Evidence Based Practice and Policy Reports

The Journal of School Nursing

2014, Vol. 30(3) 165-172
Identifying Symptoms of Depression and ª The Author(s) 2013
Reprints and permission:

Anxiety in Students in the School Setting sagepub.com/journalsPermissions.nav

DOI: 10.1177/1059840513500076
jsn.sagepub.com

Virginia L. Allison, DNP, FNP1,

Donna G. Nativio, PhD, CRNP, FAAN2,
Ann M. Mitchell, PhD, RN, FAAN2, Dianxu Ren, PhD3,
and Janet Yuhasz, M Ed1

Abstract
Early detection of mental health problems in school-age children offers the opportunity for prompt referral to treatment
which is critical to their success in school. School nurses are in a key position to screen for mental health issues in the school
setting. This article discusses how school nurses began a new initiative to use two validated screening tools, the Patient Health
Questionnaire–9 item for detecting depression and the 5-item Screen for Child Anxiety Related Emotional Disorders for
detecting anxiety in middle school/high school-aged children in selected urban schools. Students having positive screens were
referred to the multidisciplinary school-based Student Assistance Program team for further evaluation and referral. These
screens improved the identification and referral for treatment of children suffering from anxiety and/or depression by
expediting the connection to services.

Keywords
pediatric mental health, mental health screening in schools, pediatric anxiety screening, pediatric depression screening

Introduction Prior to this project, there was no formal mental health

According to the American Academy of Pediatrics, approx-
imately 14 million children in the United States had a mental
health disorder that could interfere with their ability to func-
tion (Academy of Pediatrics, 2006). Currently, there is a
national initiative in primary care to improve the mental
health of children and adolescents (Stephan, Weist, Kataoka,
Adelsheim, & Mills, 2007). School nurses can play a key
role in providing primary care to students and in identifying
the subtle symptoms associated with mental health issues
(DeSocio & Hootman, 2004; Pryjmachuk, Graham, Haddad,
& Tylee, 2011; Stevenson, 2010). Students often report to
the school nurse with somatic complaints, which are physi-
cal symptoms for which no medical cause can be identified
(Shannon, Bergren, & Matthews, 2010). Symptoms of anxi-
ety and depression are common in children with somatic
complaints (Campo et al., 2004). Screenings conducted by
school nurses in the school setting can augment the work
of mental health professionals by identifying those at risk
and expediting the connection to services. School nurses
have an understanding of mental health issues and thus can
expedite linkages with school-based mental health profes-
sionals who facilitate prompt attention and care for the child.
Effective screening of children for symptoms of anxiety and/
or depression in the school setting could change school nurse
practice in school settings.
screening tool used by the school nurses in this urban school dis-
trict and the Pennsylvania Department of School Health had no
prescribed tool or template for school nurses to use in conduct-
ing mental health screenings, although they viewed mental
health screening as an integral part of a child’s comprehensive
health assessment. The purpose of this quality improvement ini-
tiative was to have school nurses initiate the use of two validated
screening tools, the Patient Health Questionnaire–9 item (PHQ-
9; Stanford Patient Education Research Center, 2013) for
detecting depression in adolescents, and the 5-item Screen for
Child Anxiety Related Emotional Disorders (SCARED; Bir-
maher et al., 1999), for detecting anxiety in children in six
schools in this urban district. The screenings were conducted
before the routine physical examination of the sixth- and
ninth-grade students to identify children who had symptoms
of anxiety and/or depression. Students having positive screens
1
Pittsburgh Board of Education, Pittsburgh, PA, USA
2
School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
3
Center for Research and Evaluation, School of Nursing, University of
Pittsburgh, Pittsburgh, PA, USA
Corresponding Author:
Virginia L. Allison, DNP, FNP, Pittsburgh Board of Education, Pittsburgh,
PA, USA.
Email: vallison1@pghboe.net

