September is National Suicide Prevention Month and it can make the difference in someone’s life to have emotional and mental health support with access to the resources they need. Being open to mental health education and counseling as well as finding the right medication or treatment is key. Often, parents can be hesitant to have their child on psychiatric medication. Cook Children’s psychiatrists are answering parents’ questions and raising awareness to help alleviate stigma and treatment for children.

What are mental health conditions?

Depression, ADHD, anxiety and behavior problems are the most common mental disorders found in children. According to the U.S. Centers for Disease Control and Prevention (CDC), “Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, causing distress and problems getting through the day.”

Kristen Pyrc, M.D., Medical Director of Psychiatry Outpatient Services and the Partial Hospitalization Program at Cook Children’s, said they diagnose mental health conditions when they are limiting a child or teen’s functioning.

“Worries, sadness, and anger are all normal emotions, but we become concerned when a kid’s sadness or anxiety keeps them from doing things that bring them joy, or things they need to do to take care of themselves like attending school, showering and interacting with friends,” she said.

How can mental health conditions be treated? 

Both counseling and medication can be used to treat a child with a mental health condition that affects their everyday life, but parents are often hesitant about having their child try medication.

“I’ve found medication and counseling to be equally effective for a child with anxiety and depression, but the combination of both gets kids better faster and safer,” Dr. Pyrc said.

Akemi Watkins, M.D., in Cook Children's Behavioral Health also recommends medication when needed. “If a child has moderate to severe depression or anxiety, we’ll recommend starting medication because current evidence suggests that a combination of medication and therapy is more effective than medication or therapy alone.”

Why are parents hesitant about their child taking medication?

Many parents are concerned with their child taking psychiatric medication because of potential side-effects, medication dependency, the stigma associated with it and even their own experience with mental health medications. The cost of prescription medications, especially name brand, can also be a major hurdle.

If a parent is questioning their child trying medication, Dr. Pyrc recommends, “Consider the risk of not treating anxiety, depression and ADHD, and whether that keeps them from reaching their full potential.”

Is it possible to get financial help to access medication?

The cost of medication often prevents parents from having their child try it. Name-brand prescriptions, especially when they are new to the market, are also out of most people’s price range.

Both Dr. Pyrc and Dr. Watkins help patients have access to their medication by finding similar, lower cost medications and recommending ways to find more affordable pricing.

“GoodRx can help you find the lowest cost pharmacy in your area,” they said. Dr. Pyrc also tells patients about CostPlus Drug Company which has many psychiatric medications at much lower costs that can be mailed.

How can we make taking medication a routine?

Helping a child get used to a new daily routine of taking medication can be challenging. Dr. Pyrc advises “habit-stacking” to make it easier.

“It means ‘stack on’ taking medication to something that you already do every day. Most people brush their teeth twice a day, so getting into the habit of taking medication after brushing your teeth is easier than trying to remember to take it at noon,” she said.

Setting phone notifications can also be helpful and Dr. Watkins advises the parent or guardian to be responsible for dispensing medication for safety reasons.

Medication Success Stories

Both Dr. Pyrc and Dr. Watkins have seen a lot of success stories when children and teens find the right medication.

“One of my favorite memories was a 1^st grader who had ADHD and got into trouble at school every day to the point that he did not want to go to school,” Dr. Pyrc shared. “After we started medication, he brought me his behavior log that had a smiley face for good behavior every day. I still remember the look on his face glowing with pride, and honestly, that is why I do my job.”

Dr. Watkins also experienced seeing her patients’ overall well-being and mental health improve.

“I had a teenage patient with depression and anxiety, and she was started on sertraline,” Dr. Watkins said. “After getting to a therapeutic dose, she was less socially isolated, less overwhelmed with anxiety and said that she was having fewer days where she felt depressed. She felt more motivated to attend school and her grades eventually improved as her depression and anxiety improved.”

Additional Support

When parents are still debating whether or not to have their child or teen try a psychiatric medication, Dr. Pyrc recommends they visit with their pediatrician who can help them understand what is “normal” or if something does need to be addressed. She also recommends researching the American Academy of Child and Adolescent Psychiatry (AACAP) to learn more about anxiety, depression, ADHD, sleep disorders and Autism in the AACAP Parents’ Medication Guides.

In this episode of Raising Joy, we discuss a new peer-to-peer support program that is underway in Cook Children's Pediatric Intensive Care Unit (PICU). Chaplain Amanda Payne Lindsay and Katelyn Terry, RN, join us to talk about the program's goals, how it works, and the impact it's having on PICU staff.

The PICU can be a traumatic environment for health care workers, and this program is aimed at limiting the impact of stress, depression, anxiety, and burnout. The program trains appointed PICU employees to serve as supportive peers to lean on in times of need.

Listen to learn how they started the peer-to-peer support program and why similar programs could benefit workplaces of all kinds.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

In June 2018, Payton Singh arrived via ambulance to Cook Children’s Emergency Department in a barrage of flashing lights and sirens. She was just 12 years old and decided to end her short life while her parents were away from home.

Payton and her family returned to Cook Children’s this week to reunite with her medical care team who saved her on her darkest day.

“I can’t even explain the emotion and the panic that sets in as a parent,” said Brandy Lumbert, Payton’s mother. “After getting the call, I remember running into the emergency room - they knew exactly who I was. And then she flat-lined right in front of me. As a parent, you want to jump in and tell the doctors and nurses to move faster, but you’re just standing there, helpless.”

Payton and the Lumberts also shared their story on the latest episode of our Raising Joy podcast.

Payton’s brother, Kegan, found her unconscious in her room and took action well beyond his years. Though he was just 8 years old, he had the wherewithal to call 911, put the family’s dogs outside and notify his parents that help was on the way.

 When officers arrived at the Lumbert’s home in Keller, Texas, they believed Payton had been without oxygen for 12 minutes.

 “Doctors told us, ‘She’s alive but she’s not showing any brain activity,” said Nick Lumbert, Payton’s stepfather.

 The medical team was able to stabilize Payton and moved her to the pediatric intensive care unit (PICU).

 “Every day in the ICU, we’d stare at the breathing machine to see how many breaths she was taking on her own,” said Nick. “It was very hard to go through that.”

Soon after being admitted to the hospital, Payton’s neurologist pulled the Lumberts aside to show them the scans of her brain. They revealed four small spots, an encouraging sign that the damage wasn’t as dire as it could have been. Still, it was unknown if she’d ever walk or talk again.  

On day five in the PICU, something unexpected happened.

“I remember walking through the doors and we hear all of the alarms going off and we take off running to her room,” said Brandy. “She had stood up next to the bed and was ripping everything off. She looked right at us and I was flabbergasted!”

And just like that, hope began to shine on the Lumbert family.

Soon after, Payton was transferred to Cook Children’s rehabilitation unit where she embarked on the long road to recovery. Over the next six months, she underwent treatment at three different hospitals across Texas.

Now, four years later, she is returning to Cook Children’s to say ‘thank you’ to the people who saved her life.

 On Thursday, September 1, 2022, Payton and her family were reunited with the doctors, nurses, and care team members who cared for her at Cook Children’s. This emotional reunion was requested by Payton, who is now a 17-year-old high school senior. She has a job, drives a car and is planning to pursue a career as a veterinarian.

The Lumberts recently shared their story on the Raising Joy podcast in hopes of encouraging other families who may find themselves in a similar situation.

 When asked what message she has for kids and teens who are struggling with their mental health, Payton said “Get help.”

 Their episode is now available on all major podcast platforms including Apple, Google and Spotify.

 September is Suicide Prevention Awareness Month.

 Here are some signs to be aware of – though not every suicide attempt will display signs. This is why it’s important to talk to children and teens about suicide, whether you suspect they are suicidal or not. 

1. Preoccupied with death (writing, drawings)
2. Talking about feelings of hopelessness
3. Talking about being a burden to others
4. Telling loved ones goodbye
5. Decline in performance
6. Giving prized possessions away
7. Isolating and withdrawing
8. Acting highly anxious or agitated
9. Acting reckless and taking risks
10. Rages
11. Changes in sleeping and/or eating
12. Use of alcohol/drugs
13. Dramatic changes in personality and/or appearance

If you feel your child needs help, please click here to find a Cook Children's Behavioral Health location near you. You can also address your concerns with your child’s pediatrician, psychologist or therapist.

The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) offers 24/7 call, text and chat access to trained crisis counselors who can help people experiencing suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress. People can also dial 988 if they are worried about a loved one who may need crisis support.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

Anxiety and depression drive some teens to recreational marijuana as a way to self-medicate. But that coping strategy can backfire.

Health advocacy groups indicate a link between marijuana use and an increased chance for mental health problems. The National Institute on Drug Abuse and the American Academy of Child Adolescent Psychiatry, for instance, both list a correlation to schizophrenia, depression and anxiety. The Centers for Disease Control and Prevention cites those risks plus temporary psychosis – “not knowing what is real, hallucinations and paranoia” – on its list of mental health implications for dope users.

Lisa Elliott, Ph.D., psychologist/neuropsychologist and manager of the Behavioral Health Clinic at Cook Children’s in Denton, estimated that at least half of her adolescent patients report having tried or using marijuana. For those already struggling with their emotional well-being, is this something to avoid? “Yes. Put that in all capital letters: YES. We have too much evidence to show how harmful it is,” Dr. Elliott said. “There is a significant amount of research that supports the negative impact marijuana/THC use has, especially on the developing brain, so much so that it scares me for our kids’ future.”

Read more about the link between suicidality and young adults here.

Those harmful effects go beyond anxiety and depression to include impairment to intellectual functioning, memory, learning, attention, problem-solving skills and coordination, according to Dr. Elliott. Marijuana use also can cause coughing and wheezing, damage to the immune system and addiction for some people, she said. And when it comes to suicide, some studies show a relationship.    

“There’s been a significant increase in suicides as well as mental health disorders in states that have legalized marijuana,” Dr. Elliott said. “Can we say that marijuana causes suicides? We can’t really say that, but there’s a direct correlation. However, we also know that whenever you’re more depressed and also if you’re coming out of depression, you’re more likely to feel suicidal.”

Just breathe. Open up. You matter. That’s the truth behind the Joy Campaign, an ongoing rollout of articles, videos and other resources aimed to prevent youth suicide. Cook Children’s initiated the Joy Campaign in response to rising numbers of suicide attempts in our region and nationally. While raising awareness, the Joy Campaign delivers help and hope for children and teens who struggle with mental health. This article looks at the ways marijuana use complicates the picture.

How common is recreational marijuana among adolescents? The National Institute on Drug Abuse reports that 11.4% of eighth graders and 35.2% of 12th graders surveyed in 2020 said they had used marijuana in the past year. The Substance Abuse and Mental Health Services Administration calls marijuana the most common illegal drug in the United States, with particular risks for young users and pregnant women.

At Cook Children’s in 2019, there were 830 patients who acknowledged recent use of marijuana when they came to the Emergency Department (ED) for various complaints. That statistic increased to 986 patients in 2020 and 1,105 patients in 2021.  Patients as young as 10 years old were among that group who indicated “yes” to marijuana use on their ED intake paperwork.

In that three-year span at Cook Children’s, most of those who admitted using marijuana were discharged from the ED to home or self-care. Records show some of those patients left the ED against medical advice or were discharged to court or law enforcement. And there were 207 self-reporting marijuana users who were discharged from the Cook Children’s ED to psychiatric hospitals during 2019-2021.

 Dr. Elliott and others say marijuana products have become more potent in recent years. The cannabis plant’s main psychoactive ingredient, a molecule called tetrahydrocannabinol (THC), causes the “high” feeling. Marijuana can be smoked, vaped in an electronic cigarette, eaten in candy or baked edibles, or inhaled in dabs that contain especially high THC concentration.  

Recreational marijuana remains illegal in Texas. In states where it’s legal, consumers must be 21 or older to buy marijuana for non-medical use. Recreational use differs from approved medical use of cannabidiol oil (CBD). Doctors may prescribe CBD in children to help manage epileptic seizures and some other illnesses. But many young people mistakenly confuse THC with the medicinal value of CBD, Dr. Elliott said.  

To set the record straight in therapy sessions, she provides her patients with facts about the documented negative impacts of marijuana, including exacerbated problems with mental health, impaired driving, difficulty in school, diminished IQ scores, aggression, anger and legal consequences. Adolescents who admit to marijuana use tell Dr. Elliott that the drug is easy to come by, even at home or school. She asks them why they started and how it impacts them.

“They’ll say that they will smoke marijuana because it helps them deal with the stress and the trauma and as well as the conflict and unrest in our world. Some of them report that it helps them feel happier, relaxed. Several report that they use it to help them sleep. And several of them report that they used it because they were bored (during the pandemic lockdown) and couldn’t go do things.”

Depending on the reason they’re using the drug, Dr. Elliott works with her patients to treat any contributing factors such as anxiety or depression, peer pressure and low self-esteem. “I try to encourage them and lead them toward healthy coping tools,” she said. “There have been times when I have discharged patients and referred them to therapists who specialize in drugs and addiction because they’re unwilling to stop smoking. Therapy is not productive if they’re high.”  

The Child Mind Institute, a nonprofit organization promoting mental health, sponsored a virtual symposium in October 2021 that featured new research and a panel of experts on the topic “Marijuana and the Teenage Brain.” Among the symposium’s highlights: 

THC exposure in animal models has shown repeated association with increased risk for developing anxiety, depression, substance abuse disorders and psychosis. Exposure to THC changes the cells in the brain and restructures how the gene networks talk to each other.

Adolescence is a critical period for brain development. The adolescent brain is primed to take risks, satisfy immediate wants and be easily swayed by social influences.

Parents should have frequent conversations with their children about the facts that marijuana can be addictive, there’s no such thing as a safe amount, and there’s no way to predict how it will impact a person. Factors such as age, genetics and amount/concentration of the drug play a role. 

 Dr. Elliott cited the statistic that about 1 in 10 people who use marijuana will become addicted. For those who start using before age 18, the addiction risk rises to 1 in 6. Warning signs of Cannabis Use Disorder include cravings, unsuccessful efforts to quit, and increased tolerance to the drug.

“One of the most frightening concerns with marijuana use is the increase in psychotic episodes, especially in those who have a family history of mental illness,” she said. “We also know the recent research really shows that for kids and teens who smoke that higher potency of marijuana, it will increase their chances of developing psychosis nearly five times more than those who have never used.”

Parents should stay alert to behavior changes -- such as secrecy, a sudden decline in grades, less motivation – that might point to a cause for concern in teens. Dr. Elliott recommended that parents speak to their children early and often about the dangers of marijuana. Her encouragement to parents? Keep an ongoing dialogue, stay calm, and set clear expectations and boundaries. And if their teens do start using marijuana, find out why.  

“If they’re feeling stressed, let’s get them into therapy. If they need help sleeping, let’s go talk to our pediatrician and get the sleep addressed,” Dr. Elliott said. She pointed to the good news of hope for families who stay vigilant regarding drug use, social media and mental health in general.

“Parents need to increase their awareness and be hyper alert to this as being an issue. And to create that dialogue and open communication and to be willing to seek help, because if you’re willing to seek help, it teaches your child healthy coping tools.”

About Cook Children's Behavioral Health Program 

Growing up in today's world is hard, and many children or teens may go through life experiences that cause them to feel anxious, depressed or even suicidal. It can be hard for parents and caregivers to know when to ask for help. The Behavioral Health Center at Cook Children’s brings all services together in an expanded space to provide a dedicated team of physicians and professionals with the facilities, resources, tools and programs that deliver the high-quality treatment these vulnerable children need and deserve.

Cook Children's Behavioral Health (cookchildrens.org)

A young girl who was recently seen by Cook Children’s C.A.R.E. (Child Advocacy Resource and Evaluation) Team sat sobbing on the exam room floor, distraught after receiving a series of immunization shots.

Many of the children seen by the C.A.R.E. Team have experienced extreme trauma, says C.A.R.E. Team Medical Director Jamye Coffman, M.D., so even getting shots may cause intense anxiety. The team knew who to call for help.

Enter Kitty, a 7-year-old, silky-haired Golden Retriever and one of Cook Children’s six facility dogs, who quickly assessed the situation and knew exactly what to do. She went straight to the young girl who sat next to her sister and laid her head on the child’s lap.

“The little girl starts petting her,” Dr. Coffman says, “and her sister, who had been here before, says, ‘Just pet Kitty. It makes it not hurt as much—it’s Kitty magic.’ So, the little girl continues to pet Kitty, and the tears slow down, and she finally stops crying, and then she looks at her sister and says, ‘It did help. It is Kitty magic.’”

“Seeing is believing, right?” says Dr. Coffman, who also handles her canine helper. “Seeing how she helps bring kids down when they’re super anxious…and not only the kids, but the parents, too. They start petting the dog and the whole level in the room just comes down. It’s amazing to watch. She knows who to go to instinctively—I don’t know if it’s their smell, I don’t know what it is—but she tends to go to the most stressed person in the room. Sometimes it’s the parent, sometimes it’s the kid.”

But Kitty may not be the only one with magical powers.

Whether it’s highly trained therapy dogs, laid-back emotional support cats or pet pot-bellied pigs, animals appear to shoulder some of the emotional load as they interact with humans—and may even promote healthier mental health for their people, some researchers and animal handlers say.

So, what’s the secret behind “Kitty magic”? And could the human-animal bond make a difference for children and teens facing mental health issues, such as anxiety, depression, or suicidal inclinations—all on the rise since the pandemic began? The JOY Campaign asked experts who work with children and/or animals on a daily basis to discuss.

