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The Hidden Threat to Our Nation's Kids

By Emil Vernarec

Meeting the mental health needs of children requires a national effort, say public health experts. But for an individual child, help could be right around the corner in the form of a one-on-one encounter with a concerned nurse.

When nurse Mary Tonsmeire took the job of adolescent healthcare coordinator for the city of Juneau, Alaska, she had worked for a decade with hospice patients and felt she needed "something more upbeat." She knew she faced a challenge-addressing teen pregnancies and substance abuse were two big health priorities. But less visible, equally pressing needs soon became evident at the school-based health center she coordinates.

"After being a nurse for 23 years, I had thought of myself as aware," says Tonsmeire, "but I was ignorant of the extent of sex abuse, physical abuse, depression, and eating disorders among teenagers. To me, it was incredible." Even as she and her colleagues drew up plans to deal with such problems, a shockwave hit: In the span of just 22 months, in this city with fewer than 2,000 high school students, four teens committed suicide.

Such problems aren't unique to Juneau. The National Institute of Mental Health (NIMH) estimates that about 10%of children have mental health problems that interfere with their ability to function day to day and could impair their development. In any given year, fewer than 20% of them get the treatment they need. 1 Back in July,the federal Substance Abuse and Mental Health Services Administration released new survey data in which nearly 14% of teens 14 – 17 years old said they had considered killing themselves in the past year; only one-third said they had received mental health treatment.2

The stakes are huge: At the extreme end are disorders that cause severe disruptions in school and at home, place a significant emotional and financial burden on an entire family, or lead to suicide. But even in their more common, less severe forms, mental health problems can spill over into many aspects of a child's life and continue into adulthood.

Calling the problem a national public health crisis, then-Surgeon General David Satcher sponsored an agenda-setting conference on children's mental health early in 2001. Among the research and policy goals set, the conference cited the need to give frontline providers the tools and training they need to assess children's social and emotional needs, discuss them with parents or caregivers, and make appropriate treatment referrals. 3

"At every juncture in [this] process, nurses are key," says Kelly Kelleher, MD, a pediatrics researcher who spoke at the conference. "They have long been agents of health information, treatment planning, and partnership with patients, and they spend more time with patients and family - especially in behavioral change."

With these roles in mind, Kelleher, Tonsmeire, and other practitioners interviewed for this article went on to describe how nurses can help stem the tide of this national public health crisis.

Common, worrisome, and often hidden

Kelleher, director of clinical studies at Ohio State University and Columbus Children's Research Institute, says that primary care practitioners are seeing more mental health problems in children. "You can argue about the exact magnitude of the trend," he says, "but not that there's an increase." In a recent study heco-authored, the rate of psychosocial problems identified by primary care clinicians in children ages 4 to 15 rose from 7% in 1979 to 19% in 1996.4

According to government estimates, attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed psychiatric problem in pediatrics-affecting an estimated 3% – 5% ofschool-aged children. 1,5 Conduct disorder, which is marked by persistent aggression toward people and the destruction of property, is estimated to occur in 1% – 4% of children, and oppositional defiant disorder,characterized by persistent disobedience, defiance, and hostility toward authority figures, affects 1% – 6% of children.1,5

More children, however, suffer from symptoms that may be internalized and therefore less noticeable. Anxiety disorders, for instance, affect 13% of teens, and depression is estimated to affect up to 3% of children and 8% of adolescents.5

"Depression is worrisome because it causes so much impairment," says Myrna Weissman, PhD, a psychologist and researcher at Columbia University. Besides causing the characteristic symptoms of sadness and loss of interest in life, depression can directly affect a child's self-esteem, ability to concentrate, sleep, and appetite. Among its most troubling symptoms are a preoccupation with death and thoughts of doing harm to oneself or committing suicide.

