Annual team maintenance occurred for 38% of teams, and was more common for larger teams. SAP team members identified mental health (68%), trauma (44%), and parent engagement (36%) as top training needs. CONCLUSIONS: An academic partnership successfully provided the capacity to review SAP survey responses, and informed evidenced-based discussion of best practice guidelines and realignment of staff professional development opportunities.

Cooking with the Community: Addressing Food Insecurity Through Equipment Provision and Professional Instruction.

Introduction: Food insecurity is a common problem with many associated negative downstream health impacts. Despite government sponsored and private supports, many individuals struggle with making healthy, nutritious meals. Penn State's Cooking with the Community program was constructed with the objective of providing cooking equipment and instructions to increase knowledge of healthy cooking techniques and consumption of under-utilized food pantry ingredients. Methods: Four cooking demonstrations were held over an 8-month study period in 2021 designed to educate participants on under-utilized and seasonally available ingredients. Each demonstration was professionally led by a chef who taught cooking skills and the use of different equipment, which were subsequently gifted to the participants. Participants were surveyed before and after each demonstration to assess cooking perceptions and comfort using Likert scales. Final analysis was completed in 2022 using mixed effects models to analyze changes between pre- and post-demonstration. Results: There were 34 total participants. Statistically significant improvements were seen in confidence in cooking (mean increase=0.5; SD=0.2; p=0.031; 95% CI=0.1, 1.0), preparation of a simple recipe (mean increase=0.6; SD=0.2; p=0.013; 95% CI=0.1, 1.0), and cooking new foods (mean increase=0.6; SD=0.3; p=0.026; 95% CI=0.1, 1.1). Conclusions: Cooking with the Community provides valuable information on how cooking confidence may be boosted within vulnerable populations by providing cooking equipment and professional instructions on its use.

Effects of a Primary Care-Based Engagement Intervention for Improving Use of ADHD Treatments.

INTRODUCTION: Uptake of attention deficit hyperactivity disorder (ADHD) treatments is low in primary care. A quasi-experimental study assessed the impact of a primary care-based engagement intervention to improve ADHD treatment use. METHOD: Families of children with ADHD from four pediatric clinics were invited to participate in a two-stage intervention. The first step was an assessment battery to assess functioning and identify goals, followed by an in-office engagement session run by primary care staff. RESULTS: Of the 636 invited families, 184 (28.9%) completed ratings, with 95 (51%) families completing the engagement session. ADHD office visits varied based on the number of steps completed (0-2). ADHD prescriptions decreased over time in families completing neither step but increased for children previously unmedicated whose parents completed either step. Families completing both steps had the highest rates of nonmedication ADHD treatments. DISCUSSION: A brief two-step engagement intervention was associated with increased uptake of ADHD treatments.

Evaluation of a stakeholder advisory board for an adolescent mental health randomized clinical trial.

INTRODUCTION: Community engagement in research is widely accepted as best practice, despite gaps in existing frameworks to evaluate its process, context, and impact on research. The Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) study evaluated the use of a school-based major depressive disorder screening tool in the identification of symptoms and treatment initiation among adolescents, and was developed, implemented, and disseminated in partnership with a Stakeholder Advisory Board (SAB). We summarize outcomes of the evaluation strategy applied through our partnership with the SAB and explore gaps in the available engagement evaluation tools for mixed stakeholder populations including youth. METHODS: SHIELD study SAB members (n = 13; adolescents, parents, mental health and primary care providers, and professionals from education and mental health organizations) advised on study design, implementation, and dissemination over a three-year period. Both SAB members and study team members (i.e., clinician researchers, project managers) were invited to quantitatively and qualitatively evaluate stakeholder engagement after each project year. At the conclusion of the study, SAB members and study team members were asked to evaluate the application of engagement principles in overall stakeholder engagement across the study period, using portions of the Research Engagement Survey Tool (REST). RESULTS: SAB members and study team members responded similarly when evaluating engagement process (i.e., valued on team, voice represented); means ranged from 3.9 to 4.8 out of 5 points across all three project years. Reported engagement within study-specific engagement activities (i.e., meetings, study newsletter) varied from year to year, with some discrepancy between SAB member and study team evaluations. Using REST, SAB members reported the alignment of their experience with key engagement principles the same or higher than study team members. Qualitative feedback at the conclusion of the study generally matched quantitative measures; adolescent SAB members, however, reported disengagement from stakeholder activities that was not accurately or effectively captured in evaluation strategies employed across the study period. CONCLUSIONS: Challenges exist in effectively engaging stakeholders and evaluating their engagement, particularly among heterogenous groups that include youth. Evaluation gaps should be addressed through the development of validated instruments that quantify the process, context, and impact of stakeholder engagement on study outcomes. Consideration should be given to collecting parallel feedback from stakeholders and study team members to fully understand the application and execution of engagement strategy.

