Melanie Cole, MS (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. I'm Melanie Cole. And joining me today is Dr. Meredith Dennis. She's the Supervisor of Mental Health Emergency Services at Children's Health of Orange County, and she's here to highlight suicide prevention in our youth today.

Dr. Dennis, thank you so much for being with us. This is a hard topic to talk about. And as we get into some of the specifics, can you start by telling us a little bit about your story, your expertise in this topic?

Dr Meredith Dennis: Yes, absolutely. Thank you so much for having me today and especially to talk about this very heavy, but very important topic. You know, my history in this area is I actually had two friends die by suicide in high school. And so through my journey in becoming a mental health provider, I've always been extremely passionate about crisis work and specifically emergency mental health work to make sure that kids in crisis do get the help that they need and that there's no shame around that and that we're breaking down the barriers to receiving adequate mental healthcare.

Melanie Cole, MS: Well, there certainly is a mental health epidemic and less providers than we need. So, it certainly is such important work that you're doing. Now, how common is suicide in children? And while you're telling us that, what ages are they most likely to consider this as an option if they're suffering from severe depression?

Dr Meredith Dennis: So although there have been some fluctuations and changes in rates of actual suicide, as well as consideration of suicide in the adolescent population, between 2000 and 2018, the actual suicide rate among youth increased between those ages 10 to 24 from about 6.8 per 100,000 to 10.7 per 100,000. And while that's actual completed suicides, the data shows that more than 20% of teens today have actually seriously considered suicide.

Melanie Cole, MS: Like you said at the beginning, this is a heavy topic, but are there risk factors? We're going to talk about warning signs and red flags, but are there risk factors? Is this something that could be hereditary as a person at an increased risk if they've been exposed to it in their family?

Dr Meredith Dennis: So, the question about risk factors is a great question because a lot of people get really anxious or nervous regarding if there has been exposure to it, regarding if you talk about suicide, then that will give somebody the idea to start thinking about suicide or considering it. However, research has shown some pretty consistent risk factors among teens. And there's a lot, but the main ones to be aware of and to consider are feeling like a burden. And something that's important to note about this in particular is that it doesn't matter whether or not your teen is actually a burden to you or anybody else. It's really more about the fact that they feel like they are, and feeling like a burden can look like, "My family would just be better off without me. I am always troubling them with all of my challenges and all of my concerns and all of my mental health issues. And I just make it more difficult for them. Maybe I'm costing them a lot of money by having to go and seek specialty mental health treatment or emergency department visits." These are just some examples of what that can look like. And again, the important part is that they feel like a burden, not that they actually are. You know, social isolation and being disconnected from others or feeling isolated, feeling alone, feeling like you don't have anybody is also another big risk factor for teens.

History of actually engaging in any type of self-harm behavior or previous suicide attempts is another risk factor. So if your child or teen has in the past harmed themselves intentionally in any way, or has actually tried to complete suicide in the past, that can be a big risk factor. It's almost as if they are practicing and getting better at it over time. And so, that's definitely something that we want to pay attention to. And an overall sense of hopelessness, just feeling like the current circumstances, the current situation that they are in will not improve and will not get better and they are going to be stuck this way in this awful feeling or awful situation forever.

Melanie Cole, MS: I want to differentiate for the listeners, Dr. Dennis, between warning signs, red flags, and risk factors, because they are two different things. Is it possible to predict? Because I think that's the million-dollar question, right, is is there a way to tell? And you've mentioned a few things in those risk factors, but then do those translate to warning signs, or are warning signs something like cutting off school and not showing up at school or retreating to their room, other kinds of red flags?

Dr Meredith Dennis: Sure. And that's a really important distinction. And so, yes, there are definitely some differences between risk factors and warning signs. So when we get more specifically into warning signs, we want to make sure that we're looking out for things like your child or teen being preoccupied with death, talking about death a lot, talking specifically, maybe it's as explicit as talking about wanting to die or wanting to kill themselves. If they start engaging in any specific behavior, aside from what I already mentioned with self-harm behavior and actual suicide attempts, they may start to engage in more subtle behaviors, like maybe writing suicide notes. Sometimes teens and kids, the best way that they can express themselves is written. It's very hard sometimes for them to sit in front of somebody and talk about this face to face. And so, you may see these things expressed in a written form, like a suicide note, journaling, an email. It doesn't even have to be a physical letter anymore. A lot of times we actually see things on social media that teens have posted as sort of their attempt at reaching out for help and getting people to recognize that they're struggling.

Also, when teens or kids start to prepare to end their life, and this could look like maybe they have some prized possessions that they start giving away to people, or maybe they start deleting social media profiles, posting goodbye messages, things like that can also be warning signs, as well as any very drastic or dramatic changes in their behavior, including, let's say, withdrawing significantly from friends and family. Of course, it's within the normal realm for teens to be a little bit withdrawn sometimes or isolate themselves. But if they're withdrawing to the point where there's just no interaction with anybody else, and that is a change from before, those are the biggest things

to watch out for as well is if there is a change in behavior and it's very drastic.

School attendance with kids and teens can be difficult. There can be various different reasons why a youth may not want to attend school. But if you're noticing that consistently they are unable to get up, get out of bed, go to school, have very little motivation, they're just sleeping all the time, and then there's maybe like a disinterest in caring for themselves, taking care of their appearance, their hygiene, those types of things, those can also be more subtle warning signs. And then, any time a child or a teen starts to plan out how they would end their life, starts to try and gather items or objects that they may need to potentially very seriously harm themselves, that can also be a very huge warning sign that we want to look out for.

