147. Addressing Common Mental Disorders in Today’s Youth: Roundup on Adolescent Health PT2

On this compelling episode of NP Pulse: The Voice of the Nurse Practitioner®, Dr. Jessica Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN, and guest Dr. Ashley Hodges, PhD, CRNP, WHNP-BC, PMHNP-BC, FAANP, FAAN, dive deep into the adolescent mental health crisis, shedding light on the alarming trends affecting today’s youth. From the long-term impacts of the COVID-19 pandemic to the pressure of growing up in a hyper-connected digital world, this discussion explores critical risk factors, early warning signs and practical strategies for nurse practitioners (NPs) and families alike.

This episode also emphasizes the importance of upstream prevention, holistic care, reducing stigma and integrating mental health support into primary care. Drawing from decades of clinical experience, Jessica and Ashley offer compassionate, expert insight on how to recognize and respond to adolescent mental health challenges, while highlighting resources, screenings and training opportunities for NPs committed to making a difference.

Episode Transcript

(00:00):
(upbeat music)
- From the American Associationof Nurse Practitioners,
this is Cammie Hauser, nursepractitioner, nurse midwife,
and AANP education specialist.

(00:21):
(upbeat music)
Welcome to this edition

of "NP Pulse (00:30):
The Voice of the Nurse Practitioner,"
AANP's official podcast,
bringing unique nurse practitioner voices
and expertise on issues that matter most
to NPs and to our patients.
As always, be sure tosubscribe to this podcast,
share with your colleagues,and check back often
for new conversationswith nurse practitioners

(00:52):
and healthcare leadersfrom across the nation.
In this second of fourepisodes on adolescent health,
host Jessica Peck and Ashley Hodges
draw on their near 65 yearsof combined experience
to tackle one of the most urgent topics
facing today's youth,adolescent mental health
from the long-term effectsof the COVID-19 pandemic

(01:16):
to the pressures of digitallife and social media.
This episode explores the many factors
contributing to the currentmental health crisis
among teens.
Jessica and Ashley
offer practical guidancefor nurse practitioners,
including how to recognizeearly warning signs,
implement evidence-based screening tools,

(01:37):
support families without stigma,
and integrate behavioral healthinto primary care settings.
Listeners will gain insight
into common mental healthdisorders in adolescents,
such as anxiety, depression, ADHD,
eating disorders and self-harm,
along with strategies forhealth promotion and prevention.

(01:58):
The hosts also highlightcritical NP's specific resources
and certifications thatcan empower clinicians
to better support patientsand their families.
Whether you're a seasonedNP or new to practice,
this conversation providesboth the clinical wisdom
and compassionate perspective
needed to make a meaningful impact

(02:20):
in adolescent mental health care.
This podcast episode includes discussions
about adolescent behavioral challenges,
including topics such asself-harm and suicide.
These conversations areintended to raise awareness
and promote understanding,
but they may be distressing or triggering
for some listeners.

(02:40):
We encourage you toprioritize your wellbeing.
Please consider skipping this episode
if you are in a vulnerable state
or if you know someone is struggling,
we urge you to seek support
from a trusted mental health professional
or contact a crisis resource in your area.
- Hello, everyone, and welcome
to this second episode of a podcast series

(03:04):
dedicated to adolescent health.
If you missed the first episode,go back and take a listen.
It's teen dating violence
and today, we're going totalk about mental health
in adolescents.
This is brought to you
by the American Associationof Nurse Practitioners.
I will be with you for the next hour.
My name is Jessica Peck.
I am a clinical professor ofNursing at Baylor University.

(03:27):
I am also a pediatric nursepractitioner in primary care,
have been doing that formore than 20 years now,
and I think most importantly,I'm a mom of four.
I am living, breathing all of this.
I have four teens, young adults,
so this is something that'sreally important to me
personally and professionally,
and I know it is to youtoo because you're here.

(03:49):
And who is here with me ismy co-host Ashley Hodges.
Dr. Hodges, introduce yourself.
- Thank you so much, Jessica.So, I am Ashley Hodges.
I am a dual certified women'shealth nurse practitioner
and a psychiatric mentalhealth nurse practitioner.
I tell people I do (indistinct)
and that just kind ofsums it up a little bit.

(04:11):
I am retired from academia.
I was previously the associatedean over graduate programs
at the University of Alabama at Birmingham
and retired about three years ago
and decided to really pursue
what we all go into this profession for,
and that is to continueworking with patients.
So, I currently am in private practice
with River Region Psychiatry Associates

(04:33):
based out of Alabama,
where I am a psychiatric mentalhealth nurse practitioner.
And my specialty, I see allages and all conditions,
but my specialty is dealingwith victims of trauma.
I also am a nurse practitioner
and utilize my women's health skills
and my psychiatric mental health skills
at Children's of Alabama, whereI am the clinic coordinator

(04:55):
and the nurse practitionerfor the Sunrise program.
And the Sunrise program is a clinic
dedicated to treating minorvictims of sex trafficking.
So, I am pleased to be here.
- Me too, Ashley.
And that's something thatyou and I both have in common
is both of us work extensively
in the human trafficking arena.
And we work with advocacy against that,

(05:17):
providing providers witheducation about human trafficking.
And both of us though
have the heartbeat of a nurse practitioner
and that is for prevention.
And we see all of theseupstream risk factors
for human trafficking
and other kinds of traumathat adolescents experience.
And so, I know we're goingto talk about that today
and really take this froman upstream approach,

(05:38):
how can we prevent it
and then, how do werespond when it's there.
We're going to talk
about the current adolescentmental health crisis.
And Ashley, I'm sure youhave the same experience.
Everywhere I go, people are asking me,
"Is it really as bad as people say it is?
Is it really a crisis?"
And you know, Ashley, as a nurse,

(05:59):
as the most trusted profession,
it's important to me tobe trustworthy and honest
in my answer.
And I tell them,
"No, it's not as bad aspeople are saying it is,
it's worse.
It is infinitely worse."
I've been a pediatric nurse practitioner
for more than 20 years,
in pediatrics for almost 30 years now.
I'm a dinosaur in nursing.

(06:19):
And Ashley, I've never seen itthis bad. What do you think?
- I agree with you.
And you know, one thing that I tell people
is that when we look at the statistics
about one in five adolescents
experience a mental health disorder,
and we'll definitely get into details
about what we mean when wesay mental health disorders.
As a psych mental healthnurse practitioner,

(06:40):
I have to preface this by saying
that there are normalups and downs of life,
but that does not mean thatthey don't need to be addressed.
So not only are we dealing
with the normal ups and downs of life,
we're also dealing with changing hormones
and the pressures of being an adolescent.
Then, you add on top of that social media,
mass violence, political polarization.

