Wellness

• Schedule a Check-up: The American Academy of Pediatrics (AAP) recommends annual checkups from age 3 through adolescence. Schedule early to secure an appointment before the school year starts.
• Mental Health: Have open and honest conversations with children about their concerns. Speak with the pediatrician on tools to help with anxiety.
  • Parenting & Back-to-School: Emotional Safety Starts at Home
  • Raising Joy Podcast: Back to School Anxiety
• Oral health: Children should visit the dentist every six months. Make sure kids brush twice a day for two minutes and floss daily. Make an appointment.
• Update child vaccinations: Navigating vaccines can feel overwhelming. Talk to your pediatrician. The Texas Department of State Health Services requires certain immunizations before children can attend school.
  • To schedule an appointment, visit Cook Children's website or your county's health department website.
  • If a child is not of school age but attends daycare, other requirements may apply.

  • College students are required to receive the meningococcal vaccination.

    

• Sport physicals: The annual UIL pre-participation physical evaluation form applies to middle school and high school students. Sports physicals give doctors the opportunity to check for a variety of concerns, from vision issues and asthma to a lingering sprain or even a serious heart condition.

Healthy Routines

• Sleep: Sleep fuels a child's memory and concentration. Without consistent rest, children struggle to focus in class and retain what they learn, impacting their academic performance.
• Key elements for building a bedtime routine:
  • Establish a consistent schedule by going to bed at the same time each night.
  • Limit screen time at least one hour before bedtime.
  • Keep bedrooms quiet, cool and dark.
  • Create a calming routine, such as reading together.
• Transportation safety:
  • E-Bike and E-Scooter safety: Always wear a helmet.
  • Driving: Drive slowly through school zones and watch for pedestrians.
  • Car Safety: Ensure your child is in the correct car seat or booster for their age and size.
• Nutritious meals: Plan balanced breakfasts and lunches to keep energy levels stable throughout the day.
• Screen time: According to the American Academy of Child and Adolescent Psychiatry, children ages 8 to 18 in the United States spent an average of 7.5 hours a day using screens in 2025. Set clear daily limits for non-academic screen use.

Make a Plan

• Virtual care: If school district offers it, sign up for the Cook Children’s School-Based Virtual Health Program.
• Allergy action plan: Provide updated emergency allergy plans and medications to the school nurse.
• Medication management plan: Submit required doctor authorization forms for any daily or emergency medications needed during school hours.

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.

Editor's note: This story was originally published on Nov. 4, 2021.

Results are in for the 2021 Community Health Needs Assessment parent survey conducted by Cook Children’s Center for Children’s Health and one thing is clear—the mental health of children is top-of-mind for parents, particularly during the pandemic.

Half of all children ages 6 to 17 living in Cook Children’s eight-county service area have a parent who is concerned that the pandemic will have a negative impact on both their child’s education and mental health, according to the survey. The impact of COVID-19 was also noted by parents and guardians as one of the top three barriers to children receiving necessary health services, along with a lack of insurance coverage and the scarcity of needed services available in the area they live.

These barriers played a role in 137,000 children not getting needed medical care, more than 180,000 kids being deprived of needed dental care, and 63,120 kids going without needed mental health care. When compared to the same demographics from the 2015 and 2018 parent surveys, all of these numbers represent an increase in children not getting the health care they need.

The survey revealed that parents need support, too. More than 30,000 children have a caregiver not coping “very well” or not “well at all” with the day-to-day demands of parenting, and 24% of children live with someone who has a mental illness, or is suicidal or depressed.

“Parents of teens score lower when it comes to coping well with the demands of parenting than those with kids ages 6 to 11,” said Blair Williams, community health analyst at the Center for Children’s Health. “So the question becomes what do we do for parents to help them grapple with those daily parenting demands and the really tough topics that they face with their teens that are relatively new to us adults and changing almost every day.”

These results, along with many other survey data points, were shared Tuesday at the Virtual Children’s Health Summit presented by the Center for Children’s Health. Nearly 300 community members representing a number of area schools, health agencies and community organizations attended the summit.

“We recognize and acknowledge that Cook Children's isn't the only one working to improve the health of children and families in our communities,” said Becki Hale, director of Child Health Evaluation within the Center for Children’s Health. “We have such strong community partnerships and these issues around children's health are so complex that it can't just be one entity. It has to be all of us working together. We're so grateful that we have such a strong community that comes together to support one another to help families.”

Every three years the Center for Children’s Health surveys parents and guardians within its service area, including Denton, Hood, Johnson, Parker, Tarrant and Wise counties. This year the Center added Grayson and Collin counties into the surveyed region in preparation of meeting the needs of children served by the new Cook Children’s-Prosper, slated to open in late 2022. It also increased the child age range from 0 to 14 to 0 to 17.

A total of 5,715 surveys were collected from a sample of households across the surveyed region at large, not just Cook Children’s patients. Surveys were also collected from parents of special underserved populations via partners within community shelters and other local aid agencies. The results are weighted to represent the actual population of children living in the service area. That means data percentages are translated into the actual number of children within the population the percentage represents.

“We use this data to see how we might need to adjust our current programs to best address the needs we already know exist within our community because of what we see within Cook Children’s Health Care System,” Hale said. “Mental health is a good example. Because of what we are seeing in our health system data around self-harm and suicide, we’re particularly looking a little closer at what the survey reveals about mental health knowing that there may be some opportunity to adjust our programming to address that issue, especially within the adolescent and teen population. It’s another piece of the puzzle to help us figure out how to best support families and children.”

Parents reported that 19% of children ages 6 to 17 have been told by a health care provider they have anxiety, and 10% have been told they have depression. That’s higher than the national numbers of 13% and 6% respectively. In addition, Cook Children’s has recorded a record number of suicide attempts by children within the last 12 months.

“The survey reinforces what we have seen over the past year with skyrocketing numbers within our mental and behavioral health services,” said Rick W. Merrill, President and CEO of Cook Children’s Health Care System. “In 2022, we’ll dive deep into mental health access and behavioral health services. We owe it to the hurting children in our community to continue to make this a top priority.”

In addition to addressing mental health, the Center for Children’s Health will work with its community partners to explore new and innovative approaches for increasing access to food, personal health care providers, insurance, oral health care, parent support networks, injury prevention education, and opportunities for physical activity.

“The information we shared at the summit was just the tip of the iceberg,” said Chris Pedigo, senior vice president of system planning, health analytics and the Center for Children’s Health. “We’ll continue to dig deep into these issues to understand how to join with our community partners to best address these needs.”

Other notable findings include:

• 55,570 children are living in households that “sometimes” or “often” can not afford enough to eat.
• 57% of children ages 3 to 5 have a caregiver who is coping “very well” with daily parenting demands, which is lower than the national percentage of 63%; and 51% of children ages 6 to 17 have a caregiver who is coping “very well” with daily parenting demands, also lower than the national percentage of 61%.
• 70% of children ages 3 to 5 are ready for school according to their caregiver, which is slightly lower than the national percentage of 75%.
• 8 in 10 children have “excellent” or “very good” health.
• 9 in 10 children had continuous insurance coverage for 12 consecutive months prior to completing the survey.

In February, the Center for Children’s Health will release part two of its Community Health Needs Assessment, which will include a report of the “why” behind many of the survey results learned from parent focus groups and community leader interviews. That information will be combined with the parent survey results as well as the results of a community leaders survey to complete the Community Health Needs Assessment, which will be released in spring 2022.

