Selected Podcast

Suicide and Depression – Let’s Talk About It!

Contrary to popular belief, talking about suicide doesn’t make teenagers more apt to attempt suicide. An open dialogue can help tweens and teens work through some of their toughest moments and see the light at the end of the tunnel.

Pediatric psychologist Dr. Dan Marullo shares how to recognize depression, how to raise a more resilient child and how important role models can be. Let’s get rid of the stigma and treat mental health issues for what they are – physical illnesses that can be treated and overcome.
Suicide and Depression – Let’s Talk About It!
Featured Speaker:
Daniel S. Marullo, PhD
Dr. Dan Marullo is a licensed psychologist with Behavioral Health at The Ireland Center at Children’s of Alabama. Dr. Marullo received his bachelor’s degree in liberal arts from the University of Texas at Austin and a master's degree in psychology from the University of Houston–Clear Lake. He earned his doctorate degree in clinical psychology with a medical psychology specialty at the University of Alabama at Birmingham in 1993. Dr. Marullo also completed a pre-doctoral internship at the University of Texas Medical Branch in 1993 and a postdoctoral fellowship in clinical/pediatric psychology in 1994 at the Shriners Burns Institute in Galveston, Texas. Dr. Marullo completed additional postdoctoral training in pediatric neuropsychology at the Sparks Clinics/University of Alabama at Birmingham in 2004. Areas of clinical interest include pediatric psychology and neuropsychology of children with chronic medical conditions, childhood physical and emotional trauma, and the neuropsychology of developmental disabilities.

Tiffany Kazeroski: Welcome to Inside Pediatrics; a podcast brought to you by Children's Hospital of Alabama in Birmingham. Today we're talking with Dr. Dan Marullo. He's a Pediatric Psychologist with Behavioral Health at the Ireland Center here at Children's, and he received his Doctorate from UAB from their Medical Psychology program. Welcome, Dan.

Dr. Dan Marullo, PhD (Guest): Well thanks for having me.

Tiffany Kazeroski: So today we're talking about a subject that we don't necessarily love talking about, but it's necessary, and that is suicide prevention, depression in youth, in teens. There are some pretty startling statistics out there about suicide being a top killer.

Dr. Marullo: That's true. I think most people don't realize that the top killers of our children are actually behavioral in nature. We're going to talk about suicide obviously, but the top three killers overall of our youth, and this is from early adolescence through young adulthood, include accidents, suicide as number two, particularly for our fifteen through early thirty-year-old individuals, and homicide. So I always like to point out that's behavioral in nature, that's mental health issues that are important to our youth.

Tiffany Kazeroski: Absolutely, and we recognize that here at Children's because our Behavioral Health Department is full. We've got a lot of people working here, but we have a lot of children to serve from all across the state.

Dr. Marullo: Absolutely. There's a lot of misconceptions about suicide, depression in general, particularly with our youth and our children, but also that stigma that is so important and it's such a barrier to folks getting the help that they need.

Tiffany Kazeroski: Until you're dealing with it. Until as a parent or as a caregiver you're grappling with that situation.

Dr. Marullo: Absolutely.

Tiffany Kazeroski: Let's talk a little bit about depression and suicide related depression. Many times, kids may not necessarily have an intent to really hurt themselves or to understand the consequences behind what they're doing, but they just have so much going on in their heads that they just want to get away from.

Dr. Marullo: Well that's true. Depression particularly with children doesn't always look like what we expect. I think when people think about somebody that's depressed, they get this very real image in their mind, this person who is so withdrawn, and so doom and gloom.

Tiffany Kazeroski: Isolated.

Dr. Marullo: Isolated, and sad, and depressed, and kind of like Eeyore.

Tiffany Kazeroski: Right.

Dr. Marullo: In Winnie the Pooh. And that is certainly a true presentation, but it's not always the case. There's a lot of folks who suffer from depression that don't look that way, and it's particularly true for children. And certainly with younger children, even younger than the adolescents and those tweens, it can look very different.

