— Vignette — 

8-year old Olivia is a talented musician and ardent learner, but she struggled with virtual learning over the past year. She is nervous to start school, afraid that school will continue to be a challenge for her with in-person classes, stating “maybe I’m just stupid now.” She has been slow to start her morning routine, spending a lot of time in the bathroom with many prompts to come to the breakfast table. She does not want to enter the front gate when arriving at school and frequently complains of headaches, nausea, and stomachaches. During a visit to the school nurse, she makes a comment that one of her classmates was making fun of her for wearing a mask when walking to school. 

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In children and adolescents, anxiety and stress may manifest differently from how they do in adults. Moreover, anxiety and stress can present differently in each individual child. Somatic symptoms, such as headaches, nausea, upset stomach, and fatigue, are present in 50% to 95% of anxious children (Hale et al, 2017). These somatic complaints can be challenging for schools to navigate, especially in the context of the ongoing concerns about the COVID-19 Delta variant. Some children may begin to delay, avoid, and become quite angry and dysregulated when asked to go to or get ready for school. Others will isolate on the playground and have difficulties integrating socially.

Pediatricians can support children and families by inviting a dialogue about anxiety around the transition back to school and the COVID-19 pandemic and by noting that these have been and are still hard times for lots of people. Parents have concerns of their own about health, work, other children, extended families, finances, schedules, among countless other examples. Just like COVID-19, stress can be contagious and parental stress inevitably affects children. Pediatricians may assist by encouraging parents to stay calm themselves, to seek out emotional support from friends and peers, and to engage in other strategies to promote their own well-being.  These actions can enable parents or caregivers to be better prepared to support their child.

Pediatricians can model conversations for parents during visits by asking children what it is like to go back to school, acknowledging that it has been an especially rough year and it might feel different and uneasy (Wykoff 2021). Pediatricians can also brainstorm strategies to creatively grow positive feelings about attending school; these may involve starting routines before/after school, discussing favorite parts of the day, and engaging in fun activities to increase feelings of mastery. Asking about bullying is critical, especially when exploring reluctance to attend school. In Olivia’s situation, a peer was bullying her for wearing a mask before entering the campus. There are increasing instances of bullying around masks (Brown 2021). Pediatricians can empower youth and families by giving a name to these sorts of behaviors, and acknowledging that many people—kids and grownups—are angry and scared. Reminding youth that when they are following the rules, they are helping to keep their school, themselves, their families and community safe and that youth should not feel that they have to answer to taunts or teasing. Practitioners should also stress that if situations become uncomfortable for a child, they and their friends can proudly and comfortably seek support from school staff.

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Olivia visits her pediatrician for her persistent somatic complaints and they talk about her concerns. Olivia feels relieved and surprised that other peers are experiencing similar feelings. She agrees to talk with her teacher and her school counselor about what she is feeling and to take time each day to talk about school with her parents.  She feels better after telling her pediatrician about the bullying, as her pediatrician reminded her that she is helping to keep her school and family safe. Olivia begins playing music again, settling into her new routine, and soon becomes more confident at school. 

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Transitions are rarely easy and during this continued uncertain time, reminders to check in, to listen, and to support our patients and families are more important than ever. Pediatricians are well poised to work with schools and parents/caregivers to encourage open dialogue and dispel myths as well as encourage youth to engage in activities they enjoy.

Suggestions for pediatricians and primary care practitioners:

• Incorporate formal or informal screening of all children (and their parents) for anxiety and depression at all primary care visits.
• Validate parental concerns, and encourage parental mental wellbeing.
• Suggest before and after school routines to promote a feeling of security in children.
• Talk with teachers/schools about creating inclusive classrooms and addressing mask bullying.

Because of the prevalence of suicidal thoughts in adolescents (and other age groups), it is important for all medical and mental health providers to be comfortable asking questions related to suicide risk. The American Academy of Pediatrics 2016 guidelines on “Suicide and Suicide Attempts in Adolescents” urges pediatricians to screen patients for suicidal thoughts. The report identifies risk factors linked to teen suicide attempts, including:

1. Family history of completed suicide and suicide attempts
2. Personal history of suicide attempt and/or non-suicidal self-injury
3. History of physical, sexual or emotional abuse or neglect
4. Mood disorders and psychotic disorders
5. Drug and alcohol use
6. Sexual orientation
7. Firearms in the home
8. Strained parent-child relationship or living outside of the home
9. Poor school attendance and/or performance
10. Bullying, including cyber-bullying – highest risk in teens who are both bullies and victims of bullying
11. Internet exposure – particularly concerning if using more than 5 hours/day.
12. Male vs female: Girls more likely to make suicide attempts; boys more likely to have completed suicides.

Studies show that asking about suicide risk does not increase the risk of suicide attempts or “put the idea in the patient’s head” as some providers may be concerned about. It is helpful to talk with a teen patient privately to increase their comfort in disclosing sensitive information. With the stressors of the pandemic an ongoing concern for virtually everyone, it may be helpful to start a dialogue with a comment such as “The virus situation has really been a challenge for so many people and I’m checking in with all my patients to see how they are doing with all the changes and restrictions from normal activities. How are you doing?” If needed, following up on this general inquiry by asking about how things are going for the teen at home, with schoolwork, and with friends can help keep the dialogue going.   Clearly if the youth acknowledges any significant distress or depressive symptoms, a more specific inquiry such as “Have you ever thought about killing yourself or wished you were dead or never born?” would be appropriate, but given many teen’s reluctance to share emotionally sensitive concerns, it will always be appropriate to make the “ask”: “Have you ever done anything on purpose to hurt or kill yourself?”

Though for many this may feel like an emotionally charged inquiry, it is important to make the “ask” in a non-judgmental and matter of fact manner. If the answer to is yes, it is obviously important to obtain more details and it is particularly important to assess lethality and intent in determining the appropriate management. If the youth’s response is vague or otherwise unclear or seemingly uncomfortable, further dialogue is indicated.   If there is a concern about acute risk, a provider should err on the side of caution and seek out emergency mental health services.

In 2015, the US Preventive Task Force concluded that while they recommend relying on screening tools in the primary care setting to screen for depression in adolescents and adults, the evidence did not support using screening tools alone to screen for suicide risk in patients without a psychiatric disorder. When there is concern about depression, it is important to ask about suicide risk and there are questionnaires that can be useful: the PHQ9 has questions about thoughts of suicide and suicide attempts and the Columbia Suicide Severity Rating Scale is likewise a useful tool.

https://www.integration.samhsa.gov/clinical-practice/Columbia_Suicide_Severity_Rating_Scale.pdf

This report is relevant in that it highlights the importance for all providers to feel comfortable asking about suicide risk in patients. It is our hope that this article brings each of you closer to that goal.

References:

http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420

https://www.integration.samhsa.gov/clinical-practice/suicide-prevention#tools

https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/With-suicide-Now-Teens’-Second-Leading-Cause-of-Death-Pediatricians-Urged-to-Ask-About-its-Risks.aspx