Violent acts of sadness: The tragedy of youth suicide; youth violence is increasingly turning inward, and kids are killing themselves at an alarming rate. Can lawmakers do more to prevent youth suicide?

More teenagers and young adults die from suicide each year than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza and chronic lung disease combined. The sad reality is that youth suicide is a growing epidemic, ending young lives and leaving heartbroken families and communities. It is currently the third leading cause of death of 15- to 24-year-olds, and the fourth leading cause of death among 10- to 14-year-olds. Nearly 4,600 kids killed themselves in the United States in 1998, and approximately 46,000 others tried. Most give warnings; some do not.

Teenage suicides seldom make the front pages. Or do they? Andrew Wurst, 14, talked to his friends about taking his own life a month before he shot and killed a teacher and wounded three students at a high school dance. Luke Woodham, 16, told investigators that he shot nine students--killing two--because he was so miserable that he "just couldn't take it anymore." He later confessed that he had wanted to die. Another teenager who had already attempted suicide asked his parents for a gun. They gave it to him. Soon after, he took it to school, wounded a fellow student, then shot and killed himself.

More recently, Jason Anthony Hoffman took a firearm and wounded five at Granite Hills High School in San Diego. He then hanged himself in jail. He had a history of mental illness and was taking antidepressants months before the shooting.

"Without exception, every juvenile I've represented in a murder case has tried to kill himself," said Hoffman's attorney, William Lafond. "Many of these kids feel helpless and depressed and don't understand why they did what they did. When they try to understand their feelings, they can't handle it."

Research shows that up to 60 percent of school shooters may have been suicidal before they shot others, and a majority of them gave clues. Most had a history of depression and were desperate to end their emotional pain, and many communicated their agony to someone else in some way. They directed their aggression toward more than just those who hurt them. They had specific targets: themselves.

No one means to absolve these kids from responsibility for their horrific acts. They usually planned ahead, knew what they were doing, had given up on life and were not concerned about the consequences. And most planned to kill themselves before they were done.

"I didn't really see my life going on any further," Luke Woodham now says. "I thought it was all over with ... I couldn't find a reason not to do it."

We focus more on troubled children killing others than the thousands of children privately taking their lives every. year. In reality, youth violence is a tremendous problem, and suicide is a big part of it. For lawmakers, the questions are how to design policies to prevent young people from getting to this point of desperation, and how to intervene when they do.

WHAT'S GOING ON?

Suicide among children ages 10 to 14 increased nearly 100 percent between 1981 and 1998, jumping from 163 deaths per 100,000 to 317, according to the Centers for Disease Control. Suicide among African American males ages 15 to 19 rose at an even higher rate, increasing from 81 deaths per 100,000 to 164. One youth commits suicide every two hours in the United States.

There are several theories about why this happens. One is that some children are growing up without meaningful connections to adults or the support they need to successfully navigate the process of growing up. Another is that kids are impulsive and can react to a moment of crisis in their lives--such as trouble in school, relationship problems or bullying--without stopping to really think about the consequences. In some cases, impulsive behavior and access to guns is a dangerous mixture. Others blame substance abuse, media violence or copycat actions.

Depression is one of the most common problems children and adolescents face, says Mark Weist, director of the Center for School Mental Health Assistance in Baltimore, Md. "Often, mental health issues in youth are not identified, especially if they are less observable problems like depression and anxiety."

Statistics show that one in 10 young people suffers from mental illness serious enough to be impaired, but fewer than 20 percent receive treatment. Many, especially boys, keep their problems to themselves and do not seek help unless an adult intervenes. Others live in communities without mental health services or their parents distrust the help that is available.

Colorado Representative Kay Alexander points out that 80 percent of kids with mental health problems also abuse alcohol or drugs. "They are often either self-medicating or the substance abuse contributes to their mental health problems," she says.

"Mental health providers need support in raising awareness, destigmatizing mental illness and treating mental health as equal in importance to physical health," says Weist. "Since Sept. 11, there is an increased awareness that mental health issues are universal. Hopefully, this will translate into more resources for effective child and adolescent mental health programs.

Part of the problem is that troubled kids often appear to be "normal," well-adjusted students, says Weist. When 15-year-old Charles Bishop ended his life by crashing a Cessna airplane into a Tampa office building in January, he had given no indication beforehand that he intended to hurt himself. And 16-year-old Jason Flatt was a popular boy with a supportive family. No one expected him to shoot and kill himself in 1997 after breaking up with his girlfriend.

"Many boys have an exterior structure that looks healthy and happy, but behind it lies more pain than we can imagine. Often, they either feel too ashamed to talk about it or have no one they can really talk to. And they usually show signs beforehand, even if no one notices," says William Pollack, acclaimed Harvard psychologist, director of the Centers for Men and Young Men, and author of Real Boys and Real Boys Voices.

