Edilma L. Yearwood

Addressing Gaps in Mental Health Needs of Diverse, At-Risk, Underserved, and Disenfranchised Populations: A Call for Nursing Action

Psychiatric nurses have an essential role in meeting the mental health needs of diverse, at-risk, underserved, and disenfranchised populations across the lifespan. This paper summarizes the needs of individuals especially at-risk for mental health disorders, acknowledging that such vulnerability is contextual, age-specific, and influenced by biological, behavioral, socio-demographic and cultural factors. With its longstanding commitment to cultural sensitivity and social justice, its pivotal role in healthcare, and its broad educational base, psychiatric nursing is well-positioned for leadership in addressing the gaps in mental health prevention and treatment services for vulnerable and underserved populations. This paper describes these issues, presents psychiatric nursing exemplars that address the problems, and makes strong recommendations to psychiatric nurse leaders, policy makers and mental health advocates to help achieve change.

Global Issues in Mental Health Across the Life Span: Challenges and Nursing Opportunities

This article describes what is known about mental health in children, adolescents, adults, and the elderly globally in high-, middle- and low-income countries. The social determinants of health are described as well as the paradigm shift from focusing on psychopathology to looking at ways in which individuals and communities can embrace mental health promotion to decrease stigma and provide care for all individuals in resource-rich and resource-poor environments. The need to expand the content in nursing curricula to include mental health concepts at all levels of training, foster mental health research, and promote international collaboration around best practices is also discussed.

Duality in Context The Process of Preparedness in Communicating With At-Risk Children

The goal of this study was to explore the cultural meaning of parent-child communication behaviors in inner-city children at risk for common behavioral problems. Following participation in a preventive intervention called Insights Into Childrens Temperament, 40 parents of first and second-grade children were interviewed. The data were analyzed using a constant comparative method derived from grounded-theory techniques. Findings indicate that a complex communication process was used by parents with their at-risk innercity school-age children. The immediacy of safety concerns for the child, the childs temperament, and the current parental state informed the choice of communication behaviors chosen by the parent. The ultimate goal of communication for these participants was to equip their children with tools to assist them to safely navigate their school and community environments. Participants also offered several recommendations that could be useful for practitioners and researchers to incorporate into their work with inner-city families.

