Mental health worries, communication, and needs in the year of the U.S. terrorist attack: National KySS survey findings☆☆☆★

Article Outline

• Abstract
• Methods
  • Sample
• The KySS survey
• Procedure
• Data analysis
  • Worries of children/teens and their parents
  • Communication between children/teens and parents
  • Communication between children/teens, parents, and providers
  • Mental health needs of children/teens and parents
  • Survey responses before and after the September 11 terrorist attack
  • Satisfaction with the amount of information and amount of time provided by health care providers
  • Child/teen and parent responses to completing the KySS survey
  • Responses to the open-ended questions
• Discussion
• Implications for clinical practice
• Acknowledgements
• Appendix 1
• Appendix 2
• References
• Copyright

Abstract 

Introduction: To reduce the escalating rate of mental health/psychosocial morbidities in children and adolescents, NAPNAP initiated a new national campaign entitled Keep your children/yourself Safe and Secure (KySS). The objective of the first phase of this campaign was to conduct a national survey to assess the mental health knowledge, attitudes, worries, communication, and needs for intervention of children/teens, parents, and pediatric health care providers. This first report from the KySS survey describes the child/teen and parental findings. Methods: A cross-section of 621 children/teens and 603 of their parents from 24 states completed the KySS survey during visits to their primary health care providers. Results: The five greatest worries of both children/teens and their parents included knowing how to cope with stressful things in their lives, anxiety, depression, parent-child relationships, and problems with self-esteem. The majority of children/teens and their parents reported that they do not talk to their primary care providers about these issues. Participants expressed a multitude of needs and suggestions regarding how to better recognize, prevent, and deal with mental health problems. Conclusion: Opportunities must be created for children/teens and their parents to communicate their mental health worries and needs to each other and to their pediatric primary care providers to facilitate earlier diagnosis and treatment of mental health problems. Interventions are urgently needed to assist children and teens in coping with the multitude of stressors related to growing up in today's society. J Pediatr Health Care. (2002). 16, 222-234.

Current estimates are that 20% to 25% of children and adolescents are affected by some type of mental health problem or psychosocial morbidity (Melnyk et al., 2001). This translates into approximately 4 million U.S. children and youth who have a mental health disorder (e.g., depression, anxiety, substance abuse, and disordered eating) that impairs their functioning at home or at school (U.S. Office of the Surgeon General, 1999). As a result of the national terrorist attack on September 11, 2001, along with war and threats of bioterrorism, evidence has been generated that children are demonstrating significant symptoms of stress (Schuster et al., 2001) that may lead to a further escalation in these types of problems. Thus many of the morbidities and mortalities affecting children and teens in this new millennium are not physical illnesses but are a watershed of mental health, psychosocial disorders, and risk-taking behaviors (Overton, 2001). Because mental health disorders result in exorbitant human and financial costs for society, estimated at approximately 69 billion dollars per year, the Healthy People 2010 objectives target the reduction of these problems (U.S. Department of Health and Human Services, 2000).

Despite the growing incidence of mental health problems, children and teens with these problems continue to be underdiagnosed, and as many as 70% of them do not receive treatment. This situation is largely attributable to the lack of mental health professionals in the current health care system as well as inadequate screening, early intervention, and referral by primary care providers who often do not have sufficient mental health educational preparation (Melnyk & Moldenhauer, 1999; U.S. Office of the Surgeon General, 1999). Because of these escalating problems, the Keep your children/yourself Safe and Secure (KySS) Campaign was founded in 2001 by the National Association of Pediatric Nurse Practitioners (NAPNAP) for the purpose of preventing and reducing mental health/psychosocial morbidities in children and youth. The campaign is now endorsed/supported by a collaboration of 18 national nursing and interdisciplinary organizations (see Appendix 1).

The goal of the first phase of the KySS Campaign was to conduct a national survey to assess the mental health knowledge, attitudes, worries, communication patterns, and needs of school-aged children, adolescents, parents, and pediatric health care providers. This type of data was believed to be critical for the purpose of developing interventions to promote mental health as well as to prevent and reduce these problems, which are goals of the second phase of the Campaign. In addition, although some studies reported in the literature have described communication patterns between parents of children with mental health/psychosocial problems and their primary care providers (e.g., Briggs-Gowan, Horwitz, Schwab-Stone, Leventhal, & Leaf, 2000; Horitz, Leaf & Leventhal, 1998; Sharp, Pantell, Murphy, & Lewis, 1992; and Wildman, Kinsman, Logue, Dickey, & Smucker, 1997), to our knowledge no studies reported in the literature have specifically described the worries, communication patterns, and needs for mental health intervention of children/teens and parents within the same families. Although knowledge of and attitudes toward pediatric mental health problems were measured in the KySS survey, the purpose of this first report is to specifically focus on and describe the mental health worries, communication patterns, and needs of the children/teens and their parents. Serendipitously, the KySS survey began approximately 8 weeks prior to the September 11, 2001, U.S. terrorist attacks and was scheduled to be completed by September 15. However, data collection was extended for an additional 8 weeks so that the extent of mental health worries and communication patterns before and after the tragedy also could be assessed.

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Methods 

For the purpose of answering the study questions, a descriptive survey was used with a random sample of children/adolescents and their parents drawn from each region of the United States.

