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Director of Child & Adolescent Services, Ascension Illinois Alexian Brothers Behavioral Health Hospital | Vice President, Behavioral Health, Ascension Illinois

After a presentation on mental health awareness at a local high school in Chicago, a student approached the presenter and informed her that she was feeling suicidal. She even produced a letter she had written for her parents to find after a planned suicide attempt that afternoon. Thankfully, that attempt never occurred because of the mental health programs the school had in place.

In 2021, the Children's Hospital Association, American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry declared a state of emergency in child and adolescent mental health.¹ That same year, U.S. Surgeon General Dr. Vivek H. Murthy said that we are facing an urgent mental health crisis in his Surgeon General's Advisory, highlighting the urgent need to address the nation's youth mental health crisis.² In his advisory, he provided actionable recommendations for families, organizations, governments and others to take to improve the mental health of children, adolescents and young adults.

Most recently, in a June 17, 2024, opinion essay in The New York Times, Murthy re-emphasized that the mental health crisis in young people continues to be an emergency.³ Of particular concern is the rising number of young people who contemplate, attempt or die by suicide. The suicide rate among people aged 10 to 24 increased 62% from 2007 through 2021, according to the Centers for Disease Control and Prevention.⁴

Alarming statistics, published in 2023 by the Children's Hospital Association,⁵ include:

• More than 6,000 10- to 24-year-olds die by suicide each year.
• Close to 2 million adolescents attempt suicide each year.
• Among high schoolers, 20% report thinking seriously about suicide.
• About 30% of girls said they seriously considered attempting suicide, double the rate among boys.
• Suicide is the second leading cause of death for youth and young adults ages 10 to 24 (25% of all pediatric deaths).
• Among LGBTQ+ students, 25% attempted suicide in 2023.
• Suicide is the leading cause of death for Asian American youth.

When broken down further, other recent reports⁶ highlight the following alarming details:

• Between 2018 and 2021, suicide attempts by Black American youth increased by more than 36%.
• Suicide is the third leading cause of death for Latinos aged 10 to 34.

One of the many recommendations from the Surgeon General's 2021 advisory was to "expand and strengthen suicide prevention and mental health crisis services." The advisory specifically cited a need for intensive outpatient programs for children and adolescents.

MORE CONCERNING TRENDS
According to a 2024 World Health Organization and UNICEF report,⁷ adolescents aged 10 to 19 and approximately 1 in 7 children are affected by mental health conditions, with anxiety, depression and behavioral disorders being the most prevalent.

The increased use of social media has resulted in the U.S. Surgeon General issuing a recent advisory about the impact it is having on youth mental health, indicating a growing body of research about the potential harms of social media.⁸ This advisory is due in large part to the exposure to inappropriate, violent and extreme content on social media platforms.

BEING PART OF THE SOLUTION
Providing screenings, early intervention and intensive outpatient services is key to suicide prevention. One effective model has been implemented at Ascension Illinois Alexian Brothers Behavioral Medicine in Hoffman Estates, Illinois, and has been in place for more than 25 years. Level-of-care screenings are conducted 24/7 for children, adolescents and their families who are in crisis to determine how to safely and effectively recommend and provide the services needed.

Based on presenting symptoms and safety risks, recommendations are given for the appropriate level of care and treatment. Inpatient hospitalization is recommended for youth at immediate and imminent risk of harming themselves or others. Partial hospitalization or intensive outpatient services are recommended for youth who can be kept safe at home but need intensive treatment. Outpatient therapy is recommended for youth who need weekly therapy.

Our Partial Hospitalization and Intensive Outpatient programs are day programs that typically operate for six hours, Monday through Friday. Intensive outpatient programs run three hours a day, three to five days per week. Patients are typically in a program for three to six weeks. The day is structured into a combination of groups focused on different areas, including learning skills to manage challenges, develop alternative actions, and increase motivation and cognitive flexibility. We also have psychodynamic or process groups, which occur daily, are unstructured and focus on members discussing interpersonal struggles. To round out our holistic approach, we do spirituality and expressive groups. Expressive groups incorporate art, music, movement and drama.

