Child Mental Health for Pediatric Clinicians

15. Tips for hard conversations: Asking kids about suicidality, offering hope to families with Dr. Brian Kurtz

• Elise Fallucco • Season 1 • Episode 15

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How do you ask kids about suicidality in a way that helps them feel comfortable enough to talk about it? And how do you tell unsuspecting parents that their child is suicidal? We provide a framework and some tips for approaching these challenging and important conversations with families. 

 Along the way, we talk about the importance of

·      Normalizing

·      Doing “Vibe Checks”

·      Offering hope

 Dr. Brian Kurtz is a child and adolescent psychiatrist and Director of the Child and Adolescent Psychiatry Residency Training Program at Cincinnati Children’s hospital.  He serves on the Pediatric Behavioral Health Clinical Advisory Panel for Ohio Minds Matter. He helped to develop educational materials for the Ohio Minds Matter website on multiple topics, including youth suicide risk assessment. 

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Dr. Elise Fallucco:

Welcome back to PsychEd4Peds. I'm Dr. Elise Fallucco child psychiatrist and mom. Today, we're talking about ways to approach talking with kids and parents when you're concerned about suicidality. So thank you for joining us as we continue our discussion with Dr. Brian Kurtz, child psychiatrists and medical educator extraordinary. Welcome back Dr. Brian Kurtz.

Dr. Brian Kurtz:

Thank you.

Dr. Elise Fallucco:

Some of our friends and colleagues have shared feedback that they really appreciate when we give scripts or basically like a set of words or phrases that we use when we talk to kids or talk to parents about something. So keeping that in mind, when you're talking to kids about suicidal thoughts, how do you go about that

Dr. Brian Kurtz:

interview? So actually, I can think about a very specific example. Today, I was seeing a young person that I was starting on SSRI medication, and whenever I do that, I always have a conversation with them a little bit about suicide. The way that I might start that conversation is to say that I see a lot of young people who are Feeling depressed or overwhelmed. And sometimes when that happens, they begin to have feelings of not wanting to be alive anymore, thinking about suicide. They may even take steps in that direction. So let me first ask you, has that been something that you've done. Just to deconstruct what I said, it's some normalizing language because it essentially lets everyone know that we're about to go into a topic that may feel a little sensitive, but you are not being singled out and then with this patient, the patient affirmed that they hadn't really ever had any suicidal thoughts. And we talked about how important, if that were to change, that be something that get communicated to her family, who she's pretty connected to so that they could let me know and help keep them safe and figure out if we were doing anything that was making things worse instead of better. So it felt like a pretty affirming conversation today when that happened.

Dr. Elise Fallucco:

That's great. I think we have a really similar approach. One thing I would add is that I like to review confidentiality upfront. The script that I like to use, as I say something like what you and I talk about is confidential and it stays in this room between the two of us. The only time when I would have to break confidentiality would be if I were concerned, That you were seriously going to hurt yourself. Or somebody else. And then I would just want to get you help. And I also agree with you that it's so important to try to use normalizing language when you're talking with teens. so much of their growth and development is about establishing their identity. You want to feel like you fit in, like you belong, like there's not something wrong with you. And so knowing that I really try to make it a point upfront to start with the normalizing, and say a lot of teenagers can feel really frustrated or stressed. And I'll try to use their own words stressed out, overwhelmed or whatever slang word they're using. And when they feel like that, they think about wanting to fall asleep and never wake up. Have you thought about that? and they'll usually say, yeah, and then I'll get a little bit more explicit and say they'll think about wanting to end their life or wanting to do something to end their life. Have you ever thought about that? Have you ever acted on those thoughts asking about past suicide attempt? And if you haven't. This is my favorite part, asking about the protective factors when you're feeling that overwhelmed and stressed when it's this intense emotion and you want to escape, what keeps you from taking action on those thoughts? And that's where the money is. That's where you find out, usually a source of connection. It's my parent or my relative or my friend and, or sometimes my dog, I hear about pets too. Like I, I'm feeling really bad, but this is what's keeping me from doing that. And so then our job is like trying to shore up that sense of support.

Dr. Brian Kurtz:

That's such a good point. I think that's a great way to go about it.

Dr. Elise Fallucco:

Thinking about the strengths of each of our approaches, I think busy pediatricians could take away three things. One establish confidentiality, 2 normalize that kids who are feeling. Really upset can have suicidal thoughts and three, make sure to start asking about thoughts of death and then more seriously thoughts of wanting to end your life. So shifting from talking to the kid, now we bring the parent back in the room and have a conversation with them about the fact that we're concerned about the child's suicidality and how are we going to keep them safe and what are the next steps? These conversations with parents can be so hard and if you put yourself in the shoes of the parent, you can imagine how incredibly scary this is Particularly if this, the first time that you're hearing that your child's been having suicidal thoughts. And it brings up all sorts of reactions. Of course, Anytime anything is wrong with your child, you're always self reflecting like, did I cause this? Is it my fault? What did I do? What could I have done differently? Somehow it's my fault. So knowing that there's all of this, like emotional and psychological distress in the mind of the parents or the family members. How do you approach having this tough conversation with them about, Hey, I'm worried about your kid. About suicidal thoughts.

