157. Suicide Prevention: Round Up on Adolescent Health (PT3) (CE)

Youth suicide has become a national crisis, with devastating impacts on families, communities and health care systems. As one of the leading causes of death among adolescents, suicide presents a critical challenge for health care providers. In this third episode of the AANP Adolescent Podcast Series, hosts Dr. Jessica Peck and Ashley Hodges explore the growing prevalence of youth suicide, associated risk factors, warning signs and the essential role of nurse practitioners (NPs) in early identification, intervention and prevention. Through clinical insight, real-world experiences and practical tools, providers are equipped to navigate these complex conversations, reduce stigma and connect at-risk youth with life-saving care.---

Key Points:

• Suicide is the second leading cause of death among individuals aged 10–24.
• Risk factors include previous suicide attempts, affective disorders (especially major depressive disorder), substance abuse, bullying, access to lethal means and social isolation.
• Girls attempt suicide more often, but boys typically use more lethal methods (such as firearms).
• Situational triggers, such as online sextortion or bullying, can prompt impulsive suicide attempts with little warning.
• Warning signs include changes in sleep, appetite, hygiene, mood, social withdrawal, giving away possessions and expressions of hopelessness.
• Non-suicidal self-injury (e.g., cutting, burning) is a strong predictor of future suicide attempts.
• Evidence-based screening tools include the ASQ (Ask Suicide-Screening Questions), PHQ-9A, Columbia Suicide Severity Rating Scale and the Patient Safety Screener.
• Creating a safety plan and restricting access to lethal means (e.g., firearms, medications) is essential in prevention.
• Encouraging emotional literacy and normalizing mental health discussions with teens can foster resilience and trust.
• Connection, validation and early intervention save lives — NPs play a pivotal role in detection and support.
• Call to Action for providers and families:
• Don’t ignore warning signs.
• It’s okay to ask directly about suicide.
• Connection is a powerful protective factor.
• Invite listeners to share this episode and use their voice for suicide prevention.
• Encourage listeners to check out the episode notes for resources and links.

National Resources:

988 Suicide & Crisis Lifeline

Crisis Text Line: Text HOME to 741741

Megan Meier Foundation: https://www.meganmeierfoundation.org/

To claim 1.0 contact hours of continuing education (CE) credit for this program, log in to the CE Center, search for this program by name and complete the post-test and evaluation by entering the participation code that is given after listening to the podcast.

Episode Transcript

(00:00):
(lively music)
- From the American Associationof Nurse Practitioners,
this is Cammie Hauser, nursemidwife, nurse practitioner,
and AANP education specialist.
Welcome to this edition

of "NP Pulse (00:21):
The Voice of the Nurse Practitioner."
AANP's official podcast,
bringing unique nurse practitioner voices
and expertise on issuesthat matter most to NPs
and to our patients.
As always, be sure tosubscribe to this podcast,
share with your colleagues,and check back often
for new conversationswith nurse practitioners

(00:42):
and healthcare leadersfrom across the nation.
(lively music)
This episode includes in-depth discussion
about youth suicide,mental health struggles,
and related sensitive topics.
Listener discretion is advised.
If you or someone you know is struggling,

(01:03):
please consider reaching outto a mental health professional
or contacting a crisis hotline
such as 988 Suicide andCrisis Lifeline in the US.
Call or text 988.
or visit 988lifeline.org.
Your wellbeing matters. Pleasetake care while listening.

(01:27):
In this third of fourepisodes on adolescent health,
host Jessica Peck and AshleyHodges draw on their 65 years
of combined experience to tackle one
of the most urgent topicsfacing today's youth,
suicide prevention.
Youth suicide has becomea national health crisis
with devastating impactson families, communities,

(01:47):
and healthcare systems.
As one of the leading causesof death among adolescents,
suicide prisons a critical challenge
for healthcare providers.
This episode of the AANPAdolescent Series explores
the growing prevalence of youth suicide,
associated risk factors,
warning signs, and the essential role
of nurse practitionersin early identification,

(02:11):
intervention, and prevention.
Through clinical insight,real world experiences
and practical tools,providers are equipped
to navigate these complexconversations, reduce stigma,
and connect at-risk youthwith life-saving care.
By the end of this activity,participants will be able

(02:31):
to recognize key factorsin warning signs associated
with youth suicide, includingdemographic, environmental,
psychological, and behavioral indicators.
Apply evidence-based screening tools
and clinical interventions to assess
and manage suicide risk with primary care
and emergency settings.
And finally, to demonstrate

(02:52):
effective communicationstrategies to reduce stigma
and promote open dialogue with adolescents
and their families about suicideand mental health concerns.
Whether you're a seasonedNP or new to practice,
this conversation providesboth the clinical wisdom
and compassionate perspectives needed
to make a meaningful impact
in adolescent mental healthcare and to save lives.

(03:17):
Welcome, Jessica Peck and Ashley Hodges.
- Hello, everyone, andwelcome to episode three
of an adolescent series provided to you
by the American Associationof Nurse Practitioners.
We are talking today about an issue
that is extremely important.

(03:38):
It's something that we don'twanna talk about sometimes
because it's so sad and sotragic, but there is hope
and we are going to talkabout hope starting here
right now today, equippingyou as care providers
to prevent youth suicide.
My name is Jessica Peck.
I am a pediatric nurse practitioner

(03:58):
and clinical professor ofnursing at Baylor University,
and I am joined by myco-host Ashley Hodges.
Ashley, introduce yourself.
- I'm great, thank you, Jessica.
So I am Ashley Hodges.
I am both a women'shealth nurse practitioner
and a psychiatric mentalhealth nurse practitioner.
I currently am in private practice

(04:20):
out of Birmingham, Alabama
where I see patients several days a week.
I also am the clinic director
and nurse practitioner ata local children's hospital
where we run a clinic for minorvictims of sex trafficking.
- So we have all ofyour bases covered here.
And September is NationalSuicide Prevention Month.

(04:42):
This is something that is onthe mind of every provider,
every parent, because every 11 minutes,
someone in the UnitedStates dies by suicide.
And among teens in particular,
it is a rising crisis andhas been for over a decade.
It is now a leading causeof death in young people.
And Ashley, we've seen a60% increase in suicide

(05:06):
over the last 20 years.
And some of the statistics to me
that really just grab my attention,
not only as a provider, but as a parent.
I have four teenagers
and young adults, so I'm really living,
breathing this in a professionalsense and a personal sense.
We know that one in five teensreport suicidal thoughts,

(05:27):
but only about a third ofthose will share their fears
with someone, and onein 50 of those will rise
to need medical treatment.
But for every suicidedeath, there are estimated
to be about 100 to 200survived experiences.
And it's frustrating
because researchers cannotagree on a single cause.