Sample 

A total of 621 children and teens from 24 states completed the KySS survey. Children and teens were eligible for participation if (a) they were between 10 and 18 years of age and (b) they could read English. The child/adolescent subjects ranged in age from 10 to 20 years (data was included from 2 subjects who were 19 and 20 years of age), with a mean of 14 years. The mean grade level for the children and teens was 8.9 with a range between fourth grade and the second year in college (see Table 1 for demographic information on the sample of children and teens). The vast majority of the children lived with their mothers and approximately three quarters lived with their fathers. Pediatricians and pediatric nurse practitioners (PNPs) provided the primary care for the majority of the sample.

Table 1. Child/teen (N = 621) and parent (N = 603) demographics

The total sample of children/teens is N = 621. Some children and teens did not complete selected items and values were not imputed. The percentages are based on the entire sample of 621 participants. The total sample of parents is N = 603. Some parents did not complete selected items and values were not imputed. The percentages are based on the entire sample of 603 participants.

Six hundred and three parents completed the survey, which was slightly less than the number of children and teens who completed the survey. Most of the parents surveyed ranged in age from 31 to 50 years, with the majority being female, white, high-school educated, and married (see Table 1 for parent demographic information).

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The KySS survey 

After an extensive review of the literature, the items on the survey were developed by experts in each of the substantive areas that are being targeted in the KySS campaign. These areas include (a) depression, (b) anxiety, (c) disordered eating, (d) the aftereffects of divorce, (e) substance abuse, (f) physical and sexual abuse, (g) sexuality and sexual risk-taking, (h) accidental injuries and violence, (i) self-esteem and developmental asset building, and (j) parenting. Once the survey questions were developed, they were reviewed for content validity, clarity, and cultural sensitivity by a multidisciplinary expert panel comprised of pediatricians, nurse practitioners, developmental specialists, and psychologists. The KySS surveys were then piloted with 15 children/teens, ages 10 to 18 years, and their parents to assess and confirm face validity, readability, and clarity of the items. Items that were not clear or that the children and adolescents had difficulty understanding were eliminated from the survey.

The final KySS survey for children/teens and parents was formatted at a fifth-grade reading level and consisted of 60 knowledge and attitude items (e.g., “The first sign of low moods in children and teens is a drop in their grades” and “Teens who are violent are often more sad than angry”), to which subjects indicated their agreement on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). The survey also contained 13 items that tapped worry about common mental health/psychosocial problems. Specifically, the children/teens were asked, “Do you worry about any of the following for yourself?” (i.e., depression, anxiety, parents separating or divorcing, violence/being hurt, physical abuse/neglect, sexual abuse/rape, eating disorders, sexual activity, substance abuse, problems with self-esteem, the relationship with your parents, knowing how to cope with things that stress you, and being made fun of by your friends). Subjects responded to each of these 13 worry items on a 5-point Likert scale that ranged from “not at all” (1) to “always” (5). Parents responded to the same 13 worry items by responding to the question, “Do you worry about the following for your child?” Cronbach alphas of the 13 worry items with this sample was .87 for the children/teens and .90 for the parents.

Children/teens and their parents also were asked the following questions on the survey about the same 13 topics (e.g., depression, anxiety, sexual activity, violence, and self-esteem) as the worry items: (a) “How often do you talk to your parent (or your child) about the following topics?” and (b) “How often do you talk to your nurse practitioner or doctor about the following topics?” Subjects indicated their responses to each of these questions on a 5-point Likert scale from “not at all” (1) to “always” (5). Cronbach alphas for the 13 child-parent communication items were .94 for the children and .92 for the parents. Cronbach alphas for the 13 health care provider communication items with this sample were .94 for the children/teens and .92 for the parents.

In addition, participants were asked about their level of satisfaction with the amount of information their nurse practitioner or doctor gives them about common emotional and behavioral problems in children and teens, as well as the time spent on these topics. On a 5-point Likert scale, from “not at all” (1) to “very much” (5), the children and teens also responded to how much they needed each of the following: (a) more education and written information about emotional and behavioral problems facing teens and children, (b) an interactive Web site to discuss these issues, (c) more time to talk to my nurse practitioner or doctor about these issues, (d) more time to talk to my parents about these issues, (e) more time to talk to my teachers about these issues, (f) more time to talk to my friends about these issues, and (g) a big brother/sister program in my school to help me with things that stress or upset me. Parents responded to how much they needed similar interventions on their version of the survey.

Finally, children/teens and their parents were asked if they believed that the KySS survey would help them in talking to each other as well as their nurse practitioner or doctor about these issues. The subjects also responded to two open-ended questions at the end of the survey, including “What can be done to decrease emotional and behavioral problems in children and teens?” and “Tell us how we can better help you to deal with your (or your child's) emotions and behaviors or things that concern you.”

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Procedure 

Thirty-eight of NAPNAP's 48 chapters throughout the United States originally volunteered to participate in the KySS survey, and 25 chapters actually participated in the dissemination, collection, and return of survey data. A PNP from each of these chapters agreed to serve as the KySS survey coordinator. After human subjects' approval was obtained, a total of 3860 KySS surveys (i.e., 1930 parent and 1930 child/teen versions) were mailed to the KySS survey coordinators. As per the study protocol, the coordinators were provided with written instructions to randomly select 8 PNPs from their chapter who were given written instructions to randomly select 10 children/teens and their parents from their clinical sites to complete the surveys. Each parent was asked to sign a consent form of their own as well as a consent form for their child to participate in the survey. The children/teens also were asked to sign an assent form before completing the survey. The length of time to complete both the child/teen and parent versions of the survey was approximately 15 to 20 minutes. To keep the survey responses anonymous, the PNPs who were collecting the data were asked to separate the consent/assent forms from the actual surveys when completed. Parents and their children also were asked to complete the surveys independently of one another. To assess whether responses of the participants who completed the survey prior to the nation's terrorist attack were different than those of participants who completed the survey after the attack, data collection was extended for an additional 8 weeks beyond September 11.