Cook Children’s Health Care System announced today the release of its new mental health podcast, Raising Joy. The podcast is part of the JOY Campaign, which launched in April 2021 as a suicide prevention communication initiative, and aims to reach parents through honest conversations about the mental wellbeing of children and teens.

“The pandemic was extremely difficult for kids and families and we’re going to be dealing with the results of that for a long time,” said Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s and co-host of Raising Joy. “My hope with this podcast is that we can empower parents with tools and strategies they can use to support their children, as well as themselves.”

In addition to Dr. Pyrc, Raising Joy is co-hosted by Wini King, Chief of Communications, Inclusion, Equity and Diversity at Cook Children’s. Each week, the two will interview guests about topics such as depression, anxiety, stress, adverse childhood experiences, bullying and social media (to name a few).

“This is bold. It’s not something you might expect from a children’s hospital but I can tell you it’s something special,” King said. “In the few episodes we’ve already recorded, my jaw has dropped from what our guests have shared. We’ve heard incredibly impactful stories of personal struggle and resilience. I hope listeners walk away from our podcast knowing they are not alone, and that there is hope and help.”

Episode two of Raising Joy features a particularly raw conversation with pediatrician Kathleen Powderly, M.D., of Cook Children’s Pediatrics Magnolia in Fort Worth. Dr. Powderly is credited with sounding the alarm that sparked the Joy Campaign. 

In early 2021, she sent an email to leaders across Cook Children’s making them aware of the dramatic increase in suicidal patients she was seeing in her practice, some as young as 7. It turned out what she was seeing was a trend throughout the health care system and the country.  

“Dr. Powderly’s passion for this topic comes through within minutes. She courageously opened up about her own experience with depression and burnout. This is a conversation every parent and physician should hear,” said Dr. Pyrc. “Even with the first couple episodes, Raising Joy is bringing the topics that we typically bury out into the light. It’s an out-of-the-box that I’m very proud to be a part of.”

Season one of the Raising Joy podcast will run through May with new episodes becoming available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify, Google Podcasts and YouTube.

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)

But when you are plagued with mental illness or poor oral health—or a combination of both—it can be hard to turn a frown upside down, and that can have a profound impact on a child’s overall well-being.

“Our children don’t smile if they are hurting,” said Tonya Fuqua, DDS, director of child oral health at Cook Children’s. “If they have oral health disease and pain, or they are embarrassed by their smile, they don’t eat, or talk, or socialize, and they have trouble learning in school or being the best they can be as a kid. It’s the same with their mental health. If they are not in a good state of mind kids disconnect and aren’t the best kid they can be, and a domino effect happens.”

When people think about health, they rarely consider mental and oral health as part of the equation, but the two can be as taxing on the body as any other ailment. In Cook Children’s 2021 Community Health Needs Assessment (CHNA) survey of parents and guardians in the North Texas region, more than 180,000 children ages 0 to 17 went without needed dental care, and more than 63,000 without needed mental health care.

“People don’t realize the importance of oral and mental health to their overall health,” Dr. Fuqua said. “But dental disease is connected to heart health, and if you have cancer and are using certain medications, or you’re an asthmatic and using inhalers, that is going to impact your oral health. It’s the same with mental health. If you have to cope with one of these chronic illnesses, it’s going to impact your mental health, and poor mental health can stress other body systems and lead to other health issues.”

Oral and mental health also have a direct impact on each other. People with severe mental illness often neglect good oral hygiene practices and are 2.7 times more likely to lose their teeth, according to an article published in the Canadian Journal of Psychiatry. Add in an unhealthy coping strategy and your mouth and teeth are at even greater risk of disease.

“There is a clear connection between your emotions and how you handle stress,” said Kim Cox, a clinical therapist and manager of Cook Children’s Save a Smile program. “Sometimes kids handle stress in non-productive ways, like smoking and vaping, for example. That all affects your oral health as well.”

The risk is present in reverse, too. Poor oral health often leads to worsening mental health as people grapple with chronic pain and self-consciousness from an imperfect smile.

Add the stress of the pandemic on top of all of this and it’s easy to understand the recent decline in both mental and dental health among children. Cook Children’s has recorded a record number of suicide attempts in the past 12 months and, according to the CHNA parent survey, more than 170,000 children have had dental problems in the past 12 months. Parents identified the impact of COVID-19 as one of the top three barriers to their children getting the care they needed.

“There has been a marked increase in dental disease since the pandemic,” Dr. Fuqua said. “There is no surprise that when kids are stressed, disconnected or depressed, they eat. This leads to bad habits that can result in increased cavities. Also, when kids are off their routine, like during the pandemic, things go by the wayside, such as brushing and good oral health habits. Then, when kids get lots of cavities, they will not smile or even talk as much because they are embarrassed by the way their teeth look. This is a huge social inconvenience and causes kids to be even more distant and traumatized emotionally.”

Connecting the Dots

More often than not, mental illness and dental disease are treated in a silo. There is little recognition of their ties to and impact on other health issues and body systems, and little coordination between specialties in their treatment, according to Cox.

“If you have heart disease and go see a cardiologist, just because you are going to see a specialist for a specific issue doesn’t mean that part of your body is disconnected from other parts of your body and its function,” Cox said. “But for some reason, oral and mental health are seen that way. Dentists and therapists are seen as treating systems completely disconnected from a person’s overall physical health.”

Both share a similar stigma, too. Embarrassment leads many to suffer in silence.

“I call it the silent epidemic,” Dr. Fuqua said. “Nobody talks about mental health because there’s a stigma attached to it. Nobody wants to admit their child is going through a difficult time or kids don’t speak up about it. We see the same in dentistry. Many are embarrassed to admit they have issues with their teeth.”

A lack of insurance keeps many from getting the dental and mental health care they need, according to the CHNA parent survey. Insurance companies don’t cover services for mental and oral health as robustly as they do for other issues, making treatment unaffordable for many families. Dental insurance, for example, usually provides a capped maximum payout for treatment per year, but many dental procedures and treatments cost well above the typical yearly maximum.

The first step to breaking these shared barriers is for physicians and parents to talk about oral and mental health as much as they talk about diabetes, obesity, asthma, nutrition, childhood vaccinations and viruses.

“We need all of us—dentists, pediatricians and parents—talking about mental and oral health and looking at kids as a whole,” Dr. Fuqua said. “We need to always be in tune and watching for signs and symptoms. Doctors can take a quick look at a child’s teeth at their well-child check and ask them if they are seeing a dentist. Parents can talk to their kids about how their mind and mouth are feeling, and help them understand that their mental and oral health and hygiene are as important as any other part of their body.”

After all, a healthy mouth and mind help make a healthy body, not to mention a big, beautiful and bright smile.

On Oct. 19, the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP) and the Children’s Hospital Association (CHA) released a joint statement calling for more federal funding, support and access to mental health services and programs, as well as advancing policies that ensure mental health parity laws.

“Young people have endured so much throughout this pandemic and while much of the attention is often placed on its physical health consequences, we cannot overlook the escalating mental health crisis facing our patients,” AAP President Lee Savio Beers, MD, FAAP, says in the statement, adding the “declaration is an urgent call to policymakers at all levels of government—we must treat this mental health crisis like the emergency it is.”