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166
were referred to the multidisciplinary Student Assistance Pro-
gram (SAP) team.
Background
The 2008 Position Statement of the National Association of
School Nurses (NASN) states that ‘‘mental health is as
critical to academic success as physical well-being. As mem-
bers of interdisciplinary teams, school nurses play a vital role
in supporting early assessment, planning, intervention, and
follow-up of children in need of mental health services’’
(National Association of School Nurses, 2008, p. 1). Schools
play an essential role in a student’s mental health (DeSocio
& Hootman, 2004). In 2002, the President’s New Freedom
Commission on Mental Health called for a complete redesign
of the way mental health care is delivered in the United States
(Stephan et al., 2007). The Commission stated that schools
play a key role in the improvement of mental health care for
children, as an estimated 20% of our population can be reached
in the school setting (Stephan et al., 2007) and schools have the
capability of screening large numbers of children (Nemeroff
et al., 2008). A summary of the Commission’s goals as they
pertain to the school setting include ‘‘reduce stigma, prevent
suicide, screen and treat co-morbid mental health and sub-
stance use disorders, and improve and expand school mental
health programs’’ (Stephan et al., 2007, p. 1331).
In a survey of school districts in Allegheny County, PA,
mental health was chosen as the second greatest area of
research interest and concern (A Research Agenda for Schools
in Allegheny County, 2010). Resources are limited in school
districts due to the state of the economy. It is crucial that each
school district employee’s skills and expertise are utilized
appropriately (DiMarco & Melnyk, 2009). The school nurse
is a frontline health professional and a trusted person to stu-
dents, parents, and staff (Baisch, Lundeen, & Murphy, 2011;
DeSocio & Hootman, 2004; Puskar & Bernardo, 2007). School
nurses who have mental health training as part of their nursing
education, can explain the role biophysiology plays in mental
health to students, parents, and staff, and may help lessen the
stigma associated with mental health conditions (Stevenson,
2010). School nurses routinely perform assessments on stu-
dents, so adding screening to detect mental health concerns
is a natural extension.
Scope of the Problem
Approximately 20% of adolescents have a diagnosable mental
health disorder (Mental Health Disorders, n.d.; U.S. Depart-
ment of Health & Human Services, 2013). In 2011, 28.5% of
students nationwide felt sad or hopeless almost every day for
2 or more weeks in a row (Youth Risk Surveillance, 2011). The
majority of children and adolescents with mental health issues
do not receive services for their mental health disorder; when
they do receive mental health treatment, the school is their
primary source for treatment (DeSocio & Hootman, 2004).
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The Journal of School Nursing 30(3)
Depression
According to the National Institute of Mental Health
(2013b), about 11% of adolescents have a depressive disor-
der by age 18. The American Academy of Child and Adoles-
cent Psychiatry (AACAP, 2007) estimated that 2% of
children and 4–8% of adolescents have a major depressive
disorder. Females with depression outnumber males by a
2:1 ratio in adolescence and are equal in number during child-
hood (AACAP, 2007). Only half of the adolescents who have
depression are diagnosed before they reach adulthood (Zuck-
erbrot, Cheung, Jensen, Stein, Laraque, & the GLAD-PC
Steering Group, 2007). Of the adolescents who are diagnosed
with depression, only a fourth to a third of those adolescents
are receiving treatment for their depression (Zuckerbrot,
Maxon, Pagar, Davies, Fisher, & Shaffer, 2007). According
to the Center for Disease Control and Prevention in the United
States, in 2013 there were 1,442 suicide deaths in youth aged
11–18, which made suicide the second leading cause of death
in this age group (Centers for Disease Control and Prevention,
2013). Every year approximately 20% of adolescents think
about suicide and 5–8% attempt suicide (Wintersteen,
2010). Suicide risk is higher in youth with depression (DeSo-
cio & Hootman, 2004). Youth with depression are also at
greater risk of ‘‘substance abuse (including nicotine depen-
dence), legal problems, exposure to negative life events,
physical illness, early pregnancy, and poor work, academic,
and psychosocial functioning’’ (AACAP, 2007, p. 1506).
Mood disorders have high prevalence, morbidity, and mortal-
ity, yet when correctly diagnosed and treated, patients
