Digital Repository Doctoral Projects Fall 2022 Implementation of a Screening Tool to Help School Educators Identify Adolescents at Risk for Mental Health Issues Shaylee Pettit Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Pettit, S. (2022) Implementation of a screening tool to help school educators identify adolescents at risk for mental health issues Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 1 Implementation of a Screening Tool to Help School Educators Identify Adolescents at Risk for Mental Health Issues by Shaylee Pettit A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah Date: 12/16/22 ___________________________ _______________________ Shaylee Pettit, DNP-FNP, RN Date 12/16/22 Kelley Trump, DNP, MSN/Ed, RN, CNE, COI Date Faculty Project Lead 12/16/22 Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director 12/16/2022 SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 2 Table of Contents Abstract ............................................................................................................................... 4 Introduction……………………………………………………………………………..…5 Problem Statement .............................................................................................................. 5 Background ......................................................................................................................... 5 Diversity of Population and Project Site ............................................................................. 6 Significance for Practice Reflective of Role-Specific Leadership ..................................... 7 Literature Review and Framework ..................................................................................... 8 Framework .......................................................................................................................... 8 Search Methods ................................................................................................................... 9 Synthesis of Literature ........................................................................................................ 9 Mental Health Disorders Causing Disability in Adolescents ....................................... 10 Increasing Mental Health Issues with Electronic Use .................................................. 10 Limited Interventions to Prevent and Treat Mental Health Issues ............................... 11 Screening Tool Implementation to Reduce Mental Health Disorders .......................... 11 Adolescent Mental Health ................................................................................................ 12 Population Mental Health ............................................................................................. 12 Prevalence ..................................................................................................................... 13 Significance .................................................................................................................. 13 Physical, Psychological, and Social Dysfunction ..................................................... 14 School Performance .................................................................................................. 14 Long-Term Consequences ........................................................................................ 14 Suicide ...................................................................................................................... 15 Increased Technology Use Among Teens .................................................................... 15 Screen Time as a Contributor to Mental Health Issues ............................................ 16 Identification of At-Risk Students ................................................................................ 16 School Educators ...................................................................................................... 17 Barriers ...................................................................................................................... 17 Outcomes .................................................................................................................. 18 Screening Tool .............................................................................................................. 18 Possible Significance ................................................................................................ 19 Comparison of Screening Tools ............................................................................... 19 Selection of Appropriate Tool .................................................................................. 22 Use of the Tool ......................................................................................................... 22 Supportive Interventions ............................................................................................... 23 Education and Follow-up .............................................................................................. 23 Outcomes ...................................................................................................................... 24 Discussion ......................................................................................................................... 24 Implications for Practice ................................................................................................... 25 Project Plan ....................................................................................................................... 26 Project Design ................................................................................................................... 26 Needs Assessment/Gap Analysis of Project Site and Population ..................................... 26 Cost Analysis and Sustainability of Project ...................................................................... 27 Project Outcomes .............................................................................................................. 28 SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 3 Consent Procedures and Ethical Considerations .............................................................. 29 Instrument(s) to Measure Intervention Effectiveness ....................................................... 30 Project Implementation ..................................................................................................... 30 Project Intervention ........................................................................................................... 31 Project Timeline ................................................................................................................ 32 Project Evaluation ............................................................................................................. 33 Data Maintenance and Confidentiality ......................................................................... 34 Data Collection and Analysis ....................................................................................... 34 Findings ........................................................................................................................ 40 Strengths ................................................................................................................... 40 Weaknesses ............................................................................................................... 41 Discussion ......................................................................................................................... 41 Translation of Evidence into Practice…………………………………………….…..41 Implications for Practice and Future Scholarship…………………………………….42 Sustainability ............................................................................................................ 43 Dissemination ........................................................................................................... 44 Conclusion……………………………………………………………………………44 References ......................................................................................................................... 46 Appendices ........................................................................................................................ 50 SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 4 Abstract Purpose: This project aimed to introduce the Patient Health Questionnaire for Adolescents (PHQ-A) and Generalized Anxiety Disorder (GAD-7) screening tools at Ogden Preparatory Academy (OPA) to help faculty identify students at risk for mental health issues. Methodology: The participants completed a pre-training survey to evaluate prior knowledge. All participating faculty members then viewed a training video discussing the screening tools' use. After viewing the video, each participant completed a post-training survey to evaluate learning from the presentation. Lastly, OPA faculty completed an end-of-school-year survey to determine attitudes and effectiveness of the project implementation. These surveys used Likert-scale and free-text options to collect quantitative and qualitative data. Results: OPA faculty's use of these screening tools increased the number of student referrals and treatment for anxiety and depression. Additionally, participating faculty felt more confident identifying adolescent anxiety and depression after the training. Having more staff available at the school to review the screening tools and refer to a healthcare provider may be beneficial due to the high number of positive screenings. Implications for practice: This DNP project provided standardized anxiety and depression screening tools to be utilized by OPA staff. The success of the project and staff response indicated that the OPA administration should continue to utilize mental health screening in the future. In addition, using the screening tools may lead to early intervention and treatment for students with anxiety and depression. Keywords: adolescents, anxiety, depression, educators, mental health, school, screening tool, PHQ-9, GAD-7. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 5 Implementation of a Screening Tool to Help Educators Identify At-Risk Adolescents Mental health issues have become increasingly prevalent among adolescents in recent years. For example, 7.1% of children ages 3-17 years have been diagnosed with anxiety, and 3.2% of children ages 3-17 years have a diagnosis of depression in the United States. (U.S. Department of Health & Human Services [U.S. Dept. HHS], 2021). Unfortunately, 60% of this population in Utah goes without treatment (Summers et al., 2019). Adolescent mental health issues such as anxiety and depression correlate with increased electronic use. The use of social media and increased screen time negatively impact the health and development of teenagers. (Uhls et al., 2017). Teens ages 14-17 are twice as likely to be diagnosed with depression or anxiety if regularly using screens for at least seven hours a day (Twenge & Campbell, 2018). A Doctor of Nursing Practice (DNP) project that implements an effective screening tool can assist educators in combatting adolescent anxiety and depression rates. Problem Statement Adolescents with elevated levels of electronic use are at risk of developing various mental health issues, such as anxiety and depression. However, these diagnoses can be detrimental without the appropriate recognition and treatment. Introducing a screening tool intervention within the school system can help educators pinpoint students at increased risk for developing anxiety and depression. In addition, early identification of at-risk behaviors in youth, such as increased screen time, could result in more efficient diagnosis and treatment. Background Anxiety and depression are two of the most common obstacles teens face, and it is taking a severe toll in the classroom. Faculty at Ogden Preparatory Academy (OPA) have noticed higher mental health issues related to increased screen time among students. In addition, staff SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 6 members and educators at OPA identified the school as significantly impacted by student depression and anxiety. Youths ages 2-17 who have increased electronic use have decreased well-being (Twenge & Campbell, 2018). This correlation shows that educators at OPA require a standardized tool to screen students appropriately for depression and anxiety. The school setting is appropriate for implementing a screening tool because primary care providers do not identify two in three youths as having depression. As a result, these students fail to receive mental health care (Zuckerbrot et al., 2018). The failure to diagnose anxiety and depression within this age group can lead to suicide if left untreated. Suicide is the second leading cause of mortality for adolescents. Early identification of students with depression is important because it can help reduce suicide cases in adolescents. Screening tools within the school setting are helpful in the detection of depression and anxiety in this age group (Law et al., 2017). Diversity of Population and Project Site Implementing this project will benefit diversity and improve well-being among counselors, students, student families, teachers, and administrators in the Ogden area. Each OPA student has a unique background, beliefs, and personality. The educators at Ogden Preparatory Academy will utilize the screening tool to look at each student's diverse background and identify students at risk for mental health issues such as depression and anxiety. Giving direct education, materials, and training to counselors will give them the tools to screen the students at OPA effectively. In addition, the screening tool will help educators feel prepared and empowered to support students with their individualized needs. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 7 Significance for Practice Reflective of Role-Specific Leadership Doctoral education in nursing prepares nurses for the highest leadership level in practice. According to Doctor of Nursing Practice Essential II, leadership skills are critical for DNP graduates to improve patient and healthcare outcomes. In addition, possessing leadership skills helps eliminate health disparities and promote patient safety (American Association of Colleges of Nursing [AACN], 2006). The outcomes gained from implementing this screening tool are significant for future DNP practice because they draw upon providers' leadership skills. The key results of this project include collaboration between healthcare professionals and educators to support quality improvement, expansion of community and population health, and enhanced awareness of adolescent mental health based on evidence. This project provides a supportive foundation for a doctoral nursing role because DNP leaders must often lead quality improvement efforts in the clinical setting. The collaboration during the project can open doors for healthcare workers and educators to promote improved outcomes and manage risks ethically. Nurse practitioners must educate others and advocate for best practices in the community to improve patient and population health outcomes. A focus on community health is exemplified in this project and is essential for doctorate-level providers. Addressing gaps in the population helps promote disease prevention and health promotion. Additionally, evidence-based research will determine the best practice to facilitate optimal outcomes for the direct and indirect people involved in this project. As a DNP leader, utilizing evidence-based practices is an important skill to assist in safe patient care and optimal outcomes (AACN, 2006). SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 8 Literature Review and Framework This literature review will address the prevalent mental health concerns and influencing factors that affect adolescents and discuss solutions to minimize these issues within the school setting. Minimizing health concerns will be done by identifying evidence-based standards to implement screening tools and other supportive interventions for school faculty. The literature review supports the following themes: (a) mental health disorders are a primary cause of disability in adolescents worldwide (Twenge, 2020); (b) rates of depression and anxiety are more prevalent with increased electronic and social media use (Utah Department of Health [UDH], 2021), (c) little has been done to initiate in-school interventions to treat or prevent these conditions (Twenge, 2020), and (d) the implementation of a screening tool within the academic setting can reduce the prevalence of mental health disorders among teens. Framework The researcher will utilize the Psychosocial Theory of Human Development to guide this DNP project. This theory was introduced in the 1950s by Erik Erikson. This theory is built upon Freud's theory of psychosexual development by connecting developmental stages to the influence of social dynamics and psychosocial development. As humans grow, they face new challenges. Resolution of difficulties allows people to progress to the next stage successfully. Erikson's theory focuses on eight psychological phases humans must go through as they develop and grow. These stages include (a) trust vs. mistrust, (b) autonomy vs. shame and doubt, (c) initiative vs. guilt, (d) industry vs. inferiority, (e) identity vs. role confusion, (f) intimacy vs. isolation, (g) generativity vs. stagnation, and (h) ego integrity vs. despair (Orenstein & Lewis, 2020). This project will deal with the identity vs. role confusion stage because it involves the psychological development of adolescent students. In this stage, adolescents must gain an SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 9 understanding of who they are. Without resolution in this stage, the individual may face confusion and instability about adulthood's plans, roles, or responsibilities (Upreti, 2017). Search Methods The inclusion of various search terms assisted in the development of this literature review. Some of these included academic setting, adolescents, anxiety, appropriate tool, assessment, at-risk, clinical practice guidelines, depression, digital media, education, electronic use, Erik Erikson, follow-up, identity vs. role confusion, implementation, implications, importance, increased screen use, mental health, outcomes, prevalence, psychological well-being, school setting, screening tool, social media, statistics, stages of psychosocial development, suicide, teens, technology, theory, treatment, Utah, and the United States. Databases used to acquire evidence-based information include the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC), Google, Google Scholar, and Weber State University's Stewart Library online search. Database search exclusion criteria included journal articles and websites over five years old. Synthesis of Literature In a review of the literature, common themes were found and synthesized. First, mental health disorders are the leading cause of disability in teens. The second theme is that electronic use influences the increasing rates of depression and anxiety. Third, there has been limited intervention to treat and prevent these mental health conditions. A final theme during the literature synthesis is that implementing a screening tool in the school setting can decrease teen mental health disorders. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 10 Mental Health Disorders Causing Disability in Adolescents The literature illustrated that depression is a leading cause of disability among adolescents worldwide and can lead to poor outcomes if left untreated (Twenge, 2020). The AAP found that adolescent depression can reveal consequences of educational underachievement, impaired relationships, and aggravation of the severity of health conditions (AAP, 2021). Allgaier et al. (2012) also found that mental health concerns in teenagers occur with poor social functioning and higher rates of major depression as an adult. These conditions also have an increased risk of suicidal ideation (Allgaier et al., 2012). Increasing Mental Health Issues with Electronic Use The literature suggests a significant correlation between electronic use and increased mental health issues among adolescents. Twenge and Campbell (2018) completed a random study on a sample of youth. The authors found that more hours of screen time were associated with lower well-being among this age group, while those with low to no usage of electronics did not change their well-being. They also found that adolescents ages 14-17 were more than twice as likely to be diagnosed with depression or anxiety if they were high electronics users (Twenge & Campbell, 2018). George et al. (2018) also completed a study to examine the associations between daily technology use and mental health symptoms in early adolescence. This study involved 151 adolescents aged 11 to 15 years at risk for mental health problems. The participants completed baseline, 30-day, and 18-month follow-up assessments on their daily technology use and mental health symptoms. The authors found a positive correlation between these factors. They also discussed a cross-sectional study that found that adolescents who use the internet more often reported more significant symptoms of depression. Additional studies illustrate a connection between increased time spent using electronics and increased risk of developing SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 11 mental health problems (George et al., 2018). Dhir et al. (2018) completed another cross-sectional study to determine if social media fatigue in adolescents is related to anxiety and depression rates. The researchers found a positive correlation between the two factors (Dhir et al., 2018). Limited Interventions to Prevent and Treat Mental Health Issues Allison et al. (2013) found another common theme in the research related to the limited intervention and treatment for mental health concerns in adolescents. Allison et al., 2013 discussed that diagnosis only occurs among half of all adolescents before adulthood. In Utah, only 40 percent of adolescents ages 12–17 with depression receive treatment (Summers et al., 2020). Additionally, no more than one-fourth to one-third received treatment (Allison et al., 2013). Untreated depression is related to harmful effects on physical health, psychosocial well-being, and productivity in school (Law et al., 2017). Screening Tool Implementation to Reduce Mental Health Disorders Several articles