Whether you’re a younger kid starting kindergarten or a teenager starting high school, going back to school can create a lot of feelings. We asked Kia Carter, M.D., co-medical director of Inpatient and Consultation Liaison Psychiatric Services and Kristen Pyrc, M.D., medical director of Psychiatry Outpatient Services and the Partial Hospitalization Program at Cook Children’s Medical Center – Fort Worth, about how they talk to their own children when it is time to go back to school. They approached the subject from different perspectives because their children are different ages. Their back to school tips for parents cover all the bases, and we are thankful for their expertise and personal experiences as mothers!

Dr. Pyrc’s Back to School Tips for Young Kids:

• Little kids want to be big so badly, so parents should play up just how big they are going to be at their new school and all the fun things they can do when they get there.
• Read the book The Invisible String together, and remind your kiddo that you are always connected even when you’re not together.
• Tag in an older sibling or friend if you can! They can give the best advice and pep talks!
• If they are scared (which is totally normal), ask them what makes them worried. It may be the expected things like “Will I get lost? What if no one likes me?” or it could be something totally off the wall that an adult would never think of like “Who’s going to pet the dog when I’m at school?”
• Make drop-off short and sweet. Elementary school teachers are masters of distraction and comfort. I would give a quick hug and let the teacher work their magic.
• Kids look to us to know how to respond in new situations. Even if your mind is racing with worry, it’s important to put on a brave, reassuring face to set them up for success. You got this!

Dr. Carter’s Back to School Tips for Older Kids/Teenagers Addressing Anxiety:

• I encourage all teens to attend the school’s scheduled pickup/orientation as this is a way to decrease anxiety as they are able to see the school, walk their schedule and even see old friends which will help with those first day jitters when navigating such a big school. Also, you may see your old friends at these events which will help with that anxiety about reintegrating with old friends.
• Encourage teens, especially those new to a school, to join a club/afterschool organization to just get involved – this is an easy way to make new friends, provides outside engagement and even creates new hobbies/activities to keep kids busy. They may actually end up loving it. High schools have so many clubs, so most kids can find at least one extracurricular activity.
• Most middle/high school kids don’t want parents to be involved in drop off/make a big deal like we do in elementary school. As parents, we can support our teens differently like the night before or morning of – sitting down for a back to school dinner, eating first day of school breakfast with your teen a couple of minutes early, or reviewing their schedule with them the night before. This just provides some time to connect with your child in a space that is focused on something casual, while also providing the opportunity to talk about any first day anxieties and provide reassurance.
• Mostly teens worry about who they will walk the halls with, or who they will sit at lunch with, and so I would encourage teens when this is a worry – if your child has friends in their class, maybe try asking their friends if they can walk to the next class or walk to lunch together. Another tip is to try looking for familiar faces when walking the halls, or at lunch, because most likely other kids are also feeling the same way and don’t want to sit or eat alone.

To see the full list of Cook Children’s Physician Network physicians click here. 

By Linda Puga

As important as a child’s mental health is, it’s equally as important to look at how their journey impacts the people around them -- their caregivers. The ACEs Task Force of Tarrant County developed a video series called The Roadmap for Children’s Mental Health to help families navigate this health issue. These are some tips on how to take care of yourself to ensure you can be the best support system as a caregiver.

“Parents often have a lot of guilt, they have a lot of worries, they have a lot of uncertainty that they’re going through,” said Steve Chennankara, D.O., child psychiatrist at Cook Children's Psychology Clinic - Fort Worth.

First, recognize stress and model appropriate coping skills. Parents need to take care of their own mental health because as a caregiver, they make the medical decisions when it comes to their children, said Dr. Chennankara.

“For their own longevity, when it comes to endurance, they need to know that this is a marathon and not a sprint,” said Dr. Chennankara.

Second, be honest with yourself, your kids, and your peers. Manage stigmas in the ways you see fit.

