In 2015, Parkland Hospital in Dallas became the first major hospital system in the country to screen each and every one of its patients for suicide risk — at each and every visit. In March, the hospital extended those screenings to children as young as 10.
‘I didn’t understand why I was doing it’
Michelle Lemming was only 7 years old when it dawned on her: Something wasn’t right with her mother.
“She clearly was not OK, and I definitely knew that,” she said.
Lemming said her mother was struggling with depression, and over time, became the only person who could take care of her. They were living in small-town East Texas, cut off from a familial or social support system. Lemming said the isolation and the growing weight of her mother’s illness started to take a toll on her.
“I started looking for things to hurt myself, and I would hurt myself with a hammer. Then I ended up busting up a razor and using razor blades,” she said. “I would use a stool and would hurt myself jumping off a stool, trying to break bones and doing things like that. But I didn’t understand why I was doing it. It was very confusing to me.”
She was only 10 years old at the time, and by middle school, she’d picked up a handgun. This all happened many years ago. Lemming is 42 now, with her own children, and is the CEO of the Texoma Health Foundation in Denison. She hasn’t had thoughts about hurting herself since she was a little girl, but her story is not uncommon today.
Suicide rates among kids and teens on the rise
In addition to fundamental childhood stressors like abuse, neglect and poverty, kids today have more access to media coverage of high-profile suicides, more negative influences on the internet and social media, and more conduits for bullying.
“There’s quite a bit of data coming from the Centers for Disease Control showing for the first time in 2014 that [for] kids between the ages of 10 and 14, suicide as a cause of death exceeded that of homicide and motor vehicle collisions,” said Dr. Kim Roaten, a psychologist at Parkland Hospital. “So we know these rates are increasing pretty dramatically for our youngest kids — and particularly for our girls.”
The CDC reports from 2012-2016, about 11,500 children ages 10-19 died by suicide nationally. In Dallas County, over that same time period, there was about an 80 percent increase in suicides for children ages 14-17, according to the Injury Prevention Center of Greater Dallas, with the bulk of the surge happening in the last year. And the American Academy of Pediatrics classifies suicide as the second-leading cause of death for teens.
Roaten said numbers like that prompted Parkland to begin screening patients as young as 10 for suicide risk at every visit – whether it be in the emergency department, at urgent care or at outpatient primary care clinics.
“The factors change. [Suicide risk] is a very fluid situation, so we screen at every provider visit, and we did that very intentionally,” Roaten said. “We felt that if we set a time for it like every year, we would miss things. We would miss big shifts.”
The goal is to intervene wherever and whenever they can, which is especially critical for kids who may be confused and scared to seek help. One in five kids experiences a mental health condition; yet, 80 percent of them don't get the services they need.
That was the case for Michelle Lemming.
“There’s no way I would’ve shared that as a child,” Lemming said. “There’s no way I would’ve gone and talked to a teacher. I didn’t want to tell my parents, right? So how do we fix that?”
Asking the right questions
At Parkland, nurses begin with a simple questionnaire, like the asQ screening developed by the NIMH. The questions are blunt and to-the-point: Have you wished you were dead? Have you been having thoughts about killing yourself? Have you ever tried to kill yourself? Dr. Roaten said since March, Parkland nurses have asked nearly 500 kids ages 10 to 12 these questions.
“Essentially, the message we’re trying to convey is: ‘Thank you for sharing with us how you’re feeling and that you’re struggling,’” Roaten said. “We certainly don’t want the screening process to feel punitive. We really encourage our nurses to focus on expressing gratitude to the patient for sharing distress and then talking to them about the next of treatment and giving them hope by saying, ‘Look, we can get you connected to someone who can actually help you feel better.’”
So far, Roaten said the screenings have identified some young patients at moderate risk for suicide – patients who wouldn’t have known if not asked pointedly. And for kids with no risk? The screening is an opportunity for conversations and education about suicide and mental health with their parents.
Suicide prevention requires more research, some say
The call for more initiatives like this is spreading. The Joint Commission, a medical industry authority that inspects and accredits hospitals, has touted Parkland’s universal suicide screenings as a model for other hospitals.
But some medical experts say there’s not a lot of research out there on whether these screenings are effective at preventing suicide or not. Sue Curry is chair of the U.S. Preventive Services Task Force, an independent panel of medical experts focused on evidence-based disease prevention. She said the task force has found insufficient evidence to determine the “balance of benefits and harms of screening for suicide risk in adolescents, adults and older adults in primary care.”
“These kinds of initiatives need to be subjected to rigorous evaluations in order to make conclusions for the general population,” Curry said. “That is not intended as a criticism of the effort that’s ongoing, but from the perspective of the task force, we can only look at available evidence. So we need these kinds of studies prioritized and conducted in order to move the field forward.”
While the task force hasn’t yet recommended universal suicide screenings across all health care settings, it does recommend routine screenings for depression and asking about suicidal thoughts for people with a history of depression or mental illness.
For what it’s worth, Michelle Lemming believes her childhood could’ve been different had suicide been brought up at a doctor’s appointment. And she hopes her children are being asked the questions she didn't get as young girl.
“The way that my life was going, I would’ve never connected to any kind of professional help because there would’ve never been any kind of communication that there was a problem,” Lemming said. “And maybe if someone would’ve asked me, there’s no doubt that would’ve helped me at that age because you would’ve asked questions that would’ve raised flags for me.”
She may have identified what she was feeling and gotten help earlier. Most importantly, to her at least, she would’ve known she wasn’t alone.