Suicidal thoughts are increasing in young kids, experts say. It began before the pandemic.

The youngsters come in with tears in their eyes, or their fists clenched in anger. Sometimes, they show no emotion at all.

“I want to kill myself,” the kids, some as young as 8, announce inside elementary school counselor Olivia Carter’s office, where affirmations such as “Think good thoughts” and “Our school is not complete without you!” adorn the walls.

When Carter started working at Jefferson Elementary in Cape Girardeau, Missouri, in 2016, there was a school suicide protocol in place to ensure that students who expressed a desire to hurt themselves got the help they needed. Her first year, she only had to use it once or twice.

Now, she says, about one student a month at her pre-K through fifth grade school tells her that they want to die.

“Some of them will ask, ‘What does it mean to die? What happens when you die?’” Carter said. “Those existential conversations are very difficult at this level. But I would say a good number of kids understand what it means to end their life by suicide.”

For more on this story, watch NBC’s “Nightly News with Lester Holt” tonight at 6:30 p.m. ET/5:30 p.m. CT.

While suicidal thoughts and self-harm have been well documented in teenagers, mental health experts say too little attention has been paid to young children, despite growing evidence that more elementary and middle school students are in crisis.

“No matter how young they are, we take it very seriously” when students express the desire to kill themselves, said elementary school counselor Olivia Carter.Courtesy of Olivia Carter

There is limited data about these younger age groups. The Centers for Disease Control and Prevention does not include elementary or middle school students in its biannual youth survey of risky behaviors. And suicides among children 10 and younger remain rare, with 29 reported in 2019, according to the CDC.

But in interviews, more than a dozen mental health professionals, including school counselors, social workers, psychiatrists and suicidologists, said they are seeing more children as young as kindergarten who are in dire need of support.

The number of children ages 6-12 who visited children’s hospitals for suicidal thoughts or self-harm has more than doubled since 2016, according to data from 46 such facilities across the country collected for NBC News by the Children’s Hospital Association, a trade organization.

The association documented 5,485 emergency room or inpatient visits for suicidal thoughts and self-harm among 6- to-12-year-olds at these hospitals in 2019, up from 2,555 in 2016. (Full data isn’t yet available for 2020, but in the first three quarters of the year, there were 3,503 such visits.) Visits for teenagers with suicidal thoughts or self-harm at these hospitals also rose from 2016 to 2019, but at a slower rate — by 44 percent, compared to 115 percent for younger children.

The rise in troubled young children is evident around the country.

At the Children’s Center, a youth mental health clinic for children 8 and younger in Salt Lake City, the “phones have not stopped ringing” with families seeking care, CEO Rebecca Dutson said.

At the Riverbend Center for Mental Health, which works with several school districts in northwest Alabama, staff members documented a 55 percent increase from 2018 to 2019 in safety plans for children ages 6-13 who were at risk of hurting themselves.

And at the Children’s Minnesota hospital system, even as the volume of patients declined during the coronavirus pandemic, the number seeking care for mental health stayed consistent.

“I see kids where multigenerational drug abuse, mental health issues and poverty have all worked together to create several generations of really, really unwell people,” said Lori Chaffin-Britt, intensive treatment programs director at The Child Center, a mental health agency in western Oregon where staff members have noticed more behavioral problems in children as young as 5. “I see more kids looking sicker, earlier.”

Now, mental health experts fear that the pandemic — which has increased anxiety and depression among adults and teenagers, and resulted in an estimated 37,300 children losing a parent to Covid-19 — could compound the issues young children face.

“It’s probably going to be worse for those that were already struggling or were already disadvantaged by society,” said Jonathan Singer, president of the American Association of Suicidology and an associate professor of social work at Loyola University Chicago. “Little kids have essentially lost a year of socialization.”

I see more kids looking sicker, earlier.

Lori Chaffin-Britt, intensive treatment programs director at The Child Center in western Oregon

The past year has brought more public awareness to youth mental health, with advocates calling for more research into the problem’s scope and causes. They also want to see more investment in potential solutions, including increased access to school counselors amid a national shortage.

Yet, among the challenges: It is not always clear what the best treatment is for very young patients.

