Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.
Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s and a leader in pediatric critical care. Good to have you here, Dr. Segeleon.
Dr. Joseph Segeleon: Wonderful to see you again, Courtney.
Host: You have narrowed down six timely topics for us. In this specific episode, we’re talking about pediatric mental health. Dr. Segeleon, tell us why you chose this specific topic.
Dr. Segeleon: I think that if you follow both the lay literature as well as if you follow public health concerns, mental health – particularly in children – is becoming an increasing concern because of the alarming numbers. We’re seeing serious mental health issues, not only in a larger volume of children but also in younger children. And that’s why I thought it’d be great for our providers to get some insight into this subject.
Host: Let’s welcome Dr. Jennifer Haggar to the conversation. Thank you for being here.
Dr. Jennifer Haggar: Hi, thanks for having me.
Dr. Segeleon: Dr. Haggar. Oh, it’s great to have you here. And it’s wonderful to see you again. I think this is a topic that’s been on everybody’s mind and obviously it’s both a big concern to providers and also it’s a resource that tends to be scarce. I know you’re a pediatrician in the Sioux Falls area, but you bring some special skillsets to this subject. Why don’t you elaborate on that somewhat.
Dr. Haggar: As part of my training, I was able to do a year of additional training in child and adolescent psychiatry. So, I am a general pediatrician and that’s what my day-to-day looks like, but thankful for some additional experience, time with really the experts in this area, and I feel that helps me translate in my practice that bridge between general care to the psychiatric care.
Dr. Segeleon: Great, thanks. Well, we’ll go ahead and we’ll get to the subject at hand. I was just reading recently about with, in light of the pandemic from, I believe it was mid March to mid-October, there was a 25% increase in emergency department visits due to mental health situations in children. Is that what you’re seeing in the outpatient world as well, mental health issues and the pandemic?
Dr. Haggar: Yeah, I absolutely feel like that’s what we’re seeing and that’s pretty incredible when we think that overall we’ve seen less volumes, we’ve seen less hospitalizations, we’ve seen less ER visits. And then when we look at this specific area really increasing, that’s pretty striking in my practice. And I think if you talk to my partners, there’s some afternoons where most of my conversations are centered around mental health. And I really expect that to expand as we move into our summer season, when we see a lot of our adolescents that we’re going to really uncover some of the impact that this pandemic has had on our, our children and adolescents.
Dr. Segeleon: Thank you. I know in the intensive care unit here at Sanford Children’s Hospital, we have more than one and, more often, it’s usually around two patients per week, every week of the year, with a suicide gesture and a suicide attempt. We know these numbers have been increasing both in the volume of, of children as well as the early age at which children are attempting suicide. Tell our listeners out there that our primary care providers and other providers, what can they do from a prevention standpoint in their office?
Dr. Haggar: Yeah, I think as we find in so many areas of what we do, prevention is where we can have the biggest impact. I think it’s so important that we try to integrate suicide prevention into our practices even before we have a concern about a particular patient. So, this goes to talking to our families about, ‘do they have firearms in the home? Are they secured? Do they have a plan for securing medications? Do they have they looked around their home – similar to how we look around our house when we have a new lead mobile toddler, right? We start to look at where do we need a gate and where do we need to make things safe?’ We can then start to look at, okay, I have, I now have a preteen in my house, where do I need to make sure everything’s safe? And it’s not that that safety is an important at younger ages, but some of that access really leads to lethality. So if we can start to just reduce access, we can have a big impact on really the most of your outcomes of suicide.
Dr. Segeleon: Now, what about the subject of screening?
Dr. Haggar: Yeah, I think if we don’t ask the question, we don’t know that there’s a problem and screening can look a couple different ways, but in general, doing a generalized screening when a well-child is coming into the office can help us know who we need to think about. Maybe going a little bit deeper, putting kids on our radar families to just ask, make sure they’re connected to resources. There are a lot of validated screeners out there. Our office uses the PHQ-9, which is a generalized depression screener, but also has some specific information about suicidal thoughts. I think that’s a great gateway, but I don’t think it replaces the provider just asking the hard question and making sure they know if this is a concern for their patient at that time.
Dr. Segeleon: Are those questions usually asked when you’re alone with the patient? How does that work in the outpatient world?
