Crack the Case: Safety Planning and Suicidality

Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids.

Welcome to Talking Pediatrics. I’m your host Dr. Kade Goepferd. On our Crack the Case segment, we take real-life patient cases that present to a primary care setting and dissect medical decision-making, evidence-based guidance, and associated clinical pearls. It’s a case-based journey of a diagnostic dilemma with Dr. Bryan Fate that also includes some custom music to aid your medical memory.

Dr. Bryan Fate: All right, welcome to Crack the Case where we dive into real cases seen at our Minneapolis clinic to highlight medical decision-making, approaches to general pediatric topics, and life in primary care. We’ll also incorporate music written by myself and friends at the end of every episode to highlight teaching points and hopefully engage the emotive side of your brain. Today’s episode will cover the tough but incredibly important topic of suicidality and how to effectively screen, risk stratify, and ensure safety in a busy outpatient practice. So I’m Dr. Bryan Fate, a general pediatrician at our Minneapolis clinic, and with me today is Sarah Quinn, licensed clinical social worker and superhero for our providers encountering kids and teenagers in mental health crisis.

Sarah wears many hats as part of our integrated behavioral health team, meaning she and her colleagues are at the ready within minutes to meet with families and start a therapeutic relationship. I can not say enough about how amazing it is to have these services embedded within our clinic walls. Sarah, huge welcome. Thank you for being on and to get you more acquainted with our listeners, please tell me about your renowned skills as an Irish dancer.

Sarah Quinn: Thank you so much for having me, Dr. Fate. So yes, fun fact about me. I grew up in Milwaukee as an Irish dancer. I believe I saw my first Irish dancer just before I started kindergarten. My dad took me to the big Irish Fest in Milwaukee and apparently I said, “I want to do that.” And I spent the next almost 20 years dancing and Milwaukee and up here and just loved it. So I’ve been coming off of my fun season of watching dancers and our real joy right now is that my daughter just had her first St. Patrick’s Day.

Dr. Bryan Fate: Amazing.

Sarah Quinn: …As an Irish dancer as well.

Dr. Bryan Fate: Is it too late for me?

Sarah Quinn: Never too late.

Dr. Bryan Fate: Okay.

Sarah Quinn: You can always learn a new skill, but you do have to keep those arms down.

Dr. Bryan Fate: Okay. I might have problems with that. So to introduce our show today, adolescence is a roller coaster whose ride is still seared into the memory of my 36-year-old brain. Silent crushes, giant zits, feeling alone and alien, feeling at home and whole with the love of one good friend. And though it’s normal for a myelinating brain to go through these swings, suicide should never be the result of this turbulence. Tragically, suicide is currently a public health crisis. Death from suicide amongst older kids and teens surpasses those from major medical illnesses like heart disease and cancer and has only been increasing worldwide over the past 20 years.

As pediatricians, we play a pivotal role in early detection and prevention of suicidality. Recently, the AAP has recommended screening adolescents at every health encounter, providing a safety net for intervention, even when knee pain or acne are the chief complaints. But when a flag is positive, what do we do? We weren’t trained for this. And so enters Sarah as we hope to instill some tools to help decide who needs emergency support, who can go home, and how to safety plan in a busy clinic setting. So Sarah, to frame the cases today, the AAP has a helpful ABCD mnemonic for suicide evaluation and I was hoping we could go through that.

Sarah Quinn: So A stands for assess. We’re going to ask that you screen for suicide risk and assess risk level. B is for building hope and reasons for living. So maybe asking what are you good at? What do you love to do? And what do you fall back on when things are hard? C is for connect. Strengthening connections with protective adults. And D is for develop, which is a plan for keeping the child safe, restricting access to lethal means, developing a safety plan for coping in the future.

Dr. Bryan Fate: Perfect. And as a reminder, our cases are for general educational use only, are not to be considered as medical advice for individual patients and cases.

Got to crack the case with Doctor Fate.
Crack the case with Doctor Fate.
Crack the case with Doctor Fate.

