| | Improving the mental/psychosocial health of US children and adolescents: Outcomes and implementation strategies from the national KySS Summit☆☆☆
Preface  Sadly, we have reached a point in the United States in which mental health/psychosocial problems, as well as risk-taking behaviors and preventable injuries, are resulting in more morbidity and mortality for children and adolescents than are physical illnesses and disorders. This escalation in these types of childhood and adolescent problems has resulted in substantial family and economic burdens, to the point that the US Surgeon General has declared it a crisis. In his New Freedom Commission on Mental Health, President George W. Bush states that “The mental health system is failing Americans,” and one of the major barriers to care is fragmentation and gaps in care for children. As a result of this watershed of pediatric mental health/psychosocial morbidities, a landmark Summit that convened experts from multiple disciplines and national professional organizations and agencies, including nursing, medicine, social work, psychology, nutrition, education, research, and health policy, was held on March 28 and 29, 2003, in Rochester, New York for the purpose of delineating a strategic action plan to tackle these pressing issues. This supplement captures the proceedings from this national interdisciplinary summit on child and adolescent mental health, including the significance of these problems and recommendations for screening, intervention, and health promotion in each of the major task force areas. The supplement will be widely disseminated to practicing clinicians, educators, researchers, students, parents, teachers, and others who care for children and teens in hopes that it will stimulate creative implementation strategies to prevent and reduce mental health problems as well as facilitate intervention studies from which evidence can be generated to guide best practices. My own passion for and commitment to improving the mental health of children and teens developed while practicing as a staff nurse in a pediatric intensive care unit, where I witnessed the intense psychological distress of critically ill children and their parents as they faced life-threatening and terminal illnesses and injuries. This passion and commitment deepened through my many years of experience as a pediatric nurse practitioner on a child and adolescent inpatient psychiatric unit, where I continue to deliver comprehensive health care services. As I listened to the horrific stories of the children and teens on that unit who lived through years of psychological stress as a result of such factors as dysfunctional parenting and physical/sexual abuse, I often would struggle with why these children “slipped through the cracks,” in that their conditions were not discovered and treated sooner when earlier interventions may have mitigated some of their negative outcomes. Conversations with pediatric health care providers about these issues were often discouraging, because I was told by many providers that these issues were too large to confront. Furthermore, many providers told me that they do not screen for these problems because of inadequate time, knowledge, skills, and/or reimbursement, as well as the absence of mental health care providers for referral. However, with each new story from an emotionally distraught child, I grew more determined to garner a team of persons who shared a similar passion to move forward and tackle these pressing problems. With the support and assistance of NAPNAP and many talented and dedicated individuals, the “Keep your children/yourself Safe and Secure” (KySS) Campaign was formally launched in 2001 with a mission of preventing and reducing the alarming numbers of mental health/psychosocial morbidities in children and teens. I gratefully acknowledge my co-directors for the KySS Summit, Dr Dolores Jones and Dr Julie Novak, the KySS Summit Planning Committee Members and Task Force Chairs, the KySS Summit Collaborating Partners and Organizations, and the participants for their time, dedication, and ongoing commitment. Sincere appreciation also is extended to the Health Resources and Services Administration/Maternal and Child Health Bureau, which largely supported the funding for this Summit, as well as NAPNAP, Pfizer, Inc, and the Centers for Research & Evidence-Based Practice and High-Risk Children and Youth at the University of Rochester School of Nursing for additional assistance with this event. —Bernadette Mazurek Melnyk, PhD, RN, CPNP, NPP, FAAN Founder and Director, NAPNAP's KySS Campaign Purpose and goals of the KySS Summit The purpose of the KySS Summit was to convene a group of national interdisciplinary experts, representing nursing, medicine, psychiatry, psychology, education, social work, clinical practice, research, and health policy, to develop a strategic action plan to promote the mental health and safety of children and adolescents in primary care and alternative care settings. Objectives of the Summit included the following:
•identify assessment, implementation, and dissemination strategies for promoting the mental health of children and teens in primary care and alternative care settings;
•develop the content for a national Continuing Education KySS Institute to enhance screening and early interventions for pediatric and adolescent mental health problems, which will be reproduced for national dissemination;
•develop an outline for a KySS core curriculum for use in professional education programs;
•delineate strategies to affect health policy to improve the mental health and safety of children and teens; and
•review the state of evidence-based interventions in each of the KySS task force areas and make recommendations for best practices and future research.
Introduction to the problem: The rise of mental health morbidities in children and teens Approximately one in four children (ie, 15 million children) in the United States have a mental health problem that affects their functioning at home and/or school (US Office of the Surgeon General, 1999). Sadly, this figure is believed to be underestimated, in large part because of inadequate screening by primary care providers (Melnyk, Moldenhauer, Veenema, et al., 2001). Additionally, families often deny that their children have mental health problems or have difficulty discussing these issues with their primary care providers, often because of fears of associated stigma (Scheid, 2003). Mental health/psychosocial problems, risk-taking behaviors, and injuries, many of which are preventable, currently cause more morbidity and mortality in the pediatric and adolescent population than do physical diseases and disorders. Many factors have accounted for this shift in pediatric morbidities, including: (a) the advent of vaccines and eradication of diseases, (b) the discovery of effective antimicrobial agents and technological treatments, (c) changes in family composition, largely resulting from high divorce rates and single and stepparent families, (d) greater pressures on children to excel in academics and sports, (e) the rise in the number of children and teens affected by chronic illness, of which approximately one third have mental health problems, (f) a rise in the number of dually employed parents, with accompanying family stress, (g) recent terrorism, school violence, and war, (h) high levels of parental stress, conflict, and psychopathology, and (i) exposure to unfiltered media (eg, violent television and video game programs, illicit music lyrics, and uncensored Internet chat rooms and sites) (Melnyk, Feinstein, Moldenhauer, & Small, 2001; Melnyk, Feinstein, Tuttle, et al., 2002; Melnyk, Moldenhauer, Tuttle, et al., 2003; Slater, 2003). Of children and teens affected by mental health problems, 70% do not receive any treatment (Melnyk, Feinstein, Tuttle, et al., 2002). As a result of these escalating problems and inadequate treatment for them, the US Surgeon General has declared a crisis in the area of access to mental health care (Report on the Surgeon General's Conference on Children's Mental Health, 2000). Most recently, this crisis has captured the attention of policy makers with the recent US General Accounting Office (GAO) Report to Congressional Requesters (2003), which indicated that more than 12,700 children were placed into the child welfare or juvenile justice systems last year so they could receive mental health services. In addition to the human psychological and emotional costs of child and adolescent mental health problems to patients and their family members, the financial costs of these problems are exorbitant. Latest figures estimate that mental health services cost the United States $69 billion in 1996, with an additional $12.6 million allocated to substance abuse treatment (US Office of the Surgeon General, 1999). Shifts also have occurred in health professionals who treat mental health conditions, as primary care providers now deliver the majority of interventions with minimal specialty care treatment by mental health specialists (US Department of Health and Human Services [USDHHS], 2003). Specifically, for the pediatric population, only approximately 2% of children with mental health issues are seen by mental health specialists, while primary care health care providers see 75% of children with these problems (Kelleher, McInerny, Gardner, Childs, & Wassermann, 2000). Even when referrals are made by primary care providers for families to have their children evaluated or treated by mental health providers, as few as 7% follow through with these recommendations (Saravay, 1996). In addition, of the children seen by mental health providers, many fail to adhere to their treatment recommendations. As such, there is an inherent value in primary care providers being able to screen for and intervene with children and teens with these problems, because many of these professionals have established trusting relationships with families. Although pediatric health care providers in primary care and alternative care settings (eg, schools) are in a unique position to conduct screening and early and preventive evidence-based interventions for mental health problems, multiple barriers inhibit their ability to do so, including: (a) lack of time in already overloaded schedules, along with an inadequate reimbursement system, (b) lack of valid and reliable efficient screening tools, (c) inadequate mental health knowledge and skills for intervention, (d) a paucity of evidence-based interventions with demonstrated efficacy in primary care settings, and (e) lack of skills in evidence-based practice (Melnyk, Feinstein, Tuttle, et al., 2002; Melnyk & Fineout-Overholt, 2002). As a result, there is an urgent need for large-scale, effective, interdisciplinary initiatives to promote the mental health of children and teens in this new millennium. Development and launching of the KySS Campaign Any major accomplishment commences with a big dream or a vision of the outcome to be achieved. Belief in that dream also is essential if the outcome is to be realized (Melnyk, 2001). Sparked by the escalating increase in mental health/psychosocial morbidities and the realization that intensified efforts by pediatric health care providers could result in the prevention and decline of these problems, the KySS Campaign journey started with a vision to improve the mental health of children and teens throughout the United States, with the belief that it could be accomplished, along with the persistence to overcome challenges along the path to implementation. The campaign proposal was presented to and approved by the Executive Board of the National Association of Pediatric Nurse Practitioners (NAPNAP) in the fall of 2000 and formally launched in April of 2001 at NAPNAP's Annual Conference on Pediatric Primary Care. Since its inception, the overall mission of the campaign has been to prevent and reduce mental health/psychosocial morbidities in children and teens and to raise public awareness and decrease stigma associated with these problems. As such, the KySS Campaign directly addresses eight of the 10 leading health indicators in “Healthy People 2010” (USDHHS, 2000): mental health, physical activity, overweight and obesity, tobacco use, substance use, responsible sexual behavior, access to care, and injury and violence. Goals and implementation strategies to accomplish the mission of the KySS campaign were established during the first phase of the campaign's development. These early strategies were to: (1) assess the mental health knowledge, worries, and needs for intervention of children/teens and their parents through a national KySS Survey, (2) assess the mental health knowledge, screening practices, level of preparation, and needs for intervention of pediatric health care providers, (3) convene an interdisciplinary group of experts in the form of a National KySS Summit who would review data from the national survey and outline implementation strategies for the prevention and reduction of mental health problems, and (4) enhance the knowledge and skills of pediatric health care providers to conduct screening as well as early and preventive interventions for these problems, with an initial targeted focus on professionals practicing in primary care and alternative care settings (eg, schools). Funding and resources from NAPNAP, Lowe's Home Safety Council, and the Centers for Research & Evidence-Based Practice and High-Risk Children & Youth at the University of Rochester School of Nursing facilitated the successful conduct of the KySS national survey to accomplish strategies 1 and 2 (findings from this survey are reported later in this document; for a full report of this survey, see Melnyk, Feinstein, Tuttle, et al., 2002). In addition, a grant was funded by the Health Resources and Services Administration (HRSA)/Maternal and Child Health Bureau (MCHB) in the spring of 2002 that provided resources to organize the national KySS Summit. Funding from the MCHB grant also will facilitate a National KySS Institute on Mental Health Screening, Interventions, and Health Promotion Skills for Primary Care and School Health Providers in the spring of 2004 that will allow strategy 4 to be accomplished. As the proposal for the KySS Campaign was being developed, it was recognized that interdisciplinary collaboration would be key for maximizing the campaign's success. Therefore, a multitude of national interdisciplinary organizations with a vested interest in children and teens were invited to collaborate on the campaign. To date, 22 national professional organizations are now supporting or endorsing the KySS Campaign in its implementation initiatives. Highlights from presentations by featured speakers Mental health: A lifespan approach (keynote presentation by Dr David Satcher)1 Dr David Satcher, the 16th Surgeon General of the United States and current director of the National Center for Primary Care at Morehouse School of Medicine, presented a thought-provoking keynote address at the KySS Summit. In the introduction to his talk, Dr Satcher highlighted the evolution of our national health goals in the Healthy People documents, which are entering the third decade. He specifically focused on the overarching goals of Healthy People 2010, which are to increase years and quality of healthy life and to eliminate racial and ethnic health disparities. The 10 leading health indicators were outlined, one of which is mental health. Dr Satcher referred to Mental Health: A Report of the Surgeon General, which he spearheaded in 1999, followed by a supplement on Children's Mental Health, in 2001. Definition of mental health and key messages Mental health was defined as the successful performance of mental function, resulting in productive activities, fulfilling relationships with others, and the ability to adapt to change and to successfully cope with adversity. The following key messages about mental health were presented:
