By SELENA SEABROOKS

The Dallas Examiner

• Suicide is the second leading cause of death among adolescents in the United States.
• The suicide rate among ages 15 to 17 increased by 76% to nearly 12 deaths per 100,000, From 2007-2017.
• The suicide rate for youth ages 10 to 14 nearly tripled from 2007 to 2017.
• The suicide rate for youth ages 10 to 14 increase by 16% in from 2017 to 2018.
• Emergency rooms saw a 42% increase in visits due to suicide attempts and self-inflicted injuries of those ages 10 and older, from 2001 to 2016.

Source: Centers for Disease Control and Prevention

With a focus on understanding suicide risk factors and trajectories among children, preteens and other groups with a recent increase in suicide risk, the National Institute of Mental Health – the world’s largest research organization specializing in mental illness – hosted Understanding Suicide Risk Among Children and Pre-teens: A Synthesis Workshop.

The workshop was held to discuss the findings of, “Risk, Resilience, & Trajectories in Preteen Suicide.” a series of roundtable discussions. The monthly workshops, held January through April, brought together a group of experts with a diverse training and experience in the treatment and research of adolescent behavioral sciences.

Dr. Mary Rooney, a clinical psychologist and chief of the Child and Adolescent Psychosocial Interventions Research Program at the NIMH, led the workshop. She opened with a discussion on a study that was conducted recently – Advancing Research in Child Suicide: A Call to Action. The objective of the study was to highlight the concerns of child suicide and to summarize what is known and unknown about the problem of child suicide.

It was explained that the study revealed that little was known about the risk factors, prevention and intervention for suicide risk in children 12 years old and younger. Rooney stated that the study resulted in a “call to action” for the NIMH that created three roundtables that brought together experts from the fields of psychology, clinical psychology, psychiatry to focused on at-risk suicide of those ages 7 to 12.

She discussed the first roundtable that focused on suicidal thoughts and behavior in preteen children. She and Dr. Eric Murphy, program officer in the Division of Translational Research at the NIMH, led the event.

“This roundtable was focused on the science of thoughts and behavior of suicide in children,” Rooney explained. “There were three specific areas that we related to the phenomenology and suicide ideology in preteens during the roundtable meeting. These included individual characteristics and developmental status; development and refinement of screening and assessment measures; and contextual and setting-specific factors that may influence screening and assessment outcomes.”

She tied together how a youth’s ability understand and discuss emotions and thoughts is affected by his/her development level, cultural background and exposure to death and suicide.

“We know that preteens vary in their ability to report on and express their own emotions and thoughts in a meaningful way,” she explained. “The ability to self-monitor and be aware of your own thoughts, as they are happening, is an ability that develops over time as you age. While it slowly develops in typical adolescence, the variability emerges of this capability during your preteen years. Cognitive functioning, including the ability to understand more abstract concepts, like death, and the ability to understand some of the more complex questions that are included in adolescence assessment in suicidal thoughts and behaviors is another individual characteristic that varies from preteen to preteen, both as a function of age and a function of developmental level.

“The analyst acknowledges that a clear picture of a preteen’s current suicide risk level may often require input from multiple sources. It may require multiple assessment methods.”

She went on to discuss the potential scientific impact of the findings during the roundtable.

“The goal of these measures will result in robust data that can ultimately inform state-of-the-art science, scientific strategies and to develop well-targeted interventions to alter the recent upward trend in preteen suicide rates,” Rooney concluded.

Dr. Stacia Friedman Hill, Rooney’s colleague and the program chief, then discussed the second roundtable. Led by Friedman Hill and Program Chief Marjorie Garvey, it focused on measuring preteen suicide risk and protective factors.

“A significant focus of our discussions dealt with considerations of populations that may be at higher risk levels and how to challenge assessments so that they are culturally sensitive to the program. We asked participants to consider that there were some risks and protective factors that are common across different groups and also if there were some factors that were unique to specific groups,” Friedman Hill explained.

They found that suicidal thoughts and behaviors in preteens were associated with the child’s cognitive processes, which is the ability to predict how an act or behavior would affect future outcomes, using multiple results. It was also discovered a link between the family functions – including high interpersonal conflicts and low parental monitoring – and elevated risks of preteen suicide.

She said other factors might include: social rejection, changes during puberty, family separations, immigration stress, intergenerational trauma and peer socialization.

“Peer interactions may discourage you from seeking help from adults,” Friedman Hill said.