Melanie Cole, MS: Dr. Dennis, you mentioned earlier that if you talk to your child about it, does that necessarily put the idea in their head that might not have been there otherwise? I'd like you to speak about what we do. And if it's preventable to the point where if a child is feeling this way, and even talking about it, and as you said, social media and all of those things, is there a way to stop a child that is thinking about suicide that seriously? And does talking about it increase the idea and the thought of it?

Dr Meredith Dennis: Yeah. So, that's a very common misconception that I just want all parents, caregivers, school staff, anybody interacting with and working with children and adolescents who may have mental health concerns to be aware of, is that it will absolutely not plant the idea in anyone's head if you open a conversation about it and if you discuss it. What we really want to do is we want our kids and our teens to be able to come to us as a trusted person and as a safe person that they can have these conversations with. So, opening the conversation as a parent can look like, "I know that sometimes kids your age struggle with difficult thoughts and feelings or thoughts about life being so overwhelming that maybe you've thought about not wanting to be here anymore or not wanting to be alive anymore. Have you ever thought about anything like that or have you ever had any friends who have talked about that?" just as a means of opening the conversation.

One important thing to keep in mind when talking to kids and teens about suicide is that we want to make sure we ask open-ended questions and that we're not critical or judgmental. Because the more safe they feel and the more they feel that they can trust talking to you about this, the more likely they are to actually come to us if they were to ever have any of these thoughts.

And so, I absolutely understand how scary and anxiety-provoking it can be as a parent or a caregiver to hear these things, and extremely difficult as well, and worrisome and wanting to make sure that you help them in the best way that you can. And the best way that you can help them is to remain open to the conversation, to approach them in a nonjudgmental way and just listen to them, hear them out, and avoid any kind of judgment, any scrutiny, any like punitive language or behaviors towards them, and trying the best that you can to regulate your own worry and anxiety around this, because also if you're freaking out, your teen or child may start freaking out and then they may actually in response have more anxiety coming to you about it because they don't want to worry you.

We also want to make sure that we're not only aware of the warning signs, we can have an open conversation with them. But then also, we can get them the help that they need depending on what's going on at that time.

Melanie Cole, MS: Well, that's really important what you were just talking about, because there are myths about it, and some people are afraid, parents are afraid to discuss it. What are some of the signs that our child will need to see a specialist? What are some things we can do right off the bat? You mentioned listening, you mentioned being gentle about it, but what can we do? Is reaching out to a specialist, a psychiatrist, a psychologist going to freak our kids out and make things worse?

Dr Meredith Dennis: So, that's a great question, because of course we also need to know how to best help if there is a serious concern or how to seek additional help to figure out if the concern is serious or not. And so, again, going back to having like an open and collaborative conversation with your child, saying, "Hey, I'm worried about you, and I think it would be good if we got an additional person to help us figure out how best to help you right now." That could look like getting in contact with a therapist, just having somebody else to talk to when your teen is really struggling, because of course, they may not feel comfortable talking to their parent or caregiver about everything. And so, having that additional outside support can be hugely helpful. If it ever is a situation where you are immediately concerned about their immediate safety, like they're talking about, "I really do want to die, and I want to make this happen, and I want to make it happen now," that's an indication that we do want to get them emergency help, meaning we could take them to the nearest emergency room for a mental health evaluation to further look into where they're at right now and what level of help is needed. Obviously, you can always call 911 if you are in fear of your child's immediate safety. You can also reach out. Teens themselves as well can reach out to the Suicide Prevention Lifeline, which is the 988 number, and call and text is available on that. But it is never a bad idea to seek additional support.

Parents, if they feel comfortable, may also get in contact with your child's school to see if there's any on-site school resources available because those are more prevalent and readily available to students on campus than they ever have been. But the bottom line is it's never a bad idea to seek additional help and additional clarification if you need it.

Melanie Cole, MS: I'd like you to offer your best advice now to parents who are very worried about their children or who know somebody. Tell us what you want us to know. You do this for a living every day, and it is tragic if the child actually finishes and goes through with this. So, tell us what you want us to know about prevention and how it's really so important to be aware of all of what we've talked about here today.

Dr Meredith Dennis: So, my best advice as a parent or caregiver would be you are the best resource and the best help for your child. Even if you don't feel like it, or like I said, this is scary, this is anxiety-provoking for you as a parent, you are the best support for them in being able to talk about them or talk about this very difficult topic openly with them, being able to reach out to get them the help that they need if they do need additional help. And then, checking back in with them, like this is not a one-time conversation. We have to keep the conversation open and going and make sure that your child feels comfortable reaching out to you, and maybe let's say they don't. Making sure that they have somebody in their life that they feel connected enough to and can trust if they absolutely need to reach out for help, that they can reach out for help to that person.

Melanie Cole, MS: Such an important episode that we had here today. Dr. Dennis, thank you so much for joining us and really helping us to be aware and hopefully to prevent. And the National Suicide Prevention Lifeline is 1-800-273-TALK. You can also text TALK to 741741. If you have concerns, please, please use those lifelines because they are so important.

And for more mental health tips and information, please visit choc.org/mentalhealth. And for more pediatric health and wellness tips, you can visit choc.org. Thanks so much for listening to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. Together, we can keep kids happy and healthy. I'm Melanie Cole. Thanks so much for joining us today.