So as a Psychologist, we look for behavioral changes. Things that a child was doing, their normal way of functioning in the world, and now they're doing something different, and they're very different. And the other things is I mentioned kind of that stereotypical way that a depressed individual looks, a depressed child or adolescent, sometimes it can be very different. Instead of sadness you could get anger, some extreme anger. Instead of poor sleeping, perhaps they're sleeping too much or sleeping all the time as a way of perhaps escaping or just not having any energy. Instead of not eating, perhaps they're eating more than usual, and that sort of thing.

So getting back to your other point, also when you start bringing in the suicidal component, we've got to think about adolescents and where they are in their development. When you're a teenager, your brain is growing and developing, you're picking up new skills, your brain is becoming much more like an adult in terms of how you can think about the future and plan, that sort of thing. But you're not there yet so there's still a lot of more here and now.

Tiffany Kazeroski: A lot of growing to do.

Dr. Marullo: Exactly, you know? And so you had that falling out with your friend, instead of thinking about the future and how things can be better, and you can get back, it's more immediate and you feel that pain much more deeply, and it's harder to think about the future and how things can be so much better.

And there's also this whole impulsivity issue. Teenagers, children in general, but certainly teenagers can be very impulsive. So again, when they're in that here and now moment of their pain, they may act out in a way with no intent of hurting themselves, or even hurting other people, but they become overwhelmed by those emotions and now they're acting out, and then they may get themselves into a situation that they had no intention of going to.

Tiffany Kazeroski: And you think that's a physical part of a teenager's or adolescent's development, that because we tend to think of them when they get into junior high is they're so dramatic, and it's going to be the end of the world because they didn't do this. Is that actually something physical that's going on?

Dr. Marullo: That is. That is your brain growing and maturing. When you think about childhood and living through childhood into those tween years and adolescence, your body is physically growing. Well, your brain is part of your body. It's physically growing, it's making new connections. The main issue is that all these systems for teenagers are starting to come online, what we call these executive systems that help us regulate our emotion, and regulate our behavior, help us control impulses.

So all those things are coming online, they're very immature, so it is a very physical thing and that gets back to depression and even the whole issue about stigma. Depression is a physical disorder, it's a brain-based disorder. So one of the risk factors for children is, again, where they are in their development.

Certainly other things come into play as well; your environment, how you were raised, the supports that you have, and all that because that helps certainly mold how your brain grows and develops. But it's all tied in together. But you're very right, this whole issue is partly about where we are in our growth and development.

Tiffany Kazeroski: Right, and that's why we don't have people drive when they're younger, and that's why we try to-

Dr. Marullo: Exactly.

Tiffany Kazeroski: That's why the driving age is sixteen.

Dr. Marullo: Right, exactly and that's why society kind of recognizes-

Tiffany Kazeroski: Those stages.

Dr. Marullo: Yeah, that there are stages and that folks are kind of reaching that level of development. Now certainly there's a lot of variation and all that. There are some sixteen-year-olds who are very mature, and there are some sixteen-year-olds that are very immature. You kind of get that broad spectrum.

Tiffany Kazeroski: Right.

Dr. Marullo: But in general, it is very much- one aspect of this is about growth and development.

Tiffany Kazeroski: You and I were talking about dispelling that myth that talking about it causes people to think about it more, and that's not true.

Dr. Marullo: That's not true. In fact, suicide is one of those things where you need to shine light on it, because we started getting into some of the stigma about it. So traditionally we don't talk about suicide, even if it's been in our family background, we don't talk about what happened to-

Tiffany Kazeroski: Uncle So-and-So.

Dr. Marullo: Uncle So-and So, exactly.

Tiffany Kazeroski: Right.

Dr. Marullo: So there's always this big mystery, but when you do that, it sends a message that this is not okay to talk about. If a child, a teenager, an adult is having suicidal thoughts, you talking about it is not going to put more thoughts into their head. In fact, what you may be doing by talking about it is making it possible for that person to start dealing with it, and coping, and getting the help that they need.

