Last spring, the Colorado Children's Hospital declared a "state of emergency" for the mental health of young people. In the wake of the COVID-19 pandemic, the pediatric emergency rooms and inpatient departments of the hospital system were increasingly crowded with children and adolescents with severe mental illness, many of whom were suicidal.
"It was devastating to see that suicide became the leading cause of death for Colorado's children," said the hospital's CEO, Jena Hausmann, on 25.
This mental health crisis is not limited to Colorado, however. Pediatric medical systems across the country have reported significant and sustained increases in child and adolescent mental health since spring 2020. According to the June 18, 2021 edition of the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly, emergency admissions related to mental illness in adolescents ages 12-17 years old reported an increase of 31% compared to 2019. In addition the report found that in this age group the average weekly number of emergency admissions for suspected suicide attempts was 22.3% more in summer 2020 and 39.1% more in winter 2021 than in the corresponding periods of 2019. This increase was more pronounced among girls; In the winter of 2021, the presumed suicide attempts in the emergency room among girls aged 12 to 17 were 50.6% higher than in the same period in 2019.
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A confluence of factors
Research shows that psychological problems and suicidality have been increasing in children and adolescents for years. The current crisis cannot be linked to a single cause, but it is evident that isolation and fear of the pandemic have added an accelerator to an already burning flame.
Renee Turner, a Licensed Professional Counselor (LPC) based in San Antonio, points out several factors that she believes are detrimental to the mental health of children and adolescents. While declaring that she is by no means anti-technology, Turner admits that she is concerned about the impact of social media, which not only feeds cyberbullying – which, unlike "old school" offline bullying, is inevitable and ubiquitous – but also encourage children and adolescents to see the world through an artificial lens, she says. "Children do not have the ability to figure out what is true and what is true," and many parents fail to teach them how to consume online content in context, explains Turner, a registered play therapist. Technology is pervasive and many parents do not monitor or limit their children's screen time.
By the way, according to Turner, many adults struggle with their own screen addiction. She believes this adds to another modern problem: attachment problems. The emergence of double-income families, in which parents have demanding working hours or multiple jobs for financial reasons or because of professional requirements, makes it difficult to find time for bonds.
Turner also sees the pressure to live in such a performance-oriented society, another potential factor for the increase in suicidality in this population. "I see children who are chronically over-planned," she notes. These young people are involved in myriad activities in an ever-competitive environment where achievement is linked to self-worth, Turner points out. "It's all [based on] your achievement, instead of being valuable, just being you," she says.
Turner, the director of the Expressive Therapies Institute PLLC, has been counseling middle school children who are already concerned about how they will get to college. The demands on their time are so great that they stay up late to get everything done, she says. What really stands out for Turner is that some of their clients, who are in middle school and younger, are self-harming and suicidal because they don't see the end of the treadmill they are on. The COVID-19 pandemic made the situation even more difficult, she says, as children and teens struggled with online training while parents tried to work from home, look after the children, and with schoolwork to help.
Turner emphasizes that children and adolescents must have areas of their lives that exist only for pleasure – not performance. "If everything is evaluated, everything becomes work," she states.
Sarah Zalewski, an LPC specializing in child and youth counseling, was a school counselor at a Connecticut middle school when the pandemic began. She noted that the coronavirus restrictions had a profound impact on her customers and students. “The kids who went to virtual school and were separated from their peers had a lot more problems than those in school,” she says. "This routine and the connection with your colleagues is almost like a distraction from what is going on on your mind." Things that were "on a low boil" suddenly flared up, she says.
Children and adolescents also seemed to struggle with the loss of familiar routines, adds Zalewski. Interestingly enough, she noticed that students who had been over-scheduled for several years before the pandemic had a particularly difficult time coping with it.
Catherine Tucker, a licensed psychologist in North Carolina and Indiana who specializes in trauma therapy for children, adolescents, and adults, notes that early adolescence (approximately 11-14 years of age) is a particularly vulnerable period. “One of the normal pieces of development [during early adolescence] is that every generation thinks they have invented all normal problems like peer pressure, sex, bullying, dating. They feel like no one older than them can possibly understand what is happening to them, ”she says. As a result, teens often feel seen and understood by their peers, but not by adults, especially their parents, notes Tucker, a member of the American Counseling Association and a licensed middle school counselor. This is an important source of emotional confirmation that adolescents lacked while separated from their peers, she points out.
