January 21, 2022
As those of us in clinical practice know, we have seen soaring rates of mental health challenges among children, adolescents and their families during the course of the COVID pandemic, exacerbating the already tenuous situation that existed for child and adolescent mental health. We have seen rates of childhood mental health concerns and suicide rise steadily over the last decade. Across the country, we have seen dramatic increases in ED visits for acute mental health emergencies, including suspected suicide attempts. Here to talk to us today about these increasing mental health challenges, and provide us with some strategies for addressing and preventing suicidality in primary care, is child and adolescent psychiatrist Dr. Joshua Stein.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric healthcare information, as we partner with you in the care of your patients. Our guest data, ideas, and practical tips will surprise, challenge, and perhaps change how you care for the most amazing people on earth, kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. In October of last year, the AAP, AACAP, and CHA, issued a declaration of national emergency in child and adolescent mental health. As those of us in clinical practice know, we have seen soaring rates of mental health challenges among children, adolescents, and their families, during the course of the COVID pandemic, which was exacerbating the already tenuous situation that existed pre-pandemic. Rates of childhood mental health concerns and suicide rates rose steadily over the last decade. And by 2018, suicide was the second leading cause of death for youth ages 10 to 24.
Across the country, we have seen dramatic increases in emergency department visits for acute mental health emergencies, including suspected suicide attempts. Here to talk to us today about these increasing mental health challenges and provide us with some strategies for addressing and preventing suicidality in primary care is Dr. Joshua Stein, child and adolescent psychiatrist. Dr. Stein is the clinical director of the Brooklyn Park Partial Hospitalization Program at PrairieCare. He also previously served as the president for the Minnesota Society for Child and Adolescent Psychiatry, which is focused on local and national advocacy for children’s mental healthcare. In addition, Dr. Stein also serves as a psychiatrist with PAL, the Psychiatric Assistance Line, which is a free pediatric psychiatric consultation service for medical professionals through PrairieCare and DHS. Josh, thanks for joining me today.
Dr. Joshua Stein: Thank you very much for having me. I’m happy to be here.
Dr. Angela Kade Goepferd: Well, it’s no secret that our patients are struggling. Many of us in primary care have really struggled with seeing them struggle and knowing how to help them. Can you start by telling us a little bit about what you’re seeing and experiencing in your work with kids and maybe how this moment in time feels different to you than what we’ve been dealing with pre-pandemic?
Dr. Joshua Stein: First off, there’s not the classic ebb and flow that we see in psychiatric needs. Often, when children and adolescents are stressed, it’s when school is starting or school is persisting. And at the higher levels of care, whether partial hospital or inpatient, we have seen steady numbers since early 2020 without the breaks in summer or the breaks at other times.
Dr. Angela Kade Goepferd: And is there any difference in the acuity or severity of the kids that you’re seeing, or is it just more of what you were seeing before?
Dr. Joshua Stein: So, we’re seeing more of it. We’re also seeing more kids isolating, and we’re seeing more kids perhaps not developing the skills, the abilities, the stress tolerance that normally they would get from the normal day-to-day actions that they would have.
Dr. Angela Kade Goepferd: So, there must have been something about the isolation that they experienced through virtual school or whatever it was during the pandemic that there was a breakdown of coping mechanisms that has impacted their resilience, it sounds like.
Dr. Joshua Stein: Absolutely. And we’re seeing how that affects families. And then the child, as the identified patient, often really starts to struggle in all these things. Whether it was sports teams, whether it was theater, that got canceled, it really became quite difficult for a lot of kids to get by and to function. We saw some kids flourish a bit more, the kids who have a lot of anxiety. And now, as we enter, I don’t know what this is, the wave three and these continued changes, we’re seeing, as kids need to go back to school and need to regain functioning, this loss of a year and a half, two years, of growth is really hindering them. And so, we’re seeing a lot of kids showing up that maybe disappeared for a while too.