Case number one, we have Harry Hennepin, who is a 15-year-old identifying with he/him pronouns who presents for adolescent wellness check, he is otherwise healthy. And you notice that his affect is more flat than in previous visits with fleeting eye contact and single word responses. You remember that he loves anime and manga comics from last visit and asking about what he’s reading now, Harry tells you that he recently gave his collection away and chose not to try out for his school’s production of Les Mis this year. You glance through the EMR and notice his PHQ-IX is 21, his GAD is 17. And when parents do not elicit mood concerns, you broach the subject to Harry during private interview. He discloses that he’s been having thoughts about ending his life. So Sarah, your first question is how do you introduce the topic of suicidality in a patient room?

Sarah Quinn: So that’s a great question and this is where our friend, the PHQ-IX gives you that introduction. And so, oftentimes if it hasn’t come up in conversation, I will say, “Harry, I took a look at the screening tools you filled out when you came in, and I see that there’s some questions I want to ask you more about. In particular, there’s a question that here says you are having thoughts about ending your life. Can we talk more about that?” Very direct is good, very honest and open about what you’re actually asking because otherwise we risk not getting a clear answer. And if we beat around the bush like some of us do here in Minnesota, they’re not going to know what we’re really asking and we may not get the actual answers that we need to assess risk.

Dr. Bryan Fate: In addition to the PHQ-IX, what screening tool do we use in our clinic, Sarah, and what are we screening for exactly?

Sarah Quinn: So we use the ASQ, which is the Ask Suicide screening questions. If you think about the difference between the PHQ-IX and this ASQ is a five question yes no set of questions that really determines what thoughts is the child actually having and what is the acuity and the risk? Is it imminent or is it more passive? And that really helps us to figure out, again, is this a child that these thoughts are kind of coming in and out of their consciousness or are they really active and they’re making a plan for how they may want to end their lives? The PHQ-IX really just gives a quick answer about whether they’re having those thoughts in the last two weeks.

Dr. Bryan Fate: So what situations would you use the ASQ?

Sarah Quinn: So anytime that we see on the PHQ, we’re given that at every single visit. Hopefully most pediatricians are following that guideline now. So anytime that we see question nine, which is any thoughts of hurting yourself or wishing you were dead, we want to be asking the ASQ questions to any of those patients or if we know there’s a strong history of a suicide attempt in the past or any serious thoughts of suicide in the last month.

Dr. Bryan Fate: So maybe you could step us through what those questions are, Sarah, and how you ask those and frame those with the patient.

Sarah Quinn: I usually start, again, by just saying, “I want to follow up on the questionnaire that you filled out. I have just a few questions for you and I’m going to start with five yes no questions.” For teenagers, the idea that I’m going to sit there and talk to them for an hour and want to understand every little thing about their thoughts might be overwhelming. So I’m going to let them know it’s five yes, no questions and then we’ll go from there.

Dr. Bryan Fate: Maybe, Sarah, you could review those questions and demonstrate how quick it is to administer in clinic, and then we can go through what Harry Hennepin scored during his ASQ.

Sarah Quinn: So Bryan, do you want to play the patient?

Dr. Bryan Fate: Sure.

Sarah Quinn: So Harry, I’m noticing that some of your screening tools were a little concerning for thoughts of suicide, so I just wanted to start by asking you just five yes no questions to kind of see where things are at today and then we can go from there. Is that all right?

Dr. Bryan Fate: That’s okay.

Sarah Quinn: Okay. So Harry, in the last few weeks have you wished that you were dead?

Dr. Bryan Fate: Yes.

Sarah Quinn: Okay. In the last few weeks, have you felt that you or your family would be better off if you were dead?

Dr. Bryan Fate: Yes.

Sarah Quinn: Okay. In the last week, any thoughts about killing yourself?

Dr. Bryan Fate: Yes.

Sarah Quinn: Okay. And have you thought about how you might do that or made a plan?

Dr. Bryan Fate: No.

Sarah Quinn: Okay. In your whole life, have you ever tried to kill yourself before?

Dr. Bryan Fate: No.

Sarah Quinn: Okay. And what about right now? Are you having any thoughts about killing yourself right now?

Dr. Bryan Fate: No.

Sarah Quinn: Okay. Thank you so much for answering those questions. Do you mind if I check in a little bit more about how things have been going?

Dr. Bryan Fate: Yes.

Sarah Quinn: Okay.