Kitty’s magic, as well as other animals’ abilities, may begin on the most basic level for humans, experts agree. The animals don’t judge. And that nonjudgmental approach may help those facing mental health issues.

“You can talk to your dog or your pet, and they love you no matter what,” Dr. Coffman says of the unique human-animal relationship.

“I think the biggest thing is the animal accepts you, however you are,” she adds. “They don’t see if you have disabilities. They don’t see if you have scars. They don’t see any of that. They just love you and accept you for you. And that’s it.”

For children and teens who are developmentally peer-driven during this part of their lives, that can be significant, says Dr. Janet Hoy-Gerlach, Ph.D., a professor of social work at The University of Toledo in Ohio. In June, she released the first peer-reviewed research study on the beneficial effects of emotional support animals (ESAs) for those with chronic mental illness.

“It’s a unique kind of support. It’s not an evaluative relationship in the way that humans have, especially with some of the challenges kids face with their peers during that excruciating adolescence, where it’s like hyper-judgment time,” says Dr. Hoy-Gerlach, who also co-authored a book titled The Human-Animal Interactions: A Social Work Guide. “The animal is safe. Animals aren’t making a value judgment on what they’re wearing or what they’re saying or what their hair looks like.”

With extensive work in counseling, crisis work and public mental health, she became interested in the human-animal bond and how it might help people with mental health issues after years of working as a crisis clinician in community mental health, where she conducted risk assessments of clients every day. Part of assessing people in crisis involved questioning them about what stopped them from following through on suicide to help identify their lifeline, she says, adding it’s important to figuring out “what’s keeping them alive.”

Common responses she heard were what she’d been taught to expect—usually protective factors, such as “I’m afraid about what will happen to my kids,” or “I don’t want to hurt my family,” or “I wouldn’t do that to my friends,” or “It’s against my faith, my spiritual beliefs, my religion.’ But another response she frequently heard during the assessments was one she hadn’t been exposed to in classes or training, which was “I can’t leave my pet.”

“I guess I had two reactions to that. One was on a personal level as somebody who has lived with animals my whole life and loved them tremendously. Like I totally got that response. It just made sense to me on a human-to-human level,” Dr. Hoy-Gerlach says. “As a clinician, it really hit me that this was something really overlooked. People were literally saying the reason they were alive was because of their animals.”

“And this was something that had never been talked about,” she says. “I was like, how are we missing this strength? This protective factor that many people have in their lives, and we don’t ask them about it. We don’t talk about it. And we certainly don’t support them, like help them keep the animal in their life if they’re facing a barrier or struggle.”

So began Dr. Hoy-Gerlach’s journey to merge a personal passion for animals and professional passion for mental health. Much of her work since has been focused on educating others, such as social workers, mental health workers and health care workers about the benefits of relationships with animals for human wellbeing, she says, adding she also supports a more intentional approach to using those benefits in how we help people stay healthy.

Dr. Hoy-Gerlach’s recently published study focused on 11 adults with stable, chronic mental illness—ranging from anxiety to depression to schizoaffective disorder—who were matched with a shelter cat or dog through the Hope and Recovery Pet Program, a community partnership between The University of Toledo, Toledo Humane Society and ProMedica. (Six adult cats and five dogs were involved in the study.)

Using saliva tests, researchers studied the participants’ biomarkers, such as cortisol, alpha amylase, both stress indicators, and oxytocin, known as the hormone that bonds mothers to babies. During home visits, the participants took saliva tests after focused interaction with their animal for 10 minutes at one month, three months, nine months and a year.

“What we saw, while not statistically significant in this study, was a visual pattern in oxytocin going up and cortisol going down,” she says. There was no significant rise or fall of alpha amylase.

Initially, several participants mentioned an adjustment phase where they experienced a bit of stress from their routines changing with a new animal. But after that, the participants “overwhelmingly talked about an improvement in their mental health, generally and with their symptoms,” Dr. Hoy-Gerlach says.

“They talked about their animal helping or distracting them from symptoms and being a source of comfort for them,” she says. “Those probably are the two things we heard most.”

While her study focused on adults, most of the results are still relevant to youth, she says, because we’re all humans and similarly hardwired for connection.

For example, in the case of ESAs or companion animals for children and teens, it’s looking at the benefits the animals can offer in everyday interaction based on whatever impairments need to be addressed, Dr. Hoy-Gerlach says. Unlike service or therapy animals, ESAs and pets aren’t trained to do special things.

“So, if a child has a lot of anxiety, physical contact with an animal who enjoys that could be a source of regulation that could help downregulate their stress responses,” she says. “It’s not that the animal is doing anything except typical friendly dog or cat behavior, like ‘I want to sit on you.’ But for somebody who has trauma, for instance, that can be grounding. I’ve talked with people who like the cat’s purr, the feel of the fur, the warmth of the body and pressure of their weight on them.”

“It’s multisensory, plus there’s comfort in the relationship. So, it’s thinking about the ways the animal can help, based on the evidence we have on how living with companion animals can benefits humans, then looking at the child’s specific symptoms and issues,” Dr. Hoy-Gerlach says.

Other groups are also following the human-animal bond and its advantages, especially during the pandemic, which has left many Americans of all ages feeling isolated, lonely and stressed.

As part of its “COVID-19 Pulse Study,” the American Pet Products Association (APPA) reported that 11.38 million households in the United States welcomed a new pet during the pandemic, according to an October 2020 article in Today’s Vetinary Business. And three out of four pet owners said spending time with a dog, cat or another animal species “helps reduce their stress and increase their sense of well-being during COVID-19,” the article stated.

In May 2020, the Human Animal Bond Research Institute (HABRI) along with Mental Health America (MHA) released a report stating pets not only “help alleviate stress, but they also improve owners’ moods and help fight depression.” In their survey, 74% of pet owners reported mental health improvements from having pets, and 75% said a friend’s or family member’s mental health improved. The report also mentioned 96% of pet owners agreed their pet has a positive impact on their life, based on a survey conducted by Nationwide and HABRI.

The scientific research showed the human-animal bond supports better mental health and “indicates pets can make a difference for those facing mental health concerns, including anxiety, depression, loneliness and stress,” according to HABRI’s report.

About three months ago, APPA launched a “Pet Feels” Campaign in conjunction with Mental Health Awareness Month that highlighted the advantages of pet ownership as part of its Pets Add Life (PAL) program. The campaign, posted with links on the APPA website, uses a series of videos that demonstrate the way pets help people cope with everyday stressors while also giving love and support during challenging times.

Despite promoting relationships with animals, Dr. Hoy-Gerlach cautions that they’re are not always for everyone. They shouldn’t be brought into a home if there’s a history of animal violence, extreme fear of animals, severe allergies or if a family member is unable to safely interact with an animal or vise-versa.

Laura Sonefeld, “Sit…Stay…PLAY” facility dog program coordinator and child life specialist at Cook Children’s Medical Center, often is approached by families who are considering getting a pet after watching their children interact with facility dogs at the hospital. The team of six dogs—Kitty, Steve, Neely, Chanel, Zuni and Brienne—are trained to work alongside a healthcare worker to provide comfort and socialization with patients and families in a hospital setting.

Sonefeld, who handles Steve, a 3-year-old Golden Doodle on the canine team, says she frequently is asked, “How do we get a dog like your dog?” She makes sure they understand the difference between service, therapy and support animals.

The first question she asks is “Are you wanting a dog to be able to bring to the hospital with you or one for emotional support and comfort at home?” That helps her determine the type of animal they’re looking for.

Most people want a pet, not a service or therapy animal.

“They say, ‘We’ve seen the benefits on our child when they’re here and interact with one of the facility dogs, and we want that at home, too,’” she says. “And I say absolutely. You get a pet. I feel like all animals have that potential to provide therapeutic support for families.”

Whether dogs, cats or other types, animals might help the entire family, not just an individual child.

“I highly recommend it, just for that everyday stress that all of us feel because we’re human,” Sonefeld says. “It doesn’t have to be someone that’s had a huge hospital experience. It could be someone simply dealing with everyday anxiety of school, of work, of making friends. I feel like the dogs help build that confidence and remind everybody that they are loved and special—that they deserve to feel that from people they interact with, too.”

Sometimes the entire family isn’t on board with getting a pet, Sonefeld says. It might be the mom or dad who is hesitant to take on more responsibility by having an animal.

But it seems the mysterious “Kitty magic” might work on that, too.

“Whoever the one is that’s not totally convinced usually ends up being the one who loves the dog the most,” Sonefeld says with a laugh. “Once they have had the experience, they’re like, ‘Oh, OK, I get it now.’”

There is nothing more inspiring than seeing a child with a disability overcome the daily challenges they face. Their determination, strength and courage are what superheroes are made of. But, even superheroes sometimes need help carrying the mental and emotional weight of living with a difficult medical diagnosis, a developmental delay, a physical disability or a learning obstacle. It’s the part of their struggle often unseen, yet profoundly impactful to them, their families and their well-being.

Carla Morton, Ph.D., spends a lot of time with little superheroes. She is both a neuropsychologist at Cook Children’s Jane and John Justin Neurosciences Center and the mother of a child with special needs. Morton is also an advocate for children with disabilities as a founder and current president of the Fort Worth ISD Special Education PTA.

“Kids who receive special education services are at increased risk of psychiatric issues,” Dr. Morton said. “It could be the result of a primary medical diagnosis like multiple sclerosis, for example, which in and of itself causes you to be more likely to have depression. Or, it could come through an indirect route, like attention deficit and hyperactivity disorder (ADHD), which results in more social difficulties and an inability to regulate behavior.”

No matter the cause, depression is not something to ignore. It’s a risk factor for suicide.

Studies show that adolescents with physical, developmental and learning disabilities have an increased risk of suicide compared to those without a limitation. Contributing factors may include increased stress, social isolation, discrimination, a psychiatric diagnosis and substance abuse.

Take epilepsy, for example. It’s a disorder that can be associated with physical, developmental and learning impairment.

“Epilepsy and depression occur together at high rates,” said Crystal Cooper, Ph.D., principal investigator at Cook Children’s Jane and John Justin Neurosciences Center. “If you think about the general population, you might have 5 to 15% that are going to have depression in their lifetime. But if you look at those with a condition like epilepsy, their rate of depression can be up to 50%. So it's much higher compared to the general population. Given this knowledge, it is not surprising to hear the CDC report a 22% higher rate of suicide among those with epilepsy compared to the general population.”

In her role as a principal investigator, Dr. Cooper examines the relationship between neurological medical conditions and psychiatric health in order to better understand how to treat people with medical disorders of the brain. She is currently studying the impact of epilepsy on the psychological health of children.

It’s hard for a child with a physical disability to watch their friends do things their bodies won’t let them do. Constant questions from others about their limitations, burnout from intense therapies that interrupt time with their friends, and self-consciousness about their differences can erode a child’s mental health. Each of life’s developmental and social milestones they reach has the potential to present a new emotional challenge.

Depression and suicide can capture the thoughts of anyone with a limitation, even those with an intellectual and developmental disability. A review of literature by the National Institutes of Health indicates the rate of suicidal thoughts, behavior and completion among children with an intellectual disability are as high as 42%.

“Unfortunately this population has been understudied for their risk for suicide,” said Rachel Talbot, M.D., a child and adolescent psychiatrist on the medical staff at Cook Children’s Medical Center. “In general, I would say that this population is at an increased risk for depression and anxiety in addition to suicidality as they are more susceptible to the risk factors for suicide.”

Such risk factors can include having traumatic experiences—both physically and mentally—being bullied by peers, increased impulsivity, inadequate coping skills, and an inability to manage and appropriately express their feelings.

“We need to make sure that our kids with disabilities are being screened for anxiety and depression, including those with intellectual disability,” Dr. Talbot said. “We can’t overlook it.”

Impulsivity also puts children with ADHD at risk. They can quickly go from a suicidal thought to completion before anyone has a chance to intervene, according to Anne-Marie Hain, M.D., a pediatrician in the developmental pediatrics division of the Cook Children’s Child Study Center.

Superheroes Under Stress

This year has been particularly difficult for children with special needs and their families. The pandemic complicated already stressful lives and disrupted critical therapies that help these children reach their full superhero potential. Normal daily routines were in constant flux, triggering a loss of comfort and security for children in general but especially for those with special needs.

“Regular routine and ritual is important for any child,” Dr. Hain said. “But it's especially important for a child with a developmental disability. It allows them to understand what’s coming next, especially if there are communication issues.”

By nature of their disability, many struggle with anxiety, depression, isolation and a sense of loss on a good day. Add a pandemic on top of that and you have the makings of a perfect storm. Physicians at Cook Children’s Child Study Center, an educational haven for children with developmental disabilities, said they have seen an increase in the severity of their patients’ behavior disorders and aggression over the past year.

“At the beginning of the pandemic, a lot of children with developmental disabilities had a little bit of anxiety or a little bit of disruptive behavior or a little bit of weight problems,” Dr. Hain said. “And then the rug got pulled out from all of these families and the child couldn’t go to school or therapy. When all of that happened, a lot of little problems became big problems.”

Dr. Hain encourages parents to make sure their kids are sticking to a sleep schedule, getting regular exercise and participating in safe activities that spark joy to help boost their child’s mood in good times and bad.

How To Rescue A Superhero

Children with disabilities can never escape the reality of their circumstances, but there are ways to help them cope and soar to personal success. Christina York, Ph.D., is a licensed psychologist at Cook Children’s Behavioral Health Center. When she works with children who are struggling mentally and emotionally with a disability, she takes a page from the superhero playbook.

“Every superhero has a superpower. I encourage kids to focus on their ‘superpowers,’ which may be hidden,” Dr. York said. “Think of Superman and his adoptive parents figuring out he had superpowers as he grew up. We may discuss their ‘hidden superpowers’ that they aren’t yet aware of due to focusing on what is wrong.”

Maybe the child has a wicked sense of humor and is able to make others laugh and smile. Perhaps their circumstance gives them a keen sense of awareness of the needs of others and they are eager to help, encourage and show kindness. Does the child have an athletic, artistic, musical or creative talent that outshines their disability? Whatever the strength, the key is to help your child identify it, own it and use it to reframe their focus on what they can do rather than what they can’t. Show them they are more than their disability.

“Finding either character strengths or other areas of functioning where they feel confident can help buffer the effects of their disability,” said Amanda Smith, Ph.D., a licensed psychologist at Cook Children’s Behavioral Health Center.

Dr. Smith encourages her patients to research and learn about well-known people with similar challenges, as well as connect with other kids with disabilities, in order to see life’s possibilities and develop a circle of support.

Age-appropriate explanations about their diagnosis help kids better understand and cope with their circumstances. Telling a child too much or too little, or getting too technical, may lead them to think the worst, Dr. York said. Once you and your child have a good grasp on the diagnosis or disorder, consider sharing it with those in your circle.

“I think the most important thing is having the correct knowledge,” Dr. York said. “Then we walk kids through choosing who and what they want to tell about their disability. We can go into the school and tell school staff so that they're aware and can provide support. In some cases the school counselor goes into the classroom to talk to a child’s peers about their disability so they have a better understanding of what is going on and aren’t constantly asking the child ‘what’s wrong with you.’ Some kids may not want to tell anyone and feel isolated. They may benefit from discussing why they don’t want to tell anyone and how they might tell trusted people about the diagnosis, including good friends, if they change their minds.”

There are so many things children with disabilities cannot control about their bodies and lives. Where they can have a say, they should.

“Let them have a voice because it feels like their body is constantly at war with them,” Dr. York said.

Listen to what they are saying they need and work with their medical team to safely adjust care and therapies to achieve a balance for physical, mental and emotional health. A short break from therapy or a restructure of their therapy schedule may be all they need.

When a child’s disability can’t be seen, like in the case of a learning difficulty or chronic illness, it’s easy to mislabel them as lazy or having a behavior issue. This can open the door to feelings of frustration, failure, rejection and isolation. Protect against these hurtful labels by informing your child’s school and teachers about their challenges. Help your child understand the strengths and weaknesses associated and not associated with their disability and teach them how to advocate for themselves, according to Dr. York.

Most importantly, if you think your child is struggling, don’t wait to get help. It never hurts to talk to someone, even with the most basic concern. Intervening early can be a buffer to more serious issues, including suicide.

.

Bullying is an age-old issue. Generations old and new are familiar with the power plays of those that intentionally try to hurt another. It happens on the playground, in the classroom, by the locker, at the lunch table, on the bus, through social media networks and everywhere in between, and it can take a toll on a child or teen.

It’s important to understand the true definition of bullying. It is a conscious, intentional, hostile action towards another that is meant to hurt or create fear or terror, according to Lisa Elliott, Ph.D., psychologist and manager of the Behavioral Health Clinic at Cook Children’s in Denton. An act of bullying includes three elements—an imbalance of power, the intent to harm emotionally or physically and pleasure in witnessing the pain.

If you let them, bullies can plant seeds of rejection into your soul, some that can deceive you for a lifetime and create deep-rooted strongholds of confusion, fear, anger, bitterness, insecurity and thoughts of inadequacy, according to Cook Children’s mental health experts.

Research shows that adults who were bullied as a child have an increased risk of depression and anxiety; may suffer long-term negative consequences with jobs, income and relationships; and may experience poorer health. What’s worse, both those who bully and those who are bullied are more likely to exhibit suicide-related behavior.

“Being bullied can be a trauma for some kids because it overwhelms their ability to cope,” said Denise Coover, LCSW, a trauma informed care specialist at Cook Children’s Medical Center.