(05:48):
Although there's a lotof ongoing investigation
of many factors,including social media use
and economic stress and fear,and mental health disorders
and leading methods ofsuicide are firearms.
60% of all suicides in the United States
do occur by firearm.
And while girls attempt more often,

(06:10):
boys attempt in a more lethal way.
And of course, we see agreater risk for gender
and sexual minority youth.
And you know, for me, Ashley,
in professional nursingpractice, suicide was something
that I saw from time totime early in my career
as an every once in a while sort of thing.
But by the time I startedworking at a community regional

(06:31):
hospital about 10 years ago, honestly,
this was something I saw every single day.
I would have kids in theemergency room, kids admitted
to the pediatric unit who hadsurvived their experience,
but were waiting for further evaluation
or a placement that may or may not come.
And they may be boardingin the emergency room,

(06:52):
which is definitely less than ideal.
And for me, Ashley, on a personal level,
I remember when I was 19 years old,
a very, very good friendof mine died by suicide,
and I had no idea that it was coming.
That was the first time that, you know,
really it crashed into my life.
But I've seen it more and more,
and especially guiding mykids through experiences.

(07:14):
It's just something that grips the heart
of the community when it happens.
It's so tragic.
And for Ashley, you've talked about
your extensive experience asa mental healthcare provider
and all of those environmentsthat you work in.
What is the landscapelook like to you today?
- You know, I agree with you Jessica.
You know, when I startednursing, gosh, goodness,

(07:36):
35 years ago, this was somethingI came across occasionally.
And it was very unusual for me
to come across this inchildren and adolescents.
But also, we have to remember
that this was something weweren't comfortable talking about
for so many years.
There was such a stigmaassociated with mental illness.

(07:56):
There was a stigma associatedwith suicidal thoughts,
suicide attempts.
And so I've seen a definite increase in,
and I agree with you on the statistics.
I mean, we know now that suicide
is the second leading cause ofdeath in 10 to 24-year-olds.
And when you think of allsuicides, that accounts for 15%
of all suicides.

(08:17):
So there's definitely an increase in this.
In 2021, there was a surveydone of high school students,
and they found that inthe previous 12 months, 9%
of high school studentshad attempted suicide.
- That's heartbreaking.
- It is heartbreaking.
And when we look at at-risk groups,

(08:40):
then that goes up even higher.
Now, I wanna start thisout by saying that anyone
who is a living breathingcreature is at risk.
And so I don't want to minimize any group
that maybe the statisticsaren't as reflective
or don't reflect as high of a rate,

(09:00):
but can happen to anyone.
But we know through research
and through monitoring thatthere are certain populations
that have higher ratesof suicidal thoughts
and also suicide attempts.
- Yeah, and for high schoolstudents, when they broke it out
by race, it was found
that for the Black high school students,

(09:23):
the rate was significantlyincreased from 2000,
increased to 19.2% of allblack high school students.
So that is a significant disparity.
- It really is.
And I'm glad that yousaid that though, Ashley,
because two things that yousaid are really important.

(09:43):
Anyone is at risk
and we are talking more aboutit, which is really good.
And for me, you know,
I look back at the lastfive years in particular
since COVID, since the pandemic,
and we saw children who were isolated,
who were separated from theirsocial support networks,
who weren't around caring adults
as much as they were before.

(10:05):
If they were in abuse situation at home,
then that was exacerbated
because they didn't have any other outlet.
And we just saw kids whowere isolated and lonely.
And for me, at the time, I was president
of the National Association ofPediatric Nurse Practitioners
and looking across the nation
and across the world, really,I was extremely alarmed

(10:26):
about what really was a social
and emotional injury thatoccurred from isolation
that was necessary toprevent disease spread.
And I think, I hope, I wannasay I hope in the future
that we're really a lotmore thoughtful about that
and thoughtful aboutthe impact of children
and have pediatric voices
that are represented in disaster planning.
But one of the things thatcame out of that, Ashley,

(10:48):
was in 2021, the AmericanAcademy of Pediatrics
and the American Academy ofChild and Adolescent Psychiatry
and the Children's Hospital Association,
those three organizations,they issued a joint declaration
of a mental health emergency.
And I've never seen anything like that.
But again, I think they recognized

(11:08):
what we all recognizedin the pediatric world,
that the pandemic was asignificant social, emotional,
and psychological injury for children.
And we started to seeemergent presentations
of those acute mental health crises
in pediatric care centers.
I mean, they skyrocketedin those early days.
We're starting to seesome glimmers of hope

(11:29):
and leveling off a little bit.
But let's be honest,we're almost six years.
Can you believe that?
From the outset of the pandemic.
And we're still hurting,
this is not going to go away overnight.
But what you were talkingabout earlier, Ashley,
is so important and havingconversation about this
because there's so much shame
and stigma surrounding suicide.

(11:50):
And so I wanna talk aboutstigma for a little bit
and what that word means.
Because the dictionary definesstigma as a mark of disgrace
that is associated with aparticular circumstance,
quality, or person.
And if we're honest,that's a little cerebral,
but I think about it this way.
Stigma is a reallyunhealthy coping mechanism

(12:11):
that we all use to deal with our fear
that something bad will happento us or someone we love.
And stigma at its core, ifyou really break it down,
it's simply social rejection.
Because when we hear theunthinkable has happened
to someone we know maybe from a distance,
and we hear about somethinglike suicide, if we're honest,

(12:32):
our minds immediately startthis internal ticker tape
to analyze that person or family.
Were they having an affair?
Was there alcohol involved?
Mental abuse?
Was their abuse in their home?
Did they have money troubles?
And your brain kind of clicksto a stop when you find
that one thing that you see
as completely different from you.
And you get this feeling of relief, like,

(12:54):
"Oh, okay, there it is.
That's what makes them different.
So now I feel safe, thiscan never happen to me,
or I would never do that."
And then what we do asparents is we start to share
that observation with our kids
because subconsciously,we're trying to reassure them
and ourselves that, "Hey,this won't happen to us."

(13:14):
And that moment, signalinga psychological shift
is critical to me, Ashley,because that's the moment
of social rejection when stigma is born
and we place someone else ina different imaginary category
based on that characteristicthat we see as threatening
to our construct of security.
So let me give you someways that I've heard

(13:35):
that expressed before.
When teens share news of friends
or peer suicide behaviorswith their parents.
So I'll hear their parentssay, "How do they do it?"
That's usually the firstquestion that people ask.
And we should never ask that question
because actually asking about method,
it conjures up some mentalimages, it increases the risk

(13:56):
of social contagion.
But other things thatI hear people say are,
"Well, you saw that coming a mile away."
Or, "What a shame, but youknow, her dad's crazy."
Or, "How did you not know?
Are you sure you didn'tsee any warning signs?"
Or, "Why in the worldwould they commit suicide?
They had so much to live for."
Or, "How could they dosomething so selfish?"
I mean, when you think about those things,
it makes my heart so heavy.