Tucker is also of the opinion that we underestimate the value of physical contact. “Just simple touch; it doesn't have to be intimate. Just be around other people. The more we learn about neurobiology, the more we learn that things like eye contact, physical gestures, and cues can help regulate the nervous system, ”she says.
Marginalized populations are at even greater risk of mental health problems and suicide, and the disproportionate toll of COVID-19 on black, indigenous and colored communities has been an aggravating factor. Brenda Cato, a professional school counselor with experience with elementary, middle, and high school students, says many students at her mostly black high school in Augusta, Georgia saw school not as a social event but as an escape. Most of their customers come from impoverished households, where parents have multiple jobs and utilities are skyrocketing. At school, these students get two meals a day. Cato believes that the fact that these meals were not able to play a major role in the general inability of students to cope with them during the pandemic.
Working with the parents
The counselors interviewed for this article claim that parenting education is an essential part of managing the suicide crisis of children and adolescents. Understanding the warning signs of suicide and what to do if a child becomes suicidal is crucial for parents, but it all starts with establishing communication and a sense of trust and security. "The most important thing is to be able to set up a safe … [environment] in which your child can come and talk to you," says Zalewski.
She advises parents to arrange regular one-on-one meetings with their children. This could be, for example, having ice cream or playing games and talking together, but she emphasizes that the time should be passed without the parents on the phone. It is important for children and young people to have their parents' full attention, she says. Zalewski also recommends having regular conversations in which the parents communicate that everything their child says to them during this time or in this room has no consequences.
Turner's customers include over-budgeted and single parents who often struggle with the idea that they need more time to really be there for their children – time that they don't have. So Turner emphasizes that these parents have time to have a good time. “It's essentially about picking up the child where they are,” she says. “Get interested in what the child is interested in and ask them about it, get involved in their world.” Turner suggests that parents have “date nights” with their children and schedule times when everyone will turn off their phones and put them in a basket to create a distraction-free zone.
It can also be helpful to teach parents to establish “outbreaks” of listening time, says Turner. For example, if a parent is in the middle of something and a child says, "Mom, Mom, Mom", the parents can answer: "OK, I have just five minutes, so tell me what you have to tell me."
Of course, parents can have difficulty reacting appropriately when they discover that their child is going through a psychological crisis, especially when the child says, "I don't want to live anymore." Zalewski reminds parents that it is important to yourself first to take a moment to listen to your child. Then she advises parents to say something so that their child knows that they are there for them. For example: “Thank you for telling me. That was brave to tell me that. Do you want to tell me more about it? "
Zalewski then helps her customers to plan the next steps. “It doesn't have to be cumbersome,” she says. Parents can use language like, “We're going to figure out together what our next steps are. I don't want you to feel that way and I want to protect you. ”The child and parents can then discuss options.
She adds that parents should ask one crucial question: “Can you protect yourself?” If the child is unsure, she advises parents to say, “I think we may need to go to the hospital and see see if the counselor there can give us some ideas. ”In many states, customers can call 211 to reach the appropriate health authorities and even ask for a mobile crisis team to come into the house to help prepare a contingency plan she adds.
But even children and young people who have a trusting and open relationship with their parents do not always report thoughts of suicide. Therefore, counselors need to make sure parents recognize the warning signs that are similar to those seen in adults. "The scary thing is that teens can be so much more impulsive than adults, especially … children, who generally have poor impulse control," admits Tucker. "There are fewer warning signs and fewer options for intervention."
Tucker emphasizes the importance of educating parents about how they restrict children's access to suicide drugs, such as unlocking firearms and medicines at home.
[those for] "The warning signs I am looking for are not necessarily different from those [those for] adults, but they are often written off as 'teenage behavior'", says Zalewski. For example, withdrawal can either be a warning sign or simply a desire to be alone. Parents should look for big changes in their child's behavior in areas like eating, sleeping, and socializing, she says. Giving away valuable possessions is also a great warning signal, she adds.
Zalewski emphasizes that parents should not reject a child's statement that they want to harm or kill themselves. "So many parents have said: 'I thought that's only if they ask for your attention.'
Zalewski also asks parents to respect their intuition: "If you think there is a problem," she says, "there is probably a problem."
Teachable moments
Cato faced a different challenge while educating the parents of students who were classified as suicidal. “I was working in a mostly black elementary school and a teacher sent me a child who made suicidal comments,” she recalls. After examining the student, Cato called the grandmother who was the child's guardian. The woman was angry and asked how many students in the school had been tested for suicide. Cato assured the grandmother that the school hadn't tested – she was evaluating. This taught Cato the importance of educating parents about suicide rates and the percentage of children who attempt suicide or die.
