Director's Innovation Speaker Series: Youth Suicidal Behaviors: Where Do We Go From Here

Transcript

SHELLI AVENEVOLI: It's my pleasure to be here today. So just for those of you who don't know, I'm Shelli Avenevoli, the Acting Director at the National Institute of Mental Health. Thanks so much for joining. We have a few people in the room, but I know there are a lot of people online. So, thanks for joining us.

Many of you know that the NIMH Director's Innovation Speaker Series is one of our premier speaker series. It's meant to encourage broad and interdisciplinary thinking about scientific initiatives and programs and really press for theoretical leaps in science.

Innovation speakers are encouraged to describe their efforts, breaking through barriers, and developing successful new ideas, maybe even working outside their primary area of expertise, in ways that push the field forward.

And we've used this series to discuss the meaning of innovation, creativity breakthroughs and paradigm shifting. So, with this in mind, I'm very pleased today to welcome our speaker, Dr. Arielle Sheftall.

Dr. Sheftall is an associate professor at the University of Rochester Medical Center in the Department of Psychiatry. She is affiliated faculty member in the Department of Psychology at the University of Rochester as well and Director of Academic Affairs for the Diversity Inclusion Culture and Equity, or DICE Board, for the Department of Psychiatry.

Her research focuses on the developmental mechanisms in early to middle childhood that can concur vulnerability to future suicidal behaviors. Very important area. It is her goal to frame targets for early intervention to decrease the incidence of first suicide attempt.

Additionally, Dr. Sheftall studies the racial disparities present in suicidal behavior among youth. She's a member of the Congressional Black Caucus Emergency Task Force that developed the Ring the Alarm Report and continues to exam risk factors, practice, policy, recommendations necessary to decrease suicidal behaviors in Black youth.

She's also a subject matter expert for the American Foundation for Suicide Prevention and the Substance Abuse and Mental Health Services Administration, or SAMHSA, focusing on mental health promotion and suicide prevention for Black individuals.

Dr. Sheftall has received funding from NIMH and the AFSP, AMERICAN FOUNDATION FOR SUICIDE PREVENTION. And finally, she is apparently a big Green Bay Packers fan, a Columbus Crew and a Boston Celtics fan. So, despite all this, welcome. No, I'm joking. Thank you for being here.

ARIELLE SHEFTALL: Well, thank you so much for having me. I am very honored to be here. I never thought, to be very honest, that I would be present in the NIMH world and very grateful that I had great mentors to keep pushing me and to keep telling me that my work was important and that I needed to be a researcher that did good, positive things in the world. And I am so grateful and thankful for all of those people that continue to mentor me, and my husband, who I have put through many of traveling states and journeys. So, thank you, thank you, thank you, and to my children as well, for being around and just pushing me to keep moving forward. So, thank you.

So, without further ado, we're going to talk about youth suicidal behaviors, where do we go from here?

So just so everyone is aware, I do receive funding from the National Institute of Mental Health. I don't have any other relationships to disclose.

And I always start every presentation, no matter where I am, no matter what I'm doing, with these numbers in mind. So, I believe that everybody that is watching today, everybody that's in this room today, can actually make a difference when it comes to suicide prevention.

I think even though, yes, it's a hard topic to talk about, it's a hard topic to think about, but in the end, we all can do something. Whether it be a listening ear for someone, just wanting to speak and say whatever they're experiencing at that moment in time, that emotion that they're struggling with, or whether it be that they really need someone else to speak to immediately.

So, 988 you can actually call, you can text, you can chat with this number to actually get that person help. And then also the Crisis Text Line, 741 741, you text "hello" and someone will respond. I always start every presentation with this slide because it's probably the most important one you're going to see today. They're available 24 hours a day, seven days a week, 365 days of the year.

So, without further ado, I'm going to talk about some numbers. So again, heavy topic. I don't want to belittle that in any way, shape or form. If you need a break, if you need to step away, I'm not bothered by that. Please understand that is okay to do.

I'm going to talk about youth suicidal behaviors, specifically deaths, specifically self harm behaviors. So again, take the break you need and come back or don't come back. That's okay. I am not offended.

So next slide, please. So, we're going to start with preteen youth. So, five to 12 years of age is the age group that I focus most of my research on, but not always. So, we'll get to the older age group in a little bit.

But this is numbers of suicide deaths, the gold bars, and the suicide rate is actually the blue line for youth in the U.S. five to 12 years of age. And what you'll notice is that from 1990, when we first started collecting this information, to 2022 next, please we've actually seen an increase of 110 percent, so 110 percent increase in the deaths by suicide in our young people five to 12 years of age.

