A study published this past week in the journal Pediatrics shed light upon the growing mental health crisis among American youth. Between 2008 and 2015, the study documents a nearly three-fold increase in the percentage of pediatric hospital emergency room visits related to suicidal thinking or behavior. Here's the study abstract:
OBJECTIVES: Suicide ideation (SI) and suicide attempts (SAs) have been reported as increasing among US children over the last decade. We examined trends in emergency and inpatient encounters for SI and SA at US children’s hospitals from 2008 to 2015.
METHODS: We used retrospective analysis of administrative billing data from the Pediatric Health Information System database.
RESULTS: There were 115,856 SI and SA encounters during the study period. Annual percentage of all visits for SI and SA almost doubled, increasing from 0.66% in 2008 to 1.82% in 2015 (average annual increase 0.16 percentage points [95% confidence intervals (CIs) 0.15 to 0.17]). Significant increases were noted in all age groups but were higher in adolescents 15 to 17 years old (average annual increase 0.27 percentage points [95% CI 0.23 to 0.30]) and adolescents 12 to 14 years old (average annual increase 0.25 percentage points [95% CI 0.21 to 0.27]). Increases were noted in girls (average annual increase 0.14 percentage points [95% CI 0.13 to 0.15]) and boys (average annual increase 0.10 percentage points [95% CI 0.09 to 0.11]), but were higher for girls. Seasonal variation was also observed, with the lowest percentage of cases occurring during the summer and the highest during spring and fall.
CONCLUSIONS: Encounters for SI and SA at US children’s hospitals increased steadily from 2008 to 2015 and accounted for an increasing percentage of all hospital encounters. Increases were noted across all age groups, with consistent seasonal patterns that persisted over the study period. The growing impact of pediatric mental health disorders has important implications for children’s hospitals and health care delivery systems.
The study's lead author, Dr. Gregory Plemmons of Vanderbilt University speculated that bullying, decreasing age of puberty for females, social contagion, less resilience and less stigma leading to more reports of suicidal thoughts were possible contributing factors to the reported increase.
I'd like to suggest other contributing factors may be at play and challenge our readers to consider how they might contribute to a healthier and more supportive culture for kids at risk of suicidal thinking and behavior.
Technology. This study examined data from 2008-2015. Can you think of any innovation that became available around that time that transformed the ways in which teens view themselves and communicate with one another? By 2015, nearly three quarters of teens owned smartphones, 92% accessed the internet daily and nearly a quarter of teens were online "almost constantly" according to this study from the Pew Research Center. I'd argue there are at least three ways in which technology contributes to increasing rates of suicidal thinking and behavior:
- Technology provides kids with the tools to publicly humiliate one another on a scale that was never before possible. Social media and texting has also facilitated a level of vulgarity in electronic communication that didn't exist when most interactions occurred either face to face or over the phone.
- Technology intensifies the propensity common among many kids to view themselves much more negatively than their peers and reinforces their sense of inadequacy and social isolation. Kids now have raw data quantify their relative popularity through the number of "likes" and comments on their Instagram posts and other social media platforms.
- Technology exposes many kids to sexually explicit material online, which increases the likelihood of sexual behavior offline. More on that below.
School. There was an unmistakable pattern in the study data, of no surprise to those of us in child and adolescent psychiatry indicating more kids come to emergency rooms with suicidal thinking or behavior in the fall and spring, and fewer kids present in the summer. The highest rates were reported among older teens, with a 27% average annual increase between 2008 and 2015.
I'd argue that high-stakes testing in schools along with the extreme pressure kids are under to perform well enough to get accepted into their colleges of choice and to earn enough scholarship money to attend their colleges of choice, superimposed upon the increased potential for peer conflict while school is in session are all significant contributors to the higher suicide rate. We saw a huge uptick in the number of anxious and depressed kids in our practice following the 2008 stock market crash as many families had large chunks of college savings wiped out while tuition and fees continued to escalate much faster than the rate of inflation.