You Matter

As bullies target the insecurities of others, it can produce shame and guilt in the one being bullied. In the victim’s eyes, their perceived shortcoming or failure is validated by the bully. That’s when a wall goes up in many kids, and they retreat from those who can help them sift through the truth versus the lies.

“What someone says about you does not make it true,” Coover said. “And every negative thought that you have about yourself isn’t always true either. But when a bully hits on a particular insecurity, it’s hard for kids to put that into words so that someone can help them process it.”

On the flip side, those emotions are exactly what fuel bullies and their assaults. The pain bullies inflict on others is a direct result of emotions brewing within themselves, according to Coover. It’s a coping strategy, one that gives them a sense of control of their own perceived failures by elevating themselves over others.

“Kids will use behavior to say there is something wrong here,” Coover said. “And it’s up to a clinician, in-tune parents or a school system to figure out what the problem is because the behavior is telling us there’s something going on.”

It’s not that bullies bully because they are nothing but bullies. They bully because they don’t know who they are. Bullying gives them a sense of identity where they otherwise have no point of reference for purpose, belonging or intrinsic worth of themselves or others. Having a solid grasp on those things is like a coat of armor for kids against both becoming a bully and being negatively impacted by one. Establishing those values starts at home.

“We, as parents, can't be so unaware that we think that our child may not be the bully,” Dr. Elliott said. “It is absolutely critical that we not only talk about this with our children in order to protect them, but we also have to teach them how to be a good citizen.”

Dr. Elliott cautions that parents should not dismiss complaints about their child being a bully or bury their head in shame either. Address the issue. It’s a good opportunity to find out what may be behind the bully behavior, which you can then help your child overcome. Seize the moment to teach them about how to treat others with kindness and compassion. It could be an invaluable growth opportunity for your child and your relationship.

“What kids hear from you is what they will know about themselves,” Coover said about a parent’s role in building strong and resilient children.

Helping kids understand their intrinsic value as a created being can be like a shield from the flaming arrows of a bully. One way parents can plant and water the seeds of purpose and worth is by helping children identify what matters most about them and what is and isn’t true about themselves. They can also help frame their kid’s perspective by encouraging them in the journey of their endeavors, not just reveling in the outcome.

“When a kid brings home straight A’s, it’s a great thing to celebrate,” Coover explained. “But what’s more important for a parent to see and acknowledge is how hard the child worked, their dedication, how much they learned and the steps they took to achieve that. Kids need to hear that from parents, no matter the grade that resulted from their best effort and hard work.”

This helps reinforce competence, confidence and connection — as described in "Building Resilience in Children and Teens" by Kenneth R. Ginsburg, MD, MS Ed, FAAP. Resilience is the ability to bounce back from stress, trauma or hardship. It isn’t something we’re born with, but something learned. Oftentimes, through trial by fire, but also by watching others we love and respect bounce back from a difficult circumstance. Teaching kids to be resilient gives them a hopeful perspective.

The Rise of Cyberbullying

Bullies may use physical force, relentless verbal lashings or social exclusion to intimidate and control. But the rise of the internet and social media has added a new virtual venue where bullies seek to crush the spirit of their target. According to a 2018 Pew Research Study, 59% of teens have experienced some type of cyberbullying.

The pandemic made cyberbullying even easier as kids were forced out of classrooms and onto virtual platforms for learning and socializing. More time online translated to a 70% increase in hateful speech between kids and teens during online chats, according to a study conducted by L1GHT.

“This is a whole new world for parents and kids to navigate,” Dr. Elliott said. “Parents need to have controls. They need to have access to see what their kids are doing. It’s really important for parents to monitor what their kids are viewing, saying and sharing online.”

Cyberbullying can be extreme and pervasive, Dr. Elliott said. The internet is always open for business and provides harassers a direct line into the personal device of a victim. It’s fast, easy, far reaching, can be done anonymously and lives in infamy forever.

Cook Children’s experts shared these tips for protecting your child online:

• Continually educate yourself on the ins and outs of social media outlets. Do you know about TikTok, Instagram, YouTube and Snapchat, just to name a few? If not, you should. This is where your kids are hanging out. Educate yourself on how they work and how your kids are using them.

• Openly discuss bullying and cyberbullying with your kids on a consistent basis. These are conversations that need to be had more than once as your child matures. Ask your child if they have been bullied, how they handled the incident and how it made them feel. Talk to them about what they do when they see others being bullied. Are they being a good bystander? Teach them about empathy, and help them think through how to help others.

• To encourage kids to open up, have them write it, draw it or say it. If talking doesn’t come easy, kids who enjoy writing can journal their thoughts. Those with an artistic flair may prefer to illustrate them. Kids may be more receptive to talking if you strike up a conversation when engaging in an activity together, riding in the car or just having a casual discussion. Learn what communication tool works best for your child and embrace it.

When And How To Intervene

You may sense your child is being bullied if you see a change in their behavior. If they stop doing things they once loved, start spending lots of time alone in their room, are irritable and weepy or their grades plummet, you should take note that something may be wrong.

Sometimes parents need to intervene to stop a bully. Other times they simply need to problem-solve with—not for—their child. Coaching kids on how to respond appropriately on their own helps build confidence and resilience, and helps their brains develop problem-solving skills that benefit them for life.

“If we always do things for our kids, their brains don’t grow,” Coover said. So they become adults who can’t manage any kind of problem in life, because they’ve never had to do it. Someone has always stepped in to take care of it for them so their brain didn’t create those neural pathways to consider solutions.”

To know your role, Dr. Elliott says to start by determining what kind of bullying your child is experiencing. Are they being physically assaulted, verbally harassed or cyberbullied? How often is your child targeted?

If the bully is getting physical or threatening bodily harm, always report it to the proper authorities, be it school administration or law enforcement. In Texas, schools are required to adopt anti-bullying policies and establish procedures for reporting incidents. They must also notify parents and guardians of a reported incident and outline disciplinary actions for those who bully. To better understand the state’s bullying laws, check out tea.texas.gov and stopbullying.gov.

If the harassment is verbal in nature, it may benefit your child to take a different approach, one that equips them to respond to the bully themselves and helps them build life-long conflict management skills.

Don’t Feed The Rat

Knowing how to handle a bully can be the difference between a child suffering silently through relentless attacks versus a single incident that is stymied before it escalates to something more serious. It’s all about the balance of power, Dr. Elliott says, and ignoring a bully isn’t always the answer.

“Bullies thrive on a perception of power and control over another person’s emotions,” Dr. Elliott said. “Even when you ignore a bully, they still assume you are hurting inside. That perceived weakness keeps them coming back time and time again to satisfy their desire for power and control.”

Dr. Elliott has personally developed and tested a bullying response tool that she employs with her patients. Her method teaches kids to respond to bullies in a way that both quiets the harasser and builds resilience in the one being harassed. It essentially conveys a message to the bully that their opinion isn’t valued and, therefore, not offensive. She calls it The Rat Method. Click on the video below to hear Dr. Elliott explain her method in her own words.

There Is Hope

Your child can overcome either being a bully or being the victim of a bully. Together, you can create defenses against bullies, develop empathy for others and foster resilience to stop bullies and their bad intentions in their tracks. Your child’s short and long-term mental and emotional health will be better for it.

Over the past few weeks, we’ve published a series of articles about the mental health crisis shaking the foundation of our youngest generation. It’s been a difficult and heart-wrenching conversation as, together, we’ve opened our eyes to this issue. This week, we want to bring you some good news.

An innovative yet practical collaboration that embeds family therapists into Cook Children’s Neighborhood Clinics (NHCs) is expanding access to mental health services for children in some of Tarrant County’s most underserved communities. It’s a silver lining, if you will, amidst a rapidly growing crisis.

The Crisis

The critical issue of mental health struggles among children isn’t a new one. It’s been lurking under the surface for years. One Centers for Disease Control statistic states that the percentage of children ages 6 to 17 who have ever been diagnosed with either anxiety or depression increased from 5.4% in 2003 to 8% in 2007 and to 8.4% in 2011-2012. To put skin on that, approximately 4.4 million children in the U.S. ages 3 to 17 have diagnosed anxiety, and about 1.9 million have diagnosed depression. Couple that with an inadequate supply of mental health professionals across that country and you have an undeniable gap in mental health care for hurting kids. According to the American Academy of Child and Adolescent Psychiatry, there are only 8,300 practicing child and adolescent psychiatrists in the United States—a country with 74.2 million children.

Pile a pandemic on top of all of that and you have the makings of a nationwide mental health disaster. In many ways, COVID-19 opened Pandora's box. For millions of children, each measure taken to address the virus either triggered a new mental health struggle or exacerbated an existing one. The results are devastating, evidenced by the record number of children attempting or committing suicide. Some as young as 5 years old.

“I would say that, compared to last year, I have certainly experienced and seen a significant rise in the number of patients reporting anxiety, depression and even suicidal contemplation,” said Vida Amin, M.D., Neighborhood Clinics and Population Health Advisor.

The Silver Lining

Cook Children’s Health Care System took note of the adolescent mental health situation and the gap in services years before the start of the pandemic. Concern turned to action when the system began including mental health outreach as one of its yearly strategic initiatives. Over the course of several years, these initiatives have evolved from requiring universal depression screenings for all adolescents to improving access to mental health care for patients of Cook Children’s Neighborhood Clinics in fiscal year 2021. This latest initiative steered the concept of integrating family therapists into the primary care setting.

The program launched in December 2020—perfect timing given the pandemic’s toll. Three licensed family therapists rotate through Cook Children’s seven Neighborhood Clinics each week providing services that range from mental health evaluations to outpatient counseling to education for families and clinical professionals.

In its first month, NHC physicians and nurse practitioners referred a little more than 100 patients to the therapists for evaluation. By April 2021, that number had grown to more than 380 in a single month. So far, more than 111 patients have received outpatient counseling through the program.

Breaking Barriers

This care model helps alleviate three critical barriers for families seeking mental health services—access, cost and a reluctance to trust someone new with something so sensitive.

Right now in North Texas, it can take weeks, even months in some cases, to get an appointment with a therapist. There simply aren’t enough to go around. The same is true for many parts of the country.

“The demand for behavioral health care far outweighs the number of treatment providers in the community,” said Christina Reed, LMSW, director of operations at Cook Children’s Neighborhood Clinics. “It’s just too much for nonprofits and other providers to keep up with. So for us to be able to offer this to our patients gives them that access that has been lacking in the community.”

Beyond adding much needed therapists to the landscape, bringing these services in house improves access by speeding up the referral and evaluation process. It also signals that mental health is just as important as physical health. As therapists share knowledge and integrate their care plans, physicians and nurse practitioners are increasingly looking through the lens of mental health when engaging with their patients.

“It helps to demonstrate that behavioral health care is a part of health care,” said Kelly Rand, LCSW, manager of patient and family support services at Cook Children’s Neighborhood Clinics. “You don't have to go to another office somewhere that you've never been before and that’s not familiar to get that support. It crosses that barrier to where it's not two separate services. It's all health care, and it's all here together.”

Access and cost go hand in hand. If one can be overcome, the other is often the next big hurdle. Many private practice therapists do not accept insurance, especially Medicaid, leaving families no choice but to pay out of pocket.

“We serve primarily Medicaid families,” Reed said. “If you are a child or a family on Medicaid trying to find mental health services, that is challenging and that's no secret. It’s always been challenging. Our families are left without many options because they can't pay cash for a private practice therapist.”

Counseling services at the NHCs are billed to the patient’s insurance provider, be it a private insurer or Medicaid. If a patient is not covered by insurance or Medicaid, therapists connect them to a counseling resource in the community that offers free or sliding scale fee services.  

Opening up about internal struggles can be hard. Knowing who to trust with such personal and sensitive information factors into a parent or child’s hesitancy to reach out. Embedding therapists within the primary care clinics where patients have established relationships and familiarity with providers helps build a bridge between reluctance and trust.

“There is something that our families value when it is a Cook Children’s name behind that referral or service,” Reed said. “When it's their pediatrician saying, ‘it's this person I work with right here that can help you,’ there's a lot of comfort and trust in that in a world that can be really scary. There's still a lot of stigma. There's still a lot of hurdles to jump through, even just internally, when seeking out that service.”

Comprehensive Care

For children who need emergency intervention or more intensive care than can be provided through outpatient therapy, NHC therapists work with Cook Children’s emergency department, behavioral health intake department, partial hospitalization program and inpatient psychiatry program to get patients the level of care they need.

“The NHCs are now performing 200-plus psychosocial assessments and plans of care each month,” said Robert Goodwill, senior vice president and chief operating officer of Cook Children’s Physician Network. “This is an integral part of identifying specific needs related to the level or type of care a child may need. These added resources have resulted in increased counseling sessions at the NHCs as well as the ability to connect patients and families to other services in our system and our community.”

Of the nearly 1,200 referrals NHC therapists have received since the start of the program, depression and anxiety rank as the top two issues.

“Depression and anxiety are by far the most common,” Rand said. “A third one would be ADHD or issues around attention concentration. From there, I would say, issues around some kind of trauma transition or loss. So a death loss, the loss or separation of parents, a traumatic family event, or some kind of big transition in the household. Of course, those things contribute to and cause depression, anxiety and attention difficulties in children.”

As the rising referral numbers demonstrate, this collaboration is bringing critical services to the doorsteps of underserved communities. It’s making the mental health care space easier to navigate and offering help and hope to hurting children.

Like an earthquake rumbling underfoot, crumpling the ground beneath, the suicide of a loved one has a way of knocking you to your hands and knees.

After the initial shock wave throws you, constant aftershocks of emotions—running the gamut from guilt to shame to horror to inconsolable sadness—may leave you struggling to regain footing long after your loved one has died.

Survivors of suicide often experience a complicated type of grief that differs from other types of bereavement, mental health experts say.

“With suicide grief, they’re dealing with a trauma on top of the loss,” says Sharon Walker, LCSW, a therapist in Arlington who specializes in complex trauma and trauma grief. “With most people who die by suicide, it’s usually violent or tragic in some way. So, the person grieving has to deal with the fact that a person chose to take their life and that how they died. That changes the grief process.”

Walker, a former longtime-facilitator of the support group Survivors of Suicide (SOS) in Fort Worth, says another dynamic comes into play—the social stigma attached to suicide.

“Death can be tragic, like a murder or a car vehicle accident. But the stigma around suicide still exists today, and so family members have to contend with that piece, as well,” she says. “It makes their grief different.”

In April 2020, the Centers for Disease Control and Prevention (CDC) ranked suicide as the 10^th leading cause of death based on its most recent data collected in 2018. It was listed as the second-leading cause of death for Americans ages 10-34 and the fourth-leading cause for ages 35-54, according to CDC reports.

It has long been accepted that when someone dies by suicide, six people are directly affected by it. But a researched-based estimate published on the American Association of Suicidology’s website suggests the ripple effect of one suicide extends far past that, personally affecting 135 people on average. Based on that, an estimated 6.9 million people are touched by suicide annually.

The Alliance of Hope for Suicide Loss Survivors, an international non-profit group that operates an online support group, lists the dynamics that can complicate suicide bereavement on its website. The factors include circumstances surrounding the loss; post-traumatic stress; stigma and isolation; prejudices involving suicide; investigations into the deaths; religious and spiritual beliefs on suicide; family and relationship tensions; and survivors’ questions about why their loved ones chose to take their own lives and whether they could have done something differently to prevent it.

Through her years working with suicide survivors, Walker has seen families experience all of these dynamics. And some, even more than a decade later, still wrestle with them.

“Grief is not something we ever get over, and it doesn’t ever stop. What we learn to do is grow around our grief, to encompass it and incorporate it or manage it into our own life,” she says. “We walk with it.”

When talking with families and friends facing a loss from suicide, she reminds them that they can get hijacked by their grief. And that everyone has their own process of grieving the loss.

“Every time you turn around—there’s a reminder, there’s a statement, there’s a feeling, there’s an emotion—and you are overwhelmed by your grief,” she says. “And as we walk with this, and you learn to understand your own grief process, it becomes something that you can manage.”

“It’s not that the grief gets smaller, but you grow big enough around it to start being able to manage it,” she says. “And then you can take it off the shelf and touch it when you want. It becomes something that you can eventually manage and live with and incorporate in your life. But as far as ever getting over it, there is no such thing.”

Many suicide survivors circle back to help other survivors find their way out of the devastation caused by a loved one’s suicide. They take the energy from their own grief and put it toward helping others, Walker says. The success behind the SOS group she ran for 18 years was because survivors returned to give back “because they knew how devastating it was to other people.”

“And the very act of sitting there and saying, ‘You can survive this. We didn’t think we were able to either, but we’re here to help you know that you can.’ Well, as a professional, I cannot convey that any more brilliantly than what a survivor can to another survivor,” she says.

Just Breathe

Brad Hunstable, CEO of electric motor company Linear Labs in Fort Worth and an Army veteran, understands firsthand the complexities that grieving families face after losing a child to suicide.

Nothing prepared him for April 17, 2020, the day a figurative “nuclear bomb” went off in his world, altering it forever. Hunstable had just finished a call when his daughter, then 8, ran to him, telling him something was wrong with her big brother Hayden. The 12-year-old had been playing his favorite video game Fortnite in his bedroom while his dad worked from their Aledo home.

Hunstable rushed upstairs to his son’s bedroom and found Hayden in the closet, unresponsive. He called 911 and tried unsuccessfully to revive him. Hayden—described as a fun-loving, active boy who enjoyed playing sports and loved life––died by suicide four days shy of his 13^th birthday.

