By Patrick S. Tennant, Ph.D.
Project Manager, Child Mental Health
The medical director of psychiatry from Cook Children’s Medical Center in Fort Worth, Tex., recently reported an increase in inpatient admissions of children and youth related to suicide attempts, highlighting concerns about the impact of the coronavirus pandemic on child and adolescent mental health. Though a full accounting of those impacts is not yet available and the large-scale, empirical results from around the world do not indicate a single, clear pattern, there is ample reason to be concerned. Loneliness of children and youth isolated from friends and extended family can lead to mental health challenges. The loss of routine and structure can be hard on children and youth, especially those with ADHD. Increased stress on caregivers and in the family is also generally detrimental for the mental health of children and youth.
There are even more reasons to be concerned about vulnerable populations of children and youth, as the pandemic has reduced access to or eliminated previously available supports. Those supports, such as receiving free meals at school, are crucially important to many children and their absence may lead to or exacerbate mental health challenges. School closures or online education may add strain to students’ lives and could reduce the identification of child abuse and neglect. This is especially troubling as experts predict that rates of abuse and neglect and other adverse childhood experiences may be increasing, and given the connection between child abuse and subsequent suicide attempts.
But can the coronavirus pandemic really be directly connected to an increase in suicide attempts? For the reasons listed above and others, experts believe it may. Such an increase would align with the overall trend during the past decade; the CDC recently reported that the national suicide rate in children and youth 10 to 24 years of age increased substantially from 2007 to 2018. In 2017, suicide was the second leading cause of death in this age group. Though we cannot yet definitively say whether the pandemic is associated with an increase in suicide attempts, available evidence suggests that we should not rule it out and that increased suicide prevention efforts are needed. Fortunately, mental health professionals and policymakers have developed and are currently implementing ways to address these concerns.
Opportunities for Prevention
One recommended method for reducing child and youth deaths by suicide is to increase screening for suicidal thoughts or plans in pediatric primary care and emergency departments. Mirroring the report from Cook Children’s Medical Center, experts recommend these screenings are conducted even when treating pre-adolescents. The screening tools already exist for immediate use by hospitals and healthcare systems, but systems and providers will need to consider several important factors when implementing them. Thankfully, guides for addressing those factors – which include identifying who will complete the screening, ensuring the tool is developmentally appropriate for the child or youth, and establishing a protocol for how to respond to a positive screen and intervene as needed – and implementation models exist. Since the pandemic began, some have even suggested incorporating screening for mental health crises into required COVID-19 screenings as an economical route to collecting this information.
While some pediatricians and family practice physicians may not feel completely comfortable with the responsibility of screening for or responding to suicidality, programs exist to address those concerns. For example, Texas has recently implemented the Child Psychiatry Access Network (CPAN) as part of the Texas Child Mental Health Care Consortium. The CPAN is network of children’s mental health specialists who provide free clinical consultation and training to child and youth serving physicians who have questions or concerns about their patient’s mental health. Texas’ CPAN is still in the early phases of implementation, but similar models exist in many states across the country and have been identified as a way to support more robust suicide screening practices. These developments are a part of a broader shift toward the inclusion of mental health care into primary care, often referred to as integrated care, which can also support the uptake of appropriate suicide screening practices.
A lack of suitable options for mental health care available to those who report suicidal thinking has also been identified as a barrier to suicide screening. Inequitable access to care is an important issue, but pandemic-spurred changes in regulatory restrictions and reimbursement practices for the telehealth provision of mental health care may have increased access to care since the pandemic began. It makes sense that access would generally improve when patients can be “seen” from virtually anywhere, but it must not be forgotten that telehealth may actually maintain or exacerbate certain disparities in access to care because some vulnerable populations lack the necessary technology to engage in these services. On the whole, however, telehealth can meaningfully improve access to care for a segment of the population and contribute to improved suicide screening practices systemwide.
Pandemic-related uncertainty exists throughout our society at this time, including uncertainty about connections between the pandemic and rates of child and youth suicide. It is clear, however, that implementation of a system of suicide screening and response was needed before the pandemic, is needed now, and will be needed moving forward. Opportunities to broadly implement such systems exist, and COVID-related concerns about child and youth mental can motivate that action. A comprehensive screening, referral and treatment system can meaningfully improve mental health and the safety of children now and into the future.