Weissman led a recent study that assessed 73 adults who had developed major depression as teens and compared them to 37 adults who were free of psychiatric disorders as teens. Among the findings: Those who developed major depression in adolescence had twice the risk of future episodes of depression as adults and a five-times-higher risk ofmaking a first suicide attempt. 6

Nurses need to ask the right questions

A number of factors can combineto make it tougher for nurses and other frontline clinicians to detect mental health symptoms in a child and follow up on their care. They include competing demands on a nurse's time, the complex nature of psychiatric problems, otherillnesses that have to be ruled out, plus a healthcare system that traditionally has put a divide between physical and mental health. Also, psychosocial symptoms manifest themselves in many ways, and at times, any child may display some of the symptoms to some degree without having a disorder. (See the "Teachparents what to watch for" box.)

"It's not a matter of providers doing something wrong," notes Michael Murphy, a psychologist at Massachusetts General Hospital who has studied methods for improving mental health screening, "but how to weave it into their practice when their training, billing, and coordination with specialists hasn't been oriented toward mental health."

In addition, the child (or theparents) may readily describe physical symptoms but be reluctant to bring up psychosocial problems, which they may view not as a health issue but as a "personal" one.

At her school-based health center in Juneau, Tonsmeire says it soon became clear that psychosocial factors were at play in many a teenager's medical complaint. "At any health assessment we did, there was a clear correlation between what was going on physiologically and the psychosocial issues the young person was facing-divorce, falling grades, not getting enough sleep, pulling away from activities," she says.

To better identify those who might need to be referred for a mental health evaluation, the clinic began to employ standard screening instruments at initial visits that included emotional health among the various symptoms to be assessed. Tonsmeire says one tool the clinic uses is an assessment form created by the American Medical Associationin its Guidelines for Adolescent Preventive Services (GAPS). 7 It contains "three great questions on emotions," says Tonsmeire, which in brief, ask:

  • Are you happy with the way things are going for you these days?
  • Have you often felt sad or down or as though you have nothing to look forward to?
  • Have you ever thought seriously about killing yourself, made a plan, or actually tried to kill yourself?

In addition to general health screening forms like GAPS, brief screening instruments specific to mental health disorders are available. Examples include the Pediatric Symptom Checklist (see the related article "The mental health of children: A useful screening tool") and the Columbia TeenScreen questionnaires.

TeenScreen is a comprehensive program created by the Columbia University Division of Child and Adolescent Psychiatry designed primarily for use at clinics serving young people, juvenile justice facilities, high schools, and colleges. 8,9 The initial screening has two layers: a short questionnaire the teen fills out and anin-depth computer-based, interactive voice program that's based on the diagnostic criteria for more than 30 mental health disorders. (Both are available free of charge, including training.)

Teens whose score on the short form suggests a risk are asked to complete the hour-long interactive questionnaire on a computer. The young person then meets with a mental health clinician to discuss what the results indicate and determine whether referral is necessary.

Tonsmeire says her clinic began using TeenScreen about two years ago. Because the clinic is community-funded, teens can receive three free visits with a master's-level counselor, if needbe.

Screening forms must always be offered as voluntary, of course, and in the case of a minor, with a parent's permission. But even in the absence of a formal screening tool, a provider asking about a young person's emotional health can open the door to a discussion that a patient (or a parent) might otherwise not raise.

"Don't be afraid toask," says Tonsmeire. "Teenagers will tell the truth if they sense you care."

A need for sensitivity, but also directness

Raising the issue of a child's mental health can nevertheless be challenging because of a still-commonly held stigma that associates mental health problems with personal fault or weakness. As a result, parents may be reluctant to acknowledge a problem with their child. In certain cases, a parent's behavior or discord within the family maybe contributing to the child's condition.

Kelleher says a nurse or other provider's openness in asking about a child's psychological symptoms can set ane xample for parents. "Instead of hesitation or awkwardness, there's a need for candid questions," he adds.

Because mental health disorders are easily misunderstood, more than the usual amount of parent and patient education may be necessary. You'll want to be sure to use language appropriate to the educational levels of the parent and child when explaining that mental health disorders are real illnesses, not "made up." And, as with any medical disorder, treating the problem early can prevent greater impairment down the road.

