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Protect Our Childrens Future: Early Mental Health Screenings

Amber Blankenship

Western Washington University

Nurse 301: Information Literacy

Julie Samms MN, RN

November 28th, 2016

Protect Our Childrens Future: Early Mental Health Screenings

An eight year old boy sits eating lunch at a table full of his peers. The children play and

talk over food with great enthusiasm. Topics shift from recent movies, sports, and Xbox games;

each child one-upping the other in their passion and wonder. The chatter grows more intense

and the boy cannot contain his excitement any longer. The need to vent off the excitement

compels the boy to stand, his banana in hand. Giggling through a big smile he points the fruit at

his peers and calls bang, bang bang, bang! The cafeteria monitors immediately came

forward with a firm voice to enforce the schools zero tolerance rule - no pretend play with

violent weapons of any kind, especially gun play. The boy, deflated and ashamed, is escorted to

the principals office where his parents are called and threatened with his banishment from eating

lunch with peers and an offense is placed permanently in his file.

In the case above, a shooting at a local mall prompted the school to introduce its zero

tolerance policy. As school systems react to the increase of gun violence in our society,

predicaments like those suffered by the boy are not outliers. News articles write of children as

young as five being suspended from school for gun play. Historically, gun play has been a game

enacted by growing children; it often entails visions of military soldiers and use of their nerf

guns as props in their theatrical renditions. Thoughtful consideration must be practiced when

implementing zero tolerance rules. Educating children on the inappropriateness of violent play is

important; however, suspending or alienating a child for something they do not understand is

counterproductive and can lead to exactly what the educators are trying to avoid social

Isolating or shaming a child can lead to insecurities and create a sense of separation

within the childs school community. Studies have shown that these emotions can fester within a

child and lead to violence. What can school administrators, parents, and medical providers do to

combat the fear of imminent violence within schools and communities? There is a need to move

focus from simple gun play to identifying children who are truly at risk for violence and thus

take action. Implementing Mental Health screenings for youth will improve access to treatment

and improve long term outcomes for the students, decrease violence in schools, as a result

decrease long-term costs for the community.

Search Process

I began my research on the relationship of gun play and violence using gun play as my

initial search query. I extended my search using Google Scholar and OneSearch and began

looking into the process of how children are screened for mental health issues; for this I used the

phrase pediatric mental health screenings. I found a book which discussed early childhood and

adolescent development. I proceeded to use both Google Scholar and Western Washington

University library services to retrieve articles pertaining to causes of youth violence via terms

violence and youth. I then reviewed government and Centers for Disease control (CDC)

websites for facts regarding US policies and costs of violence to the communities. I researched

how to implement mental health screenings for pediatric patients and identified a gap in

knowledge base. Most mental health screenings and studies pertained to adolescents aged 12 and

older. There is a clear shortage of articles pertaining to the younger pediatric population.

Understanding Violence and Mental health in youth

Some may ask Why do we care? The CDC (2012) reports suicide as the third leading

cause of death in those aged 10-14, and the second leading cause of death in those aged 15-34.

Males are four times more likely to take their lives; whereas females were more likely to have

suicidal ideation. In fact, 60% of high school students had suicidal ideation or action. In 2010,

784 juveniles under 18 years of age were arrested for murder, 2198 for forcible rape, and 35,001

for aggravated assault. These numbers validate concerns that parents have as they contemplate

how best to raise their children.

There is a known link between youth violence and milieu ailments such as poverty,

victimization, and poor parental habits; thus, it is important for us to view violence as symptom

of a deeper, more complex illness. Merriam-Webster (n.d.) defines violence as a great

destructive force or energy used to harm or damage self, others, or property (para 1). The

environment in which people live will have a major influence on their mood and behavior.

