Is Your Child or Teen at Risk for Suicide?

Last year, 16-year-old Patrick Turner died by suicide. A high school sophomore at the affluent Corona del Mar High School in Newport Beach, California, Patrick played baseball, skied, earned A’s and B’s, and had many friends.

But Patrick’s death has since shined a harsh spotlight on the current national crisis of teen suicides. He left behind a series of letters that included an indictment on the current school culture of high pressure academics (such as the pressure to earn all A's in multiple Advanced Placement courses) that is pervasive in some schools. Patrick highlighted the danger of this academic high-stress environment: “One slip up makes a kid feel like the smallest person in the world.”

Patrick’s letters have challenged educators and parents to redefine educational success, encouraging vocational training as a viable alternative that is valued. He also challenged his fellow iGen peers to reconsider the unrealistic perfectionism rampant in adolescent social media use, such as Instagram-worthy selfies composed of carefully staged poses of friends smiling together, or photoshopped images of themselves edited to idealized appearance standards.

The latest suicide statistics for children/adolescents reveal that adolescent suicide is at crisis level. Suicide rates for children/teenagers are the highest since suicides have been recorded, from 1960. Between 2000 and 2017, suicide rates for teenage girls have doubled. Suicide is now the 2nd leading cause of death among youth ages 10-19. It is the #1 leading cause of death for older adolescent girls worldwide. This is a global crisis that requires immediate and strong prevention/intervention.

Despite these sobering statistics, there is hope. Recent years have seen large-scale, organized efforts at improving awareness of suicide risk and interventions. For instance, the American Foundation for Suicide Prevention has a widely-available template for helping families to create a safety plan. This week is National Suicide Prevention Week, and efforts at improving awareness are increasingly visible across multiple platforms, including social media. Podcasts with helpful information, such as Dr. Christine Moutier's podcast on how to deal with hopelessness, serve to help destigmatize suicide risk and treatment. Child mental health professionals have armed themselves with evidence-based clinical trainings on suicide prevention and intervention, such as the Family Intervention for Suicide Prevention (FISP) developed by Dr. Joan Asarnow. For example, at Rady Children’s Hospital of San Diego, in early 2019, all of the child mental health clinicians working in the Outpatient Psychiatry Department underwent rigorous clinical training on FISP, and this on-going training has continued with clinicians' access to weekly consultation meetings/calls to discuss how to help the children/families on their caseloads in managing suicidality.

For parents/caregivers, there is substantial research to show them how to help their children. There are two important strategies: 1) Identify and understand your child’s risk factors and warning signs, and 2) Identify and foster the protective factors.

Risk Factors can include:

1) A significant loss. This can include death of a loved one, divorce of parents, interpersonal problems (e.g., termination of romantic relationship), or financial loss such as a parent losing a job.

2) Access to lethal methods, such as firearms.

3) Being bullied and/or being a bully.

4) LGBTQ+ youth struggling within an environment that is unsupportive of the child’s identity.

5) Alcohol or substance use

6) Mental health concerns, such as depression, anxiety, trauma, or other stress-related disorders. Adolescents with ADHD can be at increased risk due to their impulsivity. Family history of suicide also increases risk for family members.

7) Suicide contagion, such as seeing sensationalistic media reports on high-profile celebrity suicide deaths, or learning about a peer's death by suicide.

Parents should take heed when they observe the following specific warning signs:

1) Changes in behavior: Difficulty concentrating, difficulty focusing on school or following routine activities, researching ways to kill oneself on the internet, increasing use of alcohol or other drugs, acting recklessly

2) Changes in personality: Appearing withdrawn, isolating themselves to their room, irritability, extreme mood changes that are more than typical moodiness, exhibiting rage or talking about seeking revenge

3) Changes in sleep patterns: Insomnia, oversleeping, nightmares

4) Talking about dying: Any mention of dying, disappearing, going away, or other types of self-harm

Protective factors can include:

1) At least one supportive and available adult. Children who feel loved and supported are more likely to feel that they can turn to the stable adults in their lives during the inevitable challenging times characteristic of adolescent years.

2) Restricting children and teenagers' access to firearms and other lethal methods of suicide.

3) Cultural or religious beliefs that discourage suicide.

4) Adaptive life skills, notably, problem-solving and conflict resolution skills.

5) Access to effective mental health care.