And when you look just at the past decade, so 2012 to 2022, what you'll notice is that we've actually seen next, please a 68 percent increase just in the past decade. So, as you can see, these numbers are increasing. We have seen decreases. I don't want to belittle that in any way, shape or form. But overall, when you look at the picture, not a good one, not a good one.

Next, please. When you look at self harm behavior, so that behavior, it ranges. It can be a suicide attempt where a child has actually tried to die by suicide. So that's an inflicted injury upon themselves. But that injury has caused harm or has not caused harm but they're in the emergency department to be seen. Or it could be a non-suicidal self injury, so hurting one's person on purpose without intent to die.

So, self harm is kind of broad, so everybody is aware. It includes a number of avenues, so to speak, of behavior. But when you look at the data for five to 12 year olds, from 2001 to 2022, we've actually seen a large increase in this age group for our five to 12 year olds. To be exact if you don't mind hitting it again for me it's 821 percent. So huge increase in the number of cases that we've seen in the emergency rooms across the United States for self harm behavior.

Looking at the past decade if you don't mind clicking again 337 percent. So, our kids are being seen in the emergency rooms. They're dying by suicide, and unfortunately a lot of the work that we've done has not focused primarily on this age group until recently.

Next slide, please. So, another slide that I wanted to show looks at birth cohorts. So, these are just kids that were born at different years. So, you've got our 1995 youth. So, kids that were born in 1995, which is the green line. Orange is our 2000. Black is 2005, and then 2010.

So, our youth that were born in 2010 are now 14 years of age, just so everybody's aware.

So, the data that we have thus far, what you see is that on the left side here, we have the suicide rate per 100,000. And that data is recently, 2022 numbers just recently came out. So, we're waiting for the 2023 data.

And what you'll notice is that, when you start to look along the age range, the rates increase, depending on how old that child is. So, at the five year old age range, we don't have, thank God, a suicide rate. But as we get older, the rate actually starts to be seen.

What you'll notice is that, for our 1995 age group so that green line the suicide rate starts to actually be a non zero around nine, nine and a half years of age. But for our purple line, which is our 2010 cohort, we actually are noticing that that rate is actually present around eight years of age. So, what does that mean? Well, it means that our children are dying by suicide a lot younger than what they did in the past and that it's not so much by certain birth cohorts, because as you can see, with the kids in 2000, they also died a lot younger than what they did in 1995.

So, the younger they get, unfortunately, the more likely we are to see a rate by suicide in these age groups.

Next slide, please. So now that we've focused on our younger little people, I wanted to focus on our older age group. So, our 10 to 18 year old age group, which does include our preteens.

What you can see here is the good news. This is the good news. This is something we should all be excited about, that suicide deaths have actually decreased 14 percent overall. So, for our 10 to 18 year olds, in the United States from 2018 to 2022, we've seen a decrease. That is wonderful news. That's something we do not take lightly, but this decrease looks very different dependent on which group you're looking at, whether that be by sex or by race and ethnicity.

So, for our female youth so what we've noticed is that when you take all of our female youth, 10 to 18 years of age, 2018 to 2022, we've actually seen a 6 percent decrease. So not as large as we would like it to be. Still going in the right direction, but the decrease is small. With our male group, they've actually seen the highest decrease, at 16 percent. So, our males are actually decreasing steadily and doing so at a rate that's a lot higher than our females at this 10 to 18 year old age group.

Next slide, please. Now, when you look at our group of youth, 10 to 18, again by race, we also see big differences here. So, for our white youth, we actually saw a decrease of 16 percent, which is great, 18 percent for our indigenous youth, American Indian and Alaska Native, which has the highest rate of suicide deaths in 10 to 18 year old youth. So that is very good news.

For our Asian youth, we've actually seen a 28 percent decrease, multiracial group, which that data just started getting collected in 2018. But again, decrease. We've seen a decrease. 15 percent decrease in our suicide rate.

But for our Black youth, big, big difference. For our Black youth, we've actually seen an increase of 20 percent. 20 percent. So, all of these other age groups excuse me, all these other racial groups are decreasing but our Black youth are not. And they're actually increasing in this age range.

For our Black males if you don't mind going to the next slide, please when you look at our Black males, which is the orange line, we actually have seen an increase of 13 percent.

For our Black females, we actually have, over this time frame, we've actually seen an increase of 42 percent. And just so everybody is aware, I think it was in 2020, I think was the right year please forgive me if that's incorrect but for our Black girls, 12 to 14 years of age, the suicide was actually the number one leading cause of death with unintentional injury. So, suicide deaths were number one in our Black girls 12 to 14 years old.