Efforts to Meet the Mental Health Needs of Children and Adolescents

As child and adolescent psychiatric-mental health nurses, we are quite aware of the shortage of treatment beds, treatment facilities, and appropriately trained mental health professionals to provide mental health services to children and adolescents. As a consequence, many of our most vulnerable individuals are not receiving early screening, a correct diagnosis, referral, or treatment. By the time most children and adolescents come to the attention of mental healthcare providers, their behavioral or psychiatric needs have been woefully neglected. In essence, our current system of treatment responds well to the “squeaky wheel” phenomenon. If a youngster repeatedly gets into trouble at school or in the community, or escalates to the point that he/she is dangerous to self or others, the system reflexively goes into crisis mode and responds by attempting to address the immediate presenting needs. Unfortunately, at this point the level of psychiatric or behavioral need may be so complex and extensive that a successful treatment outcome is jeopardized. Prevention and early intervention must become the gold standard rather than the selective, inconsistent, and haphazard approach to child mental health that currently exists. Advocates for the health and mental health of children are looking at new models that will reach more children earlier and in multiple nontraditional settings. Pediatricians, child and adolescent psychiatrists, and advanced practice nurses in child and adolescent mental health and pediatrics are all responding to the significant mental health needs of our specialty population. For example, the American Academy of Pediatrics (AAP) developed a policy statement on competency guidelines that strongly recommended that healthcare providers in primary care screen all children and adolescents for behavioral and psychiatric difficulties (AAP, 2009). In describing the need to intervene in primary care, they cited the discrepancy between the large number of children with mental health needs and the relatively low number who access and receive services; the disproportionate impact of unmet mental health needs on minority populations; the shortage of treatment specialty providers; the fact that most psychiatric disorders have their origin in childhood or adolescence; and that anxiety and depression are frequent comorbid presentations with medical illnesses in youth. In their position paper, AAP stipulated that in order for pediatricians to be competent in providing mental health and substance abuse services in their practice, changes must be made to their residency training. They also identified that their continuing education offerings should include content on knowledge and skills in caring for children who present with anxiety, depression, and substance use; skills in recognizing and managing psychiatric emergencies; skills in recognizing behavioral and mental health risk factors; and skills in promoting healthy lifestyles. Lastly, they identified that pediatric healthcare providers should commit to lifelong learning about mental health concepts and engage in collaborative relationships with mental health specialists in order to better meet the needs of children and adolescents in their own practice. Child and adolescent psychiatrists have endorsed the view of pediatricians that primary care is a natural place to screen all children and adolescents for risk of mental health or behavioral concerns (early case finding). More recently, their specialty organization, the American Academy of Child and Adolescent Psychiatry (AACAP), endorsed a position paper on Building Collaborative Mental Health Care Partnerships in Pediatric Primary Care. That document was written in response to the shortage of trained mental healthcare providers and the acknowledgment that other pediatric medical professionals are already assessing and treating youth with mental and behavioral health disorders. The AACAP “supports policies that promote mental health recovery as integral to overall health” (AACAP, 2010, p. 3). The AACAP Council further stated that “safe and effective mental and physical health care requires collaboration and communication between child and adolescent psychiatrists and other medical professionals” (p. 3). Early in 2012, a new textbook will be available titled Child and Adolescent Behavioral Health: A Resource for Advanced Practice Psychiatric and Primary Care Practitioners in Nursing. Editors and contributing authors for the text are I, Edilma Yearwood, Geraldine Pearson, and Jamesetta Newland (Yearwood, Pearson, & Newland, 2012). The book, which is published by Wiley-Blackwell, is written collaboratively by advanced practice pediatric or family nurses and child and adolescent psychiatric-mental health practitioners. The editors wanted to produce a document that would strongly advocate for mental health screening of all children and adolescents in primary care. Secondly, we hope the text supports collaboration in nursing between two specialties, both of whom provide treatment to children. Thirdly, we wanted to begin the conversation as to which child and adolescent clinical presentations could be managed in doi: 10.1111/j.1744-6171.2011.00314.x Journal of Child and Adolescent Psychiatric Nursing ISSN 1073-6077

The intersection of CBPR, health disparities, and child and adolescent mental health.

For more than a decade, communities and their academic partners have used community-based participatory action research (CBPR) to build knowledge and support social justice. CBPR has been referred to as a transformative approach to both qualitative and quantitative research that emphasizes co-learning (through which community and academic partners exchange knowledge and expertise), capacity building (in which partners commit to training community members in research processes and other skills), mutual benefit (through which knowledge produced by the research process benefits all partners), and a long-term commitment to eliminating health disparities. By exposing and addressing systemic factors influencing health behavior and tackling issues of concern to stakeholders in the community, CBPR is well suited for bridging gaps in health disparities research and addressing questions of interest to readers of the Journal of Child and Adolescent Psychiatric Nursing.

A Reflection on Ferguson

It has been a number of months since the events of Ferguson, MO, broke and captured our attention. For some, it had no meaning; some saw it as justifiable; for others there was outrage; and for yet others, there was fear and flashback of things we’ve seen before. As a graduate of the NYU masters program I can still hear Martha Rogers talking about patterns, mutual simultaneous interactions, open systems and events as dynamic. As an advanced practice child and adolescent psychiatric nurse and an African-American, I would be remiss not to raise the following issues and questions: Why in 2013 and 2014 are we seeing an increase in the number of Black adolescent males being killed? Why is there an increase in the pattern? Why are normal adolescent behaviors such as playing loud music with peers, walking home at night, or mouthing off now resulting in death for one segment of the population? The solidarity across the country of protesters who have been alarmed by these events has been well coordinated and provides some level of validation that we are not all complacent and there is a recognition of the value of all youth. I worry about the impact of these events, one after another seemingly provoked by normal human behaviors on the perception of other young Black males. What is their understanding of how normal adolescent behaviors can and does result in death?How do these events hamper their freedom to engage in the world with others from a position of curiosity, healthy adolescent risk-taking, moral development, and psychosocial understanding? How dowe as practitioners interpret, discuss, and frame these events for minority youth we work with in practice?