A multidisciplinary team of psychiatrists, clinicians, registered nurses and nurse practitioners, chaplains, teachers and expressive therapists all work together to provide holistic and comprehensive treatment. In addition to medication management and group therapy, family therapy is provided as an integral part of fostering healthy communication and conflict resolution skills, which are necessary for positive growth and outcomes.

Our treatment model is the Ascension Behavioral Treatment Framework (ATF), which is an adaptation of David Barlow's Unified Protocol⁹ for the treatment of emotional disorders. It brings together decades of clinical experience and research to provide treatment that is effective across numerous mental health disorders and conditions, including depression, bipolar disorder, anxiety, obsessive-compulsive disorder (OCD), eating disorders, nonsuicidal self-injury and suicide. It is effective because it addresses similar underlying problems in patients suffering from emotional disorders who experience strong and intense emotions, which often lead to negative reactions and behaviors.

These emotionally driven behaviors may temporarily alleviate distress in the moment but ultimately are not effective in the long term. The ATF includes modules that help patients identify emotions and negative thought patterns and how to develop skills to manage their challenges, develop alternative actions, increase motivation and foster cognitive flexibility.

While the ATF is the treatment model for all our partial hospitalization or intensive outpatient programs, we have found that treating our youth with specific diagnoses and symptoms in different programs is most effective. We have programs that specialize in eating disorders, OCD/anxiety and school anxiety/school refusal.

Additionally, within our general adolescent program, we have tracks that focus on chemical dependency, gender/sexual identity issues, communication/social skill deficits and generalized anxiety disorders. Our child programs incorporate a strong behavior management component based on a system where points are determined by attendance, respectfulness, following directions and positive participation. We also teach parents/guardians how to use the behavior management system at home. Our belief is that tailoring treatment interventions within our model provides the best outcomes.

BRINGING MENTAL HEALTH SERVICES INTO THE COMMUNITY
In addition, bringing therapeutic interventions into school settings has offered an opportunity for mental health awareness, education and early intervention. Endorsed by leading mental health experts as an effective means to provide treatment to youth,¹⁰ school-based counseling eliminates such barriers as treatment costs and transportation to a mental health center, as well as reduces the stigma of seeking help. Providing less intrusive treatment, such as individual and group counseling at school, results in significant progress, as evidenced by a 41% decrease in hospitalizations of students attending middle and high schools served by our school-based mental health programs.

The program currently serves a total of 12 middle and high schools throughout the northwest suburbs of Chicago. With consent from students' parents, services offered include individual and group counseling, crisis intervention and mental health awareness and education. Counselors placed in the schools provide Signs of Suicide training¹¹ to the entire school, including school personnel, aimed at educating academic staff in identifying students at risk of suicide and offering seamless coordination of care to trained responders. This vital component of the service provides teachers and other school personnel with the skills needed to identify and intervene in crisis situations, as often these are the only adults outside of the home who have frequent contact with the students.

In addition to suicide and crisis intervention, school personnel are offered refresher trainings on spotting the signs of abuse and neglect and understanding their responsibilities as mandated reporters when alarming signals appear.

In response to a survey of all school personnel involved in the program at the end of the 2023-2024 school year, 96% of respondents answered that the school program was "extremely valuable," and 100% responded that they would recommend the program to other schools. One school principal shared this assessment of the program's effectiveness: "Ascension's program has had a profound impact on the mental well-being of our students, decreasing student absenteeism and number of psychiatric hospitalizations, while increasing student connections and support systems at school."

This vital component of the service provides teachers and other school personnel with the skills needed to identify and intervene in crisis situations, as often these are the only adults outside of the home who have frequent contact with the students.

OUTCOMES MATTER
Measuring the effectiveness of our programs and interventions is an integral part of continuing to shape and grow our services. We use standardized and evidence-based measures, which we administer weekly at admission, to guide treatment planning, and again at patients' discharge. All our measures are self-reported.

While programs that serve children and adolescents have additional measures, the following four measures are standard across all our programs. We use the Brief Adjustment Scale-6 (BASE-6) to measure psychological adjustment; the General Anxiety Disorder-7 (GAD-7) to measure the presence and severity of anxiety; the Patient Health Questionnaire-9A (PHQ-9A) to measure the presence and severity of depression; and the World Health Organization Well-Being Index (WHO-5) to measure current well-being.

