Steven L. Pastyrnak, PhD, Psychology, Division Chief

Helen DeVos Children's Hospital

Did you catch the special supplement that came with your June issue of Pediatrics? If not, here are the headlines:

• Pediatricians should screen children for possible mental health issues at every doctor visit
• Pediatricians should develop a network of mental-health professionals in the community to whom they can send patients if they suspect a child needs further evaluation

Given that an estimated 21% of US children and adolescents have a diagnosable mental illness, with only one-fifth receiving treatment, I see these recommendations as long overdue. We know that the earlier we intervene in mental health issues, the greater the benefit; screening kids every time you see them provides many more such opportunities for early intervention.

So how do you add one more thing to an office visit?

As with so many things we do, it requires asking the right questions and looking for clues.

For very young children, you'll obviously need to ask the parent or guardian questions about the child, particularly about their recent behavior. Key clues that children may be struggling with anxiety, for instance, include stomach problems, acting out, or becoming withdrawn. Clues to depression include increased irritability and/or lack of interest in activities the child previously enjoyed.

Kids who are acting out are, most likely, expressing an outward clue to an underlying emotional problem. For instance, if a child is bullying a sibling, he may be getting bullied himself at school.

One way to get at issues with older children is to ask if they are feeling happy, mad, sad, or scared. Even adolescents will give you a specific answer to this question, which helps them categorize how they're feeling. This then opens the door for more discussion.

It is also important to recognize that anxiety and depression in children do not necessarily manifest the same as in adult. A depressed child may not be sad, but irritable and angry. A child who appears withdrawn or, as noted earlier, is acting out may have some anxiety issues.

If you suspect depression, it is also important that you assess suicidality. Just ask the question: "Have you thought about hurting yourself?" Kids are generally inclined to give an honest answer. And the question will not make the child think about suicide; we have years of data showing that asking about suicide doesn't trigger the act.

In many instances, you may be able to assess and treat the child yourself. But if you feel that the child's condition is creating a dysfunction in their life, such as affecting school performance and friendships, or if you simply don't feel comfortable dealing with such issues, you should refer.

Check out the June supplement. It includes an algorithm for assessment; sources for specialty services; and an overview of evidence-based interventions. There is even an article on proper coding for the mental health algorithm.

You might also be interested in this recent article from the Wall Street Journal about the issue of mental health problems in adolescents.

How do you screen your kids for mental health issues? What questions do you have for me on this topic?

Steven L. Pastyrnak, PhD, is the division chief of psychology services at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

Daniel McGee, MD
Pediatric Hospitalist, Helen DeVos Children's Hospital

Just in time for summer, the American Academy of Pediatrics announced new guidelines related to swimming lessons. The headline: Swimming lessons for children between ages 1 and 4 are now recommended. Previously, the AAP discouraged teaching children under 4 to swim.

I say it's about time. As the father of two children, both of whom were competitive swimmers (one of my sons was swimming competitively at age 4) I've seen firsthand the benefits of teaching children early to swim. But don't go by my anecdotal evidence; consider the same evidence the AAP Committee on Injury, Violence and Poison Prevention reviewed in making its recommendation. Namely, that better swimming ability is associated with a reduced risk of drowning (citations below).

While your patients' parents have likely heard about the new guidelines (they received wide distribution on TV, in print, and on the Internet) make sure they understand that swimming lessons is no substitute for good parenting. Remind them of other precautions they should take, including:

• Install a four-foot high, locked fence around all pools, even above-ground pools and large inflatable pools that remain filled. Studies find such fences can slash the number of pool-related drownings and other injuries by more than half. Although pool alarms are helpful, they are not a substitute for supervising your child or for a full barrier around the poo, neither are pool covers.
• Remove all containers of standing water. A child can drown in as little as 2 inches of water. We recently had a 20-month-old stick his head in the bucket of water older kids had put out for filling squirt guns.
• Never take your eyes off your child when he/she is swimming, no matter how good a swimmer you think they are. I also don't recommend relying on the lifeguard unless you know what level of training and certification he/she has received.
• Never let children, even teenagers, swim alone.
• Make sure all children in boats wear a flotation device. Ninety percent of boat-related drownings occur in children who did not wear such devices.
• Be particularly vigilant if your child has an underlying medical condition, such as seizure disorder, which can increase the risk of drowning.

Daniel McGee, MD, is a pediatric hospitalist at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

References

Smith GS. Drowning prevention in children: the need for new strategies. Inj Prev. 1995; 1(4):216 -217

 Brenner R, Suluja G, Smith GS. Swimming lessons, swimming ability, and the risk of drowning. Inj Control Saf Promot. 2003;10(4):211-216

 Rodgers GB. Factors contributing to child drownings and near-drownings in residential swimming pools. Hum Factors. 1989;31(2):123-132

 Brenner R, Taneja G, Haynie D, et al. The association between swimming lessons and drowning in childhood: a case-control study. Arch Pediatr Adolesc Med. 2009; 163(3):203-210

US Coast Guard. Recreational Boating Statistics 2008. Washington, DC: US Coast Guard; 2009. COMDTPUB P16754.21. Available at: www.safeboatingcampaign.com/

2008_statistics.pdf. Accessed May 13, 2010

Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics. 1993;91(3):612- 616

Kemp AM, Sibert JR. Epilepsy in children and the risk of drowning. Arch Dis Child. 1993; 68(5):684-685

Shavelle RM, Strauss DJ, Pickett J. Causes of death in autism. J Autism Dev Disord. 2001; 31(6):569 -576