In this episode of Manne Research Institute's In Pursuit podcast, Dr. Patrick Seed talks with Dr. Jennifer Hoffmann about the prevalence of suicidal thoughts and behaviors, which surged among children and adolescents in the United States during the COVID-19 pandemic. Dr. Hoffmann highlights how the protective strategies that start in the emergency room can help mitigate suicide risks. She shares how her research journey evolved from an interest in advocating for improved child health to a dedication to investigating the underlying causes and effective solutions to the pediatric mental health crises.

Show Notes

  • There has been an ongoing youth mental health crisis in the United States that gained national attention during the COVID-19 pandemic. Data from the Centers for Disease Control and Prevention (CDC) show that about 1 in 5 U.S. high school students report seriously considering suicide, underscoring the scale of the crisis facing adolescents today.
  • These trends worsened during and after the COVID-19 pandemic, as stressors such as social isolation and disrupted routines drove increases in depression, anxiety and suicidal ideation. These patterns were captured through large national surveys like the Youth Risk Behavior Survey.
  • Since the pandemic, Lurie Children’s implemented Suicide Risk Screening in the emergency room to children age 10 and up, revealing that about 4 percent of pediatric patients, even those seeking care for other medical issues, have some level of suicide risk. 
  • Dr. Hoffmann’s research focuses on improving systems of care and addressing disparities for children's mental health conditions.
  • She says youth suicide prevention often comes down to connection. She says evidence-based protective factors, including access to mental health services, strong family and community relationships, and reducing access to lethal means are especially important given how quickly suicidal thoughts can become actions in young people.
  • She is also leading innovative solutions. Her current research explores "Caring Contacts," a low-cost, scalable intervention that uses supportive messages to stay connected with teens after emergency visits. She is also studying practical, evidence-based strategies to reduce suicide risk in children, including how health care providers can help families implement safer storage of medications and firearms and encourage open conversations about mental health and how to teach children about the 9-8-8 National Suicide and Crisis Lifeline.

Read the Transcript

[00:00:02] Dr. Patrick Seed: Welcome to "In Pursuit," Research Perspectives from Ann and Robert H. Lurie Children's Hospital of Chicago. I'm your host, Dr. Patrick Seed, President and Chief Research Officer of Stanley Manne Children's Research Institute, one of the nation's largest pediatric research centers. "In Pursuit" is our opportunity to learn about the groundbreaking work of our researchers and to join them in their journey as they strive to improve the lives of children and families in Chicago and beyond. Our guest today works in the field of pediatric emergency medicine. While she's there for kids walking through the door with a whole range of medical problems like injuries, infections and new disease diagnoses, she's specifically focused on improving care for our children and adolescent patients with mental health conditions. Here at Lurie Children's, she's an attending physician for emergency medicine, the co-director of pediatric emergency medicine fellowship research and behavioral health medical director for emergency medicine. She's also an assistant professor of pediatrics for emergency medicine at Northwestern University Feinberg School of Medicine. I'd like to welcome Dr. Jennifer Hoffmann.

[00:01:05] Dr. Jennifer Hoffmann: Thank you for having me.

[00:01:06] Dr. Patrick Seed: Yeah, absolutely. Hey, before we start, I just want to note for everybody who's the listener, that in the course of today's episode, we're going to be covering some tough topics around suicide, suicidal thinking, prevention and research. And I want to mention this at the beginning, that if anybody listening themselves or someone they know is experiencing suicidal thoughts, please take the time to call or text 9-8-8 and get some immediate help. We've been doing this podcast for a little over a year now, and this is one of the first times that we're going to be focusing on research around mental health, so I really appreciate you joining us today. Let's start with sort of setting the stage, get a little bit of a landscape view of where we are right now in terms of rates of suicidal ideation and suicide among youth. What does research in epidemiology tell us about the frequency? I'm particularly thinking about reference points, but we all, I think everybody heard in the news, right? COVID, we really saw what everybody said: Are these new peaks and sky-high rates of that? What do we know about the pandemic and where have we come since then, Jen?