•Mental health is fundamental to overall health and well-being
•Mental disorders are real
•Mental disorders are common in the United States, with one in five Americans having a diagnosable mental disorder each year, including 13.7 million children
•Only one third of children with a mental health disorder receive treatment
•Mental disorders are as disabling as cancer or heart disease in terms of premature death and lost productivity
Dr Satcher emphasized that stigma regarding mental health problems deters treatment at three levels: (a) the individual level, because it keeps people who are experiencing a problem from acknowledging it and seeking help; (b) the family/community/societal level, because it keeps individuals from recommending help or acknowledging the problem for family and friends; and (c) the policy arena, because it keeps government and the private sector from addressing the problems. The influence of culture on mental health Dr Satcher emphasized that culture affects how individuals manifest and describe illnesses, how they cope with illnesses, the type of stresses they experience, and whether they are willing to seek treatment. Culture also affects the manner in which patients are diagnosed, the type of treatments offered, and how services are organized and financed. The influence of culture on mental health is further discussed in Mental Health: Culture, Race, and Ethnicity, a supplement to Mental Health: A Report of the Surgeon General (USDHHS, 2001). It was emphasized that Blacks are more likely to have a mental health disorder than are Whites and are less likely to seek treatment. When they do receive care, Blacks are more likely to use emergency department services. Report of the surgeon general's conference on children's mental health: A national action agenda Eight goals were established at the recent conference on children's mental health, including the following:
•promote public awareness of children's mental health issues and reduce stigma associated with mental health;
•continue to develop, disseminate, and implement scientifically proven prevention and treatment interventions;
•improve the assessment of and recognition of mental health needs in children;
•eliminate racial/ethnic and socioeconomic disparities in access to mental health care services;
•improve the infrastructure for children's mental health services, including support for scientifically proven interventions across professions;
•increase access to and coordination of quality mental health care services;
•train front-line providers to recognize and manage mental health care issues and educate mental health providers about scientifically proven prevention and treatment services; and
•monitor the access to and coordination of quality mental health care services.
Barriers to achieving these goals and to mental health care include limited finances, managed care, inadequate reimbursement, persistent stigma, health care providers' unawareness of the treatments, and consumers being unappreciative of treatment.
A vision for the future Dr Satcher emphasized that the majority of mental health problems can be treated by primary care providers and that, unless we can be successful at getting primary care providers to be more attentive to mental health problems, progress in the treatment and prevention of these disorders will be slow. He stressed that we need to do the following: (a) strengthen the education of primary care providers in the area of mental health; (b) overcome stigma of mental health problems; (c) increase public awareness of these problems and effective treatments; (d) ensure the supply of mental health services and providers; (e) ensure the delivery of state-of-the-art treatments; (f) facilitate entry into treatment; (g) reduce financial barriers to treatment; and (h) tailor treatments to age, sex, race, and culture. Who is and who isn't providing mental health services to our nation's children (featured presentation by Dr Michael Weitzman)2 The problem Child health in the United States has changed radically in the past several decades, with a major change to a focus on treating children who are relatively healthy. However, disease and disability continue to affect many children, leaving unanswered questions. At the Summit, Dr Weitzman provided an overview of the status of child health, specifically mental health, in the United States. Many key issues challenge health care providers in meeting the mental health needs of children and their families, including the need for screening and early identification, improving access to appropriate mental health care, strengthening the infrastructure, and expanding training for providers. The 1999 Methodology for Epidemiology of Mental Disorders in Children and Adolescents Study estimated that 21% of children in the United States ages 9 through 17 years have a diagnosable psychiatric disorder (US Office of the Surgeon General, 1999). It is estimated that fewer than one in five children with a mental health problem receive the needed treatment. There is a paucity of child mental health care providers, with only 6300 child psychiatrists in the United States, while it is estimated that more than 30,000 are needed. Additionally, there is a significant misdistribution of these health care providers. Recent evidence compiled by the World Health Organization indicates that, by the year 2020, childhood neuropsychiatric disorders will rise proportionately by more than 50% internationally to become one of the five most common causes of morbidity, mortality, and disability among children (U.S. Public Health Services, 2000). Dr Weitzman presented the major influences on child mental and developmental health, which include: divorce and single-parent households; social support; parental education; mental health and behaviors; loss, grief, fear, and anxiety; media; genes; intelligence quotient; low birth weight; chronic illness; race, ethnicity, and immigrant status; environmental exposures; community, education, and peer influence; health insurance; and access to and quality of care. There is an increased rate and severity of multiple child health problems. Demographic factors include low socioeconomic status, minority population, adolescent parents, and low parental education. Service factors include lack of health insurance or adequate coverage, lack of primary care, and service systems that do not function. Children with untreated mental health disorders are at higher risk for school failure and dropping out. They have increased incidences of violence, criminal activity, and suicide. In addition, abuse of tobacco and other drugs are more prevalent in these children. We know that preventive interventions for children's mental health problems are effective. A range of efficacious psychosocial and pharmacologic treatments are available. The multiple problems associated with emotional disturbance in children and adolescents are best addressed with a “systems” approach in which multiple service sectors work in an organized, collaborative way (US Office of the Surgeon General, 1999). Pediatric health care needs to be expanded to better meet the mental health care needs of all children, especially those at risk. Common behavior problems and issues Common behavior problems and issues in children include: loss, grief, fear, and poor self-esteem; eating disorders; smoking; risk-taking behaviors; chronic illness and disability effects; bullying; parental mental health; smoking and drug use; psychopharmacology; and media influences. In 1993, the American Academy of Pediatrics (AAP) adopted the policy statement “The Pediatrician and the New Morbidity.” The statement focused on the significance of mental health problems in children and adolescents. In 2001, the AAP published another statement with a renewed commitment to the psychosocial aspects of pediatric care (AAP, 2001b). Since then, social difficulties, behavioral problems, and developmental difficulties have become a main part of the scope of pediatric practice, and recognition of the importance of these areas has increased. Today's new morbidity focuses on the issues of obesity, chronic stress, divorce, single parenting, parental depression and smoking, prescribing psychoactive drugs for depression, anxiety, obsessive-compulsive disorder, attention deficit/hyperactivity disorder, and violence prevention. There is a need to commit to prevention, early detection, and management of these behavioral, developmental, and social problems. The implication of this knowledge for the pediatric health care professional is not new but, instead, requires a focus on re-examination of the approach to screening, preventing, and managing psychosocial problems in children. Maternal factors, school difficulties, and chronic illness all affect mental health. Maternal depression is a significant issue that affects the mental health of children. Various studies of maternal depression have shown that children of these mothers have increased risk of psychiatric, social, and medical problems, as well as measurable cognitive defects. Maternal smoking during pregnancy is associated with neurotoxic effects on children, including increased activity, decreased attention, and diminished intellectual abilities. Epidemiologic studies also suggest that prenatal tobacco exposure is associated with higher rates of behavior problems and school failure (Weitzman, Byrd, Aligne, & Moss, 2002). School difficulties and school failure are significantly affected by mental health. The proportion of failure to complete school that is attributable to a psychiatric disorder is estimated to be 46% (Stoep, Weiss, Kuo, Cheney, & Cohen, 2003). Factors associated with increased risk of grade retention are poverty, male sex, low maternal education, deafness, speech defects, low birth weight, enuresis, and exposure to household smoking (Byrd & Weitzman, 1994). Children with a chronic health condition are at risk for psychosocial morbidities and behavior problems. Despite evidence for effective interventions, health services for children with chronic conditions, particularly mental health services, remain fragmented and signal the need for increased attention to behavioral problems and their treatment among all health professionals caring for children. Research needs Even though the importance of identifying and treating behavioral and emotional problems in children has been recognized for many years, the amount of research in this area is scarce. A review of the April 2001 Computer Retrieval of Information on Scientific Projects (CRISP) database of currently funded research grants supported by the USDHHS demonstrated the small number of studies in this area. Of the 45,022 research abstracts in the CRISP database, 2720 (6%) contained the words “children,” “adolescents,” or “youth.” Sixty-three abstracts contained work on children, adolescents, or youth in primary care (0.14% of the portfolio). Of these 63 abstracts, only 21 (0.05% of the portfolio) addressed behavioral or emotional issues. Of the 21 projects, only 11 examined aspects of the primary care process. When the distribution of child and adult studies on the treatment of depression within primary care settings was examined, it was found that adults received 15 times the research attention compared with children. Even though the importance of primary care as a system for identifying and treating behavioral and emotional problems in children has been recognized for more than 20 years, not enough attention is being paid to this topic in the research portfolios of the National Institutes of Health and other federal agencies that support research (Horwitz et al, 2002). The gap between research and practice in relation to factors in child mental health must be bridged. Conclusion There is a pressing need to improve mental health services to children. Pediatric health care professionals need to be partners with others in the areas of risk assessment and prevention and treatment of psychosocial disorders. It is necessary to reach out to the community to find partners to help children. Pressures on families are increasing, requiring pediatric health care professionals to reach out and become more active in communities and schools and to participate with other disciplines and social support groups. Additional potential partners in the community include health departments, child care providers, churches, libraries, police departments, insurers, and most importantly, parents. Robert Haggerty stated, “We must become partners with others, or we will become increasingly irrelevant to the health of children” (Haggerty, 1995). Children's mental health will be facilitated by advocacy from pediatric health care professionals who assess for problems that place children at risk and effectively refer to and collaborate with other professionals and family services. Community-based research projects are needed to improve context-sensitive assessment of child mental health and design effective community-based interventions to improve child mental health. Mental health knowledge, worries, needs, and screening practices: Findings from the national KySS survey (featured presentation by Dr Bernadette Melnyk)1 The first phase of the KySS campaign: The national KySS survey In an attempt to better understand the mental health knowledge, worries, and needs for intervention of school-aged children, teens, and their parents, a national survey was developed, piloted, and administered to a sample of more than 1200 