By Heather Duge

Cook Children’s Emergency Department nurse manager Kara Dorman has seen an alarming trend – a significant increase in patients coming in with a seemingly invisible problem. Patients may enter the ED for an injury or illness but have a mental health concern that also needs to be addressed.

“As we track suicide screening numbers, it has been horrifying and mind-blowing to see all these kids who visit the ED for medical problems and screen positive for suicide risk,” Dorman said. “These are kids we wouldn’t have known about if we didn’t ask.”

Many times asking the hard questions is the most challenging part of identifying those who need help. That’s when Team HOPE, a specially trained group of 25 employees at Cook Children’s, enters the picture.

Dorman and ED chaplain Cameron Brown lead the team, which includes patient care technicians, paramedics, nurses, security officers, chaplains and child life specialists. The team meets monthly, participates in education and shadows the inpatient psychiatry unit for eight-hour shifts.

Dorman and Brown proactively round on patients using Trust Based Relational Intervention (TBRI) to build early rapport. TBRI is an attachment-based, trauma-informed intervention that is designed to meet the complex needs of vulnerable children. The team uses the Ask Suicide Questions (ASQ) screening tool and TBRI training has been instrumental in the screening process.

The ED screens patients during intake to ask questions about their mental health. From January through July 2023, 405 patients ages 8 and older who came to the ED for medical conditions were positive for being at risk for suicide and 19 were suicidal at the time. In 2022, Team HOPE assessed 32,000 patients ages 8 and over who came to the ED for medical conditions – 640 were positive for being at risk for suicide and 22 were suicidal at the time.

Building Early Connections

If a nurse in the ED feels like they need help, they can call Team HOPE. An intake therapist will perform a behavioral health intake assessment and provide tailored resources for the patient to get help.

Oftentimes, patients come in and don’t want to speak to anyone.

“A huge factor in saving lives when treating mental health illness is connection,” Dorman said. “Good eye contact and modeling a calm demeanor when entering the room is the first thing. We share power and control with patients such as giving them choices of what drink they would like to take with their medicine and offering green scrubs instead of an open gown. We talk about transitions of care ahead of time and introduce their new nurse before shift change.”

Behavioral health carts filled with games, clay, stress balls, model magic and journals are other tools the team uses for distraction and to get rid of nervous energy. Brown not only provides patient families with support but also the ED staff. She checks in during each shift with team members.

“I ask how they are coping and assess how they are handling things,” Brown said. “I help them when patients are dysregulated and give them permission to ask for help.”

Sometimes that means walking through a scenario such as thinking through how to go in the patient’s room while maintaining a calm presence. 

Suicide Prevention Training

Dorman and Brown attended QPR training, which is an emergency response training for someone in crisis, hosted by the Jordan Elizabeth Harris Foundation. This training helped them learn how to ask difficult questions when concerned about someone having suicidal thoughts.

“This has been helpful in having conversations with friends, family, fellow coworkers and when checking in on each other in different units,” Dorman said. “Team HOPE members are a resource for not only our patients but for ED staff members as well. The QPR training helped our team gain knowledge and feel empowered to role model that having conversations matters.”

Ellen and Tom Harris established the Jordan Elizabeth Harris Foundation in 2014 after their daughter died by suicide. They know how unexpected depression and suicide can be after experiencing it with their daughter.

Jordan was valedictorian of her high school class, a National Merit Scholarship winner, a Stamps scholar at the University of Michigan, an athlete, musician and a friendly, compassionate young woman. The JEH Foundation honors Jordan’s life by raising money to support research on depression and offering training to help people recognize signs of depression.

"Jordan was the kind of person you would never expect to take her life,” Ellen said. “She was a wonderful, kind, funny and loving person with loads of friends and interests.”

After Jordan developed depression during her senior year of college, Ellen and Tom brought Jordan home until she felt ready to go back. Her upbeat personality hid the severity of the depression. Ellen said the confusing part of depression is that people who take their lives don’t want to die – they just don’t see any other way out of the dark hole.

“The night before Jordan passed away, she was on her computer searching for a therapist,” Ellen said. “She was trying to find a way out.”

Ellen and Tom’s goal through the foundation is to help people out of the dark hole. They offer free QPR training to the public.

During the 45-minute sessions focusing on Question, Persuade and Refer, people build confidence in asking the hard questions about suicide, learn how to persuade someone to seek help and understand referral options.

The sessions also include myths and facts about depression, nationwide statistics about the depression epidemic, ways to be aware of someone struggling and verbal versus nonverbal cues. Dorman had the desire to bring their training to Cook Children’s and four months ago 25 employees at the hospital participated in a session.

“If we can save one life, everything we’re doing has been worth it,” Ellen said. “I’m thrilled to provide training for employees at Cook Children’s. It is critical hospitals have this training because the earlier you can catch depression and start treating it the greater the outcome.”

Dorman said one interaction in the ED can be the moment that changes the trajectory of a patient’s life – bringing them hope in a dark time.

“We want to connect with these patients and empower them to seek help,” Dorman said.

