Identifying and Addressing Suicide Risk in Children

Podcast Transcript

Speaker 3: Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Jasdeep Sohi: Welcome back to Little Health. I am today's host, Dr. Jasdeep Sohi, the section Head for Child and Adolescent Psychiatry at Cleveland Clinic Children's.

Today we begin our session on behavior health and psychiatry. We will discuss suicide awareness and prevention in children. This episode may contain some potentially upsetting content including discussions of suicide, so please be advised.

Our guest today is Dr. Tatiana Falcone, a child and adolescent psychiatrist and vice chair of research for pediatric behavior health, and neurosciences department.

She has also co-edited a textbook called Suicide Prevention, A Practical Guide for Practitioners. Welcome to Little Health Dr. Falcone.

Dr. Tatiana Falcone: Thank you so much for the invitation, Dr. Sohi.

Dr. Jasdeep Sohi: You're welcome. So, uh, I want to ask you some of the questions that regularly come up when we have parents talking about suicide and wanting to know what they can do better for their children. So what are some of the warning signs of suicidal thoughts in children and adolescences?

Dr. Tatiana Falcone: Yeah, so when you start seeing changes in their behavior that suddenly your kid is not wanting to do things that they normally enjoy, when they suddenly start kind of like slowly saying goodbye to the things they love. Some kids might give away some of the things that they really like.

They stop going to the parties and dances and things that they used to enjoy before. They're not even using social media anymore. They're making kind of like hopeless comments. Like, what if I wasn't here anymore? Um, I don't know that me being here is important, right. And they might make these comments casually. [Mm-hmm.] And I think as a parent, it's very important to really listen.

Also, you have the biological signs when someone start having a lot of trouble sleeping or they're sleeping too much. [Mm-hmm.] We see that for teens, you can see the opposite. Not just not sleeping, but also don't wanna do anything. Wanna be in bed all day.

I think hopelessness is definitely one of our major ones in kids with history of bipolar disorder, that they have both the depression and the mood symptoms early, mania symptoms. [Mm-hmm] like irritability not sleeping. Grandiose ideas can be the most risky period for teens who are bipolar.

Dr. Jasdeep Sohi: So it seems like, you know, when you see that something it's not going right for the child, or symptoms of depression are getting worse, and then they're doing things like giving away their belongings, which they really cared about, are really the warning signs.

Dr. Tatiana Falcone: Yes. And especially like when a kid start making these comments. And it could be like randomly, right? Like and as a parent, sometimes you say, I don't understand, right. Why they have everything that they should have. They have all the support that they can, and they're still making these comments. Depression and suicidal thoughts is an illness like anything else, right? And it's not their fault that the depression is progressing.

Even when people are getting treatment, medication, and therapy.

Sometimes the medication is not effective and people relapse on their symptoms. So being aware of this and advocating for your kid by going to your psychiatrist, going to your therapist and saying, Hey, I think what we're doing is not working. Can we change the treatment? What can we do to make it better?

Or even, let's say you're seeing the therapist once every other week and your kid is making these comments, maybe is the time to move it to every week.

Dr. Jasdeep Sohi: Yeah, that's really important. So how can we really recognize that someone is at the risk of suicide, like right now, and they need help right now? How can we identify that?

Dr. Tatiana Falcone: As a parent that's a very important question, and it's a very scary question. I think you see changes in their behavior. You see worsening of the depressive symptoms, or you see worsening in the mania symptoms like not sleeping, or you see sudden comments about hopelessness, helplessness, and they start making suicidal comments.

Also in teens is very frequent what we call not suicidal self-injury, like cutting. And before people used to think, oh, people who cut are not really having suicidal thoughts. And we know people who cut are five times more likely than the general population to attempt suicide. So when you see any changes of this behavior, increase in cutting, or any kind of self-injury, increase in hopeless comments.