We conducted a study (Screening in High Schools to Identify, Evaluate, and Lower Depression) to understand if an adolescent major depressive disorder screening tool delivered in the school setting aided in the identification of symptoms and treatment. We planned and conducted this study with the guidance of a stakeholders, including adolescents.At the end of each study year, we sent an evaluation survey to stakeholders to understand their experience, such as how appropriately the study included stakeholders and their perspectives. We also surveyed the team leading the study to understand their perspectives about stakeholder involvement. In general, both stakeholders and the study team reported feeling positive about stakeholder involvement; However, some stakeholders felt less involved as the study moved forward, and for some activities stakeholders and study team did not agree on how much the stakeholders were involved in study activities. Additionally, adolescent stakeholders reported low involvement in the study when completing the final evaluation, which, unfortunately, was not captured in the evaluations conducted in earlier study years.By evaluating the experiences of stakeholders, along with gathering perspectives of the study team, we were able to understand how well we involved stakeholders. However, additional questions remain unanswered, such as how best to involve adolescents as stakeholders, and how involving stakeholders impacted the results of our study. Evaluation tools to best understand these impacts are needed across the field of community-engaged research to answer these questions for future studies.

Effects of COVID-19 pandemic on pediatric weight: A retrospective chart review.

The COVID-19 pandemic forced United States school closures in March 2020. Students moved to online learning, fostering a sedentary lifestyle. As the pandemic heightened population disparities, the impact on weight gain may also be unequally distributed. This study aimed to evaluate changes in body mass index (BMI) z-scores and weight percentiles of pediatric patients during the pandemic and associated demographics to identify those at risk for weight gain. Methods included a retrospective chart review of patients 5-18 years-old with a well-visit in the three years 2018, 2019 and 2020; first identified with a well-visit in August-September of 2020. BMI z-scores and weight percentiles were analyzed using a correlated errors regression model appropriate for longitudinal data. This longitudinal approach was used to model outcomes by patient demographics. Interaction terms with time were evaluated for each variable. Of 728 patients, mean age was 9.7 years (2018); 47 % female, 70 % white, and 23 % publicly insured. BMI z-score did not increase significantly from 2018-2019 versus 2019-2020. Weight percentile demonstrated a slight trajectory increase over these same time points. Publicly insured patients demonstrated significantly greater increase in BMI z-score versus privately insured patients (p = 0.009). Mean differences between groups increased from 0.26 in 2018 (95 % CI [0.07, 0.45]) to 0.42 in 2020 (95 % CI [0.23, 0.61]). Results were similar for weight percentile. Publicly insured pediatric patients experienced significant increase in BMI-z score and weight percentile, but over time this trajectory remained constant. The results support targeting at risk subgroups in addressing long-term impacts of the pandemic.

A Collaborative Analysis of Trends in Referrals to the Pennsylvania Student Assistance Program from 2013 to 2018.