respond well (Andreasen & Black, 2006).
Anxiety
According to the National Institute of Mental Health
(2013a), 8% of teens aged 13–18 have an anxiety disorder
and symptoms start around age 6. According to AACAP
(2007), a review of studies revealed a prevalence rate for
anxiety in childhood at 6–20%, making anxiety one of the
most common forms of mental health disorders in children
and adolescents. Fear and worry are normal in children, but
when these fears persist, they may become anxiety (Shafer,
2010). Children often present with somatic complaints such
as a stomachache or headache. In a study by Campo and col-
leagues (2004), 42 children between the ages of 8 and 15
who presented to Primary Care with recurrent abdominal
pain (RAP) were compared to controls without RAP. This
study found that 79% of the children with RAP had an anxi-
ety disorder and 43% had a depressive disorder when com-
pared to controls without RAP (10.5% had an anxiety
disorder and 8% had a depressive disorder) and that the anxi-
ety disorder preceded the RAP symptoms. In a review of
evidence-based literature on somatization in school-age
children, somatizing children had higher levels of mental
health problems (anxiety and depression) than their peers
(Shannon et al., 2010).
Allison et al.
Mental Health Disorders and School Performance
School behavior problems, academic difficulties, and incon-
sistent school attendance are early or actual signs of mental
health problems in students (DeSocio & Hootman, 2004).
These are externalizing disorders that are easy for school
personnel to identify in the school setting (Weist, Rubin,
Moore, Adelsheim, & Wrobel, 2007). The internalizing
disorders such as depression, anxiety, and suicide ideation
are more subtle and more difficult for school personnel to
identify (DeSocio & Hootman, 2004; Weist et al., 2007).
In a cross-cultural study of three countries investigating
depressive symptoms in urban adolescents, depressive
symptoms were associated with increasing levels of interna-
lizing as well as externalizing problems (Ruchkin, Sukho-
dolsky, Vermeiren, Koposov, & Schwab-Stone, 2006).
According to the Student Assistance Program Statistical
Report for this urban school district in 2010–2011, mental
health concerns were not the primary reason for referral.
The top four reasons for referral were behavioral con-
cerns (46.8%), social concerns (43.6%), academic concerns
(24.4%), and attendance (17.4%). Mental health was not spe-
cifically listed, but suicide ideation/gesture/or attempt had a
2.2% referral rate and self-harm/injury had a 1.2% referral
rate. This supports a need to screen for and identify symptoms
of depression and anxiety in their earliest stages, because they
may precede school behavior problems, academic difficul-
ties, and school attendance issues. Children who have disrup-
tive and aggressive behaviors at an early age are more likely
to have more complicated mental health disorders over time
(DeSocio & Hootman, 2004). Students who change schools
can have a higher level of stress, which puts them at risk
of anxiety disorders, depression, and disruptive behavior
(DeSocio & Hootman, 2004). Depression often co-occurs
with posttraumatic stress disorder (PTSD), and this affects
school performance (DeSocio & Hootman, 2004). PTSD is
more common in low-income, inner-city neighborhoods
where children and adolescents have a much higher inci-
dence (4- to 10-fold) of violent crime exposure compared to
their nonurban counterparts (DeSocio & Hootman, 2004).
There is a two-way relationship between school performance
and mental health disorders: Children who have mental
health problems are at risk of poor school performance and
children who have difficulty with learning are more at risk
of mental health problems (DeSocio & Hootman, 2004).
SAP
School nurses are members of the SAP team per Pennsylvania
SAP guidelines. The SAP has four phases which include (a)
referral, (b) team planning, (c) intervention and recommenda-
tions, and (d) follow-up and support. The SAP team begins fact
finding through discussions with the referral source (in this
case the school nurse) and initiates parent contact and a student
interview. The team builds a composite of information gath-
ered and holds a conference with the parent and student.
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167
Support service options are presented to the parent and student.
Parent and student can choose in-school or community-based
services. Every school in this urban district is licensed by the
state and the county as a school-based outpatient mental health
facility to provide treatment to students and their families on-
site in the school setting.