children and teens ages 10 to 20 years and their parents from 24 states. A parallel survey also was developed and administered to more than 650 pediatric health care providers across the United States to assess their mental health knowledge, screening practices, and level of preparation to screen and intervene for these types of problems. Findings from the national survey revealed that the top five worries for both children and teens and their parents were: (a) how to cope with stressful things in their lives; (b) anxiety; (c) depression; (d) self-esteem; and (e) parent-child relationships (Melnyk, Feinstein, Tuttle, et al., 2002). Approximately 25% of the child and teen respondents worried about how to cope with stressful things often to nearly always, and 10% to 20% worried about anxiety and depression to the same extent. Almost half of the sample also reported worrying to some extent about problems with their self-esteem, their relationships with parents, and being made fun of by their friends. Despite these substantial mental health worries, an average of only 20% to 30% of the children, teens, and parents reported talking with their primary care providers about these topics. Regarding mental health knowledge about a variety of issues (eg, sexual risk taking, substance use, and disordered eating), children and teens answered an average of only 44% of the questions on the KySS survey correctly, and their parents answered an average of 54% of the questions correctly. Respondents listed a host of needs regarding mental health issues, including the top priorities of: (a) more educational handouts and programs on how to recognize these problems and (b) programs that teach children, teens, and parents how to deal with stress and build self-esteem as well as how to have better communication with each other (see Melnyk, Feinstein, Tuttle, et al., 2002, for the full report of the findings). Health care providers (ie, representing mostly pediatric nurse practitioners [PNPs] and pediatricians) answered, on average, fewer than two thirds of the knowledge questions correctly on the KySS survey. Approximately 40% of the providers, on average, reported that they did not screen at all or only sometimes for these problems in school-aged children, and about 27% admitted to not screening at all or only sometimes for these problems in teens. More than 80% of providers reported that they did not use screening tools in their practices to assist them in the identification of children with these problems, and of those who use screening tools, the Guidelines for Adolescent Preventive Care (GAPS) (American Medical Association [AMA], 1994) screening tool was most frequently cited. Almost half of the providers reported that their professional education programs prepared them “not at all” to “a little” to assess and effectively intervene for these problems. Approximately two thirds of the providers who completed the KySS survey reported that just completing it helped to raise their level of awareness and would stimulate them to: (a) seek out more information on these topics, (b) screen more frequently for these conditions, and (c) talk more to families about mental health issues (a full report of the health care provider findings is in process). The findings from the national KySS survey indicate the urgent need to develop reproducible brief intervention programs that can be tested in primary care settings to assist children and teens in coping with stress and anxiety, as well as building their self-esteem and strengthening parent-child relationships. A number of interventions to improve mental health outcomes have evidenced positive outcomes in school-based settings; however, these interventions need to be translated into clinical practice settings (Hoover, Weist, Goldstein, Schaeffer, & Brey, 2003). In addition, educational programs are needed to assist families in recognizing mental health problems and knowing where to turn for resources. For providers, there is an urgent need to develop continuing education programs with behavioral skill-building components to strengthen their screening and early intervention skills for children with these problems. Valid and reliable screening tools that can be administered efficiently in primary care practice and school-based health centers need to be developed and tested in areas in which they do not exist with the intent of making them routinely made available for use. Where screening tools already exist, health care providers must be assisted to overcome the barriers in routinely using these tools to identify children with mental health problems. Professional education programs as well as residency training programs need to strengthen content and behavioral skills (eg, communication techniques and motivational interviewing) in these areas so that persons graduating from these programs will be better prepared to deal with the most common morbidities of the 21st century. More programs that prepare dual PNPs and psychiatric mental health nurse practitioners (PMHNP), such as the HRSA-funded dual PNP/PMHNP master's program at the University of Rochester School of Nursing, are needed so that providers in primary care will be prepared to address both the physical and mental health needs of children. Dual preparation of providers in primary care will assist in removing some of the major barriers, such as access and stigma, as deterrents to mental health evaluation and treatment. Although the KySS Campaign is still in its infancy, it has gained momentum rapidly in beginning to tackle some of the most pressing issues in child and adolescent health that we face today within the context of a multidisciplinary approach, an essential element for the campaign to have the greatest positive impact. The KySS Summit is a call to action from which major implementation initiatives will be launched to accomplish the vision of promoting the highest level of mental and physical health for children and adolescents. With the continued work of KySS, the Healthy People 2010 goals will become more of a reality than just a vision. Health policy: Key elements of effective data translation and dissemination (featured presentation by Claudia Williams, Principal, AZA Consulting)3 Ultimately, the success of the NAPNAP KySS Campaign will be measured by its effect on health policy. For the effect to be significant, campaign partners representing 22 professional organizations must translate and disseminate research findings for policy makers in a language they can understand. At the KySS Summit, Claudia Williams, a policy expert from AZA Consulting, shared her expertise, wisdom, and recommendations with participants. The problem First of all, policy makers are besieged with information, and that information is often presented in a complicated and even contradictory manner. Rather than taking this approach, health care providers must synthesize information for policy makers. Information needs of policy makers must be timely and the information must constantly develop into new dissemination channels. Ms Williams encouraged Summit participants to become information brokers by organizing a briefing or conference, developing a quarterly online newsletter, and developing a Web site. Currently, these approaches are being used or developed by NAPNAP and the KySS Campaign. For KySS to have its intended impact, partners must have the information ready in a sound bite (ie, a basic nuts and bolts approach) that is fed into channels already used by policy makers (eg, their staffers or their publications). Policy makers use personal contacts to retrieve information quickly (eg, when legislative aides need information, they telephone people they know and trust). Several of the Journal of Pediatric Health Care Legislative/Health Policy departments have stressed the importance of developing a partnership with legislators, allowing policy makers to know that PNPs have areas of expertise as well as a readiness and willingness to work with them. The KySS Campaign Task Force groups, focusing on the major child and adolescent psychosocial morbidities, are knowledgeable and articulate about their areas and stand ready to share information with policy makers, both formally and informally. Assimilation of information Policy makers skim research reports quickly in search of the story line and conclusions. This scan helps them determine what action to take, if any. The goal in presenting material to policy makers is to engage them—ultimately for the issue or topic to capture their attention to the extent that they will delve into the information, reach their own conclusions, and make it their own cause. Ms Williams further stressed that KySS partners must remember that policy makers are “busy, distracted, and crisis-oriented.” Joseph Nye, Dean of the Kennedy School of Government, stated in a 1997 University of California Berkeley interview: “It's a totally different world, government, from academics. In academic life, there's no premium on time, the premium is on getting it just right. In government, if you haven't got the right answer by four o'clock this afternoon when the president meets with the prime minister, that perfect paper you get in a little bit late is an “F.”… So, this problem of how chaotic reality can be used to shape the right questions, even before you get answers, is very different in the government setting than in the academic setting.… In government, you either solve the problem or get the right answer quickly or it doesn't happen at all. And it's quite a different set of skills. The premium we put on time makes a huge difference” (Kreisler, 1998). To make research findings more useful, KySS partners must actively engage policy makers from the beginning and think of them as clients.
What questions are they trying to answer? What is their time line? KySS study findings as well as other data requiring health policy response must be presented in a practical, relevant, and actionable manner. The research must help policy makers make hard decisions. The information should answer specific questions (eg, how can this project affect health care delivery and financing? What is the intended result, the bottom line?). Telling the story When making a presentation to policy makers, it is important to lead with the conclusion or bottom line. A 2- to 4-page policy brief is an ideal tool for the presentation. Information should be presented in a bulleted format that can be read quickly between meetings or on the treadmill. The brief should be used as a conversation starter, a “mental bookmark” for longer reports. It should be organized around a clear policy “hook” using graphics, text, and visual pointers to help the reader navigate through the material. The format should be consistent and predictable. The goal is to create a bridge between research findings and policy decisions. To add depth to the presentation of recommended interventions and policies, briefs can be packaged with other tools and products, such as slides with graphs and charts, spreadsheets, annotated bibliographies, links to articles, Web sites, fact sheets, and a list of key contacts. NAPNAP Health Policy Committee members and Executive Board members have used this approach effectively with campaigns related to protecting children from bioterrorism and anti–hard liquor advertising, among others. Conclusion In summary, policy makers are more likely to use information and research findings if they are relevant and focused, easily skimmed, synthesized, conclusion-oriented, presented graphically, and brief. Timing is everything! The NAPNAP KySS partners and the thousands of professionals they represent must track and monitor the policy environment, be prepared to tell their story in a compelling manner, be consistently engaged in the policy process, and think strategically at every juncture. Charge to the task force groups Task force groups were purposely formed to include multidisciplinary experts in each of the KySS Campaign's substantive areas. The charge given to the task forces included: (a) to identify the most critical screening questions for health care providers to identify a child or teen with a problem in the area; (b) to name appropriate screening tools that are practical for use in primary care and alternative settings, along with nontraditional opportunities for screening; (c) to identify preventive and early evidence-based interventions that could be used in primary care and alternative care settings; (d) to identify further research needs; (e) to determine health promotion dissemination strategies; and (f) to identify the most useful, quality resources and Web sites for providers and families. In addition, the Task Force Groups were charged with outlining content and behavioral skills in each of their substantive areas for: (a) a KySS Institute on Mental Health Screening, Interventions, and Health Promotion (a professional continuing education workshop to be held in the spring of 2004), and (b) professional education programs. The following are summary reports from each of the Task Force Working Groups, addressing each of their requested functions. Task force summaries with outcome recommendations Child abuse: Task force summary and recommendations The Chair of this task force and author of this section is Pamela Herendeen. Background/significance Child abuse is defined as the severe neglect of a child's basic needs or the causation of nonaccidental injury. In 2000, 3 million cases of child abuse or neglect were reported, with about 1 million indicated. Of the indicated cases, 63% were neglect, 19% were physical abuse, 10% were sexual abuse, and 8% were emotional abuse. Eighty-four percent of the victims were maltreated by a primary caregiver. Every day, four children in the United States die from abuse or neglect, with most being children younger than 6 years. Between 3 and 10 million children witness domestic violence in their lifetime, and the risk of child abuse doubles if the mother is being battered. Of the children who witness domestic violence, 50% demonstrate major behavioral problems, 26% manifest aggressive behavior, and 6% attempt suicide (USDHHS, 2000a). Child risk factors include children with fussy temperaments, congenital anomalies, chronic medical conditions, developmental disabilities, behavioral problems, children younger than 3 years, and children in foster care. Parent risk factors include young parents, single parents, parents with an abuse history, unwanted pregnancy, poverty, or social stressors, substance abuse, mental illness, developmental delay, and domestic violence (Siegel et al., 1999). Key screening questions for child abuse Questions for parents:
•Are you afraid of anyone in your home?