[00:02:04] Dr. Jennifer Hoffmann: Yeah, that's a great question. So we do know that during the COVID-19 pandemic, kids experienced a lot of stressors such as social isolation, changes in routines, and that led to increases in depression and anxiety symptoms, but also increased rates of suicidal thoughts and self-harm. Some of the most recent data we have come from the Youth Risk Behavior Survey, which is a national survey of high schoolers, and that found in the most recent year as many as 1 in 5 high schoolers had seriously considered attempting suicide in the past year.

[00:02:36] Dr. Patrick Seed: Yeah. That's incredible. And so what age does that go down to? What are we talking about in terms of the group?

[00:02:42] Dr. Jennifer Hoffmann: Yeah, you know, there also was some recent data, a study published by my colleague, Dr. Donna Rouche, that looked at suicides as early as elementary school. This study looked at kids 8 to 12 years old in the U.S. And found that suicides among that group have increased 8 percent annually over the last two decades. So it definitely is more common among older adolescents, teenagers. But we're seeing this clinically in the emergency department. It seems to be starting earlier and earlier.

[00:03:11] Dr. Patrick Seed: That's really remarkable. You know, I was just thinking about in the emergency department, you're in this incredible environment of sort of a mixture of stress and anxiety and I was just curious, and I don't know if you have direct data on this, but, so maybe it's even just your general sense of things. How often are patients coming in because of a crisis versus you identifying in the course of some other workup for another urgent or serious medical problem that they're having. I'm trying to understand how many kids are sort of in that part of the iceberg that's down below the water.

[00:03:42] Dr. Jennifer Hoffmann: I think that number has increased over time of kids who come in for a primary medical reason, and we do detect some mental health concerns that we're able to address during the visit. And since the COVID-19 pandemic, at Lurie Children's, we started Suicide Risk Screening, which means asking a standardized set of questions to all kids 10 and up who walk through our doors in the emergency department. To try to find out if they are at risk for suicide, even if they're there for a primary medical reason and we finding about 4 percent of those do have some level of suicide risk.

[00:04:14] Dr. Patrick Seed: Wow, that's pretty high. What, would, have been your sort of hypothesis going into that? What did you think might be the percentage?

[00:04:20] Dr. Jennifer Hoffmann: I mean, it's aligned with the data nationally. Studies across the country are finding similar rates, and I think the emergency department is a really important setting to detect these youth because we know that youth who have chronic medical conditions do have increased risk for mental health problems as well. They tend to run together. And a lot of those chronic medical conditions can be stressful. And in that set of kids who come into the emergency department for medical reasons, they may have a higher risk than the general population.

[00:04:48] Dr. Patrick Seed: Interesting. Have you learned anything from that in terms of what might be sort of, things that are additive in terms of the risk or might be resiliency or protective factors? Are there youth that are walking through the door who sort of defy that 4 percent? Either they're much higher, they're much lower on a national level and does that tell anything?

[00:05:07] Dr. Jennifer Hoffmann: Well, I'm glad you asked about protective factors because I feel like so much of the emphasis is on risk factors, but kids are actually really resilient overall and they can go through so many things in their life and still come out on the other end okay. And some of those protective factors include being connected to mental health care. So what we try to do is kind of change risk factors to protective factors when we see children. So if they're not already connected with mental health services, we try to get them into services. Other protective factors include connectedness with the family, the school, the community. And a really important essential protective factor is to reduce access to potentially lethal means. So what do I mean by that? Suicides among kids are often impulsive acts. The time between when a thought pops into a child's head and when they act on it, about half the time is less than 10 minutes. So, if we can reduce their ability to access medications in the home or firearms that can actually make the difference between life and death. So it's really crucial to any parents listening to this podcast. Make sure if there are medications in your home, including over-the-counter. It's best to store those locked up as well as to store any firearm safely, which according to the American Academy of Pediatrics, means they should be stored, locked, and with the ammunition locked separately.