Hayden didn’t suffer from depression or have any diagnosed mental health issues. No one could have predicted he would take his own life, his dad says.

Hunstable believes isolation during the initial COVID-19 stay-at-home mandate—attending school online and not getting to see friends regularly—took a toll on his son and factored into his impulsive decision to end his own life. It was also later discovered that Hayden had accidentally broken a large-screen gaming monitor just before his death—a monitor he used to play Fortnite and similar to one he’d broken months earlier but had worked to replace.

He was excited about his new replacement monitor and was set to have friends over to play Fortnite at his upcoming birthday party, says his dad, who founded Hayden’s Corner, which advocates mandated resilience classes for children and champions responsible gaming education, in honor of his son.

Hunstable—who also produced a short documentary about Hayden’s death titled “Almost Thirteen”—has spoken to various mental health experts about youth suicide and believes impulsivity plays a huge role. (Parental guidance and discretion is advised when watching Hunstable’s documentary because the disturbing subject matter may cause emotional distress.)

“When you look at youth suicide, 55% of them are impulsive and 50% don’t have a previous mental health diagnosis,” he says. “They may have something, but it’s not diagnosed. Impulsive suicide in youth happens because a boyfriend broke up with me…I got into a fight with my parents…a girlfriend just broke up with me…I’m being bullied.

 “In Hayden’s case, he broke his monitor for a second time right before his birthday, in the middle of a pandemic,” Hunstable says.

Developing resiliency is key in addressing suicide among children and teens, he says.

 “It’s always complicated. It’s never simple,” he says of life and what sometimes leads young people to impulsively choose suicide. “When you get the perfect storm of complexity, and they haven’t developed some resilience capabilities—and you haven’t taught them or had open dialogue about these things or it’s just too much—this is where you end up.”

Hunstable believes parents need to have “uncomfortable conversations” with their children about suicide so they know how to cope if the impulse ever hits them. Research shows that bringing up the topic of suicide in an age-appropriate manner does not plant the idea in children’s minds, he says, adding “that’s a myth.”

Find a way to help them contend with their emotions and impulses, like teaching them breathing techniques, meditation, playing guitar or screaming into a pillow, he says. Let them know it’s okay to talk about it, Hunstable adds, and if it happens when you’re not around, teach them to go to a trusted adult like a teacher or a grandparent.

What would he say to parents who are hesitant to discuss suicide with their children and methods to cope with their feelings?

“I’d say, ‘Do you want to be in my shoes?’ My son disappeared off the face of the Earth. I still struggle with that concept. He was there one minute—and then he went poof. You don’t want to do this,” he says. “It has nearly broken me. It nearly broke my family. It still might.”

“Hayden doesn’t have PTSD—we have PTSD,” Hunstable says of himself and his daughter, who found her brother. “I know it sounds like a cliché because I used to think the same thing. I’d hear parents say, ‘It can happen to your kid.’ Now, I’m that parent, saying that it can happen to your kid. And what’s scary is—it really could.”

Open up

Jamye Coffman, M.D., medical director of The Center for Prevention of Child Abuse and Neglect at Cook Children’s, knows firsthand it can happen to anyone. She lost her son Aaron, 20, to suicide on Aug. 10, 2010.

“I’ve been very open about his death, open about his suicide. And what I’ve found is that a lot of people came to me with similar stories, maybe it wasn’t their child, but with suicide in their family,” she says. “I was amazed at how many people have been touched by suicide. I think they just don’t talk about it because they don’t know how people will receive it.

“I want to talk about it because I want people to know it can affect anybody,” she says. “The rain falls on everybody, right? It doesn’t matter how good, how bad, how rich, how poor––none of that matters.”

Dr. Coffman still recalls getting the call while on vacation as she, her husband and daughter were about to enter Yellowstone National Park. The news sent her and the rest of the family reeling.

Less than a week before his death, she’d been on the phone with him. He was living and working in Lubbock, where his dad, her ex-husband, lived. He wanted to go to community college, so the two had discussed plans.

She didn’t know until after his death that his girlfriend had dumped him just before the suicide. He’d been drinking heavily that night and called a friend, who urged him to call his mom. But he never made that call.

“Obviously, he wasn’t thinking straight,” she says. “He was angry, upset, drunk, sad––all those things. But at the time, nobody really expected this to happen.”

Dr. Coffman wears a necklace with the letter “A” in memory of Aaron, who “gave the best hugs ever.” She describes him as “a super loveable guy,” who was a daredevil and enjoyed skateboarding. He was accepting of others and a good friend. He also was a great big brother to his half-sister, who was seven years his junior, she says.

“He was just a sweetheart. He would call me at times just to chat, which most boys don’t do,” she says, adding the step-family issues caused tension at times, as did Aaron’s troubles with alcohol and marijuana. “Sometimes things were strained, but we still managed to maintain a relationship through all that. We knew we loved each other.”

After Aaron died, Dr. Coffman says the pain was terrible, especially that first year. She wasn’t sure she could endure it and often found herself in her closet, her designated “crying spot.” She spent a lot of time in that closet, she says.

 “When it happens, initially, you don’t think you’re going to survive it,” Dr. Coffman says. “There’s no way around it…you have to work your way through it and own it. But even though you do, it still never goes away.

“It does get better,” she adds. “The really bad moments hit you less and less as the years go by. There are less triggers. I think it was the five-year mark when I figured out, ‘I can survive.’”

She also keeps a piece of paper tacked to a corkboard on her office wall. She doesn’t know who wrote it or even where she found it, but it has made a difference to her as a suicide survivor.

The typed words on the paper are simply put:

I don’t like it.

I don’t have to like it.

What I do have to do is make a choice about my living.

What I do have to do is accept it and go on living.

The choice is mine.

Dr. Coffman has read those words daily for more than 10 years as a reminder that the choice is hers.

Tackling the magnitude of this type of grief is different for everyone, she says. Some people do well with therapy, while others may not. Some may do better with families and friends who are present and just sit and listen. Try different things until you find what works for you, she says.

Something she learned early on at a grief support clinic and has found to be true is that there are three camps of people: Those who are hurtful. Those who are neither hurtful nor helpful. And those who are helpful.

“Go to the helpful, avoid the others,” she says for those grieving the loss of a loved one’s suicide. “There were some people that I had to just not communicate with because things they said were hurtful––things they didn’t mean to be hurtful. But, you know, things like, ‘God has a reason for everything.’ Well, when you have somebody die, there isn’t a good reason. That’s not helpful.”

What was helpful for Dr. Coffman was a supportive family and friends. Those who didn’t try to fix anything but would listen when she needed to talk and let her cry when she needed to cry. It made the difference because “it was somebody who really understood me, understood Aaron,” she says.

The family also continues to talk about Aaron, which was important, she says. They still laugh together about the “silly things he did.”

“Whether it’s the cousins or my parents or his brother or sisters…we still have memories and talk about them,” Dr. Coffman says. “I think that’s important––to keep that person alive in your heart. And I think it’s one of the hardest things for people who’ve not experienced something like this. They don’t want to say their name or talk about it because they’re afraid it’ll bring up something bad for you. Well, the bad is always there. But knowing people still remember him and can talk about him and remember the fun things about him, that’s important.”

Like many parents who lose children to suicide, Dr. Coffman also struggled with self-blame and guilt after her son’s death and battled her share of “what-ifs.” She needed reaffirmation that she was a good parent and a good person. That affirmation came from a woman who worked as a secretary at Cook Children’s Emergency Room at the time of Aaron’s death. The woman, who lost her brother to suicide, sent Dr. Coffman a letter, which she says she carried in her purse for many years.

In the letter, one of the things the woman wrote was, “We do the best we can with what we know at the time.” It’s a message that applies to most everything, she says, but as a grieving parent who lost her son to suicide, it was really helpful.

“I had to remind myself of that over and over because any mistakes I made as a parent weren’t intentional. They were done because I thought it was the right thing to do,” she says. “So, hearing that from her, in what she had gone through with her brother…when I would get into the depths of guilt, I would have to preach that to myself, and I would pull out the letter and reread it.”

The death of Aaron has had a lasting effect on Dr. Coffman and her family. It changed every part of her, and it was for the better, she says.

“I don’t think I could ever be the same person,” she says. “I always tell people it has changed me down to the molecular level. It affects every part of you. It can get changed for the worse…you can become bitter. Or you can choose to change in the sense of ‘let me learn from this, let me see what ways I need to change to be a better person.’”

After his death, she did a 180-degree turn on her parenting style “because it changes your ideas of what’s important and what’s not important,” she says. She became more accepting of others, something her son excelled at. And though she thought she was already a kind person, his death helped her become even more so, Dr. Coffman says.

She wants her son to be remembered and encourages others to talk to suicide survivors about their loved ones. It’s one of the most important parts in their healing process.

“It may help them to know that someone else is thinking about their child and has fond memories. And that that person, like Aaron, affected their life in a good way,” Dr. Coffman explains. “Especially when they die young and haven’t had the opportunity to really do a lot. But, even in a short life, they made a difference and still make a difference. Because (Aaron’s life and death) changed me. It changed my husband. It changed my daughter. It changed us to be better people.”

You matter

North Richland Hills resident Ellen Harris understands that sentiment. She lost her 22-year-old daughter Jordan to suicide on March 27, 2012.

Not long after, she and her husband Tom started The Jordan Elizabeth Harris Foundation to ensure their daughter would be remembered. The Fort Worth-based non-profit group focuses on suicide prevention training and awareness, as well as funding research efforts in depression.

“There’s no question that the foundation was and continues to be therapeutic for us because it’s our way to honor her life,” Harris says. “And to bring awareness to a subject that people weren’t willing to talk about.”

Jordan was a former valedictorian and National Merit Scholar in high school and named a Stamps Scholar at the University of Michigan, where she was about to graduate with a degree in organizational studies, a field that focuses on social justice. She had been diagnosed with depression the last six months of her life, which came as a surprise to the Harris family.

None of them would have described her as depressed. Instead, Harris used adjectives like “loving and joyful,” “funny,” “smart” and “full-of-life” to describe her eldest child of three, who loved to travel and help others.

“She didn’t want to worry us, so she never let on. I can remember my brother-in-law over Thanksgiving making the comment that she was the happiest depressed person he had ever known,” Harris says. “So, deep inside, she was struggling, and none of us knew the extent.”

Jordan had done well in college but wasn’t sure what she would do after graduation. She had high-performing roommates and friends who “all seemed to know what they wanted to do. And she didn’t, which weighed on her heavily,” her mom says. “I think she believed she was a failure.”

She had told her mom she was a disappointment to the family and hadn’t done much right in life. Which couldn’t have been farther from the truth, says Harris, adding she has no doubt her daughter was dealing with mental illness at the time of her suicide.

 “She became severely depressed, only I didn’t know what that meant,” she says. “I didn’t know what depression looked like.”

Looking back, she also believes Jordan had “hit a bump in the road” but didn’t have the resilience to overcome it, Harris says. Her daughter had excelled academically, had lots of friends and was pretty. Even though she worked hard for her grades, she hadn’t had to struggle for most of her young life, Harris says.

“I think resilience is a huge part of protection when it comes to suicide,” she says. “That’s part of my theory. I think she just didn’t have a good personal resource for bouncing back when she dealt with adversity.”

“It’s really important that children do (face adversity), even if it’s breaking up with a boyfriend or having acne or something that causes you to struggle a little bit,” Harris says. “I think you need to let your kids fail and figure out how to succeed again without you fixing it.”

Jordan’s death left an “enormous hole” in her heart, Harris says, and she faced a difficult time, especially in the early days. She still can’t watch a video of her daughter, and “I don’t know how long it took me before I could even look at a picture of her without feeling crushed,” she says.

For suicide survivors, it’s important to get a support system in place to help them because the suicide rate for people who have lost someone to it is higher compared to the general public, Harris says. While trying to cope with Jordan’s death, she and her husband tried therapy and various grief support groups but acknowledged that neither of them is much of “a sharer.” Reading books about people who had experienced what she had seemed to help her, she says.

And she immediately put her son and daughter, who were both attending the University of Texas at Austin at the time, into therapy to help them deal with Jordan’s suicide. Both were extremely close to her and devastated by her death. That seemed to help them cope with the loss of their big sister, Harris says.

“Whether it’s going to your church or wherever you find comfort, I think it’s important” to get support, she says.

 It took more than a year for Harris to feel comfortable in large social groups.

“I hated the look in people’s eyes, you know, how sorry they were but how glad they were that it wasn’t them. I mean, let’s face it, that goes through people’s heads,” she says.

Harris also saw firsthand the social stigma attached to suicide. One of the foundation’s missions is to address that issue. From the beginning, she and her husband didn’t try to hide that Jordan had taken her own life. So many people with similar stories approached her, but they had never let on about what really happened with their loved ones, Harris says.

“I think death and serious illness, in general, kind of bring out interesting traits in people,” Harris says. “There were people who didn’t come around and didn’t call because they were obviously uncomfortable with what had happened and with the subject of death, perhaps, and especially the death of a child.”

“But there were other people, who were not necessarily our best friends, who just really stepped up and supported us,” she says. “Some people don’t know how to talk about things like that, and death especially is a really difficult subject. But death by suicide––there’s still such a huge stigma attached to it.”

The foundation’s goal is to have conversations with the public to eliminate that stigma and create an understanding of what’s actually behind the act of suicide. For instance, a common misconception is that those who die by suicide are just selfish, Harris says.

But, in their minds, they’re doing the opposite of selfish, she says. Many of those who kill themselves think they’ll be a burden to their loved ones for the rest of their lives and everyone would be better off without them. With the love she had for her family, Harris says, Jordan wouldn’t have taken her own life if she had been thinking clearly or really understood what her family and friends would face for the rest of their lives.

“It’s not a selfish act on their part,” she says. “This is reaching a depth of hopelessness so deep that they can’t even see anything except how they get out of this pain.”

“They don’t want to die,” she adds. “They just don’t see any other way out.”

In today’s society, social media is a major part of life for all age groups. While some use the platforms to keep up with family and friends, others use the sites for networking and job hunting. For those 18 and younger, social media has changed the way young people communicate with each other, often leading to inappropriate use, and bullying among other things.

As part of Cook Children’s Joy Campaign, which aims to reduce the number of children and teens attempting suicide, we’re looking at the role social media plays in the mental well-being of young people.

Kristen Pyrc, M.D., medical director of Psychiatry Outpatient Services and the Partial Hospitalization Program at Cook Children’s, says the number of her patients dealing with anxiety and depression has significantly increased over the past year. She’s concerned that social media is playing a role, especially during the pandemic when young people are online more than ever.

“I have seen an increase in depression symptoms in teenagers who had not had them before,” Dr.Pyrc said. “So maybe I regularly see them for something like ADHD, and now they are showing symptoms of depression on top of that.”

Dr. Pyrc said she often hears complaints from parents that their children are ‘tied’ to their phones. She believes a major problem with that is a lack of exposure to seeing friends in person, and the opportunity for kids to feel left out when they see peers online having fun without them.

“I think online culture can worsen students’ feelings of loneliness and rejection because they see their friends doing things together without them in real time,” she explained. “Also we tend to post things that highlight what’s going well in our lives, but may not tell the full story of the times that we feel sad or inadequate. When teens are feeling down, seeing everyone else having fun without them can make them feel worse.”

Katie Greer, an internet safety expert, has spent the past 15+ years educating students, parents, law enforcement, and large companies across the country about the importance of online safety.

“I have seen social media used to bring out the best in humanity, but I have also seen it rip families apart in a matter of minutes,” she said.

Greer, who began her work as the director of Internet Safety with the Massachusetts Attorney General’s Office, believes social media has evolved in ways no one was ready for. Not so long ago, bullying was something that happened mostly at school. Now, young people are bullied online, in front of countless people. Even worse, a bully’s comments can be liked and shared by others.

“Kids were already spending a lot of time on their phones and online, then came a global pandemic. Now, they’re attending school online and relying on things like gaming online and social media platforms to connect,” Greer said. “There’s a lot more opportunity for cyberbullying and while it can start with one person, it can be a matter of seconds for others to jump in with a like or a comment and gang up on the victim.”

Situations like this increase a child’s chances of dealing with anxiety, depression, and self-harm.

“We know that developmentally, children’s brains aren’t fully formed,” she said. “When we put something in front of them as complex as social media, it’s almost as if we are asking for trouble.”

Greer also warns parents about the newfound TikTok culture.

“TikTok is a platform that has created unrealistic expectations about everyday life,” she explained.

She said children and teens see their peers or influencers having “perfect” lives and begin to feel as if they’re inadequate, or aren’t enough or worth it.

“Children have a desire to fit in and they want to have as much or more than their friends,” Greer said. “When children see their friends flaunt material things, or lavish experiences, that can make them spiral.”

Another issue putting kids’ mental health in danger is ‘sexting’ or the exchange of nude photos and videos, which has become quite prevalent.

“I recently was made aware of an incident where a girl sent a guy nude photos and he leaked them. Once they were leaked, so many people saw them, the young girl was humiliated,” Greer recalled. “The family reported that this led to the young girl untimely killing herself out of embarrassment and humiliation that her photos were leaked.”

Greer said, in cases like these, it is vital to remember that not only does suicide hurt a family, it also tears apart the people who loved and supported the victim.