Urban Impact
Urban youth present to the school setting with multiple risk
factors. Children and adolescents who live in urban neigh-
borhoods have a 50–96% rate of exposure to some form of
violence (Fowler, Tompsett, Braciszewski, Jacques-Tiura,
& Baltes, 2009). This violence remains a constant for these
children and adolescents who cannot escape it (Fowler et al.,
2009). There is a positive correlation between exposure to
community violence and mental health symptoms, espe-
cially PTSD (Fowler et al., 2009). It is crucial to have a
collaborative effort among administrators, school nurses,
social workers, teachers, and staff. They all have different
scopes of practice and perspectives; yet, when working as
a team can have keener, sharper eyes to identify at-risk youth
even earlier and link them to care in a more seamless way.
Some families report negative experiences when seeking
mental health services for their child outside the school setting.
Many urban parents rely on the school to help their child in
every facet of life including mental health. Those on the out-
side looking in at the urban school often stigmatize urban
youth. Care provided in the school setting can be
destigmatized for the student/family as it is the normal school
culture for them. Mental health therapists in the school setting
have a very low missed appointment rate as the student has to
attend school. Outpatient therapy in the clinical setting has a
much higher rate of missed appointments, which is costly to
a mental health agency and also costly to the student in terms
of their health and well-being. This school district has not been
overburdened because as the schools identify more students
with mental health concerns, mental health agencies provide
more in-school therapists who are assigned to our SAP teams
to meet the demand. These services are accessible and already
in place. When a student needs more intensive therapy/treat-
ment than can be provided in the school setting, the student
is already known to the school staff, the mental health therapist
and their agency, which allows for expedited intensive mental
health services for the student. The therapist can quickly triage
the student to a more appropriate level of care, often more
intensive in nature.
Method
Design
The project director enlisted the support of six master’s
prepared Pediatric Nurse Practitioners (PNP’s) and Family
Nurse Practitioners (FNP’s) who are also employed as certi-
fied school nurses in this school district to administer the
168
screening tools as part of their comprehensive physical
examination routine. These six attended a training session
conducted by the project director. This 3-hr training
included an overview of the problem, goals of the Presi-
dent’s New Freedom Commission on Mental Health in
schools, an orientation to the screening tools, and the actual
implementation procedure.
The Commonwealth of Pennsylvania mandates that all stu-
dents receive physical examinations in kindergarten, 6th, and
11th grades, which represent important developmental peri-
ods. This school district adopted a modified examination
schedule with state approval, screening students in 9th grade
rather than 11th grade to lessen the developmental gap
between Grades 6 and 11. The mandated physical examina-
tions can be conducted by the child’s primary care provider
or performed by the PNP or FNP at school with parental
consent. Students with parental consent to have a physical
examination in school were asked to complete the PHQ-9 and
5-item SCARED as part of their examination.
This School District’s institutional review board (IRB)
approved this project with the stipulation that we inform the
parent in writing of the additional 14 screening questions
that would be included in the sixth- and ninth-grade physical
examination and allow the parent the opportunity to decline
these screening questions for their child. A letter was drafted
and mailed to the home of each parent who had given con-
sent for their child to have the state-mandated physical exam
at school. The project was submitted to the University of
Pittsburgh IRB and deemed exempt, as this was considered
a quality improvement initiative.
The U.S. Preventive Services Task Force (USPSTF)
recommends screening of adolescents 12–18 years of age for
major depressive disorder as long as appropriate supports are
in place for ‘‘accurate diagnosis, psychotherapy, and follow-
up’’ (U.S. Preventive Services Task Force, 2009). The
USPSTF concluded that there was not enough current evi-
dence of benefits versus harms to recommend screening
children 7–11 years of age (U.S. Preventive Services Task
Force, 2009). Despite the lack of evidence for screening
