Yasmeen Abdul-Karim, MD

Case vignette: A 16-year-old Nepali-born English-speaking adolescent presents for a well-child visit and notes concerns for anxiety, depression, and a history of trauma. She resides with her parents who work in hospitality with limited time off, and thus she presented for the initial office visit with a neighbor. Parents were not readily available to discuss treatment recommendations, including medication options. The teen shares a number of challenges that makes coming to appointments difficult. You also notice that the patient currently is not enrolled in insurance, though she appears eligible.

The above vignette highlights various social issues and concerns that impact access to healthcare and overall health/well-being. Social determinants of health (SDOH) and factors centered on mental health are now widely known to impact pediatric health and wellbeing. The Office of Disease Prevention and Health Promotion defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH can be grouped into five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.¹

Dr. Abdul-Karim

Additionally, when considering determinants that impact the mental health of children, it is prudent to consider parental psychosocial factors and adverse childhood experiences (ACEs), such as witnessing interpersonal violence, child abuse, parental substance use, and parental depression.² All these factors have been shown to impact an individual’s mental and physical health not only contemporaneously but also later in life.³

Screening Tool for Pediatric Social Histories

One screening tool to assist with gathering an expanded pediatric social history is called IHELP, developed by Kenyon et al,⁴ with further derivations from Colvin et al.⁵ Utilizing this tool can assist providers with identifying social needs.

The tool begins with a framing statement — “Let me ask you some questions I ask every family” — then proceeds to discuss relevant topics as shared below:

I: Income; Insurance

• Do you have any concerns about making ends meet?
• Do you have any concerns about your child’s health insurance?

H: Hunger, Housing Conditions; Homeless

• Do you have any concerns about having enough food?
• Have you ever been worried whether your food would run out before you got money to buy more?
• Within the past year has the food you bought ever not lasted, and you didn’t have money to get more?
• Do you have any concerns about poor housing conditions like mice, mold, or cockroaches?
• Do you have any concerns about being evicted or not being able to pay the rent?
• Do you have any concerns about not being able to pay your mortgage?

E: Education; Ensuring Safety (Violence)

• Do you have any concerns about your child’s educational needs?
• [DO NOT ASK IN FRONT OF CHILD 3 OR OLDER OR IN FRONT OF OTHER PARTNER] “From speaking to families, I have learned that violence in the home is common and now I ask all families about violence in the home. Do you have any concerns about violence in your home?”

L: Legal status (Immigration)

• What hospital was your child born in?
• If not in the United States: “Are you aware that your child may be eligible for benefits even though they were not born in the US? If you would like, I can have a social worker come talk to you about some possible benefits your child may be eligible for. Would you like me to do that?”

P: Power of Attorney; Guardianship

• Are you the biological mother or father of this child?
• [If not] “Can you show me the power of attorney or guardianship document you have?”
• **PATIENTS >17+ with Mental Incapacity: Ask for Guardianship.

This tool can help with identifying families with significant social needs so that one can attain further historical information and subsequently share resources to assist with any challenges.
 

Consider the Role of Adverse Childhood Experiences

Additionally, as noted, ACEs often play an important role in overall health and well-being; they include experiencing childhood abuse, neglect, and/or household dysfunction. The impact of these early exposures can lead to toxic stress that can negatively alter the brain and the body’s response to stress over time.³ There are various tools readily available online that can assist with identifying ACEs and interpreting their prevalence. The American Academy of Pediatrics has an updated page of commonly used screening tools. Early identification and intervention can help mitigate the impact of these experiences on long-term outcomes.

Important Considerations Regarding Screening for SDOH and/or ACEs:

• Please consider if screening is helpful in your space, recognizing that there are benefits and potential ethical considerations to screen or not. Ensure an interdisciplinary approach if screening is implemented to ensure that the patient’s experience and well-being is prioritized.
• Try to be intentional in your communication with parents. The patient and family are our teachers and know best what they need.
• Consider what is available in your community and what can be offered to ensure that parents and families are appropriate and eligible for a particular resource.
• Encourage continuous collaboration and partnership with community providers who offer resources that a family may benefit from to ensure that the resource continues to be available.

Returning to the Vignette

Administering the IHELP tool has led to identifying that the adolescent’s insurance has lapsed, but she remains eligible, and the family seeks support to re-enroll. The family shares concerns regarding educational needs, as the child has not attended school for the past year and is not on track to graduate. The IHELP tool also helps you identify inconsistent transportation availability. Ultimately, a social work consultation is placed which assists with re-enrolling in insurance for the child and obtaining a bus pass for in-person visits. The patient is also supported in enrolling in the use of a videoconferencing platform for virtual visits. You and your team reach out to the school, which provides valuable information regarding the child’s status and how best to support re-engagement. On follow-up, she is now readily engaged in appointments and shares she is no longer worrying about transportation, which has been helpful. She has started initial conversations with the school and has a condensed schedule for reintegration.

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Office of Disease Prevention and Health Promotion, US Department of Health & Human Services. Social Determinants of Health. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

2. Cotton N and Shim R. J Am Acad Child Adolesc Psychiatry. 2022 Nov;61(11):1385-1389. doi: 10.1016/j.jaac.2022.04.020.

3. US Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs): Preventing Early Trauma to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/index.html.

4. Kenyon C et al. Pediatrics. 2007 Sep;120(3):e734-e738. doi: 10.1542/peds.2006-2495.

5. Colvin JD et al. Acad Pediatr. 2016 Mar;16(2):168-174. doi: 10.1016/j.acap.2015.06.001.

Case vignette: A 16-year-old Nepali-born English-speaking adolescent presents for a well-child visit and notes concerns for anxiety, depression, and a history of trauma. She resides with her parents who work in hospitality with limited time off, and thus she presented for the initial office visit with a neighbor. Parents were not readily available to discuss treatment recommendations, including medication options. The teen shares a number of challenges that makes coming to appointments difficult. You also notice that the patient currently is not enrolled in insurance, though she appears eligible.

