Along with the physical illnesses and injuries treated at the Cook Children’s emergency department (ED), a standard part of care includes a questionnaire that flags possible suicide risk.

Every patient ages 8 and older in Cook Children’s ED gets screened in a process that aims to proactively identify kids and teens who might be inclined to harm themselves. Much like more familiar vital signs -- temperature or heart rate, for example -- the screening for suicide takes a pulse on the patient’s emotional well-being.

“If a child arrived to the emergency room with a fever or a blood pressure problem, we would do lab work or various tests to search for the cause of these symptoms,” said psychiatry nurse case manager Melody Hackfeld, “With mental health issues, screening for suicide and asking about sadness and worries is how you determine there is a concern that needs to be addressed.” 

Numbers reveal an alarming trend: through July of this year, 261 patients required hospitalized medical stabilization at Cook Children’s due to suicide attempts. That compares to 143 patients hospitalized following suicide attempts in the first seven months of 2020. These statistics don’t include the attempted suicides in which the patient goes straight from the emergency room into psychiatric inpatient care.

Vigilance to prevent youth suicide takes on even greater urgency given the reported rise in anxiety and depression during the COVID-19 pandemic. In response, Cook Children’s has launched the Joy Campaign communications initiative as a way to spotlight areas of help and reasons for hope. The good news in this story? More kids who speak up. Earlier detection of suicidal tendencies. A quicker path to treatment.

A child or teen who arrives in the emergency department with a broken arm, for instance, or a severe case of the flu might also suffer from unexpressed suicidal ideas. By routinely asking a few brief questions in the ED, Cook Children’s works to detect any patients experiencing thoughts about harming themselves. The preemptive strategy uses two key components… screening and assessment.

“The emergency room staff lets them know that in addition to being worried about your physical health, we want to know more about your emotional health, and if you’re having any sadness or worries,” Hackfeld said. “You’d be surprised with how many kids just open the floodgates” with honest answers and relief.

The National Institute of Mental Health developed the Ask Suicide-Screening Questions (ASQ) tool, which Cook Children’s uses. Nurses are trained to administer a five-part questionnaire:

1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you ever tried to kill yourself?
5. Are you having thoughts of killing yourself right now?

A “yes” answer to any of the five parts results in what’s called a positive ASQ, which leads to a closer assessment by the behavioral intake staff at Cook Children’s. After assessment, the range of recommendations can span from counseling to hospitalization, depending on the warning signs that surface when more in-depth questions are asked.

Experts describe the ASQ as a short, simple, valid and evidence-based method for identifying a suicidal inclination. Let’s take a closer look at how and why it fits into Cook Children’s delivery of emergency medical care.

Step 1: Screening

Patients fall into two categories. Those arriving with behavioral complaints (such as anxiety, self-harm, aggression, intentional ingestions, suicidal/homicidal ideation) are screened in the triage bay. Patients with nonbehavioral complaints (physical ailments) go through triage to be medically stabilized first. Later, during their secondary triage in the patient care rooms, the nurses screen the nonbehavioral patients. 

When Cook Children’s ED implemented suicide screening in 2017, Hackfeld and others worked to develop an educational video and computer-based training that incorporate scripts and scenarios to make the nurses more comfortable raising the topic.

“Some nurses thought if you asked about suicide it would give the child the thought, but research shows that that’s not true,” she said.

Nurses at Cook Children’s preface the conversation by asking “Do you struggle with sadness or worry?” An affirmative answer to that segue question doesn’t necessarily indicate suicide risk. But the discharge staff can provide those patients with take-home resources to help manage the sadness and worry.

ED nurse manager Kara Dorman tracks the number of nonbehavioral patients who answer at least one “yes” on the ASQ, requiring further evaluation. That number climbed from 18 patients (1.1% of the total screened) in March 2020, to 64 patients (3.4% of the total screened) in March 2021. Meanwhile, the patients who reported feeling sad or worried rose from 9.8% to 16.8%.

“Had ED staff not utilized the screening tool, then it is highly likely that no one would have known these children were struggling mentally or having suicidal thoughts,” Dorman said.

