Suicide rates are increasing across all populations. I talk about this regularly with clients, and in each and every class I teach academically, as nursing is the profession most at risk for suicide. A troubling pattern though among adolescents is especially concerning. Two of every ten teenagers have seriously considered suicide, and those of color, as well as LGBTQ+ youth are the most affected. The Centers for Disease Control and Prevention (CDC) reports that 30% of teenage girls seriously considered committing suicide and 13% attempted, between the years of 2011 and 2021. Eighteen percent of girls reported experiences of sexual violence in just the past year (CDC, 2019). Suicide statistics jump even higher for LGBTQ+ tees to 45% seriously considering it and 20% having attempted.
One of my own sons suffers from significant #anxiety, depression, ADHD, and has expressed having contemplated his own plan for suicide. Before I even heard him speak this, I feared it was true, but it punched me all the way to my core to hear him admit it. I have six children of my own. We have endured sexual assault, cyber stalking, learning disabilities, school bullies, two traumatic brain injuries, seizures, emergency surgery, personality disorders, alienation, arrest, and one of my babies has proceeded me in death. Parenting is exceedingly challenging, but there is no fear that even remotely compares with the reality that your child might feel so hopeless, so sad, or so lonely that they believe the only way out, their only option at all, is to end their own life.
These statistics paint a dismal picture of mental health among our youth. There isn't a lot of research specific to our little ones and suicide either, to help us better understand. We speculate. We blame parents and their home life. We blame #bullies and social media. We even blame their anti-depressants or their diet or screen time, but what is known is that suicide is very complex, very nuanced, and we need to approach this in a very holistic way.
As of 2021, suicide became the second leading cause of death for people between the ages of ten and fourteen (CDC, 2023). Adolescent Black girls have the highest increase in suicide attempts, but overall American Indian and Alaska Native youth had the highest rate of suicide in 2021. Our littles are in distress. More than half of all girls report feeling sad and hopeless, as well as nearly three of every four teens identifying as LGBTQ+.
As a family nurse practitioner and primary care provider, certainly I am often digging into the literature to see how I can better help my own clients, and my own children, but conventional medicine is largely about symptom management. Aggression and impulsivity is significant in those who ultimately do commit suicide so addressing these behaviors can be very important in preventing more catastrophic outcomes, and admittedly, these behaviors aren't always as overt as one might imagine. Alcohol and drugs can also play a role and again, we never think this is our child. I can't even count the number of times I have asked questions of teens in my practice, regarding their mental health, and had parents absolutely blind-sided by their answers.
The discussion around suicide in functional and integrative medicine is a little more hopeful, addressing brain health, neurotransmitters, epigenetics, and hormones, even nervous system regulation and somatic trauma, but this issue is so profoundly epidemic that we have to think more symptomatically. Expanding that to look more intimately at neuroplasticity and the healing modalities more common with trauma such as somatic therapies, grounding, vagal nerve and EMDR are also incredibly helpful, but none of these are remedies in the midst of crisis. Understand though that trauma, even chronic stress, does compromise the brain, particularly the prefrontal cortex where executive function and regulation of emotions and impulses occur. We can rewire this insult and heal if we lean into acknowledging this potential in our children, and utilizing diverse healing modalities.
Schools that have adopted the Signs of Suicide (SOS) program have found their own rates of attempted suicide decrease by as much as 40 to 64% when teens are educated about signs of suicidal behavior and how to get help, which is absolutely incredible, but schools are just as maxed out, understaffed and underfunded, as primary health care. Peer support is found to have a greater impact on college kids than even their family's support. Social connectedness, youth engagement, and positive school climate that affirms a student's effort in seeking help emotionally and mentally is vital, but sadly, not the standard.
Where's the Safety Net?
Certainly as a practitioner, maybe even more especially as a nurse-midwife, I have had a number of clients express their desire for self-harm and suicide. Parents too, have contacted me with concerns, and the mainstay in healthcare has long been to take them to the emergency room. The reality is though that unless they are willing to say they are immediately planning to hurt themselves or someone else, they are just going to release your child and refer to social and emotional therapy. This is likely unnecessary for teens most of the time, but it is how many schools will respond when informed of a child's plan. The other reality is that even after a period in the hospital, suicide rates increase by 100 times in those first few weeks after discharge.
The TRAILS Suicide Prevent and Risk Management program works with schools to build suicide prevention policies and staff trainings aligned with today's best practices, and they put a particular emphasis on building connections between schools and outside mental health professionals. Currently these relationships are few, but even when the need is identified, many parents express concern that they have no coverage for talk therapy or psychology evaluation, or that the waiting list is more than a year long. Others have told me they can't find anyone that seems helpful or too often the goal is to diagnose and blame, rather than equip and heal.
A Crisis of Social Ignorance, Negligence & Discrimination
It is clear even to me, a white woman who has some level of privilege and therefore ignorance, that our society has little reserve when it comes to invalidating and dehumanizing those who present themselves differently. Most of the research regarding teen #suicide has focused on adolescents who are white. We really don't know the depths of consequence trauma and #discrimination are casting on these individuals, but it's clear that suicide risk can be tied into the overall social climate.
