Advice for Parents on Understanding and Preventing Suicidal Behavior

Q&A with David A. Brent, M.D.

Distinguished Professor of Psychiatry, Pediatrics, Epidemiology, and Clinical and Translational Science and Endowed Chair in Suicide Studies

The University of Pittsburgh

2006 Ruane Prize for Outstanding Achievement in Child and Adolescent Psychiatric Research

2001 BBRF Distinguished Investigator Grant

In 2017, suicide was the tenth-leading cause of death in the United States, claiming the lives of over 47,000 people. Dr. Brent, you have treated and counseled numerous patients over the years who have engaged in suicidal behavior.

Before we discuss some of the warning signs and strategies that loved ones and friends can pursue in such cases, allow us to ask a basic question about risk. Could you explain to us about how the suicide rate changes with age? People often don’t understand the relation between suicide attempts, on the one hand, and deaths from suicide, on the other.

While young people attempt suicide more, the rate of suicide (deaths) goes up with age. There’s a paper that Dr. Ronald Kessler [a leading American epidemiologist] published in 1999 that shows that the incidence of suicidal behavior peaks in late adolescence and early adulthood. The first attempt occurs around then, typically, but then the number of suicide attempts declines relative to suicide deaths, over time with age. In people over 60, one out of every eight suicide attempts may be fatal. In a young person that might be one in 200.

What is going on developmentally in young people that may explain this?

Nobody knows for sure, but it parallels an increase in risky behavior in general such as substance misuse and unprotected sex, as well as the beginning of various psychiatric disorders and mood disorders. As kids go into adolescence, the limbic area (the “subcortical” part of the brain) that’s involved in emotions and reward develops first. Whereas the prefrontal cortex (higher-level processes—the braking mechanism) develops later.

This fits with the fact that a lot of suicidal behavior in adolescents is very impulsive, and why the ratio of attempts vs. deaths declines with age. It’s because suicide attempts become much more planned. A second developmental issue to consider is that adolescents have a shift in their circadian (24-hour day/night) rhythm, where they get tired later and go to bed later—but they have to get up early for school. A substantial proportion of adolescents are sleep-deprived. And we know that sleep problems are an imminent predictor of suicidal behavior and in fact magnify the issue of the imbalance between the prefrontal cortex and the subcortical part of the brain.

What signs could indicate that your loved one is contemplating suicide?

The most obvious sign is that they are talking about suicide. There used to be a myth that people who talked about suicide didn’t do it. But it turns out that people who talk about it are the most likely to engage in suicidal behavior. So that type of communication, or even more vague statements like “People would be better off without me” or “I wish I was dead” should be very concerning. Another thing to watch out for is if somebody engages in any kind of preparatory behavior such as stocking up medication or practicing tying hang nooses.

Apart from the obvious signs of talking and preparatory behavior, what are some more subtle indications?

Kids who engage in frequent non-suicidal self-injury such as self-cutting. An isolated self-cutting episode is very common, but repetitive self-cutting is unusual and is a strong predictor of suicidal behavior. I would also look out for kids with sleep problems and kids who show signs of moodiness, irritability, withdrawal, and difficulty regulating their emotions. If somebody has changed the way that they relate to their family, their friends, or how they’re doing in school, that’s a sign that something is amiss. Kids engaging in other kinds of risky behavior are also more likely to engage in suicidal behavior. Post-traumatic stress and any psychiatric disorder can also increase somebody’s risk for suicide.

Could you recommend some resources if we suspect somebody is at imminent risk?

I think it’s reasonable to ask somebody directly if they are thinking about wanting to die. And if they say yes, you could say, “Would you like to get some help? There are things we can do to make you feel better. Do you want me to help you try and access that?” And in the rare instance when the person refuses and you feel that the situation is imminent, there is the national suicide hotline (1-800-273-8255). For kids, particularly, since a lot of them don’t like to talk on the phone, there is Crisis Text Line, where they can text HELLO to 741741 and get texting support. There may also be a local mental health crisis line. In our region (Pittsburgh and western Pennsylvania) we have “Resolve,” which provides mobile crisis services. They’ll send somebody to your house to do an assessment. Other localities may have similar services—it is worth checking. And finally, the police are also a resource.