If you see any notes where the kid is making comments about why they don't wanna be here anymore, and as a parent, if you see a major change in your kid's behavior, it's time to have a heart to heart conversation. And the most important thing is to ask the questions.

Parents sometimes are afraid about asking these questions, and even providers at times could be afraid, but we know that unless you ask these questions, the kid or the teen is not gonna tell you that they're having suicidal thoughts.

So asking the questions kind of open the door for them to feel at peace and be able to really tell you how they feel. The same happened in the emergency room. There's many of studies looking at teens who come to emergency room, and when you look at teens who attempt suicide, you can see they have like three other visits to emergency room for random causes like headaches or stomachaches.

And when you ask when the kid actually attempted, you ask how long you've been having these suicidal thoughts? And the kid said, you know, three months and like, I tried to ask for help, but I, I felt afraid making that comment. I didn't wanna hurt my parent. I felt like, I was feeling guilty that I was having these thoughts so when the parent or the pediatrician or the provider opened the door for this can really help the kid to start the conversation.

Dr. Jasdeep Sohi: That's a great point, like asking that question because you know how many times we get patients in the ED and nobody has ever asked them that question, and definitely it does open the door for more conversation once you ask them that question. Like, are you feeling safe? Are you having thoughts about hurting yourself? That's a great point.

Dr. Tatiana Falcone: Yeah. And it is interesting to see that before, people used to think that if you ask these questions, then you are increasing the risk. There's plenty of research demonstrating that asking the questions do not increase the risk of suicide. Asking the question actually open the door for your patient to be able to express how they really feel.

Dr. Jasdeep Sohi: Great point. So are there like going on more into like environmental drivers, like are there any impacts like on child's mental illness or risk of suicide from bullying?

Dr. Tatiana Falcone: Yes. Bullying is an important topic when you're thinking about suicide. And bullying uh, can impact people different, I mean boys and girls. [Mm-hmm.] And cyber bullying can really impact things a lot.

So I was thinking the other day, like when we see people admitted to a hospital and they are admitted because they either attempted suicide or they were thinking about suicide, and we ask, what were the reasons why you wanted to die? I would say half of them would tell you a story about a relationship that went wrong or how people are um, making comments that are mean online, cyber bullying.

And we know that especially for teen girls, cyber bullying is a major risk for suicide. Um, so as a parent, something that you can do is kind of monitor the social media use, like I will say with some of the changes in the last couple of years and how much people are using, uh, social media is very important as a parent to look at your kids' friends, like every once in a while, look at some of the conversations.

Like with some of the social media outlets. People are very focused on how many friends they have, and they start kind of like accepting a lot of friends that are not really their friends. So when they go online to try to ask for help, and you have a thousand followers that are not really your friends, and you made a comment like, I don't want to be here, some people might respond with really mean comments back.

Dr. Jasdeep Sohi: Mm-hmm.

Dr. Tatiana Falcone: So like having a diet in social media, looking at who are your kids' friends that are really their friends and they know these people, and making sure that everybody who is close to your child is a positive influence is something that you can do as a parent.

Dr. Jasdeep Sohi: I agree with you that the media does expose these kids to like the pressure that they never had before. So going into that more, how does parents, schools friendships influence the risk of suicide?

Dr. Tatiana Falcone: I think society really can impact kids in a lot of different ways, positive and negative, right? So let's talk about school.

So if someone is really struggling academically and as a kid, as a teen, a school is kind of like your identity. So if suddenly you're not doing good at school and you are failing, and it could be because you're having depressive symptoms, you're having ADHD, and things are not getting better. Then people start becoming hopeless, right?

So recognizing those signs of depression and putting uh, tools in place, like asking a school for help, getting tutors to help the kid can really improve their self-esteem. Family. Family, you know when there's a lot of conflict in the family, when there's a lot of like financial pressures in the kid when there's a divorce or loss of a parent that can really impact someone's mental health.