She concluded that certain factors could be used to prevent preteen suicide.

“Family training, including psychoeducation and emotion regulation and problem-solving, mitigates suicide ideation and attempts,” she said. Religiosity is a complex protective for Black youth. Church participation and subjective religiosity contribute to feelings of optimism, hope, and persistence against adversity. Religiosity also affects thoughts about suicidal susceptibility.”

Moreover, relationships with trusted adults, building on cultural strengths, community engagement and community connectedness were factors that also mitigated suicide attempts, she added.

Next, was a presentation by Dr. Christopher Sarampote, the chief of Biomarker and Intervention Development for Childhood-Onset Disorders at NIMH, who led the third roundtable. He went over the findings on risk states and trajectories for suicide in preteen children. He said the panel discussion exposed the challenges in studying youth suicide and approaches to manage those challenges.

“Suicide in young children is a relatively rare event and available samples are small and may not provide enough data. Furthermore, the study of youth suicide is studied by theoretical complexity with multiple moderators and many more,” he explained. “In summary, roundtable three identified many challenges in predicting this behavior in young children.”

The last to present, Dr. Jane Pearson, chair of the NIMH Suicide Research Consortium, discussed the need to build onto the science of at-risk children for suicide. She was joined by the keynote panelists Dr. Joshua Gordon, director of NIMH, and Dr. Rachel Levine, assistant secretary for Health for the U.S. Department of Health and Human Services.

“It is a very difficult area to determine risk factors for such a very low base rate, unfortunately. [We have] very low numbers of children who died by suicide that are 12 and under, but we know it has been a growing number. So, the effort to start work to understanding the risk factors and the risk trajectory before these children act on their thoughts is really important,” Pearson said.

Levine then stated that they were just beginning to understand how youth are affected by the impact of COVID-19 on mental health changes, breaks and continuity of learning, missed life events, loss of security and safety, disease and the death of loved ones.

“There are some troubling findings that the CDC released in their MMWR. In May 2020, during this COVID-19 pandemic, emergency department visits for suspected suicide attempts began to increase among adolescents aged 12 to 17. During February to March 202, suspected suicide attempts were higher among girls and actually even higher among boys as well,” Levine stated. “The concern is that this is going to have significant public health consequences both in the short-term but also in the long term. In terms of the overall health and well-being of children and teenagers. You can almost think of this as collective trauma.”

Gordon said it was exceedingly crucial to identify which factors place young people at risk of suicide.

“There were factors in the Black community that provided tremendous resilience. And suicides among Black children were lower than the general population. That is what is changing and that is what we have to understand,” Gordon expressed. “In order to understand this, we need to understand what we would call the trajectory of risk. How things change in an individual over time. Why is that important? Because we are learning more and more that mental illnesses in general and expressions of those illnesses through behaviors such as suicide attempts, these occur in stages and phases and different approaches are necessary to intervene at different stages.”

Panelists Q&A session

Question: You spoke about your background as a pediatrician, there is nothing more tragic than a life cut short by suicide in teenage years. Can you tell us some about your experience working with troubled teens and how that has informed your commitment to these issues?

Levine: Thank you for that question. I trained in pediatrics in adolescent medicine many years ago at Mount Sinai in New York City. I actually did my research and my fellowship on adolescent suicide. I saw many teens in the emergency department called in for suicide attempts. Looking at different psychological factors and many of the different ideological factors we have been talking about. After a number of years at Mount Sinai, I left New York and went to Central Pennsylvania which is quite a difference. I practiced at the Penn State College of Medicine and Pediatrics and particularly adolescent medicine. I saw a lot of troubled teens and young adults. Particularly with eating disorders. That would be with anorexia nervosa, bulimia, or Bosa and related illnesses. We see more children with eating disorders now. But a lot of children with significant eating disorders and we would see them outpatient and we had a partial program as well as an inpatient. Of course associated with eating disorders we saw a lot of other mental health issues like mood disorders, anxiety disorders, PTSD in some teens, and we had many teens that had significant suicidal ideation some of which would require hospitalization. I think that the etiological factors were varied and we saw teens that had significant family issues buy it as a misconception that teens with eating disorders are all the teens that anorexia or bulimia all had dysfunctional families. It is not true. We saw some but others had other social issues and others, it was not as clear from an environmental point of view that might be triggering their suicidal ideation. We saw everything from some family issues. We saw teens that unfortunately had experienced trauma and sexual abuse, etc. that triggered a lot of their symptoms.