September is National Suicide Prevention Month. If you are concerned about a child’s mental health, please reach out to one of these resources or your child’s pediatrician. It is important to get help early so that children can get the support they need.

September is National Suicide Prevention Month. If you are concerned about a child’s mental health, please reach out to one of these resources or your child’s pediatrician. It is important to get help early so that children can get the support they need.

If you are not sure if your child is a danger to themselves or someone else, call the numbers below for advice or help.

Cook Children’s Psychiatry Intake Line: 682-885-3917 (press emergency prompt.)

Tarrant County MHMR Crisis Line:

• Call or text 800-866-2465. Available 24 hours a day.
• Provides face-to-face assessments to help families decide how to help their child.

If you need to talk or if you are concerned about someone, please view the following resources and call for advice or help.

National Suicide and Crisis Lifeline

• Call or text 988 for free and confidential support for people in crisis.
• Available 24/7, call or text 988 for access to mental health crisis services.
• Crisis Text Line (Text HELLO to 741741). These services are free and confidential.
• Please note: the previous 1-800-273-TALK (8255) number will continue to work as well.
• Lifeline (988lifeline.org)

The Trevor Project for 24/7 LGBTQ Crisis Support:

• Support line: 1-866-488-7386
• Text “Trevor” to 1-202-304-1200
• Chat online at www.thetrevorproject.org

 Collin County – Lifepath Systems

• Crisis hotline available 24/7: 877-422-5939
• Lifepathsystems.org
• Trained behavioral health professionals are standing by to assist you.
• This service is available for all adults and children living in Collin County, regardless of insurance or income status.

Dallas Metrocare

• Hotline available 24/7: 214-743-1215
• Metrocareservices.org
• Offers child/teen mental health services

Denton County MHMR Crisis Hotline

• 1-800-762-0157

Grant Halliburton Foundation Mental Health Navigation Line (Dallas/Denton/Collin focused)

• Granthalliburton.org/navline
• Mental health navigators can help find resources for you or someone else.
• 972-525-8181

Mental Health Connection of Tarrant County

• Mentalhealthconnection.org

RAINN: 1-800-656-4673

• National hotline for victims of sexual assault
• https://www.rainn.org/

Recognize & Rise

• Recognizeandrise.org

SafeHaven 24-hour hotline: 1-877-701-7233

• Tarrant County domestic violence service provider

SAMHSA: Substance Abuse and Mental Health Services Administration

• National helpline available 24/7: 1-800-662-4357

Transicare’s Mobile Crisis Outreach Team (MCOT) – Dallas

• Transicare.com/services/MCOT

Texas Youth Helpline

• Call or text 1-877-921-6780 for free, confidential services
• Dfps.state.tx.us/youth-helpline

Wellness Alliance for Total Children’s Health of Denton County

• Led by Cook Children’s
• watchdenton.org

Additional resources in North Texas: 

• The Jordan Elizabeth Harris Foundation: Suicide prevention training
• The Hope Squad: Students can help save a peer's life
• Hayden's Corner: Nonprofit established in honor of Hayden Hunstable to educate parents and children about mental health issues.

Resources from Cook Children's:

• Cook Children's Behavioral Health
• Cook Children’s Rees-Jones Behavioral Health Center
• Cook Children's Psychology
• Individual and family therapy
• Parent Education and Support
• Diagnostic Testing
• Childhood stress
• Helping kids deal with bullies
• Helping kids handle worry
• Helping your child deal with death
• Helping your child through a divorce
• Understanding depression

The JOY Campaign

The JOY Campaign 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. Learn more about the Joy Campaign and available mental health resources here.

The Raising Joy podcast is part of the JOY Campaign. Our hosts Kristen Pyrc, M.D. and Wini King, Chief of Communications, Inclusion, Equity and Diversity at Cook Children’s, have heard incredibly impactful stories of personal struggle and resilience from our guests on the podcasts. Episodes are currently streaming on all major streaming platforms including Apple, Spotify and Google Podcasts.

Related stories on mental health:

Let's Talk: Seven Ways to Help Kids and Teens Open Up (checkupnewsroom.com)

Raising Joy: Conversations Matter With Brad Hunstable (checkupnewsroom.com)

Reunion: Suicide-Attempt Survivor Returns to Cook Children’s (checkupnewsroom.com)

4 Things Parents and Children Can Do While Waiting for Mental Health Services (checkupnewsroom.com)

Raising Joy: When Does a Child Need Psychiatric Care? (checkupnewsroom.com)

In Their Own Words: Three Parents Open Up about Losing a Child to Suicide (checkupnewsroom.com) 

Video: Child Therapists Share Six Ways to Cope with Difficult Emotions (checkupnewsroom.com)

More articles about children, teens and mental health | Checkup Newsroom

Grant Halliburton Foundation was established in 2006 in memory of Grant Halliburton, a Dallas teen who battled depression and bipolar disorder for several years before his suicide death at the age of 19. The Foundation that bears his name works to help families and young people recognize the signs of mental illness through a variety of avenues including mental health education, collaboration, encouragement, and information. 