“I don’t think there’s a one size fits all approach. So, recognizing and being aware of the stigmas that the parents have, or the child has, or a family member has, and bringing that to the light, and processing that, and working through that is important first,” said Dr. Chennankara.

After working through stigmas with yourself and your children, you can extend these practices with your next circle of friends and family, said Dr. Chennankara.

Third, be an advocate. You never know what people are going through, so make sure you’re intentional with the actions you perform and the thoughts you vocalize.

There are different levels of advocacy, depending on where you feel like you’re at right now. Something you can do is share testimonies from your child as a way to reduce the stigma around mental health.

Having these conversations helps kids know that they aren’t alone in struggling with mental illness. 

“One in four kids go through some type of mental distress throughout their developmental period,” said Dr. Chennankara.

Fourth, remember that your best is good enough. Don’t let your opinions get clouded by too many other people.

“There is no such thing as perfect parents. And, a child does not need a perfect parent. They need a present parent,” said Dr. Chennankara.

Remember that asking for help doesn’t make you weak or a failure, it leads to more awareness. Take advantage of all the resources you can.

In order for kids to trust caregivers with the big things, they need to listen to the little things.

When your child is struggling with their mental health, it can be difficult to know where to turn. Nationwide, waitlists for appointments with child psychologists and psychiatrists can be months long. As a result, pediatricians have become the first line of defense for families who need support.

Alice Phillips, M.D., wears many hats at Cook Children’s. She’s the Board Chair of Cook Children’s Physician Network and Medical Director of Ambulatory Quality. Dr. Phillips is also a pediatrician at Cook Children’s Pediatrics Cityview, and has seen mental health concerns in her practice increase dramatically over the past 26 years. On this episode of Raising Joy, Dr. Phillips talks to us about the role of pediatricians in the mental health crisis and the growing number of tools in their toolbox to help children.

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.

We’re born with a mind, body and soul. When something goes wrong with one, it often affects another. That’s especially true for individuals with diseases of the nervous system — or the brain, spinal cord and nerves — and it’s the motivation for the development of the new Jane and John Justin Institute for Mind Health at Cook Children’s Medical Center – Fort Worth.

The Justin Institute will connect nine specialties under one roof, including Neurology, Neuropsychology, Neurosurgery, Pain Management, Physical Medicine and Rehabilitation, Psychology, Psychiatry, Developmental Pediatrics and Developmental Psychology. It is slated to open fall 2023 in Cook Children’s newly expanded Dodson Specialty Clinics building.

"All of the departments and specialties involved in creating the Justin Institute have worked really hard to break out of their silos and build a system that gives our patients a connected and well-coordinated experience," said Teresa Baker, assistant vice president, Primary and Specialty Services, for Cook Children's Physician Network. "I'm really thankful for their teamwork and focus on doing what is best for the child, and our patient families will be, too, as they see it first hand during their visits."

Physicians began building the Justin Institute’s framework several years ago after identifying a missing link within the Neurosciences program. There was little coordination among overlapping specialties that treat the mental, developmental and physical diseases and disorders associated with the nervous system.

“A majority of people with diseases of the nervous system have accompanying mental health or behavioral health disorders,” said M. Scott Perry, M.D., an epileptologist and head of Neurosciences at the Justin Institute. “For example, about 50% of people with epilepsy will also have mental health disorders such as depression and anxiety.”

That may be because epilepsy, depression and anxiety share the same abnormal brain connections, or because the stress of living with the unpredictability of the disorder leads to mental health struggles. Either way, it’s important to connect the dots of care for those with overlapping mental, intellectual, neurological and developmental health needs.

“Kids get better when all aspects of their health and wellbeing are addressed, including their medical and mental health needs,” said Kristen Pyrc, M.D., Cook Children’s co-medical director of Psychiatry. “Many of our patients are seen by Neurology and Developmental Pediatrics and Developmental Psychology specialties, so we are hoping that being part of one institute will help increase collaboration amongst the disciplines and get patients to the appropriate resources more quickly.”