The above vignette highlights various social issues and concerns that impact access to healthcare and overall health/well-being. Social determinants of health (SDOH) and factors centered on mental health are now widely known to impact pediatric health and wellbeing. The Office of Disease Prevention and Health Promotion defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH can be grouped into five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.¹

Dr. Abdul-Karim

Additionally, when considering determinants that impact the mental health of children, it is prudent to consider parental psychosocial factors and adverse childhood experiences (ACEs), such as witnessing interpersonal violence, child abuse, parental substance use, and parental depression.² All these factors have been shown to impact an individual’s mental and physical health not only contemporaneously but also later in life.³

Screening Tool for Pediatric Social Histories

One screening tool to assist with gathering an expanded pediatric social history is called IHELP, developed by Kenyon et al,⁴ with further derivations from Colvin et al.⁵ Utilizing this tool can assist providers with identifying social needs.

The tool begins with a framing statement — “Let me ask you some questions I ask every family” — then proceeds to discuss relevant topics as shared below:

I: Income; Insurance

• Do you have any concerns about making ends meet?
• Do you have any concerns about your child’s health insurance?

H: Hunger, Housing Conditions; Homeless

• Do you have any concerns about having enough food?
• Have you ever been worried whether your food would run out before you got money to buy more?
• Within the past year has the food you bought ever not lasted, and you didn’t have money to get more?
• Do you have any concerns about poor housing conditions like mice, mold, or cockroaches?
• Do you have any concerns about being evicted or not being able to pay the rent?
• Do you have any concerns about not being able to pay your mortgage?

E: Education; Ensuring Safety (Violence)

• Do you have any concerns about your child’s educational needs?
• [DO NOT ASK IN FRONT OF CHILD 3 OR OLDER OR IN FRONT OF OTHER PARTNER] “From speaking to families, I have learned that violence in the home is common and now I ask all families about violence in the home. Do you have any concerns about violence in your home?”

L: Legal status (Immigration)

• What hospital was your child born in?
• If not in the United States: “Are you aware that your child may be eligible for benefits even though they were not born in the US? If you would like, I can have a social worker come talk to you about some possible benefits your child may be eligible for. Would you like me to do that?”

P: Power of Attorney; Guardianship

• Are you the biological mother or father of this child?
• [If not] “Can you show me the power of attorney or guardianship document you have?”
• **PATIENTS >17+ with Mental Incapacity: Ask for Guardianship.

This tool can help with identifying families with significant social needs so that one can attain further historical information and subsequently share resources to assist with any challenges.
 

Consider the Role of Adverse Childhood Experiences

Additionally, as noted, ACEs often play an important role in overall health and well-being; they include experiencing childhood abuse, neglect, and/or household dysfunction. The impact of these early exposures can lead to toxic stress that can negatively alter the brain and the body’s response to stress over time.³ There are various tools readily available online that can assist with identifying ACEs and interpreting their prevalence. The American Academy of Pediatrics has an updated page of commonly used screening tools. Early identification and intervention can help mitigate the impact of these experiences on long-term outcomes.

Important Considerations Regarding Screening for SDOH and/or ACEs:

• Please consider if screening is helpful in your space, recognizing that there are benefits and potential ethical considerations to screen or not. Ensure an interdisciplinary approach if screening is implemented to ensure that the patient’s experience and well-being is prioritized.
• Try to be intentional in your communication with parents. The patient and family are our teachers and know best what they need.
• Consider what is available in your community and what can be offered to ensure that parents and families are appropriate and eligible for a particular resource.
• Encourage continuous collaboration and partnership with community providers who offer resources that a family may benefit from to ensure that the resource continues to be available.

Returning to the Vignette

Administering the IHELP tool has led to identifying that the adolescent’s insurance has lapsed, but she remains eligible, and the family seeks support to re-enroll. The family shares concerns regarding educational needs, as the child has not attended school for the past year and is not on track to graduate. The IHELP tool also helps you identify inconsistent transportation availability. Ultimately, a social work consultation is placed which assists with re-enrolling in insurance for the child and obtaining a bus pass for in-person visits. The patient is also supported in enrolling in the use of a videoconferencing platform for virtual visits. You and your team reach out to the school, which provides valuable information regarding the child’s status and how best to support re-engagement. On follow-up, she is now readily engaged in appointments and shares she is no longer worrying about transportation, which has been helpful. She has started initial conversations with the school and has a condensed schedule for reintegration.

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Office of Disease Prevention and Health Promotion, US Department of Health & Human Services. Social Determinants of Health. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

2. Cotton N and Shim R. J Am Acad Child Adolesc Psychiatry. 2022 Nov;61(11):1385-1389. doi: 10.1016/j.jaac.2022.04.020.

3. US Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs): Preventing Early Trauma to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/index.html.

4. Kenyon C et al. Pediatrics. 2007 Sep;120(3):e734-e738. doi: 10.1542/peds.2006-2495.

5. Colvin JD et al. Acad Pediatr. 2016 Mar;16(2):168-174. doi: 10.1016/j.acap.2015.06.001.

Case vignette: A 16-year-old Nepali-born English-speaking adolescent presents for a well-child visit and notes concerns for anxiety, depression, and a history of trauma. She resides with her parents who work in hospitality with limited time off, and thus she presented for the initial office visit with a neighbor. Parents were not readily available to discuss treatment recommendations, including medication options. The teen shares a number of challenges that makes coming to appointments difficult. You also notice that the patient currently is not enrolled in insurance, though she appears eligible.

The above vignette highlights various social issues and concerns that impact access to healthcare and overall health/well-being. Social determinants of health (SDOH) and factors centered on mental health are now widely known to impact pediatric health and wellbeing. The Office of Disease Prevention and Health Promotion defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH can be grouped into five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.¹

Dr. Abdul-Karim

Additionally, when considering determinants that impact the mental health of children, it is prudent to consider parental psychosocial factors and adverse childhood experiences (ACEs), such as witnessing interpersonal violence, child abuse, parental substance use, and parental depression.² All these factors have been shown to impact an individual’s mental and physical health not only contemporaneously but also later in life.³

Screening Tool for Pediatric Social Histories

One screening tool to assist with gathering an expanded pediatric social history is called IHELP, developed by Kenyon et al,⁴ with further derivations from Colvin et al.⁵ Utilizing this tool can assist providers with identifying social needs.

