Recently the American Academy of Pediatrics issued updated guidelines that call for universal screening for depression for everyone 12 years old and up, in an effort to increase identification, interventions for children and their families, and suicide prevention for children and adolescents who are suffering from depression.
According to this article on NPR.org, Dr. Rachel Zuckerbrot, a board-certified child and adolescent psychiatrist and associate professor at Columbia University who helped write these updated guidelines, says the screening “could be done during a well-visit, a sports’ physical or during another office visit.”
Parental attitudes about self-care and health beliefs about illnesses and relationships with the medical community in general may vary greatly across families, and depending on the structure of the pediatric offices and medical networks children and teens may not be seen by the same doctor for every visit. These two factors, among others, could complicate or interfere with attending yearly screenings at their pediatrician’s office. Further complications may include children and teens spending more time at a specialist’s office, and the potential lack of communication between specialists and primary care physicians about the severity of illness symptoms, severity and frequency of depression symptoms, and medications prescribed from each office that may become part of a plan for suicidality.
Schools, which are the only other location where children are regularly present besides their homes, are ideal places for these screenings to take place, and to develop and incorporate appropriate interventions and support systems for children and adolescents who are suffering from depression.
Key Things for School Counselors to Remember in Depression Screening, Suicide Risk Assessment, and Intervention Efforts:
- Privacy: Some guidance offices are no longer private spaces but instead may have multiple staff desks in the same room. Please be aware that children and teens may be much more reluctant or resistant to disclose and discuss their depression or potential for suicidality in places that lack privacy. Is there a better place available for this discussion? Perhaps the school nurse’s office, or a small conference room that is not in use, and can have a “session in progress” sign on the door?
- Verbal or Written Depression Screening: This really depends on which format the child/teen will be most receptive to- some might like the opportunity to write their answers, some really want to be heard by someone, anyone, particularly if they are seriously emotionally dysregulated and need the assistance of an adult to help identify, clarify, and sort the emotions they are feeling.
- SAFE-T (Suicide Assessment Five-Step Evaluation and Triage): Once you’ve done the screening and it indicates that the child/teen is depressed, keep going and assess for suicidality. The SAFE-T is a free, downloadable PDF tool that guides the counselor through the 5 step process of (1) identifying and exploring risk factors (2) identifying internal and external protective factors (3) engaging in the suicide inquiry (4) identifying risk level using a three level chart, and (5) documentation with clear treatment plan to reduce current risks, and interventions for youth and their parents or caregivers.
- Make and Sign a No Harm/ No Suicide Contract: First, an important note: there is never any guarantee that a piece of paper will change the direction of a child/teen’s intention, but if you take this contract seriously then you can increase the likelihood that the child/teen will take it seriously too. The first lines of the contract are clear- this is where the directives for no harm /no suicide or suicide attempt are written.The middle part of the contract should include a 24 hour/7 days a week suicide prevention hotline they can call when in crisis, like 1-800-273-TALK (1-800-273-8255), the National Suicide Prevention Lifeline, and the names, addresses, and contact numbers of key people in the child/teen’s life that they can call for help or transportation to the nearest emergency room. This is particularly important when kids/teens have more than one residence and are not with one or both parents at each residence. For children/teens with ongoing medical issues, make sure to include the pediatrician’s name and contact information on the form so the child/teen can call their primary care doctor themselves if they have to. The last part of the contract should include specific instructions for the parent or caregiver to call 911 or take the child/teen to the nearest emergency room if certain behavioral or verbal indicators are present that the child/teen has identified as indicators that suicide is imminent, and list these identified indicators clearly so that the parent/caregiver can use them as a checklist to determine the severity and likelihood of imminent suicidality and intervene accordingly. At the bottom of the contract page, have three lines for signatures: the child/teen’s, yours as a witness, and the parent’s as proof that the contract was reviewed with the parent and agreed upon. Keep a copy on file, especially since it has the names and contact information of people connected to the child/teen, and give a copy to the child and parent because they will need the hotline information and the verbal and behavioral indicators checklist.
