Screening adolescents for psychosocial concerns

Psychosocial issues are central to the care of adolescent patients. Pediatricians routinely discuss substance use, sexual health, and accident prevention with adolescents and are likely to see specific mental health concerns in about 20% of their patients. In light of rising suicide rates and the likely consequences of COVID-19, depression is an increasingly common concern. With limited access to mental health clinicians, individual pediatricians must manage patients’ mental health needs by enhancing their own skills, collocating mental health personnel in their practices, and building trusted referral networks.

Because psychosocial screening is now an expected part of pediatric primary care,¹ this article focuses on screening adolescent patients, including choice of tools and follow-up of positive results.

Selecting a validated screening measure

Clinicians can download several well-validated, no-cost, and brief measures to screen for both broad and specific psychosocial concerns in their patients (Table).

Table

One of the most common, broader screening measures, the Pediatric Symptom Checklist (PSC), has been endorsed by the National Quality Forum to assess both depression and overall psychosocial functioning, with 3 subscales reflecting internalizing, externalizing, and attention symptoms.² The PSC is available in 35- and 17-item versions, in both parent and youth self- report versions, and in more than 30 languages.

Teenagers can also complete various diagnosis-specific measures. For example, the Patient Health Questionnaire Modified for Teenagers (PHQ-9M) is a 13-item screening tool for depression and suicide risk that uses language targeted toward adolescents. Generalized Anxiety Disorder-7 (GAD-7) is a 7-item self-report measure designed to identify and assess the severity of generalized anxiety disorder (not phobias or obsessive-compulsive disorders) using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.⁴ The protocol Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) can be used to assess both substance use disorders and safety risks in patients aged 12 to 21 years—including those who do not endorse substance use—by asking about substance-related riding and driving, 2 leading causes of death in this age group.⁵

Administering the tool

The Guidelines for Adolescent Depression in Primary Care recommend annual screening (more frequently for those with higher-risk factors; eg, family history) for all adolescents 12 years and older using a validated screening tool that includes a depression measure.⁶

Who should complete the questionnaire? Parents can provide better historical accuracy and add a mature perspective on a youth’s daily functioning. Adolescents often give more accurate insight into their internal emotional states, especially the subjective experience of depression or anxiety.⁷ Given the ease of administration, a best practice might be having both a parent- and a patient-completed screen, especially if integrated into the visit using an electronic patient portal.

Assessing positive screens

Clinicians should discuss positive screens (eg, parent PSC, adolescent PHQ-9M) with the patient individually and then with their parent(s). Clinicians can ask about specific problems noted on the screenings, gather family history of emotional disorders, and assess by interview the adolescent’s daily functioning—school, family, friends, activities, and mood.

When a patient endorses suicidal ideation, clinicians should evaluate the severity of suicide risk. The Ask Suicide-Screening Questions (ASQ) approach recommends talking with the patient about factors such as the frequency of suicidal thoughts, previous attempts or self-injury, presence of a plan, substance use, bullying, family situation, access to means (especially guns and medication), and protective factors (eg, coping and problem-solving skills, meaningful relationships, reasons for living, and access to treatment).⁸ Because these issues can be difficult for teenagers to discuss, a valid assessment depends on a sense of trust and safety during the interview.

Although pediatricians and mental health clinicians are justified in feeling anxious when assessing suicidal risk because of the life-or-death concern, the expectation of accurately predicting suicidal behavior for any individual patient is unrealistic. Suicidal ideation is overwhelmingly more common than attempts, and there is, as yet, no reliable way to predict which patients with suicidal ideation will attempt or die by suicide. Still, these youths often have significant psychological distress and would likely benefit from additional assessment and a plan for managing suicidal ideation and treating their underlying psychosocial problems.

In addition to having a higher lifetime risk of suicide, adolescents struggling with psychosocial issues such as depressed mood, attentional difficulties, impulsivity, or anxiety

are more likely to have poorer physical health⁹ and be involved in accidents,¹⁰ misuse substances,^9,11 and drop out of high school.^12,13 Rather than exclusively focusing on preventing imminent suicide, mental health screening is best viewed as a valuable opportunity to identify a vulnerable group of adolescents who merit follow-up with repeated screening, monitoring, and treatment planning in much the same way that pediatricians manage chronic physical illness. By advancing their own learning and with the help of more resources, primary care pediatricians can be well positioned to identify and help their adolescent patients burdened by mental health issues.

References

1. Jellinek M, Murphy JM. Screening for psychosocial functioning as the eighth vital sign. JAMA Pediatr. 2021;175(1):13-14. doi:10.1001/jamapediatrics.2020.2005

2. Behavioral health and substance abuse. National Quality Forum. Accessed December 9, 2021. https://www.qualityforum.org/Behavioral_Health_and_Substance_Use.aspx

3.Johnson JG, Harris ES, Spitzer RL, Williams JB. The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health. 2002;30(3):196-204. doi:10.1016/s1054-139x(01)00333-0

4.Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092

5. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156(6):607-614. doi:10.1001/archpedi.156.6.607

6. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D; GLAD-PCSteering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): part I. practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081. doi:10.1542/peds.2017-4081

7. Herjanic B, Reich W. Development of a structured psychiatric interview for children: agreement between child and parent on individual symptoms. J Abnorm Child Psychol. 1982;10(3):307-324. doi:10.1007/BF00912324

8. National Institute of Mental Health. Ask Suicide-Screening Questions (ASQ) Toolkit. Accessed February 1, 2022. https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials

9. Bardone AM, Moffitt TE, Caspi A, Dickson N, Stanton WR, Silva PA. Adult physical health outcomes of adolescent girls with conduct disorder, depression, and anxiety. J Am Acad Child Adolesc Psychiatry. 1998;37(6):594-601. doi:10.1097/00004583-199806000-00009

10. Brunkhorst-Kanaan N, Libutzki B, Reif A, Larsson H, McNeill RV, Kittel-Schneider S. ADHD and accidents over the life span - a systematic review. Neurosci Biobehav Rev. 2021;125:582-591. doi:10.1016/j.neubiorev.2021.02.002

11. Malmberg M, Overbeek G, Monshouwer K, Lammers J, Vollebergh WA, Engels RC. Substance use risk profiles and associations with early substance use in adolescence. J Behav Med. 2010;33(6):474-485. doi:10.1007/s10865-010-9278-4

12. Fredriksen M, Dahl AA, Martinsen EW, Klungsoyr O, Faraone SV, Peleikis DE. Childhood and persistent ADHD symptoms associated with educational failure and long-term occupational disability in adult ADHD. Atten Defic Hyperact Disord. 2014;6(2):87-99. doi:10.1007/s12402-014-0126-1

13. Dupéré V, Dion E, Nault-Briere F, Archambault I, Leventhal T, Lesage A. Revisiting the link between depression symptoms and high school dropout: timing of exposure matters. J Adolesc Health. 2018;62(2):205-211. doi:10.1016/j.jadohealth.2017.09.024