The pandemic has caused children and teens “to face physical isolation, ongoing uncertainty, fear and grief,” the statement reads, and has exacerbated an already steady rise in mental health issues among youth—such as suicidality, depression and anxiety—noted even before the pandemic hit.

Nationally, the percentage of emergency department visits for children ages 5-11 rose by 24% and by 31% for children ages 12-17 between March and October 2020, according to the statement. And among girls ages 12-17, there was a more than 50% increase in suicide attempt emergency department visits in early 2021 compared to the same period in 2019, the statement read.

Also noted in the emergency declaration and based on research recently published in the AAP’s medical journal Pediatrics, more than 140,000 children have experienced the loss of a loved one, losing either a primary or secondary caregiver during the pandemic. Children of color have been disproportionately impacted, according to the research.

Reflecting the national trend, mental health experts at Cook Children’s Medical Center also have seen an increase in mental health issues among patients. From January through July 2021, for example, 261 patients were hospitalized for injuries following suicide attempts compared with 143 hospitalizations for the same injuries from January through July 2020.

 “We absolutely are in a state of national emergency when it comes to children’s mental health. Suicide has been the second-leading cause of death for young people ages 10-24 years since 2018, which is pre-pandemic,” says Kristen Pyrc, M.D., medical director of Cook Children’s Psychiatry Outpatient Services and Partial Hospitalization Program.

“The inability of families to access quality mental health care in a timely manner has played a significant role in the deterioration of young peoples’ mental health,” she adds. “I have to wonder how many of those suicides could have been prevented if a young person could have started mental health treatment when their symptoms first emerged.”

The increase in suicide attempts and mental health issues among children led Cook Children’s to launch the Joy Campaign in April. The campaign spotlights efforts being made to address the trend.

In the joint statement, AAP, AACAP and CHA urged policymakers to take the following measures to address the crisis:

• Increasing federal funding to ensure all families have access to mental health services;
• Improving telemedicine access;
• Accelerating the integration of mental health care in primary care pediatrics;
• Supporting effective models of school-based mental health care;
• Strengthening efforts to reduce risk of suicide in children and adolescents;
• Addressing workforce challenges and shortages so children can access mental health services no matter where they live;
• Pursuing policies that ensure compliance with mental health parity laws.

Such legislation would improve access to children’s mental health care for families and communities, Dr. Pyrc says.

“I have attended conferences through CHA that address mental health in our hospitals. Across the country leaders of these hospitals all say the same thing: They are overwhelmed by the mental health needs of the kids in their community,” she says. “If every children’s hospital across the country is struggling to address the mental health needs of their community, it says to me large-scale structural changes need to be made through legislation to increase access to mental health care for all families.”

Dr. Pyrc says she’s overjoyed the AAP, AACAP and the CHA “came together to write a comprehensive statement with recommendations that would benefit children’s mental health.” The organizations comprise more than 77,000 physician members and more than 200 children’s hospitals in the United States.

She’s hopeful new legislation would allow hospitals across the country, including Cook Children’s, to provide more help to children in need, she says.

“I know how frustrating it is for families to try to get help for their child who is struggling with mental health challenges. It breaks my heart that we cannot help every kid who needs it,” she says. “Cook Children’s is actively working to improve access to care for families in our community, and I am hopeful that new legislation will give us the tools we need to adequately address the mental health crisis.”

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.

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Talking about hard things isn’t easy, especially for a child or teen. It’s scary to be vulnerable. But talking can bring clarity. Sharing your hurts, struggles and stress can be a release, and leaning on someone you love can lighten your mental and emotional load.

“Feelings really are visitors trying to tell you a story,” said Denise Coover, LCSW, a trauma informed care specialist at Cook Children’s Medical Center. “If you ignore the story it just keeps building and building and will demand to be heard. Think of holding in feelings like a trash compactor. You keep pressing it down, pressing it down, but eventually it explodes like a volcano. Usually with frustration, anger and aggression and that’s the danger. These things need to be expressed within a safe environment and relationship. That is key.”

Kids need adults—parents, teachers, counselors, pastors and mentors—to create an environment where they feel secure and free to unpack the things that weigh on their minds and hearts. Trusted adults can help release the pressure on the trash compactor, so to speak.

“By talking with someone we trust, we are able to process our feelings as they arise,” said Marissa Benners, Ph.D., LP, a psychologist at Cook Children’s. “It makes it easier to manage the everyday demands of life without the pressure of unresolved feelings weighing us down. Sharing our feelings with others gives us an extra person who can help us problem solve and figure out the best coping strategy.”

Michael Garcia, MS, LPC, is a trauma specialist for the Fort Worth Independent School District where he works with children in crisis every day. Without a trusted adult, he cautions that a child’s development could be influenced by less positive sources.

“A child who is struggling wants to be comforted and feel safe,” Garcia said. “A loving and caring adult provides the necessary attachment a child needs to learn how to effectively communicate needs, meet those needs and manage emotional regulation. A positive and connected caregiver greatly influences the child’s ability to navigate difficult challenges.”

But many parents have their own hurts, experiences, worries, commitments and unfulfilled expectations that are barriers to being a sounding board and source of strength for their kids.

“Parenting isn’t easy,” Garcia said. “As a matter of fact, it’s my most challenging undertaking. It’s not always easy to listen to our children with empathy and compassion when our heads are spinning with finances, deadlines, relationships, piles of laundry and a myriad of daily speed bumps.”

On the flip side, kids don’t want to be a burden to their parents who they see juggling the demands of daily life.

“Kids often tell me the adults in their lives don’t care, are too busy, have their own problems and they don’t want to cause more problems,” Garcia said. “A lot of kids are empathetic to what their parents are going through and don’t want to be another burden.”

In a recent focus group conducted by Cook Children’s, several teens said feelings of fear and insecurity also get in the way of opening up to others. They are unsure how their message will be received, and are afraid of getting in trouble, being misinterpreted and, especially these days, being canceled.

When adults allow the complications of daily life, difficult pasts, fear of other’s perceptions and shame to lead, the unwritten no-talk rule sets itself up as the standard in the home and muzzles any opportunity for communication, connection, teaching and healing. It’s one thing for a child to suffer. It’s another for them to suffer in silence. Pushing hard issues under the rug, or ignoring a child’s emotions—a natural sign that something is going on—won’t make things go away. Instead, it teaches kids to hide their struggles and sets up a breeding ground for shame, guilt, rejection, lack of trust and hopelessness.

So how can parents, teachers and child advocates be a trusted adult that welcomes the hard conversations? How can trusted adults encourage communication that sheds light on the root of the issue and helps them guide kids to problem solve through a situation?

Take stock. Garcia said we can’t be a trusted adult when we feel like we have nothing left to give. Ask yourself what you need as a parent so that you can be truly present with your kids. If you need help with your own struggles, reach out. Equipping yourself will help you take care of and equip your children.

“We are all doing the best we can, and we can do better,” Garcia said. “Kids need us to be present, loving, comforting, empathetic, compassionate and honest. They need to know that they can trust us with whatever storm is raining down on them. We have to take care of ourselves so that we can take care of our children.”

Harness your own emotions. Parents have emotions too. It’s easy and natural for those emotions to surface, especially when it comes to your children. But harnessing those feelings like anger and frustration in the moment can help you see and respond to the reality of the situation, rather than getting caught up in the emotion. Responding out of anger will only frustrate a child, but responding out of love, patience and wisdom will teach them important coping skills that will benefit them for life.

