Improving Hospitals’ Support For Teens In Mental Health Crises

ANNA ROTHSCHILD: This is Science Friday. I’m Anna Rothschild. This next conversation will discuss suicide and suicidal ideation in young people. Please take care while listening. If you or a loved one is thinking about suicide or self-harm, text TALK to 741-741 or call 988 to reach the 988 suicide and crisis lifeline.

Suicide is the number two leading cause of death for young people aged 10 to 24 years old. And one in five high school students seriously considered attempting suicide last year. That’s according to the latest data from the CDC. Just let that sink in for a second.

Doctors, researchers, and mental health professionals have been looking for solutions to support our country’s struggling youth. One place to start is the emergency department. Self-inflicted injury is often a key predictor of suicide. How can emergency departments be better equipped to help these struggling teens and potentially save lives?

Joining me now to talk about her research on the subject is my guest, Dr. Samaa Kemal, an emergency medicine physician at the Lurie Children’s Hospital of Chicago, based in Chicago, Illinois. Dr. Kemal, welcome to Science Friday.

SAMAA KEMAL: Thank you so much for having me.

ANNA ROTHSCHILD: So in your study, you included nearly 16,000 youth from around the country who went to the emergency department for a self-inflicted injury. What were the patterns you found? What were the big takeaways for you?

SAMAA KEMAL: So we looked at both that visit for a self-inflicted injury, but importantly, we weren’t just looking at those visits, but also the visits that happened before the injury and the visits after the injury.

So for the visits themselves, where a child came in, they had some type of self-inflicted injury, most of these children were presented to general emergency departments, which means ones that are not specialized in pediatric care. Most of them were from different metropolitan areas. About even numbers had private and public insurance, and most of them were coming in with either poisonings or cutting events.

When we looked at times before and after that injury, we were seeing that a significant amount of those kids had actually come to the emergency department in the 90 days before and the 90 days after the injury. And many of those times when they were coming in, they were coming in with mental or behavioral health complaints, which to us kind of indicated that there were opportunities for different interventions both before, during, and after the injury itself.

ANNA ROTHSCHILD: Can I understand, so with the with the events where they came to the emergency department before, what were some of the reasons that they were showing up beforehand?

SAMAA KEMAL: So we specifically just looked at did they come in for a mental and behavioral health complaint or not? And that could run the gamut of having suicidal thoughts or having depressive symptoms, anxiety symptoms. In the visits before, it was about 38% of the kids came in with one of those types of complaints. When we looked at it afterwards, it was about 50% that came in with one of those types of complaints.

I think what’s really important is that even if a child came into the emergency department beforehand without that complaint, we know that we miss a lot of kids who come in with mental or behavioral health issues, but maybe they came in with something like belly pain or headaches. And so they don’t name it a mental or behavioral health complaint. But really, some of those symptoms may be a byproduct of the distress that they’re under.

ANNA ROTHSCHILD: In some of these cases, the kids are coming in for their first time at the emergency department with issues that may or may not be obviously related to self harm. What are some sort of questions that people in the emergency room should be asking to kind of get at whether the kids are at risk of further harm?

SAMAA KEMAL: The tool that we use in the emergency department just to do basic screening is called the ASQ or the ask suicide screening questions. Some of the questions that we ask in that screening is in the past few weeks, have you wished that you were dead? In the past week, have you had thoughts of killing yourself? Have you ever tried to kill yourself?

And they’re really, really direct questions, and so it can feel uncomfortable if you’ve never asked those types of questions before to do so. But we really emphasize for our staff normalizing this process and making sure that we’re really asking everyone and then telling patients that as well, that this is something that we do for every single patient that comes into our emergency department. We do this to make sure that you’re staying safe and that we’re doing everything we can to support you. And that’s how you preface it.

And then, like I mentioned, there are certain things that a child may come in with that feels like a really vague complaint, and maybe you’re not figuring out what the reason is for it based off of your exam or the questions you’re asking. So, for example, if a child comes in with abdominal pain and you’re really just not identifying things, we make sure to talk to all of those patients alone. We ask their parents to step out.