Family Composition/Structure. According to this study in The Lancet, kids who grow up in single parent households when compared with those in two-parent households are at more than double the risk of developing a mental health disorder during childhood or attempting suicide. The number of children growing up in single parent households continues to rise, and a minority of American children live in homes together with two parents in their first marriage. This statement isn't a criticism of the single parents, divorced parents, grandparents or foster parents who heroically raise children in difficult circumstances, but we're going to see more and more kids with serious psychiatric issues as fewer and fewer grow up with a mother and father who are married to one another.
The Declining Impact of Christianity. I've historically seen lots of kids in my practice with profound unhappiness who wished they were dead, but were reluctant to take their own lives out of fear for the eternal consequences of their actions. As more and more teens are raised in non-Christian families or families with no religious affiliation, I'd hypothesize that more teens are now less afraid of suicide than in the past.
The Sexual Revolution. While it is true that the percentage of American teens who are sexually active has been relatively stable over time, it is also true that public health officials are either oblivious to the links between early sexual activity and suicidal behavior or deliberately ignore the available research for political or public policy reasons. Furthermore, sexual activity among U.S. teens is highly correlated to suicidal behavior resulting in the need for medical attention, especially among youth from sexual minorities. And among the millennial generation represented in the Pediatrics study, the rate at which they identify as LGBT is more than double that of any previous generation.
- Overall, students who experienced sexual contact with the same or both sexes are approximately over three times more likely to have been seen by a doctor or nurse following a suicide attempt compared to students who had sexual contact with the opposite sex only and over twelve times more likely to have been seen by a doctor or nurse following a suicide attempt than students with no sexual contact.
- Boys who experienced sexual contact with the opposite sex only were seven times more likely to have been seen by a doctor or nurse following a suicide attempt compared to those with no sexual contact.
- Girls who experienced sexual contact with the opposite sex only were more than three more likely to have been seen by a doctor or nurse following a suicide attempt than those with no sexual contact.
So, what should adults who care about the emotional well-being of vulnerable youth do to reduce the risk of teens in their lives ending up in a hospital emergency room?
Responsible adults look after their children during their time online. In a country where adults are inclined to call social services when they see an unsupervised kid on the playground we seem to think it's OK to allow our kids unfettered access to environments filled with predators, pornography and openly hateful peers. Ignoring your child's online life is no different than trusting them and a member of the opposite sex to hang out in their bedroom with the door shut.
Avoid words and actions that unduly add to the pressure kids experience at school. If you're a Christian parent, do you believe that God has a plan for your child's life? If that plan involves attending an Ivy League college or some other prestigious school, do you believe God is capable of providing them access to the school and the financial means of attending? How much does your teen see you worry about their academic performance and future plans? What does your worry communicate to them?
Take your responsibilities as a spiritual leader seriously. While most of the research isn't specific to kids, faith appears to be a protective factor against suicidal behavior. We also know that religiosity in teens is a predictor of their ability to delay the onset of sexual activity.
This is purely anecdotal, but a couple of months ago I was speaking with a colleague who recently accepted a position in which they were providing ongoing treatment to a population largely composed of kids who had recently been discharged from local psychiatric hospitals. Of the first fifty kids they met with, one came from a family that was actively involved with a local church.
Familiarize yourself with the risk factors for suicidal behavior in teens and don't be afraid to ask your teen how they feel! It's always a good idea to ask when you see signs of depression or suicidal behavior, even if you feel uncomfortable. Be prepared to take the following steps if a teenager you love is thinking of suicide or serious self-harm.
Are you a pastor or ministry leader searching for resources to better understand how to support children, adults or families affected by mental illness in your church or in your community? Check out Key Ministry's Mental Health Resources page, containing links to video, articles and topical blog series designed to help you minister with persons with common mental health conditions. Also available through the website are a free, downloadable mental health ministry planning tool designed to accompany Mental Health and the Church, along with links to recommended books, like-minded mental health ministry organizations, relevant research, sermons addressing mental illness, social media resources and a compilation of stories from families affected by mental illness.