INTRODUCTION

Emotional problems that develop during childhood and adolescence can significantly impact development and may continue into adulthood. In fact, most adult psychiatric disorders involve childhood onset. Many disorders do not present as an all-or-none phenomenon, but rather progress from less severe concerns, such as adjustment problems, to significant disturbances and severe disorders. If opportunities are missed to appropriately identify these disorders, childhood-onset mental health issues are more likely to persist, causing worsening impairment and leading to a downward spiral of school and social difficulties, poor employment opportunities, poverty in adulthood, and increased health care utilization and costs as adults. These outcomes are even more pronounced for children and adolescents from underserved, low socioeconomic backgrounds.¹

Despite this critical need to address these issues there are barriers to access mental health care. An important consideration in children is their dependence on others, primarily parents, to negotiate the system, make appointments, physically transport them, and pay for treatment. Characteristics of the family such as the perceived burden of the child's problems and a family history of mental illness have been shown to have a major impact on a child's chance of receiving needed care in the specialty mental health system.²  A worrisome finding from epidemiological studies of mental health service use is the race/ethnic disparities in access to needed care. A review of the literature found that African American adolescents and Hispanic youths received fewer mental health services than did Caucasian youths.³ A study of rural youths found that African Americans were as likely as Caucasian youths to receive mental health services through schools, juvenile justice, child welfare, or pediatric primary care providers, but were only half as likely to receive care from psychiatrists or psychologists in specialty mental health settings.⁴  

An increase in pharmacologic treatments occurred in the 1990s for two of the most common mental and behavioral health disorders, attention-deficit/hyperactivity disorder (ADHD) and depression, subsequently medication rates for children are now approaching those of adults.¹ The 1996 federal Medical Expenditure Panel Survey showed a 4.1% psychotropic medication rate for 6-17 year olds and a 5.0% rate for 18-44 year olds.⁵ Another study examining private insurance found that there was a 4.3% psychotropic medication rate for 1-17 year olds as compared with 4.7% for adults.⁶ From a pharmacy perspective, this means we will likely be seeing these pediatric patients or their parents in our practice to assist them with their medication needs.

There is no question that many psychiatric disorders impose a huge economic and social burden in terms of disability and public and private expenditures. According to the 2001, 2002, and 2003 National Health Interview Surveys, approximately 5% of U.S. children ages 4-17 years had emotional or behavioral difficulties, and for approximately 80% of these children, there was an impact on their functioning.⁷ Worldwide 10-20% of children and adolescents experience one or more mental disorders.⁸ Nevertheless, only a small proportion of children with clear evidence of a functionally-impairing psychiatric disorder receive treatment.¹ The public health directive to intervene early is clear. The pharmacist and pharmacy technician can play a crucial role not only through education on specific medications but also assist with education of the parents or other family members, screening for mental and behavioral health concerns, and assisting with treatment recommendations. This activity will review prevention and screening for mental and behavioral health disorders and indicate when a referral to a mental health professional is necessary.

PSYCHIATRIC DISORDERS OF CHILDHOOD AND ADOLESCENCE

Although it is sometimes assumed that childhood and adolescence are times of carefree bliss, this is not always the case as children and adolescents may have one or more diagnosable mental disorders. Many of these disorders may be viewed as exaggerations or distortions of normal behaviors and emotions. Whether a child is behaving like a typical child or has a disorder is determined by the presence of impairment and the degree of distress related to the symptoms. There is significant overlap between the symptoms of many disorders and the challenging behaviors and emotions of normal children. Common mental disorders of childhood and adolescence fall into the following categories: anxiety related disorders, mood disorders and obsessive-compulsive disorders. Disruptive behavioral disorders including ADHD, conduct disorder and oppositional defiant disorder are also common. Schizophrenia and related psychotic disorders are much less common in this age group. This section will focus on anxiety, mood and obsessive-compulsive disorders.

Anxiety Disorders

Separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder (or social phobia) are among the most common psychiatric illnesses in children and adolescents.⁹ Anxiety is described as the anticipation of a future threat, and fear is described as the emotional response to a real or perceived imminent threat. Both are protective emotions and part of the normal repertoire of children. Distinguishing developmentally appropriate fears and anxiety from those associated with anxiety disorders can be challenging. Generally, fears or anxiety that persist beyond the expected developmental period or cause significant distress or impairment suggest an anxiety disorder. Studies show that 7.1% of children aged 3-17 years (approximately 4.4 million) have a diagnosis of anxiety and approximately only 59.3% of those with anxiety are receiving treatment.¹⁰ These disorders have an earlier age at onset than other internalizing psychiatric disorders and are associated with significant functional impairment that tends to persist into adulthood.¹¹ The anxiety disorders that present in children and adolescents place them at risk of later anxiety disorders, mood disorders, substance use disorders and disruptive behaviors.¹²

