For ways to help kids at risk, read Part 2 of this story.

If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (en español: 1-888-628-9454; deaf and hard of hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.

Anthony Orr was almost done with his high school coursework when the governor of Nevada ordered a statewide shutdown of nonessential businesses on March 17, 2020.

"He was looking forward to all of the senior activities, prom and graduation," says his mother, Pamela Orr. But all he got was a "mini [graduation] ceremony," with only a handful of students walking, wearing masks and at a distance from each other.

"That was the most we could do because of COVID," she says.

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Anthony graduated with honors as he had planned to, wearing a white robe and cap and an advanced honors sash, says Pamela. But he decided against going to college.

"Right now ... it's all online, and you just lose the whole college experience," she says.

Instead, he got a job working in construction. His parents thought he was doing fine. "He seemed happy to us," says Pamela. "He seemed happy."

But in August of last year, Anthony died by suicide.

While Pamela and her husband, Marc, struggle to come to terms with their loss, his school district in Las Vegas is trying to come to grips with the troubling statistic his death is part of.

He was one of 19 students who has died by suicide in the district since the shutdown last March. Thirteen of those deaths occurred since July.

"There's a sense of urgency," says Jesus Jara, the superintendent of the Clark County School District. "You know, we have a problem."

Suicide is complex, involving layers of risk factors, including biological and environmental ones. And it's hard to know the exact factors involved in the deaths of these 19 students.

But the sudden rise in deaths has school district officials worried that the coronavirus pandemic may have played a role. And educators and mental health care providers in other parts of the United States have the same concern.

In recent months, many suicidal children have been showing up in hospital emergency departments, and more kids are needing in-patient care after serious suicide attempts.

"Across the country, we're hearing that there are increased numbers of serious suicidal attempts and suicidal deaths," says Dr. Susan Duffy, a professor of pediatrics and emergency medicine at Brown University.

According to the Centers for Disease Control and Prevention, between April and October 2020, hospital emergency departments saw a rise in the share of total visits that were from kids for mental health needs.

Now, there are no nationwide numbers on suicide deaths in 2020 yet, and researchers have yet to clearly link recent suicides to the pandemic. Yet on the ground, there's growing concern.

NPR spoke with providers at hospitals in seven states across the country, and all of them reported a similar trend: More suicidal children are coming to their hospitals — in worse mental states.

"The kids that we are seeing now in the emergency department are really at the stage of maybe even having tried or attempted or have a detailed plan," says Dr. Vera Feuer, director of pediatric emergency psychiatry at Cohen Children's Medical Center of Northwell Health in New York. "And we're admitting to the hospital more kids than usual because of how unwell they are."

She has seen a slight increase in 10-to-11-year-olds attempting, but the majority of kids she sees are teenagers.

Other places are seeing a rise in 2020 numbers compared with 2019 as well.

The number of kids with suicide attempts coming to the emergency room at Children's Hospital Oakland, in California, in the fall of 2020 was double the number in the fall of 2019, says Marisol Cruz Romero, a psychologist and the coordinator for the hospital's behavioral emergency response team.

At Riley Hospital for Children in Indianapolis, the number of children and teens hospitalized after suicide attempts went up from 67 in 2019 to 108 in 2020. And October 2020 saw a 250% increase in these numbers over the previous October, says Hillary Blake, a pediatric psychologist at the hospital.

Psychiatrists and other doctors who work with children say the pandemic has created a perfect storm of stressors for kids, increasing the risk of suicide for many. It has exacerbated an ongoing children's mental health crisis — suicide rates had already been going up for almost a decade among children and youth.

The problems brought on by the pandemic, they say, only highlight the weaknesses in the mental health safety net for children — and point to an urgent need for new solutions.

"The stories that we hear day by day in the emergency department really speak to us about the level of difficulties, the layers of traumas and the real problems that families are facing," says Feuer.

Suicide can be prevented, and family members can play a role in keeping kids well. For ways to help kids at risk, read Part 2 of this story.

Loss of critical in-person support services

Many young people, like Anthony Orr, have no diagnosis or known history of mental illness when they start struggling with thoughts of suicide.

But the children who are most vulnerable right now, says Duffy, are the ones with underlying physical or mental illness, because the pandemic has disrupted in-person services they relied on in communities and at school.