The tool begins with a framing statement — “Let me ask you some questions I ask every family” — then proceeds to discuss relevant topics as shared below:

I: Income; Insurance

• Do you have any concerns about making ends meet?
• Do you have any concerns about your child’s health insurance?

H: Hunger, Housing Conditions; Homeless

• Do you have any concerns about having enough food?
• Have you ever been worried whether your food would run out before you got money to buy more?
• Within the past year has the food you bought ever not lasted, and you didn’t have money to get more?
• Do you have any concerns about poor housing conditions like mice, mold, or cockroaches?
• Do you have any concerns about being evicted or not being able to pay the rent?
• Do you have any concerns about not being able to pay your mortgage?

E: Education; Ensuring Safety (Violence)

• Do you have any concerns about your child’s educational needs?
• [DO NOT ASK IN FRONT OF CHILD 3 OR OLDER OR IN FRONT OF OTHER PARTNER] “From speaking to families, I have learned that violence in the home is common and now I ask all families about violence in the home. Do you have any concerns about violence in your home?”

L: Legal status (Immigration)

• What hospital was your child born in?
• If not in the United States: “Are you aware that your child may be eligible for benefits even though they were not born in the US? If you would like, I can have a social worker come talk to you about some possible benefits your child may be eligible for. Would you like me to do that?”

P: Power of Attorney; Guardianship

• Are you the biological mother or father of this child?
• [If not] “Can you show me the power of attorney or guardianship document you have?”
• **PATIENTS >17+ with Mental Incapacity: Ask for Guardianship.

This tool can help with identifying families with significant social needs so that one can attain further historical information and subsequently share resources to assist with any challenges.
 

Consider the Role of Adverse Childhood Experiences

Additionally, as noted, ACEs often play an important role in overall health and well-being; they include experiencing childhood abuse, neglect, and/or household dysfunction. The impact of these early exposures can lead to toxic stress that can negatively alter the brain and the body’s response to stress over time.³ There are various tools readily available online that can assist with identifying ACEs and interpreting their prevalence. The American Academy of Pediatrics has an updated page of commonly used screening tools. Early identification and intervention can help mitigate the impact of these experiences on long-term outcomes.

Important Considerations Regarding Screening for SDOH and/or ACEs:

• Please consider if screening is helpful in your space, recognizing that there are benefits and potential ethical considerations to screen or not. Ensure an interdisciplinary approach if screening is implemented to ensure that the patient’s experience and well-being is prioritized.
• Try to be intentional in your communication with parents. The patient and family are our teachers and know best what they need.
• Consider what is available in your community and what can be offered to ensure that parents and families are appropriate and eligible for a particular resource.
• Encourage continuous collaboration and partnership with community providers who offer resources that a family may benefit from to ensure that the resource continues to be available.

Returning to the Vignette

Administering the IHELP tool has led to identifying that the adolescent’s insurance has lapsed, but she remains eligible, and the family seeks support to re-enroll. The family shares concerns regarding educational needs, as the child has not attended school for the past year and is not on track to graduate. The IHELP tool also helps you identify inconsistent transportation availability. Ultimately, a social work consultation is placed which assists with re-enrolling in insurance for the child and obtaining a bus pass for in-person visits. The patient is also supported in enrolling in the use of a videoconferencing platform for virtual visits. You and your team reach out to the school, which provides valuable information regarding the child’s status and how best to support re-engagement. On follow-up, she is now readily engaged in appointments and shares she is no longer worrying about transportation, which has been helpful. She has started initial conversations with the school and has a condensed schedule for reintegration.

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Office of Disease Prevention and Health Promotion, US Department of Health & Human Services. Social Determinants of Health. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

2. Cotton N and Shim R. J Am Acad Child Adolesc Psychiatry. 2022 Nov;61(11):1385-1389. doi: 10.1016/j.jaac.2022.04.020.

3. US Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs): Preventing Early Trauma to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/index.html.

4. Kenyon C et al. Pediatrics. 2007 Sep;120(3):e734-e738. doi: 10.1542/peds.2006-2495.

5. Colvin JD et al. Acad Pediatr. 2016 Mar;16(2):168-174. doi: 10.1016/j.acap.2015.06.001.

Case vignette: Laura is a 14-year-old biological girl who presents to your office for a routine well-child visit. She is doing well medically but notes that over the past 3 months she has been having increasing thoughts of suicide and has self-harmed via cutting on her wrists with a blade removed from a shaving razor. You contemplate what the most salient questions are in order to determine the best disposition for your patient.

The case vignette above may sound like one that you have heard before, and if not, you undoubtedly will encounter such a situation moving forward. The rate of suicidal ideation amongst youth ages 10-24 has increased by 57.4% between 2007 and 2018.¹ Furthermore, suicide is the second leading cause of death in those aged 10 through young adulthood.² According to the Centers for Disease Control and Prevention’s 2019 High School Youth Risk Behavior Survey, 18.8% of high school students seriously considered attempting suicide, 15.7% made a plan about how they would attempt suicide, and 8.9% actually attempted suicide, with 2.5% having a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse during the 12 months before the survey.³ Children often present first to their primary care provider, and they may be the first individual who the child shares their suicidal or self-harm thoughts with. It may be useful to have a standardized approach, while using your own clinical judgment, to determine best next steps. Given the significant recent surge in children presenting to the emergency department for psychiatric needs and that environment having its own limitations (for example, long wait times, nontherapeutic space, etc.), a simple screen and brief assessment may lead to being able to maintain a patient safely outside of the hospital.
 

Screen all appropriate patients for suicide

There are, at minimum, three validated screening tools that can be used as to determine what the best next step should be. They include the Ask Suicide-Screening Questions (ASQ) developed by the National Institute of Mental Health, the Columbia-Suicide Severity Rating Scale (C-SSRS), and the PHQ-9 (modified for adolescents). We can highlight one of the screening tools here as noted below, but the choice of screener may be based on facility and/or clinician preference.

