The State Of Our Children 360: September 2024

In this month's edition, get an in-depth look and perspectives from subject matter experts about the prevalence of suicide in our region and how we can work together to have a positive impact on kids' mental health in our communities.
 

Articles in this issue:

• Talking Openly about Suicide

• Healthcare Disparities in Minority Communities: Mental Health Vulnerabilities and How to Help

• Zero Suicide Initiative: National Collaborative to Help the Kids in Our Valley

• Additional Suicide Prevention Resources

Talking Openly about Suicide

From 2013-2022, Fresno County’s annual suicide rate was approximately 10 out of every 100,000 residents. Of those 1,007 residents who died by suicide, 61 were between the ages of 10 and 19. However, this number only scratches the surface, as many suicides go unreported, amplifying the true toll of this tragic issue. Suicide behaviors such as self-harm are even more prevalent. This stark reality underscores the urgent need for awareness, understanding and action for suicide prevention.

Although rates of suicide differ across groups (gender, race, age, etc.), anyone can be at risk. Despite its pervasive nature, discussing suicide remains a challenge for many, especially when working with children. Yet, conversations are crucial in dispelling myths and offering support to those in need. This is where our own Fresno County Suicide Collaborative unites a cross section of groups in order to reduce suicides in our community. The collaborative was started nine years ago in response to a cluster of youth suicides in the Fresno area.

While the Collaborative unites government agencies, community-based organizations, non-profits, and community members, many readers might wonder, "How can I help?" The good news is that anyone can make a difference. You don’t need to be a mental health professional to provide critical support. Initiating a conversation about suicide, when done with clarity and empathy, can be a lifeline.

Key Steps in Suicide Prevention

1. Initiate Clear Conversations: Start by speaking directly about suicide. Avoid euphemisms or ambiguous language that might obscure the issue. Ask about suicide in a way that encourages an honest answer, such as, "Are you thinking about suicide?" With younger children, language such as “end your life” might be more accessible.
2. Listen Empathetically: When someone shares their thoughts of suicide, listen without judgment. Empathy can be a powerful tool in helping them feel heard and understood. Often times, with children and teens, this empathetic listening might occur over text or online chat.  
3. Keep the Dialogue Open: Encourage them to talk about their thoughts and feelings. This can sometimes bring up goals, aspirations and loved ones. This can refocus their thoughts on reasons to live, rather than immediate distress.
4. Establish Safety: If someone is in immediate danger, stay focused on keeping them “safe for now.” This could involve removing access to means of self-harm and staying connected with supportive individuals.
5. Know Your Limits: Understand that while your support is invaluable, professional help may be necessary. Immediately connect them to mental health professionals or crisis intervention services (see below). As educators, we rely on our committed network of local supports to take over the prevention effort when we’ve reached our professional limit with children in crisis, as do the parents of our students.

Accessing Support and Resources

Fortunately, there are numerous resources available for individuals experiencing suicidal thoughts and those who want to support them. Suicide prevention trainings, such as those offered through LivingWorks.net, are accessible to a wide range of individuals, including mental health professionals, educators, military personnel, first responders and concerned civilians. These trainings equip participants with the skills to recognize warning signs and effectively intervene.

In crisis situations, immediate intervention is crucial. Services like the Fresno Mobile Crisis Response 559-600-6000 or calling 911 and asking for a Crisis Intervention Team (CIT), which is comprised of law enforcement and mental health professionals, can provide immediate in-person assistance. The national suicide and crisis line – 988 – is also available 24 hours a day by online chat, call or text to support those in suicidal crisis or emotional distress.

Dispelling Misconceptions

It’s essential to dispel common misconceptions about suicide. One prevalent myth is that talking about suicide will plant the idea in someone’s mind. However, the opposite has been found to be true: open conversations can reduce stigma and encourage children and adults to seek help.

A Call to Action

As members of our community, we have a collective responsibility to address suicide prevention and support mental health. By educating ourselves, initiating conversations and advocating for accessible mental health resources for our youth, we can create a more supportive environment for those in crisis.

Together, Fresno can continue to foster straight forward conversations around suicide and foster a culture of empathy and understanding. When we do this, we can save lives and provide hope to those who need it most.

Your awareness and actions matter more than you know.

Alex Merrell E.d.S., NCSP and Hillary Reid E.d.S.

Fresno County Superintendent of Schools

Healthcare Disparities in Minority Communities: Mental Health Vulnerabilities and How to Help

Marginalized populations, including children from racial and ethnic minorities, face disproportionate impacts from healthcare disparities that exacerbate their vulnerability to mental health conditions. These disparities, including inadequate access to care, can lead to delayed or missed diagnoses and less effective interventions. In particular, mental health conditions in children may present in less recognized forms that can often be overlooked or misattributed to physical ailments, which amplifies the importance of each and every encounter with our youth.

In the Research

In 2003, the Institute of Medicine (IOM), now the National Academies of Medicine, published the groundbreaking report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health^[i]. This report brought to light the fact that health disparities are strongly tied to social and political contexts, as well as biases and inequities – and, that marginalized populations were disproportionately impacted. In essence, the report laid out that we could no longer ignore the factors traditionally felt to be outside the scope of medicine as drivers of health outcomes.