Comorbidity is common with anxiety disorders and children need to be screened for all possible sources related to anxiety. Children with one anxiety disorder are likely to have another anxiety disorder or have an increased risk for other psychiatric disorders such as depression.¹³ Children who are suffering are not always likely to present with the complaint of anxiety but more likely to present with a physical complaint, such as headaches or abdominal pain.¹⁴  Table 1 lists the symptoms correlated with anxiety in this age group. Screening should also assess for medications and substances that can cause anxiety or present similarly. Table 2 lists common medications and other substances that are associated with anxiety. Anxiety symptoms are an inherent part of the initial clinical presentation of several diseases, which complicates the distinction between anxiety disorders and medical disorders. Medical illnesses that can present with symptoms suggestive of anxiety include diabetes, hyperthyroidism, hypoglycemia, hyperkalemia, hyponatremia, hypoxia, seizures, asthma, vitamin B12 or folate deficiencies, and more rarely, pheochromocytoma.¹⁵

Treatment of younger children focuses on helping parents understand their child’s symptoms, developing skills to help their child manage distress, and helping parents tolerate their child’s distress. As soon as children have the developmental capacity to engage in assessing their own anxiety and in learning coping strategies, they are incorporated into therapy. Cognitive behavioral therapy (CBT) with exposure has the most evidence regarding the successful treatment of anxiety. Exposure refers to the planned progressive presentation of low- to midlevel anxiety-provoking stimulus with the aim of desensitizing the child to the stimulus. The goals of therapy include helping children identify anxiety symptoms and maladaptive thought processes while learning cognitive and behavioral coping strategies upon exposure. Parents or caregivers also learn these skills in order to help children practice in settings outside the therapy office.¹⁶ When anxiety symptoms do not remit with cognitive, behavioral, and environmental interventions and continue to significantly affect life functioning, psychopharmacologic agents may be helpful. There is evidence that SSRIs are effective in treating anxiety disorders in children as young as 6 years of age, but these medications do not have FDA approval for this indication.¹³ The anxiolytic effect of SSRIs can take a few days, whereas the effects of benzodiazepines are immediate. The use of benzodiazepines is discouraged with this population because the developing brain is at increased risk for dependency and substance abuse. Antihistamines (ie, hydroxyzine), β-blockers, and α-agonists are alternatives that can be used on a scheduled or as-needed basis and are usually better tolerated without concern for physiologic dependence. However, these agents, are also not approved as anxiolytics in this population.Duloxetine, an SRNI, has been approved for generalized anxiety disorder and can be used in children who are 7 years of age or older. The standard of care is CBT for milder cases and a combination of an SSRI and CBT in combination for more severe cases or cases that do not respond to CBT alone.¹³ The following table lists other disorders associated with anxiety.

Obsessive-Compulsive Disorder (OCD)

Onset of OCD often occurs during childhood, and untreated OCD can have a lifelong course. Although OCD can occur at any age, there are generally two age ranges when OCD tends to first appear. It usually occurs between the ages of 8-12 years and then between the late teen to early adulthood years. The average age at which OCD usually appears is 9-10 years of age with males having an earlier age of onset. It is estimated that 500,000 children in the United States have OCD.¹⁸ OCD often leads to avoidance of situations that trigger obsessions, and for children and adolescents, this can interfere with normal development.

Obsessions vary by individuals but tend to cluster into the following groups: intrusive “forbidden” images such as sexual, aggressive or religiously taboo images, thoughts of contamination, need for symmetry, fears of harming others, and fears of harm to oneself or loved ones. Individuals often experience more than one cluster and types of obsessions can change over time. Refer to Table 4 for common obsessions and compulsions. In addition, youths may also experience panic, depressive, irritable, and suicidal symptoms. Sudden onset of symptoms should alert the clinician to screen for group A streptococcal infections, as pediatric autoimmune disorders associated with these infections have been implicated in the development of OCD for some children.¹⁸

In children, compulsions can often be identified, but obsessions can be difficult to recognize because they are experienced internally. Many individuals with OCD may feel that giving up their compulsions will lead to intense distress. Therefore, education is an important first step in the treatment of OCD to help put symptoms in perspective. When possible, CBT is the first line treatment for mild to moderate cases of OCD in children. More severe symptoms are an indication for medication, preferably added to CBT. SSRIs are effective in diminishing OCD symptoms, but higher doses, occasionally above maximum recommended daily dose, may be necessary. Fluvoxamine, sertraline, fluoxetine and clomipramine have FDA approval for the treatment of pediatric OCD.¹⁹ It is important to recognize and treat OCD early, as early age of onset and greater impairment are predictors of poor prognosis. 