(07:02):
And to the young person,this can seem insurmountable.
And people ask me often,
"Did the COVID-19pandemic make this worse?"
And that is kind of one of thebiggest questions that I get,
and here's what I tell people.
In the 10 years leadingup to the pandemic,
we were already seeing an increase
in persistent sadness, hopelessness,

(07:24):
and suicidal thinking and behaviors.
But what happened with the pandemic
is that we saw anunprecedented, in our lifetime,
social isolation, academic disruption,
loss of caregivers.
They estimate that around200,000 children and adolescents
lost a caregiver duringthe COVID-19 pandemic.
Parents lost their jobs,which caused economic strain,

(07:47):
and we know there was an increase
in physical and emotional abuse.
So yes, I agree with you.
We are seeing this escalate
and we've been seeing this escalate
to get us to the point where we are now.
- I agree that COVID was a significant
social, emotional, andpsychological injury.
You know, I think about my own daughter
who was a senior in highschool when COVID started.

(08:07):
And she came to me one day and said,
"You know, mom, everything you told me
about how the world was goingto go is just, it's gone.
There is no SAT. There may be no college.
There's no prom. There's no graduation."
And I look back at thesignificance of that, Ashley,
and we see these generational moments,
where we see the greatest generation,

(08:28):
who knew where they were on VE day.
And baby boomers knew
where they were when JFK was assassinated.
As Gen X, we know where we werewhen the challenger exploded
and millennials knowwhere they were on 9/11.
This generation is goingto look back and say,
"Where were you when quarantine started?
Where were you when the world shut down?"

(08:49):
And this is a generationthat was born post 9/11,
so they already view the world as unsafe.
And then, we add to that living
at the speed of a smartphone.
I think that has made thisgeneration deeply anxious,
because everything, allof the world's bad news
is delivered to them in a moment,
where we got it in little moderated doses.

(09:10):
And the world was pretty small
when we were growing up, Ashley.
We saw things thathappened in our community,
or maybe we would seebad news on nightly news
or our parents would tell us about it.
Now, students can see that happening live.
And if they click on one video,
then the algorithm feeds them more
and then all of a sudden,it's shaping their worldview.
I think the otherinteresting thing about this

(09:31):
is the conversationthis generation, Gen Z,
and now, Gen Alpha, ishaving about mental health.
And we saw this reallykind of come to a head
when Simone Biles withdrewfrom the last Olympics.
And the public narrativewas very divided on this.
Some called her a hero,some called her a traitor.
I mean, this is the kind of language

(09:51):
that Gen Z was watching,
and I honestly reject both of those.
I think in that moment,she was simply a human.
And there is a balance to this, Ashley,
because there's so muchnegative talk about Gen Z,
how they're snowflakes, they're weak,
they can't handle emotions.
I think they're actuallyextraordinarily brave
to have conversations about mental health

(10:12):
that previous generationsjust refuse to have.
We still have those issuesin previous generations.
We see the greatestgeneration who was stoic,
and then that led to the silent generation
raised to be seen and not heard.
And I look back at that and I think,
"Well, of course they were,
because they didn't want totrigger their parents' trauma."
And then, we have baby boomerswho went on a hunt for love

(10:36):
and then, Gen X were the latchkey kids.
And then, Gen X raised millennials,
who love their parentsbut are mocked for it.
So, I see all of these generationalpatterns that are there,
but we know that there wasa jointly declared emergency
in children's mental health.
The surgeon general echoed this warning.
And I think it is something
that needs to catch our attention

(10:56):
because we see rising rates of suicide,
which is now the second leadingcause of death among teens.
But you know the other side of this,
the other balance of that isnot over medicalizing emotions.
And when we see the rise of social media,
this is what kids come in and ask.
They see all of these influencerstalking on social media.

(11:16):
They have one feeling of anxiety,one moment of depression,
and they wanna know if that's a diagnosis.
So somewhere in there,
I feel like we have to have a balance.
And when they come for a diagnosis,
that's what they're wanting to know.
And so, using yourexperience and expertise
as a mental health nursepractitioner, Ashley,

(11:38):
why don't you walk us through
some of the common mentalhealth disorders in adolescents
and what are they, what are we seeing,
and how do we weigh what risesto the level of diagnosis.
- And you bring an excellent point.
You know, people come in with symptoms.
And when we're talking about adolescents,

(11:58):
we're talking about children.
Those symptoms are often explained to us
by their caregivers.
And when they come in for treatment,
the first thing I do is say, you know,
"It just because you havesymptoms of depression
or symptoms of anxiety,do not be alarmed."
That does not mean thatyou're going to receive
a medical diagnosis ofmajor depressive disorder

(12:21):
or generalized anxiety disorder.
You know, there are symptomsthat are normal responses
to stress, and anxiety, and depression.
And then, there aresome abnormal responses.
And the first thing I start with
is talking about contributing factors.
You know, we have to remember,
there's a biological componentto any mental health issue.

(12:42):
Some of those are genetic,some of it's brain chemistry,
but there is a biological component.
We hear about the impact ofsubstance use, family conflict,
poverty, food insecurity, homelessness.
But two of the things thatwe don't often discuss
are the age of puberty decreasing
over the past few decades in females.
Think about the prefrontal cortex here.

(13:04):
The age of puberty's decreasing,
yet the prefrontal cortex isnot maturing at a faster rate.
And also chronic health conditions.
You know, think about children
with chronic health conditions.
We're finding now that thatsignificantly contributes
to the main mental healthissues that we're seeing.

(13:25):
So when you have patients in primary care
with chronic health conditions,
it is so critical to addresstheir mental health as well.
So, what type of things doyou need to be watching for?
Well, one are gonna beyour anxiety disorders,
and those can includegeneralized anxiety disorders,
social anxiety, panic disorders,
social phobias, and so forth.

(13:46):
And when we're talking about anxiety,
it's important to realize again,there is normal transient,
developmentally appropriateworries and fears.
And we have normal responsesto stressors in daily's life.
Everyone has some anxiety. It'sa natural survival response.
But if it's an extreme level,
what we see is that it starts affecting

(14:08):
their everyday functioning,
and at that time is whenthey need to seek help.
So, about 5% of children havesome type of anxiety disorder.
And with anxiety disorders,
regardless of whichdiagnosis they receive,
it involves excessive amounts of anxiety,
fear, nervousness, worry, and dread.

(14:29):
Also, they have physical sensations.
They're somaticize like chest pain,
heart palpitations, nausea.
They might have diarrhea,shortness of breath.
They may have stomach aches and headaches.
So when we start talking about children
missing a lot of schoolbecause of anxiety,
very often, we see thempresenting, "Mom, I have a,"
or "Dad, I have a headache."
"Mom, dad, I have a stomach ache."