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Data analysis 

Of the 3860 KySS surveys that were disseminated, 603 parent surveys and 621 child/teen surveys were returned from the 25 KySS chapter coordinators for a response rate of approximately 32%. Although a higher response rate was desired, response rates of less than 60% are common in survey research (Polit & Hungler, 1999). A decision was made not to impute mean scores for missing items on the surveys, which is the reason why the numbers of subjects are shown to vary on certain items reported within the data tables.

Descriptive statistics (e.g., frequencies, percentages, means, and standard deviations) were calculated on the survey items. Because children/teens and their parents from the same family responded to the survey, paired t tests also were used to determine if the children/teens and parents differed significantly on their responses to the survey's items regarding worry, communication, and needs for mental health intervention. A significance level of .05 was set for all analyses.

Regarding the pretragedy and posttragedy data, because the PNPs who were collecting data prior to September 11 were instructed to separate the consent forms that were dated from the actual surveys that were not dated, we were unable to identify the survey completion date for some of the participants. Therefore, these analyses were only conducted on the surveys for which the date of completion could be identified with certainty (i.e., 824 surveys).

Worries of children/teens and their parents 

In reference to the worry items, the five items that children/teens reported worrying most about included the following: (a) how to cope with the stressful things in their life, (b) anxiety, (c) depression, (d) self-esteem problems, and (e) their relationships with their parents. Similarly, the five items that approximately 65% or more of the parents reported worrying most about their children included: (a) how their children cope with stressful things, (b) anxiety, (c) self-esteem problems, (d) depression, and (e) their relationships with their children (see Tables 2 and 3).

Table 2. Children/teen and parents: major worries and communication concerning these worries^*

Table 3. Child/teen and parent greatest worries

For the total sample surveyed, children/teens: N = 621 and parents: N = 603. The paired t tests include only children/teen and parent dyads where both responded to the given item.

SD, Standard deviation.

Furthermore, parents reported that they worried significantly more about nine of the 13 items than their children reported worrying about them. In terms of total worry (i.e., a sum of the 13 worry items), parents reported significantly more overall worry (M = 23.8, SD = 8.2) than did their children (M = 20.1, SD = 7.2, t[566] = −9.20, P = .000).

Communication between children/teens and parents 

Table 4 identifies the frequency with which children/teens and their parents reported talking to each other about their worries and highlights the striking difference in how communication is perceived between both groups.

Table 4. Child/teen and parent communication with each other about their greatest worries

For the total sample surveyed, children/teens: N = 621 and parents: N = 603. The paired t tests include only children/teen and parent dyads where both responded to the given item.

SD, Standard deviation.

Overall, parents reported talking significantly more to their children (M = 27.6, SD = 8.2) about these issues than their children reported talking to them (M = 20.2, SD = 8.2, t[561] = −16.6, P = .000). Specifically, more than 90% of parents reported talking to their children, at least sometimes, about how to cope with stressful things in their life, whereas only nearly 60% of children reported that they, at least sometimes, talked to their parents about this topic. In addition, approximately 80% of parents reported that they talked to their children at least sometimes about anxiety, whereas only approximately one third of the children and teens reported that they talked to their parents about it.

Communication between children/teens, parents, and providers 

As can be seen in Table 5, although parents reported communicating more with their children's health care providers about these issues (M = 17.0, SD = 6.3) than did their children (M = 15.9, SD = 6.2, t[560] = −3.31, P = .001), there was actually little communication with providers by both groups about their greatest mental health worries.

Table 5. Child/teen and parent communication with their health care providers about their greatest worries

For the total sample surveyed, children/teens: N = 621 and parents: N = 603. The paired t tests include only children/teen and parent dyads where both responded to the given item.

SD, Standard deviation.

For example, on average, approximately three quarters or more of the children and teens who completed the survey reported that they did not talk with their health care providers at all about each of the 13 topics addressed in the survey (e.g., depression, anxiety, self-esteem, and how to cope with stressful things). Similarly, the majority of parents also reported that they did not talk to their children's health care providers about these issues.

Mental health needs of children/teens and parents 

More than half of the children/teens and more than 80% of the parents reported that they needed, at least to some extent, more education and written information about emotional and behavioral problems in children and teens (see Table 6).

Table 6. Child/teen needs (N = 621)

Needs are listed in order from highest to lowest need.

In addition, more than half of the children/teens reported that they needed more time to talk with their parents and to their friends about these issues, and approximately 35% reported that they would like a big brother/sister program to help them to deal with things that stress or upset them at school. Approximately 40% of the children and teens reported that they would like more time to talk with their nurse practitioners or doctors, and about one third reported that they would like more time to talk to their teachers about these issues. Approximately half of the children/teens and parents stated that they would like an interactive Web site to discuss these issues. Nearly 60% of the parents also reported that they would like parent groups to discuss these issues (see Table 7).

Table 7. Parent needs (N = 603)

Needs are listed in order from highest to lowest need.

Survey responses before and after the September 11 terrorist attack 

For the children and teens, those who could be identified as having completed the KySS survey after September 11 (n = 132) versus before September 11 (n = 290) reported being significantly more worried about how to cope with the stressful things in their lives (see Table 8).

Table 8. Child/teen greatest worries before and after 9/11/01 (N = 422)

These results reflect the responses of the children/teens who completed the survey prior to the 9/11 disaster (n = 290) and other children/teens who completed the survey after the 9/11 disaster (n = 132). Independent sample t tests were used for these analyses. The n for each analysis differ because some are ^*P < .05, ^†P < .01, ^‡P < .001.