We do know that belonging has a greater impact on your life expectancy than diet, exercise, and smoking combined. We are innately meant to be in connection with others as living within a protective tribe has always been paramount to survival. Outcast from the social norm then impacts one's sense of belonging. I hesitate to even share this because I know my own grief and suffering fails miserably in comparison to those who suffer discrimination because of the color of their skin, which they can't escape in any environment, but having been ostracized, bullied, threatened, and dehumanized as a midwife was quite traumatic for me. This followed my own alienation from my family and foster care as a child. It took a significant amount of therapy, self-investment, and even some time utilizing benzodiazepines to help me recover from chronic panic attacks into my fourth decade. Even after those resolved though, I suffered years with my nervous system simply freezing up, the not-so-often-talked-about-sibling to both fight and flight.
It really doesn't take long before we write a narrative that we aren't wanted, that everyone else will be better off without us when it seems society has cast us out. It's easier to believe the bad stuff, and this wiring in our brain can be hard to challenge. It requires that we separate ourselves from it, observe it, evaluate that message, and ultimately edit it. Far too many have this sort of "less than" narrative in the core memory of their cells. We know because of ancestral cell trauma that Women of Color simply haven't the same level of resiliency in childbirth, so no matter their social status, their education, their financial resources and family support, they are more likely to not survive complications during childbirth than white women suffering the same complication.
Teenagers, who live in fear of school shootings or who have to grow up learning a different set of social rules because of their skin color, already operate at a higher level of stress, so their resiliency is reduced. Any threat, as registered by their own brain, increases their mental and emotional burden. It further triggers their nervous system. The longer one endures this chronic stress, the greater our brains become at identifying and responding to potential threat which is no different than our biceps becoming more toned and powerful because we regularly challenge them by adding increased weight to our curls. We adapt, but a threat is a threat. The center of our brains regulating threat doesn't discern if this threat is in fact a sabor tooth tiger about to eat your hind-end or if it is yet another social media slur that violates your rights and questions your worth. Our agency responds in same. When our youth exist in an environment that is pervasively invalidating whether that is in school, in their social groups, church, their home, in their ancestral cell messaging or even in their own narrative, suicide risk elevates.
Create a Plan
When there is no plan, we end up treating in triage. We suppress, ignore, hide, and hope it's a phase that will resolve itself. We hold our breath and say our prayers. We address it only when forced to acknowledge it, which means repeated trips to the emergency room or worse. When families live on the fringe of society - maybe they homeschool, maybe they decline vaccinations or most all of conventional medicine, maybe they are gender non-conforming, neurodivergent, or just have real trauma from having been victimized from inequalities of power, they often freeze up when they recognize no good options before them.
My son was part of a "wrap-around" program in the county we previously lived which was suppose to include the support of the school, his therapists, his family and friends, mentors, and case managers. This was actually a grant program in the state of Indiana in effort to address teen suicide, but ironically, the case manager was quite clear that identifying and diagnosing was really the effort and solutions they really had very little. While they allocated a great deal of time to discussing "the plan of action," in reality, the so-called experts repeatedly said there really aren't a lot of options unless you want to admit him and you would still only get 48 hours of care and then an even more angry child likely to reject you, disconnect from you, and hate you even more. These programs, without sufficient resources, ultimately exhaust everyone involved so triangulation and manipulation often become the more commonly utilized tools and parents are typically to blame or the child is criminalized.
One thing experts do agree on is that teenagers look at the world differently. They have more absolutist views. They see things in starker, more rigid color with fewer grays. This makes the problem see far more daunting and consuming, and solutions more elusive. Adults are better able to see that they have a history of resiliency and that life is full of both good and bad.
When children and teenagers aren't regulated emotionally, they can harm themselves and others. They can spiral down that mental black hole without a harness and life rope. When our thought patterns repeat the same horrific solution over and over in times of distress, it more quickly becomes the solution, and the only solution, when we face troubling times. Our thoughts are just that, thoughts. They are not us, but it can be hard to separate yourself from your thoughts and observe them, and as a child, it can be a real challenge to disengage from these intrusive thoughts and instead allowing them to tread a pretty worn path in their neuroplasticity so that in that moment of despair, it does seem the most rationale response, because it certainly is the most familiar.
The even greater travesty is that in many cases, parents aren't much more emotionally regulated themselves. Addiction is evidence that these skills aren't abundant. At the core of ADHD and neuro-divergency is emotional dysregulation, and many, many adults are now self-diagnosing themselves with ADHD never realized as a child. We numb ourselves with work. We numb ourselves with alcohol. We overeat. Porn becomes our afternoon relief. Toxic relationships are our pattern. We're co-dependent, people-pleasers, and we manifest martyrdom complexes. All of this, any bit of it, is evidence of limited emotional regulation. Hey, if you're in the "just stand up and shake it off" generation, this is you, or the "stop crying or I will give you something to cry about" crowd; it's you too.