(14:50):
And those are the they present with.
They also may presentwith signs of distraction,
seem a little hypervigilant.
You may find they'rehaving trouble sleeping.
Suddenly, their sleepingpatterns have change
or their eating habits have change,
either they're not eating
or they're eating a lot out of stress.
In adolescents, we talk alot about social anxiety,

(15:11):
and this is particularly troubling
because it interferes
with social relationships and self-esteem.
And what do we know about the importance
of social relationships and self-esteem
in adolescents and children?
Left untreated, it can lead to depression,
which could lead toeven more serious issues
that we'll talk about.

(15:32):
The other thing that we often see
in children and adolescents is depression.
And about 3% of childrenexperience symptoms
consistent with depression,true depression,
in about five to 8% of adolescents.
But I honestly think thatpercentage is a little bit higher.
There's a risk for suicidal behavior.
We start seeing problems
with school failure, poor relationships.

(15:55):
And when you're having allof these type of behaviors
and they're not doing well in school,
they have poor relationships.
They begin social isolating.
What happens is their long-term,I use the word career,
whether it's an academiccareer or an actual career,
affect long-term occupational outcomes.
So, depression can be chronic condition

(16:16):
that's going to have longlasting effects if not treated.
And that's why it's soimportant to get treatment.
The treatment is acombination of psychotherapy
and SSRI medications.
And together, they canreally go a long way
in addressing this issue
and getting the child oradolescent back to a level

(16:37):
where they're not experiencingdepressive symptoms.
And the major issue thoughis early identification
and appropriate treatment.
So, I always tell parents they worry
about, well, you know, shouldI try and handle this at home?
Should we go on a vacation? Seeif that makes things better.
Should I do this? Should I do that?
And I tell 'em this, I say, "Listen."

(16:57):
I'll say, "You know what?
Don't put that burden on your shoulders.
Don't try to be yourchild's healthcare provider.
Bring them to their pediatrician.
Bring them to a primary care provider.
Let them evaluate."
And I know in a little while,
Jessica will talk aboutintegration of behavioral health
and do primary care.
Let them do an evaluation.
And if they want to begintreating, that's appropriate.

(17:20):
If they feel it's more serious
and they need to be, you know, referred
to a mental health provider,that's fine as well.
But the big things areearly identification.
So, what do we see with depressed mood?
They're usually depressed mostof the day, nearly every day.
Now in children and adolescents,
this may come across asbeing in an irritable mood.
You know, what do you want to eat?
"I don't care."

(17:41):
You know, do you want to go somewhere?
"I don't care.
Stop doing this. Stop doing that."
It comes across as an irritable mood.
They really can't find things
that used to bring 'em pleasure.
Maybe they like to gooutside and play basketball.
Now, they don't wanna gooutside and play basketball.
They found interest in going to movies.
They don't wanna go to movies.
They may lose a significantamount of weight

(18:03):
or gain a significant amount of weight.
Significant changes in sleep patterns.
They're tired all the time.Guilt and worthlessness.
They also can have lack ofconcentration and indecisiveness
and they may withdraw,
in addition to this irritability.
Not only withdrawing fromfamily but also with friends.
They also can present with aches and pains

(18:25):
and you can't find anycause for aches and pains.
Now this is tricky because,
and I'm not a pediatricnurse practitioner,
so I'll say I know that all children
experience growing pains.
There are aches and pains that they have
as their body is changing.
But if they can't find a medical cause
and it doesn't coincidewith appropriate times
for these type of aches and pains,

(18:46):
aches and pains can occurwhen they're depressed.
And they can have thoughtsof death or suicide.
Now within depression,
I'm gonna talk aboutsuicide and self-harm.
And self-harm is reallyimportant for us to discuss.
It is a deliberate injurythat is inflicted by a person
on their own body, butrealize that it's done
without any suicidal intent.

(19:07):
So people say, "Well,then why do they do it?"
Okay, so starting off,
it's kind of a way toescape emotional pain.
It's a coping mechanism.
When adolescents or childrenare exposed to trauma
or they're extremelydepressed, extremely anxious,
they can become so overwhelmed
that it's actually arelease of the tension

(19:31):
if they cause self harm.
Others become numb.
They become numb, andthey become very detached.
And so, they actuallyno longer feel anything.
Cutting helps them toquote, "feel something."
Cutting releases endorphins,
which we know are our natural painkillers.
And after time, it can become a habit

(19:52):
and it actually can become addictive.
So cutting, they usuallyuse a sharp object,
like a razor blade, aknife, a piece of glass.
They make cuts or scratches on their body.
Usually, it's enough to break the skin
and make themselves bleed.
They may do it on their wrists.
They may do it on their arms, legs,
but I also see it on the abdomen at times/

(20:14):
Or burning.
They may use a cigarette, a lighter,
something to burn themselves.
Some adolescents use erasers
and do erasers on their skinrepeatedly to break the skin
or they may use ice oruse ice and salt together
and rub 'em.
And that actually causesexcoriations on the skin.
So if it's hot outside

(20:34):
and they're wearinglong sleeves and pants,
even in the summer, youdefinitely wanna make sure
you're getting a look attheir arms and their legs.
When children come intothe primary care provider,
you know, you always wannado a good skin assessment,
not just are you lookingfor rashes and moles
and the routine things.
You're also looking forscars, unexplained scars.

(20:55):
Again, it's very importantto remember though,
that most people whocut are not attempting
to kill themselves, all right?
Now when we talk about suicide,
and I'm gonna hold off onthat for just a second,
I wanna talk a littlebit about mood disorders.
So often, I'll have parentsbring in children and say,

(21:15):
"I think my child's bipolar,"
or "My child is having manic episodes."
And that's a slippery slope,
because children go from happy to sad
and adolescents go from happy to sad
and lots of energy to sleepingall the time frequently.
But when you're makingthat type of diagnoses,
as with all of these, youwanna consult the DSM-5,

(21:38):
the diagnostic manual for mental health
and the Bible for mental health,
and make sure that they'remeeting the diagnostic criteria.
So often, I have childrencome in who in adolescents
who've been diagnosedwith bipolar disorder,
but they fail to meetthe diagnostic criteria.
Yes, if a family memberhas bipolar disorder

(22:00):
has been diagnosed with bipolar disorder,
yes, this does increase the risk
for the child or adolescent,
but it does not automatically mean
they're going to havebipolar disorder, okay?
So, we'll talk a littlebit more about suicide
when we talk about preventionlater today as well.
ADHD, remember, threeto 6% of the population

(22:21):
has been diagnosed with ADHD.
ADHD is a whole lecture in and of itself,
whole talk in and of itself.
So, all I'm gonna sayhere is that not everyone
who has trouble focusing andpaying attention has ADHD.
If you feel like your childor your patient has ADHD,
there are reliable and valid tools

(22:42):
to actually screenchildren and adolescents
for attention deficit andhyperactivity disorder.
And that the recommended treatment
is generally gonna be stimulants
and also behavioral therapy.
But I will tell you thatstimulants is the go-to medication.
But again, we'll that's awhole nother conversation.