Dr. Angela Kade Goepferd: In the midst of this lack of ebb and flow and this surge, we also have a capacity problem. So, we have a really hard time, particularly those of us in primary care, getting the kids that we’re seeing who are struggling access to child psychiatrists, access to partial hospitalization programs, inpatient treatment. What that’s left for us is having to do some of that management more and more in our primary care offices. What sort of first line of advice or assistance would you give those of us who are really struggling with the kids in our primary care practices, who are increasingly showing up with mental health struggles?
Dr. Joshua Stein: So first off, thank you to the pediatricians and the practitioners, and for your flexibility, and for this shift of caring for more and more kids. And you’re right. I’ve heard pediatricians say that it’s over 50% of their outpatient is now shifting towards anxiety and depression. First off, I would say you are doing an excellent job. And just by being there listening, sitting with the family, getting that information, it is validating. It is helpful. And it is starting to open this closed wound around mental health and mental wellbeing that they have not been able to address thus far. Often, the pediatrician, a teacher, someone that they are comfortable with is the first person. So, having that open door and being willing to talk about it is really important.
Secondly, I think getting comfortable with one or two meds is really important. And the reason why is the wait time and the access issues to see psychiatry is so long, but the other side of it is starting these meds take some time. And so, if you can be comfortable with Lexapro and Prozac is your first two SSRI trials, often that can really cover a fair duration, with appropriate treatment time, until they can get in to see a higher level of care.
Dr. Angela Kade Goepferd: One other question I might have for you is, in the primary care setting, what would you endorse in terms of screening tools or things for us to monitor how kids are doing, if we are starting initial treatment in our primary care offices?
Dr. Joshua Stein: Many pediatricians are using PHQ-9s and using these in a way to monitor. The hard thing is, even though it says the past two weeks, commonly it really is just about that day. And we know that teens’ and children’s lives move really quickly. And so, if they had a break up the day before, a rejection, a difficulty with a team, they may present with a score that super high, whereas two days earlier it was lower. And so, I use those to inform my practice, but they’re not the be all end all. I think, understanding sleep, appetite. Are they making it to school? Often, there’s a parent in the room who can be reflective and really helpful. All of those are really important skills to gather how things are going.
I think the other part that you guys really have is that longitudinal relationship. Many of these patients have been your patients since they were little. I mean, you’ve seen them grow up. And even if they’re just entering clinic, there’s some kind of knowledge of who they are. And those changes may be worn on their face. And so, I think that knowledge, that history, with a family or with a patient also is informative and can be really helpful to understand what’s going on.
Dr. Angela Kade Goepferd: One of the things that worries us a lot in primary care is suicidality. And I’d like to shift to talking about that a little bit. We’ve seen, as I mentioned, an increase in suicidality in the last decade and a lot of evolving evidence about what does and doesn’t work for preventing suicide and adolescents. So, I wanted to ask you some questions about that.
Dr. Joshua Stein: Absolutely, yeah.
Dr. Angela Kade Goepferd: My first question is about this concept of safety contracts. I think one of the things that I had been taught in my training was that that was an effective way to keep a child safe. I don’t know that the evidence fully supports that. So, I wonder what you could tell us about that and how effective contracting for safety is or isn’t with kids.
Dr. Joshua Stein: The truth is with adults and children, we’ve seen that safety contracts are not effective. They’re often reassuring to the doctor, reassuring to the nurse, the social worker, the therapist, but don’t often change outcomes. For that reason, though we may do them for legal reasons or because their hospital criteria, there’s not a lot of support that the safety contract on its own is going to be effective to keep that person safe when they leave the office. And I think that’s really uncomfortable. And that’s something that’s really hard, especially as our hospitals and partial hospitals fill up, and more and more kids are being sent home from emergency rooms, or sitting in emergency rooms, or being sent home from clinics with maybe people feeling a little uncertain about the next step.
But I do think what’s in them, if implemented correctly, at times can change outcomes. When we look at what’s in a safety contract, so like the 741741 text line, which is the suicide text hotline, and teens like to text, so I think that’s a really good starting point. By making sure somebody knows that line or knows their county crisis line number, now we’re giving them an effective tool. And so, I think that that’s the start of giving them a resource. And so, if that’s in there, but they actually know it, they’re not just signing it, that’s where we start to have and implemented a real difference.