discussed the importance of screening tools to reduce the prevalence of mental health disorders among teens. Unfortunately, there is no recommended screening tool for adolescents in the school setting, but many highly effective screening instruments are available. While there are many systematic reviews of ideal screening tools for anxiety and depression detection in adolescents, most of the literature focuses on the importance of utilizing a screening tool rather than on the best one. Allison et al. (2013) performed a research study in which school nurses administered mental health screening tools as part of their physical exam to students in the district. The researchers ensured that nurses received adequate training before administering the screening, and the study included students in grades 9-11. They asked each student to complete the PHQ-9 depression screening and 5-item SCARED screening for anxiety and other SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 12 mental health disorders. The screenings were beneficial in this study because many students received medical diagnoses for mental health concerns they were experiencing. For example, of 182 screened students, 57 students had positive screening results. In addition, eight students were diagnosed with depression, four with ADHD, and many others received mental health diagnoses. Additionally, eleven students started receiving therapy, and six other students had close monitoring by the school social worker. Without the help of mental health screening for students in this school district, these conditions might not have been caught promptly (Allison et al., 2013). Adolescent Mental Health Mental health disorders affect countless people around the world each day. These diseases, such as anxiety and depression, are not exclusive to a specific age group. Increasing numbers of adolescents are affected by mental health concerns each day. Anxiety and depression are the most common mental health concerns in adolescents, with the mean age of onset at age 14-15 years old (Siu, 2016). Tran et al. (2019) found that up to 25% of adolescents have a mental health disorder by age 18. If left untreated, these mental health conditions can lead to more severe problems, including psychosis, self-harm, and suicidal ideation (Tran et al., 2019). Population Mental Health Mental health conditions are prevalent in Utah and Nationwide. One in five adults in Utah experiences poor mental health. Mental health diagnoses can be mild or severe. They can include many different conditions, including but not limited to depression, anxiety, bipolar disorder, schizophrenia, obsessive-compulsive disorder, post-traumatic stress disorder, and phobias (UDH, 2021). Additionally, the rate of self-reported lifetime depression is higher in Utah than in the rest of the Nation (Summers et al., 2020). Untreated depression and other mental SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 13 health conditions can lead to adverse outcomes, such as suicidal ideation. Utah had the fifth-highest suicide rate in the United States from 2017 to 2019. Suicide is the eighth leading cause of death for Utahns (UDH, 2021). Prevalence Mental health disorders are prevalent among teenagers, with anxiety and depression being two of the most diagnosed conditions in children. For example, 7.1 percent of children ages 3 to 17 have an anxiety diagnosis, and 3.2 percent of children ages 3 to 17 have been diagnosed with depression (U.S. Dept. HHS, 2021). In 2011, 28.5 percent of students in the Nation stated that they felt sad or hopeless almost every day for two or more weeks. Additionally, approximately 3.1 million adolescents ages 12 to 17 in the United States have had at least one depressive episode. This number equates to 12.8 percent of this age group in the U.S (AAP, 2021). Anxiety is also prevalent, affecting at least eight percent of teens ages 13 to 18 (Allison et al., 2013). Significance Mental health conditions can have serious adverse outcomes without detection and proper treatment. Dhir et al. (2018) found that physical health is at risk when adolescents have undetected or untreated anxiety and depression symptoms. If these conditions are left untreated, serious health concerns and other long-term implications may occur. Untreated mental illness can seriously impact a person's health and well-being. Several problems are associated with untreated mental health conditions. Some of these concerns include physical, psychological, and social dysfunction. School performance also can be affected. Undetected mental health issues can lead to problems such as substance abuse, violence, early pregnancy, and severe mental SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 14 health concerns as an adult. Additionally, untreated anxiety and depression can lead to suicidal ideation. Physical, Psychological, and Social Dysfunction The AAP stated that approximately 14 million children in the United States have a mental disorder that may affect their ability to function physically, psychologically, or socially (Allison et al., 2013). In Utah, 62.2 percent of students in grades 6-12 reported that they had experienced moderate depression symptoms. According to the same report, 16.4 percent felt left out in social situations, and 15.3 percent felt isolated from others. The lack of treatment can also expose teenagers to adverse life events, physical illness, and poor psychosocial functioning (UDH, 2021). Some adverse life events include social and behavioral issues, neglected hygiene, poor self-care practices, and decreased self-esteem (Dhir et al., 2018). School Performance Over 62 percent of Utah students in grades 6-12 reported experiencing moderate symptoms of depression in 2019. Adolescent depression negatively impacts school attendance and may decrease effective learning (Law et al., 2017). In addition, teens have had higher rates of illicit drug dependence associated with anxiety and depression. Furthermore, adolescent depression and anxiety can lower school attendance and performance, impair social well-being, and result in risky behaviors (AAP, 2021). Long-Term Consequences Many long-term effects occur with untreated anxiety and depression in adolescents, and many never receive treatment (AAFP, 2018). Youth with unidentified depression and anxiety are at an increased risk of substance abuse, legal issues, and early pregnancy. In addition, teenagers who deal with these issues are more likely to have concerns with anxiety, substance abuse, and SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 15 violence as an adult (Law et al., 2017). Major depressive disorder in children and adolescents also strongly affects recurrent depression in adulthood (Siu, 2016). Suicide Adolescent well-being has declined significantly from 2011 to 2018, with declines in happiness and life satisfaction and increased rates of depression, self-harm, and suicide attempts (Twenge, 2020). The Utah Bureau of Health Promotion shows that 14.9 percent of males and 28.5 percent of females ages15– 17 seriously considered attempting suicide from 2015 to 2017. In addition, about eight percent of males and 11.4 percent of females had a suicide attempt. 3.1 percent of males and 4.8 percent of females had suicide attempts resulting in injuries necessitating medical care. (Summers et al., 2020). Emergency department admissions for self-harm behaviors tripled between 2009 and 2015 among 10- to 14-year-old girls. Adolescents who spent over five hours a day using screens were over 60 percent more likely to have at least one risk factor for suicide (Twenge, 2020). In 2019, suicide was the leading cause of death in adolescents ages 10 to 17 (UDH, 2021). Increased Technology Use Among Teens In 1995, only 14 percent of adults in the U.S. had internet access. By 2000, 53 percent of the population owned a cellphone, and 46 percent had internet access. This statistic illustrates a stark difference compared to 92 percent having a mobile phone and 87% with internet access in 2015 (George et al., 2018). Adolescents spend, on average, nine hours a day using screens, with at least three hours on their mobile phones (George et al., 2018). Adolescents have spent double the time online in the last decade (Orben, 2019). A contributing factor could be that 75 percent of teenagers own a smartphone, and half of them report feeling addicted to their phones (Chassiakos et al., 2016). SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 16 Screen Time as a Contributor to Mental Health Issues Most adolescents in the United States receive their first mobile device around the time they are in middle school. Not only are teens dealing with hormonal changes and peer pressure, but the introduction of technology in recent years has positively correlated with anxiety and depression rates in teens (Chassiakos et al., 2016). In addition, the increased use of digital technology could be associated with poor mental health, particularly in at-risk adolescents (George et al., 2018). In 14 to 17-year-old adolescents, those who were high users of screens, meaning that they used them over seven hours a day, were more than twice as likely to be diagnosed with depression or anxiety (Twenge & Campbell, 2018). In addition, those with increased electronic use also reported decreased satisfaction with life, reduced happiness, and increased feelings of loneliness, depression, and social isolation (Twenge, 2020). Moderate technology use, or around four hours a day, was also associated with decreased psychological well-being. However, low-screen users, or those who used mobile devices for one hour a day or less, did not differ in well-being (Twenge & Campbell, 2018). Additionally, teenagers who report having electronic devices in their bedrooms at night get fewer minutes of sleep than those who do not (Chassiakos et al., 2016). Lack of sleep is related to depression and other mental health issues (Uhls et al., 2017). Identification of At-Risk Students Early detection of mental health conditions in school-age children is critical for their well-being and success in the academic setting. Identifying those with risk factors for depression, anxiety, and other mental health disorders is essential for proper referral and treatment. In addition, early identification facilitates accurate monitoring of future issues over time. A screening tool can help with the recognition of at-risk students, as well as acknowledging SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 17 personal or family history of mental health disorders or suicidal behaviors. Other factors, such as substance abuse, history of abuse, recurring somatic problems, and history of foster care or other stressors, should also be considered (AAFP, 2018). School Educators Promoting optimal outcomes and addressing the mental health needs of students are crucial to having a safe and healthy school environment. Student success and optimal outcomes often depend on detection in the school setting and support from school mental health teams. School educators are an essential resource for correctly detecting adolescent mental health issues. They are often the first point of contact for students with mental health concerns. They are skilled at identifying mental health issues and providing