(23:03):
And the last thing I'm gonnamention are eating disorders.
We know that one to 3% of adolescent
and young women have sometype of an eating disorder.
And what we generally see is bulimia.
Remember, bulimia is the recurrentbinge eating and purging.
It can be chronic and relapsing
throughout their entire life.
Anorexia has about a 10% mortality rate
and it can also be chronic.

(23:24):
Most important is early treatment
and dealing with eating disorders
requires a multidisciplinary approach.
So, those are really
the most common mental health conditions
that I see in my practice
and I know that you're seeing also
in your pediatric practice as well.
- Well, Ashley, I feel likeyou just opened the gate
to your brain and invited us

(23:45):
to come and walk in fora while, and I loved it.
I was just looking at all ofthe knowledge that you carry
with your mental healthspecialty certification
and just knowing, youknow, being able to meet
these families at the point of need,
which is really important.
And there are so many things that,
so many points of wisdom
that we could get from what you just said.
And I wanna break it down a little bit

(24:06):
for that pediatricprimary care perspective.
And really, what I hear you talking about
is some of the things that are important.
When parents come to us
and they are concernedabout mental health,
we're looking at duration and severity.
How long has this been goingon and how severe is it?
Is it impacting youractivities of daily living?
Are you making modificationsto your family schedule

(24:29):
or your family routines?
Are you not going a certain place
or is everybody not going together,
because somebody has to stay home
because there's disability
even associated withsome of these symptoms?
Those say they're rising tothe level of needing attention.
And you know, for me
as a primary care pediatricnurse practitioner, Ashley,
I look at parents acrossthe scope of the lifespan

(24:51):
in my practice.
And when kids are little,say you've got a toddler,
I want you to picturethis cute little toddler
with a little cherub face
and you know, chubby cheeks, all of that,
like I love little toddlersand they are cranky.
They've got a runny nose andthey wake up in the night
and they're pulling their ear.
Those parents cannot wait.
They are counting the secondsuntil the phone line opens,

(25:14):
so they can call and make an appointment.
They wanna come in, justmake sure everything's okay.
If I say the ear is okay,they're like relieved
thinking they're gratefulthat they came in.
If I say the ear is infected, they think,
"Thank you so much.
Great, we've got it early."
We don't have that same thought process.
There's stigma associatedwith mental health conditions

(25:35):
and we all know the signs and symptoms.
You pointed out somethingimportant, Ashley,
that irritability is actuallya leading sign of depression,
one of the first presenting signs,
and it's not very endearing.
So usually, it causes someconflict and parents will think,
"Why can't you get it together?
Stopping so disrespectful."
But really, this is justan early manifestation

(25:57):
of a symptom.
But when we see those symptoms,
when we see irritabilityor maybe academic decline
or they're withdrawing from activities
or other subtle behavioraland emotional changes.
And parents have that spideysense that something's off.
And then, we start to see somatization,
which basically is psychological trauma
that's working its way through the body

(26:18):
and presenting its physical symptoms.
And I find that when I suggesteven sometimes to families
that these physical symptoms,that pain or trouble sleeping
or other things that they'representing with physically
might be related to mental health,
their immediate thought is,"That pain is not real then."

(26:38):
But the pain is real.
And depression, for example,
is actually the fourthleading cause of disability
among adolescents.
It is severely crippling.
When you have symptoms that are untreated.
That's when they're coming to us
and we have got to look andsee what is what we can do,
what can we do about it.
And I think this is somethingthat can be intimidating

(26:59):
for some primary care providers,
but let me just review that.
It is within the scope of primary care
to treat uncomplicated anxiety
that doesn't need anymedication or depression.
We can do behavioral interventions,which we'll talk about.
Primary care is definitely going to treat
attention deficit disorder.

(27:19):
The things that are outside
of primary care scope of practice
are things that are complex,when there are comorbidities,
when multiple medications are required.
Active suicidal ideation,
that's something that requiresmental health expertise.
You talked about interprofessional teams
for eating disorders.
Screening and identifyingthose eating disorders

(27:41):
is within the scope of primary care.
But people, they're not scaredso much of eating disorders,
but eating disorders are actually
the most deadly mental health disorder.
We have a lot of high riskfor death from suicide
or just biological causes
associated with physiological damage
that comes along with eating disorders,

(28:01):
particularly anorexia or bulimia.
And so looking at that, thinking,
"Okay, what can I treat?"
And then, preparing yourself to do that.
You gave such great advice, Ashley,
and looking at the diagnostic criteria.
And actually Dr. Donna Hallas,
who is another pediatric nursepractitioner and a fellow,
she and I teamed up to write an article

(28:21):
for contemporary pediatrics.
where we talked about screening tools,
exactly what you just described.
Parents come in.
We pull out those validatedscreening tools and think,
"Okay, does this rise tothe level of a diagnosis,"
or "Are we early enough that we could have
some behavioral interventions,
some wraparound support,
looking at the holisticelements around kids."

(28:44):
Because the first thing I'm going to do
is start asking them, "How are you eating?
How are you sleeping? How are you moving?"
Because we know thoseholistic health strategies
are really important.
So Ashley, let's dive into that.
Let's talk about health promotion,prevention and screening.
Let's just go there.
How do we back it up and likeyou said, identify it early

(29:05):
and encourage and empower families
for prevention strategies.
- So you know, one of the things
when we start talkingabout health promotion,
we have to keep in mind
that we are dealing withfamily systems here.
We are not just dealingwith health promotion
with one family member.
We're not dealing with health promotion

(29:26):
with just the patient.
We're dealing with everyone.
And one thing to keep inthe back of your mind,
and you touched on this Jessica,
is that we left to look at reasons
why children are leftuntreated in order to say,
"Okay, how are we going to capitalize
on our opportunitiesfor health promotion?"
And two of 'em are one,
they're just not a lot ofmental health professionals

(29:48):
and child and adolescent psychiatry.
There's also a problemwith access to care.
But one of the biggest reasonsis that parents are afraid
if their child comes into a provider
and demonstrates any of these symptoms
or the parent has any concern
that they are going to be blamed.
The parents are concernedthey are going to be blamed.

(30:10):
Either they've done something
or they haven't done something.
So when we're approaching this
from a health promotion standpoint,
we want to go into it with the assumption
and the knowledge that most parents
have the best of intentionswith their children.
And so, we're not coming in to tell 'em
what they haven't been doing right
or what they've been doing wrong.

(30:32):
We're coming in to helpthem understand what factors
are protective when dealingwith mental health conditions
and which ones are not protective.
When we talk aboutprotective factors, you know,
we have to start with just,
"Is your child getting proper nutrition?
Are they getting sufficient sleep?
Are they getting sufficient exercise?"

(30:52):
Those seems so basic, but whenwe're talking about things
like anxiety and depression,
it's so important to start at the basics.
So asking the parents, "Howmuch sleep does your child get?"
Or the adolescent, "Howmuch sleep are you getting?"
And really, confirmingthat with the parents.
Not how long are you in bed,
but how much sleep are you getting.

