By Melinda Young
EXECUTIVE SUMMARY
Rates of attempted and completed suicides have increased sharply in recent years, particularly among adolescents. A crisis care program at a children’s hospital provides case management help to teens and their families.
- Suicide attempts and deaths doubled among 13- and 14-year-olds from 2008 to 2018.
- Case managers can help emergency departments handle the influx of patients at risk of suicide by finding mental health resources for them.
- Social media may play a role in the rising number of mental health issues among youth.
After years of decline, suicidal behavior has escalated among adolescents. Emergency department (EDs) visits and hospitalizations have spiked among those who have attempted suicide or plan to.
Yet, resources to help suicidal young people are scarce.
“Emergency departments across the United States are now keeping [suicidal] kids in emergency rooms for days at a time because it’s hard to identify appropriate disposition for these kids,” says Elizabeth McCauley, PhD, ABPP, a professor in the department of psychiatry and behavioral sciences at the University of Washington. McCauley also is an associate director of child and adolescent psychology at Seattle Children’s and an adjunct professor in pediatrics and psychology at Seattle Children’s Child Psychiatry and Behavioral Medicine.
“It’s hard to get them into inpatient psychiatric units, and it’s not always clear that inpatient psychiatric units are the treatment of choice,” McCauley adds.
Between 2008 and 2018, attempted and completed suicides doubled among 13- and 14-year-olds nationwide, according to new research. This spike in suicides follows a previous decline in adolescent suicides through 2007.1
Other research shows a 200% increase in suicide deaths among girls, ages 10 to 14 years, between 1999 and 2017.2 Firearms were used in about one-third of suicides in metropolitan areas and in nearly half of suicides in rural areas.1
These escalating numbers occurred before the pandemic. Anecdotal evidence suggests children and teenagers have suffered more mental health issues since the onset of the COVID-19 pandemic. Also, clinicians in hospitals and EDs have seen more youths who have made suicide plans or attempts.
Health systems need a crisis care clinic where EDs and providers across the continuum can refer youth at risk of suicide. This type of center can use case management to help families and youth find mental health resources in the community.
For example, Seattle Children’s opened a crisis care center that helps children and their families with mental health challenges.3
“We’re a very small clinic, but our goal is to help patients avoid inpatient hospitalization or additional emergency department visits,” says Hilary Smith, MEd, a family advocate case manager at Seattle Children’s Child Psychiatry and Behavioral Medicine. “We see patients quickly — within a week of being referred — and this allows them to get access to care immediately.”
Case managers connect patients and their families to ongoing care to help them address their current crisis and avoid a future one. “We help families get the support they need within the community,” Smith says.
“For us, the case manager is the lynchpin in our operation,” McCauley adds.
Case Management in the ED
Mental health problems are serious for adolescents. Teens and their families need case management to help them when they are in crisis and need to move to an outpatient setting.
“Case/care management has become a pivotal piece of work that’s done in both emergency department settings and the medical setting,” McCauley says. “A lot of kids we see in the crisis center are kids who made suicide attempts and have been treated in inpatient [units], but we feel would be better treated in the outpatient setting.”
Assigning case managers to assist these patients helps the hospital and ED prevent overcrowding.
“Case management is a way to get good and appropriate care for the [mental health crisis] surge that we have experienced at our medical setting and children’s hospital,” McCauley says. “It’s also documented across the United States but continuing to increase during the height of the COVID years.”
COVID-19 and Mental Health
The mental health of children and adolescents was hit hard by the pandemic’s social isolation and limitations on activity with their peers. “We saw an increase in suicidal ideation and attempts, and we needed to intervene as early as possible,” McCauley explains.
The increase in mental health issues since 2008 could be tied to the rise of social media and its ties to bullying and lower self-esteem. Youths who spend time online also are missing out on face-to-face encounters with peers. This can play a negative role in their mental health.
“There has been some emerging and solid data to suggest that too much time on social media, unsupervised time on social media, and unlimited access to social media sites without parental overview and awareness of what’s going on is a contributing factor,” McCauley says.
A recent report called Shared Experiences revealed 24/7 technology causes kids to suffer, fueling sadness, anxiety, and shame. It also hinders sleep and real-life connection — all of which exacerbate the youth mental health crisis.4
“What happens to youth who are spending a lot of time on social media is they’re spending less time face-to-face and in direct engagement with other kids,” McCauley explains. “They can easily get connected to social media sites that are promoting what we think of as less-than-healthy behaviors and practices, including suicide.”
These social media encounters often provide support for poor decisions. “Social media is a factor, but it’s not the only factor,” McCauley notes.
The same is true of the pandemic, during which children and adolescents were further alienated from in-person encounters with friends. “In-person sports, choirs, youth groups, and the kind of thing that gets you actively engaged with other kids was all on hold for a while,” McCauley says. “We’ve got so many more kids who went through an important developmental period without the ability to interact with peers in a healthy, supportive kind of way.”
Even now as the pandemic’s social isolation measures are over, children and adolescents are facing more stress over returning to school and catching up with both the academic experience and social experience they missed during the long period of remote classes.
“The emerging data would suggest that online interaction does not substitute for in-person interaction,” McCauley says. “If you are face-to-face with a person and you have social anxiety, you’re working it out with the other person and compromising.”
Mental Health Stressors
When clinicians and researchers ask youth why they think about suicide, they mention several things, including family conflict, feeling inadequate in maintaining school achievement expectations, climate change, gun violence, and societal divisiveness, McCauley notes. All these factors suggest health systems could help youth with mental health issues by developing a program that incorporates case management and a team approach to help patients receive timely assistance in the community setting.
“We developed our program because we had been asked to see more and more young people — both those who come into the emergency department and those admitted to medical floors,” McCauley explains. “Those admitted to medical floors have had suicide attempts, and that is an entry point for them. The preponderance of kids who come to the ED have had suicidal ideation. They have not made an attempt, but they are thinking and talking about it.”
If a child talks about suicide at school or with another provider, they are sent to the ED. For those children and adolescents, it does not make sense to use a high-intensity intervention, McCauley says. They need outpatient mental healthcare. The problem is these resources are scarce — and the demand keeps growing. This is where a case management program that targets youth, who are referred by EDs, primary care providers, and families, can help.
The program at Seattle Children’s also accepts referrals from outpatient therapists, mental health providers, schools, and outpatient clinics within the health system, Smith says. (For more information, see the story in this issue on how the program works.)
“The way we’re able to see patients quickly — within a week of being referred — allows them to get access to care immediately,” Smith says. “Connecting people to ongoing care really does provide families with what they need to address the current crisis — and, hopefully, to avoid another mental health crisis.”
It supports families in preventing a return ED visit because they are receiving the support they need within the community, Smith adds.
REFERENCES
- Galoustian G. Alarming rates of teen suicide continue to increase in the U.S. Florida Atlantic University news desk. April 26, 2023.
- Adrian M, Blossom JB, Chu PV, et al. Collaborative assessment and management of suicidality for teens: A promising frontline intervention for addressing adolescent suicidality. Pract Innov (Wash D C) 2021;7: 154-167.
- Adrian M, Twohy E, Babeva K, et al. A unique model of care for youth in crisis: A pilot open trial. Psychol Serv 2023; Jul 10. doi: 10.1037/ser0000778. [Online ahead of print].
- Wulff R. New report on how social media negatively impacts kids. CBS News Sacramento. May 24, 2023.
Rates of attempted and completed suicides have increased sharply in recent years, particularly among adolescents. A crisis care program at a children’s hospital provides case management help to teens and their families.
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