children aged 11, it was decided to include sixth graders in
our target group as only 10 children (5.5%) were aged 11.
Setting
Six schools (two located in the east, two located in the north–
central, and two located in the south–west regions of the city)
were selected as sites for this project based upon their strong
SAP and linkage with mental health care on-site in the schools.
Instruments
Two screening tools were used: the PHQ-9 for identifying
depressive symptoms and the 5-item SCARED for identify-
ing symptoms of anxiety. The PHQ-9 was originally used in
the adult population and was shown to have good sensitivity
and specificity among adolescents aged 13–17 (Richardson
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The Journal of School Nursing 30(3)
et al., 2010). The PHQ-9 was not validated in children under
the age of 13, but it was decided to use this tool with sixth
graders in order to identify students at an earlier age. A
PHQ-9 score of 11 or higher had a sensitivity of 89.5% and a
specificity of 77.5% for identifying youth who met Diagnostic
and Statistical Manual of Mental Health Disorders, Fourth
Edition, Text Revision criteria for major depressive disorder
(Richardson et al., 2010). The receiver operator curve (ROC)
for detecting major depression was 0.88 (95% confidence
interval: [0.82, 0.94]) per Richardson et al. (2010). The
PHQ-9 has nine questions that the student answered as not at
all (0), several days (1), more than half the days (2), or nearly
every day (3). Symptom severity is assessed on a scale of 0–3
for the preceding 2 weeks. The score can range from 0 to 27.
Children receiving a score of 11 or higher on the PHQ-9 in this
quality improvement initiative were referred to the SAP team.
The SCARED anxiety rating scale was specifically devel-
oped for children and adolescents. It consisted of 41 questions
and was validated in multiple studies identifying anxiety
symptoms in children aged 8 and above (Birmaher et al.,
1999). The shortened version of the SCARED consists of 5
questions and was developed by the authors of the 41 question
SCARED (Birmaher et al., 1999). The 5-item SCARED has a
sensitivity of 74% and a specificity of 73% (Birmaher et al.,
1999). The psychometric properties of the 5-item SCARED
and the 41-item SCARED were similar for the parent and
child forms, and the ROC for the scales were not significantly
different (Birmaher et al., 1999). Based on the sensitivity and
specificity of the 5-item scale, the authors used a cutoff of 3
(¼ or >) for discriminating anxiety from nonanxiety (Birma-
her et al., 1999). Symptom severity is assessed on a scale of
0–2 for the preceding 3 months. Zero (0) meaning not true
or hardly ever true, one (1) meaning sometimes true, and two
(2) meaning true or often true. The score can range from 0 to
10. Students scoring 3 or above on the SCARED were
referred to the SAP team. This shortened version was selected
for ease of use as well as an abbreviated amount of time to
complete compared to the longer version.
Both the PHQ-9 and 5-item SCARED were ultimately
selected, as they offered the following advantages for
screening sixth- and ninth-grade students in the public
school setting: brevity without sacrificing specificity or sen-
sitivity, use of age-appropriate language, ease of administra-
tion and interpretation, and existence in the public domain
allowing cost-effective screening (Richardson et al., 2010).
Intervention
The screening tools were administered to the students at the
time of their state-mandated physical examination. Only one
(0.37%) parent wrote a note to have her child opt out of the
mental health screening. The students already completed a
short health questionnaire using pencil and paper and were
asked to complete the two short screening tools using pencil
and paper. The directions on how to complete the screens
Allison et al.
Table 1. Summary Statistics (N ¼ 182).
Screen/Screens N (%) M + SD
PHQ-9
Positive 21 (11.54) 14.67 + 3.50
Negative 161 (88.46) 3.48 + 2.92
SCARED
Positive 50 (27.47) 3.82 + 1.92
Negative 132 (72.53) 0.87 + 0.81
Both PHQ-9 and SCARED
Positive/Positive 14 (7.69) (15.14 + 3.48), (3.71 + 0.73)
Negative/Positive 36 (19.78) (5.58 + 2.81), (3.86 + 2.23)
Positive/Negative 7 (3.85) (13.71 + 3.59), (1.00 + 0.58)
Negative/Negative 125 (68.68) (2.87 + 2.67), (0.86 + 0.83)
Note. PHQ-9 ¼ Patient Health Questionnaire—9 item; SCARED ¼ Screen
for Child Anxiety Related Emotional Disorders.
were at the top of each screening tool and the school nurses
were available for any questions from the student. The
school nurse scored the screening tools and reviewed them
with the students during their mandated physical exam.