Dr. Angela Kade Goepferd: You gave a grand rounds at Children’s last year in which you talked about lethal means reduction as a way of preventing suicide. Can you tell us a little bit more about what we’re talking about when we say lethal means reduction?
Dr. Joshua Stein: So, what we see is the vast majority of people, if they have an identified way that they want to attempt suicide, if we remove that, they’re much more likely to stay safe and they’re very unlikely to substitute something else. And so, when we talk about lethal means reduction, we’re removing the means that somebody planned to attempt, whether that’s pills, whether that’s a gun, whether that’s strangulation, or use of a car. And so, we want to make their environment as safe as possible and set up as many obstacles as possible to keep that person, that loved one, that child safe.
Dr. Angela Kade Goepferd: Let’s walk through what that might look like in an office setting. Say I’m in a room with an adolescent and they’ve been having thoughts of ending their life. And then, when I ask about, is there a gun in your home? They say, yes. So now, the parent’s going to come back in. How do I initiate that conversation about lethal means reduction with the parent?
Dr. Joshua Stein: Guns are tricky. They’re used for hunting. They’re used for sport. They’re collectible. They’re heirlooms. And so, we focus, number one, on the goal is to keep your child safe. This is not a political discussion. It’s about the imminent risk right now. We talk about that guns are dangerous, because when someone’s impulsive, they can cause harm rapidly, easily, and have permanent injury. And that, for that reason, we want to have the guns out of the home for the time being. And that doesn’t mean they have to be destroyed or sold, but they can be brought at times to a local police office, to a shooting range to maybe be kept in a safe, or to a family or friends who has a safe place for them. And they need to be removed for a period of time. We often talk about that there’s also a time that they can be brought back to the home. And as we work together, and build a relationship, and understand the safety of your child, at some point we will bring them back. That’s something we’re going to check in and work on as well.
Much like CPR, they always teach you, I don’t know if you remember this, but they’re like, “You, call 911.” So, “Dr. Goepferd, call 911,” and you don’t say it to the general population, because it doesn’t happen. Because, everyone thinks someone else will do it. And so, when we’re doing lethal means restriction, we really want to identify the person that’s going to take these steps. And whether it’s locking up pills, whether it’s removing the guns, we want to decide, is it going to be mom, dad? Is it going to be stepdad? Is it going to be the foster mother? Who is it going to be that’s going to take these steps? And then, I want them to call me back and let me know that it’s been completed.
Dr. Angela Kade Goepferd: Got it.
Dr. Joshua Stein: So we’re going to have some follow through. When we’re talking about these things, it is a really big deal, and it’s really scary, and it’s really overwhelming. We also want to make sure that we’re being heard and understood. And so, we also want to take enough time in that appointment to say, “Do you understand what we talked about? Tell me what the plan is when you get home.” These are long appointments in a busy, busy, pediatric clinic. It may take some time. And this may be something where someone else may assist by sitting with the child while you’re talking through this with the family.
And I bring that up because, as much as we think kids know where all the gifts are that are hidden, and know how to unlock the alcohol covered, and they know all the tricks of the house, if we have something that is dangerous in the home, we maybe don’t want to let them know about it. So, we want to talk about, “Yeah, they know about the guns in the safe, but they didn’t know dad had a pistol in a lockbox under his bed.” So, we want to make sure we’re not giving them more information too.
When you look at the research about lethal means restriction, the whole idea is that about 74% of people who attempt suicide decide within five minutes or less than an hour that they’re going to do this. And so, we want to make things literally as hard as possible to get them over that hump when they’re feeling really, really, low. And so, we really want to make sure that we’re setting them up in that way.
An example would be, some families are Tylenol families, and we know how dangerous Tylenol can be. And so, what I may bring up with them is that children often overdose on what’s the easiest thing available. And if you have a large bottle of Tylenol from Costco, that’s easy. If you have 50 blister packs with two pills in them each, that’s really hard, and they may reach for ibuprofen, or melatonin, or something else instead. And so, we want to make it as hard as possible. And I think we can always agree, even when guns are as sensitive subject, that we want to make things as hard as possible to keep the child safe. So, we really push realistically to have as much out of the home as possible.
