by Lisa Boesky, Ph.D.

• Robert, 11, struggles in school academically and behaviorally, is regularly teased and harassed by classmates, and was recently overheard saying, “I can’t take this anymore.”
• Carrie, 16, is a popular honor student and talented athlete. When her boyfriend broke up with her and began dating her close friend, she was devastated and humiliated. Carrie’s grades began to suffer, she dropped out of sports, and seriously contemplated killing herself.
• Lucas, 17, had repeatedly been involved in physical fights, regularly drank alcohol and smoked marijuana, and was close to failing out of school. After an arrest for drug possession, he found a gun in his family’s home and took his own life.

For the past two decades, I have travelled around the country providing training, consulting and serving as an expert witness on issues related to adolescent Suicide. I am devastated and heartbroken by how many of these cases may have been prevented. “How did we miss the signs?” is a question often asked. Psychologists can play a critical role in identifying youth at risk of Suicide, as well as educating parents/caretakers and professionals who regularly interact with young people (e.g., education, healthcare, juvenile justice, social service, clergy) on how to recognize these youth.

Some key facts about suicidal youth include:

• Suicide is the 2nd leading cause of death among young people ages 10 to 24.
• More than 1 out of 6 high school students have seriously considered Suicide in the past year.
• Lesbian, gay, and bisexual youth are almost five times as likely to have attempted Suicide compared to heterosexual youth.
• Girls think about Suicide and attempt Suicide more often than boys; however, boys die by Suicide much more often than girls.
• Most teens who attempt Suicide experience unbearable emotional or psychological pain and see no other way to end their suffering.

This article highlights just a few of the issues related to how we miss some Suicidal youth.

Depression in Teens

The majority of adolescents who die by Suicide suffer from one or more mental health disorders, most typically Major Depressive Disorder or Bipolar Disorder. Unfortunately, many of the adults who interact with teens (parents, teachers, coaches, clergy, physicians, etc.) do not recognize symptoms of Mood Disorders among adolescents; this is especially true for high achievers in academics or athletics or youth who repeatedly get into trouble at school or with the law. Sadly, suicidal youth who have a mental illness are often undiagnosed and untreated or misdiagnosed and mistreated.

The most recognized signs of Depression in youth include:

• Sadness
• Crying often
• Withdrawing from friends
• Withdrawing from activities
• Talk of wanting to die
• Suicidal behavior

The least recognized signs of Depression in youth include:

• Irritability
• Agitation
• Anger
• Fatigue
• Concentration problems in school
• Restlessness
• Changes in weight
• Insomnia/Over-sleeping
• Somatic symptoms (e.g., frequent stomachaches, headaches)
• Alcohol or drug use/increased use
• Change in friends
• Behavioral Issues in school

Psychologists can play a key role in educating others that many youth who appear “mad” or “bad” may actually be “sad.” Helping adults realize that even if these youth are not sad, treating their “mad” moods and/or “bad” behavior can significantly reduce their risk of Suicide.

Youth Self-Report

Interviewing youth at risk for Suicide is essential. However, some adolescents may minimize, deny or exaggerate their suicidal thoughts or feelings. In addition to talking with youth about thoughts and feelings related to dying or killing themselves, psychologists must also take into account their observable behavior, history, current environment, and current level of support.

Some teens suffering from emotional or psychological pain may not want to talk to adults—including mental health professionals— about their innermost thoughts and feelings. Some professionals expect suicidal youth to report key words or phrases (Suicide, kill myself, want to die, etc.) during screening or assessment, but may never hear them. A variety of adults may hear statements related to a youth’s suicidal thoughts and feelings that may not be obvious enough to cause alarm. Friends and peers may hear clues or even frank statements about suicidal thoughts and feelings, but may be reluctant to relay them to an adult in a position to help.