(31:13):
(indistinct) you know, because we realize
that physical and emotionalhealth are tied together.
Then, looking at emotionalprotective factors.
Okay, do they feel comfortable expressing
their emotions to people?
Is it okay in theirhouse to be vulnerable?
So if they go to their parents
and say that they're sador say they're depressed

(31:33):
or mention one of the manysymptoms that we've discussed,
are they going to be criticized
and are they gonna be taken seriously?
So, talking to families about that.
Also spiritual.
For some individuals, spiritualis very important component.
And while the family
maybe not have a strong spiritual belief,

(31:55):
maybe the the child does.
So, you wanna talk to thechild or the adolescent
and talk to the family aboutis it important in their life?
So, you have to educatefamilies about the symptom,
what to watch for.
And again, you can givethem general overview.
Just saying, "Is yourchild's behavior changed?

(32:17):
Have you noticed achange in their hygiene?
Have you noticed achange in their friends?
Have you noticed a changein the way they dress,
their grades, their eating?
Has there been an unexplainable change?"
And that is an easy thingto tell parents, you know,
what does this look like
and what did it look likea year ago, six months ago?

(32:38):
What does it look like now?
We already talked aboutopen communication.
And with open communication,we have to make sure
that we're reducing stigma.
It's gotten better, but in some cultures,
there is still asignificant amount of stigma
around mental health issues.
And so, are we in aculturally appropriate manner,

(32:59):
are we addressing these familysystems about mental health
and can children and adolescentscome to their parents?
Now if they can't,
we're gonna talk aboutprevention strategies
and we're gonna talk aboutwho's a trusted adult,
who's a trusted adult that they can go to.
Also, we talked abouthealthy coping mechanisms

(33:21):
and stress management.
So what are, again,healthy coping mechanisms?
We talk about grounding. Anybodycan talk about grounding.
Anyone can talk aboutbreathing techniques.
Anyone can talk aboutgetting up in the morning,
making your bed, brushing yourteeth, brushing your hair,

(33:42):
getting outside and gettingsunshine, listening to music.
Anyone can talk about
and it doesn't take that long in your day.
- Those things are so important.
And Ashley, I wanna go backto the role of the parent
for just a minute,because you are so right.
Parents have troublerecognizing and accepting
that there might be amental health condition,

(34:03):
because they immediatelytake it as a judge
on their parenting.
And I wanna share a personal story,
because I have been there.
My daughter actuallyexperienced some medical trauma
related to a chronic illness that she had.
And you know, honestlyAshley, I didn't recognize it.
Here, I am a pediatric nurse practitioner.

(34:23):
She was having panic attacks
that I was misidentifyingas an asthma exacerbation,
because she did have asthma.
And so here, she's having a panic attack
and I'm trying to give her an inhaler.
And it took me a while
and somebody, you know, withoutside perspective to say,
"Jessica, this is a panic attack."
And it was so hard because I thought,

(34:43):
"Well, did I not protect her enough?
Did I not equip her with coping skills?"
And we just have to recognize
we don't think those kinds of things
when our kids get a cold orwhen they get the stomach flu.
We don't beat ourselvesup in the same way.
In that holistic approach,
I think we need to treat the brain
just like we treat the rest of the body

(35:04):
and just recognize thatsometimes things happen.
Mental health conditions
are a very complex interactionof genetic predisposition,
environmental influence,
and then situationaltriggers that can come.
Temperament plays into this.
And we just need to besupportive in the moment.
And one of the thingsthat concerns me, Ashley,

(35:25):
is that when parents experience
these signs of mental health conditions
or they're suspecting it,they're thinking about it,
they often don't go totheir primary care provider.
That's not their go-to.
Their go-to is actually the internet
and they're going to seewhat can they find on this.
And maybe that's a vitaminsupplement, a diet,

(35:46):
a, you know, something thatthey're trying to self-manage
and armchair quarterback their way
through this mental health diagnosis.
And some of the scarier things
that I've seen on this aresome trends on social media,
where you have influencers.
I'll give you a really specific example
of something I saw, Ashley.
You talked earlier about self-harm.
Now if a child is experiencing self-harm,

(36:08):
and I remember interviewing a girl
who had experiencednon-suicidal self-injury
or self-harming behavior.
She had not seen it on the internet.
She had not seen it on social media.
She basically thought she invented it
because she had never seen it before.
But she just had thatcuriosity in her mind
and this behavior started.

(36:28):
And I think that's important
because some parents think,
"Oh, well not my kid.
That wouldn't be my kid."
But she had experienced this.
And so, we were talking about it.
And when I went to lookat influencer culture,
there are all kinds ofteenagers even who give advice.
So this one reel inparticular that I saw said,
"Hey, if you have thaturge to harm yourself,

(36:49):
instead of cutting yourself,get a big thick rubber band
and get some red dye food coloring.
And put it on the rubber band
and snap it as hard as you can,
because you know you'renot cutting yourself
to leave a scar.
You'll still get that sensationvisually and physically
and voila, it's fixed."
And I remember, Ashley, watching that

(37:10):
and just feeling terrified,
because as a healthcare professional,
I think so carefully about thescience behind interventions
and what we can do.
But I think we need to recognizethat parents and kids alike
are going to the internet.
They're going to peoplewho have lived experience,
who can relate to them.
And we need to decrease that stigma

(37:31):
in talking about it in primary care.
And that can be really hard to do
because again, we have thatseparation of primary care.
If a family comes to us andthey talk about anxiety,
sometimes we have this immediate feel
like, well, that's out of myscope, I can't deal with that.
But we need to just again,treat the body as a whole.

(37:51):
And scope of practice,
we'll talk about that alittle bit here in a minute.
That is highly individual.
It depends on your education,your training, your state.
You need to do your due diligence
and seeing what you could treat.
But there are increasingorganizations who are coming out
like the National Association
of Pediatric Nurse Practitioners,
who's making a strong case

(38:12):
for the integration of mentalhealth into primary care.
And before we go there,I'll just end with Ashley.
You're so right in talkingabout prevention strategies
and having those in primary healthcare,
talking about what can we do.
Making sure we have thatholistic health approach.
We know from research on resilience
that the number one predictorof kids resilient in trauma,

(38:36):
either big T trauma or littlet trauma, is connection,
meaningful connectionto a supportive adult.
And those supportive adults
need to model healthy coping mechanisms.
So often, and we'll talk about this more
in a future episode about social media,
but we model reallyunhealthy coping mechanisms
by doom scrolling, or binge watching,

(38:58):
or bed rotting, or whatever it is.
We really need to look atthe foundational aspects
of nutrition, sleep, and exercise.
Those are so important in making sure
that we're set up for good mental health.
And as I said before, Dr. Hallas and I
reviewed some of thosevalidated tools that we can use