Developing accuracy when estimating Global Burden of Disease (GBD) in mental and substance use disorders using complex research methodology, refined data analysis and community participation

Global Burden of Disease (GBD) is a quantified estimate of health loss as a result of risk, injury or disease.1 Mortality rates along with disability estimates from multiple data sources provides a rank ordering of significant health-related issues contributing to disease burden globally. More than 13% of GBD is due to neuropsychiatric and substance use disorders.2

How can we reclaim the "voice" of child and adolescent psychiatric-mental health nurses?

The mental health status of children and adolescents globally remains bleak. I recently read the 2011 Lancet series on global mental health and read and reread the paper titled Child and adolescent mental health worldwide: evidence for action (Kieling et al., 2011). I was struck by two things. First, the number of children and adolescents in need of mental health services has grown and the factors contributing to their vulnerability have become more complex. The lack of resources to address these complex needs in lowand middle-income countries (LMIC) admittedly appears overwhelming and remains so when we fail to see changes over time. However, I was also struck by the potential role that exists for child and adolescent psychiatric nurses and indeed all advanced practice nurses who have a desire and a passion to make the lives of at-risk and psychiatrically vulnerable children better. What Kieling and colleagues provide is a blueprint for meaningful action at the population level. Given the current lack of resources in LMIC, it is impossible to reach each child who has a mental health need. However, nurses may be able to ultimately have a significant impact by conducting much needed research with this population within LMIC environments and translating those findings for use by nongovernmental organizations, policy makers, key community members, the media, and any global agency that works with at-risk youth and youth with a diagnosable psychiatric disorder. Collecting, disseminating, and using good data to inform advocacy recommendations and action should be an arena that child and adolescent nurse advocates not only consider but embrace. Kieling et al. further pointed out that while 90% of all children and adolescents globally live in LMIC, only 10% of the mental health research done on children and adolescents occur in these environments. In essence, our knowledge of child mental health is skewed toward children from highincome countries and provides us with a limited repertoire of interventions that can be used within LMIC communities.We just don’t know what might work best in these settings because there is an absence of good data. Unfortunately, when looking more closely at the research data from this 10%, the authors point out problems with sample size which in turn effects generalizability; they point to the fact that there are few longitudinal studies conducted, few randomized clinical trials, few nonpharmacological studies, few studies which are published, and very few studies that incorporate culture and community participation in the research design, methodology, and process. The gap in what we need to know in order to make a difference in child mental health on the global scale is quite wide. So perhaps this is where child and adolescent psychiatric nurses should and can focus in order to reclaim our lost child advocacy voice. As clinical, educator, and research specialists who know this population and their families well, shouldn’t we try to address this gap? Why aren’t we working to establish research teams with colleagues in our profession domestically and globally along with seeking strategic interdisciplinary partners? The focus should clearly be on increasing the volume of research conducted by nurses, seeking nontraditional funding sources such as foundations and improving research design, while keeping in mind the cultural context. In addition, we need to look at existing strengths and resilience of children and families in poor, low-resourced, and potentially violent areas, their cultural practices which may hold promise as a stand-alone or combination intervention, and consider using community cultural brokers who can be trained to assess psychiatric and behavioral symptoms and deliver more culturally acceptable interventions. Lastly, nurses need to examine the feasibility of replicating models that integrate mental health care in primary care or other existing service delivery models and carefully critique the outcome data. It is the right time for nurses in our specialty to boldly blaze a different path by addressing the significant gap that exists in child and adolescent mental health care and research globally.

