Yale Psychiatry Grand Rounds: February 3, 2023

February 03, 2023

Bringing the Bioecological Model to Adolescent Suicide Prevention: Innovation and the Intersection of Science and Practice

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00:00Lovely and generous. That was such
00:04a lovely and generous introduction.
00:06I'm completely blown away by that.
00:08Thank you and I'm really
00:09excited to be here today.
00:10I'm going to share my screen.
00:13Start my slide.
00:14So look, I gotta get that. Click shut.
00:19Like from start you all could see that,
00:21right? OK. OK.
00:24So thank you so much, Michael.
00:26As I said, this is great,
00:27and I'm really actually very excited to
00:29speak to so many of you about this work.
00:31As Mike said,
00:32it's it's new work for me.
00:33I'm bringing something that I've
00:34studied for a very long time,
00:36the biweekly logical model,
00:37which I'll tell you a little bit
00:39about 2 adolescent suicide from
00:40work that I had done in early
00:42childhood and before I started.
00:43I also want to acknowledge a key
00:45colleague that has been working
00:46really close with me in this work,
00:48Rachel Avoli,
00:48who's a research assistant
00:50professor here at NYU.
00:51She's been an incredible thought
00:53partner to me in this effort.
00:55I've noticed closures to report.
00:58So first let me start by,
01:01I begin with sort of the grounding
01:03perspectives I bring to this work.
01:04So I was trained by this lovely gentleman,
01:06Yuri Bronfenbrenner,
01:07who's a luminary in the
01:09developmental psychology field.
01:11For those of you who don't know,
01:13he really taught developmental
01:15psychologists about how to think
01:16about human development as occurring
01:18within a nested set of ecological
01:20structures that children are embedded in
01:22families and neighborhoods and communities.
01:24And it's that influence that
01:26really influences their own.
01:28Development, as he used to say, it,
01:29was a set of nested structures,
01:31each inside the next,
01:32like a set of Russian dolls,
01:33which I loved.
01:34And together we wrote about a set of work.
01:37This was back when I was doing my
01:39doctoral training around the power
01:40of what we called proximal processes,
01:42the interactions between individuals
01:43and those people that were most closely
01:46with them in their micro environments,
01:48their parents,
01:48their teachers for older kids,
01:51their friends as well.
01:52And you're going to see that
01:54weaved through the work that
01:55I'm going to talk about today.
01:57The other piece is that we spoke a
02:00lot about is the responsibility we
02:02have and this is the sort of science
02:04that to practice piece that Mike
02:06mentioned to affect change as as he
02:08used to say as scientists and citizens.
02:11This is not to sort of he didn't mean
02:13citizens in the sort of term that
02:15non citizens don't have this role
02:17but it's about the responsibility we
02:19have as part of this country to make
02:21a difference to bring science to the table,
02:23right.
02:24And so we wrote this back
02:25in 98 and again in 2006.
02:27And we said we've arrived at
02:28a point where the concerns of
02:30basic developmental science are
02:31converging with the most critical
02:33problems we're facing as a nation.
02:35It's surprising to me.
02:36We wrote that in the 90s.
02:37I think it was relevant in the 90s,
02:39and then again in 2006. I think it's
02:41even more relevant today in 2023.
02:45A little less well known than the
02:47bioecological model for Yuri's work
02:49is an understanding of something that
02:51he called the transforming experiment,
02:53and this is actually his dissertation
02:55advisor said this to him.
02:56He said, Yuri, if you wish to
02:59understand the relationship between
03:00the developing person and some
03:02aspect of his or her environment,
03:04try to budge one and see
03:05what happens to the other.
03:07And that's work that I really that
03:09sort of perspective I really brought
03:11with me as I launched my career
03:13first in a Policy Research firm.
03:15Uh, where I was doing research on welfare
03:17policy and income support policies,
03:19this is the bioecological model.
03:21Here child in the subsystems,
03:23we really tried to change the exosystem
03:25and understand the effects of kids.
03:27And then more recently,
03:28as Mike mentioned,
03:29the work that I had been doing
03:31in both pre-K quality,
03:32really trying to change the way
03:34teachers interact with kids in pre-K,
03:35but also in parenting and what
03:38we call early relational health.
03:40In both of these efforts in
03:41in the early childhood space,
03:43I've really sought hard to think about.
03:45So the work that we're doing can make
03:47sure to get out there for everyone.
03:49I do that partly through partnerships
03:51actually that's really I think how
03:52Mike and I got to know each other
03:54best was through partnerships
03:55that we were both doing with pre-K
03:57communities and we as as I said
04:00through a partnership with New York
04:02City's division of Early childhood
04:04as they were launching pre-K for
04:06all building a system to support
04:09kids originally assistant that was
04:12supporting 17,000 kids moving to.
04:15Some part 70,000 kids in the course
04:16of a couple of years and we're trying
04:18to embed research in that system and
04:20then through what I call platform.
04:22So this is a picture of a child
04:24and a pediatrician's office,
04:25which should be very familiar to many of you.
04:28So the parenting work that I do
04:30is in pediatric offices because
04:32for infants and toddlers,
04:33it's one of the places where we
04:34know parents and kids are already.
04:36They're doing a lot of visits as you
04:37well know between zero and two when we
04:39really try to leverage those visits.
04:41And so it's those perspectives
04:42that I'm trying to bring that,
04:44that that sort of work.
04:45What I've done over the last couple
04:47of decades to new work that I'm doing
04:50now in adolescent suicide prevention.
04:52I'm sure you've heard about rising
04:54rates of anxiety and depression and
04:57suicidal thinking among our young
04:59people as a result of COVID-19.
05:01But as you heard from the introduction,
05:02it wasn't COVID that actually got
05:04me into this work.
05:05I was actually drawn into this work
05:07from a very personal experience.
05:09So as Mike mentioned,
05:11I had a personally transforming
05:13experience and we lost our daughter
05:15Frankie to suicide when she was 17 years old.
05:18So she died back in 2019,
05:21about nine months before.
05:22So bad about 3 1/2 years ago now,
05:25Frankie was not what you might think
05:26of when you think of a suicidal teen.
05:28She was deeply connected,
05:29deeply engaged in school and in theater,
05:32and deeply connected to a number of
05:34other people, including her friends.
05:35But also this is her walking down
05:38the street with her twin brother.
05:39They would walk like this,
05:40arm and arm, and I would snap pictures
05:42to of them unbeknownst to them,
05:44and they would walk like this.
05:45This is on our block or on college campuses.
05:49Locked arm and arm.
05:50She just had this.
05:52You're right.
05:53This sort of strength that seemed to
05:56transcend all of her emotional struggles.
05:59As a parent, of course,
06:00I had a million questions after she left us.
06:02But as a prevention scientist,
06:04those questions focused on how
06:05the world could look differently
06:07so another family wouldn't have
06:09to go through what we had.
06:14And so I I started reading everything
06:15that I could around adolescent suicide
06:18and adolescent suicide prevention.