"They have difficulties with their mood or difficulties with learning or socialization or medical issues," says Feuer. "And now you have other layers of difficulties on top of that. These are the kids we see in real hopeless moments."

Before the pandemic, many of these children were "relatively stable in the community with outpatient resources," says Duffy.

For example, Duffy saw a 13-year-old in her ER recently who had underlying anxiety and depression. The at-home and in-school services she relied on had been suspended.

Without those supports, her mental health worsened and she started to fall behind at school, says Duffy. The girl turned to self-harm and eventually attempted suicide.

"It was her [older] teenage sister who found her in the bathroom and who called their mother, who had to leave work," says Duffy.

Feuer recalls seeing a 14-year-old last fall who began to struggle at school after developing a medical issue that hadn't been properly diagnosed because of pandemic-related delays in care. He was in constant pain and couldn't focus on schoolwork, she says.

On top of that, the pandemic had taken away his access to sports, "which was his world and life," says Feuer. "And then he looks at you and says, 'What's the point? What do I have to look forward to? You tell me, what do I have to be hopeful about?' "

Falling off the radar

Another layer of risk right now is that virtual schooling has made it much harder for teachers and school counselors to identify and help students who are struggling.

Colleen Neely is a counselor at Shadow Ridge High School in Las Vegas. Neely lost one of her favorite students to suicide last May, just two weeks before graduation. (Joe Buglewicz for NPR)

When Nevada shut down last March and the Clark County School District switched to virtual learning, Colleen Neely, a counselor at Shadow Ridge High School, on the outskirts of Las Vegas, tried her best to stay connected with her students by email.

But it wasn't as easy as being in the school together, she says.

"There are just extra barriers," says Neely. "We're not there just in passing, or they can't go to their teacher and be like, 'Hey, I want to see my counselor.' They can't stop in at lunch. They have to make that effort with an email or clicking on a computer to make an appointment."

In May, Neely's supervisor called her to give her the news that one of her favorite students had died.

"He was a smart ... shy kind of kid," says Neely. "Very kind, polite and respectful."

She was used to seeing him every day as he would stop by her office to check in. She says he had been homeless for a while and had some emotional struggles too. The school had eventually found him a family to live with.

And he'd been doing really well when the school switched to virtual learning, says Neely.

"He was passing all of his classes, going to earn the highest-level diploma that we offer at our school. So he was in a really good place," she says.

She was devastated to hear that he'd taken his own life.

"I'd just sent him an email, telling him how proud I was of him," Neely says. "And that he was almost there. And the next phase of his life was going to start."

Neely doesn't know the exact circumstances that led to his death. But she knew he was at risk because of his past struggles. And she wonders if someone could have helped him if the pandemic hadn't upended everything.

"Part of me will always question, if we had been in the building — and if he had been able to just see another adult, his friends, possibly talk to me — if things would have been different."

Social isolation

Losing the in-person interactions of life at school is itself a big risk factor.

"The vast majority of my patients want to go back to school, miss the social contacts, miss the life that they have," says Dr. Richard Martini, a professor of pediatrics and psychiatry at the University of Utah. "I mean, these kids really do have a separate life in school that's important to them."

It's among the reasons that the American Academy of Pediatrics is encouraging school districts to aim to bring back students into classrooms safely.

"There's a level of social isolation for these kids ... that they have not experienced before," Martini adds.

That isolation isn't just because schools are closed but also because the pandemic has restricted people's social lives. And that has a big impact, especially for kids in communities where extended family networks matter a lot, like in Oakland, where Romero, of Children's Hospital, works.

"Many of our patients that do have a mental health history, they really depend on extended family to be able to support them," she says. "And that's been really challenging lately."

And social isolation is "one of the highest risk factors," for suicide, she says.

New kinds of stress at home

Amid the upheaval of the pandemic, the home environment has become unstable for many kids, says Martini, pointing to job and income loss as major stressors.

Especially vulnerable are kids from families hit hardest by the pandemic among communities of color.

"Either they had the virus, they lost people to the virus or they're impacted because they are a minority and their community ... [has suffered] losses over losses," says Feuer.

Dr. Warren Ng, a child psychiatrist at Columbia University Medical Center, says one of his patients, a boy, told him he wanted to die after watching his father die from COVID-19.