Dr. Bryan Fate: And so, those were the answers of this patient. So getting those responses that you got, Sarah, I think the nice thing about the ASQ is it gives you very clear guidelines for what to do next. Who’s safe with clinical insight and planning. Who needs to go to the ER right away. How are these questions scored and how would we proceed with Harry’s case right now?

Sarah Quinn: Again, questions one and two really assess for the presence of those suicidal thoughts. And so, again, what Harry is telling us is that he’s had those thoughts before wishing that essentially he wasn’t here anymore. Question three is telling us that it moves into a slightly more acute and imminent territory that he actually wishes he could end his life and kill himself. Question four assesses for that history. So we know that he has not had a suicide attempt before, which to a degree lowers the risk because he has not had a suicide attempt before. And question five is the one that really determines acuity about can this child go home today or we know for a fact that he is likely to harm self today. So because he answered no to question four, we know that there’s no history and because he answered no to question five, there is the opportunity to do some safety planning today to try and kind of shift the trajectory for Harry.

Dr. Bryan Fate: And for providers out there, the ASQ does come with a next steps section that kind of tells how you would score this. And so, if the screen is negative where all the questions are no, if the screen is a non-acute positive which is when any of the first four questions are yes. And then an acute positive, which would be positive preceding questions. And then a positive question five, which means that we need stat safety and full mental health evaluation. So Harry would be designated as a non-acute positive and it doesn’t seem like we have to go to the emergency department immediately. What would be your next steps, Sarah, for how you talk through safety planning, including lethal means reduction too.

Sarah Quinn: In our clinic, this is often when I’m working pretty closely with the pediatrician that Harry would be seeing and we’re kind of talking about this plan together. Usually, this is when you guys get to take a break and we come in and do a little bit more work. So first of all, we always want to have close follow-up with this patient to actually get them scheduled for therapy if possible. If they don’t have a therapist, there are safety plans that we can talk a little bit more about as well. We can fill them out with a patient, we can have the patient and the family do it together, but talking about the steps towards how do we ensure that we can be as safe as possible.

And then, the biggest thing that research has shown is really the evidence for a lethal means restriction. And there’s often a focus on the why. Why is this child feeling suicidal? What happened to them? As a way to try and mitigate that risk. And it’s been shown to be pretty ineffective to focus on the why. However, if we can focus on the how and remove what they were maybe going to use to harm themselves, we see that have a really big impact on suicide attempts.

Dr. Bryan Fate: As clinicians, we should be asking about guns in the home and similar, as part of anticipatory guidance, but what questions would you ask family and Harry, just in terms of restricting lethal means access.

Sarah Quinn: So for sure we want to focus on firearms, so we will ask parents if they have any firearms in the home. If the answer is no, great. If they do, then we’re going to ask the firearms to be completely taken off the property in an ideal world. So whether that means they’re taking it to a police station for safe storage, if they are taking it to a family member that, again, lives far away, great. If they’re not willing to do that, which sometimes does happen. We live in Minnesota, a big hunting state, we are going to ask about how the gun is stored. So again, then we can get into is there a gun lock? Is the ammunition stored separately than the gun itself? Ideally the gun is completely off the property, but if that’s something that the family doesn’t feel like they can do, then we’re looking at other ways to prevent that.

So firearms is one, medications is another, and that includes over the counter medications and prescription medications. Unfortunately, we know that Tylenol itself can be very lethal in a suicide attempt. So again, we are asking parents, guardians, caregivers to get all medication locked up and make sure that the child has no access to medications. And certainly if they need a medication they can come and ask their parent and get a single dose rather than having access to the full bottle of Tylenol. The last thing then is kind of this larger category of sharps and rope like items, which we know can sometimes be a part of kids’ plan.

Sharps can be a little tricky because parents will say, well, I have to cut things or I need to cook dinner, and we have knives. So we try and work with our parents or add and talk about in an ideal world, we get rid of them for a while, this won’t be forever. Can you reduce the number of knives or box cutters or scissors in your house for a short period of time? And then again, similarly with ropes, do you have 20 ropes in your garage? What do you need them for? Can we get them moved somewhere else even for a little bit of time until your child’s in a different place with their mental health?

Dr. Bryan Fate: Super briefly, Sarah, what other components are there to a safety plan and how long does it typically take to complete?