And I will say in teens, 50% is definitely their social life. Also, one of the most frequent reasons that we see someone having a suicide attempt, especially a teen, is after a breakup of a relationship or after a breakup of a friend group. I would say that's probably like one of the most frequent that we see a lot.

So as a parent, if we know that you're teen just went through a breakup, or your teen just lost their friend group or their best friend. This is a very important time for you to be present, for you to be there for them because they're feeling lonely.

And impulsivity is an important risk factor in teens. So there's 30% of teens that might have a suicide attempt that never had any psychiatric diagnosis, or were not seeing a mental health provider, and that can happen because they went through like a really hard time and then they slowly felt that there were no other choices. So being there for them on those high risk periods is very important.

Dr. Jasdeep Sohi: Definitely. Yeah. As you said, like, you know, sometimes these kids don't even have a risk factor, but something changes in their life, which is really important for them, puts them at a greater risk. So is there any difference between boys and girls, like how trauma can impact them in terms of suicide?

Dr. Tatiana Falcone: Yes. So trauma can impact people different at different ages. So in girls, we know that bullying, like cyber bullying in the teenage years by age 16 can really have a huge impact on how they're doing. In boys we know when there's a lot of altercations in the family. So emotional trauma when you are in those ages between six to 10 can really have impact in kids.

We did a really great study a couple of years ago, and it was looking at the impact of emotional trauma, and there's this protein, it's called S 100 B. S 100 B is a protein that is normally inside your brain. And so when something happen, that protein goes into the blood.

So in some countries, like in Spain, if people are having a brain trauma and you go to emergency room, they'll check your S 100 B. If your S 100 B is elevated, you go through a full traumatic brain injury protocol, have an MRI. So we take S 100 B as like the sign that yes, your trauma is serious, right?

So we look at this protein S 100 B in teens and kids who were admitted to a hospital for suicide. And what we saw is that if you had emotional trauma the levels of the S 100 B were as high as if you were having physical trauma. So emotional trauma in the brain is one of the risk factors for suicide, and it shows biologically as physical trauma.

Dr. Jasdeep Sohi: And that's the hardest trauma to recognize because there are no signs and it's internal. So how can schools better support us in identifying students who are struggling with suicidal thoughts?

Dr. Tatiana Falcone: Schools play a big role, but for schools to play a big role, families have to play a big role. So that means. As parents, when we know our teen is struggling with depression, we have to be open with the school because if the school don't know, they can't help you. So having an open communication between the psychiatrist, the school

and your kid is very important.

Because one of the things I hear is that sometimes parents are afraid to share that their kid has depression, that their kid has ADHD, and this might be the role of a stigma. There's still a lot of stigma about, um, mental illness and they feel like people might look at their kid different if they know they're having depression or suicidal thoughts.

So every time that someone is admitted to a hospital, we try to get a consent form from the parents to be able to communicate with the school, because the school is a resource and they have counselors, social workers, team members that can check.

We can put this as an extra step if your kid just left the hospital because they had a suicide attempt, we can ask the school to make sure that the counselor at school is checking with them. You know, it could be every day. It could be once a week. If the school know they can really help. Sometimes they don't know. So having that tool is very important.

Dr. Jasdeep Sohi: So what do you think about schools like, you know, do you think schools are acute enough to help these children when they're struggling with suicidal ideations?

Like you said, like they have school counselors, social workers. Is there times when you hear from parents that their school was not able to identify the symptoms and you know, the parents didn't know what to do to seek help. Are there situations like that and how we handle them?

Dr. Tatiana Falcone: Yes. So sometimes this is very sad, but it is real, right?

Like we know that sometimes the first time that a parent has a contact with mental health is when they just realize that the kid tried to hurt themselves. And this could be cutting, this could be a suicide attempt, and when we come to see these parents in the emergency room, they're in shock. They don't understand what happened to their kid or why I am as a parent in this situation, in this moment, right?

And the same can happen to the school. Sometimes the kid might do everything that they can to hide these thoughts and feelings, right? So as parents, what you have is the change in behavior. So when you see the behavior is changing, the academic, uh, performance is changing.