Posttraumatic Stress Disorder (PTSD)

Experiencing adverse environments early in life is associated with a range of negative outcomes for children, including trauma- and stressor-related disorders. At least one trauma is reported by two-thirds of American children and adolescents while 33% of children experience multiple traumas before reaching adulthood.²⁰ Unlike most psychiatric disorders, trauma related disorders include a specified etiology as part of the diagnostic criteria. Factors that predispose individuals to the development of PTSD include proximity to the traumatic event, a history of exposure to trauma, preexisting depression or anxiety disorder, being abused by a caregiver, or witnessing a threat to a caregiver. PTSD can develop in response to natural disasters, terrorism, motor vehicle crashes, and significant personal injury, in addition to physical, sexual and emotional abuse.²¹

Although childrens’ emotional responses at the time of the trauma may vary, in the weeks and months after, children with PTSD exhibit various manifestations of re-experiencing the trauma, avoiding reminders, negative mood and thoughts triggered by the event, and manifestations of central nervous system hyperarousal. Children and adolescents with PTSD typically show persistent fear, anxiety, and hypervigilance which may cause them to regress developmentally, experience fears of strangers, the dark, or being alone, and avoid reminders of the traumatic event. Children and adolescents with PTSD are often more irritable and can experience detachment and diminished interest in activities and will reexperience elements of the events in the form of nightmares and/or flashbacks. An observer can often notice repetition of some aspect of the traumatic event in the symbolic play of children with PTSD. In addition, children with PTSD will often present with somatic complaints such as headaches and abdominal pain.²¹

Individual and family psychotherapy are central features of treatment interventions for PTSD. Treatments differ based on the age of the child, chronicity of trauma, and access to treatment. Young children may benefit from therapy focused on strengthening the parent-child relationship whereas other treatments additionally focus on creating a developmentally appropriate trauma narrative to help the child understand and process their experience. Trauma-focused cognitive behavioral therapy (TF-CBT) has the most evidence for treatment of children and adolescents with PTSD. Parents and the child receive all TF-CBT components in individualized sessions which allow for the parents and the child to express their own thoughts and feelings about the child’s trauma experience, gain skills to help the child change the trauma response, and work on avoidance techniques of trauma reminders. Research shows that parental participation significantly enhances the impact of TF-CBT.²² For children with more severe and persistent symptoms, assessment for treatment with medication is indicated. Children who have lived for an extended time in abusive environments or have been exposed to multiple traumas are more likely to require treatment with medications. Currently, there are no medications with FDA approval for treating PTSD in children. Some of the medications used to treat children with PTSD include anti- adrenergic agents (clonidine, guanfacine or propranolol), mood stabilizers, antidepressants, and second-generation antipsychotics and may be targeted toward specific symptoms (e.g., anxiety, depression, nightmares and aggression). Medications are justified primarily to treat comorbid symptoms among children and adolescents.²³

Many symptoms of PTSD can be mistaken for other disorders such as depression, anxiety, primary substance abuse, ADHD, learning disorders, bipolar disorder, and even psychosis in more severe cases. All behavioral health assessments should include inquiries related to traumatic events.²¹ It is important not to miss trauma-related etiology as this may change treatment focus. Children with PTSD may have comorbid diagnoses that require treatment and this diagnostic complexity often requires the assistance of a child psychiatrist or other mental health provider. Trauma can affect children in multiple ways and growing evidence supports a connection between victimization in childhood and problems in adulthood including long term health consequences and high risk behaviors such as smoking and unprotected sex.²⁴ It is important to treat PTSD not only to relieve the current suffering but also to mitigate long-term negative sequelae.

Depression

The incidence of depression in children increases with age, from 1% to 3% before puberty to around 9% for adolescents. Over the course of adolescence, 20% of individuals will experience depression.²⁵ The sex incidence is equal in childhood, but with the onset of puberty, the rates of depression for females begins to exceed those for males and the rate of depression in females approaches adult levels by age 15.²⁶ Depression can have significant effects when the onset occurs at this age and can lead to impaired school performance, interpersonal difficulties later in life, early parenthood, and increased risk of other mental health disorders and substance use disorders.²⁷ Just as in adulthood, childhood depression can be a chronic and debilitating disease resulting in impairment in educational, occupational and social activities.