BACKGROUND: The Student Assistance Program (SAP) is mandated kindergarten to 12th grade in Pennsylvania schools to address barriers to student academic success. Following student referral, SAP teams use a systematic process to inform recommendations for school or community-based services. To evaluate program outcomes, a review of student SAP referral trends over a 5-year period was undertaken. METHODS: The Pennsylvania Network for Student Assistance Services (PNSAS), the state leadership providing oversight of SAP, partnered with Penn State College of Medicine in a retrospective analysis of student referral data from 2013 to 2018. Public school enrollment demographics were used for comparison. Frequencies and percentages were calculated. RESULTS: Referrals (total n = 352,640) increased by 24% over the 5 years; demographics 55% male, 69% non-Hispanic white, 16% non-Hispanic black, and 10% Hispanic. Referrals were most commonly for behavioral concerns (31%). Discontinued referrals (39%) were primarily for parent refusal/no permission. Trends included rising minority and elementary referrals over the study period. CONCLUSIONS: SAP referral demographics were consistent with state public school enrollment race/ethnicity breakdown suggesting lack of systematic bias. The proportion of behavioral referrals was consistent with rising youth behavioral health needs. PNSAS must consider strategies to support rising referral numbers and trends.

A qualitative analysis of participant experiences with universal school-based depression screening.

Screening in High Schools to Identify, Evaluate and Lower Depression (SHIELD) was a randomized clinical trial of school-based universal depression screening conducted with public high schools in Pennsylvania, United States. Screened adolescents were twice as likely to initiate depression treatment compared to peers who were not screened. The purpose of this qualitative study was to understand the experience of communities participating in universal screening via SHIELD. Semi-structured interviews were conducted with school staff (n = 11), parents (n = 4) and adolescents (n = 7) from April-October 2021. A codebook was developed with 20 % of audio transcripts coded for inter-rater reliability (staff k = 0.88, parents k = 0.90, adolescent k = 0.74). The two coders divided and individually coded remaining transcripts for thematic content analysis. Three themes were identified: 1) Depression screening was well-received; 2) The main challenge with screening was inadequate staffing to manage referrals; and 3) School staff suggested alternate formats and methods for future screening. In summary, school-based depression screening was well-received, but schools experienced challenges with staffing and resources to support identified adolescents and offered alternative suggestions for future screening. Schools interested in depression screening need education and capacity building focused on barriers and challenges with the process. Learning from staff who have realized this evidence-based practice in their respective districts will support next steps towards implementation.

Insights on COVID-19, School Reopening Procedures, and Mental Wellness: Pilot Interviews With School Employees.

BACKGROUND: The COVID-19 pandemic has caused interruptions to the K-12 US school landscape since spring 2020. METHODS: In summer 2020, we completed a pilot study utilizing interviews (n = 13) with school staff (ie, nurses, educators) from across the United States. We aimed to understand the status of school operation and re-entry plans after the primary period of school closure, along with resources needed for students and staff during the COVID-19 pandemic. RESULTS: All interviewees described their school's re-entry plan as complete or in-development. Ten plans included strategies to meet students' mental health needs. Only 3 clearly planned for staff mental health resources. Interviews suggest gaps in planning and execution of mental health resources for school staff, a group already vulnerable to stress, anxiety, and burnout. IMPLICATIONS FOR SCHOOL HEALTH: Several school staff mental health resources were developed as a result of the pandemic, though ongoing impacts necessitate integration of these supports into school operation plans. This is particularly important as schools continue to navigate periods of altered operation in response to elevated community COVID-19 infection rates. CONCLUSIONS: As schools implement strategies to support students, similar consideration should be given to the adults in the school environment who teach and support school-aged children.

Adolescent Suicide Risk Screening: A Secondary Analysis of the SHIELD Randomized Clinical Trial.

OBJECTIVE: To evaluate the effectiveness of adolescent suicide risk screening to increase initiation of mental health services via a secondary analysis using data from the SHIELD (Screening in High Schools to Identify, Evaluate and Lower Depression) randomized clinical trial, which evaluated school-based screening for major depressive disorder (MDD). STUDY DESIGN: Students in 14 Pennsylvania high schools were randomized by grade to either the usual school practice of targeted referral for behavior raising a concern for suicide risk or universal screening using the Patient Health Questionnaire-9 (PHQ-9), with any response >0 to item 9 regarding suicide risk considered positive. Students identified in either arm were referred to the Student Assistance Program (SAP), which is mandated in all Pennsylvania schools. The SAP determined follow-up. Study groups were compared using mixed-effects logistic regression. RESULTS: The participants comprised 12 909 students, with 6473 (50.1%) randomized to universal screening. The study group was 46% female and 43% Hispanic or non-Hispanic Black. Adolescents in the universal screening arm had 7.1-fold greater odds (95% CI, 5.7-8.8) of being identified as at risk for suicide, 7.8-fold greater odds (95% CI, 4.6-13.1) of follow-up needs, and 4.0-fold greater odds (95% CI, 2.0-7.9) of initiating mental health treatment. CONCLUSIONS: Although the PHQ-9 is a MDD screening tool, its use in universal screening increased identification and treatment initiation for adolescents at risk for suicide. This confirms the value of universal screening and suggests that a suicide-specific risk assessment would have even greater impact on treatment initiation for identified youth. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03716869.