WHAT CAN LEGISLATURES DO?

"We need to understand all the issues around why people attempt suicide," says Oklahoma Representative Darrell Gilbert. "The more we learn, the easier it is to design policy change current laws and appropriate dollars to help with the problem."

The bottom line is that the problems are too complex for any simple solution. There is no single description of a suicidal child, and no way to make sure kids never kill themselves. But there are a variety of ways that legislatures can support practitioners, school officials and parents.

One need is more education about the risk factors for youth suicide. If teachers, parents, coaches, students and others know how to recognize the warning signs for suicide, they may have more opportunities to ask questions, listen, solve problems or aid kids in getting help. "Kids do not wake up suddenly suicidal; they get there after traveling down a long road," says Richard Lieberman, Los Angeles school psychologist. "Where we intercept these kids on the road determines what our response should be."

Each state may have different needs that can be addressed through legislation. In some cases, schools might be directed to run programs where kids role-play difficult situations and talk about better ways to work through conflict or cope with disappointment. Preliminary findings of one study suggest that mentally healthy students who practice solving life problems through role-playing with other students are less likely to get depressed or show signs of suicidal behavior. "We need funding and personnel for prevention programs in schools to teach kids valuable coping skills so that they don't travel down the path to begin with," Lieberman says.

Another approach is to improve the school environment so students feel more connected and supported. Staff can be trained to mentor children better and to stop bullying and conflict more effectively. Classes can be smaller so students get more attention and know each other better. Kids can be trained to mediate conflicts between peers.

After-school programs can also help kids stay out of trouble, learn new skills and improve their self-esteem. Some schools also take time during the school day to teach kids about suicide, although some researchers argue that this approach leads kids to think about it as an alternative when they did not before.

Other suggestions include funding mental health services for troubled students, requiring professional screening of students for early signs of suicidal behavior and restricting access to firearms.

Where lawmakers need to make the most of limited funds, it is important to make sure that prevention programs are effective and a good investment of state money. There is some research that implies that the aforementioned efforts can help reduce suicidal behavior. At the same time, there is little hard proof that individual programs are effective, even though schools report they are helping. Some researchers also suggest that certain programs may be counterproductive--such as suicide awareness--but no real data exists to show a negative impact. As a result, states can work toward ensuring better investments by requiring assessment of state-funded prevention programs.

WHAT ARE STATES DOING?

At this point we know that comprehensive, broad-based approaches are the most successful at preventing youth suicide. They include everyone--professionals from different disciplines, community agencies, parents, kids and others--in efforts to coordinate services, share resources and work together to help kids deal with the problems that may lead them to become suicidal. Basically, the comprehensive approach intervenes early to help young people overcome barriers to development and learning and grow up successfully.

Eighteen states have youth suicide prevention laws, and many have worked to put fairly comprehensive approaches in place. Washington uses general funds to educate the public about youth suicide and staff a 24-hour crisis hotline. Other states--Kentucky, Florida, New York, New Jersey, Connecticut, Hawaii and Maryland--fund school-based mental health programs for troubled students, including suicide risks. Louisiana is developing a statewide youth suicide prevention plan.

Oklahoma recently established a Youth Suicide Prevention Council to collaborate with community organizations, develop local resources, provide technical assistance to community programs, make policy recommendations to the Legislature and promote public awareness. The Legislature was responding to increased incidents and rising concern in Oklahoma, says Representative Gilbert, co-sponsor of the law. Lawmakers wanted to include various perspectives in planning a prevention policy, since "the more information we can find out about why teens are committing suicide, the more we can help mental health professionals and others--such as religious leaders and drug and alcohol counselors--to help kids with the emotional issues in their lives," he says.

Virginia and California passed new legislation in 2001 to supplement school-based prevention programs already in place. The Virginia Department of Health is now coordinating prevention activities throughout the commonwealth. California established a statewide suicide prevention week, recognizing it as a major public health concern, declaring it a state priority and encouraging development of treatment that works, including affordable mental health care. California legislators "wanted to increase awareness and move us toward comprehensive suicide prevention plans," says bill sponsor Senator Deborah Ortiz.

California's existing school-based prevention program includes training parents and school staff about the warning signs, providing a crisis hotline for kids and developing peer support groups. "We need to direct the resources to the schools," Ortiz says. "School personnel are the most likely to run across kids who are at risk for suicide where many others may not have enough knowledge or awareness to intervene."

