BY, MS, BHSA, RN, CCM, CRRN, AND , MSN, BSN, RN
Understanding why someone commits suicide is a mystery to us, but it is especially hard to understand when a child dies by suicide. In this article, I talk with Michelle Knaub, an expert in maternal and child health. I asked Michelle a few questions to help case managers understand how to address this dilemma. We hope this information helps you better understand this challenging area of practice.
AL: HOW PREVALENT IS SUICIDE IN THE PEDIATRIC/YOUNG ADULT POPULATION?
MK: According to the Centers for Disease Control and Prevention, in the United States, suicide is the second leading cause of death among children and adolescents aged 10 to 17 years, and in the past 20 years, suicide rates for this group have steadily increased. Suicide is a global and national public health emergency.
AL: HOW HAS COVID IMPACTED SUICIDE RATES IN PEDIATRIC/YOUNG ADULTS?
MK: The COVID pandemic has had a devastating impact not only on society’s physical health, but also on our mental health, and these effects have resulted in increased stress, anxiety and depression for both the adult and pediatric populations. Children are often barometers of the household, and last year, as parental stressors and community responses related to dealing with the dangers of COVID-19 became increasingly heightened, many of our children absorbed and experienced these stressors daily.
Children need to feel safe and secure in their environment to grow and meet their developmental milestones, and the horrific impact of this pandemic has left both adults and children often reeling from one trauma to the next. Children have seen their parents, grandparents, aunts, uncles and family friends become sick and sometimes die unexpectedly; parents have lost their jobs or are afraid to go to work; they can’t go outside and play with their friends as before; and play groups have all but disappeared.
Kids have been through a war, and children traditionally look to their parents for reassurance when things become unstable, but many adults are also feeling anxious and depressed and are unable to provide the reassurance our young people need. When the schools closed and the children went to a remote classroom, they were then cut off from the support of their peers. We know that many young people, especially teens, do not talk to their parents; they talk to their friends, and this loss eliminated another important therapeutic source of comfort and support.
Hospital emergency department records showed a significantly higher increase in hospital admissions related to pediatric suicidal behaviors during the 2020 COVID-19 pandemic year when compared with 2019. Months with higher rates of pediatric admissions for suicidal behaviors also correlated with those months of heightened COVID-19 community response. I witnessed this correlation in my role as a pediatric case manager at a busy community hospital.
We saw an increase in pediatric cases admitted to the hospital through the emergency room in 2021 as the result of suicidal behavior. The child would be admitted under a Baker Act, assessed, and stabilized until medically cleared for transfer to a psychiatric facility. Some days there were so many pediatric Baker Acts in our community that the child had to spend an extra one to three days in the hospital after receiving medical clearance for transfer because there were no empty pediatric psychiatric beds in our tri-county area of South Florida.
Our mental health system is ill equipped to deal with our adult or pediatric populations, but while adults often have the tools and resilience needed to cope with periods of despair, sometimes our children do not.
AL: TO REDUCE SUICIDE, WE NEED TO KNOW HOW TO TARGET OUR EFFORTS FOR AT-RISK INDIVIDUALS. IN ADULTS MORE AND MORE RESOURCES ARE IN PLACE TO HELP PEOPLE CONTEMPLATING SUICIDE, BUT WHAT ABOUT KIDS?
MK: In this population, screening for risk and intervention are key. Studies show that most young people with suicidal thoughts and actions do not express these thoughts on their own and their parents are usually unaware of these impulses. Studies also show that most young people who die by suicide have either been in contact with a healthcare provider in the three months before their death or visited the emergency room in the year beforehand.
With this information in mind, The Joint Commission issued National Patient Safety Goal #15A, which addressed universal screening in the ER for suicide risk for behavioral health patients and later issued a Sentinel Event Alert expanding suicide screening to include medical-surgical patients as well.
Universal screening of children and adolescents for suicide risk by healthcare professionals is a first step in identifying those children who need mental health services put in place to prevent suicidal behaviors. Healthcare professionals, especially pediatricians, nurses and social workers, need to become skilled in detecting suicide risk and referring those in need to appropriate mental health treatment.
Multi-media public service announcements could transmit messages of hope to children that situations can improve and provide information on who to call when they feel despondent and are contemplating suicide. Children spend a large part of their day in school; guidance counselors need training on risk assessment and referrals for help when needed.