NS, Not significant.

In addition, they reported talking significantly more often to their health care providers about how to cope with the stressful things in their lives (t[188] = 2.29, P < .05), depression (t[189] = 2.06, P < .05), and problems with self-esteem (t[188] = 2.46, P = .01) than the children and teens who completed the survey prior to September 11. These children and teens also reported talking significantly more often with their parents about violence (t[194] = 2.46, P = .01), problems with self-esteem (t[201] = 2.38, P < .05), and their relationships with their parents (t[223] = 2.58, P = .01) than did children and teens who completed the survey before the September terrorist attack.

In contrast, parents who could be identified as completing the survey after September 11 (n = 120) versus before September 11 (n = 282) reported worrying less about their children with regard to anxiety, violence, self-esteem, and their relationships with their children than did parents who completed the survey prior to September 11 (see Table 9).

Table 9. Parent greatest worries before and after 9/11/01 (N = 402)

These results reflect the responses of the parents who completed the survey prior to the 9/11 disaster (n = 282) and other children/teens who completed the survey after the 9/11 disaster (n = 120). Independent sample t tests were used for these analyses. The n for each analysis differ because some children/teens did not complete selected items and values were not imputed.

NS, Not significant; SD, standard deviation.

In addition, parents who completed the survey after September 11 reported talking significantly less often to their children about depression (t[254] = −2.03, P < .05) and substance abuse (t[254] = −2.57, P = .01) than did parents who completed the survey prior the attack. There was no significant difference in how often parents talked to their children's health care providers about mental health/psychosocial problems before and after September 11.

Satisfaction with the amount of information and amount of time provided by health care providers 

There were no differences between children/teens and their parents with regard to how satisfied they were with the amount of time, guidance, and information that their doctors or nurse practitioners provide on mental health/psychosocial issues. Overall, only 50% to 60% of the children/teens and parents surveyed were mostly to very satisfied with the time, guidance, and information they receive on these issues from their providers (see Table 10).

Table 10. Child/teen and parent satisfaction

For the total sample surveyed, children/teens: N = 621 and parents: N = 603. The paired t tests include only child/teen and parent dyads where both completed the given item.

NS, Not significant; SD, standard deviation.

Child/teen and parent responses to completing the KySS survey 

More than half of the parents and 40% to 50% of the children/teens surveyed reported that completing the KySS survey (a) helped them to become more aware of mental health/psychosocial morbidities in children and teens, (b) will lead them to get more information, and (c) will help them to talk more to each other about these issues. In addition, more than half of the parents and a third of the children/teens reported that completing the survey will help them in talking to their nurse practitioner or doctor about these issues (see Table 11).

Table 11. Child/teen and parent responses to completing the KySS survey

For the total sample surveyed, children/teens: N = 621 and parents: N = 603. The paired t test includes only child/teen and parent dyads where both completed the given item. The mean scores are based on yes being coded as 1 and no being coded as 0. Chi-square test also was used to analyze group differences with this categorical variable.

NS, Not significant; SD, standard deviation.

Responses to the open-ended questions 

Many of the children/teens and parents wrote extensive responses to the open-ended questions that were asked regarding what can be done to decrease emotional and behavioral problems in children and teens and how we can help them to deal with these issues and things that concern them. Several themes emerged from the children and teens' comments, including the following: (a) parents should be alerted to early warning signs of these problems and be educated more about them, (b) adults should ask every once in a while if everything is all right instead of waiting for their children to come to them, (c) schools should have more programs about these issues, (d) parents should talk to their children more about these things and be more involved in their lives, (e) doctors should talk more about these things, (e) children and teens need more help with stress relief, and (f) they need better relationships with their parents. One teen responded, “Tell our parents to tell us they love and care about us,” and another teen commented, “Tell parents to spend more time talking about these issues with their kids rather than fighting with each other.” One other teen commented that “I think this survey helps a lot!” and another child wrote, “We need a feelings doctor.” Many teens remarked that they wished their parents and other adults would spend more time listening to them.

Common themes of parents' responses to similar questions of what can be done to decrease emotional and behavior problems in children and teens and how parents can be better helped to deal with their child's emotions and behaviors or things that concern them included: (a) adults recognizing signs/symptoms more quickly and being more educated about these things, (b) better communication with doctors, nurses, and teachers, (c) parents being more involved in their children's lives, (d) the need to get children involved in activities/sports earlier, (e) written handouts explaining normal behavior and when the nurse practitioner or doctor needs to be contacted, (f) more education in the schools about these problems and more counseling in the schools, (g) more community-based education, and (h) guidance about how to build self-esteem in children and teens. One parent wrote, “We need to show our young kids life is and can be fun without drinking or drug use,” and another parent wrote, “Parents need to be available since lots of parents work these days and many children are left unattended for too many hours.” In addition, two other parents wrote, “Give out a paper on ways to start meaningful conversations with your teenager,” and “Provide handouts for all ages, instead of just for infants.”