So, when you compare these youth, so Black youth to white youth if you don't mind going to the next slide, please what we find is again differences, differences. We know that more males died by suicide than females. So, their rates are higher than female youth. However, for our white males, there was a 19 percent decrease present for our white males 10 to 18 years of age over this time frame. And then for our white females, there was a 10 percent decrease seen.

However, for Black males and Black females, as you saw in the previous slide, 13 percent increase for our males and a 42 percent increase for our females.

And for 2021, what we found is that Black females actually had a higher rate of suicide death than their white counterparts, and that has continued over the year where this data was actually for 2022.

Again, we'll have to see what happens for the years to come. Hopefully this trajectory will change. But that's why I'm here. That's really why I'm here, to talk about what ways we can actually move forward.

Next slide, please. Yes, just wanted to circle that. Thank you. So where do we go from here? Next slide, please. So, I always love this picture. It is one of my favorite pictures, honestly. And the reason why I show this picture is because this is how I think about collaboration.

So, this is in India. It's the Khasi of Meghalaya. And from June to November, it just rains. It rains. That's all it does. And on average they get 32 to 45 feet of rain, just rain. Rain, rain, rain.

So, they as individuals had to figure out how are they going to get from one side of the village to the other side of the village, and how are they going to help their elders, and how are they going to see their cousins, and how are they going to, you know, feed their whatever. And they figured that what they could do is take the roots of these trees and create breathing, living bridges.

So, these are pictures that are actually shown in India of these bridges. NPR did a special about it. And the quote that I found to be so telling me was that they are "Living, breathing examples of life in the past that can help us create sustainable lifestyles for the future."

And I think our collaborations with other institutions, with other individuals across domains, no matter what you're bringing to the table, can really truly make sustainable lifestyles for the future.

And, yes, this is all about the past. Yes, we know what happened in the past. We should never ever forget that. But in order for us to move forward and start to change the trajectory, we have to create these bridges of collaboration between others. So that we can actually do well, be well, live well and learn from others so that we can actually make a difference.

Without further ado, I'd like to say thank you again so much. I'm looking forward to our fireside chat. These are some resources, and I know there's a billion others out there. I do not want to say that this is every single resource known to man, but these are just some of them out there in the universe. And then also next slide, please just thanking again all the folks that I work with. It is an honor to do what I do, and I am so humbled and just thankful for every moment that I have to be able to spread the news that suicide research is needed, and I wouldn't be able to do it without the families that participate in my research. So, I'm always grateful and thankful for them for their stories and for allowing me to stand on their shoulders to be able to actually tell their stories and do something about it.

So, thank you to all of my families that have participated. And thank you to all my staff as well. So that is all I've got. Thank you.

SHELLI AVENEVOLI: Welcome, everyone. So, thank you very much. I also want to acknowledge that Dr. Stephen O'Connor is joining us for this fireside chat.

I have a lot of other questions. I'm going to start with some we prepared. But you and I were talking earlier about the importance of taking a developmental perspective here. So, you set the stage that this is a national problem and particularly impacting some groups more than others.

How would you say that your training in human development has really influenced your research? And both in developmental and family science has really influenced the way you've approached research in this problem area.

ARIELLE SHEFTALL: A lot of what I do is really focusing on the system. So, I think as an individual, it's great. Get us the help that we need, but there's a person within a system that actually can't get better unless we do something about the system.

And as a human development family science person, I think that is something that I acknowledge in my work, is that we have to look at the family settings. We have to look at the parental relationship with that kid or the kids within the system; how do siblings relate to one another and how can we take advantage of that to actually do something with prevention?

So, I've always wanted to look upon the system settings and not just the individual themselves, because if we fix, quote/unquote, that individual and we just throw them back into the system that's broken, they're not going to get any better.

SHELLI AVENEVOLI: That's really helpful. And I guess we were talking earlier, too, from the developmental piece, is you talked about from preteens all the way through to adolescence. How has your background also shaped how you're approaching those two kinds of different age groups.

ARIELLE SHEFTALL: Yeah, and I think we did talk about this. So, language is so important. When you talk to a teenager I can't do that. So, I am one of those people. Thank God for my husband who stays on top of the language. I can't. I just don't have the power.

But there's certain ways that they talk about suicide deaths, suicidal behaviors, thoughts about suicide that I have to actually educate myself on because it's very different than what it used to be.

And then even our younger people, our little people, they talk about it very differently than what adolescents do. So, I think we have to be very cognizant of the language that's being spoken about suicidal thoughts and behaviors and recognize that there is a difference.

There is a difference on how I talk about it versus how they talk about it. So that's one way. But also, we have to be very straightforward with our questions in order to make sure that we're getting the answers needed if a child needs help right then and there.