- Assist the family in finding at least three treatment sites in their area that accept their insurance: First, a very important note for all school staff: please do not threaten to expel students or bar them from returning to school if they fail to secure off-site psychotherapy in less than a week!! I cannot stress this point enough- if a student has been experiencing difficulty in school then chances are they have already been having ongoing therapy sessions at school with their school guidance counselor, mental health counselor, or social worker, and built a relationship of trust with that person that allowed their depression and suicidality to be discovered, and threatening the parent with expulsion of their child creates an adversarial relationship with the parent , a sense of penalizing the child/teen for the disclosure, and threatens to disconnect the child/teen from the one place and person they currently receive any help and support from at the school. Also, some parents may take this threat of expulsion at face value and allow the child to stay home and not attend school at all, which will likely increase isolation from help, escalate levels of depressive symptoms and suicidality risk, and potentially trigger an attempt or completion of suicide. All states in the U.S. have laws and regulations regarding mandated reporting by school personnel, and schools are required to call child protective services if there is a risk of harm to the child and reason to suspect that the parent either caused the abuse or is neglecting to address it to protect the child. Instead of threatening expulsion, try:
- Inviting the parent into your office to discuss what’s happening with the child/teen, the depression screening tool used to confirm and explore the information, and the suicide assessment information, and be prepared that the parent may be shocked and distraught. This is where it is important to build an ongoing collaborative effort between the school and the parent, who represent the two places the child/teen frequents most (school and home) and help monitor the child from both fronts. School staff, including guidance counselors, can help parents identify local psychotherapy treatment sites that accept the child’s insurance plan and provide this information to the parent while the parent is in your office. Keep a copy of the places you referred the child to for services.
- Call the treatment sites with the child and parent in your office and help them to schedule the intake session. Keep in mind that some places may have a waitlist, which is not in the best interest of the child who needs to have their intake and assessment as soon as possible. Scheduling an intake needs to factor in transportation time, the calendar availability of the site for the intake and having the billing department check their insurance before the appointment, as well as the site’s availability to see the child/teen and the family on an ongoing weekly basis. It will be especially important for the school and the treatment site to discuss any information about the school’s interventions with the child/teen up to that point, and have ongoing collaboration between treatment providers at least once a month.
- Schedule a follow up call with the parent to find out whether they attended the intake session and their experience, and find out if they plan on continuing treatment there or if they want or need to try another site. Document this discussion for your files.
School counselors, please remember that helping children and teens is a team effort. If you have been working with a child/teen for three months or longer, consider that you and your student may have better treatment progress and outcomes if you combine your efforts for individual psychotherapy with off-site family therapy support. In addition, explore your child/teen’s social circle at school for other kids who are similarly symptomatic and possibly exchanging maladaptive coping skills (ex: alcohol, drugs, self-harm tactics) that could hinder treatment progress, increase risky and dangerous behaviors, and necessitate additional medical interventions. Since the academic semesters and year follow a set schedule, a team intervention effort may also reduce the likelihood of academic jeopardy and repeating grades, which may increase depression due to separation from their classmates, friends, and social peers.
Depression screenings for ages 12 and up is a great and much needed initiative, but this will be most effective in conjunction with suicidality risk assessment and appropriate and timely interventions for individual and systemic support. Additional resources are available at www.sprc.org or at www.stopasuicide.org. Learn more about how to help people with depression and in crisis, and the treatment programs available in your neighborhoods today.
References:
Pediatricians Call For Universal Depression Screening For Teens. (2018). Retrieved on March 2, 2018, from: https://www.npr.org/sections/health-shots/2018/02/26/588334959/pediatrians-call-for-universal-depression-screening-for-teens
SAFE-T. (2009). Migraine Headaches. Retrieved on March 2, 2018, from: https://www.integration.samhsa.gov/images/res/SAFE_T.pdf
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