Everything for the Child

The Justin Institute is built around a patient-centered experience, where everything for the care of a child’s nervous system is in one place and coordinated through one referral, assessment and intake process. It’s designed to eliminate barriers to care like multiple appointments with multiple providers in multiple locations and to simplify the patient’s access to their medical team. For children and their families, it will make a day of doctor’s appointments much easier. For medical providers, it enhances their ability to coordinate care.

“The Justin Institute will help us more readily identify and align services earlier in the treatment process and steer families in the right direction, or in many directions simultaneously,” said Lena Zettler, MA, LPA, director of the Cook Children’s Department of Psychology. “For our patients who have had traumatic childhood experiences, plus mental health issues and neurodevelopmental disorders such as ADHD, this will provide better collaboration and coordination of care, hopefully in a more timely manner.”

It’s about improving the system, Dr. Perry explained. One that can admittedly be hard for families to navigate at times.

“Dealing with a disorder of the nervous system is stressful enough,” he said. “Getting the appropriate care should not make it worse. You shouldn’t have to pack up your child and go to four different places when you need a neurologist, neurosurgeon, psychologist and autism services when we can bring these services that commonly co-mingle together under one umbrella.”

At the Justin Institute, neurologists, neurosurgeons, psychiatrists, psychologists and experts in developmental and behavioral health will work together in one location where walking across the hall to consult with one another on a patient’s case will be the norm. For the patient, that translates to better, more comprehensive and connected care.

“The opportunities for collaboration between specialty departments when they are under one roof has the potential to really enhance the care that we all provide our families,” said Matt Robison, director of Cook Children’s Child Study Center, where kids with complex developmental and behavioral health disorders receive diagnosis, treatment and education.

Child Study Center’s Developmental Pediatrics department and Psychology program will physically relocate to the Dodson Specialty Clinics building as part of the Justin Institute, as well as Cook Children’s psychologists who currently function in different departments on the main hospital campus.

The move undoubtedly brings mental health care front and center and illustrates Cook Children’s commitment to connected care, according to Zettler.

“Cook Children’s understands there is no health without mental health,” she said. “Psychologists, in particular, have much to offer in assessment and complex diagnostics, and I am looking forward to future collaboration, projects and research that will be mutually beneficial for all.”

Cook Children’s already has a robust Neurosciences Research Program, but the Justin Institute will open the door for more cross-specialty studies, much like one currently underway examining the impact of epilepsy on the psychological health of children. Chrystal Cooper, Ph.D., a principal investigator with the Justin Institute, is leading that study.

“Dr. Cooper’s work is an example of the type of collaborative research that is possible across the divisions of the Justin Institute,” Dr. Perry said. “Our plan is to take the successful research program we have in neurosciences with a focus on epilepsy, cerebral palsy and movement and grow that team to include teams dedicated to autism, pain, stroke and more.”

To learn more about the specialties represented at the Justin Institute for Mind Health, visit Instituteformindhealth.org. 

By Ashley Antle

What has enough concrete to fill eight Olympic-sized swimming pools, ductwork that equals the weight of 32 male African Elephants and 160 miles of wiring that could circle a football field more than 600 times?

It is the newest addition to the Cook Children’s Medical Center campus, which adds 240,000 square feet and six new services to the existing Dodson Specialty Clinics building. The expansion, opening in March 2023, is designed to make visits to one of the more than 35 specialty clinics housed in what will ultimately be a fully integrated facility easier and more convenient for patients and their families.

“Our specialty clinics are experiencing increasing demand for services from a rapidly growing, diverse population,” said Veronica Tolley, vice president of Primary and Specialty Services at Cook Children's. “The Dodson Specialty Clinics expansion will accommodate this growth, while also allowing clinics to consolidate to one location which is a tremendous satisfier for our patient population.” 