 “One of the most important factors in creating a safe space is responding to your child in a calm and compassionate manner,” Benners said. “When adults regulate their own emotions during conversations, it helps those around them feel more at ease or relaxed. Parents can help foster open conversation by being honest about their own feelings. By calmly expressing our feelings during periods of stress, for example saying, ‘I’m feeling very frustrated at the moment and I need a few minutes to calm down,’ we help normalize feelings and we teach our kids an adaptive way to express them and to ask for help.”

Watch their cues. Kids will demonstrate they need to talk through their emotions and behavior.

“When we bottle our feelings up, they tend to come out in other ways,” Benners said.

Stomachaches, headaches, fatigue, difficulty concentrating, sleep problems, irritability, meltdowns and oppositional behavior are all indicators that your child might have something weighing on their heart and mind.

Listen. This is the most important thing an adult can do for a child, according to Garcia.

“Trust comes from actively listening without judging,” he said. “Listening with empathy, compassion and curiosity is how we encourage kids to share openly.”

Embrace your child’s communication style. Kids communicate in different ways. The key is to figure out what works best for them at their current age and stage of life and go with it.

For younger kids, play is always a good communication tool.

“What kids can do in play, they can do in life,” Coover said. “I like to give a young child a toy, like a dinosaur, and throw out a scenario. Maybe T-Rex is bullying and saying you’re green, fat and ugly and pushing. If the child doesn’t have good coping skills, the dinosaur will just sit there.”

That’s when you can start talking to them about how they would handle the situation. Ask questions that help them think through how to respond. Could you tell mommy dinosaur? Can you walk away?

For older kids, especially teens, seizing the moment while you are doing another activity together is a great way to set the stage for conversation.

“I'm a big fan of asking kids questions when you're on a car ride,” Coover explained. “There's something about that side-by-side movement where they don't really have to look at you. Maybe music is playing. You get the vibration of the car. You're not really looking at them because you're concentrating on the road. Then, all of a sudden you can get all of this information from them.”

Striking up a conversation around the dinner table is another good way to check in. Coover suggests asking your child what was one thing that made them mad, sad, happy and worried that day to get the conversation flowing.

When a child can’t find the words to speak, let them draw it or write it.

“Some kids either don't have the verbiage to be able to say it or they're feeling insecure or are afraid you're going to get mad,” Coover said. “So they'll feel more comfortable writing it. I really like notebooks for pre-teens and adolescents. Like a regular composition book. Nothing fancy.

Tell your child, ‘if there's something going on you can write it and put it right here and I'll read it and respond to you.’ With little kids, if you have them come home and just draw about their day, it’s amazing what you’ll find out.”

Be an equiper, not a fixer. It’s easy for adults to want to fix a problem for a child. That takes a lot less time than letting a child express what they are thinking and feeling, but that’s not always beneficial.

“When we constantly fix things for our kids, their brains don't grow,” Coover said. “They become adults who can't manage any kind of problem in life because they've never had to. Someone has always stepped in and just took care of it for them. So their brain didn't grow in that way. They didn't create those neural pathways to know how to consider their solutions. I think it’s important that parents know that they don’t necessarily have to fix that feeling, but actually ask if their child wants advice or insight.”

Encourage them. Help them think through the issue, and make sure they know that you are here to help them figure things out.

Check in. No matter how you communicate with your child, it’s important to check in with them regularly.

“Allocate designated time with your children on a weekly basis,” Benners said. “Put your devices away and just focus on having fun together. Teens often feel like they don’t have much control over their lives, so allow them to choose an activity that appeals to them. During this time, don’t be overly intrusive by asking questions. Instead, follow your child’s lead and you may find that they will eventually open up on their own.”

When your kids know that you can be a trusted sounding board and source of wisdom for them, you’ll have the opportunity to equip them with the life skills they need for healthy living, hopefulness and resilience.

The onset of loneliness, anxiety and depression in teens and adolescents during the COVID-19 pandemic has fueled a sharp rise in reports of dangerous eating behaviors.

The National Eating Disorders Association (NEDA) helpline saw a 54% spike in calls for support and resources to treat anorexia nervosa, bulimia, binge eating and other illnesses. Experts blame the surge on factors including stress, isolation and excessive use of social media during the coronavirus lockdown beginning last year.

Health care professionals have long known that eating disorders can be brought on by major life changes. Specialists say that for some young people who already were predisposed, the disruptions from COVID-19 triggered a full-fledged illness or a relapse from their recovery.

“Eating disorders are somewhat of a secret disorder. The more isolated you are at home, the more these types of disorders thrive,” said Joy Crabtree, a licensed psychologist at Cook Children’s. “These disorders often go hand-in-hand with anxiety disorder and depression, and the pandemic has played a role in that.”

At Cook Children’s, we initiated the Joy Campaign – a weekly series of stories addressing mental health issues in children and teens – in response to an alarming rise in suicide attempts in the past year. Eating disorders carry an elevated risk of suicide, particularly in those who suffer from anorexia. One out every of five deaths among anorexics is by suicide, according to the NEDA.

But the hopeful news: Although serious and complex, eating disorders can be treated through a combination of medical, behavioral and psychological tactics. Early diagnosis and intervention lead to better outcomes, Crabtree said.

Keep in mind a few key points:

• Eating disorders cover a spectrum of mental and physical illnesses that in the most severe cases lead to death. Anorexia typically involves severely restricted calorie intake, dramatic weight loss and distorted body image. Binge eating involves rapid and often secretive consumption of large amounts of food. Bulimia causes cycles of binge eating followed by forced vomiting, misuse of laxatives and/or excessive exercise. More information and other types of eating disorders are listed here.
• Eating disorders happen more commonly in girls and women, although boys and men can struggle too. The disorders affect people regardless of age, race or body shape.
• The American Academy of Pediatrics reported the estimate that 0.5% of adolescent females in the United States have anorexia nervosa, and that 1-5% meet criteria for bulimia.

Depression often co-exists with eating disorders. When it comes to adolescents, studies cited by the National Library of Medicine recommend a strategy of aggressively treating the depression and not just the unhealthy eating behaviors alone. Studies also recommend routine monitoring for signs of suicidal ideation, which surface when someone doesn’t want to live anymore.

The reported rise in new or recurrent eating disorders remains a relevant story, even as many of the COVID-19 restrictions have ended, because these illnesses require specialized and sometimes long-term care. As one dietitian put it … eating disorders don’t go away overnight. Treatment options range from outpatient visits to residential care to hospitalization for complications from severe malnutrition (heart disease, organ failure and electrolyte imbalance in the most extreme cases). But access to treatment isn’t always available.

In the past year, inquiries about eating disorders have trended up at Cook Children’s, although the medical center’s behavioral health Intake department doesn’t keep an exact count. Crabtree sees a tie-in to the general anxiety and depression that the COVID-19 pandemic inflicted. She listed contributing factors such as last year’s school closures, cancelation of extracurricular activities and separation from friends.

What else came into play during the pandemic? Lack of routine for sleeping and meals. Poor coping skills. Messages about food hoarding. Fears about weight gain. Pressure to look thin in social media photos and on the Zoom screen.