You know, as a parent it would be very fearful to say those words. As a psychologist doing an evaluation, it's always a little bit like, "If I say that word, which I need to..."

Tiffany Kazeroski: Right.

Dr. Marullo: And we do, but there's always a little bit of trepidation just from being a professional, you know? Because you've got to be ready to deal with that. But by talking about suicide, like in a forum like this, making it possible for people to say, "You know, it's okay to talk about that. If I see something that's going on with my child, if I see that they're struggling in some way, even if I'm not sure what's going on, it makes it possible for my child to talk to me."

Tiffany Kazeroski: And have that conversation.

Dr. Marullo: Absolutely, and the conversation is a good conversation to have.

Tiffany Kazeroski: You talked a little bit about some of the signs and symptoms and behavioral things that might be going on. What should we look for as parents?

Dr. Marullo: You know, it's a great question. Basically any change in behavior that persists, okay? So the classic symptoms of depression; depressed mood, sadness, but also irritability and anger. Again, we don't think about that as possibly being a sign of depression. So if you have a child, your child is a happy-go-lucky individual, and the next thing you know they're flying off the handle all the time, that may be a sign of depression or some other issues that may be going on.

Sleep disturbance. Again, sleeping too much or not enough. Insomnia, they can't go to sleep, that sort of thing. Same thing with appetite, changes in appetite, changes in concentration, you see their grades are starting to drop for some reason, or they're having a hard time focusing. Change in relationships, you know? Not wanting to hang out with their friends anymore, not wanting to hang out with their family. Of course teenagers like to hang out in their room and all that, but if they're isolating themselves.

Tiffany Kazeroski: Too much.

Dr. Marullo: Yeah, and engaging, that sort of thing. Physical symptoms, we don't always think about that, but that could be a sign of a child struggling. So they're having more headaches, or stomachaches, or just don't feel well for various reasons, or fatigue, that kind of thing. The main thing is any persistent change in behavior is a red flag. Now everybody is entitled to a bad day or a rough stretch, and it doesn't mean that they're slipping into depression, but anything that's different, that lasts for awhile, and raises concern for a parent, I think it's okay to start asking questions.

Tiffany Kazeroski: And then once you ask the questions, one of the problems that we have in the country, but then also here in Alabama, we are a poor state, is access to care.

Dr. Marullo: Absolutely.

Tiffany Kazeroski: And having the access in a timely manner to professionals like yourself.

Dr. Marullo: Absolutely. It's a huge problem in Alabama, certainly more than what we can do or affect from where we sit, and we're talking policy issues with our state legislature and certainly at the federal level, but as healthcare professionals we need to advocate for our patients so we need to beat that drum. As parents we need to advocate for them, we need to make sure that we have access to quality mental health services. At Children's, we have very good services, that's the good news. We're so good that-

Tiffany Kazeroski: We have lots of patients.

Dr. Marullo: We have lots of patients. Our psychiatrists, and psychologists, and counselors, and school teachers, and all the rest that work with the kids that come here do a great job, but there's more of them than there are of us, so we have to be very mindful about how we provide resources. As a parent though, my job is to make sure my child is getting the services that they need.

Tiffany Kazeroski: That's right. What are some of the barriers to people seeking treatment now?

Dr. Marullo: That's a great question. I think one of the main issues is really just misconceptions about depression and suicide, but also the stigma that goes along with that. There's still a lot of misconceptions that people have, depression is some sort of moral failing either on my child's part or on my part, or that there's something horrible that must have happened to cause this sort of thing, and just the stigma of it. The whole issue of mental health as being something different than physical health, for example.

Tiffany Kazeroski: Right.

Dr. Marullo: You know? But the notion that this is some sort of a failing on my part. When I think about this, it's like wow, you wouldn't blame somebody with cancer for having cancer. Why would you blame somebody who has depression? That is a process that's happening to them.