Your kid suddenly waking up at three in the morning, that's a, a really important biological sign of depression. And then these times when they wake up three in the morning. No one is awake, are very risky because if they get into one of these negative thoughts and they start having thoughts about suicide, they might hurt themselves.

So it's very important to recognize signs and ask for help. Go to your pediatrician, make an appointment with psychiatry, ask for a therapy appointment. And if you are at the point where you just found out that your kid cut or hurt himself in any way, don't wait. A lifesaving action can be taking your kid to emergency room.

If you have doubts, you can always call 9 8 8. There are suicides prevention counselors ready to help you and your kid, and sometimes people will say, oh, they were only five pills of melatonin, that could never really hurt them. But it's not the amount of pills that the kid took, is the thought process that they felt that they were gonna die doesn't matter what they were doing.

So the severity of the attempt is important, but if your kid attempt, please take them to emergency room, no questions asked.

Dr. Jasdeep Sohi: That's a good answer. So what if like you try everything but your child has already attempted suicide and you know, the parents are worried. They will take them to the hospital, but they're always worried, what can we do to prevent this from happening in the future?

Dr. Tatiana Falcone: Yeah. As a parent, having a kid who have chronic suicidal thoughts can be scary in many ways because you can see that sometimes they also have treatment resistant depression, right? They have tried multiple medications, they have seen different therapists and sometimes the treatment is not working.

So when kids are having chronic suicidal ideation, the role of a parent is very important because first you have to make sure your house is suicide proof. And to do that, you have to walk through your whole house with the eyes of someone who is having thoughts about hurting themselves.

So the first thing that you have to do is to get a lock cabinet and put all your medications, including, um, vitamins, uh, including your Tylenol, Advil. Those are the first things because they're available that kids use to hurt themselves.

Then if your kid has history of cutting, right, then look through your house with those eyes and pick anything that your kid can use to hurt themselves and put it in that safe. Then look in your garage and look for ropes or things that people can use to hurt themselves and put them away.

Look in your teens closet. Are there any belts? Are there any things that they can use to hang themselves? So it's very scary, but it's very important that as a parent, you walk through your house, look behind the dresser, look in all the room and make sure that, you know, there are no things there that can be used to hurt themselves.

Then also, like when you see changes in behavior, ask your kid the question, are you worried? Are the suicidal thoughts back? Sometimes I tell kids and parents that one easy way to kind of open this conversation is to pick a safe word that is not related to suicide. And when the kids said this word to you, let's say yellow, then you know that in this moment they need help and you just need to be with them. Right?

And there are safe and effective treatments for suicide prevention. So one of them is therapy. Like there are specific therapy that are evidence based for suicide prevention, like DVT Dialectical Behavioral Therapy. Um, comes the collaborative assessment for the management of Suicidality CVT with the focus on, uh, suicide ideation. So this therapy services can help prevent suicide.

So we know for someone who attempted suicide, the combination of medication and therapy is the best that we can do. And actually as a child psychiatrist who has been working on this for a while, one of the things that I felt that it was a struggle was the psychoeducation piece.

Because when we see someone, a kid and a parent who just attempted suicide, and we see them in the hospital, they're in shock. And we do this, we talk to them. We try to kind of explain the important tips and tools. But what happened is that you are in shock so no matter what we say, they forget it. So they get home and they feel lost.

So I actually wrote a book to talk about this, and it's especially for parents because I feel that having this tools in your hand are important. So it's called, Preventing Tips for Parents After Your Kid Attempted Suicide.

Dr. Jasdeep Sohi: Yeah. So it's important to make your house, uh, suicide proof, and also at the same time keep looking for warning signs.

You know, I want to know more about like treatment. Like are there role of medications in treating suicidal thoughts and how can, I know you talked a little bit about therapy, but how can you help your children in overcoming these thoughts through therapy?

