Suicidal Children in the ER
A tragedy all around, but especially in rural America
Children threatening suicide increasingly show up in our emergency departments. They are sometimes brought in on formal commitment papers, taken out by parents. Other times, grandparents or guardians, foster parents or even schools refer them to our hospitals to be evaluated and ‘placed’ because ‘we just can’t handle him (or her).’
Unless they come to a large hospital that has a pediatric psychiatry service, they are usually subject to tele-psychiatry and often to a recommendation that they be hospitalized. This, then, results in them languishing in busy emergency departments which are hardly kid friendly. They may be stuck for days or weeks before they can move to a facility where they get the actual care they need.
While it is well known that adolescents are increasingly depressed during the pandemic, and that they have more suicidal thoughts than before, this tendency among children is dark and disturbing.
A little boy of eight recently told me that sometimes he wants to cut himself or stab other people and that he wants to ‘hurt people that hurt me.’ He also told me that that he sees demons. (I’ve heard that plenty of times in my psychiatric patients but that’s a topic for another day.)
Some of these kids have a lot of underlying psychiatric issues, and typical of our times are taking multiple medications for concurrent diagnoses of depression, anxiety, PTSD, ADD/ADHD, oppositional-defiant disorder, bipolar disorder, schizophrenia and others. They often come with a long list of labels. And sadly, many have little access to intense psychiatric care. This is particularly true in rural America where I work.
You can swing cats all day in rural communities and you’ll rarely find a psychiatrist, psychologist or even certified counselor. This isn’t universal, but it’s pretty common. What these kids have is primary care physicians or pediatricians, or psychiatric nurses or nurse practitioners/physician assistants who are (bless them) present. But who are also often far over their heads. I’ve had four years of medical school, three years of residency and 29 years of practice and I have no idea what to do here either.
The children receive almost no counseling. They seldom have anyone trained to sit down and sift through their chaotic thoughts, or teach them to discern truth from false; to sift out the lies they were told or tell themselves and see good things, happy things, life-affirming things. The result is an endless, rolling experiment in this medication or that medication, changed to a new medication while another is taken off due to side effects. And all in an attempt to fix their ‘chemical imbalance.’
‘Which chemicals,’ one is tempted to ask. But to no avail. We could hold forth on dopamine and serotonin and other neurotransmitters but the fact is, we don’t check levels on those things and we don’t really have markers for cures for conditions, unlike other illnesses. An xray reveals that the fracture is healed. A falling white blood count might indicated that an infection is improving.
When it comes to mental health, it’s behavior and that’s it. So much of it is done in the dark, in a kind of thrust and parry against mental illness that often seems to go nowhere.
But with the children it’s worse. We have no idea what we’re doing as we pour more and more chemicals into their developing brains. I fear that their neurological development will be retarded, their creativity blunted, their hopelessness increased.
In my opinion, it’s that hopelessness that lies at the heart of so much that I see in these children. Hopelessness, lack of connection, lack of attention, loneliness. They’re suicidal because they live in homes that are chaotic. They live in families that endlessly fluctuate, where stability is a far-off dream. They are subject to new ‘dads’ or new ‘moms’ who then leave when the relationship with their parent ends. As such the also endure abuse, physical and sexual.
These children are hopeless because they are orphans with parents; mom and dad are drunk or high and the kids fend for themselves. Sometimes they end up with loving grandparents who step-up and decide that retirement is not as important as the children of their children. I wrote about this a few years ago:
Others end up in the foster system with caring foster-parents; others with terrible foster parents. A few are adopted. Some land with other relatives; adult siblings, uncles, aunts or even friends of the family. But as caring as they may be, these aren’t the parents the kids long for, ache for in their wee hearts of hearts.
And indeed, having met some of their surrogate parents, the despair these children feel makes total sense. Not everyone with children is good with children or should be with them at all.
So we see them, and evaluate them and someone puts them on medication in a hospital and then it’s back to the wilderness of their lives. And the cycle repeats. We see them again, and they get older and more reckless and move on into their own negative patterns as they seek solace in substances and relationships and their own children. Rinse, repeat.
Oddly enough, it is frequently the case that when these allegedly violent, dangerous children are in the hospital with us, they are docile. The nurses do their best to pet them and be kind to them, in between dying COVID patients, heart attacks, strokes and traumas. They give them snacks and coloring books, stuffed animals and just, well just time. They look in their eyes without malice or threat and they speak gently to them. Voila! They behave like children should.
It is a fascinating bit of history that during the Vietnam era there was a great concern that huge numbers of GIs would come home still addicted to the heroin that had learned to use while they were deployed oversees. However, when they came home and were out of that stressful environment, addiction rates fell dramatically. It’s worth reading about:
I imagine that what I see in these suicidal kids is exactly this. When the triggers of their negative thoughts are removed and they’re in a safe place, their brain relaxes. Their thoughts normalize. (And can I just say, when the chaos of the ER is your safe place, then home must be truly toxic…)
While I’m no psychiatrist and my only understanding of counseling is from my marriage to an excellent counselor, I do have a couple of thoughts.
I don’t know how to fix the kids who are already wounded. At least, not from a medical standpoint. I do think that they need environmental changes; or at least, changes in their environment from chaos to stability, from hatred to love, from addiction to sobriety in their parents.
What I do believe is that parents and future parents need to think long and hard about this. If you intend to use drugs and keep using drugs, do your best not to get pregnant and if you do, stay healthy and offer that child up for adoption. Do the child that kindness.
If you are a young man with a girlfriend, and you want to have children with her (or, ladies, you want to be with that man), then get married and make a solid commitment to stay together. This is the best thing for the children. Two parent homes with both mom and dad involved are healthier for the kids on multiple metrics, unless the marriage/relationship is a very negative one.
Living together, having babies, splitting up for the newest, latest relationship, all of that seasoned with some drug and alcohol abuse? That’s a sure way to drive the kids into a mental health hell from which recovery will be daunting.
Already have kids and have drug or alcohol issue? Already have a series of failed relationships? Consider a change in venue. Change towns or states and start again. Hopefully with the support of loving family or friends. Get away from the negative memories, situations and people that bring you down and bring trouble to your family.
Without a doubt, the anxiety and fear of the pandemic has contributed to suicidal thoughts in kids. But they were already struggling for a lot of reasons. I hope that we can figure this out. I hope that as a nation, and as individuals, we make the kids a prority.
Finally, it might help for us to remember that broken children are often the offspring of badly wounded adults. I think that adds an element of compassion that we have to show not only to struggling kids but to their struggling parents.
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