So, crisis does happen. It's going to happen. Whenever you ask a child about a suicidal thought or behavior and they've had that thought already present, that is going to be expressed when you ask them. It doesn't put the thought in their mind when you ask them. I know a lot of people think that. That's not true. But if they have that thought and you ask them about that thought, they're going to say yes. That's just how it works.

With older adolescents, they may or may not tell you the truth depending upon how safe they feel with you; but with kids, they're going to tell you. They will tell you right up front, no, how dare you? Or I've had children yell at me because they're so mad that I've asked them about that question because how could I ever think that they would have that thought. But I asked them that question.

I do want to acknowledge that being straightforward with kids and adolescents is really important, but also being very critical about the language that we are using to make sure that we're getting the answers that we need.

SHELLI AVENEVOLI: Thank you.

STEPHEN O'CONNOR: Thank you for that. Thank you so much for joining us today.

STEPHEN O'CONNOR: So, to your point of we need to think about the systems, you presented some data that suggested that more people young people are going to the emergency department to receive care for self injuries.

At the same time, there's an annual survey that goes out, the Youth Risk Behavior Survey, that's administered. And it has not shown the same increases in terms of youth that are receiving medical services for suicide attempts. So, it leads one to believe that maybe the setting where most youth are receiving medical services is in the emergency department.

So again, sort of really important to think about the ED versus where else youth are going to receive any kind of medical services if there's a suicide attempt.

So, understanding the locations really important. Also thinking about risk trajectories, and I'm just wondering, from some of the research that you conducted or some of what you showed us with part of your presentation, what do you think we've learned about risk trajectories at this point so we could think about preventive interventions, therapeutic interventions, either at the individual, family level, thinking about school settings, clinical settings, and then also think about multilevel interventions as well?

ARIELLE SHEFTALL: Yes, so I'm a big component of safety bubbles. I know that sounds silly but very true. I believe I think it goes back to my upbringing, so to speak, in the human development family science world that we have to educate everyone on how to prevent suicide. And it doesn't matter if it's the janitor. It doesn't matter if it's the nurse. It doesn't matter if it's the neighbor, if we are able to actually educate individuals on what to look for in the community setting, in the hospital setting, in the pediatrician's office, then maybe we could do a better job of curbing suicidal behavior from occurring.

I will definitely say that I know anecdotally that not all attempts go to the emergency room. They don't. I've had multiple families tell me that they don't trust the emergency room, that they don't trust medical providers, so they just try to treat that behavior or that concern at home.

And a lot of times those individuals are people of color, to be honest. I had a family whose daughter drowned herself, and it was a suicide attempt and unfortunately did not bring them to the hospital and they were not seeking services.

I'm like, oh, my gosh, I didn't understand. As a researcher that does this for a living, I didn't understand. But then I started to hear her talk about her experiences with mental health and her experiences with doctors, and then I was like, oh, yeah, I probably wouldn't either. I probably would try to treat this at home, but I'm not a clinician. She's not a clinician. And how do we do better with our system of care so that people can feel like they can bring their kids if, God forbid, something like that happens.

I 100 percent agree with you, I don't think all the numbers that we are actually seeing in the emergency room are actually what is actually happening for actually actually I really do believe we're seeing a smidgen of what is happening.

In terms of risk trajectories, I would say there's differences. There are differences. So, with our little people, what I've noticed is that there's not so much a diagnosis that you can pinpoint that says, yes, they're at high risk.

So, with adolescents, we have, we hope, some understanding that depression puts our youth at risk because they have those down moments. They have those moments where they're not feeling themselves. They're sad. They're blue. Bipolar disorder. We know that's related to suicidal behaviors. Borderline personality disorder, we know that's related to suicidal behaviors in adults.

For younger kiddos, what we've found it's not so much those depressed moments, so to speak, it's really the ADHD component. So, ADHD, as many of you know, high impulsivity, inattentiveness, usually, for the most part, unable to focus their attention on one thing for a very long time. And when something does happen sometimes, not always they can be very sensitive to that thing that occurred.

And sometimes they ruminate depending on where they are on the spectrum of ADHD, but not all the time. Sometimes they go to the next thing, the next thing, then the next thing. But if they're struggling with having thoughts about suicidal behavior, they can start, unfortunately, planning things maybe a little bit easier than others because their brains are always moving on to the next thing, the next thing.

So, I don't know if that is truly the reason why we found this in our own research is that ADHD was the diagnosis that those kids had when they died by suicide at that younger age range.

But not sure if that's because of the impulsivity, if it's because of the inattentiveness, or if it's because of something else. So, I think unfortunately that risk trajectory is still really unknown in our younger age group of kids.