Recent data demonstrates the following improvements:

• An increase of 39% in mental well-being and a 33% decrease in depression reported in youth participating in our School Anxiety/School Refusal program for the 2023-24 school year.
• An increase of 31% in mental well-being and a 56% decrease in depression reported in youth enrolled in our Crystal Lake Child & Adolescent programs.

Clearly, there is a mental health crisis occurring among our youth. The prevalence of mental health issues is increasing. Suicidal ideation, suicide attempts and suicide are on the rise. Emergency room visits for mental health issues are also skyrocketing. Thankfully, there are effective solutions. An investment in continuing and widening treatment and services is warranted. We need to ensure that the attempt never occurs.

Regarding the student mentioned at the beginning of this article, after receiving immediate crisis intervention, she continued with therapy services and successfully worked through her situation. The attempt never occurred; however, what did occur was the opportunity to save a life due to having the right resources available at exactly the right time and place.

CECELIA HORAN is director of Child & Adolescent Services at Ascension Illinois Alexian Brothers Behavioral Health Hospital in Hoffman Estates and Crystal Lake, Illinois. RICK GERMANN is vice president of Behavioral Health at Ascension Illinois.

NOTES

1. "Children's Hospitals Declare National Emergency in Children's Mental Health," Children's Hospital Association, October 19, 2021, https://www.childrenshospitals.org/news/newsroom/2021/11/childrens-hospitals-declare-national-emergency-in-childrens-mental-health.
2. "Protecting Youth Mental Health: The U.S. Surgeon General's Advisory," U.S. Department of Health and Human Services, 2021, https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf.
3. Dr. Vivek H. Murthy, "Surgeon General: Why I'm Calling for a Warning Label on Social Media Platforms," The New York Times, June 17, 2024, https://www.nytimes.com/2024/06/17/opinion/social-media-health-warning.html.
4. Sally C. Curtin and Matthew F. Garnett, "Suicide and Homicide Death Rates Among Youth and Young Adults Aged 10–24: United States, 2001–2021," NCHS Data Brief, no. 471 (June 2023): https://dx.doi.org/10.15620/cdc:128423.
5. "Addressing Pediatric Suicide," Children's Hospital Association, September 26, 2023, https://www.childrenshospitals.org/content/behavioral-health/summary/the-state-of-pediatric-suicide.
6. Stephanie Pappas, "More than 20% of Teens Have Seriously Considered Suicide. Psychologists and Communities Can Help Tackle the Problem," American Psychological Association, July 1, 2023, https://www.apa.org/monitor/2023/07/psychologists-preventing-teen-suicide; Caroline Silva and Kimberly A. Van Orden, "Suicide Among Hispanics in the United States," Current Opinion in Psychology 22 (August 2018): https://doi.org/10.1016/j.copsyc.2017.07.013.
7. "WHO and UNICEF Release Guidance to Improve Access to Mental Health Care for Children and Young People," World Health Organization, October 9, 2024, https://www.who.int/news/item/09-10-2024-who-and-unicef-launch-guidance-to-improve-access-to-mental-health-care-for-children-and-young-people.
8. "Social Media and Youth Mental Health: The U.S. Surgeon General's Advisory," U.S. Department of Health and Human Services, 2023, https://www.hhs.gov/sites/default/files/sg-youth-mental-health-social-media-advisory.pdf.
9. David Barlow et al., Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide (Oxford University Press, 2017).
10. Amanda Sanchez et al., "The Effectiveness of School-Based Mental Health Services for Elementary-Aged Children: A Meta-Analysis," Journal of the American Academy of Child & Adolescent Psychiatry 57, no. 3 (March 2018): https://doi.org/10.1016/j.jaac.2017.11.022.
11. "Some Secrets Should be Shared: Engaging the Entire School Community in Implementing Evidence-Based Suicide Prevention Programming," National Center for School Mental Health, https://www.schoolmentalhealth.org/media/som/microsites/ncsmh/documents/archives/PS-2.2--Shine--Some-Secrets-Should-be-Shared.pdf.