06:20And the more I read,
06:21the more I realized how much the
06:23world needed to know in order
06:24to make progress in prevention.
06:26And the first thing I realized was
06:27how much the world this world had
06:29really a very new language in it
06:31that I was completely unaware of.
06:32So I learned that the suicide community
06:34doesn't use the word committed suicide,
06:36which of course is really common
06:37in our lexicon right now.
06:39They use died by suicide,
06:40just like you die by cancer.
06:42And the reason why is actually.
06:43Because of this picture,
06:45which I think sort of exemplifies the
06:47history of suicide that was largely
06:50criminalized and considered a sin
06:52for an exceptionally long time.
06:53Actually, that history is not that far away.
06:56So this picture is a church.
06:58I believe it's in England,
06:59and the line in the grass here.
07:03Sorry, I'm going to move here.
07:04Faces to the other side of my screen.
07:07The line in the grass here shows the
07:10demarcation between the Grays of of
07:12those people who died by all other causes.
07:14Separating the graves of people
07:16who died by suicide because often
07:18these were unmarked graves where
07:20people didn't receive last rites.
07:22So in order to move away from that language,
07:25we now use the word died by suicide.
07:27So we don't sort of continue to sort
07:30of reify this, this sort of very,
07:32very wretched history.
07:34I also,
07:34I also learned that people like
07:36myself who lose somebody's suicide,
07:39it can be called a suicide lost survivor,
07:40like a Holocaust survivor.
07:42Those who attempt suicide can be
07:44called suicide attempt survivors,
07:46recognizing the strength that we all have.
07:49Suicidology is actually the scientific
07:50field for the study of suicide,
07:52which I never knew.
07:53About and and suicidology studies
07:55three things.
07:56They study intervention programs
07:58which I think are really wouldn't
08:00have dominated the field around.
08:01These are programs for people who
08:03have already been deemed suicidal
08:05prevention efforts right really to
08:06prevent a suicide and something called
08:08post Vention which is support for
08:10individuals and communities after a loss.
08:13I'm gonna talk today a lot
08:15about prevention efforts.
08:18But that was really the tip of the iceberg.
08:20Iceberg in terms of new language,
08:21as is only the start of what I learned.
08:23I also learned about the very,
08:25very high prevalence of suicidal
08:27thinking among our teens that
08:29it turns out that one in five
08:31teens have reported seriously
08:32considering suicide in the last year,
08:35one in 10 teens.
08:36These are high school kids have report
08:39having attempted suicide in the last year.
08:42So this is a a class of 25 kids.
08:44So that's five kids at a 25 kid
08:47high school class.
08:48Two to three kids who've attempted
08:50suicide and it's just in the last
08:52year and you might be saying,
08:53well of course that's because
08:55COVID just happened,
08:56these kids are really struggling.
08:58These are actually 2019 data.
08:59These are pre COVID data.
09:01So when we talk about a youth mental
09:04health crisis that's amongst us.
09:06Frankly that that that mental health
09:09crisis existed prior to COVID.
09:11I think people just started paying
09:13attention to it following COVID
09:15and of course things did get a
09:17little bit worse as well for kids.
09:19And the kids have been struggling
09:20for an exceptionally long time.
09:22I also learned about how much kids
09:24can camouflage their emotional pain.
09:25It's not surprising to have a child
09:27like Frankie who can really keep
09:29their suicidal thinking to themselves
09:31for an exceptionally long time.
09:33I learned how suicide is not
09:35about wanting to die,
09:36but often about wanting to end severe,
09:39unrelenting emotional pain.
09:40So at first I was trying to
09:42understand suicide and thought,
09:44you know,
09:45how do we understand it when there's
09:46such a strong will to live as
09:48sort of innately embedded in us?
09:49But just like when we pull our
09:52hands away from a burning stove
09:54to avoid physical pain,
09:56suicide is really the attempt to move
10:00away from unrelenting emotional pain.
10:04I learned about how for young kids,
10:07for for youth in particular
10:08for kids in schools,
10:10that the timing of risk actually
10:12coincides with school months.
10:13So this is a graph that shows you
10:15the relative rates of suicide.
10:17These are suicide deaths for.
10:20The blue lines here show you the relative
10:23rates for youth age 8 to 17 for children,
10:26the red for adults,
10:27there is seasonal variation.
10:29These are all relative rates relative
10:31to the reference month of July.
10:33Of course, rates are much higher
10:35for adults than they are for kids,
10:37so these are just relative rates.
10:40And there is some seasonal variation
10:41for both adults and kids, right?
10:43Fewer suicides in the summer months,
10:45not surprisingly.
10:46But for youth, it's really.
10:49Emphasize,
10:49it's really highlighted these there's about
10:52a 40% difference in suicide rates in January,
10:56February, March, April and September,
10:58October, November relative to July.
11:01The reference months so much higher rates.
11:03These numbers are very small.
11:04So I just want to highlight that very
11:07few kids as I said died by suicide.
11:09So these different the differences
11:11of these numbers are small.
11:13However this pattern is repeated
11:14year after year after year.
11:16So I believe these data they're
11:18also demonstrated in data.
11:19On suicide attempts for kids who
11:20show up in the emergency department,
11:22a very, very same pattern.
11:25Umm.
11:26I learned also how unpredictable
11:28suicide is based on risk factors.
11:30So there's a wonderful paper that
11:32came out in 2017 by Franklin and
11:35and as part of Matt Knox Group
11:37at Harvard that basically did a
11:40meta analysis of of a 50 years of
11:43research in suicidal thoughts and
11:45behaviors based on risk factors.
11:47Essentially finding that a we are
11:49prediction of suicidal thoughts and
11:51behavior is no better than flipping a coin,
11:54no better than chance and.
11:56Have not gotten better over
11:58the last 50 years of
11:59of research. So one of my plugs I really
12:02try to encourage people to get involved
12:04in this field so that we can do better.
12:07And in part that's because we typically
12:09use single or dual risk factors in
12:11predicting suicidal thoughts and behaviors.
12:13There's some new work that folks are
12:14trying to do about algorithms and using
12:16sort of sort of real time information,
12:19but still we are not very good at
12:21predicting who is likely to attempt
12:23or die by suicide and who is not.
12:25And it was that combination of sort of.
12:27Very, very high prevalence,
12:28especially among young people and
12:30lack of prediction that argue to
12:32me that we needed to not just be
12:35working in the mental health space.
12:36We're really important and
12:38good work is going on.
12:39But we need to complement that work
12:42outside of the mental health system
12:44and programs where for programs
12:47and spaces where kids already were.
12:49So in school buildings and
12:51emergency departments,
12:52in pediatric offices and in homes.
12:54And I'm going to tell you a
12:56little bit about that in a bit.
12:58But first I was really drawn
13:00to other stigmatized fields,
13:02so particularly cancer and AIDS.
13:05So I remember I was walking down
13:07the street one day and I saw
13:09this very large billboard.
13:10It's actually it was on Houston St.