A Report from the 6th World Conference

The 6th World Conference on the Promotion of Mental Health and Prevention of Mental and Behavioral Disorders was held in Washington, DC, November 16–19, 2010. The theme of the conference was Addressing Imbalances: Promoting Equity in Mental Health. There were approximately 500 attendees, primarily from the United States, Canada, Australia, New Zealand, Latin America, Africa, and England. In the audience were clinicians, educators, researchers, and students. Of note, many of the paper presentations focused on child and adolescent issues. The take-home message was that with shrinking global economic resources and the knowledge that many mental disorders occur before the age of 18, evidence-based strategies that focus on children and adolescents may be the most fruitful in the long run. Prevention and mental health promotion in the schools, school safety, bullying, human rights law, mental health in Latin America and the Caribbean, and health literacy for youth were among the presentations I attended. Several participants expressed support for expanding the role of schools in order to promote mental health in children and adolescents and advocated for more resources to be placed in the schools to capture students where they spend a majority of time. A question asked was “Is the school learning environment conducive to student wellbeing?” One group that has been looking at this issue from both a learning and mental health promotion perspective is the International Union for Health Promotion and Education (IUHPE, 2009). They identified that the goals of health promoting schools are to (a) maximize student learning by ensuring that students are physically, socially, and emotionally healthy; and (b) create school environments that are safe, supportive, empowering, and inclusive. Some recommendations to achieve these goals include: 1. Developing partnerships between education entities and policy makers. 2. Providing opportunities for students and parents to be active participants in school activities and decision making. 3. Presenting health issues that are contextually relevant to the community and the students. 4. Adopting strategies that take a whole school approach rather than individual class approach. 5. Promoting an open, honest school environment and consistency between school, the community, and the home. 6. Providing the needed resources to teach children about mental health promotion using multiple strategies to accommodate to different learning styles (http://www.iuhpe.org). The Health Literacy Missouri (HLM, 2010) program was another promising strategy discussed. The program is a collaborative effort between the Universities of Ottawa and Missouri. It uses a secure interactive website of health and mental health literature in a magazine format for students enrolled in school. Youth have access to hot topics, quizzes, fact sheets, and questionnaires on a variety of topics. The site can be accessed at http://www.yoomagazine.net. Topics available include dealing with unhappiness, stigma, bullying, relationships, and communication. The topic areas most accessed by youth are relationships (including bullying relationships) and mental health topics. Schools who wish to register their students must register at the website for permission for non-Missouri youth and professionals to access the materials. There is also a teacher school health magazine resource site. The teacher resource provides support and tips for dealing with common child and adolescent issues, such as anger, anxiety, and depression in the classroom and school. Dr. Brian Kean from Australia presented a single case analysis of bullying, and used Piaget’s stages of concrete operations (children observe rules but don’t really understand them) and formal operations (understand abstract concepts and able to problem solve) to discuss the developmental context within which children understand bullying. He also presented the bullying triangle of watching, doing (being the perpetrator), and victim, and the mandatory bullying reporting system in Australia. In his presentation and the discussion that followed, the issue of promoting respectful environments in schools and at home, adopting a zero tolerance rule, and consequences for perpetrators were discussed. Bullying is a global and multifaceted phenomenon that will require early, consistent, and comprehensive strategies to affect a prosocial change in the actions of watchers, victims, and potential perpetrators. An interesting approach to the discussion of supportive mental health promotion and prevention of disease progression occurred in a presentation of human rights law in the Americas through review of a document developed by the Pan American Health Organization (PAHO, 2010). The document titled Supporting the Implementation of Mental Health Policies in the Americas is available through PAHO. Readers of the document are encouraged to use it as a legal and conceptual framework to improve the health of the most vulnerable members of society, including children, the elderly, those with a mental illness, or with another type of disability. Less than 3% of the minister of health budgets in Latin American countries is spent on mental health, and doi: 10.1111/j.1744-6171.2010.00268.x Journal of Child and Adolescent Psychiatric Nursing ISSN 1073-6077