“Seeing yourself on camera, seeing others on camera, making those comparisons has played a role” in the rise of eating disorders, Crabtree said. “It was kind of a perfect storm, all this focus on food and bodies. It was very overwhelming.”

She urged parents to watch for signs of eating disorders in kids. Red flags include preoccupation with dieting, dramatic weight loss, withdrawal from friends, fatigue, dizziness, fainting, anemia, hair loss and menstrual irregularities. Anyone with concerns should contact their child’s pediatrician or call Cook Children’s to discuss referral options or possible psychological or psychiatric treatment, Crabtree said.

Getting started on treatment

Jean Mankin, a registered dietitian with Cook Children’s Outpatient Nutrition Services, works with primary care physicians to help with food allergies, obesity, picky eating and other issues. When it comes to someone with significant weight loss, Mankin starts by trying to determine whether the patient’s weight fluctuation is intentional.

“If you feel like they’re purposefully withholding food or telling you that they’re binge eating or purging, it’s important to get help,” she said. “A lot of kids are finding themselves having issues they didn’t have prior to the pandemic.”

Mankin emphasized that adolescents need to eat a well-balanced and sufficient diet because all vital organs and bone are rapidly growing and developing at this stage. Anxiety and depression can cause a dramatic decrease in appetite for some, and for others it can lead to stress eating or binging. As long as mental health problems go unresolved, the eating behaviors won’t improve, she said.

At Cook Children’s, patients with suspected eating disorders are referred to local specialists such as Carol Ann Darwin, a registered dietitian in Fort Worth who has met over her career with clients from age 8 to age 70. In April 2020, Darwin started seeing a big increase in anorexia and bulimia mainly among the 13- to 17-year-old set. She called the pandemic a nightmare.

“I went from working three days a week to working six days a week just to get these kiddos in,” Darwin said. Some individuals with eating disorders had to be hospitalized with feeding tubes until spots opened up in residential treatment centers, she said. Dietitians, therapists and treatment centers in North Texas and nationally still have waiting lists up to a month, Darwin reported.

The pandemic caused an onslaught of maladies that Darwin’s youngest clients bring up: isolation, stressful dynamics in a quarantined household, frustration with online school, loss of control. Food became a crutch to comfort and to alleviate loneliness. The challenges that were particular to 2020 compounded the usual causes of eating disorders, such as genetic predisposition and being bullied.

There’s no quick fix; Darwin typically meets with her clients in weekly nutrition consultations for two or three years – although the time frame can be less for those whose underlying depression and anxiety are mild. She said she prefers to use “gentle nudging,” rather than scare tactics, to motivate her clients to start eating appropriately.

“I’ve had several (clients) where I thought, ‘Would this have happened if COVID hadn’t come along?’ Maybe not,” she said.

Disconnection and disappointments

Dawn Dillon, a therapist in Fort Worth who has specialized in eating disorders since 1998, characterized the current demand for mental health services as an explosion. Disordered eating can come from the instinct to take action during times of uncertainty and fear, Dillon said. She drew an analogy to the people who rushed out to buy toilet paper in the early days of the pandemic. The same instinct applies to food and body image.

“We take all these things that are messy, uncertain or scary, and we manifest it through our body,” Dillon said. “Instead of saying ‘I’m scared, I don’t know what to do,’ it gets put onto the body as ‘I’m fat. There’s something to do with that – I can lose weight. I can sculpt. Or I can tone.’”

Eating disorders can originate out of a misplaced attempt to manage distress when someone feels stuck or trapped. Dillon listed a variety of scenarios that particularly applied to life for teens and young adults during the height of the COVID shutdown: Disconnection from social support. Disappointment when prom and graduation got called off. When will colleges and dorms reopen? So many unknowns.

Additionally, refusal to eat can be a way that teens, like toddlers, exert their separate identity. “In a home with no personal space and no autonomy, a lot of times eating disorders will creep up because it’s a way to assert boundaries,” she said.

Once a patient’s medical condition and food intake have stabilized, Dillon said, the mental health piece of treatment becomes vital to get to the root of the anorexia, bulimia or binge eating. Everyone involved in treatment stays vigilant for warning signs of suicide.

No one chooses to develop an eating disorder. Dillon’s current clientele includes first-timers as well as patients with persistent struggles in and out of treatment. Some patients who were handling recovery well prior to COVID-19 had to return for more therapy.

“From the research, we know that life-stage transitions are high-risk times,” she said. “You look at this pandemic, and it was a huge transition that nobody planned for, nobody expected, and nobody knew how to do it. So it makes sense that there would be a rise” in cases.

Dillon acknowledges it can be a terrifying experience for families to go through. Don’t blame yourself or make it a power struggle, she advised. “It’s hard on parents on a fundamental level, but it’s not their fault. The goal is to be aligned with your loved one as the two of you fight against the eating disorder together rather than the two of you fighting with each other.”

Imagine living through a tornado. The wind howling over the sound of sirens. Lightning illuminates your home. Then, you hear it - the roar. You watch the ceiling start to give way. Fear turns to panic. Running on adrenaline, your body prepares for the worst.

This is what trauma can feel like. While a severe weather event can be traumatic, there are many reasons a person may experience trauma. It is defined as anything that overwhelms a person’s ability to cope. But trauma isn’t always easy to spot, even though its effects can last a lifetime.

“There are three different kinds of trauma. The first is acute, or a one-time event like a dog bite or car wreck,” said Denise Coover, LCSW, a trauma informed care specialist at Cook Children’s Medical Center. “Then there’s chronic trauma, where you may have several things happening at once, like domestic violence at home and bullying at school. Complex trauma happens when traumatic experiences occur within the context of a close relationship, such as sexual abuse committed by a family member, or someone who should keep you safe.”

During a traumatic event, the body releases two major stress hormones: norepinephrine and cortisol. Similar to adrenaline, norepinephrine boosts the heart rate and controls the fight-or-flight response. Cortisol is your body’s main stress hormone and slows non-essential functions, like digestion, when a threat is perceived.

“If your body experiences this stress response on a regular basis, it can cause long-term health problems,” said Kia Carter, M.D., co-medical director of Psychiatry at Cook Children’s. “A lot of people don’t realize that chronic exposure to stress hormones can cause high blood pressure, obesity, diabetes, issues with sleep and fatigue, as well as feelings of depression and hopelessness.” 

These hormones can also increase your memory of the event, leading to flashbacks, nightmares and PTSD. But when it comes to memory overall, people who’ve experienced significant trauma may find it hard to remember in general. This is due to the part of the brain that stores memory, the hippocampus, being overexerted.

The amygdala is another part of the brain affected by the stress response. This region controls emotions and can cause someone to react differently to something as simple as a door slamming. You can think of the amygdala as the brain’s ‘watchdog.’

“If someone has experienced something like domestic violence or a shooting, they may be sensitive to loud noises,” said Dr. Carter. “That’s because their amygdala is working overtime to keep them safe. We call this hypervigilance.”

For children, hypervigilance can make it hard for them to concentrate at school and follow directions. Instead of focusing on the classroom, their brain may be trying to anticipate what bad thing is going to happen next.

The prefrontal cortex is connected to the amygdala and is responsible for rational thinking. Chronic stress in childhood can damage the prefrontal cortex, which is still developing, and lead to a survival response being triggered even when there is no danger.