She points out that the nurses are trained to make eye contact, pay attention to facial expressions, and listen to tone of voice so they don’t miss any nonverbal cues during the screening. One challenge, she said, is establishing a good nurse-patient rapport in the ED within a short amount of time.

Step 2: Assessment

When a patient answers “yes” to one or more of the ASQ questions, the Cook Children’s intake team gets called in. The goal is to determine the degree of suicide risk, and the right course to follow next.

Phillip Breedlove, intake manager, explained that the assessment process dives deeper into the patient’s mental state. Breedlove and his team need more information in order to recommend either outpatient referral, immediate inpatient care, or something in between. The assessment typically starts with easy-to-answer questions.

‘’’So tell me, you're 10 years old, right? OK, good. I had to check that. And tell me what school do you go to and what grade are you in and how do you like school? What's your favorite subject? How are you doing in school?’ You start with that,” Breedlove said. “And then like, ‘How's your appetite? Have you been eating OK lately?’ You get progressively more personal.”  

One tool used is the Columbia-Suicide Severity Rating Scale, a checklist that covers various behaviors and the intensity/duration of suicidal thinking. Responses help the intake staff to weigh the risk factors versus the protective factors when assessing what type of treatment is needed, and how soon. Risk factors include feelings of hopelessness, agitation, previous self-injury, or a specific intent to attempt suicide. Protective factors include supportive friends and family, engagement in school, and strong religious beliefs.

Breedlove said patients with suicidal tendencies have become increasingly younger during his 22 years working at Cook Children’s. The cutoff for suicide screening in the ED used to be age 10. Breedlove said age 8 isn’t too young now, especially during the COVID-19 pandemic.

“The younger ones tend to be more in that angry, upset and impulsive category, and the older ones maybe tend to be thinking it out. They're pondering it. They're mulling over ways to harm themselves. It can be an impulsive act with them as well, but a lot of times you see the impulsivity more clearly with those younger kids,” he said. “I know anecdotally that a growing number of those sad, morose children with suicidal thinking is driven by a greater degree of hopelessness than in past years.”

Breedlove predicted an uptick in positive ASQ screens when school returns to in-person learning in the fall. He advocates for more frequent dialogue about suicide -- in homes and in every medical setting. The emergency department can be an especially opportune venue for preventing suicide in kids who don’t see a pediatrician regularly. Just a few questions and follow-up assessment can uncover a potential problem that might otherwise go unnoticed, Breedlove said.

Assessment can be a therapeutic process for the children or teens and their parents when the outcome leads to resources for help. Patients frequently thank the intake staff for taking the time to gather more background that clarifies the status of their mental health, he said.

Now that schools have opened, who needs COVID-19 testing?

Rapid testing for COVID-19 can be helpful to promote isolation for positive cases, and to prevent prolonged unnecessary isolation for those children exposed to COVID-19 or with questionable symptoms. The symptoms that most likely warrant testing are combinations of the following: fever and headache, vomiting, diarrhea, congestion, loss of taste or smell, cough, muscle soreness, extreme fatigue and shortness of breath. Children with diabetes may see unexplained difficulties with sugar control. Any combination of these symptoms should be taken more seriously if there has been a known contact with a COVID-19 case.

Does a child who has had COVID-19 need a negative test to return to school?

While we have seen some schools and athletic programs requiring a negative test in order to return, this is based on outdated guidance. Testing may remain positive for weeks after symptoms have passed but does not mean that the child remains contagious. The current guidance is that students may return when their symptoms have resolved for 24 hours AND they are 10 days since the start of symptoms. In practicalities, most of these students will be waiting until the 10 days pass. If a child was hospitalized, it is recommend that they wait 20 days from the start of symptoms.

If a child is exposed to COVID-19, can we end their quarantine early with a negative test?

Testing is reasonable if symptoms develop to make a diagnosis, but quarantine should continue for 14 days from the end of the last contact. A negative test should not provide false reassurance as symptoms could continue to develop throughout the 14 day period despite a negative test.

Many parents are concerned about whether their child is at more risk for COVID-19. Which patients are at risk for more severe disease?

Risk factors for severe disease at any age include: cancer; COPD; immunosuppressed state due to organ transplant; obesity (BMI >30); serious heart disease such as heart failure, coronary artery disease, and cardiomyopathies; sickle cell disease; and type II diabetes.