13:12so this is just a few blocks from
13:14where I live in lower Manhattan
13:16proclaiming Ralph Lorenz.
13:17They said join us in our 20 year fight
13:20against cancer and I and it was like COVID.
13:22So like no one was on the street and
13:24I see this huge billboard and I was
13:26remember thinking wow, like you know.
13:28I remember my parents generation,
13:29people would whisper about cancer, right?
13:31Chest cancer, right?
13:32How did it go from a disease
13:35where my parents generation,
13:36we whispered about this disease
13:38to a time where Ralph Lauren,
13:40a private clothing company can
13:42proclaim their investments or 20
13:45year investment in Cancer Research.
13:48So how did that happen?
13:49And I started reading Souderton Murkage's
13:53wonderful biography of of cancer,
13:56the Emperor of All Maladies,
13:57which I highly encourage for
13:58those of you who have not read it.
14:00I spoke about a bunch of things about cancer,
14:03but I'll highlight couple of pieces.
14:05One is Susan Sontag and her role in
14:08changing the language that we were using
14:10around cancer and how much that mattered.
14:13She herself was diagnosed with
14:14cancer and really struggled with
14:16the sort of stigmatizing language
14:17that we were using around it.
14:19She,
14:19she spoke about that in the late
14:2270s around cancer and then around
14:24AIDS and in the late 80s and early
14:2790s and it it she was demonstrating
14:29the way in which it not only.
14:31Made her feel bad as a cancer patient.
14:34It also reduced the support
14:36she got as a cancer patient,
14:38conversations around it.
14:40But it also affected the research
14:42that we do in this area.
14:45So this quote really struck me,
14:46she said, supporting the theory
14:49about the emotional causes of cancer.
14:52And she does mean causes,
14:53and I'll tell you why in a second,
14:54is a growing literature and body of research.
14:57And scarcely week passes without
14:59a new article announcing to some.
15:01General public or other,
15:02the scientific link between
15:04cancer and painful feelings.
15:06And I'm sure you're thinking,
15:06wow, I can't believe that, right?
15:08That must have been ages ago.
15:09Well, it turns out it was in the 70s,
15:11not that long ago.
15:12She cites a Johns Hopkins study where
15:15and another one from somewhere else
15:17that basically was articulating the ways
15:19in which personality factors and depression,
15:22because they were diagnosed
15:24before the cancer diagnosis,
15:26they must be causally associated
15:28with the cancer diagnosis.
15:29And it was because cancer
15:31was such a scary disease.
15:33And it was basically a death sentence.
15:35And because we didn't understand its causes,
15:37people were throwing in all of these
15:39sort of negative attributes to it
15:41to sort of refresh, stigmatize it,
15:43really further stigmatize it.
15:44And it guided much of the research at
15:47the time in in the causes of cancer.
15:49I also thought about,
15:50I understood the ways in which the
15:52Ralph Lauren came out with that,
15:53that that huge billboard started
15:55with something called the Jimmy Fund,
15:58which those of you who may recall
15:59and if you have time,
16:00I won't do it in the interest
16:01of time we've got today.
16:03But a it's a wonderful little
16:06radio program where a boy Jimmy,
16:10no last name, no prognosis,
16:12Jimmy could be anybody's kid, right.
16:15And they play this radio program
16:17we're actually they don't talk
16:18about how sick he is.
16:20Or how much he needs help.
16:21They actually talked about his
16:22love for the Boston baseball team,
16:25the Boston Braves, and like the entire team,
16:27walks into his hospital room
16:29while he's on the air.
16:30They all sing,
16:30Take Me Out to the ball game together.
16:32And then they asked for $20,000 so
16:34we can watch the baseball game on his
16:36television set in his hospital room.
16:37And they end up raising a couple $100,000.
16:40And this is what started the the
16:43Children's Cancer Research Foundation,
16:45where Sidney Farber started that,
16:46and the Dana Farber Cancer Institute.
16:49So really important.
16:50Sort of ways in which we build
16:52sort of the both the political
16:54will for and the scientific effort
16:57around highly stigmatized diseases.
16:59I was reminded very briefly about
17:02the fight that parents of autistic
17:04kids made when they were being
17:06called refrigerator mothers before
17:08we understood the causes of autism.
17:10And they said, hey,
17:11this is not our fault that our
17:13children have autism and how important
17:14it was for them to articulate the
17:17ways in which autism was really
17:18a neurobiological disease.
17:20These are not caused by parenting behavior.
17:24Suicide, I think, has come a long way.
17:26We are talking about it more.
17:28It's in the paper a lot more,
17:29and I am encouraged by that.
17:31But I think it has an enormous
17:33uphill battle still.
17:34And I was struck not that long ago to
17:36see this article in the New York Times.
17:38It was actually about Insel,
17:41who was the former head of the NIH.
17:45A book that had just come out
17:47about kill called healing,
17:49sort of a mayor culpa book for
17:51those of you who haven't seen it,
17:53where he was basically articulating
17:54that the 13 years he spent at the NIH,
17:57they may not have made enough
17:59progress in mental illness.
18:01And so he was sort of taking stock in that.
18:05And but this quote really struck me.
18:08I'll read it and then we'll reflect, he says.
18:10I want to ring the bell to tell people
18:12we could do so much better today
18:14and there's no excuse for allowing
18:16people with these brain disorders.
18:18To languish on our streets like
18:20this and died at age 55,
18:22eating out of trash bits.
18:25I just want you to look at the
18:27language he's using to describe
18:28someone with mental illness.
18:29He's not describing his mother
18:31or his brother or his sister,
18:33his child or grandchild, right?
18:36He's describing it as somebody who
18:40doesn't actually engender a huge amount
18:42of emotional support and empathy for,
18:45and perhaps it should, but, but,
18:48but unfortunately it does not.
18:50But somebody who's languishing on our
18:52streets and dying any age 55 and eating.
18:55Of trash bins.
18:56And until we describe those with
18:57mental illness and with suicidal
18:59thinking as the jimmies of the
19:01world and the frankies of the world,
19:03I don't think we can make
19:06progress in prevention. Umm, what?
19:08I turn to prevention strategies.
19:09I look to models from industrial accidents
19:12because suicide is of course a rare event.
19:15And it struck me that one of the
19:16ways in which we addressed it,
19:18like I really needed to look to other
19:19fields to think about how do we stop
19:21relatively rare events from occurring
19:23and especially if we're going to
19:24think about that at the organizational level.
19:26And I was really drawn to James reasons
19:29work from the late 90s where he tempted,
19:31he was actually working
19:32with a lot of companies.
19:33This was sort of in the time
19:35period in the 80s and 90s.
19:37Of a lot of accidents like I Chernobyl,
19:39and other kinds of accidents
19:40like that that were occurring.
19:42He was trying to reconcile different
19:44approaches to safety management,
19:45working with what he called
19:47high reliability organizations.
19:49And he came up with this wonderful
19:50model called the Swiss cheese model,
19:52right, which I I love.