Cook Children’s launched the Joy Campaign, which this story is a part of, to bring awareness to the increase in suicides and suicide attempts being seen at the medical center. In 2020, seven Cook Children’s patients died of suicide, making suicide the leading cause of traumatic death for the first time ever. The hospital has also seen record numbers of patients being admitted for suicide attempts month after month, most recently in March when 43 children and teens were treated for injuries. While the increase in suicide attempts cannot directly be tied to the pandemic, Dr. Pyrc said children need certain things to properly function in day-to-day life.

“Kids need in-person interactions. They need sunshine and exercise and all things encompassing,” Dr. Pyrc said. “Whenever your world is mostly virtual, it can hurt both your physical health and mental health.”

What does Greer suggest parents do? Stay alert and ask questions.

“A simple, “How was your day?” or “How are your friends doing?” can go a long way in opening the lines of communication,” she said.

She emphasizes knowing what your child is looking at online and know who they are talking to. If you are concerned about your child’s safety, there are measures you can take.

“While I am typically against this and wouldn’t always recommend it, there are ways parents can use apps that will mirror their children’s phone,” Greer said. “I do believe this could hurt the trust between a parent and a child, and isn’t the best way to go about typical monitoring, and I only recommend phone mirroring for dire situations.”

Before leaving any session, Greer reminds everyone she speaks with about the importance of a trusted adult.

“I tell parents and all adults it is important that children have a trusted adult they know they can come to at all times. Parents have to be okay with the fact that the adult may be someone other than them, it is all about a child feeling safe and opening up,” she said. “I also remind every child that I come in contact with that having an adult you trust is one of the most important things you can do to protect yourself and even help a friend.”

Both Greer and Dr. Pyrc see the issue and know there is a lot of work to be done to ensure we are helping our children with their new reality. Both professionals share their tips to help parents and families better support their children.

1. Take your child’s phone before they go to sleep at night. Disrupted sleep has a negative impact on adolescents.
2. Have an open dialogue with your child without judgment and give them the ability to freely express themselves to you. Given the amount of time kids are online, these conversations should happen every day.
3. Ask about their social media. Talk to your child about what they’re seeing, how it impacts them/makes them feel, and know who they’re communicating with.
4. Ensure your child can identify a trusted adult and make sure they understand that an adult can be their go-to person at all times.
5. Talk to your child about good social media etiquette. Remind them if they see something, say something and describe how that can help save someone’s life.
6. If you believe your child is in danger, there are apps available that can monitor their phone so you can see everything they see and get them the help they need immediately.
7. Reach out for help. Do not wait until your child is in a dire situation to reach out for help and get them the resources that could save their life.

Monitor your child’s social media, and make sure you have their usernames/passwords in case of an emergency situation.

Important to note:

Instagram has an anonymous reporting tool that allows users to report when they believe something could be wrong with a friend. The site sends the person resources depending on what was reported on their behalf. These resources could be vital in saving someone’s life by simply reporting.

One year into COVID-19, it’s clear the pandemic is taking a toll on the mental wellbeing of children and teens.

In March, a record 43 patients were admitted to Cook Children’s Medical Center after attempting suicide. This staggering figure is nearly double the number of suicidal patients seen during the same time period of 2020. Even worse, kids are dying. Last year, Cook Children’s recorded seven suicide deaths, marking the first time suicide was the leading cause of trauma deaths at the hospital, surpassing child abuse and car wrecks.

“The mental health crisis was already happening, then it met a global pandemic and these are the consequences,” said Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s.

“They’re less engaged and have less interaction with others, and instead are spending more time online and in virtual settings. And it’s hard for them to be hopeful about anything because so many things, like prom and graduation parties, are canceled.”

The issue is not unique to North Texas. Doctors and nurses from across the nation are reporting similar statistics. In February, NPR released an article titled “Child Psychiatrists Warn That The Pandemic May Be Driving Up Kids' Suicide Risk.” It found that children’s hospitals across the U.S. are seeing up a 250% increase in suicidal patients in emergency rooms since the pandemic began. While there are no nationwide numbers on child suicides in 2020 available yet, experts agree there is reason to be concerned.

The Impact

More children are suffering from stress, anxiety, depression, and suicidal thoughts than at any time in recent memory. Pediatricians like Kathleen Powderly, M.D. from Cook Children’s Pediatrics Magnolia say children as young as 7 are needing help.

“I’ve had a couple of elementary school students, which you don’t see very often, who are actively suicidal or have already had a suicide attempt. I’ve also managed more kids on antidepressants since the pandemic because it’s hard to get into doctors right now,” Dr. Powderly said. “COVID-19 is not as impactful in terms of volume of cases in pediatrics, but our volume of psychiatric patients has increased quite a bit.”

Previously, Dr. Powderly was the medical director of Cook Children’s Hospitalist Group, the attending physicians who care for children in the hospital. She says her team was seeing an increase in suicidal patients before she transitioned into the office setting five years ago and that the pandemic created a perfect storm. On top of the stressors kids were already dealing with, they’re now struggling with isolation, virtual school, and a loss of activities.

“We’re not going to be able to flip the switch and just go back to normal when this is over,” said Dr. Powderly. “This is going to take some time to come out of. I’ve even had patients tell me they’re struggling with being around people.”

Members of Cook Children’s Youth Advisory Council shared similar experiences in a recent meeting. The teens said they feel more anxious being around their friends in person because they’re so used to only seeing people online now. In addition to new stressors, there is a severe lack of mental health resources across the board.

A Growing Need

“There weren’t enough psychiatric beds to begin with, and then COVID happened and the capacity was reduced because you can’t have patients sharing rooms,” said Dr. Pyrc.

The need for more inpatient psychiatric beds for children and teens has been known for years. In 2017, Cook Children’s opened the Rees-Jones Behavioral Health Center to help address the issue. The unit has 15 inpatient beds available for children between the ages of 2 and 12. As we reported when the center opened, the kids who end up here are patients with complex trauma, medical and social needs. They are often suicidal or have tried to hurt someone else. Eight out of 10 have had something traumatic happen to them. They have either been abused physically or sexually, or they have experienced some sort of neglect.

Teenagers who need inpatient psychiatric care have to be treated elsewhere but often end up waiting on the medical floor of Cook Children’s until a bed opens up in the community, which can take days. With more kids needing these services, it’s not uncommon for Cook Children’s to have a dozen or more patients waiting in a regular hospital room for a transfer to a psychiatric facility that can care for them.

“There are just not enough resources in general,” said Dr. Pyrc. “It’s an awful place to be in. This is a national problem, but it affects us here locally. We need more funding and we need more mental health professionals to care for these patients.”

On the outpatient side, finding a licensed therapist to see a child can take months. The waitlist just to see a counselor at Cook Children’s can be as high as 250 days at any given time. Even with easier access to appointments with virtual visits, there are not enough mental health professionals to meet the need.

Kia Carter, M.D., co-medical director of Psychiatry at Cook Children’s, has been a vocal advocate for increased mental health funding. Testifying in front of the Texas Senate’s Committee on Health and Human Services recently, she said early identification, intervention and treatment is essential to preventing further complications from mental illness. But there are roadblocks.

“We get insurances denying a specific level of care saying that a child doesn’t need an inpatient level of care. We also get a lot of pushback about medication,” Dr. Carter said.

She also asked lawmakers for increased support and to consider giving mental health care providers more leverage with insurance companies.

Hoping for JOY

In the meantime, Cook Children’s aims to bring awareness to the mental health crisis affecting children and teens with the launch of a new suicide prevention campaign.

The Joy Campaign is an acronym that stands for:

Just breathe.

Open up.

You matter.

“If we can just get kids to slow down, realize that what they are experiencing is temporary and that they have a long life ahead of them, I think we can make an impact,” said Dr. Powderly.

For the next month, Cook Children’s will be releasing a series of articles on Checkup Newsroom weekly that address many of the issues at play, such as the pandemic, the role of over-the-counter medications, social media, as well as how minorities and LGBTQ+ young people are impacted. We’ll also be speaking with families who have lost a child to suicide to examine the effects on parents and siblings.

If you feel your child might be struggling, here are some of the warning signs to watch for:

• Anger
• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness
• Giving away possessions 

If you’re concerned about your child’s mental health, seek help early. Schedule an appointment with a licensed counselor. If your child is actively suicidal, call 911 or take them to the nearest emergency room.

Read this story in Spanish here.

The past nine months have been marked by upheaval, uncertainty, isolation and change with the youngest among us feeling the weight of it all, and doctors at Cook Children’s Medical Center are sounding the alarm.

“I’ve been employed as a psychologist at Cook Children’s going on 26 plus years and never in my time have I seen such an intense number of patients with severe anxiety and depression,” said Lisa Elliott, PhD, manager of the behavioral health clinic at Cook Children’s. “It’s not uncommon for us to have high acuity patients periodically, but that’s become the norm for weeks and weeks where 70 to 80 percent of our total number of visits for anxiety and depression are severe.”

Dr. Elliott attributes the uptick, in large part, to fallout from COVID-19. 

A June 2020 survey of parents published in the medical journal “Pediatrics” revealed that, since the start of the pandemic, more than 1 in 4 parents reported a decline in their own mental health, and 1 in 7 reported worsening behavioral health in their children. Both a decline in parental mental health and child behavioral health were reported by 1 in 10 families, according to the study “Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey.”

Cook Children’s mental health experts say screen time, social media, academic performance pressures and lack of sleep all stress a child’s mental and behavioral health. All of those stressors have been exacerbated this year by pandemic-induced factors such as school closings, virtual learning, social distancing and isolation, according to Kathleen Powderly, M.D., a pediatrician on the medical staff at Cook Children’s. If ignored, these pressures can be a breeding ground for anxiety and depression.

And mental health experts are bracing for what is yet to come during the holidays as it’s not uncommon to see an uptick in depression and anxiety in children this time of year, particularly when there has been a significant family change, like in the case of divorce or loss of a loved one, according to Dr. Elliott.

So what is a parent to do? How do we help our children process these pressures to protect their mental and emotional well-being?

“We have to instill hope and stay calm and reasonable about it and, at the same time, not show fear.” Dr. Elliott said. “This is critical because we are going to set the tempo for our children. We will be what they follow. So it’s critical that we are calm and follow the safety guidelines, but tell our children this is not the way it’s going to be forever.”

And what better time than the holidays to model, teach and inspire hope?

Generosity Breeds Health and Hope

As stressful as the holiday season in tandem with a pandemic can be, it also presents a unique opportunity to teach children a concept that studies show actually improves mental health. It’s long been known that generosity and giving incite the same increase in one’s happy hormones as exercising. Giving makes you feel good—emotionally and mentally.

“Research shows that in addition to eating healthy and getting quality sleep, there are three things we can do to help keep depression at bay,” Dr. Elliott said. “One of them is exercising and another is socializing because they both increase endorphins. But the one that has the most long-lasting impact is philanthropy work. Doing things for others.”

A 2018 study published in the journal “Psychosomatic Medicine: Journal of Biobehavioral Medicine” showed a correlation between giving and increased activity in parts of the brain associated with altruism, reward and parental care and behavior. It further demonstrated that acts of generosity toward a targeted, or known, individual in need resulted in reduced activity in the amygdala—a positive given the amygdala is an emotion processing brain structure that signals the fight-or-flight mode when under stress. Increased activity in the amygdala is often seen in individuals with anxiety.

In addition to the chemical reactions philanthropy produces in the brain, doing good for others can help reframe one’s focus. Seeing the pain, suffering and circumstances of others gives perspective on one’s own struggles.

“Volunteer work helps create compassion because it draws concern away from ourselves,” Dr. Elliott said. “That’s why doing for others is so valuable for children. It teaches them compassion and optimism, and helps them develop gratitude.”

It also promotes the concepts of empathy and resilience, which are important building blocks for emotional and mental strength and valuable coping skills that help children deal with other challenges that come their way, according to Dr. Elliott.

This year, the need for generosity and service to others is especially great, given the economic impact of the pandemic. COVID-19 safety guidelines may require outside-of-the-box thinking to safely, yet personally, meet a need, but don’t let that stop you. It’s a great opportunity to get creative with your child.

With the help of Cook Children’s certified child life specialist Lauren Lasrich, MS, CCLS, we’ve compiled a list of ideas to help you and your family get started.

• Pack a grocery bag full of items and ingredients needed for Thanksgiving dinner for a neighbor in need. Let your child help create the menu and shop for the items together, either online or in the store. Deliver the groceries to their doorstep with a homemade card created by your family/child.
• Gather the family to rake leaves and clean up the lawn of an elderly or disabled individual. You’ll help a friend and get some sunshine and exercise for yourself and your family at the same time. Sunshine and physical activity are mood boosters!
• Adopt a family in need for the holidays. Check with your child’s school to see if they collect Christmas gifts for students in need and offer to purchase something on the student’s/family’s wish list. Get your child involved in the shopping process, be it online or in store.
• Together with your child, research a local organization or charity that promotes a cause you connect with and find out how you can help them meet the needs of those they serve. Create a family donation jar and save change to donate to the charity.
• Organize a neighborhood food drive and collect non-perishable food items from your neighborhood to donate to a local food pantry. Let your child decorate a donation box and put it on your porch so that your neighbors can safely deliver their donations.
• The end of the year is a great time to reduce and reuse! Go through your house and collect gently used household and clothing items you no longer need/use to donate to a local charity.
• Write letters/draw pictures to deployed military members or health care workers. For information on how to do this, or other ideas for supporting our troops, check out How Can I Support the Troops? 5 Ways You Can Help Deployed Soldiers at uso.org.
• Do a drive-thru Christmas caroling tour in your neighborhood. Let your neighbors know ahead of time when you plan to be out caroling so they can step outside and enjoy the show. Decorate your car ahead of time as a festive and fun family activity.
• Make toiletry kits and donate them to a local homeless shelter.

Not only will these activities help others, but they’ll give your child a project to look forward to.

“I tell people, especially during the pandemic, you have to have one thing to look forward to,” Dr. Powderly said. “It may not be the same thing that you enjoy previously, but you have to have something to look forward to because it gives you hope, and that’s what we all kind of need a little bit more of right now is hope.”

What to Watch For

Knowing the signs and symptoms of anxiety and depression can help you help your child before things get severe. For children, look for three or more of these symptoms, according to Dr. Elliott:

• Excessive worry for more time than typical. The difference between normal worry and anxiety disorder is the severity.
• Difficulty controlling worry.
• Easily fatigued.
• Restlessness and difficulty concentrating.
• Irritability.
• Muscle tension.
• Sleep disturbances.
• Sudden change in grades and school performance.
• Disinterest in a previously loved activity.

If your child is experiencing any of these symptoms and you are concerned about their mental or behavioral health, Cook Children’s is here to help. To access any of the hospital’s behavioral health services, call 682-885-3917. For emergencies, call 911.

“September of 2020 has been the highest month ever that we've seen suicidal patients admitted to our medical center,” said Kia Carter, M.D., medical director of Psychiatry at Cook Children’s. “We've seen this number rising year after year, so it's not surprising that it's this high. Suicide has become the second leading cause of death for kids and adolescents in the last year, versus two years ago when it was the third leading cause of death.”

This news comes after a near-record month in August when 29 patients were admitted for intentional suicide attempts. The patients admitted to Cook Children’s in September were between the ages of 6 and 18 years old. Dr. Carter says she feels the pandemic has played a moderate role in the increase, but that we typically see higher numbers in the fall months when kids return to school. In September of 2019, for example, Cook Children’s admitted 32 patients for suicide attempts.

“We've definitely seen this number rising in the last five years, but I do think that the amount of stress that we as a society have experienced in the last six months has caused some of our kids and adults to struggle more,” said Dr. Carter.

Virtual school may also be playing a role in mental health of kids. The Rees-Jones Behavioral Health Center at Cook Children’s has become a resource for children and teens who report feeling hopeless and not knowing how to cope with the isolation the pandemic has caused.

“I think everything in proportion is good, but when something is to this extent where some kids have had to do 100% virtual since March, it’s been very difficult,” Dr. Carter explained. “When kids have school, they have an outlet. They have other people to talk to. They have friends and social activities. Now, it’s just them, their parents and siblings.”

She says it’s important to know that some kids do very well with virtual learning, but it’s up to parents to know what works best for their child. Also, some families may have to choose virtual learning if the child or another family member falls into the high-risk category for COVID-19. In that case, parents should remember to ask for help when they need it. School counselors, nurses, teachers and their pediatrician are all great resources.

Warning Signs

Dr. Carter says the biggest thing to look for is a change in your child’s behavior, which she acknowledges can be difficult during the pandemic. She says little things like sleeping more than usual or not wanting to engage or interact in activities they used to enjoy can be signs of depression.

“Start engaging a little more and check in, like ‘Hey, are you feeling okay? I noticed you were getting a little angry at us for no reason,'” she said.

While it’s easy to write off irritation as a side effect of being a teenager, it is one of the primary symptoms of depression in children and adolescents.

Other signs to watch for include:

• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness

Dr. Carter says girls are more likely to be hospitalized for attempting suicide, but boys tend to make more lethal attempts. As for age, Cook Children’s data shows 14 to 15 years old is the average for suicide attempt admissions, but more recently, the majority of patients have been around 12 to 13 years of age.

With many kids at home alone due to COVID-19, increased access to things like medication, firearms and the internet may also be contributing to the increase in patients. Dr. Carter says her team has also seen more patients participating in social media challenges where kids are hurting themselves.

“We have seen a rise in cutting behaviors, which are a form of self-injury. This is not always considered a suicide attempt but more of a maladaptive behavioral response to stress.”

She says these are things often picked up on social media, reinforcing the importance of knowing what your child is looking at and who they are talking to on the internet.

What Can Parents Do?

Get help.