What if there’s more of a subtle underlying concern—not necessarily regarding an imminent situation—that my loved one is potentially thinking about this?

You can arrange for an assessment either with their primary-care doctor, or a mental health professional if you know of one or have access to one. And the way you would do that is you say to the person you’re worried about, “Look, I’m concerned about you. Things seem different, and not in a good way. And I think it would be helpful to get a better idea about what’s going on and what might be bothering you, because there are ways to make it better.”

In terms of people who are actually in the care system, should the family be brought in to be part of the individual’s treatment?

I would say in general the family is very important. Sometimes a patient may say to the doctors or others involved in their care, “I don’t want you to have any contact with my spouse or my family.” But as a professional, a mental health professional also can say to them, “I won’t really be able to effectively treat you if that’s your stance. Let’s talk about that.” Because people don’t make suicide attempts in isolation. There often are interpersonal motivations. They feel isolated, they feel like nobody cares. They feel they’re a burden on people. And so being able to mobilize that family support is really critical.

It’s true that sometimes families are toxic, and then you have to use your clinical judgment. But most families are more helpful than harmful and are well intended. I think that should be the starting assumption of the clinician in reaching out to relatives.

After a suicide attempt, what can you do to support a friend in their recovery?

You could ask them, “How can I be most helpful to you? Do you want me to ask you how you’re doing? Are there things I can do, or we can do together, that would be helpful?” Ask them because some people don’t want to be treated with kid gloves and don’t want to feel like a victim. Be supportive and in touch with them and let them know that if they feel despondent, they can reach out to you.

And if you’re a parent and have a presumably closer relationship, is there something additional you should do?

I think it’s similar, but there are more ground rules. Kids want to be treated the way they were before the attempt happened. And parents are freaked out because this happened and maybe they didn’t even see it coming. So now they’re hovering. And so, you want to achieve a negotiation in which the kid wants to know from the parent, “What do I need to do to for you to trust that I’m doing okay?” For their part, the parents need to be able to tell their kid what they need from them to be able to feel confident that the kid is doing all right.

It’s a negotiation. Sometimes as a therapist you have to say to the parent not to err on the side of caution to the point that they’re actually making something worse. Or you have a scenario where a kid is relatively early in their recovery but they’re doing well and now they have an opportunity to study abroad. This is something that could be really life-affirming for this kid, something they were looking forward to and you don’t want to punish them for what happened before. The whole point of trying to keep them alive is so they can have these kinds of experiences and grow and develop.

Therefore you acknowledge the dilemma by saying something like, “What could we do to make this situation safer? Because we want you to be able to grow and have life-affirming experiences.” And you see where the conversation goes. On the other hand, some kids are doing poorly and then it’s a different conversation. But for other kids, I think that you can err too much on the side of caution. And kids might become unwilling to disclose that they’re in trouble because they feel that it’s going to eventuate in restriction. It’s much better to have the conversation about the dilemma than it is to try to immediately drill down and come to a decision.

That’s tremendously helpful, Dr. Brent. Any other advice for parents as they move forward?

A lot of times parents feel that it’s their fault. And maybe there are things they could’ve done better. But kids don’t come with an operating manual, and most parents aren’t equipped to deal with suicidal crises. So just realize that you’re doing the best that you can. You could probably do better. You need specific advice in these cases that you wouldn’t have needed for a kid who didn’t have these issues. These things happen without it being anybody’s fault. Don’t get caught up in apportioning blame. Instead, try to figure out solutions that will make your family more harmonious, safer, and more fulfilling for everyone.

— Written By Peter Tarr

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