Typical statements that should alert a professional, other adult or peer to potential suicidal ideation include:

• I want to go to sleep and never wake up.
• I wish I could disappear forever.
• I wish I were dead.
• I won’t be a problem for you much longer.
• You’d be better off without me.
• If a person did ____, would he or she die?
• It hurts so much, I just can’t go on.
• Life’s just not worth living.
• No one would miss me if I were gone.
• Maybe if I died they would finally see how much they hurt me.
• Maybe, I should just kill myself…..just joking.

Themes related to youth feeling alone, that they do not belong, or that they are a burden to those around them should be particularly concerning.

Self-Injury

A number of teens secretly cut, scratch, or burn their skin in an attempt to feel better. Although known by various terms [e.g., self-injury, non-suicidal self-injury (NSSI), self-mutilation, “cutting],” this behavior reflects a youth’s deliberate harming of his or her own body without the intent to die. Self-injury can consist of superficial scratches or cuts, or deep carvings and wounds on the forearm, ankle, stomach, leg or another body part.

Young people give a variety of reasons for engaging in self-injury, including, but not limited to:

• Trying to gain control or distract themselves when overwhelmed by strong emotions or unwanted thoughts.
• Releasing unbearable tension.
• Wanting to feel “something” or feel “alive” when feeling “numb” or “dead inside.”
• Communicating with others or expressing themselves when having difficulty doing so verbally.
• Punishing themselves.
• Experiencing a temporary but intense feeling of euphoria that occurs in the immediate aftermath of hurting themselves.

Self-injury and Suicide are two different behaviors and should be assessed and treated as such. However, these two distinct behaviors can occur simultaneously. And most importantly, engaging in self-injury is a major risk factor for Suicide.

When psychologists assess youths’ Suicide-risk, they should always inquire about self-injury. Similarly, when working with youth who self-injure, their suicidal thoughts, feelings and behaviors should always be assessed.

Latina Adolescents

Latina teens (particularly those born in the US to immigrant parents) report higher rates of Suicidal thoughts and attempts in comparison to their peers. There is not enough research to tell us why, but potential theories include:

• Some parents who have immigrated to the US may have limited knowledge of mental illness (including symptoms of Depression and warning signs of Suicide).
• Stigma around mental health can result in some Latino families wanting to deal with psychological issues within the family, rather than seek out mental health professionals.
• Parents who have immigrated to the US may not have the resources to access mental health treatment or there may be little to no mental health services in their local community.
• When these families do seek out mental health assessment and treatment services, assistance is often not culturally competent.

Some first-generation Latina teens describe typical teen challenges compounded by communication issues and conflict with their parents due to differing values and priorities. They report being conflicted between their parents’ expectations that they make the family their priority, be at home when not at school, and help to care for family members versus their own desire for independence, including wanting to spend time with friends, date, or get a job.

Some young Latinas suffering from Depression or Anxiety describe not wanting to “burden” their parents with their “problems” because their parents have worked so hard and sacrificed so much for their children.

The Importance of Access

Suicide deaths among young people can be substantially reduced, even without mental health treatment, by making it more difficult to die when a youth is suicidal. One way of accomplishing this is physically limiting their access to lethal means (sometimes referred to as means restriction or means reduction).

For many individuals, a suicidal crisis is temporary—sometimes as short as an hour or less. If a highly lethal method to kill oneself is less accessible, an individual is less likely to die. Even among individuals who make a Suicide attempt, the vast majority of those who survive do not go on to die by Suicide. Protecting youth from highly lethal means of Suicide attempts is key to Suicide prevention.

What we know:

• More Suicides are completed in the United States with a firearm than by all other methods combined.
• The methods used in Suicide attempts vary widely in how likely they are to result in death, with firearms resulting in death the majority of the time.
• In the United States, the risk of Suicide is two to five times higher in gun-owning homes for all household members, including youth.
• Young people who die by Suicide often use a family member’s gun.
• Most studies (although not all) have found that if a firearm is in the home, the risk of someone dying by Suicide is lower when it is stored unloaded, locked, and separate from ammunition.