resources to students and families. In addition, school faculty can provide community resources to families. To help with student mental health concerns, educators can incorporate a recommended mental health screening tool to identify, intervene, refer, and follow up with at-risk students (Bohnenkamp et al., 2015). Schools can screen large numbers of children, which could play a vital role in improving mental health care for adolescents. Moreover, effective screening conducted by school faculty can promote students' academic success and physical well-being (Allison et al., 2013). Barriers There has been a lack of screening and intervention within the school system for mental health issues among teens. While there have been documented screenings done in some schools for depression and anxiety, little is done to initiate in-school interventions to treat or prevent these conditions (Twenge, 2020). Implementing a screening tool, utilization of other resources, referral as needed, and adequate follow-up will help address the rising numbers of teenagers with mental health concerns. According to Twenge and Campbell (2018), there has been a significant SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 18 increase in students who need academic accommodations related to anxiety and depression with minimal resources. Additionally, at-risk adolescents are likelier to have never seen a healthcare professional for mental health concerns (Twenge & Campbell, 2018). Because of this, the school is often the primary source of treatment for students. However, those who see their primary care provider face obstacles, as only 50 percent of adolescents with depression receive a diagnosis before adulthood. Additionally, primary care providers often do not identify these conditions at routine checkups and sometimes do not prescribe adequate treatment (Zuckerbrot et al., 2018). Outcomes Early detection, assessment, and treatment can significantly impact adolescent well-being and mental health outcomes (Bohnenkamp et al., 2015). Mood disorders are prevalent and can have detrimental effects if left without treatment. However, proper identification and treatment among adolescents can lead to optimal health outcomes (UDH, 2021). Educators can improve outcomes among teenagers by utilizing a screening tool to facilitate the early detection of mental health concerns in the school setting. Screening Tool A standardized screening tool intervention within the school system will help counselors identify risk factors, such as increased screen time, to pinpoint students at high risk for developing anxiety and depression. Detection of risk factors will help facilitate more efficient diagnosis, earlier treatment, and prevention of adverse outcomes. Adolescents have a very high prevalence of depression and other mental health concerns. The importance of brain development in this age group makes this an even more critical issue. The American Academy of Family Physicians has recommended that adolescents be screened annually for mental health SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 19 conditions via a proper self-report tool. Such a screening tool will likely help identify these conditions early (AAFP, 2018). Adequate evidence has shown that approved screening instruments can accurately identify mental health disorders in adolescents ages 12 to 18. In addition, intentional mental health screening helps identify students who otherwise might not be detected, increases the likelihood that the student will accept professional treatment for mental health concerns, and reduces long-term risk factors (Siu, 2016). Possible Significance The implications of a screening tool within the academic setting are significant. Early recognition of adolescent mental health issues is essential in initiating timely treatment and appropriate follow-up. Unfortunately, teenage depression and anxiety are often undetected and untreated (Allgaier et al., 2012). Additionally, reliable screening tools for youth mental health concerns play a significant role in addressing and correcting public health problems. Screening tests are typically affordable, easy to use, user-friendly, and effortlessly detect issues in the school setting. Screening tests can also help increase recognition and early detection of problems. Early detection and treatment can improve prognosis and reduce disability among teens (Tran et al., 2019). Additionally, screening tools in the academic setting can expedite the connection to healthcare services. If students are identified early on and receive appropriate intervention, they are less likely to have difficulties as they continue school (Allison et al., 2013). Comparison of Screening Tools Many mental health screening instruments have been developed for use in primary care and used in adolescents. Furthermore, sensitivity and specificity of 70 to 80 percent are deemed SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 20 acceptable for use as a developmental screening test (AAP, 2010). While this is not comprehensive, some of the most common school tools are listed. Screening Tools for Depression. There are several well-known tools in the primary care setting for depression identification, the Patient Health Questionnaire-2 (PHQ2) and the Patient Health Questionnaire-9 PHQ-9. The PHQ-9 is a nine-item questionnaire for adults in the primary care setting. Each item on this screening tool is related to one of the nine criteria of depression listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The PHQ-9 has good diagnostic validity regarding depression. It also has a sensitivity of 80 percent and specificity of 92 percent when used on adult patients. Another advantage of this screening is that it can be self-administered and free to use. The PHQ-2 is a shortened version of the PHQ-9, with only two questions. The PHQ-2 is a valuable tool in screening for depression, but the PHQ-9 is the preferred screening instrument between the two because the PHQ-9 outperformed the PHQ-2 (Allgaier et al., 2012). The Beck Depression Inventory is another popular depression screening tool with high specificity and sensitivity. Additionally, the Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) is another screening for detecting depressive disorders. However, this screening tool is lengthier than some others. Therefore, it has not been recommended for routine use in primary care but in epidemiological studies focusing on adolescent depression (Tran et al., 2019). Screening Tools for Anxiety. The Kessler Psychological Distress Scale is a standard anxiety screening questionnaire. This screening is available in a ten-question tool known as the K10, and a six-question tool, known as the K6. Both devices have been used in several adolescent mental health studies and have been proven helpful in screening teenage anxiety disorders. The questionnaires also have high sensitivity and specificity. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 21 These tools are helpful among adolescents in diverse populations. Additionally, they are relatively short and easy-to-use instruments. The K6 tool is preferable for schools or primary health care because it is quicker and received well (Tran et al., 2019). An additional tool to screen for childhood anxiety disorders such as general anxiety disorder, separation anxiety, panic disorder, and social phobia is the Screen for Child Anxiety Related Disorders (SCARED) assessment tool. It has 41 items and closely follows the DSM-IV classification of anxiety disorders. This assessment has been consistent, reliable, valid, and highly sensitive. It can be used for children ages 8 to 18 (University of Pittsburgh, 2021). Multifactorial Screening Tools. Several screening tools detect multiple mental health conditions at a time. The Mental Health Inventory-5 (MHI-5) helps expose anxiety and depression symptoms in adolescents. The original Mental Health Inventory is a 38-item comprehensive tool used to assess psychological well-being and distress in the general population. The MHI-5 is a shortened version of this screening that is just as effective as the extended version. It is also reliable, quick, and easy to complete. The MHI-5 is swift, reliable, valid, and easy to understand. It also has high sensitivity and specificity (Rivera-Riquelme et al., 2019). The Patient Health Questionnaire for Adolescents (PHQ-A) screening tool is an additional tool like the PFQ-9. However, utilization has not occurred with adolescents, and it screens for various mental health conditions that adolescents may face. The PHQ-A has a high positive predictive value, a sensitivity of 73 percent, and a specificity of 94 percent in a study sample of 403 primary care patients aged 13 to 18. The PHQ-A has the highest sensitivity and specificity for detecting adolescent depression over other examined tools. The Mood and Feelings Questionnaire-Short Form (MFQ-SF) and the Childhood Anxiety Sensitivity Index (ASI) are two additional tools to screen for adolescent anxiety and other mental health conditions. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 22 Both tools were also sufficient for screening these conditions (Bodendorfer et al., 2018). Selection of Appropriate Tool The selected tool for adolescent screening in the school setting, such as in this project, is the PHQ-A. The PHQ-9 has historically been an accurate and reliable tool, but adolescents have not benefited from the screening. It does not screen for anxiety or other related mental health conditions. Therefore, a multifactorial tool would best provide a comprehensive screening tool to detect many teenagers' issues. Additionally, this instrument had the highest sensitivity and specificity over several other devices (Bodendorfer et al., 2018). Use of the Tool Schools play a vital role in improving mental health care for children and adolescents. Schools are capable of screening high numbers of children. Screenings conducted by educators within the school setting can help identify at-risk teenagers and expedite getting them the care they need (Allison et al., 2013). Zuckerbrot et al. (2018) found that using adolescent self-report checklists as screening tools is effective in mental health disorder detection (Zuckerbrot et al. 2018). School screenings should focus on self-report questionnaires for teenagers and the presence of at-risk and protective factors among individual students (Bohnenkamp et al., 2015). A formal system should be in place to ensure adequate screening, diagnosis by healthcare professionals, treatment, and follow-up. Additionally, the AAP Bright Futures Program advises annual screening for emotional and behavioral issues in children and adolescents. Identifying risks by having students complete the screening will ensure more frequent follow-ups (Siu, 2016). SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 23 Supportive Interventions Introducing a technology family safety plan to at-risk students and their families can supplement a mental health screening tool. Individualized media use strategies can help families identify an appropriate balance between screen time and other activities, set boundaries, encourage critical thinking and digital literacy, and support open family communication. Primary care providers