(14:18):
But we contrast that withlanguage like, "I'm so sorry,
that must be so hard.
I'm so sorry to hear this.
How are you feeling?
This news is so sad.
I don't know what to say,
but I want you to knowthat I'm sorry and I care."
I really think we haveto be so intentional
in the way that we present our judgments
of others, especially to our kids,

(14:38):
because we, one day that familymay walk in those very shoes
and those preconceivednotions of our response,
they're going to stickhard and really fast.
And I don't know if you've seenPixar's movie "Inside Out,"
but I think about core memories.
It's a prime opportunityto build core memories
of compassion and kindness.
And it's important to say,

(15:00):
those first responses aren'treally intentionally cruel.
It's just a human copingmechanism that's searching
for a way to separateus from the unthinkable.
And so I think we shouldreally think about our language
around that too, becausean estimated 30 to 40%
of adults label suicide with words
like "selfish" or "cowardly."

(15:21):
And even saying "committedsuicide" is easily conflated
with committing a crime
or we label suicide Ashleyas failed or successful.
And those things can be insensitive.
People at risk for suicidealready feel like a failure
and now we say a failed suicide attempt.
So that just makes me shudder.
And so I think it's important

(15:41):
to say just simple changes like,
instead of "committed suicide,"say, "died by suicide"
or, "died of suicide,"just like you would say
"died of a heart attack"or "suicide behaviors"
or "thoughts of suicide" when talking
to your teens about concernsthey have about their friends,
it's important to talkabout it because we know
that that doesn't increasethe risk of suicide.

(16:03):
But I think, you know, thekey point here, Ashley,
is that suicide is aleading cause of death
and we need to be aware,we need to be prepared
for early action and we need to recognize
that it can happen in our world.
And I'm sure people are, you know,
one of the most commonquestions people ask
are, "How do you know?
What are those risk factors?

(16:24):
What will the signs of concern be?"
So can you share with us fromyour perspective, Ashley,
what you see as those risk factors?
- Absolutely, absolutely.
And one of the thingsthat, you know, I mentioned
and you mentioned as well,
is that there are certaindemographic factors.
There are things that make people
more vulnerable in general.

(16:46):
And so when we talk about risk factors,
we need to also include that.
But I almost hate to do that
because that then omits,somebody may say, "Oh, well good,
I don't fall within that demographic,'
or, "I don't fall withinthat geographic location,
therefore I'm not at risk."
And again, I wanna reiterate
that's not necessarily the case.
But in treating individualsand in talking to teens

(17:08):
and talking to children, it is important
to take those into consideration.
So again, the LGBT community,we know is at greater risk
for suicide attempts.
We also know that where you live
and who would think about
where you live actually increases the risk
of suicide attempts.
And the same work thatwas that came out in 2021

(17:29):
that triggered thisemergency call to action
was also looking at geographic location.
And one thing they found isthat the more rural the area,
the higher risk someone isfor suicide attempts as well.
So those type of geographicthings make a difference also.
But what kind of things in general,
regardless of where you'refrom, how you identify,

(17:53):
what type of things are risk factors?
Well, the number one risk factor
is going to be a previous suicide attempt.
If someone has had aprevious suicide attempt,
then that is the number one risk factor.
Also, has there been a familyhistory of suicide attempts?
Sometimes, after a suicideof a family member,
you'll start seeing symptoms of PTSD

(18:15):
and suicidal ideation inthe surviving adolescent,
in the surviving child.
So that's something youneed to be aware of as well.
If there's a family historyof substance use disorder
or major depressive disorder,that's a risk factor.
I can tell you though,that effective disorders
are also a high predictor.
We know that children
and adolescents with aeffective disorders are 11 times

(18:38):
more likely than the generalpopulation to attempt suicide.
So what is the mostprominent effective disorder?
Well, it's gonna be yourmajor depressive disorder.
So if they have a diagnosis of MDD
that puts them at at great risk.
Bipolar disorder puts them at risk.
Personality disorders, genderdysphoria puts them at risk.
And something we oftenoverlook is an adolescent

(19:01):
with an eating disorder or achild with an eating disorder
that also puts them at higher risk.
Substance use disorder,
a history of sexual abuse, bullying.
And later, I'll share with you a story
about bullying andsuicide, social isolation.
Those things put people at risk.
Now kind of explains itself.

(19:21):
If they have access tolethal means like a gun,
that does also increase the risk.
But something that you also mentioned
and you talking about when you're talking
to teens about suicide,if they've known someone
who has completed suicide, howshould you talk to the teen?
And one thing we really have to realize
is when there is acluster in the community

(19:41):
or there is high mediacoverage, mob an adolescent
or teen suicide,
that also puts other adolescents at risk.
And we'll talk in alittle while about trying
not to normalize suicide
because we know that ifthat starts happening,
that is also a risk factor.
- It's really soberingto look at some of those.

(20:03):
I mean, you've talked reallyclearly about some biological,
some psychological, someenvironmental risk factors.
But Ashley, there can alsobe situational triggers
because we know that teens are impulsive.
And teens are not developmentally wired
to be thinking about the long-term future.
And I was looking at one particular study

(20:24):
that looked at 152 survivors
who had survived a suicide attempt.
And this was staggeringto me, Ashley, one in four
of those survivors deliberatedfor less than five minutes
before their suicide attempt.
Another 24% were five to 19 minutes about.
Another 23% were 20 minutes to an hour.

(20:48):
That means 75% of those survivors
decided to make an attemptto take their own life
less than an hour before they did.
And we've talked a lot in this series
about some of those emerging risk factors,
and especially the online environments.
It can create a situation
where teens are makingvery impulsive decisions.

(21:09):
One of those we've sharedis the rise of sextortion.
So teens getting online, engaging
with someone they think isa peer that they perceive
as attractive, they maystart talking with each other
and they may exchangeexplicit texting information.
That can be texts, that canbe images, that can be videos.

(21:29):
And once the extortionist has that,
then they immediately demand more
or they'll share thatwith their social network.
And teens often are so afraid of this.
The FBI has actuallybeen warning about this,
we know there's more than 40kids since they've been looking
at this in the last couple ofyears who have died by suicide
and many of those in less than an hour

(21:51):
from the initial contactto when it happens.
That's why it's soimportant, Ashley, to talk
to kids about this before it happens
because you never know whenthey can find themselves
in a situation that they're just going
to make an impulsive decision.
I know I've seen thisin my clinical practice.
I had a teenager I was takingcare of in the hospital.

(22:13):
He had come in for a substance withdrawal
and he found out about a situation
where he was actuallyselling those substances.
This had happened really, really quickly.
And it was a teen who hadexperienced a lot of trauma
and his grandparents had found that.
And they had gotten ridof all of the substances
that he had and he was so afraid

(22:33):
of what was going to happen.
He actually escaped his hospital room
and tried to jump offthe roof of the hospital.
I mean, this is the kind of,
and thankfully, we were able to intervene
and his life was spared.
But this is the kind ofimpulsiveness that we see.
And one of the stories thathaunts me the most is a mom
who I met actually at a NAPNAPconference in Las Vegas.

