Screening for Behavioral Health Conditions in an International Clinical Placement

Background: This clinical project describes a mental health screening initiative conducted by nurse practitioner students in a pediatric clinic located in an elementary school in Managua, Nicaragua. Pediatric and family nurse practitioner students from the United States spend one week in Nicaragua each year in this school setting conducting well-child visits. The previous year during the clinic, a needs assessment was conducted and parents and teachers noted that the behavioral health of the school children was a concern. To address this unmet need, it was decided that behavioral health screenings would be provided (during this current clinic) to parents who were waiting to be seen for their child’s well child visit.

Details of practice innovation: Students provided well child visits to Nicaraguan school-children at an elementary school in Managua, Nicaragua. While waiting for their well-child visits to begin, parents completed a behavioral health screening tool. Validated behavioral health screens are recommended for use at well-child visits. Therefore, the Pediatric Symptom Checklist (PSC) Spanish Pictorial Version was administered to parents to be filled out before their child’s well child visit. The pictorial version of the PSC was used to account for the high levels of illiteracy in Nicaragua. The PSC is a 35 item parent report instrument. The items are rated as: “Never”, “Sometimes”, or “Often” present and scored 0, 1, and 2, respectively. Item scores are summed so that the total score is calculated by adding together the score for each of the 35 items, with a possible range of scores from 0-70. A cut-off score of 24 was used.

Outcomes: A total of 52 Nicaraguan school children were screened for behavioral health issues. The average score of the PSC was 18.87 (SD=9.43). Fourteen of the 52 (27%) school children had a positive PSC screen. Of those 14 school children with a positive screen, seven were male and seven were female. The range of scores for the positive screens was 26-54. The average score of the 14 children with a positive screen was 30.57 (SD=7.37). Those with a positive screen were referred for mental health services provided by a Nicaraguan psychologist in the school setting.

Implications: The behavioral health screening tool was well accepted by parents accompanying their children for well-child visits. Screening by parents improved detection of behavioral health problems and fostered conversations with the student nurse practitioners. Because the screenings were conducted pre-visit, it helped the nurse practitioner students with problem identification as well as with setting an agenda for the visit, engaging the family about their concerns, and balancing their attention between physical and behavioral health concerns. Understanding how childhood behavioral health problems can be identified and addressed during pediatric well child visits is important for student growth and development. Behavioral health screenings by nurse practitioner students provided increased clinical attention to children’s mental health problems.