Understanding Trauma

According to the National Council for Behavioral Health, 70% of adults in the U.S. have experienced some type of traumatic event at least once in their lives. That's 223.4 million people. 

“Sometimes, when people experience trauma, they will compare themselves to others. For example, they may say, ‘I’m not a Syrian refugee so I haven’t experienced real trauma,’” said Coover. “But it doesn’t matter, if something overwhelmed your ability to cope, that makes it traumatic for you.”

At Cook Children’s, 94% of hospitalized psychiatry patients in 2020 reported experiencing at least one form of trauma. Untreated trauma in children can cause a number of problems including behavioral issues, mood swings, depression, anxiety, self-injury, hopelessness and thoughts of suicide. Kids may feel isolated because of how the traumatic event has affected them. Coover says it’s important for parents and teachers to be aware of the signs of trauma because they’re not always obvious.

“A child who’s falling asleep at school may seem like a problem student, but when you start digging into their history you may realize that they don’t feel safe at home and they’re in survival mode. But when they’re in the classroom, they feel safe so all of the sudden they can sleep,” she explained.

Another sign of trauma in both children and adults is physical pain without a known reason, called somatic symptoms. This is often seen in the form of migraines, stomach aches, and rouge pain the body that is not associated with injury. This phenomenon has been documented by experts such as psychiatrist Bessel van der Kolk in his book ‘The Body Keeps the Score.’ Kolk claims that stress and trauma becomes stored in the body if not addressed, and can eventually lead to illnesses such as autoimmune disorders and cancer.

“Whether you remember the trauma or not, your body always does,” said Coover. “I’ve had parents tell me this or that happened but their child was too young for it to affect them and I have to tell them, “No, that’s not the case.’”

Some examples of childhood trauma include:

• Physical, sexual and emotional abuse
• Neglect
• Domestic violence
• Homelessness
• Parents with untreated mental illness and/or substance abuse
• Divorce
• Bullying
• Losing a parent
• Incarceration of a parent

“Domestic violence is one that seems to surprise people, because they think if the child isn’t being hit it doesn’t affect them,” Coover said. “But it absolutely does, even if they just hear it. Sometimes what they’re imagining is even worse, or maybe it’s spot on. And kids tend to blame themselves for their parents fighting. They take on that guilt even though it’s not theirs to carry.”

Experts like Coover and Dr. Carter also warn that isolation triggered by the COVID-19 pandemic has led to even more traumatic experiences for many kids, especially those growing up in unhealthy environments. With so many students being forced into virtual school last year, their ability to escape and connect with people outside of their home was taken away.

“We are starting to see more kids talk about the effect the pandemic has had on them,” said Dr. Carter. “I had a patient tell me recently they’d been home alone for many months and hadn’t been able to see their friends or other people. They said they were tired of living that way, this patient became hopeless about life changing, which resulted in this patient attempting suicide.” 

The Power of Sharing

Dawn Hood-Patterson, Ph.D., thinks about trauma in the context of her own life. At 17, she was living in Colombia with her family when her trauma story began.

“I lived in Colombia during the time when Pablo Escobar had a grip on many regions in the country—there were car bombs, protests and the sound of gunshots. During that period of unrest, my dad was murdered outside our home,” she said. “So when I think about my trauma story, I think about what fostered my capacity for dealing with that.”

Dr. Hood-Patterson attributes her resilience in part to her parents who gave her a loving and supportive home. She also credits the school counselors who recognized that her frequent stomach aches were not just random pain, but the result of the stress that comes with living in a country experiencing civil unrest.

“It was all the adults who recognized the trauma was bearing impact on my life, and who said, ‘This trauma is real and we see Dawn in the midst of it,’” she said. “These same people gave me tools that helped me make meaning out of the chaos. And they said, ‘Here are some friends around you that have experienced similar things so you don’t feel so alone.’”

As program manager of Community Health and Adverse Childhood Experiences at the Center for Children’s Health, led by Cook Children’s, Dr. Hood-Patterson is using her experience to help people in North Texas. She’s part of the team behind The ACEs Task Force.

Adverse Childhood Experiences (ACEs) is a term based on a study conducted between 1995 and 1997 by Kaiser Permanente and the Centers for Disease Control and Prevention (CDC). The study, which involves 10 questions about what a person experienced before the age of 18, shows ACEs are associated with high-risk behaviors, chronic disease and reduced quality of life in adulthood. In 2019, The ACEs Task Force unveiled their “Blueprint for Safe, Healthy and School-Ready Children”. The plan includes 25 ways pregnant women, families, children and caregivers need to be supported in order to counteract adversity. Access to health care, healthy food, quality, affordable and safe housing are among the top concerns. Transportation, mental health services, substance use disorder treatment and high quality, affordable child care are also priorities for the task force.

Currently, Dr. Hood-Patterson and team are working on a project that would create support groups for parents and caregivers living with adversity. The so-called ‘Caregivers Alliance’ is part of the Build-a-Bridge program, led by Cook Children’s, and is in the early planning phases. It would focus on giving people a chance to share their stories of trauma and connect.

“This was born out of conversations that we had with community partners where we learned that a lot of people who are struggling with adversity often feel like they have a laundry list of things to do,” she said. “For families who receive things like housing assistance or SNAP benefits, every conversation they have is about updating paperwork and not missing deadlines. We envision this alliance to be a space where people can be seen and heard, and support one another.”

The Caregivers Alliance would also include access to education from the Center for Children’s Health for topics like car seat safety, water safety, safe sleep practices and more.

“I’m a believer that something powerful happens when we share out stories with each other,” said Dr. Hood-Patterson. “When we have the opportunity to share our stories, whether they’re of triumph or trauma, it hones our ability to make meaning out of the seemingly meaningless chaos of suffering.”

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.”

TXT4 Tarrant Cares offers a convenient, safe and simple way to search for assistance with food; clothing and housing services; early childhood care; family support; mental health and counseling services; substance abuse programs; child abuse and neglect services; COVID-19 testing and vaccine information; and other critical needs.

By texting the word FIND to 67629, users are offered a guided search to access a list of nearby organizations to contact and provided with a ZIP code-specific list of resources. TXT4 Tarrant Cares is offered in English and Spanish and is available to anyone in Tarrant County in need of services. Examples of searches might include information on the nearest food pantry, rent assistance, or resources that can help residents apply for Supplemental Nutrition Assistance Program (SNAP) benefits.

The new texting service is associated with Tarrant Cares, an online information service populated with the most up-to-date community resource listings by United Way’s 211 helpline. TXT4 Tarrant Cares draws on the Tarrant Cares database and gives users a quick, ZIP code-specific report of nearby resources to contact for support. The community-based solution is a collaborative effort by Mental Health Connection of Tarrant County (MHC), The Center for Children’s Health, led by Cook Children’s Health Care System, and Tarrant County.

“We have a lot of amazing local organizations and nonprofit agencies standing by to support individuals and families in our community, but sometimes it can be tough to figure out where to turn when you are in the midst of a crisis,” said Tarrant County Judge B. Glen Whitley, who founded the Tarrant Cares website with MHC in 2010. “TXT4 Tarrant Cares puts those answers in the palms of their hands, literally.”