Individuals with the following conditions MAY be at increased risk for severe diseases: asthma; stroke; cystic fibrosis; hypertension; immunocompromised state due blood or bone marrow transplant, steroids, or immunosuppressing medications; neurologic conditions; HIV; liver disease; pregnancy; pulmonary fibrosis; smoking; thalassemia; and type I diabetes.

Children who are medically complex, who have serious genetic, neurologic, metabolic disorders, or congenital heart disease might be at increased risk for severe illness from COVID-19, as well as children with obesity, diabetes, asthma and chronic lung disease, or immunosuppression.

What do you do when a child has a family member who is at risk for severe disease? Does the child’s age matter?

In this situation, distance learning might remain the best option for this family. Because the disease can be contracted at any age, this should not factor into the decision. While child to adult spread may not happen as easily as adult to child, there are studies that show it does occur.

Do children who are planning to do virtual learning need to have their vaccines updated?

According to the Texas Department of State Health Services (TDSHS), vaccine rules are still in effect regardless of whether a student is participating in on-campus or virtual learning.

Read more about Cook Children's recommendations for safely returning to school on our website.

*This post includes information provided by Marc Mazade, M.D., medical director of Infection Control and Prevention at Cook Children’s and Justin Smith, M.D., pediatrician at Cook Children’s Pediatric Trophy Club.

Obesity? That's one.

Car accidents? That's a big risk too.

But would you guess the number one issue is asthma?

In Tarrant County, 19.5 percent of children suffer from asthma, according to data gathered in a survey sent to parents by The Center for Children's Health led by Cook Children's. The Community-wide Children's Health Assessment and Planning Survey (CCHAPS) was completed by more than 8,600 parents in Tarrant, Denton, Hood, Wise, Parker and Johnson counties.

"We questioned parents on everything from how often their child is buckled in properly to how many grocery stores in their neighborhood sell fresh fruits and vegetables," said Larry Tubb, senior vice president of the Center for Children’s Health. "The information we are gathering is extremely valuable when it comes to measuring the overall health of children in our region."

Overwhelmingly, parents in Tarrant County (and all of the surveyed counties) reported their children are dealing with asthma. In fact, children in this area ages 6-9 are three times more likely to have asthma than children living in other parts of Texas. While we don't know why the numbers are so high, we do know people with asthma have varying triggers, and what affects one person will not necessarily affect another. Those triggers include, but are not limited to, cigarette smoke, indoor and outdoor mold, pet dander, air pollution, dust mites, cockroaches, pollen, smoke and strong odors.

The second biggest health issue on parents minds is obesity, with 17.8 percent reporting concerns about their child's weight, activity level and access to healthy foods.

Accidental injuries rings in third. In Tarrant County, 11.9 percent of parents reported their children had been injured and required medical care. Those injuries range from car and ATV-related incidents to drowning, bicycle falls and crashes.

The fourth issue on the list is a lack of dental care for children. Parents reported 9.7 percent of children either didn't see a dentist regularly, didn't brush their teeth enough or some even reported their child didn't have their own toothbrush.

Finally, mental illness is the fifth biggest issue concerning parents in Tarrant County. Behavioral and emotional development is on the minds of 8.5 percent of respondents. Many reported their children have suffered sleep problems, self-esteem issues or have tried to harm themselves.

The survey used to gather this data is part of a Cook Children's initiative to improve the health and well-being of every child in our six-county region by 2020. This initiative launched in 2009 with the very first survey of its kind sent to parents. Since then, the surveys have been sent out every three years.

"The information provided by parents in our community is available on-line and being used by a host of organizations, including Cook Children’s, to build programs and services. There isn’t one perfect answer, but, together we are making solid progress in improving the health of the children in our community by putting the child and family at the center of our planning," said Tubb.

About The Center for Children's Health

The Center for Children's Health, led by Cook Children's, is home to the Community-wide Children's Health Assessment & Planning Survey (CCHAPS), Community Health Outreach and Community Health Research. The center's goal is to create aligned collaborations that will allow us to make our North Texas region one of the healthiest places to raise a child.

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

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

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

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

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

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

Additional resources:

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

About the author

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