19:53The sort of pictures behind reminds
19:54me of sort of Yuri's Russian dolls,
19:57right?
19:57And the ways in which we really
19:59needed to layer approaches,
20:01layer safety across a system so we can catch
20:04relatively rare events from occurring.
20:06He said we can't change the conditions
20:08under which humans.
20:09Don't change the human condition.
20:10We can change the conditions under
20:12which humans work.
20:13We could change organizations.
20:14And I won't go into a lot of detail,
20:17but this wonderful also book
20:19by Diane Vaughan which talks
20:21about the space Shuttle
20:23Challenger launch back in 86.
20:25For those of you who might recall,
20:27it was when I was in high school,
20:28exploded in mid air midair
20:3073 seconds after takeoff,
20:32killing all 7 crew members on board.
20:34And she looks at really the
20:36Nassau environment, which was.
20:38Developed a culture for normalizing deviance,
20:42normalizing risk rather than normalizing
20:46safety that permitting actions to occur.
20:49But all that guided me to really think about,
20:52for suicide prevention,
20:53a layered approach where we expect risks
20:55to occur and we really think about how
20:57to address them on a regular basis.
20:59So I started to write a series of pieces
21:01that I initially entitled what ifs.
21:03They were named after the relentless
21:05thoughts that I had following
21:07the death of my daughter.
21:09They invaded much of my waking moments,
21:11but I decided to recast them as
21:13really musings about suicide
21:15and the first one I wrote,
21:17which appeared in the New York
21:18Times just about two years ago now,
21:20March of 21.
21:23And it was what if we approached suicide
21:25prevention the way we do car accidents?
21:28It was renamed by an exceptionally
21:29wise editor.
21:30I don't want another family to
21:32lose a child the way we did.
21:33I encourage you all to read it,
21:36not just because I want you
21:37to read my writing,
21:38but because I really want you to
21:39understand more about suicide
21:40prevention and what we can do about it.
21:41And I thought about car accidents
21:43because just like suicide,
21:45it's one of these things that
21:46feels kind of unpredictable.
21:47We don't know when it's going to happen next.
21:49And in fact,
21:50when I looked at the history
21:51of seat belt safety,
21:52it was really akin to where we are.
21:54Right now with suicide prevention.
21:55So it turns out that back in
21:57the 80s when I was growing up,
21:59adults were really worried about
22:01teens dying in car accidents because
22:03we couldn't predict which kid would
22:05would die next in a car accident.
22:07Of course, we understood risk factors right,
22:09you know?
22:11You know, ice on the road, bad,
22:12bad breaks, what have you drinking, right.
22:15These kinds of things mattered,
22:16but we couldn't predict what would
22:18happen to an accident, who it wouldn't.
22:19And it turned out that,
22:21you know, at the time,
22:21the one solution we had seatbelts,
22:23were you not used by many people.
22:25My parents are super safety conscious people.
22:27They let us like float around in the
22:28back of the car like they would be shot.
22:30Like,
22:30we would all be shocked to know this today,
22:33but in fact, at the time they said no,
22:35we've got to get people to
22:36start wearing seatbelts.
22:37And it was a combination of efforts,
22:39right, that went to the like, how do we.
22:41Had them in car doors to now have
22:43the peeping sounds right that
22:44you automatically put it on.
22:46It's embedded in drivers AD and
22:48we have these clicker ticket signs
22:50on the highway
22:51that continue to remind
22:52us to all wear seatbelts.
22:54So we all put seatbelts on
22:55every single day even though the
22:57likelihood of any of us getting to
22:59an accident is exceptionally small.
23:01And I sort of drew that model
23:02as sort of analogy from that
23:04to what we might want to do in
23:06suicide prevention with roles
23:08for in my article pediatricians
23:10and orthodontists and school.
23:11Personal and parents appear sort of
23:13everybody and kids sort of ecological,
23:15ecological, universe and speak.
23:21I was also struck by roses,
23:23I reminded by Rose's prevention paradox.
23:25So those of you who know don't know,
23:27Jeffrey Rose wrote in the early 90s about
23:31something that he identified as being a
23:34paradox that we we often forget as we think
23:37about how to move populations, he said.
23:39A large number of people at very small
23:42risk can actually give more eyes to
23:44more cases of a disease than a small
23:46number of people at high risk.
23:48Because when I talk to people about suicide,
23:50they always say, though.
23:51That's great, but what can,
23:52how can we identify people so we can
23:54target our resources most effectively?
23:56It's a great question, but I want you
23:57to think about the prevention paradox.
23:591st I'm going to show you some
24:01pictures to sort of keep moving this
24:03along about how this plays out.
24:05The reason why the prevention paradox
24:07happens is that when we focus only this
24:09is for those people who like data.
24:11Remember the bell curve, right?
24:12Those people who like data,
24:13if we focus on the high risk strategy,
24:15we focus on the high risk people.
24:17We're not going to move that
24:19population mean very much.
24:20We need a population.
24:21Based strategy to move
24:23everybody and the reason why,
24:24and I'm going to show you an example
24:26from medicine and then an education.
24:28So those of you who are medically trained,
24:30which I'm sure there's lots of you here will,
24:33will permit me a little bit of
24:34leeway here as I describe a
24:36medical example from eye pressure,
24:38which I know nothing about as
24:40the developmental psychologist,
24:41but this is his example.
24:43This graph shows you the the
24:45percent that black bars,
24:47the percent of the population,
24:49the Gray bars,
24:50that percent of cases of glaucoma.
24:52And this is the relative risk
24:55of glaucoma due to intraocular,
24:58intraocular eye pressure.
25:00And of course,
25:00we know that the risk increases at very,
25:02very high pressure, right?
25:03So we imagine that most of the time
25:06we focus on that group of people.
25:08If we do that,
25:09we end up with 30% of the block.
25:12We can address 30% of the glaucoma cases.
25:14We will miss 70% of glaucoma cases if
25:17we only focus on intraocular pressure.
25:19I'm sure many of you knew that.
25:20Know that, my doctor.
25:22Virtually knew that and tested me.
25:24I'm actually,
25:24I have glaucoma and I'm down here
25:25in this part of the distribution.
25:27Thank goodness she used other approaches,
25:29but a lot of people don't.
25:31So more measures matter, right?
25:33A good doctor doesn't use a single indicator.
25:35And in fact,
25:36when we have more measures,
25:37we do do a little bit better in
25:39reducing that prevention paradox.
25:41So this is an example of 36 studies
25:43of high school dropout.
25:44We actually do really well predicting high
25:47school dropouts in my field in education,
25:49we we have multiple prediction models,
25:51but here,
25:52so imagine we have 100 kids.
25:54We're predicting who's going
25:55to drop out of school.
25:56We think based on the risk factors,
25:5820% of them will drop out of
26:00school and we do really well.
26:0275% of those kids actually do drop out,
26:04right. We're never perfect
26:05about predicting the future.
26:06In our low risk group,
26:08only 25% of those kids drop out like great,
26:11look at that difference, 25 versus 75% of
26:14kids differentiating these two groups.