[00:06:26] Dr. Patrick Seed: Yeah, that's great advice. Makes a lot of sense. I'm curious, how do the families do with the screening? Is that pretty widely accepted?

[00:06:35] Dr. Jennifer Hoffmann: So there are really good studies showing that asking youth about suicide does not put thoughts into a kid's head. It's very safe to ask a child questions about suicide, and in fact, it's likely even the opposite, that talking more openly about these topics will lower risk over time. These types of suicide risk screening questions also are very highly acceptable to families in research studies. Over 95 percent of families want their pediatrician to ask their child about suicide and to try to pick that up and connect them with care if it's needed.

[00:07:08] Dr. Patrick Seed: I'm curious how you find this career path, right? You're sort of mixing together work as an emergency department physician and then this interest in mental health. What was the origin of that and how do you bring that together? Two pretty high stress areas I have to say.

[00:07:22] Dr. Jennifer Hoffmann: You know, when I started my fellowship in pediatric emergency medicine, at the time my main interest was actually in advocacy rather than research. So I was interested in legislative media advocacy to try to improve child health. But as I went through my clinical training in the emergency department, I very quickly identified that there is a need to advocate for kids experiencing a mental health crisis. I found that there were many kids having trouble accessing outpatient mental health care, and their symptoms would just progress to the point of a mental health crisis. And that's what would land them to the emergency department, into my care for me to see them. And on the other side, I also found that after we evaluated a child, if we found that they needed inpatient psychiatric care, there's very limited access to open beds. So there were many kids who would actually become stuck in the emergency department with very long wait times of days, occasionally, even weeks at a time. Just waiting for an inpatient psychiatric bed to open. So at the beginning of my research career my first study was just to define the scope of the problem that I was seeing in my own emergency department. My very first research study as a fellow was to look at increasing visits for pediatric mental health conditions and more prolonged length of stay. I found visits lasting over 24 hours in my emergency department, increased from about 1 in 20 visits to 1 in 5 visits over seven years. And from there I expanded further by looking at national data sets, and was able to replicate my findings and show that kids across the country were facing similar barriers to accessing care.

[00:08:57] Dr. Patrick Seed: And getting back to the policy part, where have some of your data gone? And has any of it made it to the desks of some of our legislators and been part of the legislative, regulatory thought process?

[00:09:08] Dr. Jennifer Hoffmann: Well, I think for me, one of the driving factors behind my research is to generate data for advocacy. And part of that is describing the scope of the problem but also which subgroups of children are most vulnerable and most impacted. So, much of my work has focused on differences across population groups. For example, I found that more children in rural areas were visiting the emergency department for self-harm than urban areas. I also found that kids who live in counties in the U.S. that have greater shortages of mental health professionals are at higher risk for dying by suicide. So, these access barriers really matter in terms of our definitive health outcomes. And I have had the chance to use some of my research findings to prepare testimony for the Illinois State Senate and for other areas. And I have the chance also to work with the media and with reporters to disseminate my findings to publications that policymakers frequently read.

[00:10:06] Dr. Patrick Seed: You've done an amazing job actually doing that. So it's been really impressive to see. I think the time that you've spent both educating people and I think, you know, delivering the message that's research informed. So, that's been really terrific. I'm curious you know, you made reference to the rural versus more urban areas and, the increased, presentation, I think you said among rural individuals youth, for suicidal ideation and self-harm, risk. Do you have any hypotheses for why that is?

