Christine Crawford, MD, MPH, associate medical director of the National Alliance on Mental Illness (NAMI), said that “When you’re working with kids, anything can come up. Be prepared to navigate the conversation. You can never predict who the patient will feel most comfortable disclosing these thoughts to.”
NAMI
Dr. Christine Crawford
Pediatricians are the physicians most likely to be seen by children, and it’s important for pediatricians to inquire about a child’s mood, especially during child visits, according to Crawford, author of the book You Are Not Alone for Parents and Caregivers: The NAMI Guide to Navigating Your Child’s Mental Health.
Donald E. Greydanus, MD, professor and founding chair, Department of Pediatric and Adolescent Medicine, Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan, said many fellow pediatricians have said the highly compressed exam doesn’t allow enough time to ask questions. “But pediatricians must find a way to make time,” he said. “Asking about depression and potential suicidality is top priority and can help keep your patients alive.”
Some pediatricians have told him, “I’m not prepared to provide counseling.” But “your role isn’t to provide counseling, just to open the conversation, offer hope, and direct the youngster to resources that can help.”
Don’t Be Afraid to Ask
According to the AAP, all children aged 12 years or older should be screened for suicidal risk, and children aged 8-11 years should be screened “when clinically indicated.” AAP also recommends annual screening for depression in children aged 12 years or older. However, Egger thinks that screening for depression should start sooner.
Katherine Kay Greydanus
Dr. Donald E. Greydanus
It can be tempting to screen by merely giving a youngster a form to fill out in the waiting room, but Greydanus strongly advises against this approach. “The important thing is having rapport with the child, being in the same room together. You can ask some simple questions. ‘How are you doing? How are things at school? How are things with your family?’”
“When you’re screening for depression and have a kid who’s talking about sadness or low mood for more than 2 weeks and endorsing other symptoms, such as problems with sleep or appetite, difficulty concentrating, anhedonia, losing interest in things they’d usually enjoy, feeling they’re a burden to others, hopelessness about the future, being unable to function the way they used to — that person meets criteria for depression and you should have a high suspicion and concern about potential suicide,” said Crawford, assistant professor of psychiatry, Boston University School of Medicine.
She suggested probing further and being direct. “It sounds like you’ve been having a tough time. You talk about being sad. I wonder if you’re feeling so sad that you might not want to be alive anymore.” Some healthcare providers “tiptoe around when it comes to suicide, but it’s better to be direct and communicate the question in simple, plain language: ‘Have you ever had thoughts about hurting or killing yourself, that life is no longer worth living, or life would be easier for your family if you weren’t alive?’”
It’s a common myth that asking about depression or suicidality will “plant a seed” or “put ideas in people’s heads,” potentially leading to suicidality. “What we know to be true is that asking about suicide doesn’t put lives at risk. In fact, the contrary is true,” according to Crawford. Several studies have refuted this myth.
Two screening tools that might be helpful in ascertaining the presence of depression and suicidality are the PHQ-9 modified for Adolescents and the four-question Ask Suicide-Screening Questions.