can use the technology family safety plan to give families more information about the benefits and risks of technology use. These professionals could discuss reduced physical activity, inadequate sleep, cyberbullying, and weight management. The family safety plan can also help school educators and providers understand values and health goals within each family to better help them. Understanding goals allows them to encourage healthy behaviors and make suggestions for improvement (Chassiakos et al., 2016). Utilizing supportive measures such as a family technology safety plan aligns with the goals of the AAP to limit daily screen time, maintain good physical activity, healthy nutrition, good sleep, and a healthy social environment among children and adolescents (Twenge & Campbell, 2018). Education and Follow-up Education is essential when facilitating change in a process. School educators need to be able to screen for and recognize mental health issues affecting teenagers. School faculty will provide direct information about standardized mental health screening tools and family technology safety plans in a supportive setting. In-person education will allow the educators to ask any questions that may come up and provide a way to assess understanding among the group. After implementing this educational module, the educators will utilize the screening tool to determine which students are at risk for anxiety, depression, and other mental health concerns. This knowledge can help them decide which students and families would benefit from SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 24 introducing and educating them on technology safety plans. After the administration and education of the safety plans, faculty can refer students for treatment, routine follow-up, and, as needed, with at-risk students (Law et al., 2017). Outcomes The intended goal of the doctorate project is to provide guidance and training to Ogden Preparatory Academy Faculty on evidence-based tools to improve student mental health and safety. Education on the PHQ-A screening tool and creating a family technology safety plan will result in successful implementation. At the end of the teaching module, educators will feel empowered to use these tools to properly screen students for adolescent depression, anxiety, and other mental health issues. In addition, staff facilitation of this screening tool will ideally increase the number of students who receive treatment for any mental health issues they are experiencing. In addition, early identification of at-risk students could reduce adolescents with severe mental health symptoms and potentially reduce future adverse outcomes. Discussion Adolescent mental health problems can present in many ways. Unfortunately, educators can sometimes miss red flag warning signs. Schools should adequately address mental health screening since it can improve the identification and referral for treatment for teenagers suffering from mental illness symptoms. Evidence presented in the literature review has emphasized the importance of early screening in the school setting. Limitations to effective implementation within the literature include the costs of screening, the stigma associated with a positive result, and problems with a referral for follow-up and treatment (Siu, 2016). Additionally, limitations within the school setting included distraction from instruction time, lack of acceptance from parents and teachers, potential legal questions, and ethical SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 25 concerns. Despite these potential barriers, mental health screening in the school setting can have substantial benefits, such as expedited treatment and intervention (Bohnenkamp et al., 2015). Furthermore, expedited outcomes could minimize the adverse effects of untreated mental health conditions (Allison et al., 2013). Findings regarding screening tools support the need for more studies of instrument use among adolescents due to decreased research in this age group. Implications for Practice There is an increasing need for mental health services among youth in Utah (Summers et al., 2020). Outcomes include quality improvement because of the focus on population health, especially within the school setting. In addition, improved outcomes can result from implementing a standardized mental health screening tool in the academic environment for adolescents because of increased detection of mental health concerns, more efficient treatment, and adequate follow-up. Ogden Preparatory Academy can serve as a pilot for implementing this project by employing evidence-based tools to reduce adverse outcomes among students at this school. Additionally, DNP students could expand the project in the future to include other schools within the Ogden and Northern Utah area. This expansion would improve population health among adolescents. Quality improvement is a priority for improving population health, especially within the school setting. Additionally, future nursing practice can be applied because of the importance of education, safety, and population health concepts in improving adolescent mental health outcomes. This project may have important clinical implications for the health of adolescents and for developing guidelines for appropriate screening, electronic use limitations, and family technology safety plans (Twenge & Campbell, 2018). SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 26 Project Plan The project plan for this DNP quality improvement project has several parts. The first portion of the project plan is the project design. The gap analysis will then be addressed, including discussing the different populations involved. Project implementation costs and ethical considerations will also be addressed. Finally, a summary of the tools used to measure effectiveness will be presented as the last part of the project plan. Project Design The quality improvement project to implement depression and anxiety screening tools at Ogden Preparatory Academy was a process improvement project. The success of the project implementation was based on collaboration between the DNP student, the project consultant, and the staff at OPA. Following the recommendation to screen adolescents at least once per year will promote population help and assist in enforcing a health policy change (American Academy of Pediatrics, 2021). Additionally, the DNP project implementation will be evaluated with Likert scale surveys to meet the goal of process improvement. Needs Assessment/Gap Analysis of Project Site and Population Anxiety and depression are widespread issues among teens. Unfortunately, most adolescent anxiety and depression cases in Utah are untreated (Summers et al., 2019). The addressed gap was the lack of anxiety and depression screening tools at Ogden Preparatory Academy. Screening tools within the school setting are helpful in the detection of depression and anxiety among teens (Law et al., 2017). Implementing a doctorate project to introduce anxiety and depression screening tools at OPA was beneficial in addressing this prevalent problem. Additionally, many students at this school are of lower socioeconomic status, influencing their ability to seek medical care (S. Hinsley, personal communication, November 2021). SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 27 Implementing these screening tools increased healthcare accessibility for students because all students could be screened in the academic setting without traveling and paying for a visit with a healthcare provider. The direct population in this project included educators and administrators at Ogden Preparatory Academy. These individuals learned to use the anxiety and depression screening tools to identify adolescent mental health issues in the school setting. They were involved with project implementation and were the direct facilitators of screening tool administration. The indirect population consisted of 7th to 9th-grade students at Ogden Preparatory Academy and their parents. When administered by their teacher, the students completed the PHQ-9 and GAD-7 screening forms, and individual students were referred to a counselor or a health care provider as needed. A critical stakeholder in implementing this project was Suzy Hinsley, the counselor for the Junior High School students at OPA. She teamed up with the DNP researcher to determine the best way to implement the project at OPA. Cost Analysis and Sustainability of Project There were not many budget requirements that pertained to this DNP project. The main costs included paper and ink to print the students' anxiety and depression screening tools and the educational handouts to supplement the teaching module (see Appendix A). OPA absorbed all the involved project costs. The stakeholder for the project allowed utilization of the school's resources to print out any needed training materials or other documents. The price was anticipated to be no more than $100 for the school to print several hundred black and white copies. The only additional anticipated expense was the budget to train faculty. However, this training ended up being part of their monthly education modules, which they do during their preparatory time. Therefore, this will save costs because the module was completed during their SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 28 work shift. Surveys were also able to be completed during work time. The educational handout that complements the learning module will be available online for the faculty members to refer to, minimizing printing expenses. All surveys and other educational materials besides the actual screening and technology safety plan tools will be created electronically to ensure efficiency and decrease costs. OPA administrative faculty can sustain the screening process by having access to screening tools and a recorded education module to present to new staff during the training process. Project Outcomes The overarching aim of the DNP project was to educate the Ogden Preparatory Academy faculty on using standardized depression and anxiety screening tools to identify at-risk students for depression or anxiety. One of the short-term goals associated with implementing this DNP project was to initiate the use of evidence-based anxiety and depression screening tool forms. Another short-term goal was to have positive survey results from faculty regarding using the screening tools, such as faculty preparedness and empowerment in using the tools. Finally, another goal was that educators would have improved knowledge and understand the reasons and potential impact of using both screening tools. There were also long-term goals that were associated with the implementation of this DNP project. A main long-term plan was that project tools benefitted student health and job satisfaction among counselors. This goal was completed by implementing valuable and sustainable tools at OPA. Another long-term outcome of this DNP project was to create a plan to sustain the use of the project tools in future years. The plan was created by making any needed adjustments to support the continued use of the instruments after the school year. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 29 Consent Procedures and Ethical Considerations The Weber State University Institutional Review Board confirmed that this project met the standards of a quality improvement activity. Additionally, it was determined that the project does not need formal Institutional Review Board approval. The board confirmed in December 2021 that it was okay to proceed with implementing this project. Institutional Review Board approval was not needed at Ogden Preparatory Academy. Because this is a charter school, the OPA administration confirmed that further permission beyond the school's administration was unnecessary. Throughout the project implementation, student information was always protected. The DNP researcher never had any interaction with students during the entire process. Educators were taught about using the screening tools via the training modules. The educators were then prepared to screen students in their classes throughout the remainder of the school year. When educators were asked to complete surveys regarding their experience using the tools, no student information was included. Informed consent was not needed for this quality improvement project because the researcher was not interacting with the students directly. However, the OPA administration decided to create permission slips. These were given out to parents of students at the school before the project was implemented to explain the screening procedures that would be taking place. Anonymity and confidentiality were protected since no specific student information was ever discussed with the researcher, and no names were attached to any evaluation surveys. In addition, the anonymity of OPA faculty was maintained throughout project implementation. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 30 Instrument(s) to Measure Intervention Effectiveness Tools used to measure the effectiveness of the use of the GAD-7 and PHQ-A screening tools at OPA included pre-training surveys (see Appendix B), post-training surveys (see Appendix C), and year-end evaluation surveys (see Appendix D). The researcher designed these Likert-scale evaluation surveys and was evaluated by Weber State University Faculty. The surveys were also assessed by Suzy Hinsley, the project consultant and counselor for Junior High students at OPA. She confirmed that the tools were appropriate for use with faculty at OPA. The pre-training survey tool helped assess faculty knowledge before completing the education module. The post-training survey was used to assess knowledge among OPA faculty after the training. The post-training survey and year-end surveys helped determine screening tool effectiveness and success. This information helped the researcher and project consultant know what adjustments were needed for future use. Project Implementation The project implementation involved educating faculty at Ogden Preparatory Academy about using evidence-based screening tools to evaluate adolescent anxiety and depression. This age group has had mental health issues, especially in school. Preparing school educators to utilize these tools in the school setting may be invaluable for the future of adolescent students. In addition, many students do not know how to seek help for mental health issues. Therefore, this project could help students and their parents feel comfortable and know when to seek mental health care. The project was implemented using several deliverable resources. The tools utilized include depression and anxiety screening tools, surveys, handouts, and a PowerPoint presentation. Using each of these deliverable resources helped carry out project implementation effectively. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 31 Project Intervention The intervention for this DNP project was to introduce screening tools at Ogden Preparatory Academy (OPA) to help school educators identify adolescent anxiety and depression within the school setting. The associated deliverables were used to facilitate the implementation of the project. The Patient Health Questionnaire for Adolescents (PHQ-A) (Appendix E) and Generalized Anxiety Disorder (GAD-7) (Appendix F) forms were the evidence-based screening tools that were selected to aid in the screening of adolescents at OPA. The screening forms were given out when the project was implemented on March 21, 2022. To successfully implement the project, OPA educators must be adequately trained to use the screening tools. To sufficiently train OPA faculty, a PowerPoint presentation was prepared. The DNP student utilized the lecture to introduce the purpose and need for the project. The intended outcomes were also discussed. In addition, the screening tools were displayed with instructions on how to adequately use the screening tools to identify adolescent mental health conditions. A handout with a decision tree for the PHQ-A (Appendix G) and GAD-7 (Appendix H) was also given to OPA faculty to reference while screening students for anxiety and depression. Surveys were used to assess the effectiveness of the project implementation. A pre-survey tool (Appendix B) was used to evaluate the knowledge of OPA staff before project implementation. This survey was completed right before the educators completed the training. A post-survey tool (Appendix C) was given to faculty to complete two weeks after implementation to ensure that each person had enough time to review the training module. The post-survey evaluated the effectiveness of training materials and assessed faculty knowledge. During the second week of May 2022, a school-year-end evaluation survey (Appendix D) was given out to SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 32 all faculty who had utilized the screening tool during the past two months. This survey was used to evaluate the effectiveness of the project implementation. Project Timeline The timeline for this project involved the initial project proposal completion, collaboration with the project consultant, research, project development, IRB approval, deliverables creation, and survey results analysis (Appendix I). The initial steps of the project implementation took place in November 2021. At this time, the DNP student first met with the project consultant. The project proposal was revised, the research was synthesized, and the literature review was updated. The screening tools and educator survey forms were presented to the project consultant on November 18, 2021. Under Weber State University, approval for Institutional Review Board (IRB) was gained in December 2021. Therefore, IRB approval was not needed at Ogden Preparatory Academy. The teaching plan was then developed from November to February, along with preparing a PowerPoint presentation. The pre-surveys were given out, and the presentation was uploaded to the school's learning module system the week of March 21, 2022. The educators were then instructed to complete the learning module about using the screening tools during their preparation hours by the end of March. After all of the teachers had completed the training, the post-surveys were given out at the beginning of April. Students were screened starting the week of April 18, 2022, and all screenings were completed by May 20, 2022. School-year-end surveys were administered on May 23, 2022, and results were collected and analyzed over the following two weeks. The DNP student then met with the project consultant to discuss the results of the project implementation. Afterward, the consultant and SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 33 DNP student worked together to create a sustainability plan for the future use of the adolescent screening tools. Project Evaluation The goal of the doctorate project was to provide guidance and training to OPA educators on evidence-based tools to improve student mental health and safety. DNP project outcomes were measured with pre-training, post-training, and year-end evaluations for faculty. In March 2022, the project consultant gave the pre-training surveys before the training was uploaded to the school's learning module system. The project consultant then gave each participant hard copies of the pre-training survey. The survey was intended to determine a baseline of staff knowledge and attitudes regarding adolescent anxiety and depression before learning about the screening process. The training session was made available to staff in late March 2022 to educate them about proper screening tools. After viewing the training, five included staff members were asked to fill out a post-training survey to determine improved knowledge regarding screening tools. Finally, a year-end training evaluation was given to each staff member in May 2022 to evaluate project implementation and attitudes at OPA. Each of the three surveys used a five-point Likert scale to evaluate attitudes and the effectiveness of screening tools. The pre-training evaluation was a six-item survey (Appendix B) addressing feelings about adolescent anxiety and familiarity with the screening tools. The post-training survey was an eleven-item questionnaire (Appendix C) addressing many of the same questions as the pre-training survey to determine the effectiveness of the training (Appendix C). The year-end evaluation assessed comfort level with the screening tools and the perceived value of the instruments. In addition, the year-end questionnaire asked questions regarding the number SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 34 of students screened and referred. Also, it addressed the future use of the tools among educators at the school and their perception of student impact (Appendix D). Data Maintenance and Confidentiality Evaluation forms were completed with pen and paper. The project consultant made copies of the surveys and stored them on password-protected computers. Additionally, no identifying information was included in the surveys. Therefore, no names were attached to any of the evaluations. Instead, demographic data of the educators, including job position, age, race, and gender, were given from the project consultant to the DNP student. This demographic data was provided anonymously and was not correlated with any survey. Data Collection and Analysis Qualtrics was initially going to be used for data collection, but this system was not compatible with the school's learning module system. Therefore, hard copies of pre-training, post-training, and year-end surveys were given. Before the training module was completed, the five staff members were given pre-training surveys. The faculty members completed the module as their schedule allowed over two weeks. They then filled out a post-training survey. The year-end evaluation was given during the last week of the academic school year after all screenings were finished. The project consultant gave the DNP student copies of the surveys (see Appendices B, C, and D) and separate demographic information for the five participants (see Table 1). The DNP student utilized Microsoft Excel to analyze the data. Table 1 Participant Characteristics Number of Educators % Gender Male 1 20% SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 35 Female 4 80% Race White 3 60% Hispanic 2 40% Age 30s 1 20% 40s 3 60% 50s 1 20% Position Counselor 2 40% Teacher 2 40% Academic Dean 1 20% This survey aimed to determine baseline knowledge and perception of adolescent anxiety and