•Do you ever feel so frustrated that you may hit or hurt your child?
Questions for children/youth:
•Are you afraid of anyone in your home?
•Who could you tell if anyone has touched you in a way that made you feel uncomfortable, and has this ever happened to you?
Available screening tools for child abuse Very few known screening tools exist that may be helpful in the identification of child abuse. The Postpartum Depression Screening Scale (PDSS) (Beck & Gable, 2000) should be routinely used to screen for maternal depression in a child's first year of life because there is evidence to support that a mother who is depressed is at high risk for neglect and abuse of her child. The GAPS form for adolescents (AMA, 1994) briefly addresses abuse. The Task Force determined that further screening tools need to be developed in this area. Nontraditional opportunities for screening There are multiple opportunities for screening, including day care facilities (center and home-based care), schools, community centers, family resource centers, pediatric primary care offices, obstetrical offices during prenatal/postnatal visits, respite care homes and centers, community health nurse (CHN) visits, Early Intervention teams, and other preventive care programs. Evidence-based interventions for child abuse To date, there is a paucity of evidence-based interventions other than very early assessment and intervention for high-risk families. Preventive interventions, such as nurse home visitation with high-risk mothers in the prenatal and infancy periods, have shown positive long-term outcomes, including less child abuse (Olds et al., 1997). Therefore, parent education and effectiveness training seems to be a crucial element in prevention. Further research needs Much research needs to be conducted in this area. Preventive efforts in the field of child abuse have just begun. There are some new studies examining the prevention of shaken baby syndrome by educating new parents at birth. Other community-based programs are becoming available via the media, and various resource centers are emerging to target high-risk populations with programs such as parenting and coping strategies. These programs will need to be evaluated for long-term outcomes regarding child abuse statistics. Another needed area for further study is the development and testing of preventive or early interventions for violence in the home, including how the reduction of violence would affect the psychosocial morbidities of children. Health promotion dissemination strategies Interventions need to be tailored to individual community needs. There should be a policy statement that all health care practices, schools, and day care centers should have a plan for screening psychosocial morbidities, violence, abuse, and parenting capacity. The media could assume a large role in raising awareness and disseminating vital information. The following are excellent resources and Web sites for child abuse:
•Prevent Child Abuse NY (http://www.preventchildabuseny.org)
•National Clearinghouse on Child Abuse and Neglect (mailto:nccanchi@calib.com)
•Shaken Baby Alliance (http://www.shakenbaby.com)
•End Child Abuse (http://www.childabuse.org)
•Family Violence Prevention Fund (http://endabuse.org)
•Help Stop Family Violence (http://www.stopfamilyviolence.org)
Depression and anxiety: Task force summary and recommendations* The co-chair of this task force and author of this section is Holly Brown. Background/significance Depression is a major cause of morbidity among the pediatric population; it affects 5% of children and approximately 15% of adolescents, resulting in substantial impairment and health care costs (Garber & McCauley, 2002; Melnyk, Moldenhauer, Veenema, et al., 2001). As many as 40% of children and adolescents will experience a second depressive episode within 2 years and almost 75% will experience a second depressive episode within 5 years (Garber & McCauley, 2002), with many experiencing bouts of depression in adulthood. Untreated, these children and teens are at high risk for the development of co-morbid disorders, including anxiety, disruptive behavioral disorders, substance abuse, and suicide, with a 30-fold increased risk of completed suicide as well as social isolation and poor academic and occupational adjustment (Birmaher, Ryan, & Williamson, 1996). Risk factors for depression include genetic vulnerability/parental psychopathology, previous depressive episodes/subsyndromal symptoms, dysfunctional family environments, and female sex (Garber & McCauley, 2002). Anxiety disorders are among the most prevalent forms of psychopathology in children and adolescents, occurring about as frequently as asthma in the pediatric population (Santos & Barratt, 2002). The combined prevalence of anxiety disorders, according to the Surgeon General's report on mental health (1999), is higher than virtually all other mental disorders of childhood and adolescence. Nine percent to 15% of US children and adolescents have anxiety symptoms that interfere with their day-to-day functioning (Green, 1994). Affected children often struggle with low self-esteem, social isolation, inadequate or underdeveloped social skills, and poor academic functioning. Physical symptoms that significantly interfere with functioning also can be associated with anxiety disorders and include recurrent abdominal pain, chest pain, headaches, and irritable bowel syndrome. Risk factors for anxiety disorders include parental psychopathology/genetic vulnerability, exposure to chronic stress or traumatic events, unstable attachments to parental figures, and chronic or life-threatening medical conditions. Key screening questions for depression and anxiety Questions for parents:
•On a scale of 1 to 10, how much does your child worry on a day-to-day basis?
•What does your child worry most about?
•Have you been worried about your child being angry, irritable, sad, fearful, or having a change in behavior in the last month?
•How often does your child complain of headaches or stomach aches?
•Do you have any worries about your child being depressed? If the answer is yes, proceed to: Do you ever think your child thinks about hurting or killing himself?
Questions for children/youth:
•On a scale of 0 to 10, how much do you worry about things?
•How often do you get stomach aches and headaches?
•In the past month, have you felt nervous, angry, irritable, sad, depressed, or afraid?
•In the past year, have you had any thoughts about hurting or killing yourself?
Available screening tools for depression and anxiety The following tools are available to screen for depression and anxiety:
•Guidelines for Adolescent Preventive Services (GAPS) (AMA, 1994)
•Beck Depression Inventory (2nd edition) (BDI-II) (Beck, 1996)
Nontraditional opportunities for screening Mental health screening should begin prenatally, starting with the well-being of the parents as well as continued through infancy with simple developmental screening, and annually at well-child visits throughout childhood and adolescence. School nurses could conduct mental heath screening in schools with the ability to offer referrals to social workers and psychologists. Sunday-school teachers could conduct faith-based screening, and churches could provide outreach mental health services. Mental health evaluations also should be conducted prior to school suspensions. Flyers with screening questions could be placed in local stores (eg, groceries and pharmacies) to return to primary care providers. Public Service Announcements also could be made to increase awareness. In addition, family learning centers should offer information on mental health, parenting, and family wellness. Mental health information also could be provided in dental offices. Evidence-based interventions for depression and anxiety Components of Dialectical Behavioral Therapy (DBT) (Linehan, 1993) (eg, the skills of mindfulness and attention) have yet to be tested in primary care but have been successfully used with teens who have certain types of mental health problems (eg, mood disorders and borderline personality disorder). Cognitive Behavioral Therapy (eg, the Adolescent Coping with Depression and Stress Courses [Lewinsohn, Clarke, Hops, & Andrew, 1990]) has been used with groups of teens in school-based settings and found to be effective. A shortened version of the Coping with Depression course is being tested with depressed teens in primary care by Zendi Moldenhauer (Chair, KySS Depression and Anxiety Task Force). Relaxation techniques (eg, progressive muscle relaxation and imagery) have been shown to be effective in reducing anxiety in children and teens undergoing some stressful life events (eg, intrusive medical procedures). Further research needs The development and testing of brief, culturally sensitive preventive and early interventions (both group and individual) are needed for use in primary care settings with high-risk children, youth, and parents affected by or at high risk for anxiety and depression. Further tool development also should continue, with a focus on culturally sensitive brief screening questionnaires that can be used efficiently in practice. Health promotion dissemination strategies Health promotion dissemination strategies include flyers, Public Service Announcements, learning centers, training of first responders in mental health issues (eg, police and emergency medical technicians), seminars for school personnel that present quick, effective interventions, multimedia approaches, and better interface with the juvenile justice system. Excellent resources and Web sites for depression and anxiety include the following:
•Adolescent Coping with Depression and Stress Courses (Lewisohn et al., 1990) (http://www.kpchr.org/public/acwd/acwd.html) (courses can be downloaded for use)
•American Academy of Pediatrics (http://www.aap.org/)
•American Psychiatric Association (http://www.psych.org)
•American Society of Adolescent Psychiatry (http://www.adolpsych.org)
•Anxiety Disorders Association of America (http://www.adaa.org)
•Child Anxiety Network (http://www.childanxiety.net/Links.htm)
•Facts for Families—American Academy of Child and Adolescent Psychiatry (http://www.aacap.org) (handouts for parents on anxiety and depression can be downloaded and disseminated for educational purposes without cost or copyright permission)
•KySS Web site (http://www.napnap.org)
•The National Adolescent Health Information Center (http://youth.ucsf.edu/nahic/whoweare.html)
•The National Institute of Mental Health (http://nih.gov)
•Society for Adolescent Medicine (http://www.adolescenthealth.org/)
•Tools for Coping with a Variety of Life's Stressors (http://www.coping.org)
Disordered eating: Task force summary and recommendations Task Force Chairs and authors of this section are Dr Richard Kreipe and Dr Leigh Small. Background/significance Current data from the Centers for Disease Control and Prevention (CDC) indicate that the number of children who are overweight has more than tripled in the past two decades (Campbell, Waters, O'Meara, Kelly, & Summerbell, 2003; Rosenbloom, Joe, Young, & Winter, 1999). It is estimated that 13% to 15% of children and adolescents are overweight. The major negative consequences associated with obesity include type 2 diabetes, hypertension, hyperlipidemia, insulin resistance, asthma, sleep apnea, and negative coping outcomes (eg, poor self-esteem and depression). It is estimated that $127 billion are spent annually on obesity and related chronic illnesses, up from $94 billion in 1995 (World Health Organization, 1997). The prevalence of other childhood disordered eating patterns (ie, bulimia, anorexia nervosa, and eating disorders not otherwise specified) has increased similarly within the past 50 years. The incidence of these eating disorders has been estimated to be approximately 7% of male adolescents and 13% of female adolescents. Strong correlates of these food-restrictive eating disorders include overweight status, low self-esteem, depression, suicidal ideation, and substance use. Key screening questions for disordered eating Questions for parents:
•Are you concerned about your child's weight?