Children are less likely to verbalize their feelings associated with depression or meet the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) criteria.²⁵ Depressed children 3-8 years of age often present with more somatic complaints, are more irritable, display fewer signs of depression, present with symptoms of anxiety, and have other behavioral problems as outlined in Table 5. As children become adolescents and then adults, symptom presentation becomes more consistent with the DSM-5 criteria.²⁸

Treatment options for depressive disorder in children and adolescents vary by severity, similar to adult treatment. Mild-to-moderate depression may be managed with psychoeducation, family education, and psychotherapy, and more severe depressive episodes may require pharmacotherapy. Topics covered in psychoeducation include the signs and symptoms of depression, an understanding of why some children get depressed, the course of illness and the risk of recurrence. Psychotherapy options include individual or group CBT or interpersonal therapy (IPT).²⁵ IPT focuses more on the context of interpersonal relationships and how these relate to depression. There is focus on relationships with parents and the development of other personal relationships.²⁹ Both CBT and IPT have been shown to be effective for adolescents but none more effective than the other.²⁵

When the symptoms of depression are moderate and persistent, or severe, antidepressant medication may be indicated. When considering antidepressant treatment, choices should be based on depression severity, adverse effect profile, drug interactions, patient and parent preference, and comorbidities. Medications should be used in combination with psychotherapy for best outcomes. SSRIs are the first-line antidepressant agents for children and adolescents diagnosed with depression. Of the SSRIs, fluoxetine has the strongest evidence for use in pediatric depression and has FDA approval in this population.³⁰ Paroxetine should be avoided in this age group due to the increased risk of suicidality as compared to other antidepressants. In addition to experiencing the traditional side effects of SSRIs, irritability, social disinhibition, restlessness, and emotional excitability can occur in approximately 20% of children taking SSRIs and activation is more likely to occur with preadolescent children. Other SSRIs, SNRIs, and other antidepressants, such as mirtazapine and bupropion, may be prescribed but with caution due to less evidence and the adverse effect profiles. SNRIs have led to increased heart rate, blood pressure and skin problems in this patient population. Bupropion may be beneficial for patients with comorbid ADHD or a tobacco use disorder and like the SSRIs, bupropion has very few anticholinergic or cardiotoxic effects. However, the use of bupropion is contraindicated in patients with a history of seizures and those with a history of anorexia or bulimia. Mirtazapine is beneficial for patients with sleep disturbances and common adverse effects include dry mouth, increased appetite, constipation, weight gain, and increased sedation. The lack of demonstrated efficacy, high-risk adverse-effect profile potential, and lethality with overdose have led steering committees and professional organizations to recommend that tri-cyclic antidepressants not be prescribed for depression in children and adolescents and be reserved for treatment of refractory depression.²⁵ Refer to Table 6 for a list of antidepressants commonly used and their dosing schedules.

When choosing an antidepressant, frequency and timing of doses should be considered to avoid administration at school or to add complicated dosing regimens to pediatric patients. Some formulations of bupropion and fluvoxamine require multiple daily dosing, which may be a deterrent for some children and parents. Children and adolescents may be at increased risk of developing antidepressant withdrawal symptoms compared with adults, but less risk is associated with fluoxetine because of its long half-life.²⁷ When counseling on these medications the family should be warned about the adverse effects, the possibility of inducing mania, potential for reduced height and weight compared with same-age peers, and the risk of worsening suicidal thoughts or behaviors. In 2005, the FDA issued a “black box warning” regarding suicidal thinking and behavior for all antidepressants prescribed for children and adolescents. Although children face an initial increased risk of suicidal thinking and behaviors during the first few months of treatment, there is now substantial evidence that antidepressant treatment, over time, is protective against suicide. This suggests best practice is to educate the family regarding both the risks and benefits of antidepressant treatment and monitor carefully for any increase in suicidal ideation or self-injurious urges, as well as improvement in target symptoms of depression, especially in the first four weeks and subsequent three months after beginning their use. The exact duration of an antidepressant trial in youth has not been established; however, with comprehensive treatment intervention, including psychoeducation for the family, individual and family psychotherapy, medication assessment, and evaluation of school and home environments, complete remission of depressive symptoms will often be seen over a 1- to 2-month period. If medications are started and proven effective, they should be continued for 6–12 months after remission of symptoms to prevent relapse and then a slow tapering of the medications should be initiated. Consideration should be given to discontinuing the medication during a time of low stress, such as summer vacation.²⁵ It is important to reassess the child or adolescent with depressive symptoms regularly for at least six months and to maintain awareness of a reoccurrence of depression.