When a positive score was noted, the school nurse informed
the parent or guardian and then made a formal referral to the
SAP team using the standard SAP referral form. If the
student answered PHQ-9, question #9, with a positive
response, stating that they would be better off dead or of
hurting themselves in some way, there was an immediate
evaluation by the school social worker or school nurse. This
included a history, risk assessment, and recommendations.
Students having a known mental health disorder and under
care were not screened. The school nurse documented the
names, birth date, and screening tool score results on a log
developed by the project director. All completed screens
were placed in the student’s medical record that is kept in
a locked filing cabinet in each school.
The parent of any child with a positive screen received a
phone call from the school nurse, or a letter if they could not
be reached by phone, to inform them of the positive screen-
ing result and referral to the SAP team. All students with a
positive screening score were referred to the SAP team at
their school unless their parent refused the referral.
Results
Overall, 182 students completed both the PHQ-9 and the
SCARED screens. Positive screens were noted for a total of
57 (31.32%) students. Twenty-one (11.54%) had a positive
PHQ-9 screen (14.67 + 3.50) and 50 (27.47%) had a positive
SCARED screen (3.82 +1.92). There were 14 students
(7.69%) who had both a positive PHQ-9 and a SCARED
screen (see Table 1).
As noted in Table 2, females had more positive screens
than males for both the PHQ-9 (14.0% vs. 9.0%) and the
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169
SCARED scores (44.1% vs. 10.1%). The percentages are
based on the number of positive scores in the subcategories
(e.g., 44.1% positive SCARED score for females is expressed
as a percentage of females [41 of the 93] as contrasted to the
entire population screened [182]). Significantly more females
than males had positive SCARED scores (p < .0001).
No significant differences were noted regarding race, age,
or grade level. Lunch status was included as a measure of
family income. There was no significant difference between
free/reduced and regular lunch status of the student. For stu-
dents having a body mass index (BMI) < 5%, over half
(62.5%) had a positive SCARED score, while 25% had a
positive PHQ-9. For students having a BMI > 95%, over one
third (33.3%) had a positive SCARED score, while 15.4%
had a positive PHQ-9. There was a high correlation between
the PHQ-9 score and the SCARED score (correlation coeffi-
cient ¼ .39224, p value < .0001).
Discussion
As a result of these positive screens, eight (14.0%) students
were diagnosed with depression, four (7.0%) students were
diagnosed with attention deficit/hyperactivity disorder, one
(1.75%) student was diagnosed with oppositional defiant
disorder, one (1.75%) student was diagnosed with obses-
sive–compulsive disorder, one (1.75%) student was diag-
nosed with bipolar disorder, and one (1.75%) student was
diagnosed with insomnia. One (1.75%) student was involun-
tarily committed to a psychiatric hospital for suicidal idea-
tion, one (1.75%) student was placed in a partial hospital
program, and one (1.75%) student was referred to Alateen
as her life had been affected by her mother’s alcoholism.
Seven (12.28%) students received in school therapy, four
(7.02%) students received both in school and out of school
therapy, six (10.53%) students received out of school ther-
apy, and six (10.53%) students did not need formal therapy
but are being monitored by the school social worker. It
should be noted that unless the parent or student gave con-
sent to release confidential information to the school, the
school could not be informed of the evaluation/treatment
of the student by the provider. Screening for anxiety and
depression is a crucial first step in the early identification
of children and adolescents who may benefit from care by
mental health specialists.
At the conclusion of this quality improvement initiative,
the project director conducted a follow-up meeting with the
school nurses to learn what was beneficial and what could be
improved upon. All six school nurses thought the addition of
these screening tools opened up a channel to talk with the
students and parents in a deeper and more personal way
about some serious issues going on in their lives.
Two of the three school nurses of sixth-grade students
reported that some of the sixth graders had difficulty under-
standing the directions and time intervals with the PHQ-9
screen. Because of this difficulty, a strategy is needed to address
170 The Journal of School Nursing 30(3)

