Marc is an 11-year-old boy who was seen in our hospital’s Urgent Care Clinic after he was referred there from the Emergency Department (ED). His parents had taken him there after he told them he wanted to kill himself.
It wasn’t the first time Marc had told his parents he wanted to die. He said the same thing a year earlier after having cut his forearm with scissors and considering hanging himself with a belt. When the psychiatrist asked Marc how and when he was first exposed to self-harm and suicide, he answered, “I don’t remember not knowing about it; it’s everywhere—social media, online, television, my friends. Everyone talks about it.”
As mental health professionals, we feel privileged to work with children and families to address their mental health challenges and to see their return to health. But after a shared six decades working as child and adolescent psychiatrists, we are alarmed, more alarmed than we have ever been in our long careers, as we see trends going in the wrong direction.
You may have already read that hospital EDs have seen unprecedented numbers of young people presenting with self-inflicted injuries, thoughts of suicide, and suicide attempts. More of them are getting admitted to hospitals—generally a last resort, given the necessarily restrictive nature of psychiatric inpatient units and the risk of “cocooning” the child to an extent that makes it harder to return to “real life” at discharge. Even more tragically, the rate of deaths by suicide is climbing among children and teens in the United States, particularly among females. We don’t have reliable national data in Canada at this point but are concerned there may be a similar trend.
As child and adolescent psychiatrists working in a large Canadian urban children’s hospital with a busy emergency department, we are living with this new reality. As we—together with scientists, public health experts, other mental health professionals, children, and families—seek answers to the reasons for these alarming trends, we know one thing for certain. We need to come together as a community to address this crisis; no single family, no single mental health professional, no single school, no single policy, no single piece of legislation will be sufficient to push back against these alarming statistics without all of us working together.
There are a number of theories, many of them persuasive, regarding potential contributors to this increase in ED visits for self-harm and suicidal thoughts and behaviours. One, which has a positive side, is a new willingness among children and families to speak up about mental health concerns and to seek help. As mental health professionals, we are delighted by this and need to work with hospital leaders and policymakers to ensure that this courage is received with appropriate services and support.
However, the rise in admissions and completed suicides also has darker roots. We know the negative impact that high rates of social media use can have on mental health, particularly among young girls who are its most active users. The constant comparison to celebrities, to shiny images of social success can be toxic for even reasonably confident adolescents. Social media and the internet have also permitted some sinister movements—cyberbullying on a 24/7 cycle and sites that promote self harm and suicidal behaviours with encouragement, methods, and a sense of community. Indirect impacts of our children’s engagement with their electronic devices are their effects on sleep and levels of physical activity; disruptions to both are known to be major contributors to negative effects on mental health.
Children also tell us they are stressed about their futures—worried about global warming, political trends, job insecurity. It may be that these stresses are also mediated by the amount of time they spend online, where they are exposed to newsfeed after newsfeed of terrible events, reprehensible behaviour by adults, and negative predictions about the future. This exposure skews reality, persuading young people that the world is dichotomously divided between the glossy worlds of Instagram, Snapchat, and TikTok, and the dangerous, unpredictable, apparently ungovernable world of news that may or may not be reliable, populated by adults who break every rule of social engagement that schools try to enforce.
Media and communications groups that dabble in youth mental health—an enormous market—sometimes get it right, and more tragically, sometimes get it wrong. 13 Reasons Why, an enormously popular Netflix show, purported to bring self harm and suicide out of the shadows. However, it tragically ignored expert recommendations on how to do this safely. Two large studies (one on which a colleague of ours is a co-author) published in the last year demonstrated a rise in completed suicides among the show’s target audience group in the three months following its initial broadcast.
While this link cannot be definitively proven to be causal, it is undoubtedly a warning signal about the need to scrutinize these types of entertainment offerings with a more rigorous safety lens, and to counter them with exemplars of resilience such as Lady Gaga and Oprah Winfrey who have disclosed past suicidal thoughts and provide inspiration and hope on how they overcame these and found better lives.