And we preface kind of with the same thing I said before, which is, we always take some time to talk to kids individually too, and just make sure we’re not missing something. So I’m going to ask you some sensitive questions, and I hope you can be honest with me, and I want to make sure that none of these things are contributing to why you’re here today.

ANNA ROTHSCHILD: Yeah, and are they often honest with you?

SAMAA KEMAL: I think we still miss kids because sometimes children are dealing with these issues and haven’t told a single person. They haven’t told their parents, they haven’t told their friends. And sometimes we normalize it enough that they feel safe to share with us and sometimes they don’t. I’m fairly positive that we still miss people.

ANNA ROTHSCHILD: Right. So what are the current guidelines for when a kid shows up at an emergency department with a mental health complaint?

SAMAA KEMAL: Some of it depends on age and depends on how high of a concern their mental or behavioral health complaint is. So if a child, kind of regardless of age, comes in and says that they’re having suicidal thoughts or that they have done something to harm themself with the intent of suicide, then pretty much across the board they need a psychiatric evaluation. And depending on what type of center a child goes to, who does that evaluation may change.

So when you come to our center, which is a freestanding children’s hospital, we have psychiatric social workers available 24/7. And so you will always receive a full mental health evaluation from one of those specialists, and then they will determine what the safest plan for you is moving forward. But there are many, many, many hospitals across the country, and this is one of the focuses of our study, that don’t have that level of resource to care for children.

And so they may just have the physicians and the nurses that work in that emergency department who are doing these evaluations and trying to figure out what type of care level children need. And in those situations, they really lean heavily on the resources in the community and other health care systems in their area to help out.

ANNA ROTHSCHILD: If a child does come into the emergency department, what are the best practices? What interventions should be done to prevent further harm if they’ve come in after they’ve inflicted some injury on themselves?

SAMAA KEMAL: Kind of baseline, what we have been pushing for in the medical community for a while has been really any child that is in this high risk age range, which really includes 12, 13, and up, should be getting suicide risk screening. To go back to my point from earlier, we know that when children come in with suicidal thoughts, we kind of know what we need to do for them. But when they don’t, you may miss children who have those needs.

And then best practices once you’ve identified that a child is at risk for suicide, either because they do have those kinds of thoughts or they have a plan for what they were thinking to do to harm themselves, or they have actually done something to harm themselves. Once you’ve identified that that child is high risk, then they really should get some type of psychiatric evaluation.

And then if a child is going home, some of the very basic level things that need to get done is they need to have a really good safety plan in place. And what I mean by that is the parent and the child really need to know what is it that I need to do when I go home to keep myself safe? Do I need to lock up different medications and sharp objects and firearms so that I don’t harm myself?

Who am I going to follow up with to make sure that what I came in with today doesn’t continue to get worse? And so all of that gets encompassed within a safety plan. And then who they follow up with is really something that should be discussed before they go home too.

The mental health professional shortage in this country is very real and very concerning. There are not enough specialists in the mental health field for all of the kids that need it. And so sometimes a child, you want them to be able to get in with a therapist or a psychiatrist, but there’s no one available for a while. And so making sure that they at least have follow up with their pediatrician, someone who can make sure that they continue to do well when they leave the emergency department is really important.

Especially because we saw in our study, half of these children ended up coming back within 90 days. And so we don’t know if that meant that they didn’t get the follow up they needed or if the issues they were experiencing just continued to escalate. But we do think that at least part of the reason is that they’re not able to access that follow up.

ANNA ROTHSCHILD: Do you think pediatricians need additional training to help these kids?

SAMAA KEMAL: I think pediatricians are asking for additional training. Because as this problem gets worse in our country and we continue to not have enough pediatric mental health professionals, the pediatricians are the ones who are feeling this burden the most and they want to help. But some of this is beyond the scope of what you learn when you become a pediatrician. And so they want to make sure that they have the right resources.

So many pediatricians may be reluctant, for example, to start medications on a patient if they haven’t had that experience in the past. And so figuring out what types of resources pediatricians need to be able to do this type of care, I think, is important as we work at a systems level to just increase the pediatric mental health professional availability in our country too.

