September is National Suicide Prevention Awareness Month

By Lucille Carr-Kaffashan, Ph.D.

The start of the school year in many parts of the United States coincides with the annual campaign by health care organizations and advocacy groups to shine a light on a growing national health concern — suicide. September is National Suicide Prevention Awareness month, and September 10th was World Suicide Prevention Day. The primary goals of campaign organizers are to encourage authentic conversations about this very sensitive topic, and to offer hope to those with suicidal thoughts/impulses and those who care about them that it is indeed possible to get help and move past a suicidal crisis.

Educators have long been grappling with the surge in youth mental health problems, a crisis that has only worsened since the beginning of the pandemic. Although enhanced school-based mental health services have been in the spotlight of late, it is also important for all school personnel, not just mental health practitioners, to have a basic understanding of suicide and the resources available.

Youth Mental Health Symptoms and Suicidality — The Scope of the Problem

According to a study published in the Jama Network by Lebrun-Harris, L. A. et al., between 2016 and 2019 there was a significant increase in children’s mental health conditions, including a 27% increase in anxiety and a 24% increase in depression. The authors also documented a 21% uptick in behavior or conduct problems from 2019 to 2020. In its fact sheet on adolescent mental health, Mental Health Among Adolescents, the Centers for Disease Control and Prevention (CDC) reports a 40% increase in persistent feelings of sadness and hopelessness in high school students between 2009 and 2019.

With respect to suicide, the CDC reports that overall suicide rates increased by 30% between 2000 and 2018. Children and young adults account for 14% of all suicides, and while the rate for youth and young adults is lower than for other age groups, suicide is the 3rd leading cause of death for individuals who are 10–24 years old and the 2nd leading cause of death for those who are 10–14 years old. In 2019, 9% of high school students reported attempting suicide in the prior 12 months compared with 6.3% in 2009. Since the start of the pandemic, the CDC has reported a 31% increase in emergency rooms visits for suspected suicide attempts among people ages 12 to 25. Emergency room visits have increased by 51.6% for teenage girls and by 3% for teenage boys.

In March of this year, the CDC published an analysis of data gathered in 2021 about the mental health of U.S. high school students during the pandemic. More than a third (37%) of high school students reported that they experienced poor mental health during the pandemic, and 44% reported persistent feelings of sadness or hopeless during the past year.

This analysis also described some of the severe challenges young people encountered during the pandemic:

• More than half (55%) reported that they experienced emotional abuse by a parent or other adult in the home, including being sworn at, being insulted, or being put down.
• 11% experienced physical abuse by a parent or other adult in the home, including hitting, beating, kicking, or physically hurting the student.
• Almost a third of students (29%) reported a parent or other adult in their home had lost a job.

Understanding and Monitoring Risk Factors

Even the most vigilant school professionals face many challenges when trying to monitor a child’s safety. Younger children typically do not have the language skills or maturity to articulate their emotions and impulses. Teens, as part of their individuation process, can be quite secretive and actively hide things from parents and other caring adults. That said, there are common risk factors to watch for:

• A history of depression or other psychiatric conditions
• Prior suicide attempts
• Verbalizations of suicidality and/or a preoccupation with death
• Expressions of hopelessness, feeling trapped, of being a burden to others
• Mental health or developmental conditions and behaviors that increase impulsiveness and decrease judgment, such as ADHD and substance abuse
• A family history of suicide
• Having a friend or even being aware of a celebrity who died by suicide
• Sudden mood changes, including an unexpected shift to an upbeat mood
• Behavior changes, such as social withdrawal
• Changes in appearance or hygiene practices
• Recent deaths or other losses
• A sudden drop in grades or academic engagement
• An event or situation that represents a significant blow to self-esteem or a sense of belonging, or that involves public humiliation
• A history of trauma, including bullying and sexual/physical/emotional abuse
• Giving away possessions

The WHO, WHAT, and WHEN, of Suicide: WHAT YOU SHOULD KNOW

WHO

It is commonly thought that only individuals with a current or prior mental health diagnosis can experience suicidal thoughts and impulses. This is not true. While depression and other mood disorders, anxiety, PTSD, psychosis, and other mental health conditions can raise the risk of suicide, youngsters with no prior history of mental health symptoms and who otherwise would not meet criteria for a mental health disorder can also experience a suicidal crisis. For this reason, all students should be monitored for possible suicide risk.

Besides children with known mental health or trauma histories, there are certain groups of children who are consistently at higher risk. Minority youth are at higher risk due to the burdens of structural racism, intergenerational trauma, and chronic healthcare disparities. These youngsters are also likely to have experienced greater family loss and overall stress during the pandemic. LGBTQ and other gender non-conforming youth are at higher risk because of stigma, prejudice, discrimination, threats of violence, and other traumatic experiences. LGBTQ youth are also more vulnerable to identity struggles as they grapple with issues of gender, sexuality, and acceptance by family and the community at large.

Accomplished, perfectionistic students can also be at higher risk due to unrealistic and rigid standards and the fear of failure. These youngsters often excel at putting up a front and not letting on that anything is wrong. As noted by Gina Meyer, the mother of Stanford University soccer star Katie Meyer who took her own life on March 1st, “There is anxiety and there is stress to be perfect, to be the best, to be number one.”