(22:56):
And her name is Tina Meyer.
And she talked about her daughter, Megan,
who was bullied at school.
And usually, you know, bullyinghappens with that trait,
that peer sense insecurity about
Many times, it's not true,it's just a true insecurity.
And they bullied Megan about her weight.
And I'm glad Ashley,
that you mentioned about eating disorders
because a lot of peoplearen't familiar with the fact

(23:18):
that eating disorders areactually the most deadly
mental health disorder.
We get a lot more worriedabout other conditions,
but that's something that can fly
under the radar really easily.
But in this case, the bullying got so bad
that Megan's parents decidedto change schools for her
but she maintained an online presence
with some of the people whowere from her other school.

(23:40):
And the parents weremonitoring this very closely.
Megan was 12 at the time.
And there was a boy from theschool who said, "I'm so sorry
that this happened to you.
I can't believe thoseother people were so mean."
And over time, thatrelationship started to sour.
And the mom was watching this
and all of a sudden, this boy named Josh
started to say unkind things

(24:02):
until the point he basically said,
"The world would bebetter off without you."
And tragically, Meghan did lose her life
to suicide at just the age of 12.
But Ashley, the most tragicpart about that story
is that her suicide wasn'teven the most tragic thing
that happened in thefamily's retelling of it
because Josh wasn't even a real person.

(24:25):
He was a creation of some of the girls
and their mothers who hadpreviously bullied her
and were acting in this online environment
and thought just for their own amusement.
Now I'm sure they did notintend for the outcome
to be what it was,
but this is the kind ofamplified risk platform
that we have when we haveuncharted digital platforms

(24:48):
where these kinds ofbullying and abuse can occur.
And again, it's so important to talk
to teens about it beforehand
so that we look for those signs.
Because you know, one of thethings that I have seen Ashley,
and I'm sure you've seen this too,
is that when families areblindsided by suicide, they start
to go back through the past
with a fine tooth comblooking for any signs.

(25:09):
And it's important to say,sometimes, there are no signs.
Sometimes this is a reallysecret internal struggle
and sometimes, there aresigns that were there
and families feel guiltyabout missing those.
And I really hope thatwe as providers can help
to release families from that guilt
because we do the best that we can.
And it is not your faultfor not recognizing that,

(25:32):
for not seeing that becausesometimes, we just don't know.
But for those so that wecan increase our alertness,
what do you see, Ashley, asthe behavioral warning signs?
What are those things thatpeople should look for
and really pay attention,
whether it's parents looking at their kids
or peers looking at peers
or just any concerned friendlooking at another person?

(25:56):
- Right.
And you know, Jessica, Ialso wanna say that I echo
what you said about,you know, the importance
of really knowing, you know,
knowing what's goingon with your children.
And because these decisionsare often very impulsive.
But talking to your children ahead of time
because by the time it getsto that point, the window

(26:18):
between they have that thought
and it happens can be so very short.
Most of the time in thesecases, the precipitant
to the actual act happenswithin the previous 24 hours.
So think about how before,
and I don't wanna blame everything
on social media obviously,
but this is going onlong before social media.

(26:40):
Think about how access toinformation and access to friends
and access to people's access
to your child we're somewhat limited
before the advent on social media.
Now, before you know what's going on,
they could be in the roomwhile you're fixing dinner
or you know you're watching a TV show.

(27:00):
It can happen that faston a social media platform
or a text message
or any quick access to yourchild that can trigger them
to take this act.
And so it's so fast now.
And very often, parents will feel guilty
because they didn't pick up on the signs,
they didn't pick up on what was going on.

(27:22):
They didn't intervene soon enough.
Well, the problem is thatsometimes, there wasn't anything.
There was nothing.
And your child was going through something
that you didn't realize.
And so the fact thatthey live with that guilt
is a whole different discussionabout the guilt that parents

(27:42):
and other family members
or teachers live withwhen death is the result
of a suicide attempt.
And so I do think, you know, listening
to this podcast I thinkhelps equip providers
even if their parents helpsprovide you with some tools
to be able to watch forany concerning signs.

(28:02):
And you know what?
If your child says, "Mom,dad, you're being ridiculous."
You know what? That's okay.
You can be ridiculous becausethey'll be here tomorrow
and they'll be here the next day.
So I just wanted to kind of add that
onto what you had already said.
So talking about the warning signs,
and this is what I see in my practice.
Because I do have a fairnumber of adolescents
and children who have attempted suicide.

(28:24):
First of all, the obvious,if they have a stated intent.
If they say that they arethinking about it, that they want
to act on it, even ifthey don't have a plan,
that is still a warning sign.
Because they're having thoughts of death,
something is taking them down that path.
And when that even happens,you need to make sure

(28:45):
that they are getting some typeof professional intervention
to assess what is going on.
Also, are they giving away possessions?
That's something we also see in adults.
But are they giving awaypossessions to friends?
Are they giving awaypossessions to younger
or older siblings?
Obviously, that's generallygreater than the 24 hours,

(29:05):
but sometimes, it can happen very quickly.
I will tell you that whatI see most often though
are personality shifts.
Sudden personality shifts.
These are children I'veworked with for years
and suddenly, yeah, they're going
through maybe a tough time at school
or maybe they're going through a puberty,
which is the tough time and yousee some personality shifts.

(29:28):
But their personality is reallygoing beyond what the parent
or the caregiver or theprofessional thinks is normal
for their age, for theirdevelopmental stage.
So a sudden personality,
obviously if there issubstance use disorder
or alcohol abuse, then that is something
that also is a warning side.

(29:50):
What about their hygiene?
Did they use to batheregularly if they're a female
or put on makeup if they're a female,
when it was their menstrualcycle, they took care
of themself, they bathed, you know,
people were going to get their hair cut.
I mean anything related totaking care of themselves,
brushing their teeth.
I'll often see a shift in hygiene as well.
Either they're not wearingthe makeup they used to wear

(30:12):
or they're not brushing their teeth
or their skin is suddenly looking bad
like they're not caring for their skin.
Or they have a body odor.
Those are things that I also worry about.
Have you noticed a change in their sleep?
Were they sleeping fairlywell or well before?
Now, are they up a lot during the night?
Do you hear them up alot during the night?

(30:33):
Or do they have hypersomnia?
You know, and as a teenager,
I've been there, we've all been there.
There were some timesthat, bless my parents,
they would let me sleep10 hours on the weekend
or 11 hours on the weekend.
But is this becoming a pattern?
Is this becoming a habit thatthey're sleeping all the time
or napping during the day?
Also a change in their appetite.

