Behavioral Health - Key Activity 16B

KEY ACTIVITY #16B:

Screen Adolescents for a Range of Behavioral Health Needs

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration.

Overview

This activity provides general recommendations on screening for behavioral health needs for adolescents aged 12 to 18 years. This guide uses depression as an example, as most practices begin behavioral health screening with depression. As the clinical team develops skills and familiarity with screening adolescents for depression, and staffing on teams includes individuals with expertise in treating and supporting adolescents with their mental health needs, the goal is to incorporate additional behavioral health screening strategies, such as screening for anxiety, suicide and unhealthy substance use. Patient concealment about depression, substance use and previous trauma history can be high for fear that reporting such experiences will lead to emergency response and/or reporting to protective services. Developing trust with adolescents can be effective in combating this common and understandable inclination. Additionally, as mentioned elsewhere, giving adolescents the option to engage or not in screening and a further option to answer screeners through self-report via methods such as a tablet that protects confidentiality may help.

Depression is among the leading causes of disability for all ages in the U.S. Children and adolescents who frequently experience depression have functional impairments in their school performance and in interactions with peers and family members. Depression can have long-term impacts and negatively affect children’s developmental trajectories. Children and adolescents with major depressive disorder (MDD) have higher rates of recurrent depression in adulthood, other mental disorders, and an increased risk for suicidal ideation, suicide attempts, and suicide completion.[1]

Nationally, suicide is the second-leading cause of death among youth ages 10 to 19. Psychiatric disorders and previous suicide attempts increase suicide risk. Rates of suicide attempts and deaths vary by sex, age, and race and ethnicity.

Developing a process for reliably screening all adolescent children for behavioral health conditions is important because recent research reports higher rates of depression, suicide attempts and suicide rates among Black children, compared to the past.[2] Reasons for such disparities are likely multifactorial and include factors such as socioeconomic status, experiences of structural and overt racism, family structure, neighborhood effects, and childhood adversity.[3] Adverse childhood experiences (ACEs) have been shown to influence the likelihood of adolescents experiencing mental health conditions, such as depression. Some hypothesize that lower engagement with mental health services, combined with adverse childhood experiences, result in high levels of unmet need in Black youth.[4] Mental health disorders in Native American/Alaska Native youth likely arise from similar patterns of historic trauma, adverse childhood experiences, and unhealthy substance use.[5]

Implementation considerations

Implement universal screening and follow-up for adolescents, starting with depression screening.

As with depression screening for adults, the most commonly used instrument for depression screening in adolescents is the PHQ-9. Teams often start with one depression screening questionnaire for all age groups and then, as they develop skills and internal capacity at screening and managing behavioral healthcare, they consider utilizing tools specific to different age groups or populations. The PHQ-A is an adolescent-specific version of the PHQ-9 and, therefore, a natural tool to transition to when seeking a screening tool more specific to adolescents. There are two HEDIS measures for depression screening; one is specific to a validated measure of depression and another is specific to the PHQ-9. While, in general, PHMI advocates for the use of the PHQ-2 or PHQ-9 for depression screening, there are some practices who have developed familiarity and ease with utilizing other validated tools. For a summary of additional validated tools for mental health screenings for adolescents, the American Academy of Pediatrics (AAP) compiled this table. As with depression screening for adults, it is important to use a validated tool and adequately train staff to administer, score and interpret results.

For adolescents, screening responses can come from the patient or their caregiver but, ideally, adolescents are interviewed separately from their parents or caregivers. All positive screening results should lead to additional assessments to confirm diagnosis, determine symptom severity, assess suicide risk, and identify comorbid psychological problems.

While it is an important practice to screen for depression, not all young people at risk for suicide will endorse or experience symptoms of depression. Depression screening is best utilized alongside suicide risk screening (e.g., the PHQ-A and the Ask Suicide-Screening Questions (ASQ) tool). As mentioned above, screening for suicide alongside depression screening may be achievable as your integrated behavioral healthcare model evolves, or it may be something that your team is ready to test now.

As your team develops confidence in assessing and managing depression, expand to screen for other BH needs, such as anxiety and ADHD. Consider tools, such as the adverse childhood experiences screen for adolescents (PEARLS), the Pediatric Symptom Checklist (PSC), and/or the CRAFFT for substance use.

Implementation tips

The workflow for depression screening among adolescents is similar to that described in the Key Activity 9A: Screen Adults for Depression, Including Suicidality and includes the following:

  • Training staff in implementing adolescent-specific tools. This includes training staff to ask and score the tool and workflow considerations about identifying and implementing a different tool for patients as they age.
  • Incorporating strategies into well and sick visits that normalize and help families prepare for interviewing adolescents alone. For example, letting families know at the 11-year-old well-child visit that next year’s visit will include a portion when the adolescent is interviewed alone, including discussing what will be covered and legal rights around confidentiality.
  • Troubleshooting with staff about what to do, such as normalizing the activity, suggesting for future visits, and responding to family concerns/reservations, if families or adolescents do not agree with allowing the adolescent to be interviewed separately

Evidence base for this activity

  • Bridge JA, Horowitz LM, Fontanella CA, Sheftall AH, Greenhouse J, Kelleher KJ, et al. Age-Related Racial Disparity in Suicide Rates Among US Youths From 2001 Through 2015. JAMA Pediatrics. 2018 Jul 1;172(7):697.
  • Garcia JL. Historical Trauma and American Indian/Alaska Native Youth Mental Health Development and Delinquency. New Directions for Child and Adolescent Development. 2020 Jan;2020(169):41–58.
  • Patra KP, Kumar R. Screening For Depression and Suicide in Children [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://pubmed.ncbi.nlm.nih.gov/35015441/
  • Viswanathan M, Wallace I, Middleton JC, Kennedy SM, McKeeman J, Hudson K, et al. Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. PubMed. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022. Available from: https://pubmed.ncbi.nlm.nih.gov/36282939/
  • Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. practice preparation, identification, assessment, and initial management. Pediatrics [Internet]. 2018 Feb 26;141(3):1–21. Available from: https://pediatrics.aappublications.org/content/141/3/e20174081

Endnotes

  1. Viswanathan M, Wallace I, Middleton JC, et al. Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 221. Agency for Healthcare Research and Quality; 2022. AHRQ publication No. 22-05293-EF-1. 
  2. Bridge JA, Horowitz LM, Fontanella CA, et al. Age-related racial disparity in suicide rates among US youths from 2001 through 2015. JAMA Pediatr. 2018;172(7):697-699 
  3. Garcia JL. Historical trauma and American Indian/Alaska Native youth mental health development and delinquency. New Dir Child Adolesc Dev. 2020;2020(169):41-58. 
  4. Viswanathan M, Wallace I, Middleton JC, et al. Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 221. Agency for Healthcare Research and Quality; 2022. AHRQ publication No. 22-05293-EF-1.  
  5. Garcia JL. Historical trauma and American Indian/Alaska Native youth mental health development and delinquency. New Dir Child Adolesc Dev. 2020;2020(169):41-58.