Beyond the Backpack: The Mental Health Questions APPs Should Ask This School Year
By: Lisa Mathis, MSN, FNP-BC
Summer has flown by, and children are heading back to school. As healthcare providers, we know what typically follows, an increase in colds, flu, gastrointestinal illnesses, and, of course, strep throat. As Advanced Practice Providers (APPs), we know what to look for and how to diagnose these conditions because the signs are often straightforward. Vomiting and diarrhea usually point to a GI illness. A sore throat, fever, and a positive rapid strep test make the diagnosis relatively simple.
But there are other threats affecting our school-aged patients that are not as easy to see and are often much more difficult to diagnose. According to the CDC's 2023 Youth Risk Behavior Survey, nearly 1 in 5 high school students (19%) reported being bullied on school property during the previous 12 months, an increase from 15% in 2021. Among LGBTQ+ high school students, 25% reported experiencing electronic bullying, compared with 13% of cisgender heterosexual students.¹
Among youth ages 12 to 18 who experienced bullying, only about 44% reported that an adult at school had been notified. In other words, more than half suffered in silence without seeking help from a trusted adult.². The mental health implications of bullying are significant. CDC data from 2023 found that 20.4% of high school students, roughly 1 in 5, seriously considered attempting suicide during the previous year, while 9.5% reported at least one suicide attempt. Among female students, 27.1% seriously considered suicide and 12.6% reported attempting suicide. Among male students, 14.1% seriously considered suicide and 6.4% reported an attempt.
While bullying alone does not cause suicide, it can contribute to a dangerous chain of events:
Bullying → Emotional Distress → Anxiety/Depression → School Avoidance → Suicidal Thoughts or Behaviors
Suicide is complex and typically results from multiple interacting risk and protective factors. However, the connection between bullying, emotional suffering, and worsening mental health cannot be ignored. Nearly 4 in 10 high school students report persistent feelings of sadness or hopelessness. One in five seriously considers suicide, and nearly one in ten reports a suicide attempt. These statistics serve as a powerful reminder that a routine back-to-school visit may be much more than a physical examination. It may be an opportunity to identify a young person who is struggling and in need of support.
As APPs, we must take these concerns as seriously as we would a diagnosis of strep throat or otitis media. The consequences can be just as life-threatening, if not more so.
Take time during visits with school-aged patients to ask questions that may help uncover issues they are reluctant to share. In some cases, adolescents may feel more comfortable talking with their healthcare provider than with a parent or teacher. By fostering open dialogue and building trust over time, we can create a safe space for meaningful conversations. For many of us, this may be easier than we realize, especially when we have cared for these patients and their families for years. In the era of “see more patients” and decreased time spent with each patient due to scheduling demands, this may be difficult, but taking that extra time may save a life.
Consider incorporating these five questions into your back-to-school assessments:
1. "How are things really going at school?"
Go beyond asking, "How's school?" Explore academic pressures, friendships, feelings of belonging, bullying, safety concerns, and whether they actually enjoy going to school.
2. "How are you sleeping?"
Sleep patterns often provide valuable insight into a young person's emotional well-being. Ask about bedtime habits, insomnia, excessive daytime sleepiness, nighttime phone use, and whether their schedule changed significantly over the summer.
3. "How much time are you spending online?"
Look beyond the number of hours spent on screens. Ask about their experiences online, including social comparison, cyberbullying, exposure to inappropriate content, and late-night social media use. Within the NPACE September Peds virtual event there is an excellent session on the effects of technology in the pediatric patient. It is a great resource for any APP.
4. "What happens when you're stressed?"
This question can open the door to discussions about anxiety, panic symptoms, headaches, abdominal complaints, irritability, avoidance behaviors, changes in eating patterns, and other coping mechanisms.
5. "Do you ever feel like you don't want to be here?"
APPs must be comfortable asking directly about self-harm and suicidal thoughts when appropriate. Compassionate, straightforward questions are far more effective than avoiding the subject because it feels uncomfortable.
If you feel like due to time, the parents being in the room or other factors that may affect the answers you could always create a questionnaire for the patient to complete before you enter the room. This will give you time to review prior to the actual visit. Also, adding the question, “would you like to talk to the provider without a parent in the room?” will also help the patient to be honest and upfront about topics such as the depression but also sexual health. Be creative and think of ways to incorporate what is right for your office and what makes this process safe and not uncomfortable for the patient and parent.
As students return to the classroom this fall, let's remember that not every health concern presents with a fever, rash, or positive test result. Some of the most serious conditions affecting our young patients are invisible. By asking a few additional questions and creating opportunities for honest conversation, we may identify a child who needs help long before a crisis occurs.
For the latest updates and insights, the NPACE Pediatric Virtual event discusses:
-Risk of technology use with children
-Adolescent Substance abuse
-Adolescent Depression and Anxiety
-ADHD in the pediatric population
-Eating disorders in the adolescent population
"Every child deserves a champion, an adult who will never give up on them."
— Rita Pierson
1-https://www.cdc.gov/yrbs/results/2023-yrbs-results.html?utm
2-https://nces.ed.gov/programs/coe/indicator/a10/bullying-electronic-bullying?tid=4&utm