Sarah Quinn: We talk about what are some of the warning signs that maybe things are not going well. We talk about internal coping strategies that this child may have on their own. We focus on people that they might be able to call that are not necessarily professionals, but this might be a parent, grandparent, aunt, uncle, coach. And then in Minneapolis, again, I have a very specific Minneapolis kind of geography. Where do you go? We have 988 on there. We have Hennepin County Child Crisis. And then we’ve listed the emergency rooms here. You can make your own kind of based on where you’re geographically practicing. And then there’s always a question about what’s the one thing that’s most important to me and worth living for. This can take anywhere from 20 to 40 minutes depending on how the kiddo is doing with this. There’s a lot of questions we’re asking them to be really open about some pretty vulnerable things. But anywhere from 20 to 40 minutes, I would say this could range from.

Dr. Bryan Fate: Anytime we increase screening. We need to know that we have the resources and the time to adequately address the results of that screening. If we are catching teenagers who are having suicidal thoughts or plans when they come in for a knee injury, as clinicians that might not have your support, we need to know that we can do this succinctly and efficiently. So I think we showed that the PHQ and the five ASQ questions takes about how long, Sarah?

Sarah Quinn: I would say like 5, maybe 10 minutes.

Dr. Bryan Fate: And then the safety planning can certainly take longer and hopefully there’s social work and behavioral health support, but they do have wonderful templates that you fill out with the family for them to take home. They are structured in a pretty approachable way, so know that that’s available. And I just also wanted to put in a note for clinicians that as part of this evaluation, of course you also still want to be doing, if allowed a full skin exam just to be mindful of self-harm that can occur under clothing. Also doing our comprehensive heads assessment looking for abuse or unsafe relationships and harm to the patient or family, substance use of course, sexual activity of course, overt signs of psychosis or other mental health diagnoses. We need to be aware of that. And I also wanted to put in the plug that there’s very good research behind starting SSRIs for persistent depressive and anxious symptoms, especially when they culminate to the point of having suicidal thoughts or plans.

And there has been hesitancy given the black box warning of those increased thoughts in the beginning of initiating SSRI such that I think there has been less medication prescribed than we’d like. But in conjunction with proper supports and therapy and follow-up, it is a very useful adjunct to really consider starting an SSRI for patients like Harry too. So we’re going to move on to our second case.

And Purple Rain is a seventeen-year-old identifying with they/them pronouns who presents due to concerns for boils. You’ve known Purple since grade school who has struggled with major depressive disorder and anxiety. And while SSRIs have been very effective historically in the last one to two years, there has been more limited contact with the healthcare system without access to medication. You also know this is because Purple has run away from home for months at a time due to conflict with parents after coming out as non-binary.

Purple has strong support from friends and is renowned on their high school’s dance team. You suspect MRSA and wrapping things up are flagged by EMR about red flags on the PHQ-IX, your heart races and you go into a cold sweat as you’re 45 minutes behind per usual. As we’re doing more screening for suicidality, having an EMR in place that flags the physician when these results are positive is super, super important. We would not want to, when you’re looking at boils, forget to look at the PHQ-IX or those scores until two or three days later and realize that they went unaddressed. So having an electronic medical system that flags you and making sure that those safety flags are in place is super, super important. In the case of Purple, and Harry too, what risk factors are worth investigating in terms of suicidality that we know about? Things like demographics, what kids are kind of more at risk would you say?

Sarah Quinn: If we know about parent history, if there’s been a strong history of either mental health or suicide in the family, and that can be grandparents, aunts, uncles, parents. We’re again kind of raising our flags then that we want to be a little bit more attentive to what’s going on with this child. We know that people aged between 10 and 25 are inherently more at risk. Suicide is the second leading cause of death among people aged 10 to 14 and leading cause of death between those aged 15 to 24 in the U.S. So if we are sitting here in a pediatric clinic, we know that just our kids are at higher risk than the general population right now. We also know that our BIPOC kids are more at risk. Those numbers are pretty high in terms of somewhere between two and four times the rate of white children in terms of their thoughts of suicide. And then, we also know that our LGBTQ+ kids have somewhere between four and nine times the amount of risk associated with suicide than are heterosexual and non-LGBTQ kids. So Purple is at pretty high risk.

Dr. Bryan Fate: You administer the ASQ. So you ask those five questions again, and unfortunately the result is an acute positive screening. So with an acute positive screening, we know that we need some emergent mental health support. How do you go about approaching this conversation with a teenager like Purple?