Table 2. Demographic Data.

Positive PHQ-9 Negative PHQ-9 Positive SCARED Negative SCARED

(n ¼ 21) (n ¼ 161) p Value (n ¼ 50) (n ¼ 132) p Value

Sex
Male (n ¼ 89) 8 (9.0%) 81 (91.0%) .29 9 (10.1%) 80 (89.9%) <.0001
Female (n ¼ 93) 13 (14.0%) 80 (86.0%) 41 (44.1%) 52 (55.9%)
Race
Black (n ¼ 98) 10 (10.2%) 88 (89.8%) .44 29 (29.6%) 69 (70.4%) .75
White (n ¼ 66) 10 (15.2%) 56 (84.8%) 16 (24.2%) 50 (75.8%)
Other (n ¼ 18) 1 (5.6%) 17 (94.4%) 5 (27.8%) 13 (72.2%)
Grade
6 (n ¼ 37) 4 (10.8%) 33 (89.2%) 1.00 12 (32.4%) 25 (67.6%) .45
9–11 (n ¼ 145) 17 (11.7%) 128 (88.3%) 38 (26.2%) 107 (73.8%)
Lunch status
Free/reduced (n ¼ 127) 14 (11.0%) 113 (89.0%) .74 35 (27.6%) 92 (72.4%) .96
Regular (n ¼ 55) 7 (12.7%) 48 (87.3%) 15 (27.3%) 40 (72.7%)
BMI
<5% (n ¼ 8) 2 (25%) 6 (75%) .17 5 (62.5%) 3 (37.5%) .06
5–85% (n ¼ 96) 11 (11.5%) 85 (88.5%) 21 (21.9%) 75 (78.1%)
>85–<95% (n ¼ 32) 1 (3.1%) 31 (96.9%) 10 (31.25%) 22 (68.75%)
95% or > (n ¼ 39) 6 (15.4%) 33 (84.6%) 13 (33.3%) 26 (66.7%)
Age
12 and < (n ¼ 36) 4 (11.1%) 32 (88.9%) .93 12 (33.3%) 24 (66.7%) .38
13 and > (n ¼ 146) 17 (11.6%) 129 (88.4%) 38 (26.0%) 108 (74.0%)

Note. BMI ¼ body mass index; PHQ-9 ¼ Patient Health Questionnaire–9 item; SCARED ¼ Screen for Child Anxiety Related Emotional Disorders.