WHAT

First and foremost, it is important for school professionals to understand that mental illness is treatable, and that suicidal thoughts/impulses can go away entirely or improve over time. Suicide can be a go-to response when a person feels hopeless, believing that there are no solutions to one’s problems. Caring adults must remind students that suicide is a permanent solution to a temporary problem, and that there is help and reason to hope that things can and will improve.

Likewise, when talking with both parents and staff, district leadership and mental health professionals must actively challenge the myth that talking about suicide will plant the idea in the head of a student who previously had not thought about it. This is just not true. Adults must be direct in asking children about whether they are having thoughts of suicide and must use the words “suicide” or “killing yourself” instead of euphemisms like “hurting” or “harming.” These are not the same thing. If adults repeatedly raise the hard topics — isolation, depression, fear, anxiety, hopelessness, suicide — children and teens, despite their protestations, will be relieved and know they have allies who do not think they are “crazy” or “weird.”

Both staff and parents also need to know that an important protective factor for youth is the feeling of being connected. “Connectedness” refers to a sense of belonging and being cared for, by parents and caregivers as well as by other important people and organizations in a child’s life, most notably schools. Recent CDC research has found that youth who feel connected at school and at home were up to 66% less likely to experience health risk behaviors related to sexual health, substance use, violence, and mental health in adulthood. So, whatever caregivers and staff can do to promote school connectedness would help in suicide prevention efforts.

Finally, while the causes of any one person’s suicidality are complex, it is safe to say that today’s children and adolescents are growing up in a world that often feels unsafe. The lingering effects of the pandemic, the ongoing threat of gun violence, the fears about climate change and the increase in natural disasters, the persistent social unrest and racial strife, and the yet not totally understood effects of technology and social media all affect the health and well-being of America’s youth.

WHEN

Contrary to the popular belief that suicides increase around the fall/winter holidays, suicide rates are consistently higher during the months of April, May, and June. There are a variety of biological, psychological, and social theories but little hard evidence about what contributes to this annual pattern. Individuals with mood disorders, especially bipolar disorder, tend to experience a worsening of symptoms at this time of year. Increased light is thought to cause an uptick in manic symptoms that in turn can elevate risk by increasing agitation and the energy to commit suicide while at the same time impairing judgment. Spring allergies and associated inflammation may also increase risk as inflammatory processes affect the brain and are related to depression and other mood changes.

The link between spring suicidality and students could also be related to the natural cycle of the school year. By spring students have a good idea about how their school year will end up grade-wise, seniors are hearing about college acceptances and rejections, and activities like proms, performances, and team sports can bring both joy and agonizing disappointment.

How to Help

In April 2022, Effective School Solutions (ESS) published Suicide Awareness and Prevention — Maximizing Children’s Safety, which included a list of suicide prevention actions for districts to consider. As we begin a new school year and look for ways to assist students with both learning and mental health issues, it might be useful to re-look at this list and take stock of your district’s suicide prevention efforts.

Districts can:

• Re-assess and strengthen Tier 1 capacity within their Multi-Tiered Systems of Support (MTSS) framework. This might include building or expanding universal screening activities, re-examining what screening tools and methods are used, as well as the timing and frequency of such screenings. This might also include a renewed commitment to the district’s SEL curriculum.
• Regularly circulate information to parents, teachers, and other district staff about suicide warning signs and about groups that are particularly at risk (e.g., students with ADHD, trauma histories, depression, or substance abuse problems; gender non-conforming students; minority students). Even very young children can be in deep emotional pain and may want to die even though they do not understand the permanence of death.
• Offer professional development opportunities for staff to help them build confidence and skill in talking to students about difficult topics in developmentally appropriate ways.
• Circulate and post information about school-based mental health services as well as community resources, including local suicide hotlines and emergency department numbers, and the new national hotline number, 988.
• Encourage teachers and other staff to refer students to on-site counselors.
• Encourage parents to get professional help for students who are showing any of the warning signs of suicide.
• Ensure that school and community counselors work with at-risk students to develop a safety plan that includes the names and contact information for individuals to reach out to if they are feeling suicidal.
• Offer training workshops for parents about how to monitor their children’s online activity, about how to talk with their children about difficult topics like suicide, and about maximizing home safety (e.g., importance of securing guns, medication, and alcohol).
• Revisit and reinforce anti-bullying initiatives.
• Use physical education classes to inform students about the mental health struggles of sports stars like Simone Biles, Naomi Osaka, and Michael Phelps to de-stigmatize seeking help.
• Engage parents and staff in efforts to design and implement “school connectedness” initiatives.
• Develop a protocol and identify specialists to actively respond to community suicides or other tragic deaths on a school-wide basis.
• Foster a school culture that puts academic and other achievements into proper perspective, promoting a balanced approach to growth and education. An over-emphasis on grades and winning can put undue pressure on students and contribute to feelings of hopelessness.

As of July 2022, the National Suicide Prevention Lifeline is 988, although the previous 1–800–273-TALK number will continue to function indefinitely. Veterans can press 1 after dialing 988 for the Veterans Crisis Line. There are also multiple lifelines for specific groups, like LGBTQ+ youth. More information can be found on the website for the American Foundation for Suicide Prevention.