How to Address Suicide Prevention With Young Patients and Their Parents

Nearly every day, child and adolescent psychiatrist Tatiana Falcone, MD, encounters patients dealing with suicidal thoughts. Unfortunately, it’s usually after a suicide attempt.

According to the Centers for Disease Control and Prevention’s 2021 Adolescent Behaviors and Experiences Survey, 20% of adolescents have thought about suicide in the past year, 15% have made a suicide plan and 9% have taken a step toward hurting themselves.

It’s a multifactorial issue, says Dr. Falcone, noting:

• The COVID-19 pandemic and shut-downs had detrimental effects on children’s mental health, weakening their coping and socialization skills and increasing their anxiety when it was time to return to in-person school.
• Bullying has been amplified due to use of technology and social media. Instead of one-on-one bullying at school, cyberbullying can be done by a group and conducted online, so it’s not escapable even at home.
• Access to behavioral health services can be challenging, sometimes taking months to get an appointment with a child psychiatrist or psychologist.
• Kids with chronic illness (e.g., epilepsy, migraine, diabetes) are at higher risk for depression, anxiety and suicidal thoughts.

In Dr. Falcone’s recent book, A Parent’s Guide to Prevent Suicide in Your Loved One, she gives parents evidence-based tools to help their child during a crisis.

“After a child’s suicide attempt, there’s so much information that I and other providers want to share with parents, but they’re usually in shock,” says Dr. Falcone. “It’s hard for them to hear and retain the information. In that moment, they feel like there’s nothing they can do. However, there are ways to control the situation. We can put some things in place to help parents and kids manage suicidal thoughts if they arise again.”

There also are things pediatricians can do, she adds, especially to address concerns before suicide attempts occur:

1. Perform universal screenings.

“Pediatricians are the first line of care,” says Dr. Falcone. “A child may not see a behavioral health specialist, but they see their pediatrician at least once a year.”

At Cleveland Clinic, all pediatric patients are screened for depression with the Patient Health Questionnaire for Adolescents (PHQ-A) at every encounter. Soon the seven-item Generalized Anxiety Disorder scale (GAD-7) will be added to routine evaluations.

“If scores are high, the pediatrician starts the conversation about mental health,” says Dr. Falcone. “The conversation shines a light on things patients may have been dealing with on their own.”

Everyone has bad days, she notes. Depression and other mental health diagnoses have symptoms lasting more than two weeks.

“Always conduct a screening when the parent is not in the exam room and the child is alone,” she says. “Thank the child for being honest about their feelings, validate how they feel and reassure them that you will work to help them. People used to think that bringing up the idea of depression or suicide increased the risk of their occurrence. Research has debunked that myth. Children need to be offered the opportunity to talk about mental health issues.”

2. Consider depression when a patient has refractory symptoms.

Ongoing headaches, stomachaches and other physical symptoms can be indicators that a child’s mental health is suffering. Kids with suicidal thoughts have more emergency visits for physical ailments than other kids.

“If you’ve done a thorough workup and haven’t made a diagnosis, consider depression,” says Dr. Falcone.

Use a depression screening tool, she advises, or at least ask how the patient rates their mood, sleep and energy level. Ask parents if they have noticed changes in their child: not engaging in activities they used to enjoy, isolating, becoming more irritable or quick tempered, interacting differently with friends or having different friends, or performing worse academically.

3. Work with the patient and parent to determine next steps.

If the depression screening is positive, work with the patient and parent to determine next steps.

“Some patients may be open to talking with a therapist, some may not. Some may prefer to start on medication right away, some may not,” says Dr. Falcone. “Asking the patient what treatment they want to pursue increases the likelihood of a successful outcome. Treatment works best when the patient is engaged.”

If the patient agrees to be referred to behavioral health, ensure their first appointment is within one month, she adds. If that’s not possible, then follow up with the patient yourself within one month, especially if they are starting antidepressant medication.

4. If the child admits suicidal thoughts, talk to the parent about lethal means restriction.

If the scores are significant for depression, then also screen for suicide.

“If the patient affirms that they have considered taking steps to harm themselves, it’s time to create a customized safety plan with the parent and the patient,” says Dr. Falcone.

Lethal means restriction involves removing items from the home or securing them in a safe with a combination lock. The means of self-harm — such as guns, knives and medication — are different for everyone. The child’s plan determines what should be restricted.

“I tell parents to walk through their house with the eyes of an adolescent who wants to hurt themselves,” says Dr. Falcone. “If the child has expressed attempting an overdose, look for potential things they could use — even over-the-counter pain medication and vitamins — and lock them up. If the child has expressed attempting to cut themselves, then lock up scissors, knives, razors and any other tool that could be used for that purpose.”

5. Treat mental health at the same time as other chronic illness.

Children with a chronic illness, such as diabetes and epilepsy, may blame symptoms of sadness, fatigue or low energy on their primary medical condition when, in fact, they have comorbid depression.

“Many believe that depression will go away if the primary condition is better managed,” says Dr. Falcone. “That’s not true. Depression can worsen the primary condition. Treating both conditions concurrently is important.”

She concludes, “Make sure that every patient and their family leave your office with hope as well as access to local resources and the national Suicide & Crisis Lifeline, 988.”