STEPHEN O'CONNOR: And you're pointing out why it's really important to understand the mechanisms at play here so we can help develop and test the most effective interventions as well.

ARIELLE SHEFTALL: Absolutely. I think if we don't know what those risks are, how can we prevent? How can we actually do the job that we're supposed to do with creating interventions and doing a good job at preventing suicidal thoughts and behaviors if we don't know what that risk is that we should really be focusing on.

SHELLI AVENEVOLI: Yeah, I want to pick up on that idea of understanding mechanisms. So, you showed to us a chart with the figure where we saw a decrease overall in 2022. And that's not for all groups, as you just attested. But what do you think researchers should be looking at to better understand that decrease in how we might utilize that in our prevention efforts?

ARIELLE SHEFTALL: Yeah, it's hard because I think it's one of those things where you may be trying to figure out the what's the word I'm looking for? What a mental health overall was perceived during that time frame. So that data was 2022, what was the outlook, so to speak, of mental health at that point in time? Were there more interventions being performed in school settings? Performed in after school settings? Were there more dollars being dedicated to mental health initiatives? So, trying to figure out what was the atmosphere, so to speak, in terms of mental health at that point in time so that we can redo that every single year, I think it's really important.

But also, maybe even talking to community members. I think that's something that could be helpful. Having community advisory boards and just figuring out what was going on for you at that point in time, that was two years after the pandemic. I feel that people were starting to come back to life, so to speak, during that time, get back to, quote/unquote, normal. Still not normal, normal, but more normal than what it was.

But people were starting to work again. People were starting to be more social. People were starting to have outside lives. They weren't just staying in the home all the time, weren't as isolated. So maybe that's had something to do with it as well.

But I think mental health became a national imperative, I would say, which kind of put it on the map for people, not all people but for most people. The Surgeon General came out with his book about mental health and suicidal behaviors. So, to me that makes a difference. That really does make a difference. How we speak about mental health on the national, federal level I think makes a big difference and does help kids see that seeking help is actually an option.

SHELLI AVENEVOLI: Yeah. You mentioned engaging the community and understanding that. And what about youth themselves? What about engaging them?

ARIELLE SHEFTALL: Oh, yes. The reason I laugh, I have a Youth Advisory Board that I codirect at the university and those kids are brutal. I love it, though. I love it because researchers come and they present their protocols, their procedures, their ideas, and kids tear it apart. And I love that because, guess what, if this research is about them, then why not get the kids' voices involved and give them an opportunity to speak their minds and to actually make a big change that's going to be effective versus just something that you put out there that you think is a good idea.

I don't know about y'all, but I'm not a TikToker, I'm not an Instagrammer. I have Facebook and LinkedIn and that is it. And so, I don't know that world very well, but the kids do. They know all that. If you're thinking about a TikTok campaign, guess what, you probably should get them involved, just to get their insight or Instagram campaign, get them involved. Get their insights. What are they doing these days? Who knows. But I know what my kids are doing, right, hopefully, but not every kid. Not every kid.

SHELLI AVENEVOLI: It goes back to your point about language, too. So not only do they know what's in their minds and what's going around with them and their peers, but the way they speak about mental illness or mental health is very different. Not like what we were used to doing.

ARIELLE SHEFTALL: It's very different. The words they use sometimes sounds like a foreign language to me but that's because I don't know those words and the only way I can understand those words is if I talk to the youth themselves, to actually get a better understanding, what are the words you're using to describe mental health? What about suicidal thoughts? What about suicide?

Like, what are those words that you are saying out in the community that have a different meaning, a double meaning, so to speak? How do I know if your friend needs help, like if one of those words you're going to say to me that means help is needed. So, I think having the youth present is really important.

STEPHEN O'CONNOR: So, continuing to build on that theme, a lot of the work you've done is involving engaging families and children who are in distress or have recently experienced distress. So, could you speak a little bit to that, about how that has impacted you and then how that's informed your work and how it informs how you gather data as well in those instances?

ARIELLE SHEFTALL: Absolutely. So, whenever I'm in the lab and a family comes in, I make it my point of going and thanking them for being in our study because I want them to know that I'm not just a face on the flyer. I actually do care that they've come and taken the time out to actually be with my staff for two to three hours to actually give us their life story. And I believe that that's the first thing.

Being grateful, being very grateful for all the participants that do the research that you do, it's hard. It's hard to talk about these things. It's hard for kids to talk about these things. It's hard for adults to acknowledge these things that they've had these thoughts in their past or that their child has had these thoughts in the past. Now I'm bringing that back up again.