Tiffany Kazeroski: Right.

Dr. Marullo: But those are real things because people feel very much shamed about being depressed, or being anxious, or whatever, and so that makes it very difficult for them to seek help. These kids, of course I'm focusing on kids, but adults too, suffer when you have depression, when you have anxiety, severe anxiety, when you have other things you are suffering and you deserve treatment. And a part of treatment is the research. You need to have research so that we know what sort of therapies can be helpful. This is a real issue. This is an illness that needs to be treated.

Tiffany Kazeroski: Right. Okay let's talk about something positive. Let's talk about resilience and how can we instill resilience in our young kids, in our tweens, in our teenagers?

Dr. Marullo: Absolutely. That's such an important topic, and this is really all about prevention and in a sense sort of inoculating our children to experience life including the difficult aspects of life in a way that's going to be healthy so that if you're predisposed to depression, perhaps we can prevent that from happening, and if you do develop depression because of biology, and the influence of environment, and so forth, then perhaps that episode will be less dangerous, and less traumatic, and certainly hopefully keep you from slipping into suicide.

Tiffany Kazeroski: Right.

Dr. Marullo: So how do we do that? Well you know, I always think that parenting our children and teaching them how to be happy healthy adults starts in the womb. So making sure that women get proper pre-natal care, get the social support that they need, that sort of thing. As an infant, making sure that you're nurtured, held, and cuddled. It's basic. As our kids grow up to help them be resilient, they need to experience life. That also means they need to fall down, and skin their knee-

Tiffany Kazeroski: And learn how to fail.

Dr. Marullo: And learn how to fail, exactly. So as parents, as grandparents, as aunts and uncles, and caregivers, we need to teach and model for children not just how to succeed, but also how to deal when things are difficult. You know? So we shouldn't be bailing our kids out of difficult situations. And when I say that, I don't mean- if we're talking abuse and all that kind of thing, yes you need to protect them and get them away.

Tiffany Kazeroski: Of course.

Dr. Marullo: But if you're playing sports and you're on the bench because maybe you're not quite that good, you don't blow that off, you teach them how to deal with it, and you teach them the work ethic to improve their skills, and work hard, but also how to fail. You know?

Tiffany Kazeroski: And we also talked a little bit about structure as well. Kids crave structure.

Dr. Marullo: Kids- yes, kids thrive in structure. They need a routine. The younger the child, certainly, but even adolescents. The teens, they're not going to be real happy with that, they want to do their own thing, and that's understandable, but there needs to be a rhythm to their day. Now when I say structure, I don't mean every minute of the day has got to be planned out. But kids need to know what is bedtime? What is that routine? What are meals? That kind of thing. They need to have their time to do need chores, there needs to be predictability in their life, and that goes a long way to helping kids.

The other thing in addition to routine and that consistency is also good discipline. Kids need to be raised, there needs to be good consistent discipline, and that is part of building resilience. Kids learning consequences for their behavior. It gets back to with our toddlers when they're acting out in frustration, and as parents or caregivers we redirect them and teach them how to express their anger in a much more adaptive and helpful way. That goes a long way to preventing a teenager slipping into depression and suicide.

Tiffany Kazeroski: And also role models. When I think of some of our great leaders of today, some of them did not grow up in a wonderful situation, they may have been in a single parent household.

Dr. Marullo: Absolutely.

Tiffany Kazeroski: They may have been in a really poor neighborhood, but there was someone in their life who stood out, whether it be a teacher, or a coach, or a healthcare professional who helped to guide them in the right direction.

Dr. Marullo: We all need people in our lives that are positive role models. And again, the obvious person is going to be a parent or a family member, but yes it can be that coach or that teacher that takes an interest. We all need to feel that we belong and that we have worth. But again, really instilling in a child not just again how to succeed, but also how to deal with adversity. When you're doing your homework, and you're just not learning how to do long division, you need a mentor to be there and say, "No, you can do this," and work with them, and help them through that. You don't just say, "Hey don't worry about it. Who needs long division anyway?" Because if you can't learn how to deal with small adversities in your life, how can you learn to cope with the big ones?