If you’re concerned for the immediate safety of your child, take them to an emergency room. Trained professionals will evaluate your child to see what next steps need to be taken.

If you’re concerned about your child’s mental health (but not that they will harm themselves), you can contact your pediatrician, school nurse or counselor for a list of outpatient resources in your area.

If you feel your child may need a higher level of care (but it’s not an emergency), you can call Cook Children’s Behavioral Health Intake Department at 682-885-3917. Our team will help arrange referral for outpatient therapy and medication management, partial hospitalization day treatment options or inpatient treatment if needed.

Partial hospitalization allows children to receive treatment including medication management, family and group therapy at the Rees-Jones Behavioral Health Center during the day, while allowing them to go home at night. Children who are deemed an immediate danger to themselves may be admitted to the inpatient unit for 24/7 monitoring and treatment. The Rees-Jones Behavioral Health Center, is one of the few places in North Texas that offers inpatient psychiatric care for children between the ages of 2 and 12.

“Our biggest hope is that we can help families find the support and resources they need, and that we can educate our school systems about warning signs and screenings because they are hopefully going to come in contact with those kids before we do,” said Dr. Carter. “We don't want the numbers to continue to rise and we continue to lose our children. Remember that suicide is preventable.”

“We've definitely seen a high number of adolescent suicide attempts over the past couple of months, especially during COVID-19,” said Kia Carter, M.D., medical director of psychiatry at Cook Children’s Medical Center. “We've also seen younger kids endorse suicidal ideation.”

At Cook Children’s, the vast majority of patients treated for self-harming are girls, typically between the ages of 13 and 15. But Dr. Carter says she’s had patients in her unit as young as 4 years old talking about wanting to die.

“We've seen a huge increase with younger kids knowing what death is because of video games,” said Dr. Carter. “We have to assess their cognitive level and find out if they know what death means or do they think it’s like the video game where they die, but get a backup player.”

So far in 2020, 192 kids have been admitted to Cook Children’s for attempting suicide. Compare that to the same time period in 2015 when the hospital saw 88 patients - less than half of the current statistics.

Unfortunately, the data from Cook Children’s Behavioral Health Center is in line with a new study from the Centers for Disease Control and Prevention (CDC). The article, released Sept. 11, shows suicide rates among 10 to 24 year olds have increased 57.4% from 2007 to 2018.

"It's a real trend that has been demanding, for a while, a serious public health and research effort to understand what is happening and why," said Anna Mueller, an associate professor of sociology at Indiana University Bloomington. In an interview with USA Today, Mueller said she doesn’t buy that it’s just social media, though we do know many children express anxiety and depression linked to social media.

“Social media plays a big role in the mental health of children and teens,” said Dr. Carter. “They experience bullying online, they may not feel self-worth because they’re comparing themselves to what they see on Instagram. They’re also getting ideas on the internet about how to harm themselves.”

Dr. Carter says social media and sites like YouTube have made self-harm almost acceptable. She says children are looking to those avenues to find out how many pills to take or other ways they can attempt suicide.

“A lot of kids will research how much medication to take to not wake up,” said Dr. Carter. “I would say 99% of the overdoses we see have some over-the-counter component.”

Since January, 31 children have been admitted to Cook Children’s for ingesting too much Benadryl. At least three of the Benadryl overdoses are linked to a TikTok challenge, but the majority of cases were among patients intending to harm themselves. Other drugs commonly found in medicine cabinets such as Tylenol, aspirin and ibuprofen are also frequently used.

So why do children and teens take these drastic measures?

“When people feel like they're not going to get better and there's no way out, they tend to go to these levels,” Dr. Carter explained. “I think the biggest thing is hopelessness. When kids feel like they don't have anyone to talk to, they don’t feel like they can communicate with their parents or they’re getting bullied and they don’t have a social circle. Some kids also are struggling with gender and sexual identity.”

About 30% of the children assessed by Cook Children’s Behavioral Health Center report issues with gender or sexual orientation. Among those are patients diagnosed with gender dysphoria, a feeling of discomfort or distress that can occur when someone feels their gender identity differs from their sex.

“There are some kids who physically don't feel comfortable in the body they're in and they don't feel that they relate to the other girls or the other boys. We see this occur a lot around age 10,” said Dr. Carter. “A lot of times parents feel like it's a phase, and that might be true, but I would encourage parents to not minimize it because kids can begin to feel hopeless.”

She suggests parents keep an open mind, listen to their children and get them in to see a licensed professional counselor. And she says it’s ok to not agree with their feelings, but to share those thoughts with your spouse or a friend instead of the child.

“If you're resistant to it, your child's going to shut down and that can cause a whole realm of depression, hopelessness and not wanting to be alive anymore,” she said.

With COVID-19 and social distancing, spotting signs of depression and hopelessness can be challenging. Things that may have seemed out of the norm in the past, like avoiding social activities, may not be so odd now. But Dr. Carter says watching for changes in behavior is still key.

“Most kids still want to play video games and have their cell phones, so if they don’t want a new video game and all they want to do is sleep, you’re going to want to assess where that change is coming from,” she said.

Other signs of depression to look out for include:

• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness

If you feel your child needs help, please talk to your pediatrician or call 682-885-3917 for a referral to Cook Children's Behavioral Health Center.

In her more than 25 years at Cook Children's, nothing prepared Lisa Elliott, Ph.D., a licensed psychologist for the past few months. She calls them "the most challenging time I've had in all my years at Cook Children's concerning patient needs."

Since the end of school, many pediatricians, psychologists, psychiatrists, and other health care providers are seeing an uptick in teenagers with signs and symptoms of anxiety, depression, and other severe health and mental issues.

During three weeks in May, Elliott met with children she says were contemplating suicide and another she believes attempted suicide. She also made three calls to Child Protective Services, and she phoned the FBI and Exploited Children for the same case: a sexual predator attempting to get sexual pictures.

Joy Crabtree, Psy.D., and a licensed psychologist at Cook Children's, echoes many of the same sentiments as Elliott.

Crabtree's seen an increase in anxiety and depression in her adolescent patients, as well as more anxiety in younger children. Crabtree believes social isolation, being away from school (or "typical school"), and out of a routine are all things that have contributed to children's mental state right now. 

Amani Terrell, M.D., a Cook Children's pediatrician in Keller, agrees that the coronavirus has brought a tremendous degree of turmoil. 

"The sheer uncertainty of the pandemic can create fear and anxiety in anyone, especially in the face of ever-changing recommendations and expectations," Dr. Terrell said. "This microscopic, invisible monster has created a global threat to health care and the economy and has forced unprecedented interventions, including lockdowns, school closures, and pleas for social distancing. As a consequence, many of us are starting to see an uptick in teenagers with signs and symptoms of anxiety and depression.”

"The cancellation of important school events like prom and graduation can be devastating to an adolescent. Kids can feel disconnected from friends and classmates," Dr. Terrell said. "Some teens may be internalizing the stress and anxiety of parents and caregivers, who may be struggling emotionally and financially. Many youths who have already struggled with mental health issues may have exacerbations of their symptoms as a result of social isolation. They may not have easy access to counseling or other therapies."

Dr. Terrell urges parents to recognize the signs and symptoms of mental health problems (which sometimes can be confused with typical teen behavior). If they notice these problems, she advises parents to seek professional help from their child's pediatrician. Unchecked, teens with depression may be unable to cope emotionally, which can lead to dangerous behaviors, such as alcohol/drug abuse and sex. It increases the risk of suicide or self-harm. 

Our experts encourage parents to watch for any change in a child's mood. Parents may notice sadness, depression, hopelessness, irritability, anger, and hostility. You may see more tearfulness and changes in activity levels. Watch for more withdrawal from friends and family, change in friends, and loss of interest in activities once enjoyed. 

Other signs include sleep disturbance, change in appetite, restlessness, agitation, fatigue, lack of energy/motivation, feelings of worthlessness, and guilt. Depressed kids may have difficulty concentrating, making decisions, and may even see a drop in grades. 

Always be aware of signs of depression and keep a close eye on your child. Never ignore symptoms. If you see signs of depression, contact your physician and obtain referrals for a psychologist or therapist trained in pediatric and adolescent care. 

If a child is talking about suicide, get help immediately. It is critical not to ignore this cry for help regardless of their reasons. 

Know that if your child is struggling with a chronic illness, including depression, it will impact the entire family. Families will require a lot of support: emotional, financial, and physical. Most importantly, the support needs to be ongoing. It's important to allow family members to vent frustration and grieve. Therapy is beneficial. If your teen is struggling with this problem, the entire family will need help to get through it. 

If you feel your child needs help, please talk to your pediatrician or call 682-885-3917 for a referral into Cook Children's Psychology department.

Referenced from AAP- How to Recognize Signs of Depression

Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s, realizes suicide in children and adolescents is a difficult topic for most parents. But she stresses it’s one that can’t be ignored.

“As a mental health professional, my worst fear is a child prematurely ending his or her own life,” Dr. Pyrc said. “As a mother, it is hard to comprehend the profound grief families must feel in the wake of a suicide.”

A study published by the American Academy of Pediatrics found that kids ages 5 to 17 were admitted to children’s hospitals for thinking about or trying to kill themselves twice as often in 2015 as 2008. 

Statistics show suicides among young people can happen at almost any age. Suicide is the second leading cause of death for children, adolescents and young adults, ages 5 to 24 years old.

Because of these numbers, the American Academy of Pediatrics has updated its guidelines to recommend pediatricians routinely check for signs of depression in their young patients. The focus is to carefully screen patients ages 12 and over during annual checkups.

Brad Mercer, M.D., a pediatrician at Forest Park, calls the recent focus on mental health “a wake-up call” to American pediatricians and family practitioners who treat kids, especially adolescents. He said more health care providers must make time to ask children about depression and suicidal thoughts.

“We must address the mental health problems in our youth as a preventive measure,” Dr. Mercer said. ““As pediatricians, we have to take the time to interact with teens and take the time to screen for these conditions during regular office visits,”

Cook Children’s has taken several steps to screen patients throughout its system:

• Cook Children’s offers the American Psychiatric Nurse’s Association Competency Based training (6.5 hours) on suicide assessment, intervention and prevention. 
• Patients are screened at the initial intake assessment and throughout the stay on inpatient psychiatry and Partial Hospitalization Program (PHP).
• The Emergency Department (ED) and the Department of Psychiatry have combined their efforts to begin screening all patients who present to the ED ages 10 years and older, regardless of the child’s presenting problem. The staff also uses an evidence-based screening tool called the “Ask Suicide Screening Questionnaire-ASQ.
• Cook Children’s also screens for mental health issues and/or suicide in outpatient clinics (primary care and specialty), as well as screening for suicidal thoughts at each Psychology outpatient visit.

“This process has already identified several children with mental health issues and at risk of suicide that may not have previously been identified. We know that screening for suicide risk, referring to the appropriate level of care, providing a safe environment with skilled staff observation for high risk patients, and offering suicide education is imperative to address suicide prevention,” said Lisa Farmer, director of Psychiatry at Cook Children's.

Vanessa Charette, M.D., said she and her fellow pediatricians at Magnolia, screen every patient at well-child checkups, ages 12 and up for depression.

“I have found it is a good way to signal to kids and parents that we are open to talk about this and want them to ask us about it,” Dr. Charette said. “Even if on the well check nothing comes up, often a parent will return with the teen later wanting to talk about anxiety and depression. I believe the screen helps open that door and the conversation. I also find for teens that are not having any signs of depression/anxiety and wonder why they are doing the screen it still opens a conversation. I then talk about how it is great that they are doing well but that many kids are not. Parents appreciate this – it helps open why some other kids might be depressed, what can be done to prevent it and helps with empathy for others.”

More On This Topic:

• New Behavioral Health Center Offers Hope for Children in Crisis
• Pediatrician Calls Focus on Children's Mental Health a 'Wake-Up' Call
• Dramatic Spike In Children Attempting Suicide
• Pediatricians Urge Screening for Depression at Well-Child Visits
• Kidness Matters. How To Teach Your Child Empathy
• The Death of Ethan
• 13 Warning Signs of Teen Suicide
• Don't Ignore CDC's Suicide Report

Cook Children’s has been utilizing intranasal ketamine as a rescue treatment to break unrelenting migraine attacks in the emergency room and inpatient setting since December 2016. Originally, the drug was utilized out of necessity due to a shortage of dihydroergotamine – the medication previously used most frequently for persistent migraine attacks which failed to respond to outpatient therapy. The team presented their findings at the International Headache Conference in 2017.

“Until that time, little to no experience with nasal ketamine had been reported in pediatric patients,” said Adrian Turner, a clinical pharmacist at Cook Children’s. “However, our institution’s experience is broadening the horizon of potential treatment options.”

Now the U.S. Food and Drug Administration has approved esketamine, a chemical compound similar to the anesthetic ketamine, to relieve depression in hours instead of weeks. The drug, the first to be approved to fight depression since 1988, is believed to help patients who have been treatment resistant to other depression therapies.

Esketamine, developed by Johnson & Johnson, will be marketed under the name Spravato® and is a nasal spray that allows the drug to be absorbed through the lining of the nose, directly to the blood stream.

Patients using Spravato® will also be required to enroll in a Risk Evaluation and Mitigation Strategy (REMS) program to monitor for serious side effects related to sedation, dissociation, abuse/misuse and to support its safe use. Patients will be required to self-administer the drug under direct observation of a healthcare provider.

“This is potentially a game changer for millions of people,” Dr. Dennis Charney, dean of the Icahn School of Medicine at Mount Sinai in New York, told NPR. “It offers a lot of hope.”

At this time, no plans have been made at Cook Children’s to use ketamine for depression, but intranasal ketamine has been vital for helping patients with severe migraines.

Intranasal ketamine for migraines not only worked for a majority of Cook Children’s patients (almost 70 percent of patients between December 2016 and October 2017), but was safe and well tolerated. Any side effects seen, some dizziness and very mild dissociative effects (i.e. feeling funny, out of body experience) were mild and didn’t last longer than one hour after administration.

No patient had to stop due to side effects.

Turner said using ketamine for migraine offers many benefits:

1. Patients don’t need an IV or injection to receive treatment.
2. The number of medications needed to treat the pain may be reduced.
3. The time needed to treat the pain may be reduced.
4. It provides patient with a wider variety of options to treat their migraine.

Ketamine was first created in the 1960s and was largely used as a battlefield anesthetic and veterinary medicine. By the 1980s, hospitals were using the drug for sedation and severe pain.

Until recently, the FDA approved the drug in patients 16 and older for general anesthesia (dental procedures, outpatient surgery, intubation). Compared to other medications used for sedation/anesthesia, ketamine is relatively safe due to less effects on breathing and blood pressure.

In the past few decades, ketamine became the focus of studies for the treatment of depression. The Department of Health and Human Services reported an estimated 16.2 million adults and 3.1 million adolescents aged 12 to 17 in the United States had at least one major depressive episode. This is especially important when considering the rates of suicide. In 2016, the Centers for Disease Control and Prevention (CDC) reported suicide as the number 10 overall cause of death with more than 44,000 deaths attributed to suicide reported. Even more troubling, suicide was reported to be the number 2 overall cause of death for people aged 10-34, number 4 for people aged 35-54, and number 8 for people aged 55-64.

“Expanding treatment options is not only beneficial to improve the quality of lives of patients with depression, but it may also help save many lives in the future. Depression can be very difficult to treat,” Turner said. “Compared to other diseases and diagnoses, depression is not a one-size fits all treatment. Expanding the treatment options is a huge benefit to patients who have exhausted several treatment options with little to no relief.”

Aside from the new indication for depression, ketamine and esketamine both have potential use in post-traumatic stress disorder (PTSD), migraines, refractory/chronic pain conditions, and seizures. There are active studies underway in the U.S. and internationally examining the use of ketamine to treat PTSD, status epilepticus, and oral ketamine to treat chronic pain in adults and children. Cook Children's Pain team is currently treating patients with chronic/refractory pain with a ketamine IV and oral ketamine.

Some may know ketamine as a party drug. Ketamine (also known as Special K, Super K, and Vitamin K among other street names) is known as a potential drug of abuse and a drug used to facilitate sexual assault crimes. When taken illegally, users often inject, snort, or smoke the drug to feelings of calmness and out of body experiences.

Unfortunately, because these are often taken in very large doses, users also experience complications such as hallucinations, immobility, amnesia, and unconsciousness. It’s especially dangerous when given in very high doses or mixed with other drugs and/or alcohol because this greatly increases the chances of serious health problems and/or death. The World Health Organization notes that ketamine is a potential drug for abuse, but the actual incidence of dependence or overdose is rare. Chronic abuse has been linked to urinary tract problems.

But under the guidance of health care providers, ketamine has been highly beneficial.

“Our experience with ketamine has been positive,” Turner said. “The success we have seen at Cook Children’s combined with the approval of esketamine for refractory depression is very exciting. As a health care professional, it is invigorating to see years of research produce positive outcomes for our patients. I look forward to seeing Cook Children’s on the forefront of contributing to this new frontier. ”

When he began his practice 23 years ago, Dr. Mercer saw the occasional ADHD patient out of necessity. But he rarely treated a child’s anxiety, depression or mood disorder.

Because of a national shortage of child psychiatrist and psychologists, pediatricians are being asked to take on more responsibility of looking at a child’s mental health. It’s a challenge that Dr. Mercer welcomes.