Children living with a disability or disease often require ongoing care from one or more specialized physicians, like a neurologist or oncologist, for example. Juggling multiple appointments, medical equipment and other challenges that come with a chronic condition can be difficult. The Dodson expansion places vital and often overlapping specialty services under one roof, connecting the dots of care, collaboration and convenience for physicians and families.

What’s New

While adding space for clinic growth, the expansion also will support the addition of a Peaks Tech Zone, a sibling center, a cafe, a pharmacy, retail space and a maternal/fetal medicine clinic.

A cross between a technology lounge and in-person help desk, Peaks Tech Zone is a place where families can get guided, hands-on experience with devices and online applications recommended for their child’s care. It includes a self-service space and a consultation area for one-on-one assistance from a health technology advocate, or techspert, who will help Tech Zone visitors do everything from setting up their MyCookChildren’s patient portal so they can view their child’s medical chart to syncing their personal technology with medical devices and apps recommended by their child’s physician. Visitors can also learn how to utilize virtual care, telemedicine services and any new Cook Children’s innovation that helps them meet the health needs of their family.

The Sibling Support Center will take a load off of parents and give kids a safe, fun and developmentally appropriate space to spend time during their sibling’s clinic appointment.

“There are many times when parents have to bring siblings to patient appointments, and sometimes the presence of siblings ends up preventing needed clinical care from being able to happen,” said Jill Koss, director of Family Support Services. “This Sibling Support Center will allow parents to focus on their child who is a patient and, even more importantly, will allow siblings to be the focus of specific programming designed to support their emotional, psychosocial and developmental needs.”

The Sibling Support Center is generously sponsored by Panda Cares through Children’s Miracle Network Hospitals charities. It will be located on the first floor of the Dodson expansion and open to patient siblings ages 3 to 12, Monday through Friday, for up to 90 minutes per visit. Programming will include creative arts activities, play supporting growth and development, music, dramatic play, video games for older children and more.   

The new space also makes way for the Jane and John Justin Institute for Mind Health, which will put commonly overlapping specialties that treat the mental and physical diseases and disorders associated with the nervous system under one roof. Those specialties include Neurology, Neuropsychology, Neurosurgery, Pain Management, Physical Medicine and Rehabilitation, Psychology, Psychiatry, Developmental Pediatrics and Developmental Psychology. The Justin Institute is designed to eliminate barriers to care like multiple appointments with multiple providers in multiple locations and to simplify the patient’s access to their medical team. For children and their families, it will make a day of doctor’s appointments much easier. For medical providers, it enhances their ability to coordinate care. The Justin Institute is slated to open fall 2023 in Cook Children’s Dodson Specialty Clinics building.

A new 10-level parking garage for physicians and visitors will support the facility and will be easier to navigate. No more driving around and around wondering if a space will be open from one level to the next. Using dynamic signage, an intelligent parking system will alert drivers to the number of spaces available as they approach a level of the garage, making self-parking more efficient and reliable.

“Following substantial completion and certificate of occupancy, many of our clinics who currently reside in our existing Dodson facility will begin moves to the new facility through a managed transition plan beginning in late March and continuing through 2024,” said Kim Arnold, space utilization and transition manager. “Countless thousands of children and their families will enjoy this new facility, the exciting features and benefits designed to serve them. We cannot wait to implement the transition of our clinics and services, and open the facility for our patient families.”

Have you ever found yourself stunned or unable to respond to something your child has said or done? If a child or teen tells you they don’t want to be alive anymore, or that they have a plan to harm themselves, what should you do?

Kia Carter, M.D., medical director of Inpatient Psychiatry at Cook Children’s Medical Center, joins us on episode 17 of Raising Joy to answer this question.

Dr. Carter oversees a 15-bed psychiatry unit at the Rees Jones Behavioral Health Center at Cook Children’s. She also supervises consults on the medical floor, assisting children who are admitted for medical reasons, but also have psychiatric concerns.

In this episode of Raising Joy, Dr. Carter explains when you should take your child to the emergency room for mental health concerns, and what admission into the psychiatry unit is like for the patient and their family.

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.

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.