The need for the new service came from feedback by a local task force chaired by Cook Children’s that studied the impact of Adverse Childhood Experiences (ACEs). These experiences include exposure to abuse or neglect, family violence, mental illness, or any experiences that can disrupt a child’s development and lead to chronic health conditions. The ACEs Task Force worked with more than 60 partners and advisers in developing community recommendations to prevent and reduce adversities in children prenatally to age 5, to improve their health, safety and school readiness. Findings by the task force determined that getting help into the hands of local families most at risk of ACEs meant creating a more efficient and effective way for those families to access critical resources.

 “Texting is probably one of the best ways to communicate resources and information because people feel more comfortable texting than they do picking up the phone,” said Roderick F. Miles, a member of the ACEs Task Force and executive administrator in the Office of Tarrant County Commissioner Roy Charles Brooks. “Our vision is to keep people from falling through the cracks and we do that by creating space for them to advocate for themselves and be their own navigators, their own social workers—and then they become advocates for other people and help them navigate through the process as well.”

“The collective, long-term financial cost of not meeting the physical and mental health needs of our community’s most marginalized and vulnerable families is high, and the individual human cost is much higher,” said Virginia Hoft, executive director of MHC. “TXT4 Tarrant Cares is an important step forward in our efforts to level the playing field by giving everyone in our community immediate access to vital resources.”

TXT4 Tarrant Cares does not provide emergency response or the full range of service offerings provided by 211. A resource navigator can still be reached by calling 211 and information about services can be accessed online at www.tarrantcares.org. Individuals needing immediate assistance from a first responder should still contact 911.

About the ACEs Task Force

In 2019, the Tarrant County ACEs Task Force, created Circles of Support, a Blueprint for Safe, Healthy, and School-Ready Children. The effort was led by Cook Children’s Health Care System; the office of Mayor Betsy Price; the Office of Tarrant County Judge B. Glen Whitley; the Office of Tarrant County Commissioner Roy Charles Brooks; JPS Health Network; and supported by the Morris Foundation. The need for an easy-to-use texting service is a component of 25 priority recommendations detailed in the Circles of Support blueprint to assist families through difficult times.

About TXT4 Tarrant Cares (67629)

Launched in April 2021, TXT4 Tarrant Cares is a community-based texting service designed to help individuals and families in Tarrant County locate information on where to obtain critical resources—including food, housing, counseling, and childhood services. The texting service offers a guided search and delivers ZIP code-specific access to a database of local agencies and service organizations. TXT4 Tarrant Cares is an extension of Tarrant Cares, an online information service for individuals, families, caregivers and agencies. The community-based solution is a collaborative effort by Mental Health Connection of Tarrant County (MHC), and The Center for Children’s Health, led by Cook Children’s Health Care System, and Tarrant County.

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.

This is why the WATCH coalition and two of its partners, Connections Wellness Group and the Denton County Behavioral Health Leadership Team, are working together to spread messaging from the Okay to Say™ campaign.

Okay to Say is an award-winning public awareness campaign, initiated by the Meadows Mental Health Policy Institute and supported by The Hackett Center for Mental Health. Their message is simple: it’s okay to talk openly about mental health. Hope begins with open and honest conversations about mental health between trusted family members, friends, and other loved ones. WATCH, Connections Wellness Group, and the Denton County BHLT invite you to join us in working together to spread these messages throughout Denton County and the North Texas region so every child understands that it is Okay to Say.

Speak up by asking friends and family how they are feeling. Or, share how you are feeling.

Share hope by becoming a mental health supporter of someone close to you who might be struggling. There are great supporter tips on the Okay to Say website such as: Ask & Listen, Focus on Strengths, and Don’t Try to Fix.

Add your voice by sharing your journey at www.okaytosay.org or on social media using the hashtag #okaytosay.

WATCH, Connections Wellness Group, and the Behavioral Health Leadership Team have raised awareness of the Okay to Say campaign by purchasing a billboard in Denton on I-35W (Post Oak exit), sharing messages on social media, and passing out bookmarks with Okay to Say messaging at Denton County libraries. We’ve also purchased a billboard in Denton on I-35W Northbound (Post Oak exit), resulting in approximately 483,610 folks, age 18 and older, seeing this important message every week for 6 months!

“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.”

In 2018, she and her family joined the often overlooked but growing homeless population in Fort Worth. When Dana and her husband became unemployed and could no longer afford to put a roof over their heads, they turned to the Union Gospel Mission shelter for help. It was there that they were introduced to a program called the Homeless Initiative, which aims to provide a medical home for children experiencing homelessness in Tarrant County, a population of roughly 15,000.

“The Homeless Initiative program provides medical care, actually any service that Cook Children’s can offer, to the children who reside in the three shelters in Tarrant County: Presbyterian Night Shelter, Union Gospel Mission and Arlington Life Shelter,” said Pat Ballard, an RN at Cook Children’s and one of the two case managers for the Homeless Initiative. “We do well checks, sick visits, TB testing, we have a flu clinic, we get them up-to-date on vaccines, any specialty doctors that they need, dentists, dental care, dental surgery, we schedule it all.”

The Homeless Initiative began in 2008 as a collaboration between Cook Children’s and former Fort Worth Mayor Mike Moncrief. The goal was to provide a path to medical care for this vulnerable population of children who, too often, were only seen by emergency room physicians.

“Back in 2008, about 98% of homeless children in Tarrant County were using ERs for primary care issues,” said Ballard. “That’s a huge burden for any ER and it puts stress on the whole system.”

The initial goal of the program was to make sure children had a primary care physician through Cook Children’s Neighborhood Clinics. These doctors would provide appointments for things like well checks, ear infections and upper respiratory conditions. It didn’t take long, however, for organizers to realize the need for mental health services and trauma-informed care, which takes a person’s traumatic experiences into account and promotes environments of healing.

“I don’t think we fully understood the problem in the beginning,” explained Denise Coover, LCSW, trauma informed care specialist at Cook Children’s. “Many of these kids have been through a lot of trauma. The more questions we asked, the more we learned.”

Coover joined the program in 2013 and provides on-site behavioral health assessments of children in the three shelters where the Homeless Initiative operates. Many of the questions in her assessment gauge what children have witnessed or endured such as physical and emotional abuse. She adds that being able to talk to the children themselves is key because often, parents don’t know the extent of what their children have been through, especially if they’ve been separated due to time in jail or foster care.

“A lot of our children have witnessed domestic violence. We have a lot of children who make disclosures of sexual assault, physical abuse, neglect and sex trafficking,” Coover said. “When we think about trauma, we have to remember the true definition is an event, or the threat of an event, that overwhelms someone’s ability to cope. If you can think of something that would overwhelm your ability to cope, our children are dealing with that.”

According to the National Center on Family Homelessness, children experiencing homelessness get sick twice as often as other children. They also suffer from more mental health issues such as anxiety, depression and withdrawal.

“We know while these children are in the shelter, this is our opportunity to intervene with them and provide them help,” Coover said. “They can’t wait six weeks, 12 weeks on a waiting list. They need intervention and they need it now.”

To make sure children experiencing homelessness in Tarrant County get the care they need quickly, Cook Children’s provides free transportation to the program’s families.

“We have a 16 passenger shuttle with a full-time, dedicated driver that delivers our kids to every appointment that we make,” Ballard explained. “That means picking up the parent at the shelter, going to school and getting the child, bringing them back to the clinic, whatever we have to do to get that child to an appointment we do.”

And if an appointment interferes with a family’s ability to eat lunch, the driver will make a special stop to make sure parents and children don’t miss a meal.