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Discussion 

Of the 13 mental health/psychosocial issues listed on the KySS survey, school-age children and teens reported that how to cope with the things that stress them, anxiety, and depression were the things that they worried about the most, followed by self-esteem problems and their relationships with their parents. In fact, approximately 25% of the respondents worried about how to cope with stressful things often to nearly always and 10% to 20% worried about anxiety and depression to this same extent. These findings are not surprising in an era of uncertainty in the United States superimposed on the typical academic, family, and developmental stressors of growing up in today's society. Although it is not known whether worry about depression, anxiety, and problems with self-esteem is a proxy for the actual conditions, worry is known to be a subcategory of stress (Hauptman & Bomar, 1992). It is interesting to note that the percentage of respondents who reported that they worry about depression and anxiety often to nearly always on the KySS survey closely matches the percentage of adolescents affected by these disorders found in prior epidemiologic studies (U.S. Office of the Surgeon General, 1999). Further research is needed to determine whether the worry scale contained within the KySS survey is predictive of negative coping outcomes, such as depression, anxiety disorder, or problems with self-esteem. If the worry scale is found to predict these problems or has convergent validity with longer, more time-intensive valid and reliable measures, the 13-item KySS worry scale might be used as a more user-friendly, quick screening tool that could identify school-aged children and teens who are experiencing substantial levels of stress and/or who are at high risk for these problems.

Nearly 50% of this sample of children and teens reported worrying, at least to some extent, about problems with self-esteem, their relationships with their parents, and being made fun of by their friends. Worries about these issues are common in late school-aged children and adolescents as they struggle with changes in their body image, relationships with peers and parents, and new academic challenges. In addition, although children and teens of these ages often reject their parents' advice as they strive for greater independence, having a good relationship with their parents is key for developing a positive self-image (Jellinek, Patel, & Froehle, 2002).

Even though the issues that this sample of children and teens reported worrying least about were physical abuse/neglect, sexual abuse/rape, and substance abuse, 5% to 10% reported worrying about them on an often to always basis. An important question again is whether reported worry about these items is a proxy for their actual occurrence. The fact that the majority of children and teens did not report worrying about these issues could be related to them feeling relatively safe in their home and school environments. In addition, since the mean age of the sample was 14 years, peer pressure to engage in risk-taking behaviors such as substance abuse and sexual activity may have not yet peaked for many of these children.

Although their five greatest worries matched those of their children, parents clearly reported worrying about these problems significantly more than the children and teens themselves. Specifically, a substantial percentage (i.e., nearly 25%) reported worrying often to nearly always about how their children are coping with things that are stressful and approximately 30% of parents are often to always worried about their children's self-esteem. In addition, parents reported worrying about their children being sexually abused/raped, having substance abuse or eating disorders, and being sexually active more than their children reported worrying about these issues. Although this survey provides further evidence that these are all common concerns of parents of adolescents (Neinstein, Juliani, & Shapiro, 1996), it is not known whether the parents who were reporting that they are often to always worried about these issues had children who actually had or showed signs suggestive of these problems.

Regarding communication, there were large discrepancies between the reports of the children/teens and parents about how often they talk to each other about these issues. Although the majority of parents reported that they are talking to their children about these issues, a large percentage of the children/teens reported that they do not talk to their parents about them. It could be that parents attempt to talk with their children about these issues so they perceive themselves as communicating with them; however, their children may not be processing the information that is being provided or they may feel that their parents are talking at, not with them, and subsequently the children/teens may “tune them out.” It also is possible that (a) the conversations are short so that the children and teens do not process the information, and/or (b) the children and teens may not be connecting with their parents or be receptive to the guidance from them on these issues, which is a common developmental characteristic of this age group (Jellinek et al., 2002). Evidence is mounting that connectedness with parents plays an important role in the health of young people (Resnick et al., 1997). Specifically, supportive communication with parents promotes internalization of a sense of the self as worthy and appears to serve as a buffer against risk-taking behaviors (Lamborn & Steinberg, 1993; Miller, Levin, Whitaker, & Xu, 1998; Resnick, Harris, & Blum, 1993; Tuttle, 1995). Therefore, strategies to enhance communication between children and their parents are vital.

Another important finding from this study is that, despite the fact that a large percentage of children/teen and parents have mental health/psychosocial worries, only a small percentage of them reported talking to their nurse practitioner or doctor about them. This finding supports the findings of prior studies that have provided evidence indicating that, even when parents have children with emotional and behavioral problems and believe it is appropriate for them to discuss emotional and behavior problems with their primary care providers, only a small percentage of them actually discuss these concerns with them (Briggs-Gowan et al., 2000; Horitz et al., 1998). Being that a very small percentage of children and teens with mental health/psychosocial problems receive care from a mental health professional and most are treated in primary care, it is essential that they and their parents communicate their worries and concerns to their primary health care providers.

A substantial portion of children/teens and, to a greater extent, parents reported the need for additional educational and support materials about mental health/psychosocial morbidities. The plethora of written comments from the children/teens and parents to the open-ended questions provided countless numbers of suggestions about what can be done to decrease the numbers of these problems. There is a great need for creating opportunities and comfortable environments to discuss these issues, starting at an early age. For adolescents specifically, one of the major reasons for not disclosing “personal/sensitive information” is that health care providers do not routinely assure them of confidentiality prior to obtaining histories. This assurance is critical for honest forthright discussions, although adolescents also should be informed that if they are having thoughts of hurting themselves or others or if someone else has hurt them, this information must be shared for their safety. Despite the fact that adolescents often reject the guidance and advice of their parents and other adults, the adolescents who responded to the KySS survey repeatedly mentioned that they want more time to discuss these issues with their parents, teachers, and other health care providers as well as mentors/counselors who could help them cope with the multiple stressors in their lives. In addition, a large percentage of parents reiterated the need for discussion/educational groups to teach them about recognizing early signs of these problems. Many parents and children/teens also specifically commented on needing an interactive Web site or toll-free number from which they could obtain reliable information and consult health care providers with questions and concerns.