[00:10:34] Dr. Jennifer Hoffmann: You know, it's probably multifactorial, but I imagine some of the contributing factors include shortages of child-serving mental health professionals in rural areas, especially child and adolescent psychiatrists. In many of the rural counties in Illinois, there are zero practicing child psychiatrists. So that's part of it. And another part when it comes to suicide deaths is access to firearms. We know that youth who live in rural areas in survey data, they report more access to firearms in the home. There was one recent large survey study of high school students in Colorado that looked at the number of kids who could access a firearm within 10 minutes if they wanted to. And those percentages were substantially higher in rural areas than urban areas.

[00:11:19] Dr. Patrick Seed: Tell me a little bit about younger children. You know, how early can we screen a younger child? Where that has some level of sensitivity and accuracy. I'm also interested in those younger children who might screen positive or be identified as having some risk for self-harm. Is there any longitudinal aspect to that where they continue to have that risk? Or does it tend to be sort of isolated even though it's appearing at sort of this earlier age?

[00:11:46] Dr. Jennifer Hoffmann: Yeah, I mean, to answer your first question, some of the screening questions that we use have been validated to use as young as six years old. However, at this point, the American Academy of Pediatrics recommends screening every child 12 and up for suicide risk. There has been more and more recent research on rising rates among preteens. So, at Lurie Children's and many other centers, we've started screening everyone who walks in the door at age 10 and up. And younger children, if there is some clinical concern or suspicion. As for the longitudinal aspect, children who have suicidal thoughts and behaviors, often this is a chronic problem as opposed to an acute problem. There are some data that show that children with a past suicide attempt, that's one of the greatest risk factors for a subsequent suicide attempt. On the other hand, there probably is a subset of children that have acute fleeting thoughts related to a crisis in their life that's transient. It could be bullying, it could be a relationship problem, maybe someone broke up with them. Or even something like child abuse occurring in the home. And in those cases there may not be a long-standing mental health condition, but it's really those situational factors that lead to suicidal thoughts or an attempt. 

[00:13:00] Dr. Patrick Seed: There's something I think really interesting going on in our emergency room around this Caring Contacts program and things. Can you tell our listeners what that is and where did it start? And then what do we know about, what it's doing for the families that you're directing this program towards. 

[00:13:16] Dr. Jennifer Hoffmann: Well, this is an intervention that I'm really excited about and the reason is that it works on that sense of connectedness that we know is so protective against youth suicide. This actually originated in the 1970s. There was a psychiatrist, Dr. Jerome Motto, who began to send nice notes in the mail, supportive caring letters to patients after they were discharged from a psychiatric hospitalization. And he happened to do this in a randomized fashion. So for half of his patients randomly selected, he sent them letters in the mail for five years and for the other half they just got usual care, and this was one of the very first interventions that actually showed a decrease in suicides, in a randomized controlled trial. Since then, Caring Contacts have been updated for the modern world into text message format. So instead of postal mail, there have been some trials sending text messages to adult patients after an emergency visit or hospital stay with supportive hopeful messages just saying things like, you matter. We care about you. Not asking for anything in return. I was recently funded by the National Institute of Mental Health to develop and test a version of Caring Contacts for adolescents. So there's very limited research thus far with teens, but we know that teens love to use their phones. They love text messaging, and I think there's a lot of promise based on the data for this intervention that if we could keep them connected via text message after their emergency department visit, this has a lot of potential to prevent suicide attempts. 

[00:14:46] Dr. Patrick Seed: That's a really neat history and it's great that you're bringing this to the youth, to the pediatric population. Are you doing like a single message? 

[00:14:53] Dr. Jennifer Hoffmann: Yeah, so we're starting by interviewing teens to find out their preferences for how often and what types of messages they'd like to receive. But when this has been done in the past, it's typically approximately monthly for a year, sometimes more. 

[00:15:06] Dr. Patrick Seed: Yeah. That's great. I'm excited to see what that looks like. Do you have early data? Have you looked back at the, because you were doing the program right before you were, sort of formally studying it, right. 