Dr. Tatiana Falcone: Yeah, so therapy can be really helpful. Let's talk about coms.

So coms is a specific therapy that focus on giving the patient reasons to live. So focus on understanding like what were the drivers for someone to become suicidal and then targeting all those things. So it's for some people the coms might be focused on school. For some people, the coms might be focused on family. For some people might be focused about bullying. For some people might be focused about their chronic illness.

So it's very targeted to each patient. But it's an amazing therapy because you feel that after a short period, and it can be anywhere from like four to 12 sessions, so that's like three months patients and parents can leave with the specific tools to manage the suicidal thoughts because we know that the suicidal thoughts can be chronic and after they leave the hospital, these thoughts might come back.

So the importance is not what can we do to avoid the thoughts because we know they're coming back. It's how we can equip this kid with the tools they need to manage the suicidal thoughts and what can we do to help these parent so they can recognize the signs and help the kid when they need it the most.

Dr. Jasdeep Sohi: Gotcha. So when should the parent take their child to the emergency room?

Dr. Tatiana Falcone: So if your kid just hurt themselves in any way, cutting. If you look online and you saw that there was a search about anything suicide related. If your kid came to you and say, Hey mom, I'm having thoughts and they're getting really bad and I'm afraid that I might act on it.

If you look online on their social media and you saw any signs that they were. Saying goodbye to their friends. And I think having this open conversation with your kid and saying, I can be with you here right now, but I was really afraid because I saw this on my computer. Were you really having thoughts about hurting yourself?

And if they said yes, then there's no other step take them to the emergency room. I think the emergency room is there when we feel there are no other choices, right? So if this is someone who have chronic suicide ideation and then they're cutting, right? Then we have to assess and you have probably your team, the people who are trying to help you, and so you can even try to get a sooner appointment, right?

But if you ask your kid and your kid is not able to safely kind of collaborate with you on creating a plan to help them prevent the risk of harm then you have to take them to emergency room.

And when in doubt, there's always 9 8 8, the 24 7 service that anybody can call. And even when you're in doubt, you can call. And what is really good is like all the counselors who answer any of these phone calls are trained specifically to manage a suicide crisis.

Dr. Jasdeep Sohi: So, uh, once they go to the emergency room, you know, sometimes these parents have reluctance to leave their kids there if they need hospitalization. What will be your advice for those parents?

Dr. Tatiana Falcone: Think about as a parent, your kid just told you they were suicidal and they had an evaluation by someone who, their specialties to look at how severe the risk. And they then went to us and described the case. And based on all of that, we made a decision. And as a parent, people might feel afraid, like, oh, I don't wanna admit my kid to a psych unit.

I will be more afraid to taking my kid home because when you're in a psych unit, you have 24 7 supervision. So there's no way that your kid is gonna be able to do this when they're at the hospital. So if you were at home, how are you gonna be able to manage this 24 7? You might go to sleep and might wake up and your kid might not be there anymore.

So I think if you took your kid to the emergency room and the doctor recommendation was to admit the kid to the hospital, I would follow that recommendation. Right. And normally the admissions to a hospital for psychiatry are short three to five days, and after the five days you leave with tools that will help you manage your kid.

And the other issue is like sometimes when you call to make an appointment for both psychiatry and psychology, it might take a while, but if you are coming from the hospital after, uh, a risk for suicide, we make sure that you have an appointment within seven days and that could be lifesaving.

Dr. Jasdeep Sohi: That's a very reassuring answer.

So thank you Dr. Falcone for joining us today. Helping our children thrive is important. If you suspect a child or teen is struggling, connect with them. Start a conversation even if you feel awkward, let them know you care and that you're listening.

Cleveland Clinic Children's provide comprehensive mental health support for kids, teens and their families during challenging times. If you'd like to schedule an appointment with one of our providers, please call 216.444.KIDS. That's 216.444.5437.

Speaker 3: Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinichildren's.org/little-health.