Sarah Quinn: Again, the ASQ really gives you the answers and our job is to really reflect that back and to say, “Wow, Purple. First of all, thank you for telling me this, that this is where things have been lately for you. I really think that we need to work on getting you some more help with your mental health. And right now that’s probably going to look like going to the emergency room because we might need to have you get admitted to an inpatient unit, but we certainly need to make sure you have a more thorough evaluation, which will happen in the emergency room.”

Dr. Bryan Fate: I know there’s some teenagers are willing to go down and some are not. And sometimes teenagers are willing to go down and parents are not. While Purple is willing to proceed with emergent support, their parents tell you that Purple is just doing this for attention and will be fine and start putting on their coats to leave. How do you navigate when parents won’t accept emergent support or conversely, when parents are on board but the teen is not?

Sarah Quinn: This is probably one of the hardest parts about pediatric mental health is that we’ve got to get not just one person on board with the treatment plan, but two. And sometimes those opinions are really different than our own. So first of all, we want to validate Purple’s experience here. Right? Again, Purple was really honest with us. This is what they are saying to us. They are saying that they can not keep themselves safe. It’s my job as the pediatrician or as the therapist to really assess this risk.

And mom and dad, caregivers in the room, I understand that you think this might not be real, but I have to take it as fact. Purple has no reason to lie to me, and we certainly don’t want to be in a position where we regret not fully assessing this risk. So I’m going to really ask that we all get on board together and move just to this next step. We don’t know what’s going to happen after the emergency room. I’m really asking us to do this next step of going down to the emergency room just to do a further assessment. We can’t predict whether a child will be admitted to the inpatient mental health unit. What we can do is focus on what’s right in front of us, which right now we know is an acute positive ASQ and Purple is at risk.

Dr. Bryan Fate: So after approaching concerns for Purple, and demonstrating that wishes for Purple’s well-being are shared and trying to really highlight that everyone wants what’s best for Purple, the family did agree to go down to the emergency department and receive further evaluation. I will say, again, that the emergency department is not an ideal place for emergent health issues being more geared towards medical, which of course overlap in the case of suicidality and self-harm. So hopefully we can create a better system in time, but in the setting of an emergency, unfortunately that’s the best we can do with our health care system.

I know we’ve talked about a heavy topic in suicide, and I know that it can be really hard to talk about and certainly emotionally charged. And as we discussed, it is a very major issue that we’re confronting. And I just wanted to put in the plug that talking about suicide does not lead to more suicide. That has been studied. And I think it’s really important as pediatricians and mental health providers that we give it its due attention, given all the statistics that were brought up today, that we feel comfortable talking about it directly, that we don’t skirt around the issue because it usually sits in hiding and it really does require some outreach to reach someone before it reaches a point where action is followed through on. So I hope listeners become more comfortable talking about it, and I hope that they’re able to use some of these tools like the ASQ to really start screening more proactively for teenagers. So Sarah, what would be two or three take-home points that you’d have for our listeners?

Sarah Quinn: First, again, knowing that asking a direct question about suicidality and where kids’ thoughts are at will facilitate a more accurate and better conversation about safety and risks. So again, not being afraid to ask that question, you will not put the idea in a kid’s head. Second, I would say really focusing on the how rather than the why and knowing the importance of that lethal means restriction. And then the third thing is really to use a strengths-based approach by focusing on the fact that your patient is here right now and has somehow maintained safety in the past.

Dr. Bryan Fate: Part of the strengths in those adult relationships are you knowing the family and knowing what the kid loves to do, whether it be anime, basketball, TikTok dance videos, what have you, and being able to connect on those facts that you built over time with continuity and knowing that you are a part of their life too. Of course, there are very important parts that probably overshadow you, but you’ve known them for a long time and can make a difference. So until it’s time to crack another case, a musical number, to engage the emotive side of your brain and hopefully tug at your heartstrings.

Got to ask if they’re all right.
Teenagers hold on to things so tight.
Free fall in to a [inaudible 00:25:50].
We got to ask if we’ll ever know.
Depression hides so [inaudible 00:26:02].
Shine a light and [inaudible 00:26:13].
Help them love their mind again.

Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.