On this episode of Raising Joy, we meet Sonya Parker Goode, CLC, CAMS-I, director of outreach and education with Grant Halliburton Foundation. She tells us how the organization has trained more than 300,000 students, teachers, parents, and professionals on how to recognize and respond to someone in major distress or suicidal crisis. Learn more about Grant Halliburton Foundation here.

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.

Note: If you or someone you know is struggling or in crisis, help is available.  If you believe that your child is having a mental or physical health emergency, go to the nearest emergency room or call 911. Call or text 988 for the Suicide & Crisis Lifeline, a free and confidential resource available 24/7. If you have questions about your child’s mental health, contact your child’s pediatrician. 

**Content warning – this episode contains difficult subject matter. We advise you to listen with caution, knowing topics of child suicide, trauma, grief and mass shootings are discussed.

Suzy DeYoung didn’t plan on devoting her life to the subject of trauma, however, an accident involving her child led her down a path of exploring some of the most difficult subjects imaginable. For over a decade, she has studied and educated others as a trauma-informed parent. She was also one of the founding members of Sandy Hook Promise, which began after the horrific school shooting in her hometown of Newtown, CT. Most recently, she has conducted research on behalf of author Andrew Solomon, Ph.D., where she has interviewed dozens of families and experts impacted by child suicide. This discussion is enlightening, challenging and important, though it may be triggering for some.

We also want to hear from you. Please take our brief survey to let us know how we’re doing and what topic you want to hear discussed on Raising Joy.

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.

Suicide is the third leading cause of death among people aged 15 to 24 in the U.S., according to the Centers for Disease Control and Prevention (CDC). During the first seven months of the COVID-19 lockdown, U.S. hospitals experienced a 24% increase in mental-health-related emergency visits for children aged 5 to 11, and a 31% increase for those aged 12 to 17.

On this very special episode of Raising Joy, we sit down in front of a live audience in Fort Worth, Texas, to interview acclaimed author, Andrew Solomon, Ph.D. Solomon is a Pulitzer Prize finalist, National Book Award winner, TedTalk presenter, as well as a professor of Clinical Psychology at Columbia University. 

Dr. Solomon spoke to us about his recent article in The New Yorker called, “The Mystifying Rise of Child Suicides,” and recounts what he has learned from conducting dozens of interviews with parents who have lost a child to suicide. 

This is a difficult, yet important episode for anyone interested in learning more about the mental health crisis affecting youth in America.

Thank you to all who joined us for the live show and thank you to all of our podcast listeners. This event was hosted in partnership with The Center for Children’s Health led by Cook Children's. The Cook Children's Raising Joy Legacy Leadership Award was presented to the Honorable Tarrant County Judge Glen B. Whitley for his tireless commitment and decades of service on behalf of the well-being of children throughout Tarrant County and beyond.

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

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

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

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

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

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

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

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

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

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

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

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

On day five in the PICU, something unexpected happened.

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

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

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

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

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

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

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

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

 September is Suicide Prevention Awareness Month.

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

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

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

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

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

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

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.”

Over the last six months, Cook Children's has released 20 articles regarding mental health, suicide in youth and teens, and resources to help young people in crisis. Recently, we spoke with experts to learn more about what families can do to help reduce the risk of suicide attempts and learned that there are a few things that start at home. 

What do you do with expired and unused prescription drugs? Do you throw them in the trash? Do you continue to take them after expiration? Or do you simply let them sit in your home?

Experts at Cook Children’s Medical Center say it is more important now than ever to dispose of unused drugs because of the alarming statistics of young people overdosing. In July, Cook Children’s reported a record number of pediatric hospitalizations for drug overdoses in 2021 compared to previous years, particularly with opioids. 

"It is a huge problem right now. We’re seeing more kids in the hospital for opioid overdoses than ever before. The vast majority of them are intentional ingestions," said Artee Gandhi, M.D., medical director of Pain Management at Cook Children’s. 

“Teens and young adults are having ‘pill parties,’ where they are taking pills from their homes, and bringing them to a party with their friends. They then put them in one large bowl and grab handfuls,” Dr. Gandhi explained. “Not only is this unsafe, but different medications have potencies after their expiration dates and you can get sick from the medication being expired.”

Experts at Cook Children’s say the best thing to do is to safely dispose of any drugs that are expired or no longer being used for their intended purposes.

Savannah Panagopoulos, a child safety, and poison prevention specialist for the Center for Children’s Health led by Cook Children’s, says there are a plethora of take-back boxes in the area that allows people to dispose of drugs safely.

“These are permanent sites, where people in the community can come and drop off drugs, to get them out of the house. Taking medications that are no longer needed or expired out of the household could significantly reduce the chance of accidental poisoning or misuse that's intentional,” Savannah said.

Savannah says “50% of potential drug and substance abuse cases start with a friend or family member giving it to someone in the home that it’s not intended for.”

She goes on to explain that only 4% are purchased from a stranger or a drug dealer.

