Considerations for Safety and Suicidality in a Telehealth Environment

Additional Questions Submitted During Q&A

How do you specifically address the confidentiality issues before the visit with an adolescent? And what would you do when confidentiality is not an option (example: if there is a true threat to child's safety)?
Clinicians should review the limits of confidentiality at the start of each visit with the adolescent. You can consider saying something like, “I just want to let you know that what we discuss is confidential – it will stay between you and me. The only cases in which I would have to break confidentiality would be if you were to share that you were being seriously hurt by someone, or if you had serious plans to hurt yourself. In these cases, I would have to reach out to get you help. Does that make sense?”
If there is a true threat to the patient’ssafety, you remind the adolescentthat you will need to reach out to get help. In the case where the patient has serious suicidal intent and plans, you could explain that you are concerned and need to get help. Then, you can ask the adolescent if they prefer for you to tell the family/caregivers or for the adolescent to
communicate directly with them in front of you. This way, it allows the patient some sense of agency and choice in the matter, while still preserving safety.
What are your thoughts/ideas on how to facilitate the best “911 response”? In some areas, the only response options involve law enforcement which can be traumatic to families/caregivers.
Know what community-based alternative to 911 resources already exist near your patients/families, how those alternatives are funded and how to learn more about supporting and expanding these resources. Also, help spread the word to colleagues and the public about what mental health crisis alternatives to 911 are available in your area, as these are not always well publicized.
“Mental Health America” has a link to a database of community-based alternatives to police response in various cities.
Additionally, consider the availability of mobile mental health crisis teams/units in your communities.
Could you share the level of suicide risk table discussed during the live event?
Table 5 from this article: Weber AN, Michail M, Thompson A, Fiedorowicz JG. Psychiatric Emergencies: Assessing and Managing Suicidal Ideation. Med Clin North Am. 2017;101(3):553-571. doi:10.1016/j.mcna.2016.12.006
The table is not a specific recommendation, but rather one illustration of a decision-making support tool that could be made into an informational (and documentation) smart phrase in the Epic electronic medical record (EMR) environment.
This is nice recent article (that references AAP recommendations) about depression and suicide risk assessment in pediatric primary care and school-based clinics. It includes many aspects referred to by faculty of this office hours, including screening for imminent suicide risk, developing a safety plan and incorporating handoffs to urgent and emergency mental health care personnel. It helps to inform the generation of nurse triage protocols and translation to telehealth settings.
When the issue is urgent, do you direct the patient’s family to call 911 or do you the provider call 911 for them? If you direct the patient’s family to call, how do you confirm they called and got help?
Providers can consider directing the family to call 911 on behalf of the patient, if possible. If the family is not able to call 911, providers can call the non-emergency police number for the patient’s location and connect them that way. Consider having a list of non-emergency police numbers on hand.
Note: If you call 911 from your clinic, you will get dispatch for your location. It is important to know the patient’s/family’s city/county and call the number there.
This may be good to include as part of a clinic’s nursing care coordinator (RNCC) protocol or process. For example, a clinic can consider having the RNCC follow up with family/caregiver. Then, if they know where the patient is going for evaluation, like the emergency department (ED), the clinician can call the ED to give history and concerns.
Do you have any suggestions about following up with patients after crisis recommendations?
Have a plan for post-ED visit in your clinic, and/or RNCC can place follow-up call. You may not be the ultimate source of recommended interventions but serve an important organizing and patient advocacy role as the medical home.
What specific screening tools do you recommend for assessing the degree of anxiety, depression and suicidal ideation in the telehealth setting?
The AAP does not approve nor endorse any specific tool for screening purposes.
Screening tools for anxiety and depression: Patient Health Questionnaire – 9 (PHQ-9), Patient Health Questionnaire – 9 for Adolescents (PHQ-A), Kutcher Adolescent Depression Scale (KADS).
Screening tools for suicide: Ask Suicide Screening Questions(ASQ), Columbia-Suicide Severity Rating Scale (C-SSRS)
Mental Health Screening and Assessment Tools for Primary Care – This resource provides a list of mental health screening and assessment tools and information about their psychometric testing properties, cultural considerations, costs and key references.
Star Center Screening Tool Finder – Discover effective screening tools that can help identify risk and protective factors for maternal depression, developmental concerns and social determinants of health.

AAP Policy Statement: Suicide and Suicide Attempts in Adolescents (2016)
AAP Policy Statement: Promoting Optimal Development: Screening for Behavioral and Emotional Problems (2015)
Can you suggest how to improve engagement of adolescents? Often these adolescents are depressed and do not want to open up and communicate.
It is true that it can be harder to engage adolescents who are depressed, as they may be quieter and/or irritable. Sometimes it is helpful to “break the ice” by starting visits by asking about what types of things they enjoy and if they have any shows/series that they enjoy. By showing interest in the types of things that adolescents enjoy, you are conveying that you care about them as a person.
In addition, practice reflective listening by occasionally summarizing what you hear the adolescent saying. For example, you could say, “I hear that you have been struggling at home, and with your relationship with your Mom. That must be stressful.” When adolescents feel “heard,” they are much more likely to engage and feel comfortable sharing confidential information.
Can you please share references discussed during the live event?
• Virtual Office Hour: Using Telehealth to Respond to Mental Health Challenges during COVID-19 (and related AAP News article)
• Starter Guide: Providing Adolescent-Centered Virtual Care
• Online Module: Adolescent-Centered Virtual Care
• AAP Communications Tool Kit: Promoting Telehealth
• AAP COVID-19 Interim Guidance (updated regularly)
• AAP Telehealth Support Compendium
• American Telemedicine Association: Practice Guidelines for Telemental Health with Children and Adolescents (May 2017)
• Mobile Crisis Unit Services in the United States – Black Emotional and Mental Health Collective (BEAM)
• Leadership Education in Adolescent Health (LEAH) Programs
• National Consortium of Telehealth Resource Centers
• National Network of Child Psychiatry Access Programs
• Pediatric Mental Health Care Access Program
• Telehealth Tips: Managing Suicidal Clients during the COVID-19 Pandemic
Of the suicide screeners, is there a best practice for use in general or specialty pediatric office and/or telehealth? ASQ; PHQ-9/PHQ-A; Columbia.
The AAP does not identify a specific screening tool as “best practice”. That said, the PHQ-9 for Adolescents (PHQ-A) is simple to incorporate into a busy pediatric practice with or without telehealth, given it is brief and can be completed by the adolescent prior to the visit. It also provides helpful information regarding depressive symptoms and a history of prior suicide attempts.
Additionally, emerging data suggests that pairing a depression screener (like the PHQ-A) with a suicide screener (like the ASQ) may be better to identify youth at risk of suicide than a depression screener alone.
For more information, review the related AAP policy statement Suicide and Suicide Attempts in Adolescents.
Can you recommend questions that clinicians can ask to help differentiate negative attention seeking talk of self harm from actual suicidal ideation?
All forms of self-harm should be taken seriously, even when the intent is not to attempt suicide. Youth who practice selfharming behaviors are at increased risk of suicide and are demonstrating that they could benefit from referrals to mental health care to help them develop ways to improve their ability to cope with stress and manage intense emotions.