“Twenty years ago, most pediatricians referred those kids to a psychiatrist or psychologist,” Dr. Mercer said. "Today, 10 to 20 percent of my day is dedicated to treatment of those conditions. I had to step out of my comfort zone to help these kids and their families because the system has become overwhelmed and there aren’t enough mental health providers out there to take them all. I had to learn more and become better educated myself to help these kids. So, we pediatricians must now step up to meet this demand. I can tell you that at Cook Children’s Forest Park, we are very concerned about our patient’s mental health and we will ask the children we see about their symptoms. We’ll do our best to help with treatment and support. We want your children to grow up happy and well-adjusted and to live in an environment where they can feel safe.”

In any given year, 13 to 20 percent of kids have a mental, emotional or behavioral disorder, according to the American Academy of Child and Adolescent Psychiatry.

But only about 20 percent of those with mental, emotional or behavioral disorders receive care from a specialized mental health provider.

A recent report from the Centers for Disease Control and Prevention found that more Americans in every age group, from 10 to 75, are died by suicide. And the journal Pediatrics published an article that hospitalizations for suicidal thoughts and attempts double from 2008 to 2015 in the United States.

Dr. Mercer calls the recent focus on mental health a “wake-up call” to American pediatricians and family practitioners who treat kids, especially adolescents.

“We must address the mental health problems in our youth as a preventive measure,” Dr. Mercer said.

The Centers for Disease Control and Prevention (CDC) reports 1 in 5 American children ages 3 through 17, about 15 million children, have a diagnosable mental, emotional or behavioral disorder in a given year. Most of these children, about 80 percent or 12 million kids, are not identified and don’t receive treatment.

Suicide is the No. 2 cause of death for teens and it is steadily becoming more common. The rise of online bullying, family and school stresses, emotional or physical trauma, and substance abuse are among the factors contributing to this problem. But Dr. Mercer believes so is constant exposure to media and the conflicting messages it presents, unrealistic societal expectations, and a basic shift in parenting styles that never allow a child to fail at even simple situations. He believes this prevents a child from learning disappointment.

“It’s scary and sad. We are losing too many of our children to treatable conditions,” Dr. Mercer said. “And, society is at greater risk for actions sometimes taken by these individuals when their depression becomes homicidal.”

So what are we to do about it? Dr. Mercer agrees with experts at the U.S. Preventative Service Task Force and the American Academy of Pediatrics, who recommend all children age 12 and up be screened for depression during visits with their doctor.

“As pediatricians, we have to take the time to interact with teens and take the time to screen for these conditions during regular office visits,” Dr. Mercer said.

He adds parents also need to be on the lookout for signs that their child could have depression. For younger children, it often presents as excessive emotional outbursts, low self-esteem, extreme separation anxiety, or nightmares.

Often it is hard to tell if a teenager is depressed. Teens don’t often look sad, instead, they are irritable. It is important to take notice if your teen is experiencing moodiness or irritability for more than 2 weeks and it’s occurring every day, for most of the day. It is especially worrisome if it is associated with a change in sleep patterns, academic success, or the desire to socialize.

While it may have taken some doctors time to treat these conditions which cost children, families, and society so dearly, Dr. Mercer hopes pediatricians are getting better at bringing up the subject with their young patients.

“I think right now the medical community as a whole, we have to do a better job of being prepared, trained, and effective at getting our kids and families to open up about emotional problems,” Dr. Mercer said. “But we must do it and we must get better at it, and I think we have gotten better at it.”

More On This Topic:

• Pediatricians Urge Screening for depression at Well-Child Visits
• New Behavioral Health Center Offers Hope for Children In Crisis
• Dealing with Depression
• 7 Signs Your Child May Need Mental Health Help
• 13 Reasons Why You Should Be Concerned Your Child May Attempt Suicide
• Suicide of Elementary School-Aged Children and Adolescents
• 13 Warning Signs of Teen Suicide
• Is Your Teen's Smart Phone Making Them Depressed?

The 28 year old also suffers from depression.

"It's one of them things that no matter how indestructible we look like we are, we're all human at the end of the day," DeRozan said in an interview with The Toronto Star. "We all got feelings ... all of that. Sometimes ... it gets the best of you, where times everything in the whole world's on top of you."

DeRozan is not alone. Research shows that 1 in 5 teens experience depression at some point during adolescence. Unfortunately, studies also show that many parents miss the signs of three kids with depression go undiagnosed.

Because of these numbers, the American Academy of Pediatrics has updated their guidelines to recommend pediatricians routinely check for signs of depression in their young patients. The focus is to carefully screen patients ages 12 and over during annual checkups.

Kathleen Powderly, M.D., a Cook Children’s pediatrician in Fort Worth’s Magnolia office and a hospitalist, is very involved with this topic. She will be a keynote speaker at a community educational seminar on suicide prevention called the No More Symposium from 6:30 p.m. to 8 p.m. at Bluu Auditorium on the TCU campus. Dr. Powderly will discuss anxiety, social media and bullying.

Dr. Powderly is encouraged by the updated guidelines by the AAP and says 12 years old is the right age to begin checking for depression on a regular basis.

“The data I’ve been tracking as a hospitalist shows the average age of kids admitted to the hospital for suicide attempts is 14.4 so that is a good age,” Dr. Powdery said. “On average, the hospitalist service (at Cook Children’s) has admitted a child with a suicide attempt every 2 days for the last 3 years. The Symposium focuses on the multifactorial nature of anxiety, stress, suicide and how they relate. More importantly, it gives parents and the community at large tools and ideas to handle this growing problem.”

Vanessa Charette, M.D., shares an office with Dr. Powderly. She said at Magnolia, the physicians already screen every child at well-child checkup ages age 12 and up for depression.

“I have found it is a good way to signal to kids and parents that we are open to talk about this and want them to ask us about it,” Dr. Charette said. “Even if on the well check nothing comes up, often a parent will return with the teen later wanting to talk about anxiety and depression. I believe the screen helps open that door and the conversation. I also find for teens that are not having any signs of depression/anxiety and wonder why they are doing the screen it still opens a conversation. I then talk about how it is great that they are doing well but that many kids are not. Parents appreciate this – it helps open why some other kids might be depressed, what can be done to prevent it and helps with empathy for others.”

Justin Smith, M.D., a Cook Children’s pediatrician in Trophy Club and a member of the executive committee for communications and media with the AAP, said new guidelines are important for three reasons:

1. Screening helps to pick up teens who would have otherwise been missed. Signs and symptoms of depression are sometimes seen in kids who might have surprised you.
2. Sometimes children are aware of symptoms that they are feeling that they don’t associate with depression. Asking them direct questions will sometimes highlight a feeling that they have had and give them the opportunity to discuss it.
3. Talking about mental health on a regular basis normalizes the conversation. Even if the child isn’t experiencing problems right now, they begin to learn that our offices are a safe place to discuss their feelings.

More on this topic:

• New Behavioral Health Center Offers Hope for Children In Crisis
• Dealing with Depression
• 7 Signs Your Child May Need Mental Health Help
• 13 Reasons Why You Should Be Concerned Your Child May Attempt Suicide
• Suicide of Elementary School-Aged Children and Adolescents
• 13 Warning Signs of Teen Suicide
• Is Your Teen's Smart Phone Making Them Depressed?

“At the end of the day, I can’t help that my wires are a little bit differently crossed than yours,” Manziel said on Good Morning America. “I can’t help my mental makeup or the way that I was created.”

Manziel said he used alcohol has his method of self-medication and battled depression on his way to his “huge downfall.”

The former first-round draft pick told GMA that he was diagnosed with bipolar disorder a year ago. Today, Manziel said he is currently sober and taking medication for bipolar disorder.

So how do you know if your child is battling bipolar disorder?

Bipolar disorder is a mental health condition marked by extreme swings and mood and energy. It can affect the ability to function normally. The mood changes of bipolar disorder are more severe than normal ups and down.

Roxanne Boyd, LCSW, a family therapist for inpatient psychiatry at Cook Children’s, said people with bipolar disorder usually see multiple health care specialists before being diagnosed.

“For example, it can look at various times like depression, chemical dependency, even ADHD. In Johnny Manziel’s case, he was initially treated for chemical dependency,” Boyd said.

She added people with Borderline Personality Disorder are at high risk for chemical dependency, trying to manage their moods with alcohol, anxiety medication, like Xanax, or amphetamines.

Lisa Farmer, director of Psychiatric Services at Cook Children’s, said a differentiating character of bipolar disorder as opposed to unipolar depression is the presence of “clinical mania."

“Receiving a psychiatric evaluation is very important because of the risk of misdiagnosis. Medication management of depression, anxiety, and ADHD can be quite different from treating bipolar disorder. A psychiatric evaluation will help so the child is not treated with incorrect medication.”

Some use the acronym DIGFAST to refer to mania symptoms:

D-Distractability

I-Indiscretion or high risk behaviors

G-Grandiose thinking

F-Flight of ideas or racing thoughts

A-Activity increase

S-decreased Sleep

T-talkativeness or hyperverbal, pressured speech

"These symptoms will cause an impairment in the ability to complete daily activities and the symptoms will affect multiple aspects - school, home and even the inability to be successful in extracurricular activities and peer relationships," said Kia Carter, M.D., co-medical director of Psychiatry at Cook Children's. "In bipolar, I think the key is that we are looking for a combination of impairing symptoms and not just focusing on the mood swing that children or adolescents may present with."

Dr. Carter said making your pediatrician aware of any concerning symptoms early on can help with early detection and treatment if necessary. If your child is having these symptoms and there is an impairment in function, please call 682-885-3917. 

Elliott knows it can be difficult for parents to come to grips with mental health issues their child may be experiencing.

“Regardless of the reason for the mental or behavioral health illness, we have to be responsive to our children immediately,” Elliott said. “Parents sometimes wait until it’s too late to seek help before harm comes to the child or someone else, simply hoping the problem resolves itself over time.”

Parents have reported not knowing where to turn for help or having the time and funds to navigate obtaining appropriate care.

Childhood mental illness occurs in about 20 percent of all children in any given year, according to the U.S. Surgeon General. Nearly 5 million children in America have some type of mental illness, yet experts estimate that only 20 percent of them will receive treatment.

“Early identification and treatment is critical and can be a lifesaver for the child,” Elliott said. “In addition, treatment can be beneficial for all of the child’s relationships and success in school.”

Elliott offers these early warning signs:

1. Significant mood changes, including sadness, depression, withdrawal, irritability or rages
2. Intense feelings with little ability to manage the feelings, including anxiety, fear and panic symptoms
3. Behavior changes including aggressiveness, dangerous behavior, and homicidal thoughts or changes in appearance, friends, interests
4. Physical harm including self-harm and suicidal thoughts/attempts
5. Substance abuse
6. Lack of self-care including, lack of cleanliness, not eat or over eating, sleep disturbances, weight changes, pays little attention to physical health, doesn’t care about homework
7. Change in functioning including inability to concentrate, easily irritated/frustrated, gets into fights/arguments, unable to get along with others, cannot complete projects/work

If parents note any of these changes they are encouraged to speak to their child’s doctor or find a specialist such as a psychiatrist, psychologist, social worker or licensed counselor.

“A proper diagnosis is essential for guiding treatment; and this process may include a health examination and/or psychological testing,” Elliott said. “Treatment may include medications, psychotherapy which includes teaching your child coping tools and how to respond to challenging situation, as well as helping parent training/skills.”

Other resources that provide information to help parents include www.watchdenton.org, National Alliance on Mental Illness (NAMI), National Institute of Mental Health, Mental Health America.

Lisa Elliott, a licensed psychologist and clinic manager of Cook Children’s Behavioral Health in Denton, says some children may threaten suicide in an attempt to get attention or others may be struggling with depression.

“But it doesn’t matter,” Elliott said. “You must take the threat very seriously. If a child is talking about suicide, get help immediately. It’s critical not to ignore this cry for help regardless of their reasons.”

Following a suicide in the community, parents should take the time to talk to their kids.

“Use it as an opportunity to discuss their possible feelings of grief or confusion and be a listening ear and support them,” said Joy Crabtree, a licensed psychologist and clinic manager for Southlake and Northeast Clinic. “Additionally, parents can ask their child if they have ever had any extreme feelings of sadness or thoughts about hurting themselves. If current feelings about wanting to hurt themselves are acknowledged, parents should let their therapist or psychologist know right away. If they do not have a therapist or psychologist, or they are not available, they should be taken to a local mental health facility or hospital emergency room for an evaluation.”

Research has found that about 90 of people who die by suicide experience mental illness.

Elliott says teens with chronic illness, such as depression, are no different than any other child and generally want to be treated just like any other kid. But they should receive professional help and be assessed for anxiety and depression.

“Parents should watch for any change in mood like sadness, depression, hopelessness, irritability, anger and hostility,” Elliott said. “You may see more tearfulness and changes in activity level. Watch for more withdrawal from friends and family, change in friends and loss of interest in activities once enjoyed.”

Elliott says warning signs of teen suicide include:

1. Increased use of alcohol/drugs
2. Preoccupied with death (writing, drawings)
3. Talking about feelings of hopelessness
4. Talking about being a burden to others
5. Telling loved ones goodbye
6. Decline in performance
7. Giving prized possessions away
8. Isolating and withdrawing
9. Acting highly anxious or agitated
10. Acting reckless and taking risks
11. Rages
12. Changes in sleeping and/or eating
13. Dramatic changes in personality and/or appearance

If you feel your child needs help, please call 682-885-3917 for a referral into Cook Children’s Psychology department.

According to data released Thursday, suicide rates doubled among girls and increased more than 30 percent among teen boys between 2007 and 2015.

At Cook Children’s, this news comes as no surprise to the behavioral health care workers who see the young adults struggling with depression and other mental health challenges each day.

“It’s not surprising. It’s absolutely heartbreaking, but not surprising,” said Lisa Elliott, Ph.D., a licensed psychologist and manager of Cook Children’s Behavioral Health in Denton.

Since 2015, the number of children and teens admitted to Cook Children’s Medical Center after trying to kill themselves has increased significantly. There’s no data available yet to say for certain how many more of these cases there have been, but it’s safe to say the percentage is in the double digits.

“We see the increase in the numbers of calls we receive from parents looking for help whether it’s for therapy or hospitalization,” said Elliott. “Not only is this a real problem across the country, but it’s affecting families right here in North Texas.”

Elliott says one big mistake parents make is believing that stories like this don’t apply to their children. She says when suicide is in the news, parents should use those stories as an opportunity to talk to their kids and teens.

“Ask them why they think this is happening and if they find themselves wishing they weren’t here,” said Elliott. “You can find out a lot about how they are feeling, and how their friends are feeling.”

Also know that kids may not tell you the truth, even if you ask.

“I think it’s important for parents to be mindful and recognize warning signs of suicide, even if their child denies having suicidal thoughts,” Elliott said.

Warning signs of teen suicide include:

1. Increased use of alcohol/drugs
2. Preoccupied with death (writing, drawings)
3. Talking about feelings of hopelessness
4. Talking about being a burden to others
5. Telling loved ones goodbye
6. Decline in performance
7. Giving prized possessions away
8. Isolating and withdrawing
9. Acting highly anxious or agitated
10. Acting reckless and taking risks
11. Rages
12. Changes in sleeping and/or eating
13. Dramatic changes in personality and/or appearance

Bottom line, Elliott says kids need to understand that problems are temporary, but suicide is permanent.

If you feel your child needs help, please click here to find a Cook Children's Behavioral Health location near you. You can also address your concerns with your child’s pediatrician, psychologist or therapist.

Cook Children's Behavioral Health Center

Growing up in today's world is hard and many children or teens may go through life experiences that cause them to feel anxious, depressed or even suicidal. As a parent or a caregiver, it can be hard to know when to ask for help. The Behavioral Health Center brings all services together in an expanded space that will provide a talented, dedicated team of caregivers, physicians and professionals with the facilities, resources, tools and programs they need to ensure that these most vulnerable children receive the high quality treatment they need and deserve. Click here to learn more about an appointment or referral.

Both can be a self-destructive losing battle.

Guilt is a negative emotion and often unhealthy – it can make anyone unhappy, dissatisfied and unproductive. For parents, guilt comes in all forms and I can especially relate to working moms. After all, I’m one myself. According to AmericanProgress.org women make up half of the workforce in the U.S.

Care.com found that 80 percent of working moms feel stressed about balancing child care, work, home and relationships.

It's important to understand there are a multitude of reasons why a mom is in the workplace. Some women may be the sole or primary breadwinner, others work because they can't afford child care and some work because they know that working will help them be a better parent.

It's critical for us as women and mothers not to pass judgement, but rather be supportive of all working women regardless of whether they are an employed mom or a stay at home mom. All mothers are working mothers!

But for the purposes of this article, I will focus on helping employed moms feel better about their decision to work. Often that requires us to look at the definition of what being a good mother is - a good mother is not determined by the number of hours we spend with our children. It's more about ensuring our children that they are wanted, valued and loved.

Working moms, by their example alone, can teach their children the value of hard work, ambition, independence and self-reliance.

The struggle that many working moms ask of themselves, me included, is there a way to balance work and being a mom? While it's a challenge, there are some things that working moms can do to help.