Dr. Haggar: Yeah, really, it’s helpful to just create that standard and practice that in those pre-teen years, we start asking the parent to step out into the hallway. We always make sure just logistically that we have a place for them that makes it more comfortable. And even before that, introducing the concept of that, the visitor to before saying, ‘Hey, this year, we’re going to talk with, with all of us, but next year, as you’re getting older, I like to talk to you alone. So we’ll have your mom or dad step out in the hallway and we’ll make sure we have some time to talk confidentially’ can really kind of start to lay that groundwork. I also think it’s important to explain confidentiality. I usually do that with my patients once I have their parents step out. And in that is that clause that ‘the stuff we talk about is between you and me, but if you’re going to harm yourself or someone’s harming you, I have to tell somebody about that’. So, it’s an important segue to make sure that, you know, we’ve laid the groundwork for confidentiality, but it gives me the ability to keep them safe if I need to and find out something, you know, very concerning during that discussion.
Dr. Segeleon: Great. Thank you. That’s very informative. Are there specific – or general – warning signs that you see in, in children of any age really that would make you be concerned about suicide ideation or suicide actions?
Dr. Haggar: I think there are a number of warning signs and it really can look like a change from norm and that’s where parents can be good partners for us because they know their kids and if they start to see big changes, then maybe we need to make sure that’s not a warning sign, but really specifically those kids that are starting to kind of pull away, not normal teenager, ‘I want to go to my room sometimes and be alone, but really pulling back, not sharing information, being very quiet, internally oriented even with their family. If they’re starting to say things about feeling helpless or hopeless or some of those more negative, personal self comments. If they’re feeling like they’re a burden to others or if they’re going through something really hard … so we know that our patients with chronic health conditions are at higher risk. So at the time of those diagnoses and at challenging times in the diagnosis, it can be important to make sure we’re looking closely. And then we think about patients that are exhibiting signs of mental health problems, like depression or anxiety. So if those things are there, it’s a good reminder that we should be looking closely at those patients.
Dr. Segeleon: Has it been your experience that most parents have an inclination that there’s something going on that feel like something’s not quite right?
Dr. Haggar: I think parents know their kids and that’s what we do is listen to the parents, listen to the patient, they’re going to tell you what’s going on. And so I do think most of the time parents have an idea that something’s there. They may not know how much but they usually have a pretty good idea that we should be worried.
Dr. Segeleon: Great, thanks. So we do our screening, what and recognizing that resources are going to be different throughout a footprint and to the listeners on the podcast, they may have access to different resources, but what do you do with the child who screens positive in your office?
Dr. Haggar: So after you listened to this, think about what resources you have, think about your community, who you have in your clinic what you have available. Cause it’s a lot easier to, to identify that, to write down those phone numbers now than it is when you’re in a, with an acutely suicidal patient in your clinic. So sometimes we have mental health professionals in our clinic. Sometimes we have mental health professionals we can use through referral services, but identifying those ahead of time, knowing what the crisis number is in your community, knowing those kinds of things can really just make you more comfortable when you start to run into these scenarios.
Dr. Segeleon: Are there any situations where it comes up with your screening or perhaps maybe further on interviewing either the child or the parent that you really worry about safety that you really worry about ‘is this child imminently going to hurt him or herself?’
Dr. Haggar: Yeah. So I think first and foremost, we’re asking, you know, if they have thoughts about self-harm, are they having thoughts about suicide? If I have a patient endorsed that, then I’m asking, ‘have you ever thought about how?’ Starting to assess, have they thought this through to the point of a plan, if they have a plan that I’m assessing, do they have access to that plan? You know, if they’re talking about, you know, harming themselves in a specific way, would they be able to accomplish that today after they leave my office or would they have to go through some additional steps? And then I start to look at, can we lay boundaries around to reduce access to that plan? And what other ways can we help the child develop coping so that they can start to alter their thought process if they are having thoughts about self harm?
Dr. Segeleon: Are there times when you refer them to an emergency room?
Dr. Haggar: Absolutely. So if I have a patient in my office, they are thinking of hurting themselves, they have a plan of how to do it and they have access to that plan, I think oftentimes the best thing for their safety is to have them assessed at a higher level of care… whether that’s an emergency room or being evaluated for hospitalization, either just safety, hospitalization, or psychiatric hospitalization to work through what may be underlining those thoughts.
Dr. Segeleon: Okay. Thank you. That’s very helpful. Any other comments in reference to suicide or prevention that you might want to reflect upon?