Bipolar Disorder

Bipolar disorder is a severe mental condition with features that clinically results in pathological fluctuations of mood. Whereas it was traditionally considered an adult-onset disorder, it is only in the past decade that the psychiatric community has begun to accept that this disorder can occur in children. Onset of bipolar disorder before puberty is uncommon; however, symptoms often begin to develop and may initially be diagnosed as ADHD or other disruptive behavior disorders. The lifetime prevalence of bipolar disorder in middle to late adolescence is 1%–2%. Large-scale studies of adults with bipolar disorder indicate that approximately 20% of them showed symptoms prior to age 19. One of the reasons which bipolar disorder has been so difficult to identify is that the primary symptoms vary from the typical adulthood clinical presentation. Euphoric mood is rare in children and adolescence, while irritable mood, aggressive temper, mixed manic state onset, rapid cycling, and anger outbursts are much more frequent. This specific clinical presentation makes bipolar disorder difficult to differentiate from other diagnoses including ADHD or other disruptive behaviors.³²

In most pediatric patients, the first symptoms are primarily those of depression but in rare instances a manic episode may precede the depression. It is difficult to elicit classic, discrete episodes of cycling because the symptoms appear to be highly chronic in this population. Children younger than age 9 typically present with more irritability and emotional lability, whereas children older than age 9 exhibit more classic euphoria, elation, paranoia and grandiosity. Mania will typically present as a variable pattern of elevated or irritable mood along with rapid speech, high energy levels, increase in goal-directed activity, difficulty in sustaining concentration, and a decreased need for sleep often including lack of fatigue the following day. The child or adolescent may also have hypersexual behavior. The clinical picture can be quite dramatic, with psychotic symptoms of delusions and hallucinations accompanying extreme hyperactivity and impulsivity.

Bipolar illness can be difficult to diagnose and challenging to treat. It is generally recommended that children and adolescents who may have this diagnosis should be evaluated by a child and adolescent psychiatrist for diagnosis and further treatment if indicated.

Therapy for children and adolescents with bipolar disorder generally includes psychoeducational activities like monitoring symptoms, recognizing triggers, the importance of continuing medications, improving family communication with a focus on problem solving skills, appropriate expression of emotion, and developing and maintaining routines. Therapy alone is usually not usually sufficient and psychotherapy in combination with medication is the mainstay of treatment. Medications are chosen based on current symptoms, adverse effects, family preference, and differ by polarity of symptoms (depression vs mania). The best evidence for treatment of mania is with second-generation antipsychotics, followed by lithium. Non-responders may require a combination of medications. Lithium, risperidone, aripiprazole, quetiapine, asenapine and olanzapine have been approved by the FDA for the treatment of bipolar disorder in this population (Table 7). Other mood stabilizers, lamotrigine, carbamazepine, and valproate are less effective. Lithium and aripiprazole are approved for preventing recurrence in this population. The depressive symptoms in this disorder can be challenging to treat. Patients with mild depression should receive therapy and other interventions prior to considering adding an antidepressant to a second-generation antipsychotic or other mood stabilizer (lurasidone has been approved for pediatric bipolar depression) due to the potential for the antidepressant to induce mania.³³

Mood stabilizer and atypical antipsychotic medications have a variety of adverse effects, interactions, and safety concerns. Weight gain and metabolic effects are common with the atypical antipsychotics, although weight gain is also commonly associated with valproate and, to a lesser extent, lithium. Children and adolescents may be more vulnerable than adults to weight gain from these medications and, thus, likely to be at a higher risk of glucose and lipid abnormalities.³³ The adverse effect profile for mood stabilizers and atypical antipsychotic medications is extensive and individualized for each agent. The reader is encouraged to familiarize oneself with the specified medication including adverse effects and recommended monitoring prior to recommending a specific treatment course or counseling the family of a bipolar child or adolescent.

Children and adolescents with bipolar illness are at risk for poor academic, social, legal and health outcomes. The poor judgment associated with manic episodes predisposes individuals to dangerous, impulsive, and sometimes criminal activity. Legal difficulties can arise from impulsive acts, such as excessive spending and acts of vandalism, theft, or aggression, that are associated with grandiose thoughts. Due to the severity of these behavioral consequences, it is imperative to recognize the signs and symptoms of bipolar disorder in this population. Since most cases of pediatric bipolar disorder are typically referred to a mental health specialist, a pharmacist or technician may have a more limited role with this disorder. In these cases, the pharmacist or technician can actively monitor for and manage medication adverse effects, particularly weight gain, hyperlipidemia, and the onset of diabetes mellitus.

Approved Psychotropic Medications

While more detail has been given on specific psychoactive medications throughout the manuscript, the following is an easy to use reference table that lists medication, indication and the minimum age for which the medication was approved.

PHARMACIST AND PHARMACY TECHNICIAN ROLE IN PEDIATRIC MENTAL HEALTH

Given limited time available for pediatric visits and the need for adequate mental health screening many parents may not have adequate time to discuss behavioral or mental health concerns with their pediatricians. Parents of younger children may not be overly concerned about their children’s behaviors because they do not recognize that young children can experience significant mental health problems and/or because they think that the problems are transient and normative and therefore the child will outgrow them.³⁵ The pharmacy is a unique environment where we are afforded more time to interact with patients and their families, ask questions, provide education as to concerning behaviors and be a source for resources. The expanding role of the pharmacist and pharmacy technician in pediatric mental health encompasses the following broad categories: prevention, identification, assessment, referral and collaboration. Each of these will be discussed in detail in the following section.