While granting the need for sensitivity and tact, however, there's one point on which Tonsmeire says she's become "unflinching"-a point she says under scores the seriousness of illness that puts a child at risk of becoming dangerous to himself or others.

"The four young men who committed suicide [in Juneau] were different in socioeconomic background, race, and age," she says, "but they had one thing in common-all four used guns.

"If a child may be depressed," she continues, "ask the parent, 'Do you have guns in the house (or elsewhere)? If so, you need to take them out of the house. Let someone hold them for you, and don't return them to the house as long as the child is at risk.'"

A role for nurses at many levels

Beyond assessment and education, nurses may find parents need help linking up with community support and treatment services. (See the "Children's mental health resources" box.) Gail Barlow Gall, RN, ANP/PNP, the immediate past president of the National Assembly on School-Based Health Care, has cared for children as a nurse practitioner, a school nurse, and a community health nurse. She stresses the importance of nurses knowing how to facilitate referrals to mental health services in their own healthcare setting, in local school systems, and in the community. "If a parent is feeling overwhelmed, those steps may be difficult," she says, adding, "Check to see if thesystem is working for them."

Nurses can also contribute as educators in schools, parent meetings, and other community settings. Kathryn Puskar, RN, DrPh, an associate professor of nursing at the University of Pittsburgh School of Nursing, and president-elect of the American Psychiatric Nurses Association, has produced a successful eight-week course for high school students-taught by nurses-called TKC (Teaching Kids to Cope).10 While it was developed as a means for preventing depression, TKC recently received private funding to be expanded into an anger management course, says Puskar.

At the national level, momentum has been building to improve the way mental healthcare is accessed, delivered,and financed, says Virginia Trotter Betts, RN, JD, a former senior advisor on federal mental health initiatives and now director for health policy at theUniversity of Tennessee Health Sciences Center.

Meanwhile, for children who might otherwise slip through the cracks, nurses tuned into mental as well as physical health can play a powerful role. "Wherever young people are," says Betts, "we need a 'collusion' of adults who care about this."


1. National Institute of Mental Health. "Brief notes on the mental health of children and adolescents." (26 Feb. 2002).

2. Substance Abuse and Mental Health Services Administration (SAMHSA). "SAMHSA unveils data on youths contemplating suicide." 2002. (15 July 2002).

3. U.S. Public Health Service. "Report of the Surgeon General's conference on children's mental health: A national action agenda.2001. (5 Mar. 2002).

4. Kelleher, K. J., McInerny, T. K., et al. (2000).Increasing identification of psychosocial problems: 1979 – 1996. Pediatrics,105(6), 1313.

5. U.S. Public Health Service. Office of the Surgeon General. "Mental health: A report of the Surgeon General." (26 Feb. 2002).

6. Weissman, M. M., Wolk, S., et al. (1999). Depressed adolescents grown up. JAMA, 281(18), 1707.

7. American Medical Association. "AMA Adolescent Health Resources." 2002. (17May 2002).

8. Department of Child Psychiatry, Massachusetts General Hospital. "Pediatric symptom checklist." 2002. (26 Apr. 2002).

9. Columbia University Division of Child and Adolescent Psychiatry. "Columbia University TeenScreen program." (30 Apr. 2002).

10. Puskar, K. R., Lamb, J., et al. (1997). Teaching kids to cope: A preventive mental health nursing strategy for adolescents. JChild Adolesc Psychiatr Nurs, 10(3), 18.

Teach parents what to watch for

Encourage parents to tell you orthe physician if their child exhibits any of the following signs and symptoms,which may be indicative of mental illness.