The Ask Suicide-Screening Questions

The ASQ, developed by the National Institute of Mental Health, include the following four binary questions plus a fifth acuity question, as follows:

1. In the past few weeks, have you wished you were dead?

2. In the past few weeks, have you felt that you or your family would be better off if you were dead?

3. In the past week, have you been having thoughts about killing yourself?

4. Have you ever tried to kill yourself?

a. If yes, how?

b. When?

The following acuity question is to be asked if any of the above are answered “yes”:

5. Are you having thoughts of killing yourself right now?

a. If yes, please describe.
 

Assess the level of risk

Once you have screened a patient, you need to assess the level of risk to help determine the level of care required. Returning to our original case vignette, does the patient warrant outpatient management, crisis evaluation, or an emergency psychiatric evaluation? You may have already decided that the patient needs an emergency mental health evaluation from a local crisis clinician evaluation and/or the emergency department. However, you may also find that the screen did not elicit imminent concern, but it does warrant a brief assessment to further elucidate the level of risk and proper disposition. One such instrument that may be helpful is the Brief Suicide Safety Assessment (BSSA) – also developed by the NIMH as a tool linked to the ASQ. There are clear and specific instructions in the BSSA with suggestions on how to ask questions. Important components to the BSSA include:

• A focus on a more thorough clinical history – including frequency of suicidal ideation, suicide plan, past behavior, associated symptoms, and social support/stressors
• Collateral information (e.g., further details from those who know the patient such as family/friends).
• Safety planning.
• Determining disposition.

The BSSA may suggest that a crisis/psychiatric evaluation is warranted or suggest that a safety plan with a mental health referral will likely be sufficient.
 

Triage and safety planning

A safety plan should be created if you determine that a patient can be safely maintained as an outpatient based on your screening, assessment, and triaging. Traditional safety plans come in many different forms and can be found online (Example of a Safety Plan Template). However, most safety plans include some version of the following:

• Increased supervision: 24/7 supervision with doors open/unlocked.
• Reduced access: medications (prescription and OTC) locked away; sharps and firearms secured.
• Adaptive coping strategies (e.g., relaxation techniques such as drawing or listening to music).
• Reliable persons for support (e.g., parent, therapist, school counselor).
• Outpatient mental health provider follow-up and/or referral.
• Provision of local crisis and national hotline contact information.
• Use of a safety plan phone app completed with patient.

Envision a safety plan as a living document that evolves, grows, and changes with your patient/family – one that can be easily reviewed/updated at each visit.
 

Returning to our case vignette

Laura returns to your office for a follow-up after a 10-day stay at a hospital-diversion program or inpatient psychiatric unit. The decision is made to use the primary care NIMH ASQ/BSSA algorithm, and you determine the patient to not be at imminent risk following the screen and assessment. Laura is triaged as appropriate for outpatient care, you collaborate to update the safety plan, regular follow-ups are scheduled, and a mental health referral has been placed. Thus, there are tools to assist with screening, assessing, and triaging pediatric patients with suicidal ideation that provide the patient with appropriate care and treatment and may help alleviate the need to have a patient present to the emergency department.

Dr. Abdul-Karim is a child psychiatrist at the University of Vermont University Children’s Hospital in Burlington.

Additional resources

The American Academy of Child and Adolescent Psychiatry has developed information that can be provided to families about suicide safety precautions that can be taken at home, which can be found here: Facts for Families. Suicide Safety: Precautions at Home.

Screening tools listed above can be found here:

ASQ Toolkit.

C-SSRS.

PHQ-9 Modified for Adolescents (PHQ-A).

References

1. Curtin SC. National Center for Health Statistics. “State Suicide Rates Among Adolescents and Young Adults Aged 10-24: United States, 2000-2018” National Vital Statistics Reports..

2. Centers for Disease Control and Prevention, National Center for Health Statistics. “Underlying Cause of Death 2018-2019” CDC WONDER Online Database. Accessed 2021 Jul 31, 6:57:39 p.m.

3. Centers for Disease Control and Prevention. 1991-2019 High School Youth Risk Behavior Survey Data.

Case vignette: Laura is a 14-year-old biological girl who presents to your office for a routine well-child visit. She is doing well medically but notes that over the past 3 months she has been having increasing thoughts of suicide and has self-harmed via cutting on her wrists with a blade removed from a shaving razor. You contemplate what the most salient questions are in order to determine the best disposition for your patient.

The case vignette above may sound like one that you have heard before, and if not, you undoubtedly will encounter such a situation moving forward. The rate of suicidal ideation amongst youth ages 10-24 has increased by 57.4% between 2007 and 2018.¹ Furthermore, suicide is the second leading cause of death in those aged 10 through young adulthood.² According to the Centers for Disease Control and Prevention’s 2019 High School Youth Risk Behavior Survey, 18.8% of high school students seriously considered attempting suicide, 15.7% made a plan about how they would attempt suicide, and 8.9% actually attempted suicide, with 2.5% having a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse during the 12 months before the survey.³ Children often present first to their primary care provider, and they may be the first individual who the child shares their suicidal or self-harm thoughts with. It may be useful to have a standardized approach, while using your own clinical judgment, to determine best next steps. Given the significant recent surge in children presenting to the emergency department for psychiatric needs and that environment having its own limitations (for example, long wait times, nontherapeutic space, etc.), a simple screen and brief assessment may lead to being able to maintain a patient safely outside of the hospital.
 

Screen all appropriate patients for suicide

There are, at minimum, three validated screening tools that can be used as to determine what the best next step should be. They include the Ask Suicide-Screening Questions (ASQ) developed by the National Institute of Mental Health, the Columbia-Suicide Severity Rating Scale (C-SSRS), and the PHQ-9 (modified for adolescents). We can highlight one of the screening tools here as noted below, but the choice of screener may be based on facility and/or clinician preference.

The Ask Suicide-Screening Questions

The ASQ, developed by the National Institute of Mental Health, include the following four binary questions plus a fifth acuity question, as follows:

1. In the past few weeks, have you wished you were dead?

2. In the past few weeks, have you felt that you or your family would be better off if you were dead?

3. In the past week, have you been having thoughts about killing yourself?

4. Have you ever tried to kill yourself?

a. If yes, how?

b. When?