(30:54):
You know, these signs often go together
and what a parent willsay to me is, "You know,
I can't put my finger on it,
but they just don'tseem like they feel well
not eating as much,just not sleeping much,
but taking some naps.
You know, she used to dress nice,
she's not dressing nice anymore.
I don't really know a lot of her friends

(31:14):
We think she took somealcohol from the cupboard."
You know, those type ofthings I start hearing
and sometimes even lessobvious to the parents.
And so those are some earlysigns that you can kick up on.
Now when you talk about younger children,
children under the age of eight,
it's a little bit different.
If obviously an 8-year-old starts talking

(31:37):
about hurting themselvesand causing their own death.
Or if they start like doing gestures
like they're strangling themself
or like they're puttinga gun to their head.
Those are warning signsthat we need to clue into
with very young children.
But the overall, you cantell a sense of hopelessness,

(31:59):
there's nothing they'relooking forward to.
Maybe a family vacation's coming up
and they're generally excited about it,
they're not excited about this.
They're not interested in making plans
for starting back to school.
And obviously, you know,you can distribute a lot
pf that to puberty, toadolescent behavior.
But generally, these are in extremes
and it's more than one thing

(32:19):
and it is a little more sudden shift
than you would normally see.
But very often, my patients present
with these symptoms, these warning signs.
- You know, I think it's reallyimportant for us to be able
to recognize those asclinicians when patients come in
because I'm sure you have thesame experience I do when go
into clinic and you're lookingat your schedule for the day

(32:42):
and you're looking atthose chief complaints
to see what's coming in.
It's an ear infection, it's a stomach bug,
it's a sports physical.
You don't see suicidal ideation.
Like that's not what's there.
It's usually going to presentas some of those signs
that you were talking about.
Sleeping trouble, youknow, difference in eating,
maybe low blood sugar, things like that.

(33:03):
And as clinicians, we haveto be really astute to that.
And I think this goes back,Ashley, to some of the shame
and stigma we were talking about before
because parents, theyhave this spidey sense,
they know their kids,they know something's off.
But for example, if you thinkabout when they're young
and they have an ear infection,
they don't have anyhesitation at all in calling

(33:25):
and making an appointment andmaking sure everything's okay.
But I think that parents approach things
a lot more cautiously when they come in
and they may kind of wonder about that
and they're looking to seewhat you're going to say.
And I think we need to leadwith courage about that
and really just be bold and direct.

(33:45):
But while beingcompassionate and sensitive,
but just normalizingconversations about self-harm
and about suicide.
And you know, during the pandemic,
when I was on anotherpodcast talking about
this very subject, I had anurse practitioner write in
and tell me that she hada patient who she believed

(34:06):
to have suicidal thoughtsand he was in her clinic
and she talked about how much fear she had
and just asking directly, "Areyou having suicidal thoughts?
Are you having thoughtsof killing yourself?"
Because it just feels sointrusive and so invasive.
We worry about offendingthe parents, you know,

(34:27):
or that the parents willthink we're giving them ideas
that they didn't have before.
But we know that askingdoes not increase risk.
Asking saves lives.
And so we need todifferentiate between emergent
and urgent presentationsand seeing and just asking.
You can use some screeningtools, which I know
you're about to talk about, Ashley,

(34:48):
but just asking, "Are youthinking about killing yourself?"
And if the answer is yes, thenthe follow up question is,
"Do you have a plan?"
And if they have thought about a plan
or a method, it's so important,
that is an emergency situation.
And depending on where you live,
that may be involvinggoing to the emergency room
and may be involved in goingto your primary care provider

(35:11):
immediately for connectionto mental health services.
And may be involved at contactinga mental health provider
that you already haveestablished a relationship with.
But that is something that's emergent.
And this just goes back
to what we talked aboutin episode two, Ashley,
about the importance
of integrating mental healthinto primary care visits.

(35:31):
Because so many of thesetimes when we get to the point
of suicide that's related to depression
or anxiety, that's somethingthat's usually been simmering
for quite a while.
But I really would love foryou to use your expertise
and let's equip our colleagueswho are listening here,
what do they do?
When they come in,
maybe that chief complaintis specifically articulated,

(35:55):
maybe it's not, maybe it's vague.
And as providers, we'retrained to recognize risk.
What would be some screeningand assessment tools
that nurse practitionerscould use in primary care
right then to meet the familyat their point of need?
- Right.
And you know, one thingI wanna stress to people
who are in primary caresettings, you know,

(36:19):
or in the emergencydepartment, it doesn't matter.
They're gonna see children outside
of a mental health settingwhere you are going
to be looking at them,their physical condition.
One thing that is important to remember
is that non-suicidalself-injury is a high predictor
of future suicide ideationand suicide attempts.

(36:42):
Now, that being said, so ifyou see that there's cutting,
burning, any type of burning,
and it doesn't have tonecessarily be a lighter
or cigarettes, sometimes they use ice
or they'll put salt on the ice
and rub it to burn their skin.
If you see scratching,sometimes they'll use an eraser,
a pencil, whatever.
If you see scars, ask about those scars.

(37:04):
And you don't wanna makea huge over, you know,
to do about it, but youwanna ask, "Hey, you know,
what is that from?
What is that from?"
And you know, and become familiar
with what non-suicidalself-injury scars look like.
What's very typical?
Where are they generally located?
You know, very often you'llsee them on the forearms,
sometimes you'll seethem on the inner thigh.

(37:25):
But I can tell you that they also try
to hide that from their parents.
I have several patientswho have been found
to be cutting under theirbreasts where it's hidden
by bathing suits where it's hidden
by clothes, by brassieres.
They also sometimes cancut on their abdomen
if they feel no one'sgonna see their abdomen.
So make sure you'repaying attention to that.

(37:47):
And what's most importantone, is to make sure that,
that it's healing properly, obviously.
'Cause I'm sure they werenot done in a sterile
or clean method.
So make sure it's healing properly.
But also, you wanna findout what's the cause,
why are they doing that?
Are they doing that becausethey wanna feel something?
Are they doing that because they're mad?

(38:08):
Are they doing it becausethey saw it on TikTok?
Why are they doing it?
And work to get to the bottom of that.
And you know, if you'reconcerned, refer them
to a mental health professional.
If obviously, just like Jessica said,
if it seems like somethingurgent, then you want
to send them to the emergency room
or to a crisis centerappropriate for their age.
So also as the nursepractitioner, what else can we do?

(38:32):
All right, so the first thingis to protect the patient.
I wanna put that outthere first and foremost.
Our number one goal isto protect the patient.
And what does that look like?
Well, one, it's about assessing risk
and we've talked about risk factors.
So we wanna make sure that wedecrease those risk factors.

(38:53):
And how do we do that?
Well, there's some that are modifiable
that we can decrease that we can address.
But also removing lethalmeans if they have guns
in the house, you wanna make sure you talk
to the family aboutputting those guns away.
I have many families wholock up all their knives.
I have families who make sureall medications are locked up,
that bedsheets are taken up.