How can we get children/teens to ask for help? The single biggest myth is that asking a teenager about suicide makes them think about dying by suicide. This is a pervasive concern by many parents, but is also one that is easily abated by the strong research. Studies after studies have shown that asking about suicide does not increase the risk of suicide. Rather, asking about suicide can decrease the risk and potentially saves lives. If a teenager is thinking about suicide, purposefully avoiding the topic is akin to indicating to the teenager that their problem is too scary and unwieldy for even the parent/adult figure to talk with them about it. It can increase the teenager's sense of isolation and feelings of hopelessness. An example of how to ask your teenager about potential thoughts of suicide: “I noticed that you’ve been staying in your room every night since you and Jackie broke up, and today I noticed that you did an online search for stories about suicide. Are you having thoughts about hurting yourself?”

During your talk, let your child or teen know you love them and emphasize how important they are to you. Be empathic and listen; do not minimize their verbalized stresses; and encourage them to identify their future goals. Do let them know they’re not alone, and that you are there for them. Inform them there are effective treatments to help reduce their hopelessness. Give specific examples of people you both know who have needed and received mental health help.

What can parents/caregivers do to help? Help your teenager to increase behavioral activation. Research studies show that behavioral activation, e.g., engaging in behaviors that feel rewarding/reinforcing, is very effective. Meta-analyses have shown that behavioral activation is as effective as medication (in the short term), and somewhat better than cognitive therapy, in the treatment of suicidal behaviors and depression.

Encourage and support your child or teen to engage in reinforcing or rewarding activities, such as going to the movies with friends, walking the dog, playing a sports game, working on a Lego project, and bowling or hiking. It is most helpful to include face-to-face, in-person activities. While you may start by encouraging your child to increase his or her rewarding activities, be sure to obtain professional help with a therapist who is experienced in behavioral activation treatment.

Be sure to minimize your child or teen's exposure to media (including social media) about completed suicides. Reading and hearing repeated stories about suicides can increase a vulnerable individual’s risk for attempting suicide. Suicide contagion is a real phenomenon but can be managed by limiting your child’s exposure, especially during suicide risk periods.

Finally, when it comes to potential suicidal thoughts, it is better to err on the side of caution. If you have a feeling or intuition that something doesn’t feel right with your child, if you notice warning signs, and/or if you recognize your child has many of the risk factors for suicide and few protective factors, seek professional help.

Contacting any general mental health provider is usually not enough. Be sure to find a mental health provider who has experience with youth struggling with suicidal ideations, who has training in evidence-based therapies for suicide and depression for children and adolescents, and whom you and your child feel comfortable talking with during your first session.

What can we do to help the other children and teenagers in our communities? It takes a village. 16-year-old Patrick Turner urged all of us to: "Be inclusive...and be nicer to each other." We can teach our children and their peers, both through our own actions and active teaching, to reach out to fellow peers and be kind to each other. These simple efforts can ultimately foster crucial social connection.

When teenagers feel a sense of belonging and connectedness in their environment, they then have decreased their isolation and developed an important protective factor against suicide risk. Encourage your children to make friends with those who don't have any; to stand up for those who are in need. For example, at Torrey Pines Elementary School in La Jolla, California, a parent, Dr. Sara Weibel, spearheaded a student-led club focusing on inclusion, diversity, and helping children have a sense of belonging in her school community. These efforts may save the life of a youth who is being bullied, or struggling with their sexual orientation, or feeling isolated. With these kinds of efforts replicated across the world, we can help make a big impact on turning the tide against the rise in youth suicides.

Resources in the U.S.:

Immediate help, 24/7: National Suicide Prevention Lifeline, 1-800-273-TALK, or Crisis Text Line by texting TALK to 741741.

The Trevor Project, aimed for bisexual, transgender, and questioning youth, 1-866-488-7386

American Foundation for Suicide Prevention

To locate a therapist trained in anxiety, depression, PTSD, and suicidal behaviors, go to Anxiety and Depression Association of America (ADAA) Therapist Directory

Psychology Today Therapist Database

Resources in Canada:

Canada Suicide Prevention Service: Immediate help, 24/7, Toll-free phone number: 1-833-456-4566, or text message number: 45645

http://www.crisisservicescanada.ca/

International Resources:

International Association for Suicide Prevention: http://www.iasp.info/resources/Crisis_Centres/

https://www.nowmattersnow.org/