BARRIERS TO INTERVENTION

One challenge is that all these solutions require money, creating a balancing act for state legislatures with limited budgets. But research points to prevention as a long-term investment due to the emotional and economic toll that suicide takes on the population. Aside from the loss of lifetime contributions when a citizen dies prematurely, emergency room use for suicide attempts costs states an average of $33,000 per visit. With approximately 730,000 attempted suicides per year nationwide that can be a pretty hefty price tag. To some degree, federal resources--such as Medicaid and the Maternal Child Health Block Grant--can help states pay for more prevention initiatives, but reimbursements can be difficult. And there is still some question whether and how much the state should be involved in these issues.

Senator Ortiz suggests that "it may take work to realize that there are successful programs out there, but it will take long-term, sustained resources to build awareness. We can save money by investing in prevention, but it is a hard case to make in difficult fiscal times."

Other challenges-such as the general stigma surrounding mental illness services--can make it harder for children and their families to get treatment or take part in prevention activities. Many are afraid that their information will not be kept confidential. Parents may also feel that life and death are family matters that should not be addressed at school. School officials also have a limited duty to protect students from harm and may be concerned about liability issues, especially if prevention efforts are ineffective.

"The challenge is to intervene, to get these kids what they need, and they need to be connected to different systems for different problems," says Iowa Representative Ro Foege. "Because of the variety of issues, the team approach is important. But the team needs to include parents, counselors, school nurses, social workers, community organizations and all others who deal with behavioral health. Everyone needs to come together to address the issue instead of being so fragmented."

WHY NOW?

Being scared and unhappy can be part of growing up. But when it gets too hard and they do not know how to cope, unhappy kids often act out their feelings--sometimes by hurting themselves or others. Suicide is ultimately a mental health problem, but there are triggers and contributing factors that lead young people to turn to suicide as a solution, rather than dealing with their problems in healthier ways.

"It is alarming that we live in a time when so many teenagers feel they have nowhere to turn," says Texas Representative Geanie Morrison. "As a society, we must do more to provide a safety net and let these children know that this is a terminal solution to a temporary problem."

There is no doubt that youth suicide is a tragic act of self-violence that wreaks havoc on the lives of young people and those they leave behind. "We have to look beyond whether we are saving money," says Montana Representative Paul Clark. "We are talking about kids' lives. We are also talking about the health of our families and society. Increases in suicidal behavior should be a red flag for legislatures."

RELATED ARTICLE: THE FEDERAL SAFE SCHOOL INITIATIVE

In response to high profile school shootings during the past decade the Secret Service and the U.S Department of Education have been working together to analyze the events and learn how to prevent them.

Because most of the young shooters told at least one other person of their intent, it is believed that some attacks could be prevented. But how?

Researchers spoke to 40 surviving school shooters to find out more about their motives and events leading up to the attacks. They learned that:

* There is no profile of a school shooter. They were all very different.

* Most attackers had easy access to guns.

* Over two-thirds of the attackers felt harassed or bullied, and many were motivated by revenge.

* Most did something before the attack that raised concern or suggested that they needed help.

* In many cases, feeling suicidal or desperate could have been a motivation for the attack.

* The risk factors for targeted violence are similar to risk factors for suicide.

"There is no profile of a suicidal child," says Marisa Reddy, one of the primary researchers on the project, "but there may be behavior along the way that could be a warning, just as there often is with targeted violence." She says researchers found that many of the school shooters had thought about or tried suicide in the past, and believes that any efforts to help them move "away from desperation and toward real hope and options for the future" will pay off.

"The best way to deal with youth suicide is through the development of a comprehensive strategy that links schools, communities and families; focuses on early identification of youth experiencing problems; and refers them to appropriate resources," says Bill Modzelezki, director of the United States Department of Education Safe and Drug Free Schools Program.

WARNING SIGNS FOR YOUTH SUICIDE


Depression                            Losing interest in activities once
Access to firearms                     enjoyed
Drug or alcohol use                   Unplanned pregnancy
Lack of parental guidance or support  Previous suicide threats or
Doing poorly in school                 attempts
Feeling disconnected to the school    Low self-esteem
  community                           Unhealthy interpersonal
Suicidal thoughts                      relationships
Talking about death or the            Victim of sexual abuse
  afterlife when sad or bored         Witnessing domestic violence or a
Withdrawal from friends and family     victim of it
Problems with sexual orientation      Hopelessness
                                      Exposure to violence or trauma
                                      Impulsive or aggressive tendencies
                                      Giving away prized possessions

Source: American Psychiatric Association, U.S. Public Health Service,
The Surgeon General's Call to Action to Prevent Suicide. Washington,
D.C. (1999).

Julie Thomerson is a former NCSL specialist in youth violence and delinquency.