Question: From the research I did, and if I tell you when it was, it was a long time ago…What I found when I was reading some of the literature about this was that a lot of the children and teens aren’t always chronically depressed. You would think that someone who is suicidal would probably be chronically depressed but the role of impulsiveness and the co-associate with attention deficit disorder was prominent. I was wondering your thoughts about that.

Gordon: I’m glad to have some give and take. In my own research fellowship, I worked on related issues to this inhouse model, quite a little different than teens. What we learned from both studies of individuals who had died by suicide, models as well as that there are neurotransmitter systems in the brain that regulate impulsivity. Those are disrupted in many individuals who have died by suicide. Moreover, that impulsivity as a personality factor can be found at higher levels in individuals who died by suicide through a process called psychological autopsies. Which are an interesting thing and were pioneered in Pennsylvania at a university in Pittsburgh. I think it is fair to say that there is a very tight linkage between impulsivity and death by suicide in a portion of individuals who have died by suicide. I don’t know, although there is probably some known, and if people know they can speak up, whether that relationship is tighter in teenagers or in children. For lots of reasons, I think it could be. One other thing I would say about your observations that might temper that relationship just a little bit is that as you know from being a pediatrician in children, depression can be difficult to see. Even for parents. It can manifest in ways that are not typical of adults. You may not see someone withdrawing completely or see somebody who is looking sad or depressed or crying. You may see a child who is more irritable or behaviorally acting out s a symptom of what we think is a similar biological process although I still say we need more research. It does point to the challenges involved in recognizing risk and the reason why we need to study young children specifically for risk for suicide. Not just think that because we understand what young adults or adults do, they might apply there. There will be different regions of risk factors.

Question Since we are on the subject of what we understand and research that leads us to that understanding, I am curious, your progress from a practitioner to being in charge of the health of an entire state and really issues more around policy in addition to practice. Policy as it affects practice from a public health perspective. We are speaking to a mixed group but there are a lot of scientists here who do research on suicide prevention and they are trying to come up with the findings and discoveries that will guide public health practice. What thoughts do you have about how we bring understanding and novel approaches from the research world into the practice world?

Levine: I think that that part of research is important. We usually think of translational research from the bench to the bedside but let me take it further. I have been at the bench and not a long time, but I have certainly been at the bedside and now I am in the office. I am thinking about how to implement those policies from a public health perspective, previously just in Pennsylvania and now nationally. I think that all of that is important so what you learn at the bench in terms of maybe some of the biological factors that you have been discussing like the neurotransmitter factors, but also thinking about other issues I deal with which is the disease of addiction and substance use disorders and opiate use disorders. We have learned a tremendous amount of the bench that has had specific applications to seeing patients. Then we have taken those to the public health arena. I will use the example of opioids, in terms of control of pain. The saga is well-known about how opioid pain medications have been overprescribed and maybe a faulty application of bench research to the bedside and how we have tried to address that. The medication that locks on which we have had significant work and distribution and administration and medication for opioid use disorder that we are looking to implement from a public policy perspective. That has been an example. In terms of suicide, there is certainly youth suicide, there are certainly experiences that I have learned and taught at the bedside evaluating and treating children and teenagers that we are working to implement from a public policy point of view. One would be making sure that we have enough professionals, making sure that we have enough child and adolescent mental health professionals to be able to evaluate and to treat those young people. We certainly don’t. We have significant shortages of child and adolescent psychologists and psychiatrists and others types of asters level and other therapists. The importance of implementation of school programs, school prevention programs and teaching resilience in schools, school evaluation programs, and then referral programs. That would be something that we would learn at the bedside that we would want to implement from our public health perspective. So we certainly value tremendously the gains from research and from the National Institute of Mental Health and the research that you all sponsor and throughout the academic medical centers and other facilities throughout the country, that help people in the clinic and in the hospital that we can implement from a public health, public policy perspective.

Question Schools play an important role in mental health. In many jurisdictions, actually delivering mental health care for troubled children. Certainly, as a referral source. To mental health, where it is available. What are you seeing? What is the nation seeing in terms of issues around mental health in the context of COVID in the schools being shut down, or hybrid, or limited in person? How has that affected our ability to deliver care? What are we doing to try to address that issue?