Leveraging Community-Engaged Research to Address Adolescent Depression with Pennsylvania Public Schools and Communities.

BACKGROUND: The prevalence of adolescent major depressive disorder increased from 8.3% in 2008 to 14.4% in 2018, and suicide is now the second leading cause of death among U.S. adolescents. OBJECTIVE: Describe the process of community-engaged research methods used to develop a randomized clinical trial (RCT) comparing the effectiveness of school-based universal depression screening on depression identification and treatment engagement, compared with standard symptom-based depression recognition. METHODS: We engaged stakeholders with personal or professional expertise and schools enrolled in the study. Qualitative methods aimed to elucidate barriers and opportunities during RCT development. RESULTS: Stakeholders were instrumental in all phases of RCT development. Qualitative feedback from participating schools, students, and parents informed RCT development and implementation. CONCLUSIONS: The inclusion of community-engaged research methods provided opportunities to collaboratively address barriers to RCT design and implementation with school communities. This dialogue was invaluable in establishing relationships to further address mental health and other controversial adolescent health topics in future research.

Treatment Engagement Following a Positive Mental Health Screening Questionnaire.

INTRODUCTION: Less than half of U.S. adolescents with major depressive disorder receive treatment. Despite the U.S. Preventive Services Task Force 2016 statement supporting primary care major depressive disorder screening, there is limited data examining whether positive screens prompt treatment engagement. This study evaluated treatment engagement following a positive Patient Health Questionnaire-Adolescent Version screen and assessed the impact of demographics, clinical variables, and provider recommendations on treatment engagement. METHODS: This was a retrospective cohort study (analysis November 2021) of adolescents aged 11-18 years seen at a primary care clinic of an academic medical center from July 2017 to December 2018 and identified with a positive Patient Health Questionnaire-Adolescent Version (broadest definition score ≥10; ≥1 for Item 9 regarding suicidal thoughts; yes for unscored Items 1, 3, or 4; or very or extremely difficult for unscored Item 2). Positive screen by score ≥10 alone was also considered. The primary outcome was treatment engagement, defined as initiation of a psychotropic medication, or a behavioral health treatment session within 1 year of symptom identification. RESULTS: Of the 1,315 eligible adolescents, 23.0% had a positive Patient Health Questionnaire-Adolescent Version (n=302) by the broadest criteria; 92/302 (30.5%) engaged in treatment. Patients whose providers recommended treatment had 7.32 times the odds (95% CI=3.76, 14.2, p<0.001) of treatment engagement. For those positive by Patient Health Questionnaire-Adolescent Version ≥10 (85/302, 28.1%), 37/85 (43.5%) engaged in treatment. The influence of provider recommendations was comparable (OR=6.96, 95% CI=3.56, 13.6, p<0.001). CONCLUSIONS: Less than half of adolescents with a positive Patient Health Questionnaire-Adolescent Version at an academic primary care clinic engaged with treatment. Provider recommendation was an impactful intervention to improve mental healthcare treatment engagement.

Screening in High Schools to Identify, Evaluate, and Lower Depression Among Adolescents: A Randomized Clinical Trial.

Importance: Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment. Objective: To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation. Design, Setting, and Participants: This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools. Interventions: In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9. Main Outcomes and Measures: The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year. Results: A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity. Conclusions and Relevance: In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern. Trial Registration: ClinicalTrials.gov identifier: NCT03716869.

The association between state-based provisional attendance periods and adolescent middle school-entry vaccination coverage.