(39:20):
in primary care to help parents identify.
This is on the normalspectrum of human emotion.
Here are some ways that youcan promote mental health.
Here are some thingsthat you can do at home.
Some simple things likehaving family dinner together
on a regular basis.
And it doesn't have to be gourmet, Ashley.
I'm not talkingcandlelight and jazz music.
I'm talking maybe that'speanut butter and jelly

(39:41):
around the kitchen island.
But having that connectionis really important.
It helps prevent mental health conditions
that increases the overallgeneral sense of good wellbeing.
So, we can give them
some of those health promotion strategies.
And then when we have ascreening that is concerning,
then we can look atthe diagnostic criteria

(40:02):
and determine can weaddress this in primary care
or does it need to be referred.
Now, that may be at theannual wellness visits,
the American Academy of Pediatrics
recommends universal depressionscreening starting at 12.
It may be when we seebehavioral signs of concern,
or it may be when they come in with signs
that they perceive as physical,we see as psychosomatic.

(40:25):
So, that's really important.
So Ashley, let's dive into integrating
that mental health and primary care.
You have that specialty certification.
Where do you see thatline in that process?
- So, that's an excellent question.
You know, there are not enoughmental health providers.
And we also know that getting someone

(40:47):
to a mental health provider
is sometimes even more difficult,
either there's not one available
or they don't want to seea mental health provider
because of associated stigma.
And fortunately, there hasbeen this national move
for quite some time now aboutintegrating behavioral health
into primary care.
And with that, one ofthe most important things

(41:09):
that can be done is the screening.
The screening, early identification.
And when I say screening,I'm gonna go back again.
I don't just mean the patient.
Now, obviously, the mother, or the dad,
or the caregiver's not your patient.
But you can observe the interactions
between the family member or caregiver

(41:31):
and determine are theparents also nervous wrecks?
Are they extremely anxious?Are they depressed?
Are they struggling with those things?
Because we know that those things
will directly impact our patient
or it may be a result of ourpatients' mental health issues

(41:52):
or behavior.
So, we have to look atthe entire family unit.
Now, we talk about screening.
Screenings can be done, likeyou said, in primary care.
PHQ-9, I'm gonna start there.
A PHQ-9 is a greatvalidated, reliable tool
to administer at every visit.
And I always say the PHQ-9,

(42:13):
not this little abbreviatedPHQ-2 that some people use,
because with the 9, there'sa number 9 question.
And that number 9 questionfocuses on suicide.
And I think it's extremely important,
even in a primary care setting,to include that question.
If they score positive on that question,
then again, it's withinthe scope of practice

(42:36):
and expectations as aprimary care provider
to then do risk identification.
Is this a passing thought thatthey're having about suicide
or is this actually an active concern?
And go ahead and thatdetermines your action.
Are you gonna refer them toa mental health professional
or do you need to send 'em to a hospital?
And really, the Columbia protocol

(42:57):
is going to be the best oneto use for that as well.
So in primary care,
that's really the evaluationof the family unit,
the assessment andevaluation of the patient,
their symptoms, theseverity of their symptoms.
And many healthcareproviders will go ahead
and start treating, ifappropriate, with medications.

(43:18):
If they're dealing with anxiety,
if they're dealing with depression,
the recommended start isgoing to be with an SSRI.
It is completely acceptablefor you to start an SSRI
on one of these patientsand just make sure
that you're counseling themappropriate about the risks,
including the increase insuicidal thoughts and actions.
That is a black box warningwith these medications.

(43:41):
But again, iterate to them,
really express that these medications
can provide a lot of help.
So, initiating treatment
and monitoring theirresponse to that treatment
are definitely within the scopeof practice of primary care.
- Well, we are goingto post some resources
and so make sure youcheck out the resources
that are posted with this,
because there are somegreat screening tools

(44:03):
that many NPS may not be awarethat they're even available.
Just like you talked about the PHQ-9
and looking at screeningsfor anxiety like SCARED.
The Survey of Well-beingin Young Children.
There's a brief infant andtoddler emotional assessment.
There are all kinds ofscreening tools that you can use
to even look at things,like sleep or depression.

(44:27):
For substance abuse, there's the CRAFT.
There's an ASQ,
which is an AskSuicide-Screening Questions.
We'll post some of those resources there
and you can see what mightbe helpful in your practice.
Another resource that Ithink is really important
for people to know about Ashley,especially in primary care,
is the National Network of ChildPsychiatry Access Programs.

(44:48):
Now, I know that was a long name.
You can go to nncpap.org
or look in the resources, we'll post this.
But this is actually aprogram you can go on.
There's a program in almost every state.
So, it may be that you find your state
is one of the just couple
that don't have a resource program,
but this is where itworks a little differently

(45:08):
in each state.
But you can go on andregister as a provider
and as a primary care provider,
you can have access tosomeone who is an expert,
a provider who's an expertin mental health care
and do phone conversations.
So, I'll give you an exampleof how this works in Texas.
If I am registered and I see a patient
who comes in with a mental health concern

(45:28):
and I'm really not surehow to navigate it,
how to diagnose it, whatscreening tools to use,
what should be my level of concern,
I can do a consult andthey can walk me through
that initial encounter knowing what to do,
whether to refer, whether I can treat it,
because sometimes, I mayneed to refer, Ashley.
And I refer and they say,"Great, we'll see you

(45:49):
at an out of network mentalpsychiatry, you know, provider
in six months."
And then, I think,
"Okay, great, what am Igoing to do in the meantime?"
And they can help you kinda navigate that.
And it has been reallygame changing for me.
And so, I think everybodyshould know about that for sure.
And look at that.
And the other things thatpeople should think about

(46:11):
are there are some advanced training
and certification opportunities.
And I wanna spend our last time together
really talking about this
because if you'recertified in primary care,
there are some things that you can do
and you should investigate
what is within the scope of your practice
to treat in primary care.
Another great resource
comes from Dr. Bernadette Melnyk,

(46:32):
who is a renowned pediatricnurse practitioner
and she has a program called COPE2Thrive.
You can go to COPE2Thriveand look at that online.
It's COPE and the number 2Thrive
and look at it cope2thrive.com.
And she has cognitive behavioral therapy,
where you can get sometraining on how to provide

(46:52):
cognitive behavioraltherapy in primary care
and even how to bill for it,
because that is an importantpractical consideration.
These things take time, Ashley,when we're in primary care.
And so, how do you set up yourpractice for success in that?
How do you function appropriately
within the scope of your practice,
but also meet parentsat the point of need?

(47:14):
Now, there may be some peoplewho are listening and think,
"I wanna get some additionaleducation and certification."
We're seeing an explosion in enrollment
in the mental health,
psychiatric mental healthnurse practitioner programs.
And I want, Ashley, sinceyou have that certification,
I want you to talkabout the scope of that,
what that process looks like.