According to earlier reports^[ii],[iii] when it came to mental health, persons from racial and ethnic minorities were less likely to seek and receive care due to having less access to mental health services than their White counterparts. And when they did, they were less likely to receive the same quality of care.

The IOM report did not simply document the evidence behind the disparities in treatment. The report laid out a comprehensive, multi-level blueprint for addressing disparities at the patient care and systems levels, as well as regulatory and policy interventions.
 

Individuals from racially and ethnically minoritized populations are less likely to have a documented mental health condition.

Fast forward 21 years – a study just published in JAMA in June 2024^[iv] looked at 40,618 youth deaths by suicide (ages 10-24 years) over an 11-year period (2010 to 2021) and found that nearly 60% had no previously documented mental health condition. Nearly 47% of those youth died by firearm. Additionally, the study found that individuals from racially and ethnically minoritized populations, as well as those who died by firearm, were significantly less likely to have a documented mental health condition.  

What are the implications for us?

It is well recognized that many individuals have contact with the healthcare system within months, weeks and even days before a death by suicide. This is true for pediatric patients, as well. According to the American Academy of Pediatrics^[v],

• 80% of adolescents had contact with a healthcare provider within 1 year of their death
• 49% of youth visited an emergency department within 1 year of their death
• 38% of adolescents had contact with a healthcare system within 4 weeks of their death, and
• 34% of individuals 15 years and older had contact with a healthcare provider within 1 week of their death

Responding to Kids Who Present with Somatic Symptoms

Somatic symptoms are physical symptoms, such as headache, fatigue, or abdominal pain, one can experiences as a result of a mental health condition such as depression or anxiety. This is common among most youth and adolescents, as physical symptoms are much easier to talk about. Kids are less likely to mention they are struggling with their mental health or have suicidal thoughts unless they are directly asked. As a result, it is important to consider the following when our youth present with somatic symptoms:

• Have a low index of suspicion for an underlying mental health condition when youth have somatic complaints, particularly when working with racial and ethnic minority children, as they are less likely to have a documented diagnosis.
• Address and document any suspicions you may have about their mental health and ask directly if they have experienced suicidal thoughts.
• Talk through their feelings and help to identify any triggers or stressful situations that induce enhance their emotions.
• Discuss stress management and coping techniques and resources available.
• Create a follow-up plan to avoid any delays and to ensure necessary support and treatment.

About the Author

Dr. Carmela Sosa-Unguez is a Valley Children's complex primary care physician, Valley Children’s Pediatric Residency Program Associate Program Director, Clinical Assistant Professor Affiliated with Stanford University School of Medicine and Guilds Center for Community Health Director.

Zero Suicide Initiative: National Collaborative to Help the Kids in Our Valley

In September 2022, Valley Children’s Healthcare was one of 16 children’s hospitals from across the country selected to participate in the Cardinal Health Foundation’s Zero Suicide Institute, a partnership with the Children’s Hospital Association.

In 2010, work of the National Action Alliance for Suicide Prevention led to the conclusion that healthcare, in particular, was a critical sector in which to address the issues of suicide prevention. As we know better than most from our strong community collaboratives, suicide prevention is not the purview of only healthcare, schools or clinicians – but rather it takes all of us, working together, to ensure that we don’t lose a single child or adult to suicide.

Valley Children’s Healthcare has done a significant amount of work over the last few years around suicide screening, prevention and care in our hospital and across our network. From consistent suicide screenings to staff education and support, we have been diligently working to help our patients struggling with their mental health.

The Zero Suicide Institute opportunity has given us added support and encouragement in this area, including refinement of our data collection, embedding suicide safety plans into our electronic health records, and establishing a “caring contacts” initiative to reach out to kids and their families after an emergency department or inpatient stay where a child’s suicide risk was assessed to be moderate to high.

The grant officially concludes at the end of this year but Valley Children’s is firmly committed to continuing this most important work. We are profoundly grateful for all of our community partners who walk alongside with us in this work.

The goal of zero deaths by suicide is an aspirational goal for sure. And it is the only goal that makes sense.

About the Author

Lynne Ashbeck is Valley Children’s Senior Vice President and Chief Community Impact Officer. 

Additional Suicide Prevention Resources

References

^[i] Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, editors. Washington (DC): National Academies Press (US); 2003. PMID: 25032386.

^[ii] U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999.

^[iii] U.S. Department of Health and Human Services. Mental Health: Culture, Race, and Ethinicity-A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; 2001. 

^[iv] Chaudhary S, Hoffmann JA, Pulcini CD, et al. Youth Suicide and Preceding Mental Health Diagnosis. JAMA Netw Open. 2024;7(7):e2423996. doi:10.1001/jamanetworkopen.2024.23996

^[v] Strategies for Clinical Settings for Youth Suicide Prevention, American Academy of Pediatrics. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/strategies-for-clinical-settings-for-youth-suicide-prevention/ Accessed August 13, 2024.