Levine: I think it has severely, significantly impacted the abilities of schools to play that role. For example, one thing that we have seen, I know it’s not in Pennsylvania and we see throughout the country is a dramatic drop in referral to children research, to child protective services. I would love to say that that is because those concerns do not exist. But it is not. It is because many of those concerns were observed in schools. By teachers, by guidance counselors, by administrators, by coaches, etc. That is eventually leading to a child protective services referral for evaluation and intervention. That does not happen when you are looking at it or you are trying to do school for millions of kids mostly, remotely. Also, the student assistance programs that are throughout the programs, that are throughout the United States in terms of schools. They are severely curtailed in a virtual environment. So, we are looking forward to schools fighting back in the fall. The key to schools coming back in the fall is getting our population vaccinated, which was back to one of the comments that I made before. That means, having teachers and school personnel vaccinated, but it also means vaccinating other adults. It is parents and extended families and vaccinating right now, teens 12 to 18 nationwide. Hopefully, before the end of the year, depending on the results of the clinical trials. We need to get our kids back to school.

Question We have another question about what can schools do. There is a concern about kids picking up ideas from other kids by social media. So, if there is a school awareness or assembly in terms of, what are we learning about the kind of contagion peace and what is best practices there?

Levin: Having suicide contagion sounds dramatic but I think it is real. I have seen it. I think that schools have to be careful about the big assembly where they eulogize the young person who tragically passed away because a young person who is feeling vulnerable and insecure, may not feel they get that attention. We also saw this not only in social media but on our TV program and I won’t name it so I don’t get sued but a TV program which talked about a youth suicide where there was that. You have to be careful how the media depicts and schools depict these things.

Gordon: There is something known about contagion and more being done to look at it. There are some successful programs and again I would say we are in the phase of evaluating them but school districts can pair with local mental health providers to develop responses. I think that is one method to try to combat these issues.

Pearson: From that perspective, you’re trying to reach the kids that are most acute. How can you help them without taking them to the emergency room but getting them into care right away? An emergency evaluation then trying to get them to care. There is another level of kids already known at risk and if you talk to school personnel, there are a number of kids. Schools are now asking questions like has social-emotional learning built-in some protective factors. Again, our expert panels are thinking about what specific mechanisms of action. What have certain interventions done that actually do protect kids and for how long? Through what kinds of situations? We know not everyone reacts to stress the same way, but in a broader population but from a public health perspective, these are really important questions.

Last question: There are highly diverse youth and we have talked about youth facing trauma but there is sexual minority use, intersectional use, who might be racial minorities as well as sexual minorities. I’m wondering if you want to speak to some of the challenges we face in terms of trying to help all these diverse groups and trying to reach them in meaningful ways that don’t cause more harm. What kind of research could be used to improve all of that?

Levine: I think the data is better for teenagers than for children, but sexual and gender minority youth are certainly at risk of increased mental health issues and increased risk of suicide. I want to emphasize though that it is not being LGBTQ that increases your risk of having mental health issues such as depression, anxiety, PTSD, suicidal ideation, it is bullying and overt discrimination that LGBTQ loses face whether from home or at school. There is evidence that having one supportive adult, and it doesn’t have to be a parent or in the family, but having one supportive adult really attenuates that risk. The other last word I will say is that there is significant evidence that trans youth that are treated with a well-established guidelines that are accepted by the American Academy of Pediatrics and the Endocrine Society etc., our evaluation and treatment according to well-established standards of care. Those used, do absolutely great. They do well socially and well in the communities and in their schools and have very little mental health issues. Young people that face humiliation, harassment, nonacceptance at either home or school and do not have access to those standards of care, actually have more mental health issues and I want to emphasize that in the light of several state laws that have been passed.

Gordon: I think that is an excellent point that gets to a significant chunk of the issue here. I will point out that it is mechanistic in approach. We see mental health as the mechanism that leads to the disparity and in this case as you stated the evidence is clear with that. That it is about the discrimination by an individual in the context of their communities. That also points, of course, to interventions that you might want to use to reduce that risk. Such as providing the opportunity for mentoring from understanding adults. This would be one pathway forward. I will add in that it is important to think about the context, the community context, the individual level context as one is trying to reach the youth in trouble. Whether they be LGBTQ or other youth and of course as we mentioned, there is now an increased risk in Black youth. Considering that context and looking for innovative ways to reach intersectional youth and to reach Black youth to reduce their risk of HIV and ensure that they get tested and get care if they are at risk. I think taking some of those lessons learned and applying them to the problems of suicide prevention and other mental health issues in marginalized populations is something that we really need to look at.