As mental health professionals, we know that these issues extend beyond our capacity to address. Hospital admissions may keep children safe for a brief period of time and allow us space to try to teach them and their families better coping strategies, or when necessary, to start a medication, but sending them back out to a toxic environment presents enormous challenges and heightens their risk of relapse.
How can you help? Here are some ideas:
1. For those of you who are parents, grandparents, uncles, aunts, mentors, educators, or who work with children and adolescents, educate yourself about what they are exposed to.
- Ask non-judgemental questions about what they are watching on social media and online.
- Ask them to share them with you and then keep asking questions rather than lecturing.
- Ask them about their friends, about what they think the impact is of their social media use, but from a place of curiosity, not judgment.
- Ask—don’t avoid—questions about self-harm and suicidal thoughts and educate yourself on how to respond (we’ve provided some good, evidence-based resources below) and figure out how to get help if needed.
2. Advocate in your school and community for more afterschool activities and opportunities for educating young people on what they can do to help themselves.
3. Talk about the world and current events. Limit your young child’s exposure to sensationalist news outlets and talk with your adolescent about the skewed perspective on the world that over-exposure to news may bring. Engage with your child about the political figures of the day. Ask about their views before sharing your own opinions and values, and listen carefully and respond thoughtfully to what they have to say.
4. If your own family isn’t at a stage where you need to be present around the clock, volunteer some of your free time to support child and youth mental health. If your family does need you, consider whether you can volunteer as a family.
5. Contact your local school boards and politicians to ask questions about what is being done to help children and youth in your communities. Are they getting physical activity at their schools? Do their schools have an anti-bullying strategy that is effective? Is your community safe for children to wander alone? Is there enough green space, daycare placements? Are children living in poverty? What mental health literacy opportunities are available to children and families?
6. Lobby your elected officials to work with media and communications corporations to listen to the evidence on how to portray mental health and to hold them accountable when they don’t. These businesses have enormous power and influence on our children’s minds and they need to use it well. Advocate for more regulation of the internet to ensure that children can be protected from individuals who deliberately try to harm them.
As mental health professionals, we continue to feel privileged in our work. But we are alarmed, more alarmed than we have ever been in our careers. And we need your help. Marc and his parents need your help. Working together, we can make our communities safer for our children.
Bridge, Jeffrey A. et al. Association Between the Release of Netflix’s 13 Reasons Why and Suicide Rates in the United States: An Interrupted Time Series Analysis Journal of the American Academy of Child & Adolescent Psychiatry, Volume 59, Issue 2, 236 - 243
Burstein B, Agostino H, Greenfield B. Suicidal Attempts and Ideation Among Children and Adolescents in US Emergency Departments, 2007-2015. JAMA Pediatr. 2019;173(6):598–600. doi:https://doi.org/10.1001/jamapediatrics.2019.0464
Curtin SC, Heron M. Death rates due to suicide and homicide among persons aged 10–24: United States, 2000–2017. NCHS Data Brief, no 352. Hyattsville, MD: National Center for Health Statistics. 2019.
Kelly, Yvonne et al. Social Media Use and Adolescent Mental Health: Findings From the UK Millennium Cohort Study The Lancet EClinicalMedicine, Volume 6, 59 - 68
Niederkrotenthaler T, Stack S, Till B, et al. Association of increased youth suicides in the United States with the release of 13 Reasons Why [published online May 29, 2019]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2019.0922
Viner RM, Gireesh A, Stiglic N, Hudson LD, Goddings AL, Ward JL, Nicholls DE.
Roles of cyberbullying, sleep, and physical activity in mediating the effects of social media use on mental health and wellbeing among young people in England: a secondary analysis of longitudinal data.
Lancet Child Adolesc Health. 2019 Oct;3(10):685-696. doi: 10.1016/S2352-4642(19)30186-5. Epub 2019 Aug 13.