the student’s reading and literacy skills. Reading the screening
instructions on their own was problematic, but when the School
Nurse read the instructions and questions out loud with them,
they seemed to understand and answer the question accurately.
Many urban youth are below grade level in their reading and lit-
eracy skills and also experience test-taking anxiety. The school
nurse could give the student the option of having the nurse read
the instructions and questions aloud. This may ease the experi-
ence of answering the screening questions and accommodate
the students’ limitations. If this screening program is imple-
mented system wide, it should be expanded to include all phy-
sicals performed by PNP’s and FNP’s. In the 2011–2012 school
year, the school nurses who are PNP’s and FNP’s performed
2,883 mandated physicals district wide and 3,059 other physi-
cals including sport, work permit, and driver permit physicals.
The number of screens performed could be doubled if nonman-
dated physicals are included in the screening program.
Limitations
Implementers of a future system wide screening program
should consider replacing the PHQ-9 with the PHQ-A
(Mayo Clinic, 2012). The PHQ-9 has been modified for ado-
lescents, the PHQ-A Depression Screen. It uses additional
words geared to the adolescent such as irritable, weight loss,
school work, and has the addition of two yes/no questions at
the end about suicidal thoughts and attempts.
Five of the six school nurses became aware of students
who were already receiving mental health treatment after
screening and referring them to the SAP team. Prior to this,
the school nurse was unaware that the student was in
treatment. There is a need to improve the system of commu-
nication between the school nurse and school-based SAP
coordinator regarding students receiving treatment.
Practice Implications
The school nurse’s expertise contributes to school-wide efforts
to close the gaps between acknowledgment of a child’s mental
health needs and accessing care. Having another health profes-
sional on-site to screen children only strengthens our efforts to
not allow any child to ‘‘fall through the cracks.’’ Children’s
mental health problems can present in a variety of ways. It is not
unusual for children who are high achieving and well attending
to mask their depression/mental health concerns. It is also easy
for educators to miss red flag warning signs in children with
high academic achievement. Effective screening of children for
symptoms of anxiety and/or depression in the public school set-
ting could change and strengthen school nurse practice in
school settings. School districts need to address the issue of
mental health screening in the school setting. School health ser-
vices need to update the health history forms to incorporate
social, emotional, and behavioral health information. This qual-
ity improvement initiative shows a need to screen for symptoms
suggestive of anxiety and depression in the school setting.
These brief screens improved the early identification and refer-
ral for treatment of children suffering from symptoms of
depression and/or anxiety by expediting the connection to ser-
vices. If students are identified earlier and receive appropriate

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Allison et al.
interventions, this may minimize the difficulties they experi-
ence as they go through school (Stevenson, 2010).
Recommendations for Future Study
It is recommended that this quality improvement initiative be
expanded to the entire school district. It should be offered and
possibly implemented in schools throughout Pennsylvania and
nationally as long as supports are in place to handle the positive
screens (accurate diagnosis, psychotherapy, and follow-up).
This school district is in a unique situation, with a strong, 28-
year-history of a SAP that includes a school-based model for
mental health services. All of the schools are licensed as mental
health facilities, with the accompanying supports in place to
handle positive screens, which many districts may not have.
It is recommended that PTSD be further studied in the
inner-city school setting, as depression and anxiety are fre-
quently comorbid conditions with PTSD, all of which affect
school performance. Also, PTSD is more common in low-
income, inner-city neighborhoods where youth have a higher
exposure to violent crimes (DeSocio & Hootman, 2004).
Acknowledgments
Special thanks to my colleagues who implemented the screening
tools in their schools: Lucretia Anderson, FNP, Kathy Crisanti,
PNP, Bridgetta Devlin, PNP, Linda Diskin, FNP, Wendy Emery,
FNP, and Cindy McQuaide, PNP.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biographies
Virginia L. Allison, DNP, FNP, is a certified school nurse at
Pittsburgh Board of Education, Pittsburgh, PA, USA.
Donna G. Nativio, PhD, CRNP, FAAN, is an associate professor
at School of Nursing, University of Pittsburgh, Pittsburgh, PA,
USA.
Ann M. Mitchell, PhD, RN, FAAN, is an associate professor at
School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
Dianxu Ren, PhD, is a faculty director at Center for Research and
Evaluation, School of Nursing, University of Pittsburgh, Pittsburgh,
PA, USA.
Janet Yuhasz, M Ed, is a student wellness coordinator at Pitts-
burgh Board of Education, Pittsburgh, PA, USA.