Dr. Jennifer Haggar: I do think that it’s important for, especially for those of us who care for adolescents, to go back to what we know about their development, which is one of the riskiest things about them is they’re impulsive. And so while sometimes this comes after an episode of depression, sometimes they don’t have an underlying mental health disorder and they have something hard happened in their life, either in their family or a relationship … and then they make a choice in that instant to harm themselves. And so remembering that it is not just that kid who has a chronic mental health disorder, but that really all of our adolescents, because by development, they are impulsive or at slightly increased risk.
Dr. Segeleon: There is a, a relationship I think, between, for example, attention deficit disorder and suicide, is that correct?
Dr. Haggar: Absolutely. It’s one of the risk factors is just a tendency towards impulsivity. And that probably also brings out other important things… like, if you have a child who is using substances, who is using alcohol or other substances, that also increases their likelihood because it impairs their ability to think through the situation in the way that they normally would.
Dr. Segeleon: Let me ask you two things, and I know we have some time to talk about this, but to two things that just came in my mind, family history of mental health disease, or suicide. And also if you could, let’s talk about teenage clusters and we’ve seen this both in the media recently we saw a show that had some publicity about this. So if you could comment on those two things: family history, what relevance it has and then clusters, when a suicide occurs in a school or a peer group, something like that.
Dr. Haggar: Yeah. I’d love to talk about those. And I might just pull in a couple other risk factors so we can make sure that we’re identifying all of those patients. So we know that exposure to suicide increases suicide so that that’s clusters. If we have, if you are in a community and a suicide happens, your patients are at risk. And it’s the impact of that, the trauma of it, the awareness, the perception, there’s so many pieces that go into it for children and adolescents, but we certainly see increase suicide around other episodes of suicide. Having a family history of suicide has a similar impact. So, a parent first degree relative, or just a family member who was close for that child can also increase their risk, trauma and abuse. If you have a patient with a history of trauma or abuse, they are at increased risk. Isolation, which is a little scary when you look at that on the list and think that most of our teenagers are experiencing that to some extent with the pandemic, medical illness, which I touched on. And as you talked about that, that impulsivity. So I think those are all important things to identify as we’re assessing a patient in our office to really put that all together into a package to understand their true risk.
Dr. Segeleon: Dr. Haggar, you know, these subjects can be very sensitive and very challenging to get there, to ask these questions of your patients of kids. What recommendations and advice can you give to the providers listening on how you can approach some of these really difficult subjects and questions with their patients?
Dr. Haggar: Yeah, I think that’s so important. I think that’s what I miss most about being in training is watching other doctors be doctors and learning from how they do it. And so I think after you’ve had the conversation about confidentiality, hopefully when you’re with the alone, but if it has to be with the parent, that’s okay too… it’s important to just ask the question, which is, ‘have you ever had thoughts about hurting yourself? Have you ever wished you were dead? Have you ever had a way that you would hurt yourself?’ Just go through some of those practice, scripted questions … ask them, make eye contact with the patient. You know, this isn’t the time to be adding to my notes, but just give them the space to answer it. And I think that’s what I found most in my psychiatric training was I was pretty impressed with how open kids and adolescents would be and how much information they would share if you just ask the question.
Dr. Segeleon: Great. Well, wonderful advice. Thank you. So wrapping up a little bit here, what, when as a provider for those listening, when would I refer to a specific child psychiatrist or a mental health professional?
Dr. Haggar: This can be a challenging topic. And so I would really encourage the listeners if you’re feeling uncomfortable, reach out whether it’s a conversation with one of the experts, just to help you build up your skills or whether it’s to refer that specific patient. Most specifically, if you have a patient who is acutely suicidal in your office, they need a higher level of care. So that’s a time to refer. This is my personal belief, but I think if you have a patient who has attempted suicide, they deserve at least a psychiatric evaluation with a child psychiatrist, if not ongoing care with them. Having attempted suicide themselves puts them at increased risk for that again. I think that having someone really with that expertise in their field is an important piece of their medical team.
Dr. Segeleon: Well, great. Thank you. I know this is a topic that is very heavy but it is a topic on a lot of people’s minds. And I know that this is a scarce resource and we are so thankful to have you in our community and to have your expertise. I really learned a lot in just this brief period of time. So thank you again.
Host: Thank you, Dr. Segeleon and I echo that Dr. Haggar, thank you so much for your time and your expertise and all that you do here at Sanford.
Our Called to Care Podcast series focusing on children continues with topics from appendicitis to good sleep hygiene and the use of antibiotics right here with our Sanford Health experts. Thank you again for being here and thanks for all you do.
We’ll see you soon.