(39:14):
I mean, I have parentsthat go to extreme measures
to assure that theyhave minimized the risk.
You also want to increasetheir protective factors.
So identifying protective factors,
and you don't wanna just say,
"So, what are your protective factors?"
But you know what?
So what kind of things doyou have going on next week?
You know, what are you excited about?
You know, in your notes,

(39:36):
you notice that they liketo play tennis, you know,
"So tell me about tennis recently you have
any big tennis events coming up?"
Also, you wanna talk abouttheir social support systems
because very likely, ifthey are being bullied
or being harassed or don'thave a lot of friends
or in arguments with friends
or not getting alongwith teachers, you know,
you wanna help them to identifypeople who are supportive,

(39:59):
people who are there forthem, who can help them
to navigate the complex motionsthat they are going through.
So when we talk about,I said assessing risk,
but there are also some screening tools.
And I want, again to reiterate
that whatever screening tool you use,
make sure it is validatedfor your population.

(40:19):
So often, I will see peoplewho have six-year-olds
and they're using an adult screening tool,
which clearly is notappropriate, it's not validated.
So one of the screening toolsthat I often recommended,
it's a four-question screening tool,
and it's called the ASQ or the ASQ.
And it's an ASQ suicide screening tool.

(40:40):
And that can beadministered for screening.
Remember, they're notdiagnostic, these are screening.
The other is the PSS, whichis the patient safety screen.
Some people will use the PHQ-9A,
but I will tell you from my experience,
that does not sufficientlyevaluate or assess
for suicidal risk.

(41:00):
So I actually, if you'regonna use the PHQ-9A,
I encourage you to also use the ASQ.
So use them together
and that way, you'regetting a broader picture.
The Columbia Suicidal Severity Scale
obviously is used extremely often
and frequently in theclinics where I work.
And then also there is a triage version

(41:23):
of the Columbia SuicidalSeverity Rating Scale.
There's a triage version that you can use.
Now, a little while ago I mentioned,
less than eight year olds.
When you're screeningless than eight-year-old,
you wanna ask about thinking about death.
And they may not evenknow what suicide means.
So thinking about their owndeath, thinking about death,
are they doing things likegrabbing at their throats

(41:47):
to choke or guns to head?
Do they have non-suicidal self-injury?
I do see that in some of,I have a four-year-old
that I have in my practicethat has a history
of non-suicidal self-injury.
Also are parents or are youseeing impulsive aggression?
And again, this is lessthan eight years old.
So you want to go ahead and assess them.

(42:08):
Now, children less than eight years of age
are by nature, low riskbecause of their age.
But I do, and I mentionedthis in the beginning,
that our Black adolescentshave a two times more likely
to attempt suicide andhave suicidal thoughts.
So but you wanna cross the board screen.
So eight to 11-year-old,
do you wanna screen when appropriate?

(42:31):
Okay.
And then 12-year-olds, it's universal.
So I generally tell peopleif you're seeing someone
in private practice oryou're seeing someone
at the hospital,
you need to screen themevery time you see them.
And that's my general rule,
- You know, I thinkit's so important for us
to talk about suicide in clinic to teens

(42:51):
who have suicidal thoughts,
suicidal ideations, suicidal attempts.
But it's so important totalk to other kids in teens.
You know, Ashley, I have a veryvivid memory of my daughter
who was in early high school.
One day, we got a phone call that one
of her very good friends'siblings had died by suicide.

(43:11):
And we went to pick her up from school
and my daughter was there.
And the immediate aftermath of that,
and we have to acknowledge that kids
are likely going toencounter this in some way,
whether it's someone theyknow, very personally,
someone in their community,someone in their family, we need
to make sure that we areopening the conversation

(43:33):
to talk about this.
So you can use situationalprompts if you see a story
on the news, if you see astory in your community,
if the school sends homesomething, use that situation
to say, "Hey, I'd like to havea conversation about this."
And Ashley, as you said earlier, you know,
most kids are not going to say,
"Oh, that sounds lovely, mother.

(43:55):
I would love to talkto you about suicide."
I mean, no one's going to say that.
So I think it's importantfor parents to push
through those uncomfortable conversations
and say, "I recognizethis is not something
that we ever want to talkabout, but it's important.
And I want you to know,you can always come to me
with any questions and ask about that."
As I talked about earlier,we need to be as adults,

(44:17):
really considerate inthe language that we use,
describe the events
and be considerate in thequestions that we're asking.
Being aware of what youtalked about earlier, Ashley,
is suicide contagion, becausethat is a real phenomenon.
And one thing that I do
for my kids is I put crisisnumbers in their phone

(44:37):
as a contact and it's justhelp when you need it.
That's how it is labeled.
And I encourage them to sharethat with their friends,
saying, "If you everfind yourself at a point
where you can't reachout to a trusted adult,
which you should, and Iencourage you to do that,
but just if you ever findyourself really desperate
for someone to talk to, here is some help

(44:57):
that you can have."
We want to give them as manyliteral lifelines as we can.
And one of the ways we can do that too
is just promotingemotional literacy at home.
Just naming and claiming feelings.
Just saying, "Hey, Isee that you feel sad.
What's making you feel sad?"
And just instead of, "Why are you sad?
Why are you grumpy?
Why do you have to be like that?"

(45:18):
As sometimes we just liveat such a fast speed,
Ashley, I find myselfguilty as this as a mom,
and I treat my kids unpleasantemotions as an inconvenience.
And shame on me.
I really try to catch myself with that
because I think we're onour way to sports practice,
or we got homework to do,

(45:38):
or I'm on my way out the door to work
and I don't have time for this.
But we have to make time for that.
We have to create a culture
where we just pay attentionwhen we send something is wrong,
just a little blip that goesacross their face thinking,
"Okay, I'm going to sitdown, drop everything
and follow up with that."
As adults, we need to teachhealthy emotional regulation

(46:00):
and coping mechanisms when wehave, you know, some stress.
Are we going out for a walk?
Are we getting some sunshine?
Are we making sure we'rehydrated and well-nourished?
Or are we sitting forhours on end bed rotting
and binge eating andthose kinds of things?
Because when we do thaton a regular basis,
our kids are going to copy that too.

(46:22):
And one thing you saidearlier was really important
about TikTok, Ashley,or other social media,
because we see teens who see parents
who don't have good digitalliteracy in this world,
they don't know as much about technology.
And it gives the impression like, oh,
parents just don'tunderstand today's world,
but you know who does?
These influencers I see on social media?

(46:43):
And they told me this.
And I think I've shared before,
I saw one influencer talking about
harm reduction for cutting.
And this wasn't anyone
who had any experience or credentials.
It was a teenager who got on
and said, "Get a really thick rubber band,
snap it really hard against your wrist
with some red food dye.

(47:04):
Then you'll have thesensation of harming yourself,
but you don't really harm yourself.
Problem solved."
And that's somethingthat's really dangerous.
We need to make sure that as parents,
we tell our kids we may notknow everything that's going on,
but we do have wisdom to share.
We do have care that we can give
and we do have ways to seek those answers.

(47:25):
What are other ways thatyou think that parents
need to know about whatto watch for, when to act?
And how do we reallypush past all this stigma
and shame that we've beentalking about, Ashley?
- Well, I think like, you know, we said
that from the onset, you wantto make sure that parents
know how to have thatinitial conversation.