The rise of vaccine-preventable disease outbreaks calls for a deeper understanding of the impact of policy on school-entry vaccine compliance. Provisional attendance policies vary by state but permit under-vaccinated students a limited period to attend school while receiving their immunizations. The primary objective of this study was to clarify the relationship between annual immunization coverage and state provisional policies for a single-dose of school-entry-required adolescent vaccinations: tetanus, diphtheria, pertussis (Tdap), meningococcal conjugate (MCV4), and human papillomavirus (HPV). From June 22, 2020 to August 20, 2020, the Immunization Action Coalition and state-level Department of Health (DOH) webpages were reviewed with email confirmation with a DOH representative to determine provisional period policy. Vaccination coverage for Tdap, MCV4, and HPV were obtained from the Center for Disease Control's National Immunization Survey. Overall, 49 states and D.C. legally mandate exclusion of vaccine noncompliant adolescents, and the majority of jurisdictions assign responsibility for exclusion to local school officials (84%). Complete provisional period data was obtained for 46/51 jurisdictions. The effect of provisional period length categorized as 0 days (18 jurisdictions, 35.3%), 1 to 30 days (18 jurisdictions, 35.3%), 31+ days (10 jurisdictions, 19.6%), and "unclear" (5 jurisdictions with incomplete data, 9.8%) had no significant association with annual adolescent vaccination coverage for Tdap (p = 0.82), MCV4 (p = 0.08), and HPV (p = 0.76). Provisional policies may not increase vaccination coverage as anticipated. Unintended consequences, such as increased nonmedical exemptions and increased demands on clinical providers, are additional factors to consider.

"I wouldn't even know what to do," Adolescent and Parent Perspectives on Identifying, Understanding, and Seeking Help for Adolescent Depression.

Within the context of a randomized clinical trial (RCT) of school-based depression screening, the study objective was to understand parent and adolescent perspectives on school-based depression screening and barriers to help-seeking for adolescent depression. From May-Nov. 2019, separate focus groups were held with adolescents (8 groups, n = 52) and parents (6 groups, n = 36). Two coders individually coded 20% of transcripts to establish interrater reliability (adolescent k = 0.76 and parent k = 0.80). Remaining transcripts were then separately coded and reviewed to develop three themes: (1) Both recognized depression as a serious issue that needed to be addressed in schools, but had confidentiality and communication concerns; (2) Both parents and adolescents believed the majority of adolescents would seek help with depression from friends more than any other source; and (3) Neither adolescents nor parents could clearly describe steps to take if their peers (adolescents) or adolescents (parents) were depressed. We intend to address identified barriers and concerns in the context of the larger RCT.

National Survey of School Employees: COVID-19, School Reopening, and Student Wellness.

BACKGROUND: During spring 2020, COVID-19 forced widespread United States school building closures in an unprecedented disruption for K-12 students and staff. Partnering with the American School Health Association (ASHA), we sought to identify areas of concern among school staff planning for school reopening with the goal of addressing gaps in resources and education. METHODS: This 16-item web-based survey was distributed via email to 7467 ASHA members from May to June 2020. Topics focused on 3 Whole School, Whole Community, Whole Child components: physical environment, health services, and mental health. Chi-square tests were used to identify differences in responses by school characteristics and school role on each survey item. RESULTS: A total of 375 respondents representing 45 states completed the survey. The majority were female (91.7%), white (83.4%) and non-Hispanic (92.2%), and school nurses (58.7%). Priority concerns were feasibility of social distancing (93.6%), resurgence of COVID-19 (92.8%), and the availability of health supplies (88.8%). CONCLUSION: Understanding staff concerns in the context of the Whole School, Whole Community, Whole Child model better positions the school community to address ongoing gaps and changing needs as schools continue to address COVID-19 complications.

School Nurse Perspectives on COVID-19.