Dr. Angela Kade Goepferd: Could you walk us through a couple of common things that you would do for lethal means reduction? So, we’ve talked about getting guns out of the house. I heard you mention lockbox for medications. You mentioned getting rid of the Costco Tylenol, large pill bottle. What are some other things maybe that I’m not thinking of or people listening might not be thinking of that we should be focusing on?
Dr. Joshua Stein: Other examples would be car keys. We do see a lot of single car crashes that were in fact suicide attempts. This is for adults and for older adolescents. Another one would be hard alcohol or alcohol in general. We see, especially in our older adolescent population, alcohol is present in a lot of suicide attempts. It, of course, is disinhibiting, it can bring up emotions that we’re not expecting, and can lead to that impulsivity.
When we talk about self injury, often making it harder, things like box cutters, razor blades, pencil sharpeners, and then the sharpest knives in the home. Realistically, there’s always something. But also if somebody has to become MacGyver to figure it out, that’s a large obstacle, and it may give them enough time to plan something or use something else. And so, we really want to make things harder.
We also encourage parents, who are trying to make their house safer, if they’re going to lock anything up, if they use a key box, to keep the key on themselves, like on a necklace, somewhere like that. One more tip, the trunk of a car or the glove box of a car can also be really useful. It’s something that’s to get into and you need the keys to the car, plus you need to unlock it, and things leave the house during the day, especially if the child’s going to be alone.
Dr. Angela Kade Goepferd: You mentioned teenagers who might be engaging in self-harm behaviors. And I’d love to talk a little bit more about that, and specifically differentiating self-harm behaviors, like cutting, from suicidality or suicide attempts. And is this a spectrum of behavior? Are they completely unrelated? How would you help us sort through that differentiation?
Dr. Joshua Stein: The moniker that gets used is NSSI at times, which means non-suicidal self injury. And then, on the other hand, there’s SIB, which is self injurious behaviors. And then, finally SI, which is suicidal ideation. And I think of there’s this Venn diagram where there’s people who are absolutely not suicidal, but self-harming, for a variety of reasons, whether it’s stimulation, whether it’s boredom, whether it’s calming down, whatever it may be. Then, there’s people who are suicidal, but don’t self-harm. Then, there’s a large group in the middle. There’s coexisting suicidal ideation as well as self-harm.
Self-harm is much more common nowadays. There’s some reasons for that, including likely social media. You can reach different audiences and be exposed to different things as a child. But it is more present. And so, we do see a lot more cutting without any suicidal thoughts, and even at times without depressive thoughts. It can be a really maladaptive or negative coping skill to just get through hard times. At times, though, we do see it tied to chronic suicidal thoughts as well. No matter how you look at it, it’s a warning sign that a kid’s not okay and they don’t have effective stress tolerance skills to get through hard moments.
Dr. Angela Kade Goepferd: If we see a child in clinic, for example, who has notable scars on their arm from cutting, what would be some key questions we would want to ask to sort out where in the Venn diagram that behavior is living?
Dr. Joshua Stein: Just reflecting how you would ask it, and I think it depends on what type of provider you are. I may ask just, “Hey, what is that all about? What happened over there?” Often, there’s a great deal of shame or embarrassment. And I would say, “No, this is something actually that I do. Like I help kids who are cutting themselves, or hurting themselves, or burning themselves to understand why they do it, what it accomplishes, and how to do it less.” And so, I think that having a way to bring it up and just saying that it’s okay, and this is something I work with, because there’s often a great deal of shame around it. And then, trying to understand, is it getting worse?
Self-injury becomes a really big issue when it goes from being superficial, every so often, to a lot of the time, to deep, to needing stitches, to being dangerous on its own, even when it’s not tied to suicidal thoughts. And so, when it becomes a crisis is when it’s happening more often, when it’s getting deeper, when it’s required medical intervention. Those are some really important things to figure out. And then, to understand, why does it happen? And what are you trying to accomplish? For the most part, kids are not trying to attempt suicide when they self-harm. They’re trying to block emotional distress with physical pain and the release of stress hormones that happen when they do self-injure.