“Not only does disposing of the drugs safely give you peace of mind, but it’s also important to dispose of them to keep our environment safe. Not flushing the drugs down the toilet, putting them in cat litter, etc.,” Dr. Gandhi said.

She also reminds families that flushing drugs down the toilet is dangerous because of the harm it can do to our water systems. Dr. Gandhi says Cook Children’s pharmacy has a take-back box, which is easy and convenient to use. The box is located inside the retail pharmacy at Cook Children's and accepts any medication, with the exception of liquids. 

“You don’t have to talk to anybody, you don’t have to see anyone. You put it in the disposable container and walk away,” she said. 

Cook Children’s also has a system in place that also texts families to remind them to take back their unused medications and to keep them out of the reach of children.

“We do this so families don’t run into a problem with children unintentionally or accidentally ingesting medication that is not safe for them,” Dr. Gandhi said.

Savannah says while most take-back locations are located in pharmacies, there are other locations, such as police stations, that are open 24 hours a day for safe disposal.

“A good rule of thumb is to take off all labels with any identifying information before you drop them off,” Savannah said. ”Although all drop-off locations are in secure areas that is something we tell people to practice for safety and privacy.”

The United States Drug Enforcement Administration (DEA) also hosts national take-back days across the country every year. In April, more than 4,000 law enforcement agencies participated, which resulted in nearly 900,000 drugs being taken out of homes and disposed of safely. The next National Take Back Day is Oct. 23, 2021. Information about national takeback days can be found here.

Both Cook Children’s experts want families to know and spread the word about this resource. It is important to know that you don’t have to wait for a medication to expire and if the medication is expired, you can drop it off before you go and get a fresh prescription.

Cook Children’s Center for Children’s Health has a page dedicated to poison prevention. The North Texas Poison Center is open 24/7 and can be reached at 1-800-222-1222. You can find information about drop-off locations in North Texas, pain management, and more.

It is important to note you cannot dispose of items such as needles, oxygen tanks, thermometers, and sharps when dropping off your medication.

Dr. Gandhi says the most important thing to remember is, if you are done taking medicine and have used it for the intended purpose, dispose of it like you would an antibiotic or anything else.

“This goes for over-the-counter medication such as Tylenol, Ibuprofen, Aleve, etc,” she said.

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.

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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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.”

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

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

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

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

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

You Matter

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

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

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

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

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

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

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

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

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

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

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

The Rise of Cyberbullying

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

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

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

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

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

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

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

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

When And How To Intervene

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

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

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

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

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

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

Don’t Feed The Rat

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

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

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

There Is Hope

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

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

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

The Crisis

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

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

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

The Silver Lining

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

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

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

Breaking Barriers

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

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

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

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

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

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

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

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

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

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

Comprehensive Care

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

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

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

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

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

Sometimes the first step toward saving the world begins in your own backyard.

That’s the hope for Frances Wampler and Blair Williams, two staffers at the Center for Children’s Health led by Cook Children’s, who are part of a team exploring how communities might target youth suicide as a standalone issue.

There are several “ifs” to contend with, but the two women believe it’s worth exploring the steady climb of youth suicide cases in the nation and determine what’s happening on the local and state levels.

“We see it in the headlines, see it on social media—even clinicians are expressing concern over it,” said Williams, who is a community health analyst and member of the community health needs evaluation team at the Center. “So, we’re seeing this as a rising need.”

Wampler and William’s decision to pursue the issue resulted from a culmination of events. In September, Wampler’s nephew, 19, died by suicide, leaving her family reeling from his death. And years earlier, Williams suffered the loss of a close family friend, a 15-year-old who took her own life. Their shared experiences, along with other data—including the Center for Disease Control’s report marking suicide as the nation’s second-leading cause of death among ages 10 to 24 in 2018 and a reported increase of self-harm cases seen at Cook Children’s last year—propelled the two women to pitch the idea of collaborating on exploring whether area communities needed help with this complicated issue.

“I know how hard it was for me and my family to experience the things we did,” said Wampler, program coordinator at the Center who focuses on child abuse. “He was my nephew, but he felt like one of my bonus kids. I felt like I lost one of my children, and I would take that heartache away from any person I could. I don’t want that to be the end of his story. He was not the last decision he made in his life...he was so much more than that.”

“I just want to do something with that—and I don’t know­­—try to save the world,” she said.

While discussing Wampler’s nephew’s death, she and Williams made note of how often youth suicide overlaps with other issues, such as firearm and poison injuries, child abuse and neglect, Adverse Childhood Experiences (ACEs), mental health and so on.

“These are things that the Center already has programming around,” Wampler said. “I was like, ‘We have to do something.’”

The two decided to take it to Center leadership and were given the green light to pursue it and “do some digging on the data,” Williams said.

“They’ve been really supportive of this,” she said. “That, to me, is really powerful because our leaders heard our concerns and supported us in our efforts to keep every child safe from injury.”