Pennsylvania responded to the COVID-19 pandemic by closing schools and moving to online instruction in March 2020. We surveyed Pennsylvania school nurses (N = 350) in May 2020 to assess the impact of COVID-19 on nurses' concerns about returning to school and impact on practice. Data were analyzed using χ2 tests and regression analyses. Urban school nurses were more concerned about returning to the school building without a COVID-19 vaccine than rural nurses (OR = 1.58, 95% CI [1.05, 2.38]). Nurses in urban locales were more likely to report being asked for guidance on COVID-19 (OR = 1.69, 95% CI [1.06, 2.68]), modify communication practices (OR = 2.33, 95% CI [1.42, 3.82]), and be "very/extremely concerned" about their safety (OR = 2.16, 95% CI [1.35, 3.44]). Locale and student density are important factors to consider when resuming in-person instruction; however, schools should recognize school nurses for their vital role in health communication to assist in pandemic preparedness and response.

Parent Views on School-Based Depression Screening: Findings From a National Survey.

PURPOSE: This study explored parent views on school involvement in screening and identification of adolescent depression. METHODS: This was a cross-sectional Internet-based survey with the C.S. Mott Children's Hospital National Poll on Children's Health. Of 2,004 parents (63.4% response rate), 770 had a middle/high school student and were eligible for this module. Poststratification weights were generated by survey vendor Ipsos. Descriptive and bivariate results were calculated; multinomial logistic regression models controlled for parent sex, race/ethnicity, education, employment status, and school level. RESULTS: Parent respondents were 54.8% female, 57.5% white, 64.3% above a high school education, and 79.7% employed; 76.2% were answering based on a high school student. Most parents supported school-based depression screens starting in sixth (46.7%) or seventh (15.1%) grades, although 15.9% responded no screening should be done. Among parent respondents, 93.2% wished to be informed of a positive screen. Regression analysis found parents of middle school students were 4.18 times more likely to prefer sixth versus 9th to 12th grade to start screening. CONCLUSIONS: Most parents support middle school depression screening but overwhelmingly wished to be informed of a positive result. Guidelines for maintaining adolescent confidentiality in a school-based depression screening program will require careful consideration.

Effectiveness of Universal School-Based Screening vs Targeted Screening for Major Depressive Disorder Among Adolescents: A Trial Protocol for the Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) Randomized Clinical Trial.

Importance: The prevalence of annual major depressive disorder (MDD) episodes among adolescents in the United States rose from 8.3% in 2008 to 12.8% in 2016. Despite the US Preventive Services Task Force 2009 endorsement and 2016 reaffirmation of universal adolescent MDD screening in primary care, many adolescents are missed, as more than 60% lack annual preventive health visits and MDD screening remains inconsistent. Objective: To compare the effectiveness of universal school-based screening for adolescent MDD vs the existing process of targeted screening based on observable behavior. Design, Setting, and Participants: Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) is a randomized clinical trial that will take place in at least 8 Pennsylvania public high schools among at least 9650 students enrolled in 9th through 12th grade. Students will be randomized by grade to either targeted screening (current process) or universal screening (intervention). Students in the targeted screening arm will complete mandated school health screenings, which do not include an MDD screening. These students will be observed through the academic year for referral to the Student Assistance Program (SAP), required in all Pennsylvania schools. If a student exhibits behavior concerning for MDD raised by any contact (eg, teacher, parent, peer, or self-referral), SAP will triage the student and provide follow-up recommendations. Students in the universal screening arm will complete the validated Patient Health Questionnaire-9 (PHQ-9) from September through December of the academic year. The PHQ-9 includes 9 close-ended questions and is scored from 0 to 27. Students with a positive result (ie, score >10) will proceed to SAP triage. Students in the intervention arm will also be observed for behavior concerning for MDD during the school year, potentially prompting SAP triage referral. The primary outcome will be the proportion of adolescents referred to SAP triage who are recommended for additional MDD-related services and successfully engage with at least 1 SAP recommendation. Observers will not be blinded to patient groups, and an intention-to-treat analysis will be used. Discussion: The SHIELD trial began with 3 schools during the 2018-2019 academic year. Screening in the intervention arm with the PHQ-9 is currently underway for the remaining schools, with a goal of completion of all PHQ-9 screenings by December 2019. This trial addresses the US Preventive Services Task Force call for large, high-quality randomized clinical trials to better understand the effects of MDD screening and quantify the proportion of adolescents with screen-detected MDD successfully referred and treated. Trial Registration: ClinicalTrials.gov identifier: NCT03716869.