depression at school. It also assessed confidence levels in identifying at-risk students for anxiety and depression using a five-point Likert scale (see Table 2). The five educators completed the pre-training evaluation before the training module regarding mental health screening tools. The complete pre-training evaluation is included in Appendix B. Table 2 Pre-Training Evaluation Based on a Five-Point Likert Scale Strongly Disagree Disagree Neutral Agree Strongly Agree OPA students experience depression 2 (40%) 3 (60%) OPA students experience anxiety 1 (20%) 4 (80%) Confident in identifying students at risk for depression using PHQ-A 1 (20%) 2 (40%) 2 (40%) Confident in identifying students at risk for 1 (20%) 2 (40%) 2 (40%) SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 36 anxiety using GAD-7 Screening for depression using PHQ-A may lead to recognition and treatment 4 (80%) 1 (20%) Screening for anxiety using GAD-7 may lead to recognition and treatment 4 (80%) 1 (20%) OPA educators completed the post-training evaluations after the school's learning system training module was finished. The post-training survey repeated each of the six questions on the pre-training evaluation form. This was to determine if there was improved knowledge among OPA educators. In addition, direct questions were asked regarding the ease and use of the training materials. The questions involved asking for suggestions for improvement and things the participants liked about the training. This is useful in determining if changes in training videos or materials are needed in the future (see Table 3). The complete post-training evaluation form is included in Appendix C. Table 3 Post-Training Evaluation Based on a Five-Point Likert Scale Strongly Disagree Disagree Neutral Agree Strongly Agree Notes OPA students experience depression 2 (40%) 3 (60%) OPA students experience anxiety 2 (40%) 3 (60%) Confident in identifying students at risk for depression using PHQ-A 1 (20%) 4 (80%) SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 37 Confident in identifying students at risk for anxiety using GAD-7 1 (20%) 4 (80%) Screening for depression using PHQ-A may lead to recognition and treatment 5 (100%) Screening for anxiety using GAD-7 may lead to recognition and treatment 5 (100%) Training applicable to my job 1 (20%) 1 (20%) 3 (60%) The training was easy to understand 2 (40%) 3 (60%) Recommend training for future use 3 (60%) 1 (20%) One (20%) did not answer. Common Themes What would have improved this training? Three participants (60%) said they would not make changes to the training. One participant (20%) suggested changing the wording of a phrase in the training video. In contrast, another (20%) suggested doing two shorter videos for each screening instead of one video with two separate parts. What did you enjoy about this training? Three participants (60%) said the training was easy to understand. One (20%) participant noted that the training would assist in identifying at-risk students, and one (20%) did not answer this question. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 38 Year-end evaluations were completed after all educators completed the training on their education module system and pre- and post-training evaluations. The year-end surveys were used to determine staff comfort levels with the screening tools and the perceived efficacy of the screening tools. The year-end evaluations were also used as a comparison with previous surveys. Educators were asked in this survey if they felt that the screening tools should continue to be utilized at OPA and suggestions for improvement in the future. Participants were also asked if screening tools at OPA have benefitted them in their role at work. The number of surveys and referrals completed was also assessed (see Table 4). The complete year-end evaluation form is included in Appendix D. Table 4 Year-End Evaluation Based on a Five-Point Likert Scale Strongly Disagree Disagree Neutral Agree Strongly Agree Comfortable using PHQ-A to identify adolescent depression 1 (20%) 4 (80%) Comfortable using GAD-7 to identify adolescent anxiety 1 (20%) 4 (80%) PHQ-A is effective in identifying adolescent depression 1 (20%) 4 (80%) SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 39 GAD-7 is effective in identifying adolescent anxiety 1 (20%) 4 (80%) Screening tools should be continued in the future at OPA 5 (100%) 1 to 5 6 to 10 11 to 15 16 to 20 21 or more Number of students screened using PHQ-A 5 (100%) Number of students screened using GAD-7 5 (100%) Number of referrals for depression based on PHQ-A 5 (100%) Number of referrals for anxiety based on GAD-7 5 (100%) Common themes Suggestions to improve screening One participant (20%) said that more mental health workers are needed in the schools. Four participants (80%) did not respond to this question. How project implementation has benefitted participants One participant (20%) was surprised at the number of students that needed to be referred. Four participants (80%) did not respond to this question. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 40 Findings The facilitation of this screening tool by OPA faculty has primarily increased the number of students who receive referrals and treatment for anxiety and depression. It was found that over 75% of screened students needed a referral to a healthcare provider. One participant suggested that it would be helpful to have more mental health care workers in the schools due to the high number of positive screenings. It was also determined that confidence levels in identifying adolescent anxiety and depression increased significantly based on pre-and post-training results. Additionally, all five participants recognized in the post-training survey that using the screening tools may lead to early intervention and treatment for students with anxiety and depression. Furthermore, each of the five educators felt that this screening process needed to continue at OPA in the future due to the high number of positive screenings and referrals. Strengths This DNP project provided standardized anxiety and depression screening tools to be utilized repeatedly by OPA staff now and in the future. The success of the project and staff response indicated that the screening tools should be continued for the next school year. The survey results showed that the project was successful and that minimal changes were needed. This project was also successful because the training presentation was easily understandable. Each of the five educators was well informed on utilizing the screening tools, and each was able to screen many students. In addition, the participants were somewhat diverse, with both Caucasian and Hispanic races, a variety of different ages, and both male and female gender. The SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 41 diversity in this project is a benefit because the training was applicable and understandable to each person. Weaknesses There were also some weaknesses identified. The first is that only five staff members from OPA were involved in the screening process. This provided limited data compared to if more educators were involved. Another limitation is the lack of responses to some of the survey questions. Three questions between the three surveys did not get answers from all five participants. Two of these questions only had one response. These questions were regarding suggestions for improvement and perceived benefits to the person's role. The lack of answers to these questions may make it difficult to decide which changes are needed for the next academic school year. As perceived by one of the educators, an additional weakness is that the PHQ-9 and GAD-7 training should be separated into two different videos instead of one with two distinct parts. Discussion This project aims to introduce the PHQ-A and GAD-7 screening tools at Ogden Preparatory Academy to help school faculty identify students who are at risk for mental health issues. To accomplish this goal, a training video for OPA staff discussing how to utilize the screening tools properly. Surveys are used to evaluate for an increased understanding among participating faculty and determine the project implementation's attitudes and effectiveness. The provided tools improve confidence in screening for anxiety and depression among participating staff members. In addition, using the PHQ-A and GAD-7 screening tools in the school setting increases student referrals and treatment for anxiety and depression. Translation of Evidence into Practice SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 42 The American Academy of Family Physicians recommends that adolescents be screened annually for mental health conditions via a proper self-report tool. The PHQ-A and GAD-7 screening tools help identify these conditions early (AAFP, 2018). Adequate evidence illustrates that approved screening instruments can accurately identify mental health disorders in adolescents ages 12 to 18. In addition, intentional mental health screening helps identify students who otherwise might not be detected, increases the likelihood that the student will accept professional treatment for mental health concerns, and reduces long-term risk factors (Siu, 2016). Furthermore, depression is a leading cause of disability among adolescents worldwide and may lead to poor outcomes if left untreated (Twenge, 2020). Unfortunately, there has been limited intervention and treatment for mental health concerns in adolescents, and diagnosis only occurs in half of all adolescents before adulthood. Furthermore, only 40 percent of adolescents with depression receive treatment (Allison et al., 2013). According to AAFP recommendations, a standardized screening process using the approved PHQ-A and GAD-7 screening tools is utilized at OPA. Implementing the screening tools indicates success in the school setting because it increases the number of students who receive referrals and treatment for anxiety and depression. Over 75% of screened students require a referral to a healthcare provider. These students are likely to go unrecognized and untreated without the help of screening tools. Project success and staff response indicate that the screening tools should be continued in subsequent years with minimal alteration due to the high number of positive screenings and referrals. Furthermore, confidence levels among participating staff in identifying adolescent anxiety and depression increased significantly based on pre-and post-training results. Implications for Practice and Future Scholarship SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 43 There is an increasing need for mental health services among youth (Summers et al., 2020). Ogden Preparatory Academy is a pilot for standardized anxiety and depression screening due to the successful use of evidence-based tools to reduce adverse outcomes among students. Screening adolescents using the PHQ-A and GAD-7 tools may lead to early intervention and treatment for students with anxiety and depression. The implications of a screening tool within the academic setting are significant. Early recognition of adolescent mental health issues is essential in initiating timely treatment and appropriate follow-up. The significance of the devices is illustrated in this project implementation. Therefore, adolescent mental health screening using evidence-based tools should continue to be implemented in the school setting. Screening tests are affordable, easy to use, and readily detect mental health concerns in the school setting (Tran et al., 2019). Implementing a standardized mental health screening tool in the academic environment will likely result in increased detection of mental health concerns, more efficient treatment, and adequate follow-up. The study results also suggest that it may be helpful to have more mental health care workers available in the school setting due to the high number of positive screenings. Sustainability The project consultant and the DNP student worked together to discuss the results of the project implementation and created a sustainability plan for the use of adolescent screening tools. OPA administrative faculty will maintain the teen mental health screening process by sustaining access to the screening tools and education module. The educational materials, including the video regarding the use of the screening tools and the corresponding handout, are available online and via saved files as references for faculty members at OPA. All surveys and other educational materials are created electronically to ensure efficiency and decrease costs. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 44 Electronic resources allow for decreased printing expenses and the ability to train new faculty on the screening process efficiently. The availability of electronic resources makes this project sustainable in additional facilities. The digital files containing the screening tools, education module, and reference handout are universal, so they may also be implemented at other schools. Dissemination The project results are shared with the project consultant and the five participants at OPA. A plan is developed to continue the adolescent screening process during the next academic year and subsequent school years. In addition, the success of the screening process and evidence-based findings are introduced to the administration of other local charter schools. The dissemination involves sharing all electronic resources for sustainability at other charter schools. After the PHQ-A and GAD-7 screening tools have been successfully implemented at additional academic facilities, the standardized screening process will expand to other charter schools and school districts throughout Utah. Standardizing adolescent mental health screening throughout the state is essential in combatting mental health issues and decreasing suicide rates. Conclusion Instituting the PHQ-A and GAD-7 screening tools in the academic setting helps identify students at risk for mental health issues. For example, faculty at a Utah charter school have been trained to use these standardized tools to identify students at risk for anxiety and depression. Staff at the school reported improved confidence after watching a short training video on using the screening tools. Additionally, these evidence-based screening tools effectively enhance the number of adolescents referred for treatment by a qualified healthcare provider. Over 75 percent of students participating in the anxiety and depression screening were referred to a provider. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 45 Having more staff available at the school to review the screening tools and refer them to a healthcare provider would be beneficial due to the substantial number of positive screenings at this school. The project's success and staff response indicate that screening adolescents in the academic setting are essential. Screening in schools may lead to early intervention and treatment for teens dealing with anxiety and depression. Launching a standardized screening process in other facilities may increase the number of youths treated for anxiety and depression. The screening process is likely to have substantial implications, such as (a) improved educational achievement, (b) stronger relationships, (c) a decrease in severe health conditions, (d) a reduction in adult depression, and (e) a lower risk of suicidal ideation among adolescents (AAP, 2021). With such substantial outcomes for today's youth from the introduction of this screening process, it is apparent that evidence-based anxiety and depression screening tools need to be standardized in schools locally, regionally, and nationally. SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 46 References Allison, V. L., Nativio, D. G., Mitchell, A. M., Ren, D., & Yuhasz, J. (2013). Identifying symptoms of depression and anxiety in students in the school setting. The Journal of School Nursing. https://doi.org/10.1177/1059840513500076 Allgaier, A., Pietsch, K., Fruhe, B., Sigl-Glockner, J., & Schulte-Korne, G. (2012). Screening for depression in adolescents: Validity of the patient health questionnaire in pediatric care. Depression and Anxiety 29(10), 906-913. Doi: 10.1002/da.21971 American Academy of Family Physicians. (2018). Depression in adolescents: AAP updates guidelines on diagnosis and treatment. American Family Physician 98(7), 462-463. Retrieved from https://www.aafp.org/afp/2018/1001/p462.html American Academy of Pediatrics. (2021). Adolescent depression screening. Retrieved from https://www.aap.org/en-us/professional-resources/quality-improvement/Project- RedDE/Pages/Depression.aspx American Academy of Pediatrics. (2010). Mental health screening and assessment tools for primary care. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aaphealth-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf American Association of Colleges of Nursing. (2006, October). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/DNP/DNP-Essentials Bodendorfer, V., Borge, R., Schuman, C. (2018). What are the best screening tools for assessing depression and anxiety in children and adolescents? Evidence-Based Practice 21(8), 29- 30. Doi: 10.1097/01.EBP.0000544859.73911.98 SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 47 Bohnenkamp, J. H., Stephan, S. H., & Bobo, N. (2015). Supporting student mental health: The school nurse's role in coordinated school mental health care. Psychology in the Schools 52(7), 714-727. Doi: 10.1002/pits.21851 Chassiakos, Y. R., Radesky, J., Christakis, D., Moreno, M. A., & Cross, C. (2016). Children and adolescents and digital media. Pediatrics 138(5), e1-e18. Doi: 10.1542/peds.2016-2593 Dhir, A., Yossatorn, Y., Kaur, P., & Chen, S. (2018). Online social media fatigue and psychological well-being – A study of compulsive use, fear of missing out, fatigue, anxiety, and depression. International Journal of Information Management 40(1), 141- 152. https://doi.org/10.1016/j.ijinfomgt.2018.01.012 George, M. J., Russell, M. A., Piontak, J. R., Odgers, C. L. (2018). Concurrent and subsequent associations between daily digital technology use and high-risk adolescents' mental health symptoms. Child Development 89(1), 78-88. Doi: 10.1111/cdev.12819 Law, W. C., McClanahan, R., & Weismuller, P. C. (2017). Depression screening in the school setting: Identification of the depressed adolescent. NASN School Nurse 32(6), 364-370. https://doi.org/10.1177/1942602X17726095 Orben, A., & Przybylski, A. K. (2019). The association between adolescent well-being and digital technology use. Nature Human Behaviour 3, 173-182. Doi: https://doi.org/10.1038/s41562-018-0506-1 Orenstein, G. A., & Lewis, L. (2020). Erikson's stages of psychosocial development. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK556096/ Rivera-Riquelme, M., Piqueras, J. A., & Cuijpers, P. (2019). The revised Mental Health Inventory-5 (MHI-5) as an ultra-brief screening measure of bidimensional mental health in children and adolescents. Psychiatry Research 274(1), 247-253. Doi: SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 48 https://doi.org/10.1016/j.psychres.2019.02.045 Siu, A. L. (2016). Depression in children and adolescents: Screening. U.S. Preventative Taskforce. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatem entFinal/depression-in-children-and-adolescents-screening#bootstrap-panel--1 Summers, L., Meppen, D., & Ball, S. (2019). Utah's mental health system: A collaborative endeavor of the Kem C. Gardner Policy Institute and the Utah Hospital Association. Retrieved from https://gardner.utah.edu/wpcontent/uploads/MentalHealthReportAug2019.pdf Tran, T., Kaligis, F., Wiguna, T., Willenberg, L., Nguyen, H., Luchters, S., Azzopardi, P., Fisher, J. (2019). Screening for depressive and anxiety disorders among adolescents in Indonesia: Formal validation of the centre for epidemiologic studies depression scale – revised and the Kessler psychological distress scale. Journal of Affective Disorders 246(1), 189-194. https://doi.org/10.1016/j.jad.2018.12.042 Twenge, J. M. (2020). Why increases in adolescent depression may be linked to the technological environment. Current Opinion in Psychology 32(1), 89-94. https://doi.org/10.1016.j.copsyc.2019.06.036 Twenge, J. M., & Campbell, W.K. (2018). Associations between screen time and lower psychological well-being among children and adolescents: Evidence from a population-based study. Preventative Medicine Reports, 12, 271-283. https://doi.org/10.1016/ j.pmedr.2018.10.003 Uhls, Y. T., Ellison, N. B., & Subrahmanyam, K. (2017). Benefits and costs of social media in adolescence. Pediatrics 140(s2), s67-s70. https://doi.org/10.1542/peds.2016-1758E SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 49 The University of Pittsburgh. (2021). Child and adolescent bipolar spectrum services: Instruments. Retrieved from https://www.pediatricbipolar.pitt.edu/resources/instruments Upreti, R. (2017). Identity construction: An important issue among adolescents. IOSR Journal of Humanities and Social Science 22(6), 54-57. Retrieved from https://www.researchgate.net/profile/Rashmi- Upreti/publication/317941230_Identity_Construction_An_Important_Issue_Among_Adolescents/links/59a0622aaca2726b90114998/Identity-Construction-An-Important-Issue- Among-Adolescents.pdf U. S. Department of Health & Human Services. (2021). Children's mental health: Data and statistics. Retrieved from https://www.cdc.gov/childrensmentalhealth/data.html Utah Department of Health. (2021). Complete health indicator report of suicide. Retrieved from https://ibis.health.utah.gov/ibisph-view/indicator/view/SuicDth.Ut_US.html Weber School District. (2021). South Ogden Junior High. Retrieved from https://wsd.net/schools/junior-high-schools/south-ogden Zuckerbrot, R.A., Cheung, A., Jensen, P.S., Stein, R. E. K., & Laraque, D. (2018). Guidelines for adolescent depression in primary care (CLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics, 141(3), 1-21. https://doi.org/10.1542/peds.2017-4081 SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 50 Appendix A SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 51 Appendix B SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 52 Appendix C SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 53 Appendix D SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 54 Appendix E SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 55 Appendix F SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 56 Appendix G SCREENING TOOL TO IDENTIFY AT-RISK ADOLESCENTS 57 Appendix H Appendix I