“There are problems with admitting them into the hospital, because they have anxiety from being away from their parents,” said Dr. Meghan Schott, medical director of psychiatric emergency services at Children’s National Hospital in Washington, D.C., where about 30 to 40 percent of psychiatric emergency room visits are elementary and middle school children. “There’s not a lot of services geared toward younger kids.”

Why are more children in crisis?

The reason more young children are seeking help is not entirely understood. Research into what leads a child to contemplate suicide at this age is limited, but experts see multiple factors at play.

Counselors point to online bullying and an increased use of social media starting at a young age. More children are getting their first cellphone in elementary school, and then stay up late checking it, counselors said.

For children of immigrant families, one clinician noted the toll of changes to immigration policy in recent years; a 2018 study based on interviews with more than 200 Latino parents found both adults and children in their families had higher levels of anxiety due to fears of deportation and anti-immigrant rhetoric. Poverty has an impact too, experts said, as the percentage of children eligible for free or reduced-price lunch jumped to 52 percent from 38 percent over the past two decades.

“If housing is unstable, if there is food instability, that all contributes to anxiety and stress, even for students as young as I have,” said Carter, the Missouri school counselor. Nearly all the students at her school meet federal qualifications for free or reduced lunch.

One study last year analyzing more than 11,000 9- and 10-year-olds in the United States found that 1.3 percent reported they had tried to kill themselves, while 9.1 percent reported engaging in self-harm. It also concluded that family conflict and financial adversity were significantly associated with suicidal thoughts in these children.

We need to try to figure out why they’re making these attempts at such a young age.

Diana Whalen, psychiatry professor at Washington University School of Medicine

But Diana Whalen, one of the study’s authors, said more research is needed.

“We need to try to figure out why they’re making these attempts at such a young age,” said Whalen, a psychiatry professor at the Washington University School of Medicine in St. Louis. “We need to open our eyes to the fact that this is going on.”

Financial factors may be especially prevalent among children of color, who are far more likely to live in poverty than their white classmates. A 2016 study found that children ages 5 to 11 who die by suicide were more likely to be Black and male, compared to children ages 12 through 14 who killed themselves.

Yet, research has shown Black, Latino and Native American children are less likely than white children to have access to mental health care services — often due to lack of insurance or unavailability of mental health clinics in their neighborhoods. A study published this week found that Latino children are nearly three times as likely as white children to face delays in being seen in the emergency room for a mental health concern.

“The Latino and African American communities are willing to embrace services that are culturally sensitive, and available, and meet the parents where they’re at,” said Bridgette Mitchell Sanders, a registered play therapist of nearly 25 years in Los Angeles. “Sometimes services aren’t that. They require the parents to do activities beyond their work day, and sometimes parents have multiple jobs or transportation issues.”

In a best-case scenario, the experts said, more children are getting help for mental health issues because there is more awareness and less stigma attached to seeking care at this age.

Whalen said many of her teenage clients say they have had suicidal thoughts since elementary school — but were not taken seriously by their parents when they expressed them.

“It’s kind of brushed off or ignored, but they are having these intense emotions and they need to be helped much sooner,” she said.

Recognizing signs of distress

Depression and self-harm do not necessarily look the same in young children as they do in teens and adults.

A child might suddenly show less interest in playing outside or struggle with schoolwork or display new behavioral problems, said Renée Turner, a licensed professional counselor and registered play therapist who practices in San Antonio. Rather than stating outright that they are contemplating suicide, the children she treats may say things like, “What would the world look like without me?” or “It was a mistake to have me.”

Sanders said many times, expressing a desire to die is “really a way for children to express the amount of pain they are in.”

“In their minds, they want to cease to exist because it means being away from the pain,” she said.

While adolescents might engage in high-risk behaviors as a form of self-harm, Wesley Puckett, a licensed social worker for Lauderdale County Schools in Alabama, has worked with elementary school children who hurt themselves by aggressively rubbing an eraser into their arm, or by banging against a wall.

Self-harm and later suicide attempts have some overlap, but these behaviors are not necessarily an indication that someone is suicidal; experts say they’re often an attempt at self-soothing.

The reasons children give for self-harming range from being grounded for failing a class to grieving the loss of a parent, Puckett said.

In his district, social workers often find out a child is having a mental health crisis through software that detects when a student searches for something that causes concern on a school-issued device. Counselors may then call their caregivers.