Wampler and Williams’s preliminary research efforts could potentially support the 2021 Community Health Needs Assessment. The Community Health Needs Assessment is conducted by Cook Children’s every three years to assess children’s health needs and the board uses the information to develop implementation strategies for addressing these needs.

They’re not sure how COVID-19 may affect this issue, let alone community health needs across the board, but youth suicide was on the rise well before the virus hit, Williams said. In 2012, the number of suicide deaths surpassed the number of cancer and heart disease deaths - causing suicide to be the 2^nd leading cause of all deaths in Americans ages 1-44 every year since.

“Part of it is recognizing there are several community partners and agencies that are well-equipped to handle this,” Williams said. “Part of the assessment is not only looking at the data, but it’s also looking at what resources are in the community that can be used to help.”

As it stands, the Center is in the data collection phase of the 2021 Community Health Needs Assessment process. They’ll sift through all sorts of data, such as what local health departments are seeing, what the CDC says, what the national and statewide numbers on children’s health needs show, and what’s happening inside and outside Cook Children’s walls. They’re currently conducting focus groups, a parent survey, a community leader survey, and key informant interviews, among other things. When finished, the data will be synthesized and a report published as the 2021 Community Health Needs Assessment.

Wampler and Williams are proud that the question they raised about what the Center can do to support youth suicide prevention has been met with a team approach to investigate this important topic further. They acknowledge this task is a huge undertaking. But both are passionate about getting help to children and families who need it.

Recognizing that this is becoming more of a trend is an important step, Williams said.

“There are so many great resources in our community, so many great partners. We have a wonderful health care system, a great employer who recognizes this issue. So, what can we do with these great assets and protective factors to keep kids safe from all types of harm, including harming themselves?”

Regardless of their findings and the various factors that come into play, Wampler and Williams believe ramping up awareness surrounding self-harm and suicide is key to preventing it among young people. But awareness doesn’t equate applying stereotypes, they said.

Even if children do “check off those boxes” for suicide risk factors, it doesn’t mean they’ll try suicide, Williams said. She encouraged all families to have a mental health plan to address any crisis that may arise.

“There are people who have multiple adversities and risk factors who lead very successful, healthy lives, and probably go on to help many other people, too,” she said. “It’s just recognizing that it needs more awareness. It can happen to anyone and to be prepared. If you’re in crisis, it’s going to be harder to seek out help. So, have that help lined up for you.”

Wampler agreed.

Normalizing conversations about thoughts of suicide, even if it’s uncomfortable for families, she said, also might help with prevention. Her nephew had supportive friends and family, played football in high school and had joined the military, she said, adding the family “had no idea he was feeling that way.” No one saw his suicide coming.

“I don’t think it’s talked about enough,” she said. “I don’t know how hard that would be to say, ‘I want to hurt myself.’ But you don’t have to suffer in silence. You can tell somebody that you’re struggling and get help.”

There may not be a simple answer to preventing youth self-harm and suicide, Wampler and Williams said. What leads to it and how to prevent it is often muddied by a multitude of factors, some controllable and others not.

But one aspect of it is clear to both women.

“For me,” Williams said, “if we can save one child, well, that is (saving) the world.”

“Yes. That’s right,” Wampler quickly agreed. “That one child is somebody’s whole world.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Just Breathe

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Open up

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

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

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

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

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

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

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

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

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

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

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

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

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

The typed words on the paper are simply put:

I don’t like it.

I don’t have to like it.

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

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

The choice is mine.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You matter

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Greer also warns parents about the newfound TikTok culture.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Important to note:

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

Statistics, no matter how alarming, sometimes blur into faceless numbers when parents hear them on TV or read them in a news story.

That’s until it’s your child in the emergency room, hooked to an IV while receiving treatment for ingesting too many pills—in this case, over-the-counter pain meds often used to relieve menstrual cramps—with the intent of harming herself.

And then suddenly, those numbers have a face. For Betty, a Tarrant County mom who asked not to be identified to protect her 14-year-old from any stigma attached to her attempted suicide, the face that came fully into focus was her own teenage daughter’s.

Betty’s daughter is among the many children and young adults across the country who’ve used excessive doses of common drugs, like pain relievers or allergy medications, with the intent of harming themselves. National studies have shown OTC meds as the No. 1 means used by youths in suicide attempts and the third-leading cause of youth suicide deaths.

“I really didn’t put those in the category of prescription medications, so I never put them away,” Betty said of the handful of OTC meds—a combination of Motrin and Midol—her daughter swallowed earlier this year. (Motrin contains ibuprofen, and Midol is a mixture of acetaminophen, caffeine and pyrilamine maleate, an antihistamine.) “I want other people to know, and to even have lockboxes for their medications, so that someone else doesn’t have to go through what we went through.”

Her daughter, who went to school but said it wasn’t the same because of COVID restrictions, had felt isolated and been sad because she missed her friends, she said. She faced the typical teenage stuff like low self-esteem, Betty said, but she had no idea her daughter was considering suicide.

“She’s seeking treatment now, but I want to be really clear, ‘Put all your medications away, not just your prescription medications,’” she said.