The following acuity question is to be asked if any of the above are answered “yes”:

5. Are you having thoughts of killing yourself right now?

a. If yes, please describe.
 

Assess the level of risk

Once you have screened a patient, you need to assess the level of risk to help determine the level of care required. Returning to our original case vignette, does the patient warrant outpatient management, crisis evaluation, or an emergency psychiatric evaluation? You may have already decided that the patient needs an emergency mental health evaluation from a local crisis clinician evaluation and/or the emergency department. However, you may also find that the screen did not elicit imminent concern, but it does warrant a brief assessment to further elucidate the level of risk and proper disposition. One such instrument that may be helpful is the Brief Suicide Safety Assessment (BSSA) – also developed by the NIMH as a tool linked to the ASQ. There are clear and specific instructions in the BSSA with suggestions on how to ask questions. Important components to the BSSA include:

• A focus on a more thorough clinical history – including frequency of suicidal ideation, suicide plan, past behavior, associated symptoms, and social support/stressors
• Collateral information (e.g., further details from those who know the patient such as family/friends).
• Safety planning.
• Determining disposition.

The BSSA may suggest that a crisis/psychiatric evaluation is warranted or suggest that a safety plan with a mental health referral will likely be sufficient.
 

Triage and safety planning

A safety plan should be created if you determine that a patient can be safely maintained as an outpatient based on your screening, assessment, and triaging. Traditional safety plans come in many different forms and can be found online (Example of a Safety Plan Template). However, most safety plans include some version of the following:

• Increased supervision: 24/7 supervision with doors open/unlocked.
• Reduced access: medications (prescription and OTC) locked away; sharps and firearms secured.
• Adaptive coping strategies (e.g., relaxation techniques such as drawing or listening to music).
• Reliable persons for support (e.g., parent, therapist, school counselor).
• Outpatient mental health provider follow-up and/or referral.
• Provision of local crisis and national hotline contact information.
• Use of a safety plan phone app completed with patient.

Envision a safety plan as a living document that evolves, grows, and changes with your patient/family – one that can be easily reviewed/updated at each visit.
 

Returning to our case vignette

Laura returns to your office for a follow-up after a 10-day stay at a hospital-diversion program or inpatient psychiatric unit. The decision is made to use the primary care NIMH ASQ/BSSA algorithm, and you determine the patient to not be at imminent risk following the screen and assessment. Laura is triaged as appropriate for outpatient care, you collaborate to update the safety plan, regular follow-ups are scheduled, and a mental health referral has been placed. Thus, there are tools to assist with screening, assessing, and triaging pediatric patients with suicidal ideation that provide the patient with appropriate care and treatment and may help alleviate the need to have a patient present to the emergency department.

Dr. Abdul-Karim is a child psychiatrist at the University of Vermont University Children’s Hospital in Burlington.

Additional resources

The American Academy of Child and Adolescent Psychiatry has developed information that can be provided to families about suicide safety precautions that can be taken at home, which can be found here: Facts for Families. Suicide Safety: Precautions at Home.

Screening tools listed above can be found here:

ASQ Toolkit.

C-SSRS.

PHQ-9 Modified for Adolescents (PHQ-A).

References

1. Curtin SC. National Center for Health Statistics. “State Suicide Rates Among Adolescents and Young Adults Aged 10-24: United States, 2000-2018” National Vital Statistics Reports..

2. Centers for Disease Control and Prevention, National Center for Health Statistics. “Underlying Cause of Death 2018-2019” CDC WONDER Online Database. Accessed 2021 Jul 31, 6:57:39 p.m.

3. Centers for Disease Control and Prevention. 1991-2019 High School Youth Risk Behavior Survey Data.

Case vignette: Laura is a 14-year-old biological girl who presents to your office for a routine well-child visit. She is doing well medically but notes that over the past 3 months she has been having increasing thoughts of suicide and has self-harmed via cutting on her wrists with a blade removed from a shaving razor. You contemplate what the most salient questions are in order to determine the best disposition for your patient.

The case vignette above may sound like one that you have heard before, and if not, you undoubtedly will encounter such a situation moving forward. The rate of suicidal ideation amongst youth ages 10-24 has increased by 57.4% between 2007 and 2018.¹ Furthermore, suicide is the second leading cause of death in those aged 10 through young adulthood.² According to the Centers for Disease Control and Prevention’s 2019 High School Youth Risk Behavior Survey, 18.8% of high school students seriously considered attempting suicide, 15.7% made a plan about how they would attempt suicide, and 8.9% actually attempted suicide, with 2.5% having a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse during the 12 months before the survey.³ Children often present first to their primary care provider, and they may be the first individual who the child shares their suicidal or self-harm thoughts with. It may be useful to have a standardized approach, while using your own clinical judgment, to determine best next steps. Given the significant recent surge in children presenting to the emergency department for psychiatric needs and that environment having its own limitations (for example, long wait times, nontherapeutic space, etc.), a simple screen and brief assessment may lead to being able to maintain a patient safely outside of the hospital.
 

Screen all appropriate patients for suicide

There are, at minimum, three validated screening tools that can be used as to determine what the best next step should be. They include the Ask Suicide-Screening Questions (ASQ) developed by the National Institute of Mental Health, the Columbia-Suicide Severity Rating Scale (C-SSRS), and the PHQ-9 (modified for adolescents). We can highlight one of the screening tools here as noted below, but the choice of screener may be based on facility and/or clinician preference.

The Ask Suicide-Screening Questions

The ASQ, developed by the National Institute of Mental Health, include the following four binary questions plus a fifth acuity question, as follows:

1. In the past few weeks, have you wished you were dead?

2. In the past few weeks, have you felt that you or your family would be better off if you were dead?

3. In the past week, have you been having thoughts about killing yourself?

4. Have you ever tried to kill yourself?

a. If yes, how?

b. When?

The following acuity question is to be asked if any of the above are answered “yes”:

5. Are you having thoughts of killing yourself right now?

a. If yes, please describe.
 