•Does your son or daughter make negative comments about his or her body or weight?
Questions for children and youth:
•Are you concerned about your weight?
•Do you eat breakfast every day?
Questions from the GAPS (AMA, 1994) (available on the Web as downloadable, noncopyrighted forms [www.ama-assn.org/ama/pub/category/2280.html] in both English and Spanish): For the younger adolescent:
•Do you spend a lot of time thinking about ways to be skinny?
•Do you do things to lose weight (eg, skip meals, take pills, starve yourself, vomit, etc)?
•Do you work, play, or exercise to make you sweat or breathe hard at least three times a week?
For the middle to older adolescent:
•Are you satisfied with your eating habits?
•Do you ever eat in secret?
•Do you spend a lot of time thinking about ways to be thin?
•In the past year, have you tried to lose weight or control your weight by vomiting, taking diet pills or laxatives, or starving yourself?
•Do you exercise or participate in sports activities that make you sweat and breathe hard for 20 minutes or more at a time at least three times during the week?
The parent GAPS The parent GAPS form has a series of check-off boxes about which concerns parents have for their adolescent, including “weight,” “diet/nutrition,” “amount of physical activity,” as well as related issues, such as “self-image or self-worth,” “change of appetite,” and “physical development.” Nontraditional opportunities for screening Nutritionists, coaches, all school personnel (day care, after-school, teachers, guidance counselors, and nurses), obstetrics and gynecology practitioners, and youth groups such as Boy Scouts and Girl Scouts (the idea of earning a “KySS badge” was discussed as a means of highlighting the KySS campaign) all could provide screening. Of all of these options, the school nurse probably has the greatest likelihood of being able to identify longitudinal growth chart information (height and weight change over time) that could be recorded on growth curves available from the CDC (http://www.cdc.gov/growthcharts/) and flagged when the body mass index changes in a pattern that indicates need for further intervention (excessive increase or decrease into the low range). Evidence-based interventions for disordered eating, including obesity No evidence-based interventions for disordered eating were identified for use in primary care settings. Community-based and school-based interventions exist but are not particularly user-friendly. Very few evidence-based interventions exist for children or adolescents; those for adults show limited, if any, support for the effectiveness of such interventions with respect to counseling regarding either nutrition (http://www.ahcpr.gov/clinic/3rduspstf/diet/dietsum.htm) or physical activity (http://www.ahcpr.gov/clinic/3rduspstf/physactivity/physsum.htm). There should be a link between nutrition and physical activity in any intervention that is designed. The focus should be on life-long, healthy habits, not the avoidance of either obesity or eating disorders. Some evidence exists to support cognitive-behavioral and interpersonal therapy for persons with anorexia and bulimia. Further research needs Descriptive correlational studies are needed to determine the nature of the following relationships: (a) physical activity and educational outcomes, and (b) consumption of breakfast and eating disorders. Randomized controlled trials to determine effects of primary care interventions on outcomes are urgently needed. In addition, the effects of using Web-based tools, such as computerized questionnaires and interventions, on outcomes should be studied. Research also could be based in popular magazines read by youth, but Web-based. Faith-based approaches to identify cultural issues that might be better approached through nontraditional venues, especially for Black families, for which the church may be a central focus, are needed. All interventions will need to be culturally sensitive. Health promotion dissemination strategies Professional organizations affiliated with KySS, as well as others, such as those for nutritionists, school nurses, and coaches, could be key in dissemination strategies. In addition, other routes of dissemination could be professional meetings representing a wide variety of disciplines, Web-based distance learning, as well as local, state, and federal partnerships. Excellent resources and Web sites for disordered eating include the following:
•Bright Futures in Practice: for Nutrition, Physical Activity, and Mental Health (http://www.brightfutures.org)
•American Academy of Pediatrics (http://www.aap.org/)
•Centers for Disease Control and Prevention (http://www.cdc.gov/growthcharts/)
•Facts for Families, the American Academy of Child and Adolescent Psychiatry (http://www.aacap.org)
•GAPS (http://www.ama-assn.org/ama/pub/category/2280.html)
•Society for Adolescent Medicine (http://www.adolescenthealth.org/)
Injury prevention: Task force summary and recommendations Task force chair and author for this section: Dr Michelle A. Beauchesne Background/significance Instead of disease and pathology, unintentional injuries are now the leading cause of death and disability among children and young adults (US Preventive Services Task Force, 2003). Unintentional injuries account for 60% of all adolescent injuries, with violence responsible for the remaining 40% (Potter, 2003). Motor vehicle accidents remain the leading cause of death for children and young adults younger than 24 years. The risk varies with age, with the highest incidence in adolescents (National Highway Traffic Safety Administration [NHTSA], 1999). Injuries kill more adolescents than all diseases combined (CDC, 2002). Every year, 4.5 million children younger than 14 years are seen in the emergency department for injuries, including poisonings and falls, sustained in their homes (CDC, 2002). In addition, an estimated 3.5 million children younger than 15 years sustain sports/recreational injuries each year (Disaster Center, 2001). Rainer (2001) reports that 100,000 to 200,000 head injuries occur each year, with the incidence peaking in early childhood and again in mid to late adolescence. As a result, Healthy People 2010 calls upon health professionals to reduce these risks and promote healthier and safer lifestyles. Accidents and injuries frequently occur because parents or caregivers are not aware of their child's capabilities. Parents need more education on developmental milestones. Anticipatory guidance practices are built on the premise that parents and caregivers are better able to plan and prepare for the next stage of their child's development if they are provided with information beforehand. This information assists them in anticipating what risks their child will encounter in the coming months. Parents need to understand the greatest risk to their children's lives is injury, although all children are at risk some are more at risk than others. The key is to help parents understand their child's development and to match the child's developmental stage with appropriate supervision. Key screening questions for injuries Questions for parents:
•Do you know where your child is? Where does your child spend time?
•Who is watching your child?
•Who gives you help watching your child?
•What do you think your child should be doing developmentally?
•Do you talk about safety with your child?
Questions for children/youth:
•Who watches you when your parents are not home?
•Are you comfortable caring for yourself?
•What do you like to do? Is there anything your friends can do that you would like to be able to do also?
•What things do you do to keep yourself safe (for example, do you wear seat belts in the car and a helmet when bike riding)?
Available screening tools for injuries Many appropriate primary-screening tools exist. Therefore, the focus should be on increasing the consistency and quality of screening in practice. Screening tools include the following:
•Bright Futures (http://www.brightfutures.org)
•GAPS (AMA, 1994) (http://www.ama-assn.org/ama/pub/category/2280.html)
•Ages and Stages Questionnaire (http://www.dbpeds.org)
Nontraditional opportunities for screening Everywhere children spend their time should be considered as a potential venue for screening, including play groups, churches, emergency departments, day-care facilities, playgrounds, schools, gymnasiums, and athletic centers or fields. Evidence-based interventions for injury prevention No evidence-based interventions were identified; however, user-safety campaigns have been successful, such as for use of seat belts, helmets, and car seats. Further research needs Studies are needed that investigate the relationship between children who start fires with maternal depression, substance abuse, at-risk families, and alcoholism. The relationship between injuries and child, as well as parent mental health issues, specifically suicide, also should be studied. In addition, patterns of injuries as well as systems failures should be described. Health promotion dissemination strategies Everyone who cares for children and teens should be educated about injury prevention, including parents, grandparents, child care providers, teachers and counselors, coaches/trainers/equipment managers, Boy Scout and Girl Scout leaders, school nurses, and peers. A public health model similar to that used in the immunization campaign should be used for dissemination. National media campaigns (eg, public television and Nickelodeon) on hazard assessment and education should be implemented, and a simple composite list of resources that can be Web-based should be developed with the opportunity to delve deeper as needed. Educating the public in recognizing that the Internet is the latest safety threat to children and teens is critical. Train-the-trainer workshops would be an excellent avenue for dissemination. Creative and entertaining measures, such as Youth Expression Theater-Vignettes and Literary program-readiness program, also should be considered. In addition, mentor/peer mediation/role model programs within schools should be developed in which older children and adults are used as role models and trainers (eg, Big Brother/Rites of Passage programs/Intergenerational models). Finally, it will be important to partner with public health, police, schools, churches, and other community resources as well to create culturally competent materials and address gender issues/sexuality issues/specific injuries. Excellent resources and Web sites for injury prevention include the following:
•Children Safety Network (CSN), National Injury and Violence Prevention Resource Center (http://www.childrenssafetynetwork.org)
•The Injury Prevention Program (TIPPS), AAP (2001) (http://www.aap.org)
•Put Prevention In Practice Program (PPIP), US Preventive Services Task Force (2003) (http://www.ahcpr.gov)
•Healthy Child Care Campaign: National Health and Safety Standards Guidelines for Out of Home Child Care (http://www.childrenssafetynetwork.org)
•National Safekids Campaign (2001) (http://www.safekids.org)
•KIDSAFE (http://www.kidsafe.org)
•Lowe's Home Safety Council (http://www.loweshomesafety.org)
Parenting and marital transitions/family conflict: Task force summary and recommendations Chairs and authors for this section are Dr Elizabeth Hawkins-Walsh, Dr Neil Herendeen, Dr Bernadette Melnyk, and Dr Linda Alpert-Gillis. The quality of parenting, as well as the mental health/emotional state of parents, are key factors in predicting child outcomes (Melnyk & Alpert-Gillis, 1997). However, parents today are faced with a multitude of stressors that create barriers to optimal functioning and mental health (eg, balancing work and family life, inadequate access to mental health services, and lack of family support systems). In addition, single parenting and separated/divorced/remarried family situations have become more the norm than the rarity, which place children at risk for adverse mental and physical health outcomes. Therefore, there is an urgent need for pediatric health care providers to place a heavy focus on parent screening and education during routine well-child care. Each well-child visit should be used as an occasion to “orient” parents to the true purpose of well child care and to the importance of attending to both mental and physical well being in these visits (Green, 1994). Asking direct questions about the child's emotional and behavioral functioning, as well as questions about parenting satisfaction and parenting challenges, may assist in the screening and diagnosis of mental health problems and convey to parents the clinician's interest in these domains. Repeated studies conducted during the past 50 years have demonstrated that between 25% and 70% of all the questions that parents have for pediatric health care providers concern child behavior (Blum, 1950; Deischer, Engel, Spielholz, & Standfast, 1965; Hickson, Altemeier, & O'Connor, 1983). Therefore, it is of particular concern that the KySS national survey, along with other recent studies, have begun to raise doubts about continuing confidence among parents today that pediatric primary care providers are interested in and knowledgeable about their child's behavior, and more importantly, have the time to talk to them about it (Garrison et al., 1992; Hawkins-Walsh, 1999; Melnyk, Feinstein, Tuttle, et al., 2002). At the very point in time that behavioral problems are assuming a greater role in the health and well-being of youth, the position of the pediatric health care provider as counselor and advisor to parents may be threatened. The 21st century must bring dramatic changes in the ways that pediatric providers support and attend to parenting stress and concerns about child behavior. Key screening questions for parenting/marital transitions Questions for parents:
•What is the easiest part about being your child's parent? What is the hardest?