Children/teens who completed the survey following the September 11 terrorist attack reported more worry about certain issues than did those who completed the survey before the attack.

The horrific tragedy and all of the media attention that followed it may have broken the “illusion of immortality” that is common during the adolescent years. Evidence to support this rationale was provided by an online poll, conducted by Harris-Interactive between September 19-24, 2001, with teenagers ages 13 to 18 years. This survey found that about half of the nation's teens were fearful that terrorism would strike near them, twice as many as in July of 2001 (Collier, 2001). Only 36% of teens surveyed believed that the government could prevent similar things from recurring. In contrast, parents who were surveyed after September 11 may have been more focused on the tragedy and the state of the nation as well as the victims' families and less preoccupied with their own family's issues. Catastrophes are known to adversely affect adults, who may focus more on their own responses during the time of tragedy, especially for those who personalize the event (Dixon, Rehling, & Shiwach, 1993). In addition, the parents surveyed after September 11 may have been more focused on how they might help the families affected by this tragedy, which is a common strategy of coping (i.e., to take constructive action in a time of uncertainty) (Schuster et al., 2001).

Additional reports from the KySS survey data are forthcoming regarding the mental health knowledge, screening practices, and satisfaction with care of pediatric health care providers as well as the mental health knowledge and attitudes of children/teens and their parents. Further analyses of the KySS data set also is warranted to answer several other compelling questions (e.g, do the mental health worries, communication, and needs for intervention differ based on gender, geographic location, and whether children are in their early, middle, or late teen years? What are the mental health worries, communication, and needs for intervention of children/teens from various cultural/ethnic groups?).

Some limitations of the KySS survey deserve mention. First, because the survey was cross-sectional, conclusions cannot be drawn regarding causality (e.g., whether worry does indeed lead to depression or anxiety disorders). Second, regarding the data collected before and after September 11, we do not know the change in worries or communication patterns in the same group of children/teens and their families across time. The findings would have been strengthened if we were able to re-survey the same children/teens and parents who completed the survey prior to as well as after the terrorist attack. Third, although the NAPNAP chapter survey coordinators were provided with written instructions to randomly sample PNPs from their chapter to collect survey data and those PNPs were given written instructions to randomly sample children and parents from their practice sites to complete the surveys, these random sampling strategies may not have been consistently implemented. A few chapters reported that, instead of random sampling, they needed to enlist volunteers to obtain the survey data. Fourth, the families who completed the survey were predominantly white and middle class. Therefore, caution should be used in generalizing the data to other populations. Data on these issues are needed from more minority and low socioeconomic families, including fathers.

Finally, the response rate in this study was less than desired, although it could have conceivably been higher than the 32 percent reported. What is not known is the actual number of surveys that were disseminated by the PNPs to potential subjects and not returned as well as the number of subjects approached for study participation. It is plausible that some PNPs may not have approached potential subjects for participation once they received the surveys; however, all surveys that were disseminated to the PNPs were factored in when calculating the study's response rate. Therefore, the response rate reported may be skewed low because, in survey research, it is acceptable as a strategy in calculating response rates to omit all questionnaires that are not delivered to the subjects (Babbie, 1997).

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Implications for clinical practice 

This survey has clearly identified an urgent need to assist children and teens in coping with the stressful things in their lives in addition to creating avenues for children/teens and parents to discuss their worries about mental health/psychosocial problems with their nurse practitioners and physicians. Pediatric health care providers should not only routinely approach these issues by using well and illness visits as “windows of opportunities” to elicit these types of worries and concerns, but should provide an environment that prompts children/teens and their parents to talk more about these issues. For example, the data from this study indicated that completing the KySS survey alone facilitated greater awareness, communication, and information-seeking about these problems for a substantial number of children/teens and their parents. Therefore, having the KySS survey or other similar surveys available (e.g., the Pediatric Symptom Checklist [Jellinek et al., 2002]) for children/teens and their parents to complete while waiting to be seen by their primary care providers could prompt all stakeholders to discuss, screen for, and seek out more information about these issues. Ultimately, these screening strategies could lead to earlier detection of and intervention with children/teens affected by mental health/psychosocial morbidities.

In today's society, children and teens are confronted with multiple stressors for which they need to be taught coping skills, stress-reduction techniques, and self-esteem/developmental asset building before maladaptive coping mechanisms develop (e.g., cigarette smoking, substance abuse, disordered eating, sexual risk-taking). Therefore, there is an urgent need to develop, test, and implement more theoretically driven, reproducible primary prevention programs for children and teens that are effective in getting to the “root of mental health problems and risk-taking behaviors” in both pediatric primary care and school settings. Once data are generated from these studies, policy makers need to be educated about the evidence they produce so that widespread dissemination of these programs can occur across the United States.

The KySS survey also indicated that parent-targeted interventions surrounding these issues need to take a high priority. Parents of children and teens desire more education about mental health problems/psychosocial morbidities and specifically need to be given anticipatory guidance about the early signs and symptoms of these problems as well as parenting strategies to prevent them. Providing parenting classes, Web sites, and support materials in pediatric office settings are all strategies that may raise knowledge, awareness, and parenting confidence in how to detect and handle these morbidities. In addition, assisting parents and children/teens with building healthier relationships and communication patterns with one another is important in reducing risk for these problems.

