Published in the New York Times, June 28. 2021

When Marie, 11, called a suicide prevention hotline in October, nobody saw it coming. Not even Marie herself, who had been bottling up feelings of loneliness and sadness for months without telling anyone.

Her relationships with some of her closest friends had started to suffer when school went online last year, and she worried about losing other people in her life, too. What if they moved away? What if they died?

One weekday afternoon, she put on her headphones and listened to music while taking a walk, and she began to get increasingly upset. Even now, she isn’t sure exactly why.

“I knew that I needed help, but I didn’t really know who to go to,” she said.

She searched for a suicide prevention hotline on her phone, and wondered momentarily whether the crisis counselors would take her seriously. Then, she called.

With Marie’s permission, a counselor conferenced in Marie’s mother, Jackie, who was a 25-minute car ride away. They came up with a plan to keep Marie safe until Jackie could arrive. (Their surname and those of other families interviewed for this article are being withheld to protect their privacy. Marie is being identified by her middle name.)

The next day, Marie told her mother that “in the past, not too long before that, she had brought scissors in her bedroom with the intention of hurting herself, but didn’t know how to,” Jackie said. “I was completely blindsided.”

It wasn’t as though Jackie was unaware of the mental health crisis affecting adolescents. She works as a nurse at two different pediatric intensive care units on the East Coast, where she has treated many children who attempted suicide in the past year.

“Some of them we’ve asked, ‘How did you get the idea to do this?’” Social media is their typical response, she said. “They don’t grasp that if they hurt themselves, it might not be something we can fix, and they might not get better.”

Interviews with mental health providers and data from hospitals across the country reveal that while providers are continuing to see a surge in teenagers visiting the emergency room for mental health problems, the number of children in crisis under the age of 13 is also on the rise, and has been for years.

The youngest patient under Jackie’s care who had recently attempted suicide was 8 years old. She survived, but another child, also under 13, was not as fortunate, and became an organ donor. Jackie said that most of the children who come in after suicide attempts are girls who have overdosed on pain medication, like Tylenol. Some of them now face liver damage. Once, after a particularly difficult day at work, Jackie called her husband and asked him to lock up all the Tylenol and Motrin in their home.

“I don’t want to ever think we’re immune to these things,” she said.

‘We will see this crisis grow in the fall.’

Even before the pandemic, a mental health crisis was brewing among children struggling with bullying, abuse, eating disorders, racism or undiagnosed mental health conditions. But now, children are facing even more stressors, like the loss of a family member to Covid-19, adjusting to remote school or the anxiety of returning to in-person school.

“It’s almost like the pandemic threw gasoline on embers that were already glowing,” said Heather C. Huszti, chief psychologist at Children’s Hospital of Orange County in Orange, Calif. “We’ve never seen it this bad.”

For young children, the pain can feel endless.

“It’s like, ‘This is my life now. Do I have anything to look forward to?’” Dr. Huszti said. “Because they just can’t think long term.”

CHOC, where Dr. Huszti works, has the only inpatient psychiatric center in Orange County that can take children under 12. In order to be admitted to one of the center’s 18 beds, a child must be a current or imminent threat to themselves or to others. When the center first opened in 2018, about 10 percent of the children were under the age of 12. In 2020, that number began to increase, and now has more than doubled, Dr. Huszti said.

“We have some days where every kid in the unit is under 12,” she said.

National data shows a similar pattern. In November, the Centers for Disease Control and Prevention published a study that compared how often children came to emergency rooms in the United States for mental health reasons versus other types of concerns. The agency found that between April and October of 2020, there was a 24 percent increase in the proportion of mental health emergency department visits for kids ages 5 to 11 compared with the same period in 2019.

The problem appears to be particularly dire among girls. During 2019 and 2020, the proportion of mental health-related emergency department visits was higher for girls under 18 than it was for boys of the same age, the C.D.C. reported.

“I anticipate that we will see this crisis grow in the fall as kids return to school and are trying to adjust to making up for a year of lost development,” said Dr. Jenna Glover, a child psychologist at Children’s Hospital Colorado in Aurora.

Among children who die by suicide, there are stark racial disparities. The rate of suicide in Black children under 13 has been increasing over the last decade and is two times higher than among white children. In two editorials published on Monday in JAMA Pediatrics, the authors called on funding agencies and journals to prioritize research on Black youth suicide; and emphasized the need for preventive efforts that target stigma and institutional racism.

‘The younger the child is, the longer they wait.’

Children’s hospitals, which typically have few (if any) available inpatient beds for mental health patients, have begun to run out of room.

“The younger the child is, the longer they wait,” Dr. Huszti said. “It just breaks my heart.”

Some inpatient psychiatric units may not be able to admit kids under 12, she added, because they often require more one-on-one monitoring than older kids, as well as age-specific therapy.

In April, 11-year-old Lu and her mother, Nicole (their middle names), had to wait in an emergency room in Ohio “all day and all night” because the hospital’s 13 pediatric beds were full and two kids were in line ahead of her. They were eventually transferred to a behavioral health hospital nearby. Lu befriended other kids there who had their own mental health struggles, including some who were several years older. At one point, she saw someone get sedated and restrained.

“I was concerned,” Nicole said. “She was exposed to so much there that I wouldn’t want her to be exposed to.”

During the pandemic, Lu underwent “a really big personality change” that Nicole attributed to the “perfect storm” of isolation, hormones and genetics. (Nicole was diagnosed with depression and anxiety when she was in her early 20s.) Lu became immersed in social media, and appeared to be caught in an algorithm that kept showing her videos of sad kids, her mother said.