I think it's really important to just be grateful and thankful, first and foremost, but also be okay with what you're feeling. I have these conversations with my staff all the time that this topic is hard. This is a really hard topic.

I've been doing this since 2007, and I still have moments where I'm just like, oh, that was a hard appointment or that was a hard conversation, or that was really, really tough. We had to hospitalize somebody because they were suicidal.

So those are really tough moments, and being able to have really good self care, I know it's something people say all the time, right? But it's really important to have those things and to dedicate time to those things.

I hope I answered the question. I'm sorry if I did not.

STEPHEN O'CONNOR: No, you did, absolutely. It's very fluid. We know about like these experiences and there's dynamics between the parents and the youth and things are at play and your kind of walking into this type of data that you gather.

ARIELLE SHEFTALL: Just to acknowledge that it's okay to not answer a question. I think that goes a long way. For some parents, some kids themselves, guess what, you don't have to answer anything I ask you; I just want to learn from your experience, but it's okay to say pass, or it's okay to raise your hand or to say huh uh, whatever you want to do, just let me know. We tell them that in the beginning, when we're asking them, consenting them, we allow them to understand what questions we're going to ask but also what's going to happen if there's a question that they answer that indicates stress or indicates distress. So, we want them to not be surprised in any way, shape or form.

SHELLI AVENEVOLI: So, at NIMH we get to set research priorities. And you know we've been doing a lot in the suicide space and kind of building up our portfolio in preteen, and your work has really focused on understanding risk factors across youth, across these developmental stages. So, what would you say to us are some remaining gaps in this space, either in preteens or adolescents or both?

ARIELLE SHEFTALL: I think for me, the remaining gap is community. That's where I'm trying to focus my energies, honestly. I love research. I love what I do and it's something that I'm very, very happy to do, but I think if I'm unable to translate my work into the community, then I've done a disservice.

So, I've been working really closely with a Black youth charter school called UPrep, sixth grade to 12th grade, and it's all boys, all young Black boys. And I was informed that there's one white youth. It was funny, somebody told me there's one white youth, all Black boys and one white youth, and I've been working with them. And working with schools is hard work. Whoever does it, God bless you, but it's hard work.

They call you on the dime and say, hey, you want to do this thing? Oh, yes, you just have to go because you want to form that rapport. You want to form that bond with them in order to make them feel that you're a trusted source.

So, I actually just met with them on Tuesday this past week and we're going to do a whole month in May for mental health. We're going to have it called the Mental Health Takeover and every Friday we're going to do something for mental health, and all the kids are going to be involved. And it's Friday because it's their half days. So, we're going to just take the whole morning/afternoon and do something that's mental health oriented.

And I'm just so excited. I'm so excited to be able to bring my knowledge to them and say, hey, what do you want to do? What do you want to do? How can I help you? How can we do this together as a team? And hear them out, hear what their needs are.

Another thing they told me that they want to do like a coat drive because some of their kids don't have winter coats. In Rochester, you need a winter coat. You need a winter coat. But they don't have coats. They don't have coats. Like they're necessities, some kids don't have the necessities.

How can I even talk mental health if I can't help you with your necessities? So that's going to be a part of one of the things we do with this school is doing a coat give away, basically, and you don't have to have a brand new coat, you can have my kid's coat that he grew out of.

Just opportunities to think about helping and providing communities with the knowledge that we have about mental health and wellness, and I think that is our gap. We do a really good job in schools. We do a really good job with our parents, somewhat, I would say somewhat, but our communities.

I think that's where we're struggling is getting our community involved because, for some groups, community means everything. It really does.

SHELLI AVENEVOLI: Thank you.

STEPHEN O'CONNOR: One more question for you.

ARIELLE SHEFTALL: Go for it.

STEPHEN O'CONNOR: You mentioned the community angle. We're trying to focus a little bit more on that, understanding what confers risk and protection at the community level, I think we need more data on that to inform what these prevention strategies are. Those are good points.

The field has focused more and more on traditionally underserved, understudied groups. So, your work with Black youth is a good example of that. But you also were talking about these different age groups, and I'm wondering so there's developmental experiences, milestones, right, for different groups, considerations.

So how do you think about those developmental factors when you think about prevention at the individual level or at the family level? How do you understand the most important things to focus on beyond the diagnosis that could be useful?

ARIELLE SHEFTALL: No, that's a great question. I think for me, the first thing, with the younger kiddos, is just exploring what emotions are. So, understanding what are my emotions? And if I feel this way, what does that mean if I feel this way? And how can I help you with that feeling, whether it be happy, whether it be sad, whether it be joyful, devastated, distressed, what are those things that I can do to help you?