26:17That seems great. Well,
26:18why don't we put all our resources here?
26:20We'll look at those numbers.
26:21If we do that, more than half of the kids.
26:24The dropout are still
26:25from this low risk group.
26:26We will miss more than half the kids if
26:28we only focus on a high risk strategy.
26:31So that's what we're doing right
26:32now in suicide prevention.
26:33We have a high risk strategy only,
26:35so we need.
26:36Better single measure we do
26:38better with more measures.
26:39We reduce the paradox.
26:41But we're still not doing perfectly,
26:43and so we need something that
26:45allows for a continual risk so
26:46we can catch more of these kids,
26:48or we need universal interventions.
26:52Unfortunately,
26:53we actually have that new suicide screening,
26:55so I'm not gonna again go
26:56into detail on this,
26:57but there's a wonderful measure
26:58called the Cassie I'm using in another
27:00study I'll show you in a second,
27:01developed by Cheryl King has 24 clinical
27:05and psychosocial predictors that are used.
27:07But because of an adaptive
27:08test and done on a tablet,
27:10it only takes a couple minutes
27:11for a kid to fill it out.
27:13And you can get really strong sensitivity and
27:16specificity of of youth suicide screening.
27:18There's a number of other tools as well,
27:21but Even so,
27:22we can't fully.
27:23Eliminate that prevention paradox.
27:24So we really do still have to think about
27:28universal interventions or asking every kid,
27:30which I'll tell you about in a second.
27:33But I'm sure you're might be
27:34asking a question at this point.
27:35I don't know how well this is known
27:37now because I've been talking
27:38a lot about suicide,
27:39but many of you might be thinking,
27:41is it really OK to screen for
27:42and ask about suicide?
27:44When I put the idea in a kids head,
27:45I think this is one of the
27:47biggest fears people have is,
27:48well, if I talk about it,
27:49I'm going to suggest it,
27:51especially for young kids are
27:52very suggestible, right?
27:53Well it turns out that protested really,
27:56really carefully.
27:56So Maddie Gould at Columbia did a
27:59wonderful randomized trial where
28:01she evaluated the iatrogenic.
28:03Risk of youth suicide screening
28:05programs and found absolutely no
28:07evidence of iatrogenic effects.
28:09And in fact,
28:10for those kids who are struggling
28:12the most who had some who are
28:15at some risk for depression,
28:17those kids actually saw a reduction
28:19in distress by being asked
28:20about suicidal thinking.
28:22OK.
28:22And that's been confirmed and
28:24excuse me later in meta analysis
28:26and this is not new data.
28:28So this actually study came out in 2005,
28:31so nearly 20 years ago.
28:33And it's still not common knowledge.
28:38Why do you? I think people don't know
28:41this well enough. Actually, sorry.
28:43Why do I think actually this works?
28:45Why do actually I think that people
28:47that kids actually feel less
28:49distressed when you ask about it.
28:50Well, I think it's back to
28:51like my early childhood work.
28:52So one of the things I've studied
28:54for a very long time and early
28:56childhood is emotions understanding.
28:58So if you walk into a pre-K classroom
29:00today and you often hear teachers say,
29:02Johnny, I see you're really angry,
29:06you know, right.
29:06Why do teachers do that and
29:08why do parents do that?
29:09We are learning how to label emotions so
29:11that kids learn how to label their emotions.
29:14The notion is if you can label it,
29:16you can regulate it.
29:17So we use these feeling cards and we
29:20teach kids the difference between sad and
29:22angry and happy and jealous and shame,
29:25right?
29:25We teach these emotions that are really
29:27hard for little kids to understand.
29:29So we know that for little kids,
29:31but somehow we don't sort of
29:32translate that to older kids because
29:34we're so scared of suicide, right?
29:36But if we talk about it more,
29:38if kids can label what does it
29:39feel like to feel suicidal,
29:41it'll allow them to regulate it more.
29:44And I think,
29:45and I wouldn't want to say
29:47as parents and providers,
29:49you can ask about it the way
29:50you ask about other ailments.
29:52And so I do a lot of parent webinars
29:53where I talk to parents about,
29:55you know, listen, you can say,
29:56and I know this is really scary and
29:58really hard, but it is OK saying,
30:00hey, you know, I saw that, you know,
30:03you've been really down lately,
30:04you know, and I just have to ask,
30:06are you thinking about suicide?
30:08We talk about that now a lot in
30:09our home and and then you could
30:11ask a series of questions that's
30:12much the same way that you would.
30:14Ask about a headache or stomach ache
30:16and I can discuss that more in questions.
30:18I don't think it's understood
30:20because of the history that we have
30:22of suicide as a crime or a sin.
30:24And I also think partly because
30:26also people are scared about
30:27something called contagion,
30:28which I also think is very poorly named.
30:31Suicide is not contagious.
30:32If you talk about it,
30:33you can't catch it, right?
30:35It's actually a clustering.
30:37There is a.
30:38Uh,
30:39there is some evidence that in some places,
30:43after suicide deaths,
30:44sometimes other children,
30:45other youths take their lives.
30:47It is a very scary thing.
30:48It does have to do with the way in
30:50which we message about suicide.
30:52That really matters.
30:55But you can message now about suicide
30:57in ways that is actually safe.
30:58Avoid what's called the Werther effect
31:00from gotta and seek the propaganda
31:02effect from Mozart's magic flute.
31:04I won't go into that.
31:05This is not a literature class.
31:06But for those of you who
31:08might know those references,
31:09the National Excellence Alliance has
31:11a wonderful set of guidelines about
31:13suicide language and safe messaging
31:15that includes not using that word.
31:17Commit that I mentioned at the beginning.
31:18Don't report the method of suicide.
31:20Don't ask about that,
31:21because I can re traumatize
31:23people and don't sensationalize.
31:25Um, around suicide deaths because again,
31:28it's it's retraumatization, people.
31:30And we can really turn these messages
31:33to prevention by adding resources.
31:35So you'll see at the end of my slides,
31:37I always include.
31:40Resources to places so people know where
31:42to get help if they're struggling.
31:45And messages about successful coping,
31:47about people who've struggled with
31:49suicidal thinking who have actually
31:51come out on the other side and we pair
31:53those together and actually have shown
31:56in some randomized trials near Croton.
31:58Fowler has shown a wonderful randomized
32:00trials about the benefits of these
32:01kinds of coping messages instead.
32:06So in terms of suicide prevention,
32:08one of the most universal prevention
32:10efforts we have out there right
32:12now is something called 988.
32:13And I hope you've all heard of that now,
32:15and if not, I'm telling you about it today.
32:19So it used to be a 10 digit number that
32:21was in existence for an exceptionally
32:23long time and a few years ago.
32:26The law about changing it to
32:27a 3 digit number, 988,
32:28some people would remember it
32:30would be out there.
32:31So there is a phone number, it's there 24/7.
32:33You can call it anytime.