(47:34):
And then, I'll talk
about the pediatric primarycare mental health specialist.
- Sure, so if you are already
a pediatric nurse practitioner,
if you are already certified
as a pediatric nurse practitioner,
you are eligible to go back.
And most universities are offering this.

(47:55):
We're seeing a really significant increase
in the number of universities
that are offeringpostgraduate certificates.
Whether you have amaster's or a DNP already,
they're offeringpostgraduate certificates.
And so if you want to go back
and expand with dualcertification like I did
in psychiatric mental health,
you can reach out to oneof those universities

(48:17):
and generally, they willevaluate your core courses
to determine do you have torepeat any of your core courses,
but then you'll do allthe specialty courses
related to that population foci.
And then, you will do theclinicals also associated.
Now remember, that experiencedoes not count as education.

(48:37):
So, you may have beenproviding behavioral health,
that may be the majority ofyour practice, behavioral health
as a pediatric nursepractitioner practitioner
but remember, that cannot countas educational preparations.
So in most cases, it takes ayear, maybe four semesters,
but it's definitely worth it.
And then, you're eligible to sit
for your national certification with ANCC.

(48:59):
- And we are seeing moreand more NPs do that
either through their primary certification
or going back, like you said,
for a post-master certification.
And one thing that I think alot of NPs are not aware of
is that pediatric primarycare mental health specialist.
Now, this is abbreviated PMHS.
And basically, what this is

(49:20):
is a specialty certification pathway
that helps you to havespecialized knowledge
and expertise in pediatric mental health.
Now, it's primarily for peoplewho are already certified
as pediatric nurse practitioners
or family nurse practitioners.
It's also available to some CNS pathways.
And you can look at the eligibility

(49:42):
at the pediatric nursingcertification board.
You can go to pncb.org
and look and see what you wouldneed to do to be eligible.
Now, there's someeducation that's required,
and there are a lot ofdifferent pathways for this.
There is a program calledthe KySS Program, KySS.
There also is a program through

(50:02):
the National Association ofPediatric Nurse Practitioners.
One of the things they didafter the pandemic started
and the child healthemergency was declared,
they had an initiativecalled NAPNAP Cares,
where they offered all of the education
that you need to be able to be eligible
to sit for certification in this exam.
And they just open newpathways for faculty roles.

(50:26):
So if you're in a facultyrole, if you're an educator
and you're interested in getting this,
there is a pathway for you too.
Now, it requires around 2,000hours, clinical practice hours
in pediatric developmentalbehavior and mental health,
but there are a lot ofdifferent ways to that
and to get that.
So, I encourage you ifyou're thinking, you know,

(50:47):
"I really want to take that next step.
I'm seeing this in my practice."
You know, Ashley, whenI served as president
of the National Association ofPediatric Nurse Practitioners
during COVID, and I commissioned a survey
and helped publish a survey
looking at the impact of the pandemic
on pediatric advanced practice providers.

(51:08):
And what we found was overwhelmingly,
their concern evenearly, we saw that swell
before the emergency was declared,
before the Surgeon General said something,
we saw NPs on the groundin the clinic saying,
"We are seeing this mentalhealth crisis coming."
And we're seeing moreand more who are saying,

(51:29):
"I want to be better prepared.
What can we do?"
And we've just given you twoways that you can do that
and that may be really helpful to you.
Now if you're not quite there,
another resource that you maywanna look into is a textbook
that was written by Dr. Melnykwho I talked about before,
Bernadette Melnyk andPamela Lusk, her colleague.

(51:49):
It's called "A Practical Guide
to Child and AdolescentMental Health Screening,
Evidence-Based Assessment Intervention
and Health Promotion."
I have found this to be really helpful.
It goes through all of the screening tools
that are available, well, thatyou can use in primary care.
What is the age? What is the indication?
What do you do about it?
And there's even handoutsin here for parents.

(52:12):
So if you're looking atjust being able to meet
those patients at thepoint of need and thinking,
"What can I do?"
That would be another good place to start.
And again, we'll post allof these resources for you,
but I think it's importantfor you to think about
if you are seeing this in your practice,
what are you prepared to do now?

(52:32):
What is within your scope of practice?
What is your capability?And then, what could you do?
Are there things that you cando to better prepare yourself
to meet patients at their point of need
to help with this integrationof mental health care
into primary care
and to facilitate thosetransitions more easily

(52:53):
when they need specialty certification?
Well, Ashley, we have talkedabout so many different things.
I wanna know now, steppingback from this conversation,
what are the importanttakeaways, do you think?
Did we miss anything?
What are the take home points
that we want our listeners to have?
- I think it's one ofthe most important things

(53:14):
is treating the family,
including the family inyour treatment plan as well.
Making sure that you're giving good advice
and not parenting the parent,or lecturing the parent,
or pointing out how youwould do it differently.
I think it's important toengage in the conversation
on what are their obstacles,what are their barriers,

(53:37):
what are their challenges inimplementing protective factors
for their child's mental health.
We even know that very,very young children
who have chronic stress are at higher risk
for later mental health issuesalso utilize your resources.
And Jessica has provided
a number of very valuable resources.

(53:58):
I also wanna let you know about NAMI,
or the National Alliancefor Mental Health,
that is for healthcareprofessionals across healthcare
and for patients.
It is an excellent resourceabout mental health issues,
but also real life advice onmaintaining mental health,
identifying mental healthissues, treating mental health,

(54:19):
and the importance of successfullytreating mental health.
Also, the JED Foundation,the JED Foundation.
It is a nonprofit organization
and it's for mental healthissue, mental illness as well.
And it is for healthcareproviders as well as consumers.
So, those are two other.
And then the other is theColumbia Lighthouse Project.
And please join us for ourupcoming podcast on suicide,

(54:43):
because I will go into significant detail
about suicide screening
and we'll talk about different resources,
like Columbia LighthouseProject and others.
The other thing I wanna round up
what I have to say is aboutbe careful with diagnoses.
It's really tempting to give
someone a diagnosis ofmajor depressive disorder.
It's really tempting to give someone

(55:04):
a diagnosis of generalizedanxiety disorder
or a mood disorder.
Please remember that those diagnoses
are likely to carry themthrough the rest of their life.
I have so many patients whocome to me, not just children
but adults as well that have been given
a diagnosis for billing purposes,
whether it be major depressive disorder,

(55:25):
schizophrenia, bipolar disorder.
And I screen 'em and say,"Great news, I don't believe
that you meet the criteria for this."
It is still so hard toget them on a track,
where they still don'tfeel like they're living
under the shadow of that diagnosis.
And think of the years it'saffected them even before then.
So be very careful whatyou're doing with diagnoses

(55:49):
and what you're putting in the chart.
- That is a great piece of advice.
The last thing isnetwork, network, network.
- Yeah.
And so yes, go to NAPNAP,
go to your professionalorganization meetings,
but go to where thereare other professionals,
other nurse practitionersfrom other populations,

(56:10):
stuff like AAMP conferences
or any of their groupswhere you can network.
Because I can't tell you how many people
that are primary careproviders I work with
that will call me and say,"Hey, I've got a patient."
Like don't tell mespecifics about the patient
and I can give them advice notbased on a specific patient.
Okay, keep that in mind.

