As a result of COVID-19, isolation, interpersonal tensions, losses of loved ones, barriers to extended family supports, poverty, job insecurity, and lack of socialization with other children and teens have been a cumulative and interactive burden for communities throughout the United States and elsewhere. The bell-shaped curve demonstrating the distribution of psychosocial disorders in our population has shifted to the right, meaning that the prevalence and severity of a wide range of problems have increased.
Anxiety and depression were already common disorders among teenagers and adolescents, who are especially sensitive to the layered consequences of COVID-19. There is growing concern that the pandemic has added to the rising rate of adolescent suicide and that any increase in depression will also increase the number of adolescents with suicidal ideation. (1,2)
Now that the pandemic is being brought under better control and schools are reopening, the structure of school, activities, and social relationships will likely help some adolescents feel less depressed and anxious. Many psychologists have hypothesized, however, that the byproducts of COVID-19 (ie, persistent isolation during quarantine, financial strain, and sickness or death in the family) will have lasting effects on adolescent mental health. These effects may be further exacerbated by the stresses related to reestablishing social relationships, shifting from remote school to the intensity of a classroom, and facing the burden of "catching up" on their academic work and testing (particularly for students with higher support needs and/or those without adequate access to technology over the past year). Because adolescence is a time of such rapid change, every year marks a further blossoming of identity and concomitant stresses, and this second year of COVID-19 dramatically increases the need to assess the psychosocial functioning of adolescents.
How should pediatricians in primary care approach the recognition and management of psychosocial concerns in adolescents who are facing the usual developmental challenges intensified by COVID-19? How should pediatricians assess severity and whether additional primary care management or referral is appropriate? How should they frame their role in adolescent suicidal ideation and suicide prevention? What is the role of primary care follow-up?
Although parent observations and questions about their child's mental well-being are always useful in encouraging recognition during a pediatric office visit, parents may not have the awareness or comfort to discuss potential problems in this setting, especially at an early point in adolescent psychosocial disorders. Screening all adolescents for general psychosocial problems and/or depression (3) is the recommended and effective approach to recognition and is now a quality standard of the American Academy of Pediatrics, Medicaid, and the US Preventive Services Task Force, paralleling screening for growth and health indicators (eg, hematocrit, urine). Screening has been facilitated by electronic medical record (EMR) systems that allow parents and teenagers to complete screens online or on electronic devices, then automatically score and post the information in the EMR prior to the visit.
For broad psychosocial screening as well as depression screening, the Pediatric Symptom Checklist (PSC) is a validated, approved, and widely used questionnaire....