Finally, for a long time, health care providers have been identifying barriers to the early identification of and management of mental health/psychosocial problems in primary care, including inadequate education about these issues, lack of easy to use screening tools, lack of time to deal with them, and lack of mental health specialists for integration in primary care settings (Costello & Pantino, 1987; Jellinek, 1982; U.S. Office of the Surgeon General, 1999). However, progress has been slow in these areas. As such, nurse practitioner and medical school programs must strengthen their core content in these areas so that graduates are more prepared to screen for and deal with these issues as they emerge from their educational programs. More nurse practitioner programs also are needed that offer dual preparation of PNP and psychiatric mental health nurse practitioners so that providers can be equipped to assess and manage both the physical and mental health of children and adolescents in which there is not a stigma associated with the need for mental health referral, another barrier that often delays the early treatment of these problems. For health care providers already in practice, intensive workshops and continuing educational experiences to teach behavioral skills in the screening and early management of these problems also is needed. Pediatric providers also need to be introduced to and begin to use the newly released Bright Futures in Practice: Mental Health (Jellinek et al., 2002) as a guide for incorporating more mental health screening, anticipatory guidance, and early management into their practices. This guide and its associated tool kit for use in screening, care management, and health education can be downloaded at the following Web site: www.brightfutures.org/mentalhealth/.

Now that the first phase of the KySS campaign is completed, the intervention phase is ready to commence. With recent funding by the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA)/Maternal-Child Health Bureau, a KySS summit will be held in the fall of 2002. This summit will convene a group of multidisciplinary experts from across the United States to develop a strategic action plan to prevent and reduce mental health/psychosocial morbidities in children and teens, including strategies to enhance primary care providers' ability to assess and provide early interventions with children/teens and a KySS core curriculum for nurse practitioner and medical school programs. As part of phase two of the KySS campaign, a national 3-day intensive KySS continuing education national workshop also will be held and placed on CD-ROM to aggressively disseminate the program nationally to nurse practitioners, nurses, and physicians. In addition, current KySS campaign plans include the development of a clearinghouse of screening tools as well as educational support/resources for health care providers, parents, and teens on NAPNAP's Web site at www.napnap.org. With these strategies as well as all of the ongoing persistent efforts of other national organizations, federal agencies, researchers, policy makers, and health care providers, the Healthy People 2010 objectives specific to the mental health of children and adolescents can become more than a vision, but a reality.

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Acknowledgements 

We offer special thanks to the NAPNAP Executive Board and the NAPNAP Foundation; all of the PNPs who collected survey data at their clinical sites; all of the children/teens, parents, and health care providers who completed the KySS surveys; and the following KySS Survey Chapter Coordinators who disseminated and returned KySS survey data: Mary Coleman, Sharolyn Dihigo, Janice Francischine, Colleen Guiney, Rhonda Hertwig, Cindy Hockman, Cheryl Jacobson, Beth Ann Jalbert, Linda Kerr, Ann Komelasky, Nancy Lovett, Linda Malone, Jean Martin, Renee McLeod, Allyson Neal, Susanne Newton, Maddie Nichols, Adrienne Platt, Patricia Reilly, Amy Rothman, Patti Trzcinski, Lisa Sharp, Barbara Thompson, Bobbie Serra, and Ruby Villavisencio. In addition, we thank the following persons who assisted with voluminous KySS data entry and verification: Phyllis Bazan, Yolanda DiCamilla, Eileen Fairbanks, Florence Hamilton, Carly Kilgore, Ann Kraska, Hose Munoz, and Lisa Spath.

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Appendix 1 

The KySS Campaign endorsing/supporting organizations include the American Academy of Nursing, the American Academy of Nurse Practitioners, the American Academy of Pediatrics, the Association of Faculties of Pediatric Nurse Practitioners, the American Nurses Association, the American Psychiatric Nurses Association, the Association of Women's Health, Obstetric and Neonatal Nurses, the International Society of Psychiatric-Mental Health Nurses, the National Association of School Psychologists, the National Association of School Nurses, the National Association of Social Workers, the National Certification Board of Pediatric Nurse Practitioners, the National Nursing Coalition for School Health, the North American Nursing Diagnosis Association, the National Association of Neonatal Nurses, the National Organization of Nurse Practitioner Faculties, Sigma Theta Tau International, and the Society of Pediatric Nurses.

For more information about or to volunteer for the KySS campaign, as well as to obtain the complete data tables for all worry and communication items from the KySS survey, please contact the NAPNAP National Office at (877) 662-7627 or e-mail Bernadette_Melnyk@urmc.rochester.edu.

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Appendix 2 

Bernadette Mazurek Melnyk is Founder and Director, NAPNAP KySS Campaign, Associate Dean for Research and Professor, and Director, Center for Research & Evidence-Based Practice and PNP Program, University of Rochester School of Nursing, Rochester, NY. Nancy Fischbeck Feinstein is Assistant Professor of Clinical Nursing, Center for Research & Evidence-Based Practice, University of Rochester School of Nursing. Jane Tuttle is Associate Professor of Clinical Nursing and Director, FNP Program, Center for High-Risk Children & Youth, University of Rochester School of Nursing. Zendi Moldenhauer is Senior Associate and a Doctoral Candidate, Center for High-Risk Children & Youth, University of Rochester School of Nursing, and a PNP in private practice. Pamela Herendeen is Assistant Professor of Clinical Nursing and a PNP, University of Rochester School of Nursing & Pediatric Out-Patient Services, Golisano Children's Hospital at Strong, Rochester. Tener Veenema is Assistant Professor of Nursing and Emergency Medicine, Center for High-Risk Children & Youth, University of Rochester School of Nursing and School of Medicine & Dentistry. Holly Brown is Assistant Professor of Nursing, State University of New York at Stonybrook, and a Psychiatric/Mental Health Nurse Practitioner, Child and Adolescent Out-Patient Psychiatric Services, Golisano Children's Hospital at Strong, Rochester. Sharon Gullo is Adjunct Instructor, Education and Wellness Program, University of Rochester School of Nursing. Madelyn McMurtrie is Clinical Practice Chairperson of NAPNAP and a PNP at Child Health Associates, Ann Arbor, Mich. Leigh Small is Senior Associate and a Doctoral Candidate, Center for High-Risk Children and Youth, University of Rochester School of Nursing and a PNP at Genesee Health Services, Rochester.

