July is “Purposeful Parenting Month,”1 designed to help contemporary parents be more “purposeful” in their relationships with their children. To provide deeper insight into the role psychiatrists might play in treating adolescents with mental health problems and working with their parents, Psychiatry Advisor interviewed Stephanie Hartselle, MD, assistant professor of psychiatry, Warren Alpert School of Medicine, Brown University and psychiatrist in private practice in Providence, Rhode Island. Dr Hartselle is also a national committee member of the American Academy of Child and Adolescent Psychiatry (AACAP).
Psychiatry Advisor: What role do you think the psychiatrist plays in promoting adolescent health and working with parents?
Dr Hartselle: Psychiatrists should advise parents that their number one job is to keep their children safe. This involves knowing what their children are doing, what apps and texts are on their phones, and who the child is spending time with. Children are growing up in a world of unprecedented access to information, strangers, friends, choices, and news. Parents must step in and monitor their children’s behavior, especially online, and provide leadership.
Psychiatry Advisor: What do you mean by “leadership?”
Dr Hartselle: In my clinical experience, I have seen a trend toward parents not disciplining or setting boundaries for their teenagers. The absence of structure, rules, and limitations increases anxiety in children. When I speak to parents, I compare the situation to walking into a job on the first day and being given no guidelines, instead being told, “you’ll have to figure it out yourself.” That would be a terrifying work environment for an adult. In a similar fashion, children need parents to define house rules and stick to them, and to initiate a dialogue regarding who their friends are and what they are doing. Even if the teen does not want to talk, parents should continue the discussion as best as they can.
Psychiatry Advisor: Why do you think parents are not taking this approach?
Dr Hartselle: Well-intentioned parents may be reacting to harsh parenting that they themselves grew up with. They do not realize that, even if the child does not act scared, it is terrifying for a youngster to be left adrift, twisting in the wind, without any parental direction.
Psychiatry Advisor: How do adolescents typically come to you for help?
Dr Hartselle: Occasionally, teens independently reach out for help, but typically they are initially screened by a primary care provider (PCP) and referred for help, or the parents bring them in for treatment because, for example, they have found drugs or a suicide letter. I think some parents and many school counselors are doing a better job asking about teen mental health, but we need to continue to improve the initiation of these discussions in educational and medical settings.
Psychiatry Advisor: How do you think adolescents feel about seeking or receiving mental health help?
Dr Hartselle: There is some evidence2,3 of an increased demand for help on the part of adolescents. Although there are no formal studies, we think that the stigma once attached to seeking help may be lessenin, and psychiatric and psychotherapeutic help are slowly becoming more accepted and better understood both as a medical treatment and as part of overall wellness.
Psychiatry Advisor: How should psychiatrists, other professionals, and parents react to suicide threats?
Dr Hartselle: Any statement about suicide must be taken seriously. Whether it is “made up” for some secondary gain or an actual statement of intent or ideation, it must be addressed emergently, as adolescents are at high risk for suicide.4
Psychiatry Advisor: What are the risk factors for suicidality?
Dr Hartselle: Psychiatric hospitalization is a well-known risk factor, as is substance abuse disorder.5-8
One of the major risk factors is a previous suicide attempt.9,10 Approximately one-third to two-thirds of individuals who attempt suicide will make a second attempt during the first year after that attempt, often resulting in completion.10-12 This is important to keep in mind even when treating older adolescents, since individuals who have attempted suicide continue to be at high risk as long as a decade following the first attempt.
Having a history of trauma and abuse raises the risk for suicidality considerably,13 and adolescents who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) are also at higher risk.14,15 Gender plays a role, with females being at higher risk for suicide attempts and males at higher risk for completion.4 Access to firearms further raises the risk.4
Although a family history of suicide increases the risk, it is harder to study this type of history because even a generation ago suicide attempts were not discussed, so the evidence base is not as robust.
Psychiatry Advisor: Are there any risk factors that were not present a generation ago or earlier?
Dr Hartselle: There are 3 relatively new risk factors.
Peer victimization and bullying have always raised the risk of suicide to some degree. In 1995, studies showed a twice-elevated risk for bullying in terms of suicide attempts and completions. In those days, bullying was conducted in person or perhaps via telephone — there was no social media back then. Today, we are starting to study the impact of social media, although the data have not caught up to the number of actual events because data must be collected and systematically analyzed.15,16 There are high-profile cases of social media bullying leading to suicide and well known cases of peers cheering someone on to complete a suicide attempt. Children and adolescents also have increased avenues for finding ways to engage in suicidal activity. We expect that when we start digging into the data we will find escalating rates of suicide risk.
Media coverage and events such as live suicides broadcast on Facebook and similar forums increase the phenomenon of suicide contagion, or suicide clusters. The age of 12 to 24 is a factor for the highest cluster suicide risk.17 The level of contagion is augmented when the adolescent not only hears about a completed suicide, but actually witnesses it.
Glamorization of suicide is a second relatively recent development. For example, after the suicide of Robin Williams, a celebrity made a statement to the effect of, “Well, now he’s free.” The psychiatric community expressed concern about the media publishing statements lie these because young people may walk away feeling, “If Robin Williams, who had so much going for him in his life, needed to be ‘free,’ what does that say about my life?”
The increasing focus on non-suicidal self-injurious behavior is the third important development. For many years, it was thought that this behavior did not correlate with a higher risk of suicide, but recent studies have shown that it is actually a risk factor.18 In the last couple of decades, teens have been talking about it more often, and self-cutting and burning have been openly discussed at school and on social media.19 Although increased discussion may have opened the door for some teens to come forward and seek help, there have been youngsters in my practice who said that they tried cutting because their friends were doing it. And I have seen an increased rate of nonsuicidal self-injury both in my private practice and in the university hospital system. This is alarming to all of us.
It is important to understand the reason a patient is self-injuring. I ask questions such as, “Are you cutting to relieve emotional pain? Are you cutting to feel something? Are you curious? Are you practicing?” I also ask, “Are you being bullied? Are you having trouble with someone on social media?” There are excellent risk assessment tools that can be used to evaluate self-injury and I encourage professionals to use them.18,20