“I had to actually explain that to her,” Nicole said. “I was like, ‘Hey did you know if I like a picture of a pair of tennis shoes, I’m going to probably keep seeing pictures of tennis shoes?’ And she looked at me, and she was like, ‘Really?’”

A couple of months ago, Nicole had the sudden urge to check the text messages saved on her daughter’s tablet. That was when she discovered that Lu had been planning on harming herself and had also written a goodbye letter.

How did we get here?

Even though the stigma surrounding mental health care has declined somewhat in recent years, “we have not yet given people the skill set or the resources to know how to manage their mental health, how to prevent or how to respond to suicidal thoughts,” said Dr. Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention.

Many children also have underlying psychological problems that simply aren’t being addressed. A study published in JAMA Pediatrics found that in 2016 half of the estimated 7.7 million children in the United States with a treatable mental health disorder did not receive treatment from a mental health professional.

Finding a provider can be difficult. The American Academy of Child and Adolescent Psychiatry reported that there is a severe shortage of child psychiatrists in nearly every state in the country. In California, for example, there are only 13 practicing child and adolescent psychiatrists for every 100,000 children under 18.

Insurance companies don’t reimburse mental health services as highly as they do medical services, which makes it far less profitable for providers to treat mental health patients, experts say. For example, in Connecticut, Medicaid reimburses hospitals $2,665 per day for a standard pediatric inpatient admission and about $1,000 per day for a pediatric psychiatric hospitalization, said Ryan Calhoun, the vice president of strategy and care integration at Connecticut Children’s.

Finally, the American Academy of Pediatrics recommends mental health screening for all children 12 and older during well-child visits, but it is not standard practice to screen children younger than that, said Dr. Tami D. Benton, psychiatrist-in-chief of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia.

“Previously, the under-12’s were identified as a low-risk group,” she said.

That’s not the case anymore, she added.

Kate, who lives in Colorado, was in the third grade when she told her parents that she didn’t want to live anymore. For much of her childhood, she has suffered from sensory processing disorder, attention deficit hyperactivity disorder and anxiety, and she was bullied in elementary school.

“I felt like I was just a waste of space,” Kate, who is now 12, said in an interview. “I was in so much pain.”

Back when she was 8, her parents took her to the emergency room, where they stayed for about 12 hours until it was determined that Kate would be safe at home.

“You just feel like, gosh, what have I done wrong as a parent? How am I not supporting my kid?” said Hope, Kate’s mother.

“Don’t feel shame,” she advised other parents. Instead, take a deep breath and call the pediatrician or a crisis line, Hope said, “so that you don’t feel alone.”

‘There’s no place to send them.’

Connecticut Children’s hospital in Hartford does not have any inpatient beds for pediatric psychiatric patients. It takes an average of one week before kids in the emergency room can find a bed elsewhere, Dr. Jennifer Downs, the division head of child and adolescent psychiatry at Connecticut Children’s, said during an interview in late May.

On that particular day, 10 of the 37 children in the emergency room for mental health reasons were under 13. Some children wait for an inpatient bed for as long as a month, she added.

“There’s no place to send them,” said James E. Shmerling, the president and chief executive at Connecticut Children’s. “Every existing resource in the community has a backlog.”

In Colorado, the situation is also critical. This year, at any given time, about half of the kids in the pediatric emergency department at Children’s Hospital Colorado are experiencing a mental health crisis, which prompted the institution to declare a state of emergency in May.

Not only are Colorado’s emergency rooms full, so are the long-term pediatric residential facilities. More than 70 children with severe mental illness had to go out of state to find a residential treatment program over the last year and a half, some traveling as far as South Carolina, Florida or New York, said Heidi Baskfield, the vice president of population health and advocacy at Children’s Hospital Colorado. It’s a problem that other states, including Connecticut, are grappling with too.

Searching for solutions.

Health care institutions have been scrambling to find ways to treat more children with acute mental health needs. CHOC, for example, is planning to open an intensive outpatient program in the next year for children in middle school who are suicidal as well as a program to offer specialized therapy to children who are 8 and under.

At Children’s Hospital of the King’s Daughters in Virginia, there was a 300 percent increase in mental health emergency department visits among 2- to 12-year-olds from 2015 to 2020. The hospital is in the process of expanding its outpatient program to include group therapy for nearly all children, which will allow them to be treated faster than they would have if they needed to wait for one-on-one therapy, said Dr. Mary Margaret Gleason, a pediatrician and child and adolescent psychiatrist there.

“The emergency room situation is a crisis, but it will be fixed only if we look at the preventive efforts that come well before,” said Dr. Gleason, who has a special interest in working with children under 6. “When you get into the preschool age, the level of unmet needs is extraordinary.”

The hospital is also constructing a new building that will have 60 inpatient psychiatric beds — currently they have none — including units for children with neurodevelopmental disorders and kids with concurrent physical and mental health needs, for example diabetes and depression.

Connecticut Children’s is educating teachers and pediatricians about how to manage children with behavioral and mental health conditions, and provides them with a phone number for real-time advice from a mental health professional, Dr. Shmerling said. He is hoping to add a medical psychiatric unit to the hospital — with as many as 15 beds — next year.

Some states, including Colorado, are starting to funnel more money toward mental health services, though providers say even more is needed.

“For now, we do need beds to meet the surge,” Ms. Baskfield said. But, she added, children also need support from schools and at the primary care and outpatient level so that fewer of them require intensive care.

“We can’t build our way out of this crisis,” she said.If you are having thoughts of suicide, call the National Suicide Prevention Lifeline:1-800-273-8255 (TALK) or text TALK to 741741