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.

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.

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.

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.

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.

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.

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.

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.