Assess the level of risk

Once you have screened a patient, you need to assess the level of risk to help determine the level of care required. Returning to our original case vignette, does the patient warrant outpatient management, crisis evaluation, or an emergency psychiatric evaluation? You may have already decided that the patient needs an emergency mental health evaluation from a local crisis clinician evaluation and/or the emergency department. However, you may also find that the screen did not elicit imminent concern, but it does warrant a brief assessment to further elucidate the level of risk and proper disposition. One such instrument that may be helpful is the Brief Suicide Safety Assessment (BSSA) – also developed by the NIMH as a tool linked to the ASQ. There are clear and specific instructions in the BSSA with suggestions on how to ask questions. Important components to the BSSA include:

• A focus on a more thorough clinical history – including frequency of suicidal ideation, suicide plan, past behavior, associated symptoms, and social support/stressors
• Collateral information (e.g., further details from those who know the patient such as family/friends).
• Safety planning.
• Determining disposition.

The BSSA may suggest that a crisis/psychiatric evaluation is warranted or suggest that a safety plan with a mental health referral will likely be sufficient.
 

Triage and safety planning

A safety plan should be created if you determine that a patient can be safely maintained as an outpatient based on your screening, assessment, and triaging. Traditional safety plans come in many different forms and can be found online (Example of a Safety Plan Template). However, most safety plans include some version of the following:

• Increased supervision: 24/7 supervision with doors open/unlocked.
• Reduced access: medications (prescription and OTC) locked away; sharps and firearms secured.
• Adaptive coping strategies (e.g., relaxation techniques such as drawing or listening to music).
• Reliable persons for support (e.g., parent, therapist, school counselor).
• Outpatient mental health provider follow-up and/or referral.
• Provision of local crisis and national hotline contact information.
• Use of a safety plan phone app completed with patient.

Envision a safety plan as a living document that evolves, grows, and changes with your patient/family – one that can be easily reviewed/updated at each visit.
 

Returning to our case vignette

Laura returns to your office for a follow-up after a 10-day stay at a hospital-diversion program or inpatient psychiatric unit. The decision is made to use the primary care NIMH ASQ/BSSA algorithm, and you determine the patient to not be at imminent risk following the screen and assessment. Laura is triaged as appropriate for outpatient care, you collaborate to update the safety plan, regular follow-ups are scheduled, and a mental health referral has been placed. Thus, there are tools to assist with screening, assessing, and triaging pediatric patients with suicidal ideation that provide the patient with appropriate care and treatment and may help alleviate the need to have a patient present to the emergency department.

Dr. Abdul-Karim is a child psychiatrist at the University of Vermont University Children’s Hospital in Burlington.

Additional resources

The American Academy of Child and Adolescent Psychiatry has developed information that can be provided to families about suicide safety precautions that can be taken at home, which can be found here: Facts for Families. Suicide Safety: Precautions at Home.

Screening tools listed above can be found here:

ASQ Toolkit.

C-SSRS.

PHQ-9 Modified for Adolescents (PHQ-A).

References

1. Curtin SC. National Center for Health Statistics. “State Suicide Rates Among Adolescents and Young Adults Aged 10-24: United States, 2000-2018” National Vital Statistics Reports..

2. Centers for Disease Control and Prevention, National Center for Health Statistics. “Underlying Cause of Death 2018-2019” CDC WONDER Online Database. Accessed 2021 Jul 31, 6:57:39 p.m.

3. Centers for Disease Control and Prevention. 1991-2019 High School Youth Risk Behavior Survey Data.

Adam is a 14-year-old who presents for “behavioral concerns” as recommended by his teacher. He is in the eighth grade and is struggling academically and socially. He has intermittent outbursts and poor engagement with other children, and often refuses to do schoolwork. He is seen in the outpatient primary care clinic, usually with his mother and two older siblings, one of whom typically translates for his Arabic-speaking mother. Adam is bilingual, although he prefers Arabic. It is difficult to understand the presenting concern as Adam states that he is doing well and is unsure why the teacher would have made such a report. Mother notes that she does not see these behaviors at home either.

What must we consider? Are there potential barriers, alternate ways to engage, and what role may culture have?

There are many things to consider in the above case, including language barriers, nuanced interactions, and cultural expectations and norms. To understand the scope, statistics reveal that the United States leads the world in its immigrant population with about 44.8 million foreign-born persons in 2018, which accounts for approximately 13.7% of the U.S. population.¹ In 2019, 30,000 refugees were resettled in the United States.² In 2017, immigrant children made up 27% (19.6 million) of U.S. children, of which second-generation children (born in the United States to immigrant parents) were the vast majority at 16.7 million.³ Given this information, it is self-evident that we live in a multicultural society; it is imperative to consider the cultural context in which our patients and families are presenting.

FatCamera/E+

Culture is defined as a set of shared beliefs, norms, values, and behaviors exhibited by a group. Culture plays a role and impacts children in various ways throughout their development. Health care providers would benefit from aspiring to exude cultural humility – learning with and from patients and their families with openness, kindness, and a desire for collaboration. The provider also must consider a family’s history of migration as the response to migration may vary based on age, personal experiences, age at which migration occurred, language abilities, and amount of cultural engagement in the new country (i.e. acculturation).^4,5
 

Cultural framework model

One example of a potential framework to use to engage within a cultural context includes the LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model,^6,7 which initially was developed to be used within a family medicine clinic. It includes the following:

Listen with sympathy and understanding to the patient’s perception of the problem. Try to understand their perspective of symptoms through considering their thoughts regarding etiology and treatment options.

Explain your perception of the problem. Have a dialogue about what you perceive is the likely cause based on a medical perspective.

Acknowledge and discuss the differences and similarities. Engage in open conversation while being cognizant that there may be similarities and differences in the perception you may have versus your patient’s perception. Try to find areas that can be engaged in and an alliance built upon, as well as respectfully and humbly addressing any concerns about potentially harmful patient understandings.

Recommend treatment. Present a treatment recommendation that considers both yours and the patient’s perspectives.

Negotiate agreement. Discuss, collaborate, and finalize a treatment plan that considers a biopsychosocial and spiritual/religious model of care that is patient-centered and personalized such that the main goal is optimal health and wellness for the patient/family.