(56:30):
But I can give them advice on a condition
or a presentation advice onwhat I think they should do
and does this need to bereferred to someone else.
And I do the same for them.
If I have a patient who comes in
and they're having some hypertension
or they're looking at their blood sugars
or their liver enzymesand I have a concern,
I have people.

(56:50):
I have my collaboratingphysician in Alabama.
We're required to have a collaborator,
but I also have colleagues,
nurse practitioner colleaguesthroughout the country
that I can reach to.
I have Jessica that I canreach out to for pediatrics.
So, make sure you network, network
because that is how you'regoing to really learn the best.
- Ashley, I love it.
And I just wish I could comefollow you around for a day.

(57:13):
And it is so encouraging,even having this conversation
between me and you on a personal level,
even though I know tens ofthousands of our friends
are listening and that is great.
But it's so encouraging to know,
hey, you're in this with me.
You're seeing the same things I'm seeing
and we are working together,
because when we look atthe landscape of the world,

(57:33):
it can be easy to feeloverwhelmed, to feel discouraged,
and quite frankly to feel burned out,
to feel like is what we're doingreally making a difference.
And then just having thisconversation with you,
having people listen and say,
"Hey, you're not alone."
We are right there with you.
We are working to make a difference.
And that really does make a difference.

(57:55):
I think my last thingsthat I would think about
as we, I'm reflecting on our conversation
is especially for children and teenagers.
Let's talk about theteenagers just for a second,
who often will struggle witha mental health condition.
And so often, we have to remember,
one thing we didn't say
is that those mental health symptoms
most often will show up before age 11.

(58:17):
They're just not recognized.
And I'll see parents who will go down
a long line of GI referrals,invasive procedures.
And I just think what would happen
if we would just recognize those things
as mental health conditions?
Of course, it's ourresponsibility to make sure
that we rule out any physical cause.
That is important.

(58:37):
And as we have increased awareness
of mental health conditions,we need to make sure
that we don't lose our sensitivity
to look for things like diabetes
or other physical conditionsthat can be there.
But in talking aboutthe teenagers, Ashley,
I would encourage you tothink about your practice
and think is your practice teen friendly.

(58:57):
When a teenager walks in there,
is it just all balloons and teddy bears
and all little kid kind of stuff
or do you have a teen corner?
Do you have a teen room?
And all you have to do for a teen corner
in your waiting room isjust put phone chargers
over in the corner.
They will come.
They will be feel like, "Oh,you are prepared for me,"
which is really helpful.

(59:18):
But just thinking about thephysical environment saying,
"I'm prepared to meet you where you are."
Yes, I see children. Yes, I see teens.
I think that's reallyimportant when you're looking
at just meeting thoseteens where they are.
And the other important thingI am reflecting on you saying,
Ashley, is talking about beingcareful with that diagnosis

(59:39):
and I think you're so right.
And we also need to be careful
when we do give that diagnosis.
So often, we deliver italmost with an apology.
You know, that, oh, it's, you know,
it's anxiety and we tiptoe around it,
but if we normalize it, I thinkthat can be really helpful.
And I think about mydaughter who struggled

(01:00:00):
with her mental health
following that medicaltrauma that she had.
And there was one summer, Ashley,
where I was serving as a camp nurse,
and she came running into the cabin,
just running hysterical, just crying.
She had a panic attack.
She was so embarrassed,
because it had happenedin front of her friends.
She ran into my room.
She locked the door.
And those friends came running in

(01:00:21):
and they were, of course,concerned and confused.
They had no idea what had happened.
And I remember in that moment
having such a visualizationof what that was like.
And I remember telling my daughter,
"You have support on theother side of the door.
You have people who careabout you, who love you,
who want to help, but just don't know how.

(01:00:43):
And you can either lock the door
and you can sit hereand suffer by yourself
or we can open the door and invite them in
and help them to help."
And so, we just gave thema simple explanation.
This is what anxiety looks like.
Here's the things that youneed to do to be supportive.
Here's when you need to goand get help and get an adult.
And you know, Ashley, it was so touching

(01:01:03):
because those friends were empowered.
They had a mission.
They knew exactly what they needed to do
to be a support to their friend.
And I think we can do that as NPs.
We can show up for kids and families
in some of their most vulnerable moments.
And that is no small thing.
And in a world where stigma

(01:01:24):
just still surrounds mental health,
we can be a safe place and a steady guide
and a voice of hope.
And I just want to tell our listeners,
every time you'relistening without judgment,
you're noticing thosequiet signs of a struggle.
You're giving reassurance.
You are making a difference that ripples
far beyond the encounter that'shappening in that exam room.

(01:01:46):
And you may not alwayssee the impact right away,
but the care that you are providing
is planting seeds of resilienceand trust and healing.
So, keep going.
When the system feels too heavy,
when progress feels too slow,
when the crisis just seems overwhelming,
remember that you are not alone.
And that work you're doing isreally sacred. Kids need you.

(01:02:09):
Families rely on you. Ascolleagues, we need you.
The future is brighter becauseof your hands, your heart,
and your clinical wisdom.
And Ashley, I especiallyfeel that way about you.
And just thank you so muchfor this conversation.
And we hope that it's empowering
and that it equips NPs out there
to continue making a difference.

(01:02:33):
- Thank you, Jessica, forhaving me. Always a pleasure.
- It is. It's a greatteam, great partnership.
(upbeat music)
Don't forget to tune in.
Be on the lookout for the next episodes.
We are going to be talkingspecifically about suicide.
This is something thatrequires a lot of care

(01:02:54):
and a lot of information.
We'll be talking about that.
And then, we'll be talkingabout social media,
and especially the risk factorsassociated with social media
and some of those sexualhealth risk factors
that we're seeing comingup with deep fakes
and notifying technologyand AI, and all the things.
If you're feeling overwhelmed, don't.

(01:03:14):
Just join us back here next time.
We'll see you as we continue to talk
about adolescent health.
- To our listeners, thankyou for visiting "NP Pulse."
This second episode of a four-part series
has been made possible by AANP education.
Continuing educationcredit for this program
may be claimed through May 31st, 2026.

(01:03:38):
To claim credit, log into
the CE Center at aanp.org/cecenter.
Search for this program by name
and complete the evaluation
by entering theparticipation code Mental25.
That is M-E-N-T-A-L
25.

(01:03:59):
Your feedback isincredibly important to us.
Thank you for listening.
(upbeat music)