Romero also recalls suicidal kids she has seen recently who have lost family members to the virus or have parents who are currently sick and hospitalized.

"Families who have lost family members, parents who have lost jobs, kids who have lost contact with people who are close to them, children who have experienced some significant challenges at school," says Martini. "All of these experiences are fairly traumatic."

A child faced with these layers of difficulties can easily start to feel overwhelmed, he says.

"They may also be in a position where they feel they can't talk to anybody, even their parents," he says. "And as the number of solutions for that situation dwindle, they may begin to think that I'd rather be dead than sort through this."

Especially when there is so much uncertainty around when the pandemic will end.

"I think it's the coupling of those things that are pretty daunting for a lot of our youth," says Dr. Nasuh Malas, a psychiatrist and pediatrician at the University of Michigan. "I mean, these are kids, right?"

Suicide can be prevented, and family members can play a role in keeping kids well. For ways to help kids at risk, read Part 2 of this story.

Thinking about prevention

In Clark County, the school district is grappling with what it can do to prevent more suicides. Last July, it started using a software that alerts staff when it identifies at-risk students by monitoring their online activity. The staff then contact parents and offer support.

"We're trying to find kids that are just the 'silent screamers,' " says Jesus Jara, the district superintendent.

After an abrupt spike in suicide deaths among students, officials at the Clark County School District held a series of listening sessions and are looking for ways to bring the most vulnerable students back for some in-person support. (Joe Buglewicz for NPR)

In October, the district hosted a series of listening sessions with parents and other stakeholders to try to understand what's going on with student mental health and how to help. Based on the feedback it received, it is in the process of bringing some kids back to in-person school in small groups for academic and social and emotional support.

Nearly six months since their son died, Marc and Pamela Orr are still struggling to cope with their trauma and grief.

"Sleep is elusive," says Pamela. "Any time can be a hard time. I mean, I can be in the grocery store, and I see his favorite breakfast cereal, and I just have to stop what I'm doing and just leave because anything, everything can be a trigger for the intense sadness."

To cope, she and her husband go on long walks every day. They are also seeing a therapist for the first time and talking to other parents of youth who died by suicide. And in the process, they find themselves asking questions about suicide and mental health that they'd never asked before.

For example, why don't schools and workplaces talk more openly about mental health and suicide?

"At work, we have all these tools — hard hats, gloves and glasses" to safely work with electricity, says Marc, who's a crew foreman for NV Energy. "We have nothing for mental health. ... It's not talked about. Everybody turns a blind eye to it because it's taboo, it's icky."

He also wonders why schools don't have mental wellness checks for students. "They get well-checks, you know," he says. "Insurance pays for a well-check. But there's not any mental [health] screening that's done or emotional screening."

A crisis, but also an opportunity

The rise in mental health problems among children should spur the country to fix its mental health care system, argues Dr. Jennifer Havens, a child and adolescent psychiatrist at New York University.

"Crisis is often an opportunity," she says.

To start, the U.S. should provide routine mental health checks for kids from a young age and their families, she says: "It should be just part of what we do to keep people well."

Hospitals and behavioral health care providers are already required to do depression screenings for adolescents, she says; schools should also be doing these screenings.

"We have to be able to identify the kids ... particularly for getting kids who are in early stages before they're really sick, and help them," says Havens. "You don't have to wait until kids try to kill themselves."

And mental health care providers can help teachers learn to spot the early signs of problems, says Martini.

The solutions aren't just at schools. We also need better access to mental health care services for kids, says Martini.

"There is an incredible backlog in getting children mental health services," he says. "If I had all the money in the world, I think what I would do is really invest in a broad scope of services for teenagers and children."

Those services would include day treatment programs that are less intense than in-patient units and can diagnose a child's problems. He would also expand access to telepsychiatry and create more programs that send mental health care workers into people's homes.

But the biggest roadblock in making all this a reality is a lack of parity in insurance coverage for mental and physical health, says Havens.

"There are a lot of preventive interventions that are effective," she says. "But the way the [mental health care] system is set up, we can't actually get paid to do that."

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Ultimately, the country needs to invest in kids' mental health, she adds. But, "there's no magic bullet here," she says. "We need to have a robust [mental health] care system ... and insurance companies need to pay for it."

Copyright 2021 NPR. To see more, visit https://www.npr.org.

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