And happy is easy. Clap a hand. High five, done. Joyful, same thing. But in the distressed moments, how can I be a source of strength and support for you at that younger age? That would be where I would like to focus some of my energies on that younger age is understanding emotions, understanding what that means and giving coping mechanisms to kids when they're under distress when they're not feeling so happy, so to speak.

And for older youth, emotions are not as much a problem, understanding what emotions are, but I think they are a little bit different in terms of what their needs are. So, we talked a little bit about this at lunch, is this misinformation that is perceived on social media and educating them on what is good information to digest and what's bad information to digest.

And that some of the good information might not work for you. That's okay. There might be other ways for you to actually be okay that aren't for me and acknowledge that that differs depending on who you are, what you come to the table with, and just be very mindful of that and acknowledging that it's okay to be in your own skin, I think, is something else. Because as a society, that's not something that we actually put on a platform.

We want to look this way, certain way, feel this way, act this way; but, no, just be you. Be who you are and be okay with who you are and acknowledge the fact that you are going to have a bad day.

Like, that's what humans do. We have bad days. We have good days. But we have bad days too. So, acknowledging that and being okay with that and also understanding what those things are that you can do when you are having a bad day.

So I think that is something that I would start at like 12 years of age and move up the lifespan, to be honest, because I think even as adults we could kind of feel good about that as adults being okay where we are, acknowledging that, yes, we've had bad days, but also acknowledging that this day is going to be okay. We just need to figure out what we can learn from this bad day and try to move forward. And if we can't move forward, it's okay to get help to be able to move forward.

STEPHEN O'CONNOR: Thank you.

ARIELLE SHEFTALL: Thank you.

SHELLI AVENEVOLI: I want to make sure to see if anyone in the audience or online has questions.

MODERATOR: There's a huge number of questions online. I wanted to apologize to the 95 percent of those asking questions we'd have to be here until next week, but I did try I tried to tie some of them together as best I could.

So, you did talk a bit about the potential benefits of social media, understanding what's correct or what's helpful and what's not so much. But as is true for many of us in our generation worrying about youngsters, there's, of course, a lot of concern about the adverse impacts of social media.

ARIELLE SHEFTALL: Absolutely.

MODERATOR: This is a huge topic now. But sort of connected to that, there was a question also related to suicide contagions. You can imagine that there's sort of room for that sort of consideration. So, any thoughts about all of that?

ARIELLE SHEFTALL: Yeah, such a big question but I'll try my best. So, I think, yes, suicide contagion is real. We all know that to be the case. We've seen it unfortunately in our own work, at our own schools that we work with. That is something that is real.

I think ways we can actually prevent suicide contagion is how we actually deal with the suicides that actually have occurred.

A lot of schools, unfortunately, aren't as well versed with that. I know when I was in Ohio, there was a suicide death of a teacher. And they did not do a great job. I hate to say it, but very true. And they ended up taking the memorial away from the door of the teacher because they didn't want a mess in the hallway. I was like, what? These kids are mourning and having this memorial is actually beneficial. Like not acknowledging the fact that this person has passed away is actually the worst thing you can do.

So, I think educating the schools themselves on what can be done, what is being done that actually works and works well, is really important.

And I know in Ohio, Columbus specifically, John Ackerman, at Nationwide Children's Hospital, does a really great job for training at schools to actually know what to do when a suicide does occur.

In terms of social media, social media is always that question I get, honestly, because I work with youth. I work with families. I think social media, for some people, it's great. That's fine. That's what you want to do. Mazel tov to you. I don't do it, as I indicated.

But I will definitely say that social media can be used in a positive way. I really believe that. I really truly believe that.

So, what I'm going to do I'm going to get an Instagram account for our lovely NIMH people that are in this lovely auditorium with me and we're going to do positive, positive, positive things.

And we have to be cool I know that's probably not a cool word anymore but we have to be cool with it, right, for our youngsters to actually gain momentum.

So, I think again talking to the youth, right, what would be cool, quote/unquote, cool not using the word cool but how could we as an institution and those funded by NIMH really take social media by storm and make a positive outlet for kids?

I did recommend that we get Drake and Kendrick to do a rap battle about suicide prevention. So, I'm working on that. We'll see how that goes. If want to, that would be great.

But I think that's an opportunity. Kids are on social media. It is what it is, unfortunately, or fortunately, whichever way you go, but we do have to do something about it and acknowledge that it's happening and make sure that we do something positive in order to combat all those things.

STEPHEN O'CONNOR: That's a good point. Consistent with the Papageno effect from The Magic Flute, important to get the stories out there, know people are going through hard times but finding their way through, not just focusing on whether there's some difficult thing that's occurred.