In younger children

In older children and pre-adolescents

Changes in school performance

Substance abuse

Poor grades despite strong efforts

Inability to cope with problems and daily activities

Excessive worry or anxiety (e.g., refusing to go to bed or school)

Change in sleeping and/or eating habits


Excessive complaints of physical ailments

Persistent nightmares

Defiance of authority, truancy, theft, and/or vandalism

Persistent disobedience or aggression

Intense fear of weight gain

Frequent temper tantrums

Prolonged negative mood, often accompanied by poor appetite or thoughts of death

Frequent outbursts of anger

Source: National Mental Health Association. "Mental illness in the family. Recognizing the warning signs & how to cope." (19 July 2002).

Children's mental health resources


The Center for Mental Health Services (CMHS)
Knowledge Exchange Network (KEN)
This government–sponsored service can direct callers to federal,state, and local organizations dedicated to treating and preventing mental illness. The Web site offers a "services locator," which enables visitors to find services and resources in their state.
(800) 789-2647

National Alliance for the Mentally Ill (NAMI)
NAMI is a nonprofit advocacy organization. Visitors to the NAMI Website can locate local affiliates by first clicking on the "Support" button on the left side of the home page.
(703) 524-7600
(800) 950-NAMI [6264]

National Mental Health Association (NMHA)
NMHA is a nationally recognized resource for information on mental illness and treatment and referrals for local treatment services. It offers a network of more than 340 affiliates and referrals to more than 7,000 organizations nationwide.
(800) 969-NMHA (6642)

Reading materials for parents

"Promoting Children's Mental Health"

"Child and Adolescent Mental Health"

"Medical Library: Behavior and Mental Health Issues"
(Information on children's health from the American Academy of Pediatrics and other leading medical societies.)

Crisis hotline

National Hopeline Network
Callers to this hotline can reach a certified crisis center 24 hours a day, seven days a week.
(800) SUICIDE (800-784-2433)

Resources for professionals

"American MedicalAssociation Guidelines for Adolescent Preventive Services (GAPS)"

"Columbia TeenScreenProgram"

"Pediatric SymptomChecklist (PSC)"

"Report of the SurgeonGeneral's Conference on Children's Mental Health: A National ActionAgenda"

The mental health of children:
A useful screening tool


GAIL BARLOW GALL is the immediate past president of the National Assembly onSchool-Based Health Care and a doctoral student in health policy at the University of Massachusetts, Boston, School of Nursing.

Here's how you can incorporate a brief mental health screening tool into your assessment of a child's total health.

The ideal approach to meetingt he mental health needs of children involves prevention, early detection, intervention, and management. Nurses in pediatric, school, or family clinics not only help assess a child, but may often serve as "the glue" that holds the plan of care together, coordinating parental participation, insurance coverage, transportation, and school and community services.

Any nurse who is involved in assessing children needs to consider psychosocial risk factors. In selecting a tool to help identify those at risk, you need to feel comfortable using it and be confident that it will be acceptable to your patients.

One such tool for pediatric mental health screening is the Pediatric Symptom Checklist (PSC). The PSC, which was developed by researchers in the department of child psychiatry at Massachusetts General Hospital, has been tested and validated in urban and suburban settings.1,2 My own experience with it has been in school-based health centers.

There are two versions of the form (both available in English and Spanish). The "Pediatric Symptom Checklist" is designed for children under age 12 and should be completed by a parent. The other version, the Youth Report PSC (Y-PSC), is designed for children between the ages of 12 and 18, and should be filled out by the child himself-with parental consent. (You can view the Y-PSC at .)

Gaining more insight into a child's well-being

Before giving the appropriate form to a parent or child, it's important to ensure that the individual is comfortable putting his answers in writing and that he understands that completing the form is strictly voluntary. You must also make sure that he canfill out the form in a private area.

Getting parents-or the children themselves-to complete a PSC or Y-PSC is easier if there's a clear protocol in place for selecting which patients are to be assessed, such as all new patients or all those coming in for well visits. Explain that the form is used for all patients and enables their providers to understand a child's health needs better. You should also reassure them of the confidentiality of this and other records. Nevertheless, some may not feel comfortable with the form, and no one should be coerced to fill it out.