The issue of reducing access to lethal means, particularly firearms, does not have to involve politics, policy, or gun control legislation. Psychologists can educate parents/caregivers about the dangers of having a firearm in the home and encourage them to remove it if their child is a high risk for Suicide. They can contact their local police station, as many will temporarily hold an individual’s firearm.

Stress Among Young People

The most recent American Psychological Association annual survey on “Stress in America” found teens reporting more stress than adults. The most common reported sources of stress in this study were school, getting into a good college or deciding what to do after high school, and financial concerns for their family. A different survey found that in addition to school, teens were also stressed by their parents, romantic relationships, problems in friendships, and younger siblings. In the APA survey, one-third of the teen respondents said they feel sad or depressed, overwhelmed, or lie awake at night due to stress.

Research has found that Suicidal ideation and Suicidal behavior are highest among youth who were both victims and perpetrators of bullying. Increases in Suicide risk appear to be similar for victims and bullies regardless of whether they were involved with in-person bullying or cyber-bullying.

Suicide is a complex behavior and is rarely caused by one factor. However, one or more stressors often play a significant role in a teen’s suicidal thoughts or behaviors.

Psychologists and other adults in youths’ lives should not minimize the stress children and teens experience, assist them when needed, and ensure that young people learn healthy ways to cope—ideally from a very young age.

Elementary-Aged Youth

Our understanding of Suicide among children under the age of 12 is limited due to a paucity of research. However, a study recently published in Pediatrics points to some important issues and starting points all psychologists should be aware of.

Children aged 5-11 who died by Suicide, were more likely to:

• Be boys
• Be African-American
• Die by hanging/strangulation/suffocation
• Die at home
• Experience relationship problems/arguments with family members

These children were less likely to leave a Suicide note. A current mental health problem was observed in one-third of the children who died by Suicide. Surprisingly, a diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD) was more common among this young group than a diagnosis of Depression. Tragically, only one-third of the children told anyone about their Suicidal thoughts, feelings or intentions before taking their own lives.

Psychologists play a key role in reducing the number of tragic youth Suicides. California has recently become the seventh state in the country to require that all licensed psychologists be trained in Suicide risk assessment and intervention. However, many youth who kill themselves are not being seen by (or may never have been seen by) a psychologist. Therefore, we must ensure that all adults raising, teaching, treating, coaching, and interacting with young people recognize youth at risk for Suicide and know who and how to refer them for help. Peers need to know how to recognize the warning signs in their friends and be encouraged to reach out to a trusted adult for assistance.

Most youth suicides are preventable. We know more now about the assessment and treatment of Suicidal thoughts and behaviors than ever in history. Psychologists can take the lead in forming a more responsive safety net for children and teens experiencing unbearable emotional, psychological or situational pain. It is, quite literally, a matter of life and death.

 *Attend the upcoming Critical Issues in Child & Adolescent Mental Health (CICAMH) conference on March 23rd and hear Dr. Lisa present key issues related to “assessing” and “treating” young people at high-risk for Suicide. 

Dr. Lisa is a Clinical Psychologist, National Speaker, Expert Witness, Consultant, and Author of several books, including “When to Worry: How to Tell if Your Teen Needs Help—and What to Do About It.”  She has been interviewed by Anderson Cooper, Bill O’Reilly, CNN, CNN International, NPR, 20/20, Fox News and in print by USA Today, US News & World Report, and People Magazine among others.

Dr. Lisa specializes in Suicide among adolescents and has worked with challenging and dangerous youth in psychiatric hospitals and juvenile justice facilities. In addition to providing high-energy and content-filled presentations to professionals across the country, She consults on issues related to Suicide and serves as an Expert Witness on lawsuits related to Suicidal individuals in correctional and treatment facilities. Find out more at TroubledTeenExpert.com.

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