Prevention

It is important that families become familiar with factors that can help promote health, both physical and mental. There are clear physical and behavioral health benefits from regular exercise, optimal nutrition, meditation, yoga and participation in social activities. Other contributing factors that directly impact overall health include adequate sleep and use of relaxation techniques. The American Academy of Pediatrics recommends engaging families in conversations to encourage consumption of fruits and vegetables, avoid sugar-containing drinks, encourage physical activity and to make a family plan around limiting screen time.³⁶

Identification

Surveillance for concerning behaviors consists of the following elements: checking in, eliciting concerns, asking open-ended questions, listening for red flags, identifying risk factors, and monitoring closely over time. The essential components of a primary care surveillance for mental health concerns should generally include a review of the youth’s general functioning in different aspects of their life. Below is a list of questions that can be helpful in opening a discussion regarding behavioral health surveillance.³⁶

• How are things with you and your parents?
• How are things going in school? Ask about academics, activities, social interactions.
• How are things with your peers/friendships?
• How are things at home? (Include siblings, family stressors)
• How would you describe your mood? (May ask the parent to describe the child’s mood)

Social-emotional and psychosocial screening can be performed to identify the presence of symptoms of emotional, behavioral, or relationship disorders and those environmental factors that negatively influence development. Screening tools are brief, easy to use, and can be administered as a questionnaire or using an interview format. A positive screen typically warrants referral for a more thorough assessment by a pediatrician or a mental health specialist. The use of screening tools can facilitate early identification and interrupt the advancement of symptoms. The following are some screening tools that can be utilized in a pharmacy setting.

• Strengths and Difficulties Questionnaire (SDQ)- This tool assesses general behavioral health including emotional symptoms, conduct problems, hyperactivity/inattention, and peer relationship problems. Available at: https://www.sdqinfo.org/a0.html.
• Pediatric Symptom Checklist (PSC)- This tool assesses cognitive, emotional and behavioral problems. Available at: https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf.
• Patient Health Questionnaire 9 (PHQ-9) Modified for Teens- This tool assesses risks for depression and suicide. Available at: http://www.pedpsychiatry.org/pdf/depression/PHQ-9%20Modified%20for%20Teens.pdf.
• Self-Report for Childhood Anxiety-Related Emotional Disorders (SCARED)- This tool assesses the presence of childhood anxiety disorders such as generalized anxiety disorder, separation anxiety disorder, panic disorder, social phobia and school phobia. Available at: https://www.pediatricbipolar.pitt.edu/sites/default/files/SCAREDChildVersion_1.19.18.pdf.

Assessment

Any of the above activities can be completed by a pharmacy technician. When an emotional or behavioral problem is mentioned by the patient or parents, elicited by an interview, or identified by a screening instrument, the next step should include a more comprehensive assessment and plan for triage by the pharmacist. The pharmacist should be involved in a meaningful conversation about the findings from the screening process and can be involved in a follow-up plan if asked to do so by the patient, family or other health care provider. Response to screening results and additional assessment is required to determine appropriate referral resources, safety planning, need for immediate attention or action, and follow-up appointments and services. If there is any concern about the child’s safety, the evaluation of the risk of danger to self (e.g., suicidal ideation, plans, or attempts), danger to others (e.g., assault or aggression), and screening for other factors that could heighten the risk of danger to self or others such as physical or sexual abuse, substance use or abuse, or unsafe environments should be assessed. The pharmacist must keep in mind mandatory reporting by a provider of suspicion of physical or sexual abuse or neglect to the local human services agency.

Referral

After completing the assessment, the pharmacist should make a referral to the appropriate provider. At this point, the child may be referred to their pediatrician for follow-up or depending on the severity of the behavioral/mental health issue a child and adolescent psychiatrist or other qualified child mental health professional is necessary. When in doubt, the pediatrician is a good first step who can then triage the patient if additional resources or specialized care are required. The presence of drug or alcohol abuse may require referral to community resources specializing in the treatment of these addictive disorders. For academic difficulties not associated with behavioral difficulties, a child educational psychologist or multidisciplinary learning disorder team may be most helpful in assessing patients for learning disorders and potential remediation. In many states, patients who are publicly insured or do not have mental health insurance coverage may receive assessment and treatment services at their local mental health care center. Patients with private mental health insurance typically need to contact their insurance company for a list of local mental health professionals trained in the assessment and treatment of children and adolescents who are on their insurance panel. The pharmacist or pharmacy technician could assist the family by providing information to connect the family with the appropriate resources and services. 