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References 

1. Babbie E. Survey research methods. 2nd ed. California: Wadsworth Publishers; 1997;
   • View In Article
2. Briggs-Gowan MJ, Horwitz SM, Schwab-Stone ME, Leventhal JM, Leaf PJ. Mental health in pediatric settings: Distribution of disorders and factors related to service use. Journal of the American Academy of Child and Adolescent Psychiatry. 2000;39:841–849
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (640 KB)
   • CrossRef
3. Collier K. Teens and terrorism: A whole new world. Parenting Teens. 2001;1:4–5
   • View In Article
4. Costello EJ, Pantino T. The new morbidity: Who should treat it?. Developmental and Behavioral Pediatrics. 1987;8:288–291
   • View In Article
5. Dixon P, Rehling G, Shiwach R. Peripheral victims of the herald of free enterprise disaster. British Journal of Medical Psychology. 1993;66:193–202
   • View In Article
6. Hauptman M, Bomar P. Gender differences in knowing about hypertension: The Black experience. Healthcare for Women International. 1992;13:57–65
   • View In Article
7. Horitz SM, Leaf PJ, Leventhal JM. Identification of psychosocial problems in pediatric primary care. Do family attitudes make a difference?. Archives of Pediatric and Adolescent Medicine. 1998;152:367–371
   • View In Article
8. Jellinek MS, Patel B, Froehle MC. Bright futures in practice: Mental health. Washington, DC: Georgetown University, National Center for Education in Maternal and Child Health; 2002;
   • View In Article
9. Jellinek MS. The present status of child psychiatry in pediatrics. New England Journal of Medicine. 1982;306:1227–1230
   • View In Article
10. Lamborn SD, Steinberg L. Emotional autonomy radix: Revisiting Ryan and Lynch. Child Development. 1993;64:483–505
    • View In Article
    • MEDLINE
    • CrossRef
11. Melnyk BM, Moldenhauer Z. Current approaches to depression in children and adolescents. Advance for Nurse Practitioners. 1999;7:24–29 97
    • View In Article
    • MEDLINE
12. Melnyk BM, Moldenhauer Z, Veenema T, Gullo S, McMurtrie M, O'Leary E, et al.  The KySS (Keep your children/yourself Safe and Secure) campaign: A national effort to reduce psychosocial morbidities in children and adolescents. Journal of Pediatric Healthcare. 2001;15:31A–36A
    • View In Article
13. Miller KS, Levin ML, Whitaker DJ, Xu X. Patterns of condom use among adolescents: The impact of mother-adolescent communication. American Journal of Public Health. 1998;88:1542–1544
    • View In Article
    • MEDLINE
    • CrossRef
14. Neinstein LS, Juliani MA, Shapiro J. Psychosocial problems and concerns. In: 3rd ed.  Neinstein LS editors. Adolescent Healthcare. A Practical Guide. Baltimore: Williams & Wilkins; 1996;p. 1090–1106
    • View In Article
15. Overton S. Mental health of children before/after terrorism. http://www.ivanhoe.com/doc…althofchildrenbeforeafterterrorism.html2001; Retrieved from
    • View In Article
16. Polit DF, Hungler BP. Nursing research. 6th ed. Philadelphia: Lippincott; 1999;
    • View In Article
17. Resnick MD, Barman PS, Blum RW, Bauman KE, Harris KM, Jones J, et al.  Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. Journal of the American Medical Association. 1997;278:823–832
    • View In Article
18. Resnick MD, Harris LJ, Blum RW. The impact of caring and connectedness on adolescent health and well-being. Journal of Pediatric and Child Health. 1993;29(Suppl):S3–S9
    • View In Article
19. Schuster MA, Stein BD, Jaycox LH, Collins RL, Marshall GN, Elliott MN, et al.  A national survey of stress reactions after the September 11, 2001, terrorist attacks. New England Journal of Medicine. 2001;345:1507–1512
    • View In Article
20. Sharp L, Pantell R, Murphy O, Lewis CC. Psychosocial problems during child health supervision visits: Eliciting, then what?. Pediatrics. 1992;89:619–623
    • View In Article
    • MEDLINE
21. Tuttle J. Family support, adolescent individuation, and substance involvement. Journal of Family Nursing. 1995;1:303–326
    • View In Article
    • CrossRef
22. U.S. Office of the Surgeon General, Department of Health and Human Services . Mental health: A report of the surgeon general. http://www.surgeongeneral.gov/library/mentalhealth/home.html1999; (chap. 3). Retrieved from
    • View In Article
23. U.S. Department of Health and Human Services . Healthy people 2010. http://www.health.gov/healthypeople/Document/HTML/Volume2/18Mental.htm2000; Retrieved from
    • View In Article
24. Wildman BG, Kinsman MA, Logue E, Dickey DJ, Smucker MD. Presentation and management of childhood psychosocial problems. The Journal of Family Practice. 1997;1:77–84
    • View In Article