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How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.
Bring in the Parents: Modeling Validation, Structure, and Optimism
If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.
Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.
With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
Introducing the Topic
When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.
Help Parents to Be Good Listeners
Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.
Identify Coping Strategies
In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.
Focus on the Basics
Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.
Set Up Speed Bumps
Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.
Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
Acknowledge the Strain
Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.
Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.
Bring in the Parents: Modeling Validation, Structure, and Optimism
If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.
Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.
With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
Introducing the Topic
When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.
Help Parents to Be Good Listeners
Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.
Identify Coping Strategies
In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.
Focus on the Basics
Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.
Set Up Speed Bumps
Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.
Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
Acknowledge the Strain
Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.
Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.
Bring in the Parents: Modeling Validation, Structure, and Optimism
If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.
Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.
With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
Introducing the Topic
When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.
Help Parents to Be Good Listeners
Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.
Identify Coping Strategies
In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.
Focus on the Basics
Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.
Set Up Speed Bumps
Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.
Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
Acknowledge the Strain
Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.
Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].