Collaboration

If the pharmacist is comfortable after the referral they may be involved with the collaboration of care. This can include monitoring for adverse effects of psychoactive medications, improvement in symptoms, or helping with adherence issues. The pharmacist or pharmacy technician can continue to be a valuable source to connect the patient with applicable community resources to further support the patient and the family.

SUICIDE IN CHILDREN AND ADOLESCENTS

Suicide is almost always associated with a psychiatric disorder and should not be viewed as a philosophic choice about life or death or as a predictable response to overwhelming stress. Most commonly it is associated with a mood disorder and the hopelessness that accompanies a severe depressive episode. In 2018, adolescents and young adults ages 15 to 24 had a suicide rate of 14.45%. Based on the most recent Youth Risk Behaviors Survey from 2017, 7.4% of youth in grades 9-12 reported that they made at least one suicide attempt in the past 12 months. Female students reported attempts almost twice as often as male students (9.3% vs. 5.1%). African American students reported the highest rate of attempt (9.8%) versus Caucasian students (6.1%). Suicide and homicide rates for children in the United States are two to five times higher than those for the other 25 industrialized countries combined, primarily due to the prevalence of firearms in the United States. The vast majority of young people who attempt suicide give some clue to their distress or their tentative plans to commit suicide. Most show signs of dysphoric mood (anger, irritability, anxiety, or depression). A majority of those who attempt suicide will have experienced a crisis event such as a loss (e.g., rejection by a girlfriend or boyfriend), public shaming, a failure, or an arrest prior to completed suicide.³⁸ A pharmacist and pharmacy technician involved in mental health could be a valuable resource for the pediatric patient and family to help identify risk factors associated with suicide. Refer to Table 8 for specific risk factors.

Although suicide attempts are more common in individuals with a history of experiencing trauma, behavior problems, and academic difficulties, other suicide victims are high achievers who are anxious and perfectionistic and who commit suicide impulsively after a failure or rejection, either real or perceived. With ubiquitous social networking technologies and the presence of digital profiles, posting distressing messages electronically and aggression in the form of cyber-bullying are important to identify and discuss when conducting risk assessments and obtaining information about sources of stress. Many young people who attempt suicide give some clue to their distress or their tentative plans to commit suicide. If a child or adolescent expresses suicidal thinking, it is critical to ask if he or she has an active plan, intends to complete that plan, and has made previous attempts. It is important to avoid debating the value of life, minimizing their problems or giving advice. Suicidal ideation accompanied by any plan warrants immediate referral for a psychiatric crisis assessment and can usually be accomplished at the nearest emergency room.³⁸ Table 9 lists warning signs related to suicide.

Suicidal ideation and any suicide attempt must be considered a serious matter. The adolescent should not be left alone, and the desire to help and concern about the individual should be expressed. At this point in the intervention, the pharmacist should become the primary contact. If it is not an immediate crisis consider meeting with the patient and the family, both alone and together, and listen carefully to their problems and perceptions. It is helpful to explicitly state that with the assistance of mental health professionals, solutions can be found. A thorough suicide assessment requires some level of expertise, a considerable amount of time, and contact with multiple sources of information. Most patients who express suicidal ideation and all who have made a suicide attempt should be referred for psychiatric evaluation and possible hospitalization. Referral for further assessment is always appropriate when there is concern about suicidal thinking and behavior. Both the pharmacist and technician should be aware of his or her own emotional reactions to dealing with suicidal adolescents and their families. You may be reluctant to cause a family stress or go against their will and require an emergency evaluation or may have unfounded fears about precipitating suicide by direct and frank discussions of suicidal risk. When in doubt it is always better to take an active approach, have honest and open discussions and provide referral and resources to the family and patient. Some community resources include calling the National Suicide and Prevention Lifeline at 1-800-273-8255 or texting TALK to 741741 to text a trained counselor from the Crisis Text Line for free 24-hour access for assistance.³⁸ As a health care professional, a calm and honest approach will aid in helping to find the safest and best possible outcome for both the adolescent and the family.