Information on The National Suicide Prevention Hotline as well as any local hotline numbers should be placed prominently in schools, playgrounds and other areas to let children know where to get help. Efforts to reduce pediatric suicide activity must be a broad-based community effort.
AL: SHARE WAYS THAT CASE MANAGERS CAN RECOGNIZE THOSE AT RISK FOR SUICIDE IN PEDIATRICS AND YOUNG ADULTS.
MK: Risk evaluation is a key component of the case management process and should be part of every case management assessment. A history of prior suicide attempts, mood disorders or substance abuse are risk factors strongly related to suicidal behaviors, and recognition and treatment of these risk factors is crucial in preventing pediatric suicides. Other risk factors that case managers should look at include a history of abuse, neglect, family conflict, domestic violence, and social isolation, including bullying.
Our LGBTQ and trans youth, who struggle with their very identity on a daily basis, are a very high-risk population with startling rates of suicidal thoughts and behavior. All of these risk factors can result in depression and a history of suicide attempts, which are the two major red flags for suicidal behavior in the pediatric population.
AL: BESIDES THE LOSS OF A CHILD/YOUNG ADULT, WHAT IS THE IMPACT ON THE FAMILY WHEN A CHILD/YOUNG ADULT DIES BY SUICIDE? HOW CAN CASE MANAGERS HELP THEM HEAL?
MK: The loss of a child is horrifying, and this loss can be compounded by the way the child dies. Parents who lose a child to suicide experience intense pain, and they suffer greater rates of depression, despair and divorce than parents who lose a child to trauma or disease. They also report greater feelings of blame, shame and isolation as well as a lack of support after the death. It is not unusual for grieving parents to express suicidal thoughts themselves.
Case managers must recognize that these parents are vulnerable and in need of support and linkage to treatment. We should reach out to them, listen to them, sit with them, hear their stories and offer support and resources whenever possible.
Provide parents with information on support groups and therapists who specialize in bereavement counseling. Compassionate Friends is a national support group with over 600 chapters that provides bereavement counseling for those who have lost a child. Urge the parents to contact this group to benefit from the support they offer and to connect with other survivors of suicide who have gone through what they are experiencing.
Another resource to look into is the National Suicide Prevention Hotline (1-800-273-TALK) as well as local hotlines in place in your community. Parents of children who have died by suicide often experience guilt, thinking and feeling they should have known how the child was feeling, thinking maybe there were things they could have done to prevent the suicide. These thoughts and feelings are a normal part of the grieving process, but help the parents realize that while sometimes there are warning signs, often pending suicide is not recognized even by trained professionals. Urge the parents to allow their friends and family to help them heal by accepting their offerings of emotional support, cooked meals, cleaning assistance or help with childcare. Let them talk about their child knowing they will always be that child’s mother or father.
AL: WHAT ARE SOME INTERVENTIONS FOR CHILDREN/YOUNG ADULTS AT RISK FOR SUICIDE?
MK: Interventions that reduce identified risk factors and build resilience are crucial. Individual and family therapy are cornerstones of treatment with both pharmaceutical and non-pharmaceutical treatment options available. A case manager or social worker should be assigned to the family to help remove any treatment barriers as well as to monitor compliance with the treatment plan. Follow up with this population is very important as non-compliance is sometimes an obstacle to wellness with this group.
AL: WHAT ARE COMPETENCIES CASE MANAGERS CAN WORK ON TO IMPROVE ASSESSMENT SKILLS TO RECOGNIZE AT-RISK CHILDREN/YOUNG ADULTS FOR SUICIDE?
MK: Case managers must work to become prepared to help reduce the growing public health crisis of pediatric suicide. We can do this by seeking continuing education courses and seminars on the subject that will give us the tools we need to better understand and help our children and young adults. We must use our skills of active listening, empathy and understanding to develop a therapeutic rapport with our patients so they allow us to help them. Also, our community and public health systems must work together to do a better job to develop and implement standard competencies for healthcare professionals caring for patients with suicidal behaviors. We need to be given the tools and community support to mitigate this public health crisis as we will be seeing the negative effects of these social upheavals for many years. Social worker and psychoanalyst Erica Komisar has written on the effects of this pandemic on our children and states, “COVID-19 has opened a Pandora’s Box of emotional, behavioral and mental health issues that will be difficult to put back in the box once the pandemic is under control.”