Cato did not approach the situation with the pupil's grandmother from the attitude, "Your child is suicidal and you will get help". Being a mother herself, she knew that if she didn't understand what was happening to her own child, she wanted someone to guide her. So Cato sat down with the grandmother and explained that her granddaughter would not necessarily be on medication or need ongoing therapy. However, Cato recommended that the child be examined by an expert. She told the grandmother that the school just wanted to make sure the child was okay and that she wouldn't harm herself. Cato also assured her that her granddaughter would not be stigmatized or labeled as a "problem student," nor would a note be included in her permanent file. “I think it's all about how you communicate with people,” says Cato. Grandmother's concerns are also understandable, she adds. Black students are often – and disproportionately – diagnosed with serious mental health problems, says Cato, adding that she has seen black students being sent to special school classes solely because of disciplinary problems.
After the student was medically cleared, Cato worked with the student to create a re-entry plan that included regular check-ins. These were sometimes as simple as casually walking the child and asking them to rate their day on a scale from 1 to 10.
Cato tries to turn all her interactions with students and parents into educational moments. She provides them with brochures, resources, and emergency phone numbers, and every time she visits a classroom she reminds students that the counselors and teachers are there for them. She says she's trying to help them understand that it's not uncommon to feel this way. She deliberately uses “we” when speaking to students: “We have all gone through difficult times; we all need help sometimes. "
Zalewski considers it important to point out the resilience strategies already used by children and to appreciate them. If listening to music helps a child or helps them feel better, then it is a good skill to use, she says. The discovery of coping strategies helps to build children's self-confidence, she notes, and it also informs parents about their children's coping strategies.
By the way, Zalewski found that her young clients often love teaching their parents the strategies they learned in the session. To encourage clients to practice a skill outside of the session, she recommends teaching their parents how to take proper deep breaths and explaining what deep breathing does to the brain to calm the body. "Because we then help parents regulate, [and] we co-regulate," says Zalewski. "It can really give a child a sense of self-efficacy that many children lack because children are naturally powerless."
She also works with clients on mindfulness, guided imagery, progressive relaxation, identifying what physical activities they enjoy and why. For example, a child might like to play basketball in the driveway, but in Connecticut, snow often gets in the way. So Zalewski helps them to find out the source of their enjoyment: is it physical energy that they are consuming? Is it the repetition? Then they consider alternatives such as using weights in the basement. Zalewski is a staunch advocate of anything that can get customers to move around and (if possible) to go outside. "For most people, nature is reparative," she notes.
Tucker says children and teens were already experiencing disconnection stress before the pandemic, which they think could be associated with too much screen time. When kids and teens get back to personal activities, finding a healthy balance between screen time and social activities like exercising, working on art projects, or just hanging out together is important, she emphasizes. She also believes the current practice of banning breaks in favor of exam preparation or other extra class work has contributed to the children's anxiety. She argues that children need a lot more time for free play and imagination.
Help for the helpers
Julia Whisenhunt, LPC and Certified Professional Counselor, specializes in studying and training others in suicide prevention. She always aligns her workshops around suicide dates to “help people understand that [suicide] is not uncommon”. Its aim is not to normalize suicidal thoughts, but to let people know that it is happening and that help is available.
"I know there is an assumption that talking about suicide makes people suicidal, but research doesn't back it up," notes Whisenhunt, an ACA member who is an associate professor in the University of Advisory Services West Georgia (UWG). “I think the opposite is the case. I believe that training saved lives and helped people. I know that. I've lived it. Suicidality is there – people just fight in silence. "
In training people who are not psychiatrists, it is important to emphasize that their role is not to “rescue” a person who is at risk of suicide, but rather to bring them help, adds Whisenhunt ]
Although Whisenhunt's workshops are aimed at college staff (and students in positions of authority such as resident associates), she is trained in Applied Suicide Intervention Skills Training (ASIST), which can be used to train staff in public school districts. ASIST is a 14-hour research-based training from LivingWorks, says Whisenhunt. The UWG advisory department does ASIST training with interns, and Whisenhunt says they feel much more confident after the course, even though they have already learned a lot about suicide in their program.
One of the main components of ASIST is the “path to help in life,” explains Whisenhunt. "You have a model of how to talk to someone about suicide." She tells the interns that this is a model that sums up everything they already know, but presents the information in a format that is easily accessible during the crisis.