AGGRESSION AND VIOLENT BEHAVIOR IN YOUTH

The tragic increase in teenage violence, including school shootings, is of concern to health professionals, as well as to society at large. There is strong evidence that screening and initiation of interventions can make a significant difference in violent behavior in youth. Types of behavior in children and adolescents can include a wide range of behaviors including explosive temper tantrums, physical aggression, fighting, threats or attempts to hurt others (including thoughts of wanting to kill others), use of weapons, cruelty toward animals, fire setting, intentional destruction of property, and vandalism. Children as young as preschoolers can display violent behavior and any sign of these behaviors should be taken seriously and not considered a phase the child will outgrow.³⁹

There are several potential risk factors to consider when assessing the dangers and predictors of violent behavior. This includes a history of violence or aggressive behavior, including uncontrollable anger outbursts, access to guns or other weapons, history of getting caught with a weapon in school, and a family history of violent behaviors. In addition, children who witness abuse and violence at home or in their community and/or have a preoccupation with themes of violence (e.g., TV shows, movies, music, video games) are also at high risk of such behavior. Victims of abuse either physical, sexual, and/or emotional are more susceptible to feeling shame, loss, and rejection. The difficulty of dealing with abuse can further exacerbate an underlying mood, anxiety, or conduct disorder. Children who have been abused are more likely to be perpetrators of bullying and engage in verbal and physical intimidation toward peers. Substance use is another factor frequently associated with violent behavior particularly because it impacts judgment and is often associated with decreased inhibition and increased impulsivity. Socially isolated children also carry a high risk for violent and dangerous behavior. These include children with little to no adult supervision, poor connection with peers, and little to no involvement in extracurricular activities. These individuals may be more likely to seek out deviant peer groups for a sense of belonging. ³⁹

If a child is at risk for violent or dangerous behavior, the most important intervention is to talk with the child immediately about an alleged threat or behavior. The child’s past behavior, personality, and current stressors should be considered when evaluating the seriousness and likelihood of engaging in a destructive or dangerous behavior. If the child already has a mental health provider, they should be contacted immediately. If they are not reachable, the child should be taken to the closest emergency room or crisis center to evaluate safety and the potential need for hospitalization. It is always acceptable to contact the local police for assistance, especially if harm to others or lethal means are suspected. If a child refuses to talk, is argumentative, responds defensively, or continues to express violent or dangerous thoughts or plans, crisis intervention is also warranted. It is important to note that violent behavior is often associated with suicidal impulse and in the process of assessing violent behavior, suicidal ideation should not be overlooked. Any comment about wishes to be dead, or hopelessness, should be taken seriously and intervened on immediately.³⁹

Although the prediction of violent behavior remains a difficult and imprecise endeavor, several important prevention efforts should be supported and encouraged. Research studies have shown that much violent behavior can be decreased or even prevented if risk factors are significantly reduced or eliminated.³⁹ The presence of firearms in the home, the method of storage and safety measures taken when children are present, and access to firearms outside the home should be explored regularly with all adolescents and monitored by their parents. Encouraging parents to be aware of their child’s school attendance and performance and encouraging an active role in learning about their children’s friends are all appropriate methods to reduce the risk of violent behavior. In addition to efforts directed at dramatically decreasing the exposure of children and adolescents to violence in the home, community, and through the media, talking about violence and personal safety is necessary given the rise of violence in public places, especially schools. The most important factors to consider when discussing such a difficult topic is to be honest, be the source of information (not the media), reassure the child that they are safe, and address concerns at an age-appropriate level. The American Academy of Pediatrics sponsors a national website that provides guidance on how to talk with children about violence and threats to personal safety in addition to many other resources.⁴⁰ Violence in society certainly needs to be addressed from a more global perspective but appropriate prevention efforts and providing tools to appropriately deal with violence may help to alleviate violent behaviors in children and adolescents.

CONCLUSION

A pharmacy provides a unique setting to assist in opportunistic screening for mental and behavioral health due to the accessibility and the general public’s high level of trust in the pharmacist. Because patients visit their pharmacies frequently, pharmacists and pharmacy technicians may be the first healthcare providers who recognize a mental or behavioral disorder either through simple observation, screening methods, or by being an avid listener to the concerns of a parent or other family member. Studies have highlighted that when consumers developed a trusting relationship with their pharmacist they felt the pharmacy was a safe place to discuss their mental health concerns, showing the importance of not just the physical space but the rapport with health professionals that is important in mental health care.⁴¹

While it has been consistently recognized that pharmacists have a broad range of skills in medication management, counseling patients and facilitating medication adherence strategies in the delivery of mental health care, a new and evolving role of the pharmacist and pharmacy technician involves the expanding involvement in prevention, identification, assessment, referral and collaboration of behavioral and mental health concerns. If pediatric-onset mental health issues are appropriately identified the downward spiral of school, social or emotional difficulties during the childhood years and the difficulties transitioning into adulthood may be considerably decreased. Reducing the burden of mental health disorders would not only have a positive benefit for society but also make for healthy and well-developed children that go on to lead productive and emotionally fulfilled lives into adulthood. Pharmacists and pharmacy technicians are uniquely positioned to use and share resources with patients and can provide a unique and meaningful aspect of care and support for children, adolescents and other family members who are experiencing psychiatric disorders, suicide or violence related thoughts or behaviors.

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