Hospitalist nurse practitioner Amber Jewison and psychiatrist Kia Carter, M.D. were featured on the nationally-syndicated show “The Doctors” on Thursday, Nov. 5. The show highlighted a recent trend of TikTok videos that encourage viewers to take excessive amounts of the common allergy medicine diphenhydramine, aka Benadryl.

Cook Children’s first reported on these videos on Checkup Newsroom over the summer after three teens were admitted to the hospital for overdoses.

“We had three patients in a week who specifically told me they saw a video on TikTok that told them they could take Benadryl to get high, and it gave them a specific number (to take),” Amber said in an interview on "The Doctors." “When I viewed that video, I was pretty shocked.”

Patients who overdose on Benadryl can have abnormal electrocardiograms (EKGs) and may not be able to urinate. It’s even possible to suffer seizures. Amber has treated such patients and says parents are usually shocked to find out their child has overdosed.

“I try to tell parents that it’s really good to know what’s out there on social media and to be aware of what your kids may be doing,” she said.

And it’s not just shocking for parents. Medical professionals are also surprised to see healthy adolescents and teens taking part in these dangerous challenges.

“I was alarmed, I was extremely shocked that children are participating in something so lethal,” said Dr. Carter, who is also the medical director of Psychiatry at Cook Children’s. “Being a parent myself, it’s petrifying to think about the idea of my pre-adolescent daughter participating in this.”

So why do teens participate in dangerous viral challenges like the one involving Benadryl?

“I think people have to realize that children’s brains are not fully developed like an adult and judgement and executive function are a huge part in making decisions. When we see kids participating in these high-risk behaviors, we have to remember that their brains are not fully developed,” said Dr. Carter. “There’s some research also to show that social media and participating in these challenges is activating the reward center in the brain, which can cause kids to become further attached to participating in these challenges.”

Dr. Carter says it’s also important to realize the difference between a child participating in an online challenge, and one who is actively trying to harm themselves. She says kids who are taking part in challenges because they want to fit in are usually active and part of a social group. Kids who are taking medicines or over-the-counter substances to harm themselves are often excluded or bullied on social media.

Her advice for parents - be aware.

“Know what your children are doing on social media, participate and ask questions,” Dr. Carter said.

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

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

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

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

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

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

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

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

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

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

So why do children and teens take these drastic measures?

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

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

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

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

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

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

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

Other signs of depression to look out for include:

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

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

The CDC found:

• That suicides increased by 56% during the 10-year span among people ages 10 to 24 years old.
• Suicide attempts among African-American teens increased by 73%.
• Suicide is the second-leading cause of death for teens from all demographics and the third-leading cause of death among black youths between the ages of 15 to 19 in 2017.
• In 2017, 2,200 teens between 15 to 19 years died by suicide.
• 1 in 5 high school students admitted to experiencing suicidal thoughts and 1 in 10 said they devised a plan to carry it out.
• The increase in the rate of suicides among 10- to 14-year old children have almost tripled between 2007 and 2017.

The CDC collected data from nearly 199,000 high school students by the CDC and Prevention’s Youth Risk Behavior Study.

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

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

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

“I have found it is a good way to signal to kids and parents that we are open to talk about this and want them to ask us about it,” said Vanessa Charette, M.D., a pediatrician at Cook Children’s Magnolia office in Fort Worth. “Even if nothing comes up, often a parent will return with the teen later wanting to talk about anxiety and depression.”

While researchers say they aren’t sure of the exact causes for the rising suicide rates, experts point to a rise in depression among adolescents, drug use, stress and access to firearms might all be contributing factors.

Lisa Elliott, Ph.D., a licensed psychologist and clinic manager of Cook Children’s Behavioral Health Clinic in Denton, is simply fed up. She’s seen too many kids come into her office depressed, frightened or even suicidal because they can’t get away from their bully or bullies.

“I think that bullying is worse than ever before because of cyberbullying,” Elliott said. “Kids can’t get a break.”