Children spend most of their days within school and at home, and as a result, these environments

are chief contributors to a childs developing personality. Likewise, a childs parents are

primary character models; consequently, their daily actions make deep impressions; conflict

within the household, like domestic violence, substance abuse, and symptoms of a parents

mental illnesses can have a profound impact. If the child is exposed to frequent hostilities in the

home, it is reasonable to believe they would begin to view violence as acceptable behavior.

Eisenbraun (2007) has cited that students who grow up in these settings, where structure

is poor, have an increased likelihood of becoming bullies. Neglect or isolation can create feelings

of fear and anxiety. In order to dominate or gain attention, bullies will harness their anxiety and

externalize terroristic behaviors towards others. Young people who become involved with
violence are vulnerable, have limited opportunities for gaining status in more pro-social ways

and do not see education as a route to self-advancement. (Mcara & Mcvie, 2016, p.76)

Victimization of a child from parental abuse or bullying has been shown to create an increase

likelihood of committing future violence themselves relative to the development of anxiety and

decreased self-esteem. Eisenbraun (2007) also cited a study that found that 16% of girls and

21% of boys reported carrying weapons for self-protection. (p. 46)

Genetics have been reported to have a direct influence on behavior. Children born from

parents who have been diagnosed with antisocial personality disorder have an elevated risk for

developing conduct disorders and aggression (Copelan, 2006). Impulsive aggression, the failure

to control mood and aggressive impulses, is thought to be a trait which anticipates violent and

criminal behaviors and has been shown to be predisposed to genetics (Copelan, 2006). As cited

by Seo, Patrick, & Kennealy (2008), studies have made connections between low serotonin

levels, a chemical in the brain that is known to regulate mood, and criminal behavior.

When is the best time to intervene? Research has not fully supported mental health

assessments in children prior to age 12, depicting that children younger than this are too difficult

to assess. Conversely, Galehouse & Foley (2012) argue that early identification of risk factors

and assessment of childs temperament and self-regulation can help direct interventions and

safeguard better outcomes for the child and family. Further, they suggest that the development of

mental and behavioral health starts at birth.

Temperament, considered a behavioral response, is present at birth and is continuously

evolving, adapting to the childs environment during the first year of life. Scholars have

associated temperament to physical, emotional, and social outcomes for children and have made
connections with a number of mental health disorders such as attention deficit hyperactive

disorder (ADHD), anxiety, and depression. Extreme temperaments, in children, are thought to be

associated with oppositional defiant disorder, antisocial behavior disorders and other behavioral

concerns later in life (Galehouse & Foley, 2012).

Self-regulation is cited by Galehouse & Foley (2012) as the interactions of the childs

temperament and their ability to adjust emotions in response to their environment. It is

imperative for a child to learn the ability to manage these emotions and reactions in order to

adapt well within society. Unlike temperament, the ability to self-regulate behavior and

emotions develops in tandem with the childs brain until hardwiring is completed at about eight

years old. (Galehouse & Foley, 2012, p.22) Frequent exposure to stressful atmospheres, cause

struggles in self-regulation, known to scholars as dysregulation. This can be later associated with

psychiatric disorders, addiction, sexual abuse, compulsive spending, and crime.

Children who are good self-regulators have a natural ability for attention or focus and

have higher levels of achievement. Research has shown that the ability of blocking distracting

information from the focus of attention, known to scholars as executive attention, shows

improvement from ages 2 through 7, whereas studies of older children and adolescents found

little change in skill from eight to adulthood. This suggests that there is a tight margin of

opportunity where interventions have the most likelihood of success. Regulating behavior

requires the ability to suppress a more dominant response in favor of non-dominant one.

Galehouse & Foley (2012) continue to detail how inability to cope and manage behavior as a

child is a prediction of poor adjustment to school and challenges with peers. Shy temperament

has been shown to be affiliated with internalizing emotions such as negative self-talk which often
leads to depression. It is important to assess a childs temperament and behaviors to provide the

best tools to help the child to manage and cope with challenging moments and thus improve their

chance for success in school and life.