“With a lot of parents, they’re just blown away that they’re getting this call from a school,” Puckett said. “They’ll say, ‘I never would’ve known my kid is thinking about this stuff.’”

This is consistent with research. Last year’s study on 9- and 10-year-olds found parents and caregivers were unaware their children had tried to kill themselves in 88 percent of the cases, and half didn’t know their children had thought about suicide.

Brandy Bielicki at the park where she used to take her daughter, Kodie.NBC News

Last summer, Brandy Bielicki experienced how rapidly a mental health crisis can overtake a child when her 10-year-old daughter, Kodie Dutcher, died by suicide in Baraboo, Wisconsin.

Kodie was an easygoing girl, who liked to keep her hair in a ponytail. She never argued if her mother said she couldn’t afford to buy something at a store, Bielicki said, and she loved to FaceTime with relatives.

On the evening of July 6, Kodie wrote a short note and left the house without shoes. Authorities found her body nearby the next day; police said her death was a suicide.

Kodie Dutcher.Courtesy of Brandy Bielicki

Bielicki, 31, said she was very close with her daughter and didn’t see any signs Kodie felt suicidal. There were no clues in the girl’s diary or text messages, she said, and teachers at school told her they hadn’t noticed anything unusual.

A registered nurse, Bielicki had been trained to spot signs of suicidal thoughts, but the guidance wasn’t specific to young children. She said everything had seemed so normal; she and Kodie were about to leave for vacation, and her daughter had just lost a tooth.

She believes her daughter had acted on an impulse and may not have known the consequences of her actions or that help was available.

“My 10-year-old probably didn’t know there was a suicide hotline number,” she said.

Asking the question

A silver lining of the pandemic, experts say, might be the increase in attention on youth mental health it prompted. Teens have pushed districts to create more mental health support in their high schools. Several states are debating giving students mental health days off from school.

Utah went a step further, passing a law this year to require elementary schools to offer suicide prevention programs. At hearings for the bill, advocates said this would help give elementary students the language to ask for help, pointing out that sometimes young children will say “I have a tummy ache” when it’s actually the physical manifestation of stress.

For more of NBC News’ in-depth reporting, download the NBC News app

National efforts to help young children include Lifelines, a crisis intervention training for K-12 students and faculty. Three years ago, Lifelines created a program designed for fifth and sixth graders in response to growing demand from school districts.

“We heard it all over — it wasn’t just in one state, it was multiple states,” said Maureen Underwood, a social worker and psychotherapist who co-developed Lifelines. “We often had elementary school teachers come to our trainings for middle school staff.”

Lifelines’ programming for younger children is designed to teach problem-solving skills for stressful situations, types of secrets kids shouldn’t keep and how to ask for help from a trusted adult. The staff training aims to dispel myths about suicide, including the fear that raising the topic with children is risky. Research has shown that asking someone whether they have contemplated suicide does not increase the chance that they will act on those thoughts. This holds true for children, too.

“For those who have recently had thoughts of suicide, asking the question seems to reduce distress,” said Singer, the American Association of Suicidology president.

I don’t think students have nearly enough access to school counselors who can teach those baseline skills of coping and being able to express yourself.

Olivia Carter, elementary school counselor in Cape Girardeau, Missouri

Singer wants the CDC to ask younger children about suicide and self-harm in its Youth Risk Behavior Survey, which currently only polls high schoolers about suicidal thoughts, though some states include middle schoolers as well. He also believes schools could play a role in screening children’s mental health, and pediatricians’ offices could offer more information on warning signs.

Carter, the Missouri elementary school counselor, teaches her students coping skills, such as taking deep breaths while counting or stepping away from a stressful situation for a drink of water. She hopes children will come to her, or to another adult, before they consider suicide.

But with so many students, it can feel overwhelming. She is the only school counselor for her 380 elementary students, which, as is the case in many schools across the country, is above the recommended ratio of 250:1.

“I don’t think students have nearly enough access to school counselors who can teach those baseline skills of coping and being able to express yourself,” she said. “The scope of what we’re working on is huge.”

If you or someone you know is at risk of suicide, please call the National Suicide Prevention Lifeline at 800-273-8255, text TALK to 741741 or visit SpeakingOfSuicide.com/resources for additional resources.