No child is bully-proof. Elliott offers parents the following talking points when speaking to their child about bullying:

• Even people who say they're your friends can bully you.
• You should confront your friends when they're being hurtful to you or others.
• Retaliating may feel good temporarily, but refusing to stoop to the bully's level will win you more popularity in the long run.
• When you hear a false rumor, just ignore it and be yourself.
• You're most likable when you respect yourself and others.
• Bullies usually have their own insecurities. Returning meanness with kindness is the best way to break down their defense.

Elliott advises parents to monitor their child’s computer and cell phone, and encourage them to spend less time on social media. If bullying expands onto social media, then parents should talk to their child’s teacher, coach or another school official.

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

Elliott says warning signs of teen suicide include:

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

If you would like to schedule an appointment, refer a patient or speak to our staff, please call 682-885-3917. 

Sources for this Topic:

• Cook Children's Behavioral Health Center
• Youth Risk Behavior Surveillance System (CDC)
• Report: Suicide Attempts Among Black Teens Increased by 73 Percent (The Root)
• Suicide attmepts increasing among black children and teens, study finds
• Youth Suicide Rate Increased 56% In Decade, CDC Says
• Suicides and homicides on the rise in young people (NBC News)

The number of children showing up in emergency rooms for suicidal thoughts and attempts is on the rise, especially during the school year.

According to a new study published by the American Academy of Pediatrics, kids ages 5 to 17 were admitted to children’s hospitals for thinking about or trying to kill themselves twice as often in 2015 as 2008. Researchers at Monroe Carell Jr. Children’s Hospital at Vanderbilt embarked on the study after noticing more pediatric patients being kept in the hospital with mental health issues.

They found that girls are attempting suicide more often than boys. They also found that suicide attempts were highest during the school year and decreased during the summer months.

“On average, during the eight years included in the study, only 18.5 percent of total annual suicide ideation and suicide attempt encounters occurred during summer months,” the research team wrote in the publication.

Half of the encounters examined in the study involved teens aged 15 to 17.

Numbers High at Home

This disturbing trend is also evident at Cook Children’s.

In 2016 and 2017, more than 390 children were seen by the Psychiatry department at Cook Children’s for an attempted suicide. The team was consulted on more than 1,040 total cases for issues including depression, anxiety and/or attempted suicide. The majority of the children who attempted suicide were female (317 female, 76 boys) and the average age was about 14 years old.

Also like the study, the majority of suicide attempts seen at Cook Children’s occurred during the school year.

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

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

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

“I have found it is a good way to signal to kids and parents that we are open to talk about this and want them to ask us about it,” said Vanessa Charette, M.D., pediatrician at Cook Children’s Magnolia office in Fort Worth. “Even if nothing comes up, often a parent will return with the teen later wanting to talk about anxiety and depression.”

Suicide Attempts among Young Children

Another study published by the AAP found that younger children who die from suicide are more likely to do so impulsively while early adolescents tend to struggle with depression for some time then plan and carry out suicide. The researchers found that younger children were more likely to have experienced ADHD symptoms while early adolescents were more like to have experienced depression symptoms.

“What is important to realize is that in a young child, thoughts of suicide can occur without depression symptoms,” Dr. Pyrc said. “I have to wonder if some of the elementary-school-aged children meant to end their life, or if they act impulsively not fully appreciating the consequences. Unfortunately, the result is the same regardless of the child’s intent. A child’s life has ended prematurely, and family and friends are left with immense grief and a lifetime of regret.”

Dr. Pyrc said in childhood and adolescence, depression is more likely to present with irritability and angry outbursts than sadness. Young people are remarkably resilient and able to ‘compartmentalize,’ meaning they can feel deeply sad when alone but are able to socialize with their friends and appear happy on the surface.

Depression also manifests as changes in energy and sleep as well as social withdrawal, a drop in grades, or not engaging in activities they once enjoyed. If you see some of these signs and symptoms in your child, it may be time for an assessment. Starting with your pediatrician is a good first step because they can help assess for depression symptoms as well as rule out any medical problems that present similarly to depression.