Once the PSC or Y-PSC is completed, the nurse scores it and attaches it to the medical chart for that visit. The total score is derived by adding the sums of all the items as follows: Items marked "Never" get a value of 0, those marked "Sometimes" get a value of 1, and those marked "Often" get a value of 2. Total scores in the mid to upper twenties indicate a potential problem.3 (For full details on scoring, point your browser to

Getting kids the care they need

Keep in mind that the form is not meant to be diagnostic but to help identify potential psychosocial problems and decide whether a referral is appropriate. If you plan on discussing the score with the patient or parent, try starting with a simple remark and question, such as "It seems like there's a lot going on with you (or withyour child). How are you managing?" Or, "I see you have checked off these symptoms. Is that new for you? How are you doing?"

Open-ended questions such as these help set the stage for further exploration of the symptoms. Nurses who do the screening should be trained to assess risks for suicide, substance abuse, and psychoses. If you are in such a role, you should also know who to contact for assistance in the assessment, determination of urgency, and transfer of care, when necessary.

Depending on the setting you work in, you may be responsible for tracking and documenting next steps. Did the patient and/or family get a referral form to see a mental health specialist? Was the appointment kept? What kind of treatment was recommended and what outcomes achieved?

A study of the Y-PSC in a school-based health center found that the tool was accepted by students, and staff reported that it improved the quality of their referral decisions.4 Interestingly, 12% of the 383 teens completing the form asked for additional mental health services. Nearly two-thirds of students referred were identified by the Y-PSC as having a psychosocial problem.

By becoming knowledgeable about mental health and the use of assessment tools, nurses can use their expertise not only to help evaluate individual children and families, but also to advocate for them so they obtain appropriate care. For more details on the use of the PSC, obtaining a copy, and research validating the tool, visit the PSCWeb site at or call (617) 724-3163. Another Web site, "Bright Futures in Practice: Mental Health," is also an excellent resource for nurses, and can be accessed at .

For more information on the mental health of children, see the related article, "Thehidden threat to our nation's kids."


1. Department of Child Psychiatry, Massachusetts General Hospital. "Pediatric symptom checklist." 2002. _general.htm (26 Apr. 2002).

2. Jellinek, M. S., Murphy, J. M., et al. (1999). Use ofthe Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: A national feasibility study. Arch Pediatr AdolescMed, 153(3), 254.

3. Department of Child Psychiatry, Massachusetts General Hospital. "Pediatric Symptom Checklist: Detailed information." 2002. .org/psc_detailed.htm (7 June 2002).

4. Gall, G., Pagano, M., et al. (2000). Utility of psychosocial screening at a school-based health center. J Sch Health, 70(7),292.

Pediatric Symptom Checklist (parent form)

Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child's behavior, emotions, or learning, you may help your child get the best care possible by answering these questions. Please indicate which statement best describes your child.

Please mark under the heading that best describes your child





Complains of aches and pains


Spends more time alone


Tires easily, has little energy


Fidgety, unable to sit still


Has trouble with teacher


Less interested in school


Acts as if driven by a motor


Daydreams too much


Distracted easily


Is afraid of new situations


Feels sad, unhappy


Is irritable, angry


Feels hopeless


Has trouble concentrating


Less interested in friends


Fights with other children


Absent from school


School grades dropping


Is down on himself or herself


Visits the doctor, with doctor finding nothing wrong


Has trouble sleeping


Worries a lot


Wants to be with you more than before


Feels he or she is bad


Takes unnecessary risks


Gets hurt frequently


Seems to be having less fun


Acts younger than children his or her age


Does not listen to rules


Does not show feelings


Doesn't understand other people's feelings


Teases others


Blames others for his or her troubles


Takes things that don't belong to him or her


Refuses to share

Total score

Does your child have any emotional or behavioral problems for which she/he needs help?

( ) N

( ) Y

Are there any services that you would like your child to receive for these problems?

( ) N

( ) Y

If Yes, what services?


Source: Department of Child Psychiatry, Massachusetts General Hospital. "Pediatric symptom checklist." 2002. (26 Apr. 2002).

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