Betty is far from alone in facing this issue. Other parents across the nation also are grappling with children and teens who are intentionally overdosing with easily accessible OTC meds.

In a study published by The Journal of Pediatrics in May 2019, Nationwide Children’s Hospital and the Central Ohio Poison Center found that suspected suicide attempts by self-poisoning in children and young adults had doubled in the past decade. The research, which targeted ages 10 to 24 during 2000 to 2018, also showed suicide attempts using OTC meds had tripled among girls and young women.

The same researchers later expounded on the initial report, pointing out that the two most commonly used substances among all age groups were OTC pain relievers—such as acetaminophen, ibuprofen and aspirin—followed by antidepressants.

Last year, a study conducted by the Center for Injury Research and Policy and the Central Ohio Poison Center at Nationwide Children’s Hospital focused specifically on the use of OTC pain relievers in suicide attempts, showing a 57-percent hike in overall cases from 2000 to 2018. Children and young adults between 6 to 19-year-old made up half of the cases, and of those, 73 percent were female, the study showed.

Researchers analyzed 549,807 suicide-related calls made to poison control centers across the United States that involved OTC medications. The study, published in Pharmacoepidemiology and Drug Safety journal, also determined a 34-percent rise in the frequency of those cases during that time period, caused primarily by a jump among calls involving 6- to 19-year-old females, researchers said.

The results from the study showed the breakdown of OTC substances involved in the calls: 48 percent, acetaminophen alone; 33 percent, ibuprofen; and 19 percent, aspirin. Acetaminophen and aspirin accounted for 65 percent and 33 percent of deaths, respectively. Aspirin created the most serious medical outcomes for 36 percent of the cases and 68 percent of the cases with aspirin were admitted into a health care facility compared with other OTC pain relievers. Overall, while suicide-related cases using acetaminophen and ibuprofen climbed, the number involving aspirin decreased, researchers found.

Although local numbers on these types of cases are not yet readily available, physicians at Cook Children’s Medical Center are noticing a similar increase in intentional OTC medication overdoses.

Stacey Vanvliet, M.D., an inpatient pediatric hospitalist at Cook Children’s, said suicide attempts “have become part of my daily practice” and most are overdoses on a substance that’s “convenient for the children and teens to grab.” While it’s mostly older ones, children as young as 8 or 9 come in for attempting suicide, she said.

“Commonly, we see Tylenol, Motrin, aspirin, Benadryl—things that people just stock in their cabinets to have on hand,” she said. “We see teenagers take huge handfuls of them.”

Many people have a misconception of how dangerous these drugs can be when ingested over the recommended dosage, Dr. Vanvliet said. For example, high levels of acetaminophen (as in Tylenol) can cause liver damage or acute liver failure as well as other serious health issues.

“I think another misperception is that there’s a certain type of patient or type of teen that might try to overdose. Or that there’s a certain stressor or pattern, so to speak, that this happens and then the teen goes for pills or whatever it may be,” she said. “But in my experience, that’s not the case. We certainly have children who have undergone significant trauma and have mental health issues…but we also have children who haven’t shown a whole lot of warning signs and are very high achievers.”

When a child or teen attempts suicide, it’s usually an impulsive decision, Dr. Vanvliet said, which makes the accessibility to OTC meds more dangerous.

“You’d be amazed at some of the things that trigger them to make a serious attempt. It can be something as small as, ‘My mom took my phone away because I got a bad grade,’ or ‘My best friend is mad at me,’” she said. “It’s not necessarily anything that’s huge…but they make these snap decisions, and they go take a handful of pills, and it could be really damaging. It happens over and over, unfortunately.”

So, what can be done to keep children safe? Many health experts and researchers propose restricting the amount of OTC meds that can be purchased at one time and suggest unit-dose packaging, such as blister packs, as well as promoting safe storage for OTC and other medications.

Responding to that call, The Jordan Elizabeth Harris Foundation, a Fort Worth-based nonprofit group that targets suicide prevention, plans to launch Keep All Meds Secure (KAMS) public awareness initiative this summer. Christina Judge, the foundation’s executive director, said the initiative includes educating families and caregivers on the dangers of various medications, providing lockboxes for safe storage and advocating safe disposal of old medications. The foundation also offers free suicide prevention training to help parents to know what to look and listen for with a child who might be considering suicide.

The initiative began with a phone call that Judge received. A frantic mother, whose daughter had taken a handful of Tylenol and a handful of Advil, called the foundation seeking help in finding a bed at a mental health facility for her daughter.

“The pivotal moment was just hearing the anguish in the mother’s voice,” Judge said. “I asked her, ‘Did you know that these drugs in the hands of a suicidal child could be lethal?’ She said, ‘No. We just keep them in the cabinet above the sink.’”

“Well, that was enough for me,” Judge said, who researched the topic, presented a case for it and sought funding for the initiative.

Vanvliet believes programs such as KAMS will help with suicide prevention among children and teens.