Dr. Pyrc stresses it is vitally important to take children seriously when they say they want to die.

“I think it is easy to dismiss a statement like this from a child because it is hard to imagine that they fully understand what they are saying, but I would sure hate to be wrong,” she said. “I think it is important to believe our children and get help for them when they make suicidal statements. If you are concerned that a child may hurt him or herself or others, please seek professional help as quickly as possible. If you feel the threat is imminent, please take them to the Emergency Room for an assessment.”

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

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

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

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

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

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

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

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

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

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

Some use the acronym DIGFAST to refer to mania symptoms:

D-Distractability

I-Indiscretion or high risk behaviors

G-Grandiose thinking

F-Flight of ideas or racing thoughts

A-Activity increase

S-decreased Sleep

T-talkativeness or hyperverbal, pressured speech

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

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

But recently, a mom wrote in for help, looking for advice to help her with a heartbreaking problem. Her husband is dying and she wanted to know how to talk to her young children about what her family would be going through in the very near future. For the answers, we went to our experts.

“It’s important to explain to children that a parent is sick, and it’s a type of sickness in which he or she will get sicker, not better,” Joy Crabtree, Psy.D., a licensed psychologist at Cook Children’s Urgent Care and Specialties in Southlake, Texas. “The dying parent should be involved as much as that person is able in terms of planning and engaging in special activities with the kids (together and separately) during periods that he or she is well enough to do so.”

Crabtree suggests lots of pictures be taken and the parent write special letters to each child to be opened later at specific ages or milestones. In the future, after the parent passes, there will be periods of grief that pop up and perhaps a sense of sadness or a feeling from the kids that they were robbed the opportunity to share proud moments or special occasions with both mom and dad.

“If that comes up, the kids can be encouraged to write those thoughts down, either randomly or in letter format,” Crabtree said. “They can simply keep an ongoing journal of what they wish they could tell the parent who died or even write it on a note and tie it to a balloon and set it free. They might keep a box of drawings or notes that they make for mom or dad.”

Crabtree suggest the children go into therapy and the dying parent join as well if possible to address and get support/guidance for questions/behaviors that are coming up for the kids. “There is certainly no guidebook or specific right or wrong way to handle the process,” Crabtree said. “It will be tough no matter what, but with open communication, sharing memories, and the understanding that all questions and thoughts are welcome, they can work through it together.”

Lisa Elliott, Ph.D., a licensed psychologist and clinic manager of Behavioral Health for Cook Children’s in Denton, said she has seen a family go through this first-hand. She said the young father did an “incredible job of leaving a legacy” for his 2 year old by writing a book for her and lots of letters for her at critical points in her life, such as starting kindergarten, middle school, high school, graduation, turning 13 and 16, getting married and becoming a mom. The parents also bought charms for their daughter to be given to her on those critical dates.

Lena Zettler, MA, LPA, director of Psychology at Cook Children’s, said finding the right words to describe what’s happening will be crucial to helping the child through such a difficult time and the way the message is delivered will depend on the age of the child.

• Very young children will not understand the abstract concept of death, and saying that “daddy is passing on” may be more confusing.

• Children should know that their parent will not be asleep, and some concrete things like “death happens when our heart stops beating."

• Kids will usually ask questions that they are ready to hear the answers to, so listen to what they are actually asking about and answer that. Most times they need more concrete answers than we expect.

• When answering, give kids some time to process … say a few sentences, and then wait until the child is ready to hear more.

“We often use a lot of words and kids under 10 may not be able to process more than a few sentences at a time,” Zettler said. “Make sure all the kids get the same info, but it may mean talking separately to the children if their age ranges are broad (example, a 3 year old and a 10 year old). Include both parents in the conversations if both parents able physically.”