1. First and foremost is to realize we can’t do it all! We absolutely have to let go of some things, especially the unrealistic expectations. It's important to identify every household member’s needs and obligations and to realistically prioritize them. By changing our expectations, we can change other’s expectations of us.
2. We are bombarded with “expert” advice on what we “should” do to be a “good parent.” The bar that has been set for defining what a good parent should do is often ridiculously high and unrealistic. It is critical to remember we do not have to have gourmet meals on the table every night to qualify that we meet the good parent standard. What is most important, as noted previously is to make sure our children know they are very much wanted, loved and valued.
3. We have to enlist everyone’s cooperation and assign responsibilities, even to our children provided they are developmentally appropriate. When our kids were of school age, my husband and I shared the carpool responsibilities, as well as household duties.
4. When we are with our children it's very important to be present and intentional with them. Remove or minimize distractions, be engaged and interested in them. Set aside special time with each child, even if it's a few minutes a day. My son who is a grown man still talks about our hot chocolate/coffee stops as I would take him to elementary school.
5. Create special family activities that nurture each other, but create activities that fit into your schedule and budget. This might be a family board game night, baking cookies or reading a book together. Children also deeply value traditions – creating your own traditions with each child and as a family are very important.
6. Working moms often feel guilty about working and want to make their children happy. Our goal as parents is to raise our children to be responsible adults, which means we set realistic expectations, we assign responsibilities and chores, we follow through with consequences and we teach life lessons.
7. Learn how to set boundaries and how to express those boundaries in a kind way. It’s Ok if you can’t attend every PTA or school function during the day. Communicate that you would love to help and then provide for them the manner in which you can help and in that communication, include your time constraints.
8. Forgive yourself if something does not get accomplished or completed in the manner you had desired. By accepting responsibility and being flexible you are setting an example for your child that we all make mistakes, but we need to be accountable and responsible for them.
9. Create time for yourself and take care of yourself. You will not be good for anyone if you do not take care of yourself.
10. Utilize resources and supports. One of your best resources and support systems are other mothers. Find a local support group on the web or create one with your friends and/or co-workers who can share tips with and/or ask for help and ideas. Find daycares/providers that will assist with homework. Share carpooling responsibilities with other parents. Hire trusted and competent high school or college students to help with facilitating transportation to other activities.

Consider all of these options to help relieve the stress and provide more quality time with your children.

Remember what is most critical is to ensure our children that they are wanted, valued and loved, while raising them to be responsible adults.

The pop superstar gave an interview in the most recent edition of Vanity Fair and talked very frankly about her battle with postpartum depression, following the birth of her son. She said her postpartum depression made her feel "very inadequate" and as if she "made the worst decison of my life."

New moms experience all sorts of feelings, thoughts, and behaviors that their non-pregnant selves would never dream of! In the first few weeks after delivering a baby, about 80 percent of women will experience crying for no reason, impatience, irritability, anxiety, fatigue, sadness and trouble concentrating.

When do these feelings extend beyond “normal” and into the danger zone?

According to Diana Lynn Barnes, PsyD, an expert on maternal mental health, these are common feelings expressed by women with postpartum depression:

• No one has ever felt as bad as I do (helplessness)
• I have made a terrible mistake (anxiety)
• I am all alone and no one understands (isolation, withdrawal)
• I’m a failure as a mother, woman, and wife (guilt, diminished self-esteem)
• I will never be myself again (hopelessness)
• I’m losing it (despair)
• Everything is an effort (exhaustion)
• I have such trouble deciding (disorientation, confusion)
• I feel like I have soda fizzing through my veins (anxiety)
• Sometimes I think everyone would be better off without me (suicidal thinking)

Luckily, risk factors for postpartum depression are known, so at-risk women and their families can be proactive about their postpartum mental health. Make sure your pregnancy care provider knows about:

• Personal or family history of depression, anxiety, obsessive-compulsive disorder, postpartum depression or psychosis.
• Personal or family history of thyroid illness, chemical dependency, or alcoholism.
• Premenstrual dysphoric disorder.
• Past experience of trauma (physical, emotional, sexual abuse).

Postpartum psychosis is a serious, life-threatening illness that increases the risk of a mother committing suicide, killing her baby, or abusing or neglecting her baby. It occurs in about 0.1 percent of births, begins suddenly within two weeks of delivery, and may require emergent psychiatric hospitalization. A personal or family history of bipolar disorder, postpartum psychosis, or a previous psychotic episode are the most ominous risk factors, but women without any risk factors can develop postpartum psychosis. If you notice a new mom experiencing these things, it’s time to get help NOW:

1. Strange ideas or beliefs which are often of a religious nature, i.e. receiving prophecies, supernatural baby, evil baby (delusions).
2. Hearing commands.
3. Receiving secret messages from TV, music, books, online, etc.
4. Unwanted and disturbing urges to commit violent or other terrible acts.
5. Hallucinations involving smell, sight, or touch.
6. Intense fear of what she might do and a desire to escape.
7. Inability to sleep, a drastic increase in energy, euphoria (mania).
8. Not making sense when talking, easily distracted (disorganized speech, flight of ideas).
9. Frequent arguments, irritability, annoyance, and conflict with family members.
10. A false idea that people close to them are dishonest, dangerous, or trying to hurt them or their baby (paranoia or suspiciousness).
11. Confusion about where, when, and who they are time (disorientation).
12. Obvious lack of self-care.
13. Feeling unable to care for her baby, or extreme worry that she can’t keep the baby safe.

The great news is that postpartum depression and psychosis can be effectively treated, especially if help is sought early.

• The widely used screening tool - the Edinburgh Postnatal Depression Scale
• Postpartum Support International
• More about Diana Lynn Barnes, PsyD

What's under the microscope now is how mental health played a role in these unsettling crimes. While one involved a documented case of schizophrenia, the other is not so clear but may have been tied to depression or possibly a head injury. Yes, these are extreme examples of issues regarding mental health, but they are also reminders of what could go wrong if mental well-being is left unchecked.

It's long been reported that Texas is lagging when it comes to mental health spending. In fact, the state ranks 49th in the country for such spending per capita. At Cook Children's, The Center for Children's Health is working with local partners to expand awareness and access to mental health resources in one local county that especially needed help.

"We have seen higher rates of diagnosed mental illness, bullying at school, self-esteem issues and experience in trauma in 2015 than we did in 2009," said Courtney Barnard, Coordinator for Regional Outreach Services at Cook Children's. "The CCHAPS data tells us what is happening according to parents, but it does not tell us why it’s happening."

Barnard says it could be that kids are experiencing mental health issues and bullying more often or it could mean that parents are more aware of these problems and know what to look for and ask about. The latest numbers from CCHAPS will be the focus of the Denton County Child Health Summit on May 12, 2016, which will be presented by Cook Children's Center for Children's Health. There will also be discussion about the efforts and impact of the Wellness Alliance for Total Children's Health (WATCH) of Denton County. WATCH is a coalition of public and private organizations, born out of the CCHAPS data. The group offers mental health resources to kids, teens, parents and professionals as well as critical support to service providers.

"Moving the needle on children's health is a long-term process because it requires people and organizations to make changes in knowledge, skills, attitudes, beliefs and behaviors," Barnard said. 

About WATCH
The Wellness Alliance for Total Children’s Health (WATCH) of Denton County is a collaboration of both public and private organizations and individuals who are invested in the total wellness of Denton County’s children. WATCH currently works to increase awareness of and access to mental health services in Denton County. Visit www.watchdenton.org for more information.

I have to start with an apology.

It’s not that I didn’t care, or wasn’t concerned.

I asked about feedings and dirty diapers. I asked about sleep positioning. I asked about your plans for vaccination. I educated on how to take a temperature and what a fever is, whom you should call when you are concerned.

I know a lot about your baby from our little time together.

But, I often forgot to ask about you.

Sometimes, if you looked particularly tearful, concerned … I don’t know, maybe distraught, I asked how you were doing. You might have said “fine” and I probably left it that.

Recent news reports reminded me that I should be doing better.

Depression affects about 30 percent of women between 18 and 44 years of age. I don’t want to get bogged down with more stats, but about 15 percent of women in their reproductive years take antidepressants. Most experts agree that untreated depression carries much more risk to babies than medications for depression. Studies have shown mixed results with most indicating that they are safe and others indicating a slight increase in risk for birth defects.

A special US Preventative Service Task Force report stated that all adults should be screened for depression but placed particular emphasis on the importance of screening pregnant and new moms. They conclude that screening should be implemented “with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”

If new moms should be screened for depression, who is going to do it if I don’t? Many don’t go back to their obstetricians until six weeks. What doctor are they seeing in the mean time? Who is going to screen them for postpartum depression? It has to be me.

Many pediatricians do this very well. They have built a system in place and screening has been part of their process for years.

Those of us who didn’t have many reasons…

Other priorities took over.

Checkup times are too short.

We’re not sure what we would do when we identified someone with postpartum depression.

But none of those are good excuses.

Because of this, I promise to work to develop a system that works.

I have to.

For you and for your baby.

I will report back with more soon.

Sincerely,

PS. Symptoms of postpartum depression can include:

• Increased irritability
• Loss of patience
• Quick mood changes
• Excessive energy or extreme fatigue
• A sense of feeling hopeless or overwhelmed

If you are someone you know is suffering from these symptoms, please ask for help from someone. Start with a friend or a doctor but do not suffer in silence. There are resources available.

About 3 percent of kids suffer from severe selective eating, to the extent that they can't eat out at a restaurant, said lead researcher Nancy Zucker, an eating disorders specialist at Duke University Medical Center in Durham, N.C.

Severely selective eaters are more than twice as likely to be diagnosed with depression or social anxiety, when compared with kids who'll eat anything, according to findings published online Aug. 3 in the journal Pediatrics.

Alaina Everett, a Cook Children’s licensed psychologist in Denton, says severe picky eating can be treated from a psychological/behavioral perspective as well as through oral-motor and sensory therapies and trying new foods for children who have severe selective eating can be terrifying.

“The fear is only intensified when parents make threats or express anger and frustration,” Everett said. “In our psychology department we emphasize the belief that kids do well if they can. Likewise they will eat well if they can. But there are obstacles that get in the way. Whether the original issue is a sensory processing disorder, oral-motor weakness or a gastrointestinal problem, all these kids have one thing in common, anxiety.”

From a psychological standpoint, these kids have had unpleasant experiences with food and the lingering trauma may be real. This is especially true for well-meaning moms who hide veggies in their kids’ favorite foods. If you have a seriously picky eater, Everett says this strategy will back-fire big time.

So how much anxiety can meal time actually cause?

“It is not uncommon in my practice to see children cry, scream, hide under the table, and quite literally shake at the sight of a novel food or when asked to join me at the table,” said Amanda Fyfe, a speech-language pathologist at Cook Children's in Arlington and Mansfield. “The anxiety severe picky eaters cope with is real and it can be intense. These kiddos often have months or years of negative food experiences fueling this fear, and unraveling it takes real work on everyone’s part. “

Fyfe says severely picky eaters:

• Have a significantly limited food repertoires (think 10 foods). These foods are probably similar in some way, although figuring out the rhyme or reason to what your little guy will or won’t eat can be mind boggling. It may be that his safe foods are the same color or have the same texture.
• Frustrate us with behavior that makes mealtime at home a catastrophe and eating out unheard of. He may refuse to eat with your family or cry and scream at the sight of the casserole you’ve so lovingly prepared.
• Refuse foods based on ALL sensory properties, including appearance, smell, texture, and taste. A picky eater may not even tolerate an offensive food on his plate. The sight of a non-preferred food may cause gagging, retching, and vomiting. Eating is more than simply chewing and swallowing. Interacting with, smelling, touching, and tasting are ALL important steps in the eating process. And disruption can occur at any step.
• May struggle to meet nutritional demands

“A child will not eat the broccoli and pork chops if you wait him out. He just won’t,” Fyfe said. “In fact, he may grow more and more rigid in his food selection because he IS hungry and grumpy. If a food or experience causes a child stress, discomfort, or pain, he will avoid it, plain and simple.”

Fyfe says these children are hypersensitive to foods in ways most of us might not even consider when planning our meals. Foods have to pass many tests before deemed acceptable for consumption, believe it or not, and severely picky eaters really put their meals to the test.

The first and possibly the most important test his dinner must pass? What it looks like. Children are acutely aware of the color of the food and may question why the color, shape, or size changes from bite to bite or from meal to meal. In addition, they might become overwhelmed by the smell of a particularly pungent food (think roasted broccoli, guys) and lose all ability to even consider tasting it. The texture of yogurt or pudding may cause a gag with incredible force. All of these reactions to food can lead to increased behavior disruption and meal time chaos.

“They can taste everything,” Everett said. “Zucchini pasta does not fool anyone and they are likely to stop eating pasta altogether. Presenting motivators like extra video game time can help, but it doesn’t solve the underlying anxiety. The scenario will just repeat itself when the next new food is presented.”

If your child shows signs of extreme picky eating, you will need some help. Talk to your child’s pediatrician about scheduling a feeding evaluation with a speech-language pathologist to determine the origin of the feeding woes and develop strategies to improve the eating experience for the entire family. A child psychologist may also be used if necessary.

http://www.npr.org/sections/health-shots/2015/08/03/428016725/could-your-childs-picky-eating-be-a-sign-of-depression

https://childhealthanddevelopment.files.wordpress.com/2012/03/kaytoomey.pdf

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.

A young person with a history of depression is obviously at a greater risk of suicide. Parents want to be alert for any changes in their adolescent’s typical behavior. They may have been very active in sports in the past, or band, theater, or cheerleading, and now are less interested or involved. They may be isolating themselves, not only from family, but also from friends. Motivation may be dropping, along with grades. You may see sleep patterns change and the teenager may be sleeping for extended periods of time and be difficult to wake in the morning. One may also notice their need for sleep is decreased or they are having difficulty falling asleep. Appetite may change as well and they may eat a lot more or a lot less, and actually be losing weight.

If a young person is talking more about death, dying, and have a sense of hopelessness, that is a big concern. Drug use and other impulsive or risky behavior can place them at a greater risk of suicide as well.

When there is a suicide in a community, parents should discuss it with their kids, particularly since they have likely already heard about it at school or from friends. Use it as an opportunity to discuss their possible feelings of grief or confusion and be a listening ear and support them. Additionally, parents can ask their child if they have ever had any extreme feelings of sadness or thoughts about hurting themselves. If current feelings about wanting to hurt themselves are acknowledged, parents should let their therapist or psychologist know right away. If they do not have a therapist or psychologist, or they are not available, they should be taken to a local mental health facility or hospital emergency room for an evaluation.

Even if a young person does not have a desire to harm themselves, their feelings of grief and sadness about a peer’s suicide can be significant, regardless if they were a close friend or just an acquaintance. Again, be a support for them and encourage them to discuss, and work through their feelings. Answer any questions they may have and explain, if appropriate, any similar feelings the parents may have as well. This may also be an opportunity for the adolescent to make a positive out of a negative experience. They may consider starting a grief support group, work on a memorial for the person who has passed away, or engage in volunteer activities. Sometimes putting feelings of sadness into positive activities can be helpful in the grieving process.

Above all, parents should be “tuned in” to their children. When unusual behavior changes are occurring, ask about them. Additionally, reassure your children you are always there for them, no matter what issue they are facing.

If you feel your child needs help, please call 682-885-3917 for a referral into Cook Children’s Psychology department.

Additional resources:

• Cook Children's Psychiatry and Psychology department
• Dealing with depression
• Resources & education
• 5 ways to fight depression
• When depression is severe

About the author

Joy Crabtree, Psy.D., a licensed psychologist for Cook Children’s, sees patients at Cook Children’s Urgent Care and Pediatric Specialties in Southlake, the first such pediatric facility in town. Previously, she worked seven years in Denton at Cook Children’s Psychology. She moved to Southlake to be closer to home. She sees patients Monday through Thursday, and on Friday she evaluates patients for conditions such as ADHD or autism Joy is married to Tim Crabtree and they have three children. If you feel your child needs to speak to a psychologist or psychiatrist, talk to your pediatrician or call 682-885-3917.

Depression is a biological illness with a strong hereditary link. Generally, 35 to 40 percent of depressed children have inherited their disease. Usually, parents notice that their child is depressed around the teen years. 

Teens with chronic illness, such as depression, are no different than any other child and generally want to be treated just like any other kid. But they should receive professional help and be assessed for anxiety and depression. 

Parents should watch for any change in mood like sadness, depression, hopelessness, irritability, anger and hostility. You may see more tearfulness and changes in activity level. Watch for more withdrawal from friends and family, change in friends and loss of interest in activities once enjoyed. Other signs include sleep disturbance, change in appetite, restlessness, agitation, fatigue, lack of energy/motivation, feelings of worthlessness and guilt. Depressed kids may have difficulty concentrating, making decisions and may even see a drop in grades. 

Always be aware of signs of depression and keep a close eye on your child. Never ignore symptoms.  If you see signs of depression, contact your physician and obtain referrals for a psychologist or therapist who is trained in pediatric and adolescent care. 

Children threatening suicide may be trying to get attention or may be struggling with depression. But it doesn’t matter. You must take the threat very seriously. If a child is talking about suicide, get help immediately. It is critical not to ignore this cry for help regardless of their reasons. 

Know that if your child is struggling with a chronic illness, including depression, it will impact the entire family. Families will require a lot of support: emotional, financial and physical. Most importantly, the support needs to be ongoing. It’s important to allow family members to vent frustration and grieve. Therapy is very helpful. If your teen is struggling with this problem, the entire family will need help to get through it. The good news is it’s available. If you feel your child needs help, please call 682-885-3917 for a referral into Cook Children’s Psychology department.

About the author

Lisa Elliott is a licensed psychologist and clinic manager of Cook Children’s Behavioral Health, located at 3201 Teasley Lane, Ste. 202, Denton, TX 76210. To make an appointment, call 940-484-4311. Cook Children’s Psychology provides care focused on children’s behavior, from ages 3 years through 17.