“Education for parents and keeping those substances safe, I think, is a big part of preventing this from happening,” she said.

For Betty, what happened to her daughter has made her even more vigilant. She has always paid close attention to safety in her house. The family’s guns are always locked away in a safe, along with prescription medication. Now, she secures her OTC meds, too, she said.

She’s thankful her daughter, who’s getting ongoing treatment, didn’t suffer any long-term health effects from the incident. But Betty is highly aware that it all could have ended much differently that day her daughter tried to overdose.

“I think she got scared and came to me and told me. I’m so glad she did,” Betty said. “And I have to say if there were more pills in the bottles, we would have had a much different situation…it could have been much more harmful.”

“Like I said, we’d locked up everything else except for that. And if we had locked that up, maybe we would have avoided this,” she said.

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.

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

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

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

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

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

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

Warning Signs

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

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

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

Other signs to watch for include:

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

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

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

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

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

What Can Parents Do?

Get help.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So why do children and teens take these drastic measures?

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

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

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

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

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

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

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

Other signs of depression to look out for include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Referenced from AAP- How to Recognize Signs of Depression

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)

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

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

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

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

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

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

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

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

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

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

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

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

More On This Topic:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More On This Topic:

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

The 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.”

Tracy Jensen often thinks about her son, Ethan. He was someone with an amazing aptitude for learning. “He was a boy who had eyes to notice others who, like him, were in pain and suffered silently, Tracy said. “He was a boy who had the heart to care.”

Ethan never stopped caring about life. It was just the pain became too frequent and too painful for him. Ethan suffered from muscle pain in his back and right leg. At 5 months old he had a fatty tumor removed from his spine. His spinal cord was unable to be untethered and the scar tissue that remained was also troublesome.

Tracy and her husband, Eric, wonder when their son’s suffering began. Was it before his birth? Was it at 5 months old when he had the surgery? Was it later as scar tissue tangled the cord?

As they became aware of their son’s pain, they tried to help but they weren’t sure how, other than with over-the-counter medications, massage therapies and hugs.

Ethan didn’t really know how to help his pain and neither did most adults in his life. When he asked for medication or begged to lie down or go home, his requests were typically met with scoldings for him at school. Most didn’t understand how such a usually active child could truly be suffering.

Over time, Ethan learned to mask his pain.

“A child in chronic pain who is continually misunderstood is going to have emotional struggles such as depression,” Tracy said. “It is not reasonable to expect a child to know how to understand these issues, and my son was no exception. He struggled to process the facts of his life and this caused him to be more and more frustrated.”

Before he entered middle school, Tracy found a book on healing a child’s chronic pain. She continued to research and found that Cook Children’s offered a pain management program. It was there that the family met Artee Gandhi, M.D., medical director of pain management.

“Dr. Gandhi and company were incredibly responsive and devoted to Ethan's needs,” Eric said. “He was enamored with her in particular because she took his interests seriously and treated him as a young man rather than a child. However, Ethan was not always honest with her about the severity of pain he was experiencing. He sometimes believed that the doctors would not believe him or that they would think he was exaggerating his pain level to get medications.”

All through high school and beyond, Ethan studied science online. He taught himself subjects such as organic chemistry, DNA and gene therapy, and pharmacology. He learned how drugs, and different doses, acted and interacted in the body. He thought he understood enough to be safe with whatever he used for pain. He thought he was in control of his pain as he learned to manage it himself. He bought over-the-counter meds and used them off-label. He found ways to obtain prescription pain medication without a prescription.

The pain management team knew Ethan's level of self- education made him a challenge. Dr. Gandhi warned him about self-medicating and the dangers. Unfortunately, like many in their late teens, Ethan believed he was indestructible.

Ethan never stopped coming to clinic, but as time progressed he began to cancel and reschedule appointments more frequently. His parents believe that by mid-2015, Ethan thought surgery was his only chance for relief. The surgeons were able to straighten a significant portion of his lower spine regarding the pain, and as he was tapered off of his pain medication he began to once again self-medicate.

Eventually, drugs, especially opioids, were the only things that made him feel better. It was only slightly better, but that was OK for him, at least for a while. After the realization that his surgery failed to entirely alleviate his pain, Ethan became increasingly afraid of how his pain would continue to impact his life. He was afraid of what others would say, or what they thought of him. He believed no one would understand. He ultimately decided that he would have to treat his pain himself.

According to the Medical Examiner, Ethan died of mixed drug toxicity.

“We are only now looking back and asking ourselves if we could've done much better,” Eric said. “That day, my son was freed from his pain, but our pain would just be beginning.”

About the source

Artee Gandhi, M.D., is a pediatric pain management specialist and anesthesiologist. She has trained across the country including residency at the University of Missouri and fellowship at Stanford Univeristy. Cook Children's Pain Management program cares for infants, children and adolescents with chronic and acute pain. C​ook Children's is one of a few children's hospitals in the U.S. providing a comprehensive pediatric pain management program.