•What worries you most about your relationship with your child?
•Have there been any changes in your family in the past year (eg, separation/divorce, remarriage?)
•On a scale of 0 to 10, how stressed are you on a day-to-day basis? How depressed?
Questions for children/youth:
•If you were a teacher, what grade would you give your mother (father) on being a parent?
•On a scale of 0 to 10, how good do you feel about your relationship with your parent(s)?
•On a scale of 0 to 10, how much arguing/fighting goes on in your home?
•Have there been any changes in your family in the past year?
Available screening tools for parenting and marital transitions Use of one of the growing number of available brief, psychosocial screening tools should be incorporated into well-child visits. An example is The Pediatric Symptom Checklist (Jellinek & Murphy, 1990), a valid and reliable screening questionnaire that can be completed by parents and youth in the waiting room. This tool has been examined in a large number of studies with heterogeneous samples with good replication and ability to identify children in need of further evaluation. The Parenting Stress Index is a valid and reliable measure to assess the amount of stress being experienced in the parenting role (Reitman, Currier, & Stickle, 2002). In addition, given that parental depression and anxiety are known to have a negative impact on children, screening tools that tap these outcomes (eg, the State Anxiety Inventory by Spielberger, Gorsuch, & Luschene, 1977, and the Beck Depression Inventory, 1996) should be used routinely in primary care settings.
Nontraditional opportunities for screening Day-care centers are an outstanding and highly underutilized avenue for screening parents for potential difficulties. In addition, because more than half of women are now working outside of the home, corporate set-tings are another venue in which screening could be accomplished. Churches and other faith-based groups would be another opportunity to conduct screening. Evidence-based interventions for parenting and marital transitions Pediatric clinicians need to be better aware of some of the existing interventions already available to them and perhaps underutilized: (a) the Creating Opportunities for Parent Empowerment (COPE) programs for parents of young children experiencing marital separation and divorce (Melnyk & Alpert-Gillis, 1997); low birth weight premature infants (Melnyk, Alpert-Gillis, Feinstein et al., 2001); and children experiencing hospitalization and critical illness (Melnyk, Alpert-Gillis, Hensel, Cable-Billing, & Rubenstein, 1997); (b) home visitation programs by nurses, which have been shown to reduce risk of abuse and neglect and to improve parent child communication and enhance child development (Kitzman et al., 2000); (c) parent effectiveness training groups and early interventions to improve parent competence in handling difficult behaviors; which have shown improved behavioral outcomes and school performance (Gross & Grady, 2002; Webster-Stratton & Taylor, 2001) and (d) INSIGHTS into Children's Temperament, an evidence-based program that teaches parents about their children's unique temperament styles and how to best support them (McClowery, 2002). The effectiveness of providing well child care in groups also has been supported as efficient and desirable by many parents. This format may be particularly successful with young parents, or those who are less confident in discussing parenting practices with providers from different sociocultural groups (Dodds, Nicholson, Muse, & Osborn, 1993). Further research needs There is an urgent need to develop and test brief preventive and early parenting interventions that can be delivered within primary care settings, especially for families at high risk for adverse outcomes (eg, those experiencing family conflict and transition and those who have children showing early behavioral problems). Given that the recent KySS national survey indicated that the top worries for school-aged children/teens and parents were how to cope with stressful things, anxiety, depression, and their parent-child relationships, primary care intervention studies that facilitate communication and assist parents in helping their children to cope with developmental stressors also are greatly needed. Health promotion dissemination strategies In addition to primary care sites, alternative care settings may offer better avenues for delivering pediatric care and promoting the health of children and parents. As children spend less time in the home and receive more “parenting” by surrogates, providers must reach out to nonparental caregivers in schools and day care settings as well as use these sites to deliver health promotion interventions. Because the majority of parents are now employed, corporate settings would be an outstanding arena in which to implement health promotion strategies. Excellent resources and Web sites for parenting and family transitions include the following:
•Adventures in parenting. How responding, preventing, monitoring, mentoring, and modeling can help you be a successful parent. National Institutes of Health: National Institute of Child Health and Human Development (NICHD). This parenting resource, released on January 23, 2002, incorporates three decades of research on effective parenting techniques and healthy development. It can be downloaded for free at http://www.nichd.nih.gov/ or can be obtained free by calling the NICHD Information Resource Center at 1-800-370-2943.
•Bright Futures Center for Education in Child Growth and Development, Behavior and Adolescent Health (http://www.pedicases.org)
•Bright Futures in Practice: Mental Health (Jellinek, 2002). This document can be downloaded at http://www.brightfutures.org/mentalhealth/
•Creating opportunities for parent empowerment (COPE): Evidence-based programs for parents with children experiencing marital separation and divorce, hospitalization, critical illness, and those experiencing the birth of a premature infant. Rochester, New York: The University of Rochester Medical Center. Copies can be obtained from Bernadette_Melnyk@urmc.rochester.edu or by calling (585) 275-8903.
•Parent Soup. Parent Soup is an online resource that provides parents with information on topics from A to Z, including what to expect in their children's development at every age, including the teen years (http://www.parentsoup.com/)
Building resilience in youth: Task force summary and recommendations Task force chair and author for this section: Dr Judith Vessey Background/significance Resilience refers to children's ability to successfully mature in healthy ways despite psychological stressors, adverse social situations, or physical limitations. It is dependent on healthy coping abilities. Resilience is influenced by inborn factors, including gender and temperament. However, the development of resilience is a dynamic process that is fostered by a nexus of protective factors. Individual, familial, school, and community protective factors are known to promote resiliency. Individual protective factors include but are not limited to: (a) an accurate and positive self-appraisal (eg, self-esteem, body image, and skill sets); (b) internalized positive values (eg, empathy and honesty); (c) good social/coping skills and a positive peer group; (d) good communication, critical thinking, and problem-solving abilities; (e) scholastic competence; (f) school connectedness; (g) the ability to accept responsibility for one's actions; and (h) a belief in a positive future. Familial protective factors include but are not limited to: (a) caring, supportive relationships with parents and other family members; (b) positive role modeling; (c) parental involvement in their children's activities; (d) religiosity; (e) opportunities to develop appropriate levels of independence; (f) access to and discussion of divergent viewpoints; (g) engendering trust; and (h) clear behavioral boundaries and consequences. Community and school factors include but are not limited to: (a) a quality education; (b) supportive community infrastructure (eg, physical resources and meaningful recreational programs); (c) effective prevention policies; (d) positive and clearly articulated behavioral norms; and (e) opportunities to develop new skills and increase self-confidence. In addition, national, state, and local policies and legislation need to support youth-oriented programs designed to help strengthen youths' developmental assets. There is a substantive literature on what comprises resilience. Key screening questions for resilience Questions for parents:
•How does your child handle stress?
•What are your “family rules,” and how do you discipline?
•What are your most, and least, favorite times with your child?
Questions for children and youth:
•Please tell me about your best friends and what you like and dislike about school.
•When things go wrong (eg, bad grades, family disagreements, etc), what do you do?
•Are you teased (bullied), and if so, what do you do about it?
•How do you get along with your parents?
Available screening tools for resilience No screening tools have currently been identified. A variety of instruments are available that measure an aspect of resiliency (eg, self-concept), but most are not very amenable to the primary care setting. Nontraditional opportunities for screening A variety of professional, lay, and volunteer personnel interface with youth in formal and informal settings. These persons include but are not limited to school nurses and counselors, coaches, and youth group leaders. All have opportunities to promote the development of resilience in youth. Formal screening to identify at-risk youth, however, may be more difficult. Of concern is that the most vulnerable of youth are likely to have the least contact with individuals in nonprofessional settings (eg, intramural activities and faith-based groups). Evidence-based interventions for resilience There is accumulating evidence to support that children and teens with protective factors (eg, good self-esteem and coping skills and connectedness to parents or another adult) have less negative mental health outcomes than those without those factors. Therefore, any activity that will help boost a child's “protective factors” should lead to better outcomes and less risk-taking behaviors (eg, participation in sports or clubs, families eating dinner together, tutoring when academic difficulty occurs, and attending church, synagogue, or mosque). Further research needs Intervention studies need to be conducted on the promotion of protective factors that are known to create resiliency in both primary care and alternative care settings. Studies that test brief interventions for children who experience traumatic events (eg, divorce, death of a family member, onset of a chronic condition, terrorism, etc.) are needed. Health promotion dissemination strategies A number of associations and groups can help disseminate information on resiliency, including KySS and professional organizations affiliated with KySS; school counseling, social work, and administrative personnel; vetted Web sites and Web-based learning; partnerships with local, state, and federal governmental organizations (eg, Health Resources and Services Administration, Maternal and Child Health Bureau, and Centers for Disease Conrol and Prevention, Division of Adolescent and School Health); and partnerships with nongovernmental organizations (eg, Girl Scouts and Boy Scouts), foundations (eg, Annie E. Casey Foundation, W.T. Grant Foundation), and faith-based organizations. Excellent resources and Web sites for resiliency include the following:
•American Psychological Association (http://www.helping.apa.org/resilience)
•ERIC Clearinghouse and other organizations (http://www.resilnet.uiuc.edu)
•Search Institute (http://www.search-institute.org)
•Girl Power (http://www.girlpower.gov/girlarea) (for girls 9 to 14 years of age)
Adolescent sexuality: Task force summary and recommendations Task force chair and author for this section: Dr Carol Roye Background/significance Unprotected sexual activity, sexual activity while very young, adolescent pregnancies, dating violence, and bisexual and homosexual activity cause substantial physical and psychosocial morbidity among adolescents in the United States. Each year, almost 1 million teenagers, 11% of all young women aged 15 to 19 years, become pregnant, with 78% to 85% of the pregnancies unplanned (Alan Guttmacher Institute [AGI], 2000). The rate of teen pregnancy is notably higher among Black and Hispanic teens (Donovan, 1998). Teen mothers also are especially likely to experience depression and social isolation and drop out of school, leading to long-term poverty (Furstenberg, Brooks-Gunn, & Morgan, 1987). Young people who are lesbian, gay, bisexual, or transgendered (ie, sexual minority youth) also experience considerable psychological morbidity. Studies have demonstrated that suicidal intent and suicide attempts are significantly higher among adolescents who are homosexual or bisexual (Russell & Joyner, 2001). Dating violence and date rape also have come to light as serious threats to adolescent women's health (Rickert, Vaughan, & Wiemann, 2002). These crimes result in a number of medical and mental health consequences, including eating disorders, notably purging and use of diet pills (Thompson, Wonderlich, Crosby, & Mitchell, 2001). Key screening questions Questions for parents:
•How comfortable are you in talking with your teen about sexuality?