When we fail within reason, we should model how to do that, and how to accept our challenges with grace. And that doesn't mean that you don't say, "Hey I'm angry, but here's how I'm going to deal with my anger. I can either go punch holes in the wall, which my child will see, or I can find some healthy ways of dealing with that."

Tiffany Kazeroski: Right. Talk it out.

Dr. Marullo: Talk it out, find ways of coping and dealing with adversity. So again, I don't want to say that just because we give kids a solid-

Tiffany Kazeroski: Foundation.

Dr. Marullo: Foundation in their childhood, that nothing bad is ever going to happen to them, they can still- they may be at risk for other reasons, but again that gets back to understanding this is an illness. We don't cause this. These protective factors can certainly help mitigate that, and certainly help them cope and deal with that illness if it should come to that.

Tiffany Kazeroski: Right, and bottom line, we need to treat behavioral mental health as an illness.

Dr. Marullo: It is an illness. In some cases, children may need psychiatric hospitalization so that they can be in a safe environment and stabilized as they're getting those- their suicidal thoughts and their depression under control. That's not a failure. And the literature is pretty clear that a combination of psychotherapy and medication tends to be the most effective combination. So it's not like you've got to choose one or the other, it's sort of a package. I'm fond of saying that medication certainly helps improve symptoms in terms of helping with sleep and kind of helping you with just that icky feeling that you get when you're depressed, or anxious, or whatever, helps you with your appetite, and so forth, but it doesn't teach you anything, and that's what psychotherapy is all about, is teaching you how to cope and deal with the issues, with the condition that you're struggling with. This is a medical emergency, suicide is, it is a medical emergency and it's no different than if you came in the hospital in some sort of shock, and it's a time to get stabilized and to start treatment or to carry your treatment further.

Tiffany Kazeroski: So you talked about behavioral health issues, suicide, depression. It is treatable.

Dr. Marullo: Absolutely.

Tiffany Kazeroski: And there is hope because we've seen lots of children come through our hospital, and through your clinic, and come out on the other side and live very full productive lives. What are some good resources for kids, maybe teenagers who are looking for help, and then also for parents?

Dr. Marullo: You know, if you're a teenager who is feeling suicidal yourself, or you have a friend that you're concerned about, it's okay to speak up, okay? Go to that trusted adult, go to your teacher, go to your school counselor, ask to talk to your pediatrician. There are suicide hotlines that you can call, 1-800 numbers. There's local suicide hotlines that can be very beneficial to you. But the main thing is for yourself or for that friend that you're concerned about, don't keep this in silence. This is a time to get help. For parents, similar resources. One, don't freak out. It's okay to talk to your child about what's going on if you have any concerns, and if you don't know what to do, that's okay. Again, there are resources. Again, there are suicide hotlines that are open to you. Call your pediatrician, call your family doctor. They're your front line resources for that. If you're concerned that your child is eminently thinking of suicide, of truly hurting themselves, or even acting out aggressively against other people, call 911. Go to your local emergency department. The main thing is speak out.

Tiffany Kazeroski: Talk about it.

Dr. Marullo: Talk about it. Talk about it. Take opportunities to talk to your kids. If things pop up on the news about something that happened in the community, or a favorite pop star or whatever who's struggled with depression or has attempted suicide or committed suicide, use that as an opportunity to talk about these things. Make it okay.

Tiffany Kazeroski: That's right.

Dr. Marullo: It is okay to talk about these things. We should, we need to shine a light on this.

Tiffany Kazeroski: Thank you so much, Dan. Thanks for all of your insight and advice.

Dr. Marullo: Thank you.

Tiffany Kazeroski: Thanks for listening to Inside Pediatrics. More podcasts like this one can be found at