About Pain Management

The Cook Children's Pain Management program uses a team approach in caring for infants, children and adolescents with chronic and acute pain. Cook Children's is one of a few children's hospitals in the United States providing a pediatric pain management program. 

Our team includes a board certified anesthesiologist trained in pain management, a licensed clinical social worker specializing in psychophysiology, a dedicated physical therapist and pain management nurse coordinator.

Because of our team approach, patients will see their physician, physical therapist and psychophysiologist in one visit. 

Patients can make an appointment and physicians may refer a patient by calling our offices at: 682-885-PAIN (7246). New patients, for your convenience, please have your insurance information ready when you call.

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

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

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

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

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

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

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

Elliott says warning signs of teen suicide include:

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

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

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

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

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

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

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

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

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

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

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

Warning signs of teen suicide include:

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

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

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

Cook Children's Behavioral Health Center

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

The boy is challenged to complete 50 tasks in as many days. Each time the challenge becomes more dangerous to the teenager, ending with him taking his own life, while live streaming to social media.

It sounds like a horror movie or a hoax, but at least two sets of parents say it’s frighteningly real.

The Blue Whale Challenge begins with something seemingly harmless, maybe a little scary, like watching a horror movie. Each task becomes more dangerous, including drinking bleach or cutting themselves.

Parents of a 15-year-old San Antonio boy are blaming the Blue Whale Challenge for their son’s recent suicide. CNN reported a teen girl taking her life after participating in the challenge.

Schools from across the United States are warning parents about the challenge.

An article in USA Today said children are finding out about the game through social-media channels like Instagram, Snapchat, YouTube and texting.

Teen suicide is the third leading cause of death among 15 to 24 year olds and 90 percent of those who took their own lives had a psychiatric disorder.

“The Blue Whale Challenge is dangerous because it preys on children who are already vulnerable,” said Lisa Elliott, Ph.D., manager of the Psychology Clinic in Denton. “At this age, so many teens are already willing to do anything to feel like they are a part of something or to be included. This challenge plays into many of those desires.”

When talking to your children let them know they aren’t in trouble, but you want to discuss something you’ve heard in the news recently.

For kids in elementary school, ask them if they have seen anything online or heard anything lately that concerns them or scares them. There’s no need to bring up the Blue Whale Challenge directly to them.

For middle-school aged children, follow their lead to see if they want to discuss the challenge.

For older teens, be more direct and ask them about the challenge. Tell them you are aware of the challenge and you are concerned about it.

“I’m concerned about this culture of suicide right now,” Elliott said. “Suicide is not a trend. It’s not something that kids can be a part of and everything will be Ok. It’s final and scary. We have to talk to our children and let them understand there’s nothing interesting, sexy or cool about suicide. It’s not only the end of your life, but leaves all of your family and friends devastated.”

While talking to their tweens and teens, Elliott asks that parents also take the opportunity to reinforce to their kids that even if they hear of it at school happening to a peer, they should let an adult know. Reports have said that friends were aware of what the Texas teen was doing, but no one said anything.

Elliott says it’s also important for parents to let children know they are there for them and available to talk. If your teen is troubled, explain that whatever is troubling them will pass in time.

“Being a teen is a very difficult time,” Elliott said. “It’s sometimes hard to understand that the things that seem so important to them at that time will not matter in a couple of years. To them, it’s all about the present. So if they break up with a boyfriend or girlfriend or didn’t get chosen for a team or picked on by others, it sometimes seems like there’s no tomorrow. That’s when parents need to be there most for their child. Sometimes, it’s just about listening.”

Parents are advised to search hashtags such as #BlueWhaleChallenge on the social sites their kids use and do not let the children erase their history.

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.

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

But many experts are concerned the portrayal of the lead character Hannah’s death may not only be difficult to watch for young people, but it may also glorify suicide.

Alaina Everitt, a child psychologist at Cook Children’s, was first introduced to the book “13 Reasons Why,” 10 years ago through her mom, a middle school librarian. At that time the book was being pulled because it was “sensationalizing” suicide.

“Even though it was written 10 years ago, the types of bullying portrayed in the story remain relatable to the kids I see today, the only difference being the technology behind it. What sets this story apart from others is that it emphasizes the bystander. The effects of bullying trickle down from those who allow it to happen, who see it, maybe even disapprove, but do nothing,” Everitt said. “It’s easy to be a bystander, to keep things to yourself and not risk your own reputation. But just because they don’t throw a punch or post a pic, they are not innocent. The bystander is one of the 13 reasons.”

Local school districts have sent communication to parents to make them aware of the series. Some have encouraged an open dialogue with their child regarding the subject matter depicted in the series and book.

Lisa Elliott, a licensed psychologist and manager of Cook Children’s Behavioral Health in Denton, says children may watch the series and threaten suicide in an attempt to get attention.

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

With the show so prevalent in the news, it may present parents the opportunity to talk to their kids about an extremely uncomfortable topic.

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

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

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

Elliott says warning signs of teen suicide include:

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

If you feel your child needs help, please click here to find a Cook Children's Behavioral Health location near you.

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.

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.