[00:15:16] Dr. Jennifer Hoffmann: So I worked with some collaborators at Nebraska Children's Hospital who have implemented Caring Contacts for the past three years. They've been sending postcards out to adolescents there. And we found that it only takes about one hour of personnel time over the course of a year to write these messages. And it costs about $5 to buy a few postcards and stamps. So it's a pretty low-burden intervention that especially if we can convert it to text message, it's very scalable. And I think a future goal could be to try to embed it into crisis call centers, which also have text services so that youth could enroll in it from any emergency room across the country. 

[00:15:52] Dr. Patrick Seed: That's awesome. That'll be great to see how it works. I'm always fascinated by these interventions that are, you know, really pretty and straightforward. Really sometimes the most effective thing, so that's really neat. 

[00:16:04] Dr. Jennifer Hoffmann: It's really just about one person in the world still cares about you and, that can make the difference in preventing suicide.

[00:16:10] Dr. Patrick Seed: I was curious a little bit of without getting deep into the politics of things, you know, obviously we're in a federal administration that's making a lot of changes and one of the things that I kept thinking about your work and others was really around and it might not just apply to the CDC, but I'm going to bring up the Centers for Disease Control, which really has had an expanded mission for a while, right? That they look at the epidemiology of things like suicide, like they do, you know, obesity or asthma or other things sort of, is disease epidemiology in general. And, you know, recently it's been announced by Health and Human Services that they are going to bring the CDC back to what, they would say, has been the core reason the CDC was founded and its mission, which is really to look at preventing and managing infectious disease outbreaks. And I'm curious what role the CDC and other public health agencies have sort of played in partnership with you and your colleagues in terms of suicidality and interventions? As well as epidemiology, right? We have to sort of know where we stand and who might pick up that work if the CDC is not doing it any longer? 

[00:17:10] Dr. Jennifer Hoffmann: Well, what I can tell you is that during the pandemic, the CDC was often the first agency to publish on trends, impactful trends in epidemiology across the country. They were the first to show that during year one of the pandemic there were rising emergency room visits for youth, for suicidal thoughts. And then during year two, they identified a concerning trend among girls that wasn't there among boys. So I think there is really important work to be done around mental health epidemiology, that it's hard to replace that with any individual researcher or institution. Just with the amount of data they have access to the surveillance systems that have been built over many years. And I think it would be a disservice if we weren't able to have access to data on mental health trends moving forward. 

[00:17:57] Dr. Patrick Seed: What's a message for parents and caregivers listening today that you'd want them to remember about children's mental health? 

[00:18:03] Dr. Jennifer Hoffmann: Well, I think it starts with just having open, honest conversations with your teen about their mental health. And if you have any concerns, the first person you can talk to is your pediatrician. More and more these days, pediatricians are well equipped with not only screening, but also brief interventions that can be delivered. There are more offices that have a mental health professional co-located in that general pediatrics office. But as I mentioned earlier, if there's one thing, one action for you to do today to prevent youth suicide, it's to make sure that any medications and firearms in your home are stored, locked, and safely in case your teen has an impulsive thought. And we wouldn't want anything to happen. And also you can educate your teen about 9-8-8, as you mentioned at the beginning of this episode. That's the National Suicide and Crisis Lifeline. It's available via phone call as well as text 24 hours a day, seven days a week, and that's a way for your teen to access immediate care through a mental health professional. 

[00:18:59] Dr. Patrick Seed: Yeah, fantastic advice. And then I think like all of us to find connectedness which will help cross a lot of dimensions of our lives. Thanks Jen for joining today. It's really been outstanding having you share your critical expertise and your research with us and how you're connecting that with both patients and families and as an advocate with legislators. We're really grateful for the compassion and the professionalism that you have for our patients. 

[00:19:22] Dr. Jennifer Hoffmann: Thank you for having me. 

[00:19:23] Dr. Patrick Seed: For more information on Stanley Manne Children's Research Institute at Ann and Robert H. Lurie Children's Hospital of Chicago. Visit our website research.luriechildrens.org.