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Mental and behavioral health depression screening at Children

The one question that can help identify depression in teens

The teenage girl wore a blue sweatshirt, leggings and a ponytail — a typical teen. She had a loving family, did well in school and was usually all smiles. In all her years seeing Sharyl Paley, MD, a pediatrician at Children’s Wisconsin Bayshore Pediatrics primary care office, she never hinted at any mental health issues.

At the start of her annual wellness exam, Dr. Paley handed her a clipboard with a single sheet of white paper that contained one question: "Over the past two weeks, how often have you been bothered by any of the following problems?"

It then listed nine statements, including:

Little interest or pleasure in doing things.

Trouble falling asleep, staying asleep, or sleeping too much.

Feeling bad about yourself — or that you’re a failure or have let yourself or your family down.

Thoughts that you would be better off dead or of hurting yourself in some way.

The girl completed the questionnaire and handed it back. As Dr. Paley reviewed her responses, she tried not to let her face fall.

The depression screen was positive — alarmingly so.

When Dr. Paley asked her patient about it, the girl broke down. “The hard part was that this child’s sibling was dealing with some serious mental health issues, but no one had realized that this young woman was struggling as well,” said Dr. Paley.

Fortunately, the girl’s parents were receptive to her need and Dr. Paley helped the family identify a therapist. A few months into therapy, the teen is already showing signs of improvement. But her story raises the question — what if no one had asked?

Power of a screening tool

With one in four Wisconsin teens reporting that they experience depression, screening is a powerful tool that can help to start a cycle of attention and action — as opposed to denial and stigma.

Dr. Paley and her colleagues at Children’s Wisconsin’s primary care clinics have made a serious commitment to screening for mental illness in adolescents. In 2019, 97.2 percent of adolescents seen at Children’s Wisconsin primary care locations were screened, and of those, 21.1 percent had positive screens. Children’s Wisconsin has the highest published rate of screening, reflecting the system’s commitment to kids’ mental and behavioral health, and since starting the screening in 2016 has performed more than 80,000 screens.

“We’re seeing more and more kids with dysthymia (mild depression) or who are feeling sad,” said Dr. Paley. “There’s also more anxiety — kids are experiencing more school pressures and more social pressures, including social media.”

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Dr. Paley says that to parents or teachers, this can often look like inattention or distractibility. Sometimes parents think kids are pulling away in a “normal” teenage way. 

“Parents often aren’t sure what’s going on with their kids and may not realize how deep or severe their depression or anxiety is,” said Dr. Paley. “They may notice their teens pulling away from friends, but may think it’s just because they don’t want those friends anymore. This simple screening tool can be a powerful way to start discussion where there hasn’t been discussion before.”

Giving kids tools sooner

With increased awareness of kids’ mental health, Children’s Wisconsin pediatricians are starting conversations with kids sooner — even before they start filling out the depression screening at age 12. Kristin Bencik-Boudreau, DO, a pediatrician at Children’s Wisconsin Bayshore Pediatrics, uses words younger children can understand and routinely asks patients ages 8 and up, “Do you feel worried or sad?”

Sometimes the answer is surprising.

“I recently saw an 11-year-old girl and when I asked her that question, she said ‘I’m worried about school shootings,’” said Dr. Bencik-Boudreau. “Her school had never had a threat, but she had been very anxious about it, even having trouble sleeping. Her parents and even her twin were unaware she was feeling that way.

“There is so much brought out that we never would have known without asking. It’s like these kids are holding it all in until they’re ready to explode,” she said.

Through working with the child and her family, the child’s fears were eventually calmed — simply by bringing that fear into the open.

“As pediatricians, we’re starting to talk to kids when they’re quite young — 8, 9, 10 years old — to give them tools like meditation and healthy ways of destressing like exercise,” said Dr. Paley. “I tell my patients that practicing mental health is just like practicing for a sport or musical instrument — the more you practice, the better you’ll be.

“Helping kids think about these feelings and giving them tools for dealing with them can help prepare them if, because of their development or a life event, they become prone to anxiety or depression,” said Dr. Paley “As with any illness, prevention is the best and safest medicine.”

When therapy isn’t enough

Even for kids who have previously identified mental health challenges, the screening can serve an important purpose –– to track their progress, or lack of it.

When a teenage boy who had been working with a therapist came in for a well-child visit, Dr. Paley discovered his depression screening score had increased significantly.

“This kid was using all his energy, working the strategies he had learned in therapy, doing everything he could,” she said. “He was holding on, he wasn’t yet suicidal, but he was exhausted and spiraling down.”

With the help of the screening data, the boy’s parents became open to other approaches to care and ultimately supported their son in trying medication. Now, he’s participating in school and activities more and feeling better.

“I talked to him the other day and he thanked me,” said Paley. “He said the medication has really helped.”

Overcoming stigma

For some parents, seeing screening results over time can help them recognize and accept when their child needs help. Dr. Bencik-Boudreau recalls a patient, a teenage boy who admitted struggling with his mental health, whose parents didn’t believe he needed help.

“Finally, through screening results, I was able to work with the family and help this young man start seeing a counselor. Once he began to get help, the parents were able to accept it,” Dr. Bencik-Boudreau said. “We’re still working on overcoming the stigma of all of this — helping families understand that this is just like any other illness and there are treatments, tools and yes — sometimes medication — that can really help.”

Screening kids across the system

The work of its primary care pediatricians is just one way Children’s Wisconsin is approaching the goal of screening all patients for mental health concerns, no matter where they are seen and at what age. The Emergency Department also routinely screens teens for suicide risk, and several specialty areas integrate mental and behavioral health into their care for kids.

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But that’s just the beginning. As part of its five-year plan for improving mental and behavioral health services, Children’s Wisconsin plans to implement screening at every touchpoint where kids get care: from adoptive and foster care services, to school nursing programs to specialty clinics.

“We know that universal screening is the right thing to do,” said Amy Herbst, vice president of Mental and Behavioral Health at Children’s Wisconsin. “We’re developing the tools and protocols that will let us help ensure that every Wisconsin kid can get the right care at the right time.”

Meanwhile, at Children’s Wisconsin primary care offices from the North Shore to Midtown to Kenosha, Dr. Paley, Dr. Bencik-Boudreau and their colleagues will continue to work with one child and family at a time, with the belief that mental and behavioral health care is an integral part of a trip to the family doctor.