Another major goal for the Homeless Initiative is to make sure families transitioning out of homelessness have everything they need to succeed. Cynthia Thomas, LMSW, another case manager for the program, spearheads this mission. She says her job is to support and empower families experiencing homelessness.

“I provide strollers, car seats, anything a parent would need. They may need assistance in the education system, or school supplies. My role is to find out what non-health resources are necessary for them to be successful,” expressed Thomas, who works for The Women’s Center of Tarrant County.

While such supplies are necessary for success, Thomas’ main goal is to cultivate life skills families can take with them when they leave the shelters. To foster these skills, she organizes parenting classes several times a week at all three shelters. Thomas works with community volunteers and organizations across Tarrant County to create educational presentations meant to equip parents for raising children and teens.

“When they leave the shelter, we want them to feel empowered and we also want them to be able to speak for themselves,” said Thomas.

Some families need a little extra help with this, especially those who have children with special needs. Thomas often acts as a mentor and spokesperson for these parents who may have trouble navigating the special education system.

“A lot of times, the parent doesn’t understand the verbiage of the special education program, so I will go through it with them so they understand it better,” said Thomas. “One of the most rewarding parts of my job is seeing parents gain confidence and feel empowered. One mother was too afraid to say anything during meetings we had with the school. I was able to watch her learn how the system works, become comfortable and lose that fear.”

It’s been 11 years since the Homeless Initiative began and the impact is visible. As of December 2018, nearly 16,000 children and their families had been transported to medical appointments through the effort. Forty-five percent of those children returned to a neighborhood clinic after leaving the shelters, meaning they were no longer using emergency rooms as their medical home.

“I can go in the clinic two, three years later and I’ll see a mom sitting in the clinic with her kids,” said Ballard. “That’s really nice to see that you’ve made a difference in their medical care.”

The program isn’t intended to be just an appointment at a doctor’s office. Cook Children’s hopes it will be a support system when families need it most.

“It’s a chaotic world right now, but this is one of the things we don’t have to stress about,” said Brown-Bonner. “When I forget something, I get a reminder. They go above and beyond to make sure you’re comfortable and that things are taken care of. I’m very grateful and I know that there are other parents that are as well.”

For the Homeless Initiative team, the work seems never ending, but they know their efforts have a higher purpose.

“We know the outcomes for these children are not good if there’s no intervention medically and emotionally,” said Coover. “But the thing about resilience, that is the ability to bounce back from difficult life experiences, is it just takes one person believing in a child to build the resiliency they will need to succeed.”

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.

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.

Unfortunately, it’s also a troubling trend among today’s high school athletes.

Cook Children’s pediatrician David H. Goff, M.D., FAAP, calls overstressed, busy children a huge problem – both in the classroom and on the playing field. In his Denton office, Dr. Goff sees patients who suffer from a variety of symptoms like chronic abdominal pain, anxiety and depression.

“I see this over and over. I look in the child’s eyes. They are exhausted. I say to the parents, ‘You need to cut back,’” Dr. Goff said. “And it is amazing to me. They say, ‘We can’t. No way. We have a tournament this weekend.’ For any successes we have, we have 100 more burnouts.”

The American Academy of Pediatrics agrees with Dr. Goff. A group of eight organizations, including the AAP, released a consensus statement regarding their concern with today’s high school athlete.

The AAP states, “Student athletes report higher rates of sleep disturbances, loss of appetite, mood disturbances, short tempers and inability to concentrate than non-athletes.”

The recommendations focused on the importance of educating students, parents and coaches on mental disorders in student-athletes; the stress involved with today’s athletes and ways to monitor their behavior.

Concerns of the AAP included the injuries and stress related to student athletes training year round, which doesn’t give them time to rest and recover.

The AAP said these athletes also face stress from poor performance on the playing field, injuries, concerns about getting cut from the team and trouble keeping up with school work, along with their extracurricular activities.

Because of the stress involved, student-athletes may suffer from “a pattern of lack of sleep and under-recovery” and chronic fatigue that puts him or her at risk for anxiety and depression. Other issues include:

• Physical (Physical conditioning, injuries, environmental conditions)
• Mental (Game strategy, meeting coaches’ expectations, attention from media and fellow students, time spent in sport, community-service requirements, and less personal and family time)
• Academic (classes, study time, projects, papers, examinations, attaining and maintaining the required grade point average to remain on the team, and earning and maintaining a collegiate or academic scholarship).

David Gray, M.D., medical director of Cook Children’s Orthopedics and SPORTS, agrees with Dr. Goff that too much activity can simply be harmful to a young person.

With the advent of select sports and recreational leagues, Dr. Gray said children now play the same sport year round without getting a break from those activities. He wants young athletes to have variation in their activities. If not, the repetitive nature of the same sport creates stress and strain especially on growing bones.

Dr. Gray and his colleagues see children who never have a break during the year sometimes playing on two or three different teams during the same season. He said it’s too much stress on their growing skeleton, causing muscle aches, strains and pain.

Both Dr. Gray and Dr. Goff stress children, especially before they reach high school, should focus on participating in several different sports to prevent using the same muscles year round. They say it also helps the child avoid getting burned out on that specific sport.

“For kids, sports are great and you learn a lot from them, but they should be fun,” Dr. Gray said. “Kids need to enjoy them too. You don’t really want a 12 or 13 year old performing to the point where they are having injuries that could actually impact them as an adult.”

Dr. Goff admits this subject quickly places him on his soapbox. But it’s because he sees so many of his patients facing stress and are simply not happy.

He sees them come in with dark circles under their eyes and behind closed doors and just one-on-one with him, they admit to a different story than what they have been telling to their parents.

Far too often, Dr. Goff hears the regrets of parents, but only when it’s too late. The child has gone off to college and the parent wishes they had taken a trip to the Grand Canyon with their family, instead of racing off to another game.

“I ask the parents to leave the room so I can talk to the child,” Dr. Goff said. “I ask, ‘Do you really want to do this?” They say, ‘No I’m tired.”

The scary part of this story is that far too often the parents are trying to do what’s best for their child, but in reality they are doing harm.

Dr. Gray said he is beginning to see injuries in children as young as 8 years old with ACL injuries. Injuries that were once thought not to happen until children were much older.

“Another problem is that the really good, young kids are getting left behind,” Dr. Gray said. “They are burned out because they are pegged to be the superstar and they get over worked, over trained and over pushed. Some get burned out and pushed to the wayside and other kids, who were not as big, catch up by the time they are in middle school. They have more passion and they are not burned out. And they pass them by.”

Both Dr. Gray and Dr. Goff also see phantom injuries – muscle aches or headaches. Anatomically there seems to be nothing wrong with the child. In reality it’s the child hinting he or she needs a break.

So what should a parent do? Here’s a start:

• During the year give the child down time and a chance to recuperate. This is the case physically for sports and mentally for school.

• Vary the child’s routine to avoid burnout

• Give your children an opportunity to tell you if they are enjoying themselves.

“It’s easy to succumb to parental peer pressure,” Dr. Gray said. “Parents are afraid if they don’t do something their child will be left behind. What’s most important is that your children enjoy sports, or enjoy their activities and has a good mental outlook on life. It’s hard for parents to not live vicariously through their children. It’s a hard lesson for parents. You want the best for your child and want your child to be successful. But sometimes less is more.”