Screenings and Interventions

One in five children and adolescents have some form of mental health issue and 70% of

adolescents with mental health problems do not receive care. (, n.d.

para. 1) Accordingly, it is necessary to create opportunity to screen for mental health and

behavioral problems and provide needed care to these minors. Two opportunities for such

screenings have been identified. As children and adolescents spend a large quantity of time at

school, it is thought to be the best place to implement a screening process. Primary care visits

present a second opportunity for physicians and nurses to assess risk factors. Many of these risk

factors are recognizable during interactions between family members or with staff. Once

identified, primary care providers (PCP) can direct care for the patient and make needed referrals

to appropriate liaisons.

Berger-Jenkins, McCord, Gallagher, & Olfson (2008) completed a study analyzing the

use of a mental health screening tool within a primary care office. This tool, known as the

Pediatric Symptom Checklist (PSC-17), was presented to parents upon arrival. They were

directed to answer the 17 assessment questions which screened behaviors of internalizing,

externalizing, and attention difficulties. Outcomes illustrated that parents given the checklist

were eight times more likely to disclose concerns for mental health struggles. These outcomes

also showed that primary care providers were more likely to inquire about these ailments, were

three times more apt to diagnose a problem, and ten times more likely to arbitrate.
A concern was voiced of over burdening mental health referral services. However, this

study provided evidence against such a claim as practitioners were less likely to make referrals

which implied that this screening was able to direct practitioners focus of care (Berger-Jenkins et

al., 2012). Primary care physicians can best manage care and have the ability to prescribe

medications; yet, have less opportunity for interaction with the student. To best address this

issue, it is necessary to implement screenings within the school system itself.

A study by Essex, Kraemer, Slattery, Burk, Boyce, Woodward, & Kupfer (2009) assessed

internalizing and externalizing symptoms in kindergarten and grades 1, 3, and 5 in order to

develop a 15-minute questionnaire to be filled by parents at the start of the academic year. This

tool would be used to help identify students who were most at risk. Symptoms were found to be

either variable or consistent within different groups. Isolated events were found in particular

groups, however, the group who displayed secondary symptoms of either internalizing or

externalizing behaviors, exhibited these consistently over the four years of study. These children

were accurately recognized in first grade. This study further supports the importance of early

universal mental health screenings for the early identification of children in need. When

appropriately identified, tailoring of suitable interventions improves the overall health of the

minor and decreases the risk violence within the school and community (Essex et al., 2009).

Screening all school children for mental health disorders and identifying those who are at

risk for violent behavior is a complex and challenging process. Several screening tools have

been developed to help identify students at risk for emotional and behavioral disability.

However, the accuracy, speed, and ease of use are important characteristics when considering

their implementation. The Emotional and Behavioral Screener (EBS) is clear, concise and
requires only a minimal expense of educator time. In this tool there are ten questions requiring

the educator to score the student on a scale from 0 (no problem) to 3 (severe problem). These are

then added together to grade the EBS score. The student is considered at risk if they score at 80

percent or greater.

There are several ways to implement the EBS. A three-tiered model appears to be the

most useful and less biased model. As Pierce, Nordness, Epstein, & Cullinan (2016) cited,

students fall into one of three levels of risk: 80% will fall into a low risk category, 15% in a

moderate risk, and 5% will fall into a high risk category. This three-tiered model includes

assessing and grouping students into these three risk categories as well as implement three levels

of prevention. The primary level of prevention, otherwise known as Universal, is for all

students. It allows for structured classroom time and working through morals and pro-social

behaviors. The secondary level, known as Selective or Targeted, is for students requiring more

aid and educator time. The tertiary level, Indicated, is for students who were unsuccessful during

previous mediations and require more intensive, personalised interventions. Educators at a

school which trialed this tool over one year expressed feeling more cognisant about their

students behavioral needs and were able to make adjustments to classroom structure

accordingly. They described improvements in the mood of their classrooms and reported

sending fewer students to the principals office for disciplinary actions (Pierce et al., 2016).