Dr. Angela Kade Goepferd: It triggers for me this addictive compulsive thinking around it.
Dr. Joshua Stein: If you look at some of the med trials going on and some of the approaches, in some cases being approached similar to like trichotillomania, in skin picking. And so, looking at use of N-acetylcysteine and other medications that seem to help some of those really compulsive behaviors. You’ll hear kids say like, “I don’t even realize I’m doing it until I have like seven, and then I finally stop.” And so, you can get really in the nitty gritty with them about, “Well, why did you stop? What made you realize it was too far? Was it that you started bleeding? Was it that it became overtly painful?”, trying to work on that.
I think, the other part that I talk a lot about with kids is the unintended consequences of self-injury. So, they know it can maybe get them through a hard moment at times, but the maladaptive, the negative part is they may not be comfortable going swimming, or they can only wear long sleeves around certain people, or they’re embarrassed, or they know how upset their parents get and then they lose their phone for a week. So I think it’s really important, those unintended consequences that they’re not thinking of more than just the pain, or bleeding, or infection, to try and explore that and build upon awareness from it.
Dr. Angela Kade Goepferd: Maybe in closing, you mentioned parents and how upset parents can get when they see their children cutting. And I really appreciated your words when we started talking about the role that pediatricians have been playing in this mental health crisis. And maybe we could close with talking a little bit about how we, as pediatricians, might engage parents as they are also right in the midst of dealing with this crisis among kids and tips that you might have for us of about how to engage parents around their child’s mental health crisis.
Dr. Joshua Stein: And I can’t say this is my idea. I learned this in training. I always talk about, what is our hope today? What do we hope to achieve versus what is wrong? I also always inquire about, what makes your kid shine? My goal is not to just help a kid feel better or be less depressed. My goal is to get them back to for half of Minnesota hockey, for back to the arts, or back to singing, or back to their youth group, or back to horse riding. And so, it’s always like, that is what we’re going for, regaining functioning and regaining enjoyment of things. And so, I think first off, opening it with, what is your hope? Because, that offers optimism. I think also really validating how distressful it is for a parent to have a kid who is needing monitoring or hurting themselves, but also sharing that this is your kid’s way of showing us they’re not okay, that we need to work to support them.
I know sometimes you guys feel over your head, and I know sometimes we feel over our head, and this is not a field of easy questions. It’s a field of gray areas. I always wondered why our training was so long. We only have like 20 meds to learn. But it’s because there’s a lot of patterns, and there’s a lot of differences, and there’s a lot of unsaid things. And so, I would just say, if you’re feeling lost with a patient or you don’t know what the next step is, to give us a call at PAL, and myself or Dr. Klapperich, we’re the two docs who are usually on, will go through it with you and try and come up with some ideas and get more support in that way. I just want you to know you’re not alone as a pediatrician. And even though it may take six months to get in with someone, we’ll walk you through it. And I’ve had docs who we talk every three weeks, because the patient’s needing that level of support.
Dr. Angela Kade Goepferd: And can you share with us the number that folks should call or how we could find it? Is there a website?
Dr. Joshua Stein: Mnpsychconsult.com.
Dr. Angela Kade Goepferd: Okay.
Dr. Joshua Stein: I think that’s the best way. And you can just send a quick sign up time. We’re available 8:00 to 6:00 every Monday through Friday. And we work on your schedule. It’s actually a real joy to do. And it’s been a chance to meet a lot of my pediatric colleagues. We also do trainings to build comfort with those psych meds. So, you have your first two, first three, steps for antidepressants, first two, first three, steps for ADHD meds, and are just feeling really comfortable in that way.
Dr. Angela Kade Goepferd: Well, Josh, thanks so much for joining me today. I feel like you’ve given a lot of really helpful examples and strategies. And I think that’s what we need right now is we all work together to keep kids and teenagers safe and get through this time that we’re in or evolve into whatever new time we’re heading in. But hopefully a time when, as you mentioned, kids can really thrive again. And that’s what we want for all kids.
Dr. Joshua Stein: Thanks so much for having me and honoring this. This is awesome.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Lexi Dingman is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.