When we lack emotional dysregulation we are often just getting by, exhausted, and overwhelmed. We haven't any real hobbies because we don't have the mental space for it. We drop ourselves on the couch and let the television entertain us or we sit on the phone for hours, swiping through tick tock clips. Sound overwhelms us. Lazy people annoy us. Ignorant people make us want to punch them in the throat, or so I am told. But we are not able to co-regulate our children when we can't even regulate ourselves, and we certainly can't model emotional regulation to our children if we haven't yet acquired these skills ourself. This is why finding a good therapist is not always helpful once ominous issues are apparent. This is a maintenance plan. Good talk therapy is for your brain what the gym is for your body. We need to continue to process our experiences, self-evaluate our responses, add more tools to our emotional intelligence quotient, and hold ourselves a little accountable for our own evolving maturity. We all have some level of trauma we will spill onto others if we aren't doing our due diligence.
What is Your Child's Ability to Function?
When our nervous system is well regulated, we are capable of functioning in a way that is in line with the expectations of meeting our daily needs. This is a teenager who has good attendance, who performs well on their tests and turns in assignments, they are aware of what is expected of them and they get along with others at school. They are satisfied in and out of school and have a reasonable desire to participate in both school and family life, whether or not there is conflict. They eat, sleep, and move.
When we live in a state of fight-or-flight though, our brain prioritizes survival. Our teenagers will miss the little things like instructions, assignment deadlines, and they will forget their computer chargers. They are easily irritated because everything is perceived as a threat, even when it really isn't. They lack motivation and have intrusive thoughts. They may have difficulty sleeping and they aren't likely to invest themselves in healthy habits, although girls are more likely to because they better mold themselves into social expectations. Trying something new is likely to feel like a threat and be strongly resisted. They may isolate themselves and not pay a lot of attention to friends, or be over thinkers, noticing every tone of voice and facial expression.
As adults, we can appreciate this. When we are always on the go, it can be impossible to just sit in silence. Massages aren't enjoyable because we are working down our mental to-do list. Meditation is literal torture. The thought of turning off one's thoughts seems like an impossible reality. When we become accustomed to stress long-term, it becomes our norm, but a healthy, regulated person will thrive in every way. Someone in survival mode, is just trying to get by. The concern is that this leaves little reserve for managing the insults life will inevitably through at you, especially when you are young with few emotional resources.
Imagine your child being so emotionally regulated that he feels comfortable crying. Did you know that crying helps move the nervous system back into a #parasympathetic state? So does rocking and dancing and laughing. Can you imagine your son embracing a friend of his who is crying, hugging him and giving him space to feel his big emotions? Can you imagine your child being spoken to in a cruel manner by a bully and recognizing that had nothing to do with them whatsoever, but instead was a reflection of how the bully thinks of themself? This takes so much work, and there are certainly boundaries in this too, but this type of regulation is where our teens better thrive.
The reality is too though, that suicidal ideation is a fairly common occurrence. Most people have thought about it at some point in their life. For most adolescents this is also quite manageable. It may be a lifelong vulnerability, and I would want to assure we are protecting the brain and regulating emotionally. This is where I like to invest in my pediatric clientele, in the relationship, but this isn't done well when the only outreach is for triage purposes. Wellness exams allows me that opportunity to explore beyond more common complaints, and also to educate.
There are scenarios that can elicit suicidal behaviors that are not necessarily reflective of their emotional or mental norm. For example, there are many medications that can cause severe mood changes, including suicide, and for the life of me, I can't understand why so many practitioners prescribe these without a second thought or even mention of the risk. Antivirals given for flu, for example, pose this risk while only cutting off about one day of their flu symptoms. Steroids as well, can cause significant psychological ramifications, including suicide, but are commonly prescribed inappropriately just to appease consumers who believe they are necessary. New anti-depressants have risk for suicide ideation, particularly in teens, so when newly prescribed, these children should be under a watchful eye for the first few weeks.
More importantly, are you asking your child about whether they have thought of hurting themself? If you don't feel comfortable doing so, I am happy to have that conversation. I will hold space for it. You will not cause suicidal behavior by asking about it. If the answer is yes, we can start to discuss it and identify the underlying cause, strategize how to offer your child a safe place, identify how to create new coping strategies, and consider more aggressive conventional management while in triage mode. I was the mom afraid of the diagnosis, afraid of the implications of pharmaceuticals, afraid of not ignoring the underlying issues, but I think what I wish I had known is that emotional and mental health crisis isn't as apparent as hemorrhaging. We would never offer herbs to someone bleeding out; we use our anti-hemorrhagic drugs and once stabilized we can support with more integrative options. When your kid isn't thriving, rather than sink into that as your norm, not sure what to do, connect. Let me help you discern if we can get serious about supportive practices and rewire some neuroplasticity, correct some imbalances in nutrition or even inflammation or hormones, but also, maybe we need to consider some short-term triage control? It can be a lot easier to implement #healing practices when you aren't drowning in emotional crisis.