32:35It's not just for suicidal thinking,
32:37it's also if you're struggling with
32:39any kind of emotional distress.
32:40But these come from this wonderful man,
32:45Chad Vera,
32:46who back in 1952 developed
32:50this after 17 years.
32:52Earlier.
32:52He had presided over the funeral of a
32:55young 13 year old girl who had died by
32:58suicide when she got her first period.
33:00And she didn't know what was happening
33:02to her. And so she took her life.
33:04This was in 1935.
33:05He presided over her funeral and he said,
33:08hey, I didn't know you young girl,
33:09but I'm going to make sure
33:11your life made a difference.
33:12And he eventually opened up a
33:15suicide helpline for himself.
33:17He started reaching out to people to
33:19talk to them if they were struggling,
33:21they came to him.
33:22And he was so good at what he was doing,
33:24he ended up with lines out his door.
33:26So he hired a bunch of volunteers to,
33:28like,
33:28hang out with these people and give them
33:30like tea or biscuits or something like that.
33:32I don't know,
33:33what was England.
33:34And.
33:34And one day he opens his door to,
33:37you know, talk to the next person.
33:39And the crowd has largely dissipated.
33:41And he realized that.
33:42The volunteers that he had hired
33:44who were untrained because we're,
33:47we're actually helping these people
33:49reduce their emotional distress
33:51because just talking about it
33:53can actually make a difference.
33:54And so we started something
33:57called befrienders worldwide,
33:58and it was based on active listening.
34:00So listen to somebody accepting
34:03understanding and empathizing,
34:04but no giving advice and no counseling.
34:07And that's what the 988 and other actually
34:10international numbers are all based on,
34:11is this sort of. Defender program.
34:13I wish we called our helpline
34:15a befriender program.
34:16I think more people would call and
34:18not be so scared of the line itself,
34:20but it is about that.
34:20It's just sitting and listening
34:23because letting it out can actually
34:25release a lot of the pain.
34:28What else do we know works
34:29universally in suicide prevention?
34:31It turns out accepting
34:32policies really matter.
34:33Same sex marriage laws,
34:34wonderful work by Julia Richman and same
34:37sex marriage laws reducing suicidal
34:39thinking and and behaviors among a
34:41particularly among LGBT plus youth.
34:43Keeping people safe really matters.
34:45So it really matters if we
34:46reduce the length of time.
34:48We increase the length of time
34:50between someone having a thought
34:52of taking their life and someone
34:54actually attempting and and and
34:56keeping people away from from there.
34:58Of a primary choice of means
35:01can actually do that.
35:03We can.
35:04There's really wonderful evidence
35:05at the population level about
35:08firearms somewhere got firearm
35:10restrictions and States and some
35:12work from other countries on on
35:14on on keeping guns more safely,
35:17hotspot protection.
35:19So in buildings,
35:20putting up barriers or netting
35:22around buildings that have been
35:24where suicide deaths have occurred.
35:27Really interesting.
35:28They're from pill packaging
35:30in the UK where they went to.
35:34One at a time pill packaging
35:36and reduced amounts of analgesic
35:37medications that you can purchase.
35:39And because people could only
35:41purchase it in smaller doses,
35:42smaller amounts of pills,
35:43people are less likely to take their lives.
35:46There's modest substitution with
35:47all of these, so sometimes some
35:50people do substitute other methods,
35:52but it's not.
35:53But it's still.
35:54The net reduction is lower
35:55because most people,
35:57many people who choose a method
35:58typically and if they're restricted
36:00from accessing that method,
36:02won't try that day and then they survive.
36:05Really interesting work on carbon emissions.
36:07So it turns out that the 1970
36:09Clean Air Act which reduced which
36:12required new cars to be produced
36:15with a catalytic converters and
36:16and and reduce the amount of carbon
36:19emissions coming out of cars.
36:21Actually by the time those cars
36:23were majority in the in the streets
36:25which is the 1990s we see lower
36:28rates of suicide deaths due to
36:30carbon monoxide poisoning for
36:32both adults and for youth which
36:33is really sort of interesting.
36:35That's a public health effort
36:37for climate change actually had
36:39a suicide prevention effort,
36:40became a suicide prevention effort.
36:44At the person level,
36:45we can have there's a wonderful
36:47app on a phone that you could all
36:49download today and show people that
36:50you love who might be struggling called
36:52the Stanley Brown Safety Plan app.
36:55But as a as a doctor or as a parent,
37:00you can also remove access
37:01to lethal means in your home.
37:02And one of the things that always
37:04strikes me is that we spend lots of
37:06time protecting our homes for baby,
37:08baby proofing our homes, right?
37:09Those plugs that go in the wall
37:12or we're told for every child to.
37:14Place them on their back to prevent SIDS.
37:16But we didn't understand the what.
37:18We don't understand the cause of SIDS.
37:19We built every child to lie on
37:21their back as a baby, right?
37:23We can remove access to lethal means for
37:25every single kid and every single home,
37:27irrespective of risk.
37:29That means locking up guns and over the
37:32counter and prescription medication.
37:35So I think every family should
37:37have a lock box for things that
37:40kids might struggle with.
37:41We screening also works and it
37:43turns out a pediatric office.
37:45This is a great place to screen
37:47parents appreciate you know
37:49accept it youth accept it.
37:50So high acceptability and feasibility
37:52of doing it in medical settings and
37:55particular and benefits efficacy
37:56evidence around the link between
37:59around the impact of screening and
38:02then connecting to care of course
38:05relative to not doing either.
38:07And it turns out there's really
38:09interesting population level efforts.
38:10There was Garrett Lee Smith Act
38:12that was passed under the
38:14Bush administration in 2004.
38:17Invested in communities.
38:18So this was money that went to
38:20communities for them to invest
38:22in suicide prevention efforts.
38:24Really good evidence of these
38:25sort of community wide efforts.
38:27People use them in lots of different ways.
38:29Built a lot of different kinds
38:30of programs with them.
38:31It's now a new version called the Stand Up.
38:34I'm sorry that I don't remember
38:35the full acronym of that.
38:36It's like suicide training and awareness
38:38and something out there that Biden just
38:40signed but there's no money behind it.
38:42So even though it's been passed in
38:44Congress and signed into law, it needs
38:46money and investments for communities.
38:48Little invest in suicide prevention.
38:51At some of this work.
38:54We are testing right now just
38:56keeping eye on time here.
38:57So we are testing some of this work
39:00through a randomized trial called we care.
39:03This is work that's being
39:04funded right now by NIMH.
39:06We just launched it with Michael Lindsay
39:08and Cheryl King that I'm doing where
39:10we are taking youth who present to the
39:12emergency department for any condition.
39:14So a broken knee or asthma,
39:16they walk in the door.
39:17We are doing a small eligibility survey
39:19with them and then randomizing them
39:22to a combination of that screening.
39:24That I mentioned the cafe and then have
39:26a positive screen connecting to care.