ANNA ROTHSCHILD: Yeah. What is your advice to adults who are worried about the young people in their lives if they feel like there are young people who might be at risk of injuring themselves or taking their own lives? What do you tell those parents or teachers?

SAMAA KEMAL: This is such a hard thing, I feel, to deal with as a parent, a caregiver, a teacher, a mentor, a coach. But what I would emphasize is that there is no one who knows these children better than those people. Me as a physician, meeting your child for the first time in the emergency department, I’ve certainly seen patterns in kids before and may be able to pick up some things, but it’s really going to be the people that spend most of the time with the kids that are the first ones to recognize when things aren’t going right.

And some of those patterns, if a child tells you that they’re feeling depressed or that they’re having suicidal thoughts, I think many parents would know to be concerned about that. But there may be more subtle clues like having significant difficulty sleeping, having changes in their appetite, losing interest in activities that used to make them happy, withdrawing themselves, not wanting to spend time with their friends.

And those subtle clues oftentimes come before those more severe clues later on. And so if you start to notice those patterns as a parent or caregiver or important person in a young person’s life, I would just say to listen to your gut feeling about that and try to start some open communication about what you’re noticing with the child.

A lot of times children need you to take that initiative in approaching the conversation and letting them know it’s OK to feel how they’re feeling, but you just want to help them. I really strongly recommend just initiating the conversation and letting them know that you’re happy to help them seek out extra help. That extra help in the beginning may just be setting up that visit with your pediatrician. It may be looking for resources in the community, for a therapist.

And certainly if you feel like as a parent or caregiver that things have escalated to the point where you’re worried about their safety, that is what places like the emergency department are for. And even if at the end of the emergency department visit we find that your child isn’t at risk to hurt themselves, you did the right thing by seeking care. And so that’s what we are there for, to support you in that.

ANNA ROTHSCHILD: This is science Friday from WNYC Studios. If you’re just joining us, I’m talking with Dr. Samaa Kemal, an emergency medicine physician at the Lurie Children’s Hospital of Chicago, about youth suicide interventions in emergency departments. What made you decide to do this research?

SAMAA KEMAL: I am very passionate about preventing injuries and deaths in children that we know are preventable. So I think a lot about violent injuries in children. I do research both in suicide and in other types of violence. And I just find that these types of injuries and death are really tragic. But I am motivated by that idea that we can make a difference and we can make a change with the right interventions and with the right efforts by everyone, not just us as health care professionals, but also families, communities, policymakers. Sometimes we just need the evidence to show that it’s a problem and also the research to show what the right solutions are too.

ANNA ROTHSCHILD: How do you feel about the future of youth mental health in this country? Are we paying enough attention? Are we allocating enough resources to address this issue?

SAMAA KEMAL: I think that it would be very easy to lose hope in the last few years, especially in the context of the COVID-19 pandemic. We’ve seen really large increases in pediatric patients having mental health distress. We see it in having more emergency department visits, more hospitalizations, more deaths. And that is really distressing for everyone.

But I also think that people are talking about it and people are asking for changes. We have seen policymakers discussing it as well. And I think at a large structural level, the solutions that we still need are more pediatric mental health professionals and more resources for all of the health care professionals and other community workers who are doing this type of work. So to answer your question, I don’t think enough resources are there yet, but I do think people are paying attention and that the tide is shifting in the right direction.

ANNA ROTHSCHILD: Well, thank you so much, Dr. Kemal, for speaking with us and for doing this research.

SAMAA KEMAL: Thank you. And thank you for bringing light to this really important topic. I appreciate the time.

ANNA ROTHSCHILD: If you or a loved one is thinking about suicide or self-harm, text, TALK to 741-741 or call 988 to reach the 988 suicide and crisis lifeline. We also have more resources on our website at sciencefriday.com/prevention.

Copyright © 2024 Science Friday Initiative. All rights reserved. Science Friday transcripts are produced on a tight deadline by 3Play Media. Fidelity to the original aired/published audio or video file might vary, and text might be updated or amended in the future. For the authoritative record of Science Friday’s programming, please visit the original aired/published recording. For terms of use and more information, visit our policies pages at http://www.sciencefriday.com/about/policies/