(47:47):
That when they have that conversation,
it's not while they're at the pizza place
or while they're at a Mexican restaurant
or it's not for opportunity.
It's a time when theyfeel the child feels like
they're in a safe environment,that the parent knows
how to ask directly.
And use very clear wordingthat's gonna be appropriate.

(48:07):
And also, validate the child's feelings
or the adolescent's feelings.
Validate their feelings aboutwhat they say, you know,
saying things to them.
And very often our response is, "Oh well,
you wouldn't do that to your family.
Why would you do that to me?"
And automatically, that puts up a barrier.
And I can promise you,
those words are not gonna deter them

(48:30):
from attempting suicide.
What you wanna do is say,"I hear what you're saying.
I hear you.
I wanna help you.
I'm here to help you."
And validate, "I understandwhat you're saying.
I hear that this is upsettingto you or concerning to you."
And then seek out the appropriate help.
There is a 988 that can be called,

(48:50):
that is the NationalSuicide and Crisis Hotline
that can be called.
That's when there's notan immediate threat.
But I tell parents that I work with,
'cause I have to educateparents frequently
about the things we've already discussed.
Decreasing lethal means,the signs to watch out for,
but also about telling them, "If you need
to call 911, call 911."

(49:10):
If your child is threatening
to commit suicide actively, call 911.
Do not try and put them in a vehicle.
I've had adolescents actuallyjump out of a moving vehicle.
Just call an ambulance,call a medical professional
who can come and helpyou if you are concerned
that this is an immediate threat.
So another thing parents can do is partner

(49:30):
and as professionals, we canpartner with communities,
we can partner with our schools,you know, and help them.
Do they have good policiesand procedures in place?
Do they know how to respondand deal with the aftermath?
I mean, skills training,prevention strategies,
peer support, you know,
help the schools establish community links
if they don't have something in place.
And that's something healthcare providers

(49:52):
are very good at doing,that's also something
parent association cantake on as a priority.
So I think all those are very important.
Another thing I wanna addon real quick, Jessica,
that you said about stigma.
You know, I like mypatients to understand,
and this doesn't matter who my patient is,
how old they are, how young they are.
If they're saying they are having thoughts

(50:14):
of committing suicide,
then it does not mean we're gonna be sent
to the hospital and locked away.
I can tell you the number one barrier
to seeking services is the stigma
and the fear ofdiscrimination and judgment.
And so, you know, tell them, you know,
if they tell you this,
it doesn't mean you're gonna push a button

(50:36):
and people are gonna come running in
and take them into the hospital.
You know?
And so how you approach this is important.
With adolescents, I usevignettes honestly very often
that are empirical base.
Sometimes the adolescents,
they can play a hypothetical peer.
Sometimes, they're more likelyto express some concerns

(50:58):
or some thoughts.
They may be more likely to respond
to kind of informal servicesfor hypothetical peers.
Or, you know, interventions-based services
for hypothetical peers.
And so if they feel morecomfortable discussing it
from that standpoint, that's okay too.
That opens another doorfor safe communication.

(51:20):
And it also opens adoor for them to realize
that you're not judging them,
you're talking about ahypothetical situation,
but obviously, as a provider,you are going to be aware
that this is about the adolescent.
- You know, it's really a sad reality
that we live in the worldthat we live in today.

(51:40):
Just the influence of social media
and that pressure to be perfect.
I did a suicide preventionevent in my own community.
And Ashley, when the kids walked in,
I gave them each a sticky note.
And I told them, I askedthem this question,
"What do you see on social media
that your parents don't know about?"

(52:01):
And I had them write theiranswer on the sticky note
and then come and put them on the wall.
And then I invited theparents to look at the wall
and the parents ran overthinking they were going
to see things like, you know,abuse, violence, pornography,
these kinds of things.
But I was stunned Ashley,when I saw one word
over and over and over onalmost every sticky note.

(52:25):
And that word was "perfection."
That was the burden
of this generation just feelingthe pressure to be perfect.
And I think sometimes justteens feel they can't take
that pressure anymore.
And I remember in myclinic seeing one patient
who was just released from the hospital
after surviving a suicide attempt.
And the parent's greatestconcern was they wanted me

(52:47):
to write a note saying thatshe had been in the hospital
for something, anything other than that.
Pneumonia and infection something.
And they even went so far
as there were two childrenfrom the same school
who had had a suicideattempt in the same week
that had the same name.
And they were surmising out loud thinking,
"Well maybe, you know, noone knows about this one

(53:08):
and they have the same name."
They'll just say, "Oh, itwas that other person."
And I see that primal fear.
I see it as well-intentionedas parents wanting
to protect their kids,
but we have to be willingto face the real threat
of death rather thanjust the threat of death
by social injury.
And so one of the waysthat we can do that,
you mentioned it briefly,Ashley, is means reduction.

(53:31):
And that's really important.
Making sure if you have a teenwho is having any thoughts
of suicide and just any family in general.
These are great safety tips.
I wanna review them reallyquickly before we wrap up here.
But as I shared at the topof the show, more than 60%
of suicides in the UnitedStates happened by firearms.
So making sure

(53:51):
that you remove firearmsfrom the home entirely,
if at all possible.
And if they are in the home,which it's honestly preferable
that they're not, wanna makesure I'm clear about that,
but that they're stored, unloaded,
locked in a secure gun safe
with the ammunition storedseparately and locked.
Now we know that boys are more likely
to choose a lethal means like a firearm.

(54:12):
Girls are more likely toattempt and attempt by overdose.
So something that parents can do
and that NPs can equip parents to do
to make sure their home is safe,
is locking up all the medications.
And that includesprescription, over-the-counter,
whether it's painkillers,antidepressants, sleep aids,
sedatives, things that seemas innocuous as Tylenol

(54:34):
or cold medicine, only keepsmall necessary quantities
on hand, just enough that you would need.
Teach them to never takeanybody else's medication
and dispose of those properly.
Don't, you know, hoardexpired medications.
And don't flush them down the toilet.
Most pharmacies will have a take back day
where you can take those medications

(54:55):
and they will dispose of them safely.
It's important for to think about alcohol
or other substances, make sure
that you're removingalcohol from your home.
Or other things like vaping devices
or other substances thatcould impair judgment
and increase the riskof self-harm or suicide.
And lastly, looking athousehold chemicals,
even things like bleach, ammonia,insecticides, pesticides,

(55:19):
antifreeze, gasoline.
Keep them in a childproof locked cabinet
even for older teens.
But the bottom line isthat suicide is preventable
and treatment works.
And we need to take astrengths-based approach.
You talked about this so well, Ashley,
restricting the access to lethal means,
but connecting them to reasons for living.