ARIELLE SHEFTALL: No, I 100 percent agree. Being a motivator, encourager, a person that I've gone through my own mental health concerns and battles when I was younger. 14 years of age my mom died by cancer, and it was very hard. I was starting ninth grade. I didn't have a place to live. I was separated by my younger brother and I and I don't be little that in any way, shape or form. I tell my story because I want people to understand that this happens to normal people. It's okay. It's okay to have these thoughts and feelings about suicidal behavior, but it's how you react and how you get the help needed in order to decrease those thoughts. They are more common than people would think they are.

MODERATOR: So, two more questions I'm going to try to tie together. One of them is given the lower rates of engagement of Black youth and mental health services, there's sort of issues associated with how they access information, perhaps in the context of primary care or the emergency department, but so related to that, there was also a question that asked, in terms of national messaging that's going on regarding youth suicide, to what extent you thought it was equally kind of impacting different racial and gender groups?

ARIELLE SHEFTALL: No, that's a great question. I think, unfortunately, we still need some help in that arena, I would say. I think we have these glimpses of hope that occur.

So, if you guys remember how long ago was that there was a rapper, Logic, I think that was his name that did a song about the National Help Line. I don't know where he is now today, but again that was very powerful. I think after his song came out, thousands of youths and their family members and everybody else around the world did call their help line to get that help they needed.

But I think, unfortunately, that lasted for so long. And then we kind of went down the hill and this way and that way and then 988 came out and we tried our best to promote that in different racial and ethnic groups. I don't know how well we're doing, to be 100 percent honest because I haven't looked at that data specifically.

But I do know that some people still don't know that that's the number to call. So, they still are calling the 1 800 number, which is fine, that still works, but you don't have to call the 1 800 number, there's just three digits now. I think we're struggling with getting information out to the community, in communities of color, I really do believe that. And some of the advertisements or marketing materials that we have may not look like the people we're trying to serve.

SHELLI AVENEVOLI: We'll take one more quick question, if you have one.

MODERATOR: This is kind of tracking backwards, but in terms of identifying suicidal ideation in very young children, also the deaths you had some numbers there, five to 12. This is kind of backwards in terms of the general feedback, but there were numbers of people asked about the various ages.

ARIELLE SHEFTALL: How do you identify suicidal behaviors in the younger age? They sometimes don't understand – actually, I would say seven times out of 10 they don't understand that death is final. And it's really hard for them to understand that if they do these behaviors, that they are not going to come back because of the games they play, the movies they watch. Everybody comes back. Everybody comes back to life after they've died.

We were talking about this earlier. And that's not truthful. Like once you, unfortunately, have died, you are dead. And it's the concept of death. Unfortunately, younger kids have a hard time understanding the concept of death.

But I think there are ways to have conversations about those things that aren't so scary. So again, having conversations about just thoughts that they're having in general, just how are you doing? How was your day today? Having those like clear cut, easy, quote/unquote, conversations can actually create a safe space for kids to talk to about thoughts about suicidal behavior.

In our research, we just ask them up front. We just ask them. We don't sugarcoat it, because you'd be surprised, some of the kids do know exactly what you're talking about, and it really just depends on their experiences with life and so on and so forth.

But most kids that we talk to do understand what we are saying to them. We outright we don't ask, well, what do you think about when the flowers and this and that. No, we just ask them, have you ever had thoughts about killing yourself? And if they say yes, okay, then we get more information about it. But it's not the first question we ask them. We build rapport. We build rapport. We do games. We do fidgets. We color with them. We make sure that they feel comfortable in the space that they're in in order to share that information. And then we ask the hard questions, just to make sure that they're safe.

SHELLI AVENEVOLI: Thank you. I always try to squeeze in too many questions, but I just want to give you the last minute to say you've mentioned community a lot of times and engagement of community and youth, and this is something I think we want to prioritize even more than we already do at NIMH. Do you have any parting words of advice for us?

ARIELLE SHEFTALL: Yeah, you know, I would definitely say young people are wanting and willing. They are wanting and willing to talk about this topic. And the community wants to create a safety net but they early having a hard time understanding what to do.

So as researchers, I think it's really important for us and at the NIMH level to really engage community partnerships and members and boys’ and girls’ clubs and after school programs and the youths themselves, let them be at the table to think about what would be best for them in terms of preventing suicidal behavior.

SHELLI AVENEVOLI: Arielle, thank you so much for joining and thanks for taking the trip down to spend the time with us. And thank you to everyone who organized this event. Thanks, Stephen, for joining.

ARIELLE SHEFTALL: Thank you.