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The people who attend the Tattered Teddies workshop in Calgary to learn how to talk to kids about suicide usually already have one in mind, someone who has them worried.

The workshop teaches them to watch for unusual behaviour in children younger than 12, collect a fuller picture from teachers, coaches and family and not be afraid to ask “The Question”: Are things so bad that you are thinking of killing yourself?

“It’s a hard place to go – to ask that little seven-year-old in pigtails,” says Kevin Hodgson, a social worker who co-developed and now conducts the half-day workshop.

But new research suggests that, for a growing number of elementary school-age children, suicide is a subject that adults must be prepared to raise.

The study, published in JAMA Pediatrics by three Montreal physicians, analyzed 30,000 emergency room visits by American children between the ages of five and 18. According to the findings, visits related to suicide attempts doubled between 2007 and 2015 – and 43 per cent involved children younger than 12.

Although the study was based on U.S. data, the lead author says the trend is similar in Canada.

Brett Burstein, an emergency room physician at Montreal’s Children Hospital, says that in the past three years alone the hospital has seen a 55-per-cent increase in visits related to suicide.

While one theory is that a greater awareness of mental-health issues has increased the number of parents bringing teens and children in for help, Dr. Burstein points out that more than 87 per cent of the cases assessed in the paper went beyond thoughts of suicide to an actual suicide attempt.

That’s especially worrisome, he says, because attempting suicide is the strongest predictor that a child may eventually die by suicide.

“Emergency departments are not equipped with the resources to deal with this problem,” he said, citing a lack of access to specialist care and the need for more training for doctors.

The study adds to research showing increasing reports of mental-health issues among children and youth. Previous research also found that emergency departments are likely to be a first point of contact for young people dealing with psychiatric issues – a pattern that, 2018 Ontario research suggests, is even more common for immigrant youth. Yet many young patients leave the hospital without seeing or being referred to a mental-health specialist.

A study published in January in Pediatrics using the same U.S. data found that only 13 per cent of young people who went to an emergency department with a psychiatric problem were seen by a mental-health specialist – despite visits that lasted, on average, more than three hours. A 2017 Ontario study found that the majority of patients over 16 who were treated in emergency after a suicide attempt were not seen by a psychiatrist within six months.

Suicidal behaviour among young children is rare – in the new U.S. study, suicide-related issues accounted for just 3.5 per cent of all emergency department visits. While research is limited, studies suggest that, compared with teenagers, who are affected more by romantic and peer relationships, family conflict is a major factor for young children, who are more likely to be diagnosed with attention-deficit disorder than depression.

A Norwegian study of suicide victims under the age of 15 found that younger children were half as likely as teenagers to express their suicidal thoughts, either verbally or in writing. But there are warning signs, such as missing school and withdrawing from friends and activities. In the cases he has seen in his emergency department, Dr. Burstein says young patients have often said something to their parents or texted a peer, or an observer has caught a worrisome post on social media.

For this reason, Mr. Hodgson says, he tells the workshop participants to trust their instincts – in his experience, worried adults have rarely been wrong. “If we wait for them to talk to us,” he said, “we could be rolling the dice with their safety.”

Think of the nine-year-old staying silent with thoughts of suicide, he said. By the time they turn 16, “they have been thinking about it for half their lives. That is a heavy weight to carry.”