(55:41):
Where do they have hope for a future?
How can we help them developskills and problem solving?
Conflict resolution, nonviolent ways
of handling disputes, supportfrom ongoing healthcare.
These are all protectivefactors when they feel like
they have a connection to their school
or their community whenthey have a strong sense
of self-worth and theyhave physical safety

(56:02):
and physical health.
And connection to shared family,
religious, or spiritual beliefs.
Those are all protective factors.
So Ashley, I think youhad a story to share.
I'm going to let you wrap itup and give the last word here.
- Absolutely, absolutely.
You know, and a story I wanna share
is it highlights the importanceof looking at risk factors

(56:23):
and highlights the importance
of including parents in the process
of developing a safety plan.
And keeping, again,
what did I say is our number one priority,
it is to protect our patient.
So I have a brief story realquick about a young lady
and I've changed a few details,
but a 15-year-old female
and she was brought intothe clinic by her mother.

(56:45):
And her mother said, youknow, her daughter had been,
she had noticed a changein her personality.
She was very active in sports.
She was no longer wantingto go to practice.
She was not eating, shewas sleeping all the time.
She was never an angryor irritable person,
but suddenly, she was angryand she was irritated.

(57:05):
Well, after all this was going on,
her daughter one dayattempted to hang herself.
And this was before hermother had brought her
for mental health treatment.
She had seen a pediatricianand been started on an SSRI.
The SSRI did not increaseher suicidal ideation.
She later disclosed thatshe had been planning
to attempt suicide all along.

(57:27):
So she come to find out shehad actually was being bullied.
She was being bullied at schooland being bullied online.
She was slightly overweight,
but because she was an athlete,
she was bullied about her weight.
And these were people whohad been friends of hers.
Also that she had shared a few secrets
with some friends of hers
and they were telling the whole school.

(57:49):
Also it came out intalking to this young lady,
that there was a teacher
who had previously been ather school and no proof,
but some suggestion
of maybe some inappropriateconversation with this teacher.
And the patient thoughexpressed missing this teacher,
this was a strong resourcefor her and her eyes.
The patient actually told me

(58:09):
that the teacher wasno longer at the school
and that's why she was missing them.
But there was possibly aninappropriate relationship.
So after the suicide attempt,
after trying to hang herself,her parents locked up guns,
locked up knives did notallow any alone time.
She always had some typeof adult supervision.
A bedroom door was notallowed to be closed,

(58:29):
bathroom door had to be unlocked.
And they immediately,
after a week of hospitalization,got her in to see me.
So when her mother was talking with me
and the patient was there as well,
the patient was not reallyanswering many questions,
tearful, but not saying much.
After her mother left theroom, I had a long discussion
with the patient, first ofall about confidentiality.

(58:51):
And expressed to herwhat confidentiality is
and what laws that I had to abide by that.
I also, and this is a very important thing
and something we do not do enough,
is I discuss the limitsto confidentiality.
And I always documentin my chart, you know,
confidentiality discussed.
Limits to confidentiality, discussed.

(59:13):
Patient verbalizes understanding
because there are limits.
So we continued with adifferent SSRI increasing that.
She started cognitive behavioral therapy.
I met with the family,
got the family also involvedin a type of therapy.
Her mother was very proactive,changed her some things
around in her school towhere she didn't have

(59:34):
to engage these individuals,blocked them on social media
and started limiting thegirls access to social media,
that she seemed to be doing well.
I saw her at four months.
She seemed to be doing well
and I received a call later that night
that she was back in the emergency room
for cutting deep under her breast.
It was not a suicide attempt,

(59:55):
but obviously, there wassomething else going on.
So I actually thoughtshe was in the hospital
for only 24 hours on that incident.
I saw her immediately afterthat hospital incident
and she disclosed to me
that she actually hadhad a sexual relationship
with the teacher and wasexperiencing guilt from that,
and therefore she started cutting again.
So we are now six months out.

(01:00:17):
She's still in therapy.
She's getting ready tostart back to school
for the next year.
The family has been veryproactive in making sure
that she is not in the same lunch session
with the children who were bullying her.
She is not in any classes with them.
She's still playing sports,
but she's playing on a differentleague now to avoid them.
But also, the school is involved.

(01:00:38):
And so instead of thepatient just being bullied
and feeling like she hasno recourse, there is now
the counselor and theprincipal are very aware.
So the school's involved.
They've had education on how to respond
should she become highlyagitated, highly upset,
or saying that they'rethreatening her or bullying her.

(01:00:59):
And she seems optimistic.
Her outlook with thecognitive behavioral therapy
is now very much focused on,"I don't have to see them.
If I do run into them, that's okay.
I feel good about myself."
And her self-talk has nowsignificantly improved
and there's been no otherreport of suicidal ideation

(01:01:20):
and there is now a pendingcase against this teacher.
So it took the school,it took the hospital,
it took mental health, it tooktherapy, it took medication,
and it took very involvedparents to get this young lady
to the place where she is now.
So that really highlights it.
And I tell parents also, in addition
to the crisis text lines

(01:01:40):
and hotlines, there'salso information online
through the Trevor Projectthat parents can read about.
And also at AAP Healthy Children,
the American Association ofPediatrics, healthychildren.org,
that's also an excellentresource for parents as well.
- Well, it's always good to hear
when there is a successful outcome

(01:02:00):
and you know, that's oneof the things we're going
to talk about in the nextepisode, Ashley, is grooming
that happens online
and reframing what kids may see
is an inappropriate relationshipthat is actually abuse,
that can definitely be a contributor
to mental health issues and suicidality.
And that's something we'll talkabout in online risk factors
in the next episode.

(01:02:21):
So just wrapping up today, thankyou so much for joining us.
Just remember that youare empowered to act.
It is okay to ask directly about suicide
and connection is apowerful protective factor.
And when patients andfamilies are connected to you,
for you to screen and toconnect them to resources
that they need is literallywork that is lifesaving.

(01:02:44):
Wanna reiterate that Suicideand Crisis Lifeline, 988
and check out the episode notes
for a lot more resources and links.
Thank you again, on behalf of myself
and Ashley, thank you for your time.
We know it's your most valuable resource
and we look forward toseeing you at episode four.
If you miss episodes oneand two, check those out

(01:03:04):
and we will continue exploringadolescent health risks.
- Thank you.
(lively music)
- To our listeners, thankyou for visiting "NP Pulse."
This third episode of a four-part series
has been made possible by AANP Education.
Continuing education creditfor this program may be claimed

(01:03:27):
through August 31st, 2027.
To claim credit for this program,
log into the CE centerat aanp.org/cecenter.
Search for this program by name
and complete the evaluation
by entering the participationcode, PREVENT25.
That is P-R-E-V-E-N-T 25.

(01:03:50):
Your feedback is important to us.
Be sure to check out previous episodes
including Teen Dating Violence,
Roundup on Adolescent Health Part One,
episode number 138 of the "NP Pulse."
And Adolescent Mental Health,
"NP Pulse" episode number 147.

(01:04:11):
Stay tuned for episode four in this series
on Adolescent mental healthscheduled for release
in November of 2025.
As always, thank you for theexcellent work you do every day
to take care of patients.