39:28This is actually for black youth using
39:30an intervention that Michael Lindsay
39:32developed those particularly about
39:34reducing the barriers and in promoting
39:36facilitators for black youth and their
39:38families and encouraging engagement and care.
39:40So we are doing follow-ups in
39:43awhile and a bunch of years.
39:44I'll be happy to come back and chat
39:47about what we find with this effort,
39:49but it's really about moving interventions
39:52into the places where kids are.
39:55But school based prevention
39:56is where my heart is right.
39:57I'm an I'm a developmental psychologist,
39:59but I do a lot in schools and I just
40:00come out of doing a whole set of
40:02work in pre-K as we started with.
40:03It turns out it's a really nascent field.
40:05So even though this is where kids are there,
40:08there's a whole set of adult focus programs.
40:10They're called gatekeeper programs.
40:12They train adults to recognize
40:14the signs of suicide,
40:16but they and they typically
40:18increase adult knowledge but not
40:19necessarily student help seeking.
40:21It works out best when teachers
40:22already know something or already
40:24have connections to kids.
40:25But otherwise not,
40:27it's not enough frankly.
40:29It turns out there's some peer focused
40:31programs that actually do seem to work.
40:33The pure awareness programs did,
40:34the old style ones didn't work that
40:36well because they basically just said
40:37kids like here's what it looks like.
40:39And in fact sometimes they re
40:41stigmatized it a little bit the the,
40:43the it's resting unitized suicide.
40:47But these new programs are really
40:49trying to work directly with friends
40:51and I'll show you why in a second.
40:54So there are a few programs, there's three.
40:56And when I think about like
40:57other areas and my nose is right,
40:59other areas of where we know about
41:01school based prevention like in,
41:03I don't know,
41:04social emotional learning interventions
41:05or reading or math even right there's
41:08there's 10's and 20s and 30s and 40s
41:10right programs that are out there that work.
41:12And the fact that we only have three
41:14programs that show any evidence of
41:16efficacy feels frighteningly small to me.
41:18And none have reported evidence
41:20separately for marginalized case.
41:21So these are studies that were
41:23largely done on white students
41:25or at least not separated out.
41:26We also don't know the effects on
41:28LGBT class kids, who are one of the
41:30kids that are most at risk. Umm.
41:34Let's see, what am I doing on time?
41:36OK, so the programs that work
41:38do build on what we know about
41:40what works for adolescents.
41:42One of the most important things for
41:43adolescents is to work with their friends,
41:45right? When we all know this,
41:47adolescents are really influenced
41:49by friends we know.
41:52We've studied for a long time.
41:53The negative role appears
41:54play on their friends,
41:55but it turns out there's lots of evidence
41:57that peers play a positive role as well.
41:59Really interesting work on safe driving.
42:01Like if you drive,
42:02if your friend is a safe driver,
42:04you're more likely to be
42:05a safe driver yourself.
42:06Right.
42:06And other kinds of efforts that have
42:09really demonstrated the ways in which
42:11kids positive behavior can be norm
42:12setting as well for their friends.
42:14And so in this case,
42:15we really want to change norms around
42:18help seeking and around talking
42:20about mental illness coming forward,
42:22being honest about it.
42:24I won't do a lot of this,
42:26but I'll do this very quickly.
42:27So there's really interesting work in,
42:28in the neurobiology of adolescence
42:31of the adolescent brain that
42:33this is Eva Telzer's work.
42:35We used to think about the adolescent.
42:37Data is being basically two parts a,
42:38a small cognitive control system
42:40that was just being outweighed by the
42:42social emotional system, the amygdala.
42:44And basically the idea was, OK,
42:46well, we've got to dampen down this,
42:48these emotions to give the air
42:50traffic control a little bit
42:52more power for the adolescents.
42:53This is why they're doing like risky things.
42:56And Ava tells her is really showing
42:58the ways in which it's actually
43:00three parts to the adolescent brain,
43:02that it is the prefrontal cortex,
43:04but that the, the, the that's being,
43:06that's the cognitive.
43:08General system,
43:08but it's being outweighed by two
43:10systems in the adolescent brain,
43:11the amygdala,
43:12which is the social emotional system,
43:14but also the ventral stray Adam which
43:17is actually approach reward system.
43:19So basically the notion is is that
43:22kids are being sort of activated by
43:25their needs for new experiences.
43:27And so it argues that we need to give
43:29kids new experiences so that they
43:31don't get involved in in the riskier ones,
43:34in the in the more detrimental ones.
43:36And it turns out social rewards
43:37carry particular weight.
43:38If we help kids do things,
43:41that is risky, risky,
43:43but sort of positive risky.
43:46There's a wonderful piece by Eva
43:48Telzer and her colleagues that talks
43:50about how pro social risk taking
43:52that she talks about helping others
43:54with a social cost to yourself.
43:56And so I think a lot about that
43:58with regard to suicide prevention.
43:59Imagine if you have to take your friend
44:01to go get help and sort of come out,
44:03help them come out about their
44:05mental illness, so to speak.
44:06That's a risky thing for an I lesson to do.
44:09Risk their friendship,
44:10but also really powerful.
44:11That could be really salient for them.
44:14And of course, I was really inspired
44:16by Frankie's friend community.
44:17So as an artsy kid,
44:19Frankie said tons of time
44:20in the theater office.
44:21It was tucked behind the 6th floor of a
44:23large and bustling New York City High School.
44:25That's where she dropped her backpack
44:27and had her lunch and all those kinds
44:29of things and snuggled with teens.
44:31And it was there.
44:32There was also this little corner
44:33of the office where kids could
44:35go when they were struggling.
44:36And Frankie went there when
44:37she was struggling,
44:38outside of sort of the prying eyes of
44:40adults in her school and a friend of
44:42hers who is about a year younger than.
44:44Frankie was there once, struggling.
44:46A lot of kids went to that space
44:48to kind of hide was crying.
44:50She was overwhelmed with school or something,
44:53and she told us how Frankie
44:55just went in there,
44:56found her there and just sat with her.
44:58And it helped her feel better just
45:00having someone to sit with her there.
45:03And so after Frankie died,
45:05this girl Rebecca decided to
45:06remake the corner of that office
45:08with a whole group of friends.
45:10And they put Post-its on the wall with
45:12words like it gets better and you matter,
45:14and phone numbers to
45:16call each other for help.
45:17And they built this kind of space with
45:19support and affirmation and healing.
45:21And so when I was looking
45:23for prevention programs,
45:24I thought those that would mirror what I
45:26saw here in Frankie's friend community,
45:28a kids with who,
45:29after a profound loss,
45:31could really build a space like this.
45:33And that brought me to a
45:35program called Directing Change.
45:35I'm going to say that last a little bit
45:38of time showing you what this program
45:40is that we're starting to evaluate.
45:42It was developed by a set of
45:44colleagues out in California.
45:45It's been out in California for a while.
45:48They basically what happens is
45:49kids makes 30 and 62nd films
45:52in mental health awareness and
45:54suicide prevention and submit them.