•Are you worried about your teen becoming or being sexually active?
Because of confidentiality issues (and laws), primary care providers should not discuss the adolescent sexual behaviors with parents. Instead, providers can open a discussion of sexual development and sexual risk behaviors with the parent and child to begin a dialogue between the two. Questions for youth:
•Are you having sex? (defining oral, anal and vaginal sex)
•Some people are attracted to guys, some to girls, some to both. What about you?
•Has anyone ever forced you to have sex?
•Are you using anything to prevent infections or pregnancy?
Available screening tools for sexuality The GAPS questionnaire (AMA, 1994) is a screening tool for sexuality. Nontraditional opportunities for screening Unlike depression or eating disorders, sexuality is a normal part of life. It also is very sensitive, which makes screening for sexual issues very challenging and difficult to accomplish in a community-based site. However, one nontraditional opportunity is the sports or working paper physical examination. These examinations may be the only reason that some teens come to a health care provider for care. Although the provider may concentrate on assessing the young person for rule-out conditions, this is an important time and may be the only time to screen for issues relating to sexuality. Evidence-based interventions for sexuality Whereas many interventions have been shown to be effective at promoting healthier sexual behaviors, none are user-friendly. A randomized clinical trial of a video intervention to promote condom use by adolescents who use a hormonal contraceptive is currently being conducted (Roye & Hudson, 2003). Additionally, a 4-week session group intervention to reduce adolescent sexual risk-taking behaviors through information/motivation/behavior change strategies is beginning to show promising outcomes (Morrison-Beedy, Carey, Aronowitz, Mkandawire, & Dyne, 2002). Evidence also exists that peer educators are effective in reducing sexual risk-taking behaviors (Aten, Siegel, Enaharo, & Auinger, 2002). Further research needs The following question should be answered: How brief can an intervention be and still be effective? If “brief” does not work well in primary care settings, how can we alter primary care settings to allow more time for counseling and education? Epidemiologic studies of changes in pregnancy and sexually transmitted infection rates are needed as funding is shifted away from effective programs (political doctrine, abstinence-only funding). Studies are needed to determine what works when, for whom, does one size fit all? Also, studies are needed to examine the length of well-child visits and sexuality assessment (eg, does more time lead to better assessment?). Health promotion dissemination strategies The following strategies can be used to disseminate information about adolescent sexuality: celebrity public service announcements, television programming with healthy messages about sexuality, a Web site for parents, children, and providers with information and screening tools, and working with school personnel. The CDC Web site, an excellent resource for sexuality, has a variety of health topics related to teen pregnancy, reproductive health, and sexually transmitted diseases (http://www.cdc.gov/health/adolescent.htm). Substance abuse: Task force summary and recommendations4 Chairs and authors for this section are Dr Carol Loveland-Cherry and Dr Jane Tuttle Background/significance The use of alcohol, tobacco, and marijuana remain considerably higher than the Healthy People 2010 targets, and new concerns are emerging about “club” or “designer” drugs (US Public Health Service, 1998; USDHHS, 2000a). According to the Youth Risk Behavior Survey (CDC, 1998; 1999), 52% of high school students reported using alcohol in the past month and 33% were involved in binge drinking. One quarter admitted to using marijuana in the preceding month, and 20% reported a history of inhaling intoxicating substances. Approximately one in four children younger than 18 years are exposed to alcohol abuse in their families (Grant, 2000). Adolescent children of substance abusing parents appear to experience more problem behaviors as measured by the Youth Self Report form of the Child Behavior Checklist (YSR-CBC) (Achenbach & Edelbrock, 1983) when compared with peers, particularly males and urban dwelling teens (Gross & McCaul, 1990-91). Strategies to prevent adolescent substance use and abuse must begin early in childhood (Tweed, 1998). Because evidence has supported that parents introduce important risk and protective factors for the development of adolescent substance use and abuse (Loveland-Cherry, 1999), health care providers need to provide ongoing anticipatory guidance and counseling on parenting effectiveness strategies from a very early age in children's development. Key screening questions for substance use Questions for parents:
•What are your family's norms/values/beliefs about alcohol and other drug use?
•Are you worried about your child and drug or alcohol use?
Questions for children/youth:
•Do you know friends who have drug problems?
•What do you think about alcohol and other drug use?
•What does your family think about smoking, alcohol, and other drug use?
•When is the first time you smoked, drank alcohol, or tried drugs?
•Have you ever tried to cut down on your use of drugs and/or alcohol?
Available screening tools for substance use Most existing screening instruments are designed to identify alcohol problems in adults (eg, the Michigan Alcohol Screening Test). The AMA's GAPS (1999) self-report questionnaires are increasingly being used in primary care settings and have several questions about personal and family alcohol and other drug use and consequences. The Task Force recommends that the use of GAPS questionnaires for 12- to 21-year-olds be encouraged in primary care practices. Nontraditional opportunities for screening School health programs, including school-based health centers, have a vital role in screening adolescents for a variety of problems. Preschool programs such as Head Start, Early Intervention, and day care programs may be places where early parenting concerns are identified. Evidence-based interventions for substance use Evidence suggests that authoritative parenting, which involves consistent limit-setting and discipline combined with love, warmth, and involvement, is correlated with fewer high-risk behaviors in adolescence compared with permissive (Melnyk & Alpert-Gillis, 1997; Melnyk, Feinstein, Moldenhauer, & Small, 2001), authoritarian (National Institute on Drug Abuse, 1997), or inconsistent styles of parenting (Brook, Whiteman, Brook, Gordon, & Whiteman, 1990). Therefore, during well-child supervision visits as early as the toddler and preschool years, style of parenting should be assessed and teaching should be conducted regarding effective parenting strategies. Counseling during early childhood also should focus on diminishing family stress levels and conflict if assessment reveals a problem in this area. In a family in which there is a high level of stress and conflict or dysfunction as the result of mental health problems, children are at high risk for alcohol use or abuse. Making appropriate referrals for the family is an important step in preventing alcohol use and other mental health problems in children during their later years. Further research needs How some of the screening and intervention techniques designed for adults work with adolescents is a critical question. In addition, more data about culturally appropriate brief screening instruments and interventions for adolescents from other cultural backgrounds are needed. Health promotion dissemination strategies Parents of young children should be taught techniques for building their children's self-esteem and competence as well as problem-solving, coping, and social skills (Loveland-Cherry, 1999). Parents should be advised that teens who are able to communicate freely with their parents and who feel emotionally connected to them are less likely to engage in alcohol use and other risk-taking behaviors (Hawkins, Catalano, & Miller, 1992). In addition, parents should be counseled to stay involved in their teen's life, build a stronger relationship with him or her, and communicate directly about the risks of substance abuse. If a parent's relationship has not been good with his or her teen, reassuring the parent that it is never too late to overcome conflicts will provide renewed hope and encouragement to take steps in rebuilding their relationship. Referrals for family therapy or individual counseling may be in order. Excellent resources and Web sites for substance use include the following:
•The Substance Abuse and Mental Health Services Administration (SAMHSA) (http://www.health.org)
•Strengthening America's Families: Model Family Programs for Substance and Delinquency Prevention (http://www.strengtheningfamilies.org)
•National Institutes of Health/National Institute on Alcohol Abuse and Alcoholism (http://www.niaa.nih.gov/publications/children)
Violence prevention/bioterrorism: Task force summary & recommendations Chairs and authors for this section are Dr Lisa Bernardo and Dr Tener Veenema. Background/significance Violence is a crucial public health issue in America. Violence permeates society, through individuals, families, and communities. On a global scale, violence erupts as war, terrorism, and other atrocities. Individual exposure to and participation in violence occurs at young ages, beginning with parental discipline practices. Parental discipline leading to physical and psychological wounds and injuries is corporal punishment. In youth, violence manifests in behavior directed inward (eg, suicide, disordered eating, and drug or alcohol use) or outward (eg, homicide, bullying, date rape, and animal cruelty). Drive-by shootings, gang conflicts, prostitution, and other violent activities flourish in some communities. Schools are not immune to acts of violence, with bullying and shootings being reported with greater frequency. In response to incidents of violence in schools, the vast majority of schools have plans for evacuation, lock-down, and sheltering in place should a perpetrator enter the school or be in a close proximity to the school. World events, such as the September 11, 2001, attacks, threats of bioterrorism, and violence in the Middle East and other countries, can evoke feelings of fear and a lack of safety and security among children and families, leaving youth and families feeling vulnerable in their own communities.
Natural and human-made disasters strike without warning as well, with some communities better prepared than others for hurricanes, heavy snowfalls, and other weather-related events. Key screening questions Questions for parents:
•What discipline methods do you use for your child?
•Do you have guns in the home?
•Have there been stressful events your family is dealing with recently?
Questions for children and youth:
•What do you do when you get angry?
•Has anyone done anything to you that you didn't want them to do or that you didn't like?
•Do you feel safe (ie, at home, at school, in your community)?
•How have the events of the world affected your family?