School Based Health Centers (SBHC), consists of both medical and mental health

providers and help to improve student access to health care. These are located on school grounds

and are operated or affiliated with an outside community health agency or hospital. It was

reported that adolescents were 10-21 times more likely to use an SBHC for mental health
services than a local community health center (Carroll, Kilcoyne, & Galehouse, 2012). SBHC

support the success of students by following medication regiments and assisting with health plan

and education development. These centers typically employ Advanced Practice Nurses (APN)

and at times will employ both APNs and school RNs (Carroll et al., 2012).

Funding and Implementation

The Mental Health in Schools Act of 2015 is a bill to amend the Public Health Service

Act and extend projects related to children and violence and improve access to school based

mental health screenings and programs. This will provide funding of up to $200,000,000 in

competitive grants and be distributed by the Substance Abuse and Mental Health Services

Administration (SAMHSA). These funds will be used to train volunteers, families, and other

community members to recognize symptoms of behavioral and mental health impediments.

Youths of the ages 12-22 cost the US more than 10 million dollars, or a minimum of $45,472 an

individual. This figure includes costs of police work, court appearances, property damage,

custody costs and housing unemployable youths (Eisenbraun, 2007).

Education is a vital piece of implementing such courses within the educational system.

Educating staff regarding emotional and behavioral disabilities and other mental health needs is

imperative for the recognition and support to these students. Developing an educational platform

for youth themselves can help with recognition of bullying, victimization and assist with

prevention of further violence. It can further be used to teach about emotional disorders such as

anxiety and depression, how to avoid them, and their long term outcomes. Teaching coping skills

to manage stress throughout life would also be a focus. Above all, educating both the students
and community as a whole will combat the stigmatization of such disorders and help to alleviate

the sense of isolation of those afflicted.


Although there is correlation between violent behavior and mental disability, not all

mentally ill children will grow to be violent. If the United States is having this influx of mass

shootings, is there an influx in mental disabilities? It would also be interesting to compare the

statistics of mental illness verses number of shootings in the United States against those of other

countries. Data gathered from this research could assist in investigating further into the cause of

the increase in youth violence.

Current research supports the importance of implementing screenings for mental health

within the school platform. However, few touch on the importance of adding such screenings for

children under 12. Yet, children ages 5 through 8 are at an ideal age for intervention due to the

dynamic state of self-regulation in this period (Galehouse & Foley, 2012). Screenings as early as

kindergarten can identify internal and externalization temperaments which may lead to comorbid

conditions and future mental health disparities (Essex et al, 2009).

Implementation of early mental health screenings in schools and clinics for children as

young as five identifies those suffering early enough to intervene while temperament and self-

regulation habits continue to form. Tailored interventions are then able to grant children the

ability to develop the skills needed to manage stress, promote positive lifestyle, and feelings of

belonging toward their family and their community. If these interventions are successful,

children will be more likely to triumph throughout life and be less likely to turn to violent,

aggressive behaviors. Additionally, increased welfare for schools provides educators with the
ability to deliberate on scholarly teachings and governments the ability to allocate saved funds to

improve other community programs.

Educators and primary care providers must look past the distractions of gun play and

focus on the roots of violence. It is imperative that clinicians begin to look further upstream to

identify the social and genetic determinants of mental health. A preventative stance must be

taken to provide better opportunity of success for our youth and thereby protect the safety of our


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Health Screening in a Low-Resource Pediatric Primary Care Population. Clinical

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Carroll, E., Kilcoyne, A., & Galehouse, P. (2012). Advanced practice nurses interfacing with the

school system. In E. Yearwood, G. Pearson, & J. Newland (Eds.), Child and adolescent

behavior health (pp. 22-36). doi: 10.1002/9781118704660

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