Zettler says if you don’t know the answer to a question, it’s OK to say you don’t know (for instance, “How long can daddy play ball with me?”). Also, kids of all ages need the same information over and over again, so be prepared to have many conversations. They may ask you a serious question and after a brief, but accurate answer from the parent, they may go right back to playing and acting normally. That is OK … they are taking in the amount of information they can process at that time.

“Celebrate mom or dad’s life NOW while that person is still here; talk about what is happening,” Zettler said. “Don’t forget that kids need to play. That doesn’t change when something like this happens. In fact, playing is the best way that kids have to learn new coping skills.”

Remember to provide support for the children and notify caring adults at the children’s schools. There may be additional support that teachers, nurses and counselors can provide.

Read age appropriate books on grief/terminal illness together (parent and child, or as a family). Books on death may not seem relevant while the parent is “just sick,” but books on death/loss may be more helpful after the death. Zettler says examples of books on terminal illness and coping with that for kids are: “Beyond the Rainbow” and “Help me Say Goodbye.”

Zettler says some children may struggle academically early on. Some kids, however, may seem less disrupted and more able to keep up their school work. That doesn’t mean they aren’t grieving, or that their academics may not suffer later. If they are getting behind academically, and they have not had school problems, before, don’t panic. They will catch up. If they have had problems before in school, definitely reach out to school personnel and consider getting the help of a psychologist or therapist.

“Kids will be afraid, unhappy and may act out more than usual,” Zettler said. “Don’t see this as abnormal or behavior ‘problems.’ You can still enforce rules especially if kids get aggressive but be patient with each other. Try to help them find words to express their feelings. Tell them that it is OK to have feelings. Reassure kids with words, with your presence, and with other comforting things like maybe a stuffed animal. It is OK if they “regress” during this time and do things they stopped doing when they were younger. If they really struggle with this or with difficult behavior, see a psychologist or therapist who has experience with pediatric grief or loss.”

Resources

“Preparing Your Children For Goodbye: A Guidebook for Dying Parents” by Lori Hedderman.

http://www.centerforloss.com/wp-content/uploads/2014/10/A-Childs-Grief.pdf

http://www.cancer.org/treatment/childrenandcancer/helpingchildrenwhenafamilymemberhascancer/dealingwithaparentsterminalillness/dealing-with-a-parents-terminal-illiness-toc

About our sources

Cook Children's Behavioral Health services provides a broad range of care that focuses on children from ages three years through 17, and their families. We also have some limited services available for children age 2. 

As part of family-centered care all of our professionals are qualified both through education and experience to work with children who have behavioral and emotional challenges. Our psychiatrists are board certified in child and adolescent psychiatry and our psychologists and therapists are all licensed independently in Texas.

To access any of our services, please contact our Intake Department. To expedite your call, please have your child’s date of birth and insurance information ready.

“Try to react calmly and unemotionally,” said Joy Crabtree, Psy.D., a Cook Children’s psychologist in Southlake. “Discuss what words are off-limits in your family and why those words are unacceptable. Help your kids find other words that are acceptable in similar situations.”

Of course, children who use bad language heard the word somewhere beforehand. Most commonly, children can learn curse words by hearing them on television, video games or – oops – from their parents.

“The more children are exposed to those words, the more numb they become to bad language,” Crabtree said. “Hearing the words frequently makes kids more likely to use those words themselves.”

Parents should closely monitor the entertainment their children are exposed to and be good role models by using their appropriate language around their children. If the child continues to use bad language, parents should consider discipline methods that including taking away allowance, giving him or her time-out or limiting television or game time.

For more information

Cook Children's Behavioral Health services provides a broad range of care that focuses on children from ages 3 through 17, and their families.  As part of family-centered care all of our professionals are qualified both through education and experience to work with children who have behavioral and emotional challenges. Our psychiatrists are board certified in child and adolescent psychiatry and our psychologists and therapists are all licensed independently in Texas.

To access any of our services, please contact our Intake Department. To expedite your call, please have your child’s date of birth and insurance information ready.