The following are tips to consider in the life-long process of becoming more culturally aware:

• Be willing to learn with your patients and be thoughtful about your own feelings/thoughts/behaviors that may be positively or negatively impacting those interactions.
• Be aware of your own identity and what that may contribute to the clinical space.
• Recognize that you are not meant to know everything, but being open to the journey and learning process will go a long way.
• Try to shift the focus from paternalistic medicine to collaborative and patient-centered approaches.

The case at hand

In returning to our case and applying the LEARN model and cultural humility, we may be able to uncover more of the story. Adam is seen at a subsequent appointment, and you determine it best to obtain an in-person interpreter for this appointment. As you listen to the story, you learn that his father was killed early in Adam’s life, his mother has suffered from depression, and they moved here 3 years ago from a refugee camp, where most of their family continues to reside. He notes that at times he feels that he is back in that space and that he also feels frustrated. He is accustomed to doing well academically, but English has been difficult to learn.

You explain your understanding and acknowledge concerns for his past experiences playing a role, the importance of having community supports, and that learning a new language is challenging. You recommend that the school offer culturally appropriate interventions, trauma-informed assessments, and English-language opportunities. Adam and his mother note willingness to engage in this plan but would like to speak to their local religious leader as well.

Collaborating in a manner similar to this will likely build a therapeutic alliance between the patient, their family, and caretakers, thus leading to improved outcomes.

For further reading, consider AACAP Finding Mental Healthcare for Children of Immigrants and the American Academy of Pediatrics Providing Culturally Effective Care Toolkit.
 

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. “Key findings about U.S. immigrants.” Pew Research Center, Washington, D.C. (2020)

2. “Key facts about refugees to the U.S.” Pew Research Center, Washington, D.C. (2019)

3. “Immigrant Children.” Child Trends, Bethesda, MD (2018).

4. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. (Philadelphia: Lippincott Williams & Wilkins, 2015, pp. 139-45).

5. Lewis’sChild and Adolescent Psychiatry: A Comprehensive Textbook, 5th ed. (Philadelphia: Lippincott Williams & Wilkins, 2017, pp. 111-22).

6. Berlin EA, Fowkes WA Jr.A teaching framework for cross-cultural health care. Application in family practice. West J Med 1983;139(6):934-8.

7. Paediatr Child Health. 2018 Feb;23(1):66-9.

Adam is a 14-year-old who presents for “behavioral concerns” as recommended by his teacher. He is in the eighth grade and is struggling academically and socially. He has intermittent outbursts and poor engagement with other children, and often refuses to do schoolwork. He is seen in the outpatient primary care clinic, usually with his mother and two older siblings, one of whom typically translates for his Arabic-speaking mother. Adam is bilingual, although he prefers Arabic. It is difficult to understand the presenting concern as Adam states that he is doing well and is unsure why the teacher would have made such a report. Mother notes that she does not see these behaviors at home either.

What must we consider? Are there potential barriers, alternate ways to engage, and what role may culture have?

There are many things to consider in the above case, including language barriers, nuanced interactions, and cultural expectations and norms. To understand the scope, statistics reveal that the United States leads the world in its immigrant population with about 44.8 million foreign-born persons in 2018, which accounts for approximately 13.7% of the U.S. population.¹ In 2019, 30,000 refugees were resettled in the United States.² In 2017, immigrant children made up 27% (19.6 million) of U.S. children, of which second-generation children (born in the United States to immigrant parents) were the vast majority at 16.7 million.³ Given this information, it is self-evident that we live in a multicultural society; it is imperative to consider the cultural context in which our patients and families are presenting.

FatCamera/E+

Culture is defined as a set of shared beliefs, norms, values, and behaviors exhibited by a group. Culture plays a role and impacts children in various ways throughout their development. Health care providers would benefit from aspiring to exude cultural humility – learning with and from patients and their families with openness, kindness, and a desire for collaboration. The provider also must consider a family’s history of migration as the response to migration may vary based on age, personal experiences, age at which migration occurred, language abilities, and amount of cultural engagement in the new country (i.e. acculturation).^4,5
 

Cultural framework model

One example of a potential framework to use to engage within a cultural context includes the LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model,^6,7 which initially was developed to be used within a family medicine clinic. It includes the following:

Listen with sympathy and understanding to the patient’s perception of the problem. Try to understand their perspective of symptoms through considering their thoughts regarding etiology and treatment options.

Explain your perception of the problem. Have a dialogue about what you perceive is the likely cause based on a medical perspective.

Acknowledge and discuss the differences and similarities. Engage in open conversation while being cognizant that there may be similarities and differences in the perception you may have versus your patient’s perception. Try to find areas that can be engaged in and an alliance built upon, as well as respectfully and humbly addressing any concerns about potentially harmful patient understandings.

Recommend treatment. Present a treatment recommendation that considers both yours and the patient’s perspectives.

Negotiate agreement. Discuss, collaborate, and finalize a treatment plan that considers a biopsychosocial and spiritual/religious model of care that is patient-centered and personalized such that the main goal is optimal health and wellness for the patient/family.

The following are tips to consider in the life-long process of becoming more culturally aware:

• Be willing to learn with your patients and be thoughtful about your own feelings/thoughts/behaviors that may be positively or negatively impacting those interactions.
• Be aware of your own identity and what that may contribute to the clinical space.
• Recognize that you are not meant to know everything, but being open to the journey and learning process will go a long way.
• Try to shift the focus from paternalistic medicine to collaborative and patient-centered approaches.

The case at hand

In returning to our case and applying the LEARN model and cultural humility, we may be able to uncover more of the story. Adam is seen at a subsequent appointment, and you determine it best to obtain an in-person interpreter for this appointment. As you listen to the story, you learn that his father was killed early in Adam’s life, his mother has suffered from depression, and they moved here 3 years ago from a refugee camp, where most of their family continues to reside. He notes that at times he feels that he is back in that space and that he also feels frustrated. He is accustomed to doing well academically, but English has been difficult to learn.

You explain your understanding and acknowledge concerns for his past experiences playing a role, the importance of having community supports, and that learning a new language is challenging. You recommend that the school offer culturally appropriate interventions, trauma-informed assessments, and English-language opportunities. Adam and his mother note willingness to engage in this plan but would like to speak to their local religious leader as well.