The first part of the model is about the connection with suicide, she says. It has two main tasks: to research evidence of a suicide risk and then to identify and name warning signs. As soon as warning signs are recognized, the trainees learn to act directly without mixing around the bush, says Whisenhunt.
Whisenhunt and her follow-up trainers also point out to workshop participants how to talk about suicide and what to do when someone expresses suicidal thoughts. She cautions participants not to ask, “Are you thinking of harming yourself?” Because it can mean many different things to the person. Instead, she encourages trainees to be direct and not be afraid to use the word “suicide”. For example, you might ask, “Are you thinking of killing yourself? Are you thinking of suicide? "
She also advises them not to ask central questions. “If you ask, 'You're not thinking about suicide, are you?', The person will know the answer you want to give them,” explains Whisenhunt. "If the person seems hesitant, trust your gut feeling, talk a little more, make them feel more comfortable and circle around again."
She also asks people to keep asking about suicide. Don't ask just once and feel “relieved that you got this out of the way,” she insists. “If you feel like you need to ask and the answer doesn't feel right, ask again,” she says. “A lot of people don't want to die – they just want the pain to stop. Help them to know that there is another way out. "
Consultants must also be willing to provide resources, adds Whisenhunt. She advises her trainees to keep hotline numbers on the phone and to carry suicide prevention cards in their wallets.
“When you talk to a person and hear about their despair, you will likely hear something that means they don't want to die. It's often like, 'I don't want to leave my dog,' ”says Whisenhunt. “When you hear this little thing that says they don't want to die, then [want to] not be manipulative, [but] you say, 'I know you are in a lot of pain, but it seems … to me like you would you still think about life because you want to be there to take care of your dog. "This is the turning point – where they begin to turn away from suicide and turn to life."
Consultants can then ask clients if they want to come up with a plan to keep them safe for the time being, continues Whisenhunt. The use of the term “for now” is important, she stresses, because when people are in a suicidal crisis it is overwhelming for them to live for years and years. The security plan should extend for hours or days – until the person can be connected with help, she explains.
The ASIST safety plan includes "protective devices" and "safety aids". According to Whisenhunt, security guards include protecting clients from risk factors such as a plan to die from suicide, problematic alcohol or drug use, past suicidal behavior, or mental health issues that could increase the risk. The counselors can help clients consider ways to mitigate these risks, for example by reducing or eliminating drug use.
Guarding also involves being vigilant and looking for evidence of previous suicide attempts to protect the client, adds Whisenhunt. The client can be impulsive, for example, so it is part of his security that someone stays with him for a few days.
Safety aids are elements that help improve a person's safety, explains Whisenhunt. Counselors can help clients consider the strengths they already have and the support they need to build. "It's strength-based," she says. "We try to help individuals to recognize their strengths and resilience and to see options that will help them feel better."
In preparation
Counselors may be trained in suicide analysis and prevention, but using that knowledge can still be a daunting prospect, admits Zalewski. For this reason, she emphasizes the importance of specialized training. If possible, she recommends counselors find a local training opportunity with someone who can continue to serve as a resource for them afterwards. She decided to work with a mobile crisis team to find out more about helping people in suicidal crises.
"There are many modalities for the suicide assessment," notes Zalewski. “I would recommend not just choosing one modality for learning. To be competent, you have to have a good understanding of what's out there. Whatever you choose to work for has to suit you as a person. Discover What's Out There [and] You will learn several. … It is worth it. So if you are confronted with a child who has decided that they no longer want to live, don't look in your filing cabinet or text them with the message 'OMG'. "
Supervision is also essential, emphasizes Zalewski. “As a consultant,” she says, “you can easily get to the point where you think: 'I've been doing this for years and don't need supervision.'” But that's not the case. Sometimes, says Zalewski, she is sure that she knows something, but the supervision helps her to recognize that what she thought she knew was at some point twisted.
Consultants also need their own sources of support in doing this difficult work. “When you work with children and young people at risk of suicide, that is very important,” admits Zalewski. "It's so easy to question yourself." And if the all too imaginable happens and a client commits suicide, the counselor will need reinforcement, she adds.
“Everyone makes their own decisions in the end,” she says. All that counselors can ultimately control is the level to which they are providing the best preventive tools to clients, and "a good manager will help you assimilate that."
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Laurie Meyers ist leitende Autorin bei Counseling Today. Kontaktieren Sie sie unter [email protected]
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