Dr. Brian Kurtz:

I think there's some degree of vibe check that happens. And so I'm looking at the way that they're communicating with their non verbals, right? Their facial expressions, their body language. You can tell there are some parents where they're tying themselves up in knots when that's the vibe, they need to hear from you as the clinician, I can tell you're feeling really scared right now. But I can tell you that I have been here before with other families, and we have gotten through this, and here's how we're going to do it. This is the sort of, tools that we're going to be using. It's going to, take some time and effort here, but I'm confident that we can get from this really scary place where we are today to a much better place because I've seen it happen many times and hearing that is incredibly powerful for a lot of families. I think another kind of a vibe can be Denial It feels so out of the blue that you can see some parents are beginning to tell themselves a narrative that it's not really the case.

Dr. Elise Fallucco:

Especially in primary care, I parents are saying, Hey, I just thought we were coming for a well visit. And you're telling me what? It's such a

Dr. Brian Kurtz:

shocker. And I think in those cases. In some ways, we need to acknowledge the great wish that the parent has that their child would be emotionally 100 percent healthy. But to try to highlight that there is a bit of a discrepancy between that wish and the reality that we're experiencing right now. This is what I might say to a parent, it's I, I can see how surprising this feels and how sudden this feels. I think from talking to your son it's been really hard for him to be able to convey to you how he's been feeling lately. And I think that's why it's so sudden. I think that we absolutely can can do things that will help. I'm worried that if we do nothing, that we could be in a scary place. So things like that.

Dr. Elise Fallucco:

essentially what you're doing is you're, you're observing as you call it, the vibe check, mom did not see this coming and you see it in the way that their eyes are wide and how they look tense and shocked and you just reflect that back to them. I can tell this is not something that you were expecting to hear. And then I like to normalize after that and say, Very often a lot of times when teenagers or kids are feeling this way, it's something that they keep, really deep inside and it's very hard to see. I'm addressing the unspoken parental fear of how did I miss this and how can this be? Very few of the kids are just spontaneously reporting suicidal thoughts to their family. And just letting the parents know this is why we screen or this is what we found. And I love the part that you said too, about all of the confidence and the hope that, here's where we are and we have a plan and here is what we're going to do to try to help your child feel better.

Dr. Brian Kurtz:

I had a supervisor that once told me that when some patients and families are feeling so overwhelmed by a situation that they can't be hopeful that they can't summon hope within themselves that it may be our job as the person taking care of them to try to carry the hope for them.

Dr. Elise Fallucco:

that's awesome. That's beautiful. As I'm getting older, I'm seeing more and more of this, not just from the perspective of the clinician taking care of the kid in the family, but the perspective of a loved one, or extended family member or family friend, and you really begin to appreciate this can be so hard and everything that's going on and, develop a lot more empathy for what the families are going through.

Dr. Brian Kurtz:

This is a bit of a tangent, but it's worth saying because it requires so much that we summon within ourselves to help these patients and families when they're in their crisis, that it's worth giving yourself grace as a provider who's doing this work that you will have feelings about this, that this will take something out of you, that you will also need to find ways to refill your own, emotional buckets so that you can have the capacity and the energy and the sense of mission to continue.

Dr. Elise Fallucco:

Yeah, I think, we're oriented towards what can we do or say to help our patients and a huge thing we can do to help our patients is to, be aware that these conversations and these situations can be taxing and challenging and, making sure to put our own oxygen mask on first when we can. Always. And to give ourselves grace for not asking perfectly and for screwing up sometimes.

So to recap for busy pediatricians, how to approach talking to parents about suicidality. Three steps. One assume many parents may be surprised to hear this, two reassure them that it's not unusual to not see signs or to not be aware that your kid is having suicidal thoughts, because kids are often very good at hiding it. And three, make sure to provide hope and next steps.

Dr. Elise Fallucco:

Thank you so much, Dr. Brian Kurtz.

Dr. Brian Kurtz:

It's been a real pleasure. Thank you.

Dr. Elise Fallucco:

I love talking with you about this. And I hope you will join us at Psyched4Pede some other time to share your knowledge.

Dr. Brian Kurtz:

Happy to.

For our friends and colleagues. If you want more information about sample scripts or to review these three points in talking with kids and parents about suicidality, please check out our website at psyched. The number four paeds.com. And if you liked this episode or found it helpful, Please take the time to rate and review or share it with a friend thanks so much see you next time