Collaborating in a manner similar to this will likely build a therapeutic alliance between the patient, their family, and caretakers, thus leading to improved outcomes.

For further reading, consider AACAP Finding Mental Healthcare for Children of Immigrants and the American Academy of Pediatrics Providing Culturally Effective Care Toolkit.
 

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. “Key findings about U.S. immigrants.” Pew Research Center, Washington, D.C. (2020)

2. “Key facts about refugees to the U.S.” Pew Research Center, Washington, D.C. (2019)

3. “Immigrant Children.” Child Trends, Bethesda, MD (2018).

4. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. (Philadelphia: Lippincott Williams & Wilkins, 2015, pp. 139-45).

5. Lewis’sChild and Adolescent Psychiatry: A Comprehensive Textbook, 5th ed. (Philadelphia: Lippincott Williams & Wilkins, 2017, pp. 111-22).

6. Berlin EA, Fowkes WA Jr.A teaching framework for cross-cultural health care. Application in family practice. West J Med 1983;139(6):934-8.

7. Paediatr Child Health. 2018 Feb;23(1):66-9.

Adam is a 14-year-old who presents for “behavioral concerns” as recommended by his teacher. He is in the eighth grade and is struggling academically and socially. He has intermittent outbursts and poor engagement with other children, and often refuses to do schoolwork. He is seen in the outpatient primary care clinic, usually with his mother and two older siblings, one of whom typically translates for his Arabic-speaking mother. Adam is bilingual, although he prefers Arabic. It is difficult to understand the presenting concern as Adam states that he is doing well and is unsure why the teacher would have made such a report. Mother notes that she does not see these behaviors at home either.

What must we consider? Are there potential barriers, alternate ways to engage, and what role may culture have?

There are many things to consider in the above case, including language barriers, nuanced interactions, and cultural expectations and norms. To understand the scope, statistics reveal that the United States leads the world in its immigrant population with about 44.8 million foreign-born persons in 2018, which accounts for approximately 13.7% of the U.S. population.¹ In 2019, 30,000 refugees were resettled in the United States.² In 2017, immigrant children made up 27% (19.6 million) of U.S. children, of which second-generation children (born in the United States to immigrant parents) were the vast majority at 16.7 million.³ Given this information, it is self-evident that we live in a multicultural society; it is imperative to consider the cultural context in which our patients and families are presenting.

FatCamera/E+

Culture is defined as a set of shared beliefs, norms, values, and behaviors exhibited by a group. Culture plays a role and impacts children in various ways throughout their development. Health care providers would benefit from aspiring to exude cultural humility – learning with and from patients and their families with openness, kindness, and a desire for collaboration. The provider also must consider a family’s history of migration as the response to migration may vary based on age, personal experiences, age at which migration occurred, language abilities, and amount of cultural engagement in the new country (i.e. acculturation).^4,5
 

Cultural framework model

One example of a potential framework to use to engage within a cultural context includes the LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model,^6,7 which initially was developed to be used within a family medicine clinic. It includes the following:

Listen with sympathy and understanding to the patient’s perception of the problem. Try to understand their perspective of symptoms through considering their thoughts regarding etiology and treatment options.

Explain your perception of the problem. Have a dialogue about what you perceive is the likely cause based on a medical perspective.

Acknowledge and discuss the differences and similarities. Engage in open conversation while being cognizant that there may be similarities and differences in the perception you may have versus your patient’s perception. Try to find areas that can be engaged in and an alliance built upon, as well as respectfully and humbly addressing any concerns about potentially harmful patient understandings.

Recommend treatment. Present a treatment recommendation that considers both yours and the patient’s perspectives.

Negotiate agreement. Discuss, collaborate, and finalize a treatment plan that considers a biopsychosocial and spiritual/religious model of care that is patient-centered and personalized such that the main goal is optimal health and wellness for the patient/family.

The following are tips to consider in the life-long process of becoming more culturally aware:

• Be willing to learn with your patients and be thoughtful about your own feelings/thoughts/behaviors that may be positively or negatively impacting those interactions.
• Be aware of your own identity and what that may contribute to the clinical space.
• Recognize that you are not meant to know everything, but being open to the journey and learning process will go a long way.
• Try to shift the focus from paternalistic medicine to collaborative and patient-centered approaches.

The case at hand

In returning to our case and applying the LEARN model and cultural humility, we may be able to uncover more of the story. Adam is seen at a subsequent appointment, and you determine it best to obtain an in-person interpreter for this appointment. As you listen to the story, you learn that his father was killed early in Adam’s life, his mother has suffered from depression, and they moved here 3 years ago from a refugee camp, where most of their family continues to reside. He notes that at times he feels that he is back in that space and that he also feels frustrated. He is accustomed to doing well academically, but English has been difficult to learn.

You explain your understanding and acknowledge concerns for his past experiences playing a role, the importance of having community supports, and that learning a new language is challenging. You recommend that the school offer culturally appropriate interventions, trauma-informed assessments, and English-language opportunities. Adam and his mother note willingness to engage in this plan but would like to speak to their local religious leader as well.

Collaborating in a manner similar to this will likely build a therapeutic alliance between the patient, their family, and caretakers, thus leading to improved outcomes.

For further reading, consider AACAP Finding Mental Healthcare for Children of Immigrants and the American Academy of Pediatrics Providing Culturally Effective Care Toolkit.
 

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. “Key findings about U.S. immigrants.” Pew Research Center, Washington, D.C. (2020)

2. “Key facts about refugees to the U.S.” Pew Research Center, Washington, D.C. (2019)

3. “Immigrant Children.” Child Trends, Bethesda, MD (2018).

4. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. (Philadelphia: Lippincott Williams & Wilkins, 2015, pp. 139-45).

5. Lewis’sChild and Adolescent Psychiatry: A Comprehensive Textbook, 5th ed. (Philadelphia: Lippincott Williams & Wilkins, 2017, pp. 111-22).

6. Berlin EA, Fowkes WA Jr.A teaching framework for cross-cultural health care. Application in family practice. West J Med 1983;139(6):934-8.

7. Paediatr Child Health. 2018 Feb;23(1):66-9.