Available screening tools for violence Available screening tools for violence include the following:
•Age-appropriate measures and tools for identifying posttraumatic stress disorder (PTSD)
Nontraditional opportunities for screening There are three nontraditional opportunities for screening for violence and bioterrorism. One opportunity is self-screening for the effects of violence. Such screening includes public service announcements through the media, such as television, radio, and public transportation. A second opportunity is through community shelters, such as women's shelters or shelters for homeless people. Many of the people who use these facilities have experienced violence first-hand, either as perpetrators or victims. A third opportunity is through venues where children are the predominant population, such as schools, day-care centers, and camps. Evidence-based interventions for violence prevention Acknowledging that violence is a problem for children and families is the first step in selecting age-appropriate interventions to address violence. There are a plethora of “home grown” programs enacted by school districts, camps, and other children-focused venues that promote anger management and “bully proofing” schools. Two organized efforts are Bright Futures (http://www.brightfutures.org) and conflict resolution programs such as Positive Adolescent Choices Training (PACT, http://www.ncef.org/pact.htm) and Second Step (http://www.cfchildren.org/program_ss.htm). Further research needs Research is needed to create evidence-based practice guidelines for preventing violence in children, families, and society. Population-based, randomized controlled clinical trials and longitudinal studies are typically rigorous enough to yield meaningful results. Interdisciplinary teams, including psychologists, veterinarians, children, and families, strengthen research programs by respecting and including the expertise of all involved. Research is needed in the treatment of children following exposure to radiologic, biologic, and chemical agents. Bench research or computer-generated research is probably the strongest research method to address these needs. Health promotion dissemination strategies Strategies to prevent violence/bioterrorism must be incorporated into current academic curricula for all health care professionals. Health care professionals need to learn how to recognize, treat, and monitor children exposed to radiologic, biologic, and chemical agents. Once this formal education is accomplished, professionals will require ongoing professional training conferences to keep up to date on effective strategies for recognizing, treating, and preventing violence and bioterrorism in children and families. Training should incorporate specific needs of children with chronic illness and those dependent on medical technology. Excellent resources and Web sites for violence and bioterrorism include the following: Federal:
•Office of Homeland Security (http://www.ready.gov)
•CDC (http://www.cdc.gov)
•Federal Emergency Management Agency (http://www.fema.gov) (http://www.femakids.gov is pediatric specific)
•Emergency Medical Services for Children (http://www.ems-c.org)
•National Institute of Mental Health (http://www.nimh.nih.gov)
•Maternal Child Health Bureau (http://www.mchb.gov)
Professional Organizations/Other:
•American Academy of Child & Adolescent Psychiatry (http://www.aacap.org)
•AAP (http://www.aap.org)
•National Center for Post Traumatic Stress Disorder (http://www.ncptsd.org)
•Association of Maternal and Child Health Programs (http://www.amchp.org)
•America in Grief, Sigma Theta Tau International (http://www.nursingsociety.org)
•Johnson & Johnson Pediatric Institute, LLC (http://www.jjpi.com)
Outcomes of the KySS Summit with implementation strategies The energy and enthusiasm generated at the KySS Summit was palpable. In addition, a major strength of the Summit was the multidisciplinary team approach, which brought a varied and comprehensive perspective to the discussions and strategic planning. A number of implementation strategies that were outlined have been launched in a short period since the KySS Summit was conducted in late March. #1. KySS Institute planned The content for a National KySS Institute on Mental Health Screening, Interventions, and Health Promotion for Primary Care and School Health Providers was planned. It was recognized that didactic content alone is not sufficient to change health care provider screening and intervention practices. Therefore, a critical component of the KySS Institute that will be held in late April 2004 will be interactive sessions that will enhance provider skills in such areas as communication skills, advocacy, and motivational interviewing. In addition to didactic content in screening and management of common mental health problems in the substantive areas that match the KySS task forces, providers will receive resources that will assist them in delivering early and preventive culturally sensitive interventions, including brief counseling techniques and behavior change strategies, in primary care and school health settings. Content also will include appropriate use of diagnostic categories to achieve reimbursement for the evaluation and management of these types of problems as well as psychopharmacology, given the recent upsurge in the use of medications for children with mental health problems. In addition, emphasis will be placed on efficient screening tools, mobilizing available resources (eg, Bright Futures in Practice: Mental Health), case management, and evidence-based practice. Portions of the Institute will be taped for duplication on CD-ROM for widespread dissemination. #2. KySS Train-the-Trainer Portable Continuing Education Program From the KySS Institute, a Train-the-Trainer Program will be developed that can be transported from region to region throughout the United States to enhance the mental health knowledge and skills of pediatric health care providers from multiple disciplines. #3. KySS Online Continuing Education Program Shortly following the KySS Institute, plans are to place the KySS program online for continuing professional multidisciplinary education. #4. KySS Core Curriculum Multidisciplinary experts in each of the task force areas outlined necessary content and behavioral skills for mental health screening, early intervention, and health promotion in their respective areas. Plans are to develop and publish a KySS Core Curriculum that can be used in multidisciplinary professional education programs. In addition, a proposal is currently being developed for an intensive faculty education initiative so that educators will have these needed skills to be more successful in integrating them in their curriculums. Optimizing the mental as well as the physical health care of children by strengthening educational programs as well as offering continuing education was a key recommendation from the recent Future of Pediatric Education Conference held in June of 2003, sponsored by the Macy Foundation. #5. KySS Guide to Mental Health Screening, Early Intervention, and Health Promotion Part I of a KySS Guide to assist pediatric health care providers in the aspects of efficient mental health screening, intervention, and health promotion has been created and is currently being pilot tested with pediatricians and PNPs to further refine it for best practice. Once created, plans are to format the guide to a personal digital assistant (PDA) for more efficient use. #6. KySS Web site A Web site that will serve as a clearinghouse of mental health screening, evidence-based interventions, and health promotion materials for multidisciplinary pediatric providers and families is currently being expanded for this purpose at http://www.napnap.org. Materials and suggested Web links and resources are now available at this Web site for health care providers, parents, teens, and school-aged children. #7. KySS Across America A major national bicycling and walking event to raise funds to establish a KySS Foundation to fuel further KySS initiatives is currently being planned for the summer of 2004. Outreach will occur to all of the KySS collaborating organizations to participate in this event. Not only will this event raise funds for the KySS initiatives, but it will raise awareness of these issues publicly and through the media as well as help to decrease the stigma of mental health problems in children and teens. Emphasis will be placed on intergenerational family participation in the event. #8. KySS Public Awareness Campaign The KySS Across America event will launch a major public awareness campaign throughout the country. Multiple dissemination formats (eg, advertisements, news briefs, posters, videos to be played in primary care practices, and educational handouts) will be used to help raise awareness of mental health problems and decrease their stigma. The media will be targeted as a major collaborator to assist with these public awareness efforts.
#9. KySS Health Policy Initiatives KySS initiatives have now been designated as the number one health policy priority for NAPNAP. Shortly following the KySS Summit, it was learned that there were a few congressmen and senators who were disturbed by the recent GAO report (2003) with the news that more than 12,000 children were placed in the juvenile or foster care systems for the sole purpose of receiving mental health treatment. Therefore, a KySS policy brief was written by Dr Bernadette Melnyk and delivered to senior staffers at these congressional offices by Dr Melnyk and Stacy Harbison, one of NAPNAP's legislative representatives, to assist them with accurate information that could be used in the drafting of a bill to improve mental health access and services. Since this visit, a bill has been drafted by Congressman Kennedy entitled the National Resilience Development Act of 2003. One goal of this bill is to coordinate the efforts in researching, developing, and implementing programs to increase psychological resilience and decrease distress reactions and maladaptive behaviors of Americans, including children, as they relate to terrorism. The KySS Campaign will continue its efforts of placing an emphasis on affecting health policy for improvement in access, funding, and quality of mental health services to children and teens. #10. KySS Evidence-Based Practice and Research Initiatives The KySS Campaign will be placing emphasis on the creation and dissemination of evidence-based interventions to improve child and adolescent mental health outcomes. In addition, plans are to allocate a certain amount of funds from the KySS Foundation to support the development and testing of mental health promotion and early intervention strategies in primary care and alternative care settings. Conclusion We have reached an era in which mental health/psychosocial problems, risk-taking behaviors, and preventable injuries cause more disability and death in children and teens than do physical health problems. As such, there is an urgent need for multiple, large-scale implementation strategies to improve outcomes for affected children and to prevent their continued escalation. The KySS Campaign and recent KySS Summit, an interdisciplinary national effort, has delineated a strategic action plan to confront and minimize these alarming problems. Continued success of the KySS initiatives will be dependent, in large part, on ongoing coordinated multidisciplinary team efforts with persons who possess a passion and commitment to improve child and adolescent mental health outcomes in partnerships with federal agencies and professional organizations, as well as sustained funding.5 Acknowledgements The KySS Summit was a collaborative partnership among NAPNAP, the University of Rochester School of Nursing, the American Academy of Pediatrics (AAP), the Leadership Education in Adolescent Health Program at the University of Rochester, the Monroe County Health Department, and many of the KySS endorsing/supporting organizations. We offer a heartfelt thanks to each of these collaborators. Special thanks to the KySS Summit co-directors and Planning Committee members, the KySS Task Force chairs, and the following for their support/assistance with the KySS initiatives: The NAPNAP Executive Board The NAPNAP Foundation The NAPNAP National Office Staff Upstate New York Chapter of NAPNAP HRSA/Maternal and Child Health Bureau Faculty and Staff, Center for High-Risk Children and Youth, University of Rochester School of Nursing The Center for Research & Evidence-Based Practice and COPE Study Team; University of Rochester School of Nursing KySS Summit Participants NAPNAP Chapter KySS Survey Coordinators All NAPNAP Members who assisted with the KySS survey Lowe's Home Safety Council Johnson & Johnson Pediatric Institute, LLC Pfizer, Inc. Pediatric Nurse Practitioner Class of 2003, University of Rochester School of Nursing Tiffany Abbey Margaret Brady, PhD, RN, CPNP Joe Casey Janet Banks, PhD, RN, CPNP Patricia Chiverton, EdD, RN, FNAP Eric Escobar Nancy Fischbeck Feinstein, PhD, RN-C Mary Margaret Gottesman, PhD, RN, CPNP Barbara Hawthorne Barbara Kelly, PhD, RN, CPNP Andrea Lennon, MS Madelyn McMurtrie, MS, RN, CPNP Michael Namarato Bobbie Crew Nelms, PhD, RN, CPNP Elaine O'Leary, MS, CPNP Richard Ricciardi, MSN, CPNP Kate Phillips David Satcher, MD, PhD Pamela Sawdey, BS Jay Stein, MD Joan Timian Claudia Williams References *.
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☆ Sponsored by the National Association of Pediatric Nurse Practitioners, the Health Resources and Services Administration/Maternal and Child Health Bureau, Pfizer, Inc, the Center for Research & Evidence-Based Practice, and the Center for High-Risk Children & Youth, University of Rochester School of Nursing, and the Upstate New York Chapter of NAPNAP. ☆☆ Reprint requests: Bernadette Melnyk, University of Rochester School of Nursing, 601 Elmwood Ave, Rochester, NY 14642; Email: Bernadette_Melnyk@urmc.rochester.edu PII: S0891-5245(03)00167-6 doi:10.1016/j.pedhc.2003.08.002 © 2003 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. | 1 of 4  |
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