45:56They make them by themselves and they
45:58submit them to a statewide contacts
46:00contest on March 1st of every year.
46:02Very clear rubrics and disqualifying.
46:04Rules for that safe messaging,
46:05I told you was so important.
46:07A few years ago they packaged it for school,
46:10so they get they used to get a few 100 films.
46:12They actually thought they only
46:13get 50 in the first year.
46:14They got several hundred.
46:15They get about 1000 films a
46:17year even during COVID,
46:18but they packaged it and that's what these
46:20great these that light green bars are for.
46:22They get a few 100 films from the school
46:24based program where school leader
46:25like a teacher leads a whole group
46:28of students in making these films.
46:29I'm going to show you them in a second.
46:31They have resources and TA and
46:33they submit the the films to the
46:35contest and then they plan an event.
46:38To share them with the school community.
46:40I'm gonna show you a film.
46:42Let's watch.
46:51Alex, you know what to do. Hey bro.
46:56Look, I'm just going to be
46:58totally honest with you right now.
47:00You know, I've noticed that you've
47:01been acting weird for a few weeks now,
47:03and then you didn't show up to school today.
47:06And and I'm just starting to get
47:08really worried about you. I gotta ask.
47:10Are you thinking about suicide at all?
47:13I mean, I I realize you can't answer
47:15that question because on the phone, but.
47:19Look, if you're listening to this right now,
47:21just please give a number.
47:23Just call that number before
47:25you make a decision.
47:26But, you know, there are people here
47:28to help you go through this, you know.
47:30Absolutely not in this alone.
47:32Yeah, I'm here for you too.
47:35I'm gonna. I'm gonna try your
47:36house and see if you're there.
47:38OK.
47:39Bye.
47:43Orange County mental health
47:44crisis line my name is Chris.
47:45How can I help you today? Hi.
47:53Really powerful films that these kids make.
47:58So these kids are trying to
47:59share three things and that's it.
48:01How to recognize the signs of suicide,
48:04how to find the words to
48:05ask that question directly,
48:06which is a really scary question to ask
48:08and how to connect your funds to care.
48:10In this case, they would connect
48:12them to the that helpline that
48:13I just told you about 988.
48:15And they are safe,
48:16positive and action oriented messages.
48:18They amplify youth voice.
48:19So kids are telling them the way
48:21kids tell stories and they're
48:22by youth for youth and they're
48:24betting their own identity in them.
48:26So the kids, you know,
48:27you saw the poster in the back.
48:28They look like these kids spaces.
48:30They are building them out that way.
48:32They're speaking to each other.
48:34They were organically tailoring
48:35them to their their communities
48:37and to their identities.
48:41We spoke to a bunch of advisors
48:43to understand how this was
48:44getting implemented in schools.
48:45There's a huge amount of flexibility,
48:46which you know, as Mike knows this
48:48isn't easy to do in a school building.
48:50So kids teachers can do this in
48:52any classrooms they want to,
48:54they can do it in.
48:55We spoke to some that we're doing
48:56in a video production class,
48:57a film class and other school did
48:59it in the first year seminar for
49:01all freshmen and 1/3 school did a
49:04Co led by the English teacher and
49:05then linked it to other English
49:07classes so schools can actually
49:09decide where this best fits,
49:11which is the teacher that early.
49:12Handle this and do this kind
49:14of activity with their kids.
49:15Is it the film teacher?
49:16Is it the seminar, the guidance counselors?
49:18Is it the English teachers?
49:20Is it the health teachers?
49:21And they have a lot of flexibility
49:22in how to do that,
49:23which really matters for implementation.
49:26I started with the ecological model,
49:28so I'm going to show you that we feel
49:30this is really ecologically infused.
49:32Kids learn about suicide
49:33prevention through filmmaking.
49:34Their friends learn,
49:36the advisors learn,
49:37but their families also learn as
49:39the kids talk about their school
49:40projects and then they share
49:41the films with the school.
49:42Community and sometimes even
49:44in local movie theaters.
49:45And then the other piece is that the,
49:48the the people could created
49:50this program really do mentor the
49:52students who are winners to become
49:54suicide prevention advocates.
49:56And I'll show you some of that in a second.
49:57I'm going to kind of keep moving
50:00this forward because I am nervous
50:02about our timing here.
50:03I just want to show you quickly couple
50:05of these quotes from kids that we
50:06got when we talked about the program.
50:08So you might be thinking, well,
50:10it's involving kids that must
50:11know a lot already.
50:13This kid said, yeah,
50:14I used to think there were such narrow signs.
50:16And then I was doing more research and
50:18putting more science into our film.
50:19And there was a long list that I found.
50:21And I was like, wow,
50:21it's a lot more than I thought it was.
50:23So just knowing all these things off
50:25the list and just making me aware,
50:26more aware,
50:27and I'm checking on my friends more.
50:30So really building out knowledge at
50:32a much more nuanced way for kids.
50:35This one I'm gonna actually Fast
50:38forward because it's about a kid
50:41who came to a teacher and really
50:44got support for helping a friend.
50:46But it also the other piece of
50:48the program that we were really
50:50surprised by is the connectedness
50:51that really built out and belonging.
50:53And I'm going to show you a
50:54couple of quotes about that.
50:55So Umm,
50:56this kid said it's a learning
50:59experience about what we all
51:01experience while we're all different,
51:02while we all of our distinct differences
51:04that make us who we are unique.
51:05Right here, all humans at the base level,
51:08that's what connects us.
51:09So by talking about mental illness
51:11and talking about suicide,
51:12they started realizing that everybody
51:14struggles in different kinds of ways and
51:17was a really important connecting piece.
51:19And then this one kid talked about how
51:20would she shared her films should be
51:22kept to become really raw and vulnerable,
51:24she said, and people would come to her.
51:26So part of this was kids were reaching out,
51:28checking on each other,
51:29but part of it also was kids
51:30were coming to them, she said.
51:32It's sort of like other people feel
51:34like they know me in that way so
51:36they can approach me and do the same.
51:37She said some people will be like, hey,
51:39I remember you mentioned something
51:41about this resource that's been helpful
51:42and you can you give me that name?
51:44And then she talks about how having someone
51:46your age who's like you is really important.
51:48It's less daunting.
51:49And then the last.
51:51Oh, and then kids also really emerged
51:53as these suicide prevention leaders.
51:54This kid was like, I had never thought
51:56I'd be doing any of this when I made my film.
51:57She's actually talking in panels now.
52:00And we think that actually,
52:01it starts with the kids who make the film,
52:03but it really spreads to the
52:04other kids in the school building.
52:06And the result is it really.
52:07Changes conversations in schools.
52:09So this kid said before,
52:11it was kind of like one of those
52:13things where no one talks about it but,
52:14you know, like just go to the counselor,
52:16you know, and no one actively says,
52:18hey, if you need me, I'm here.
52:20But after directing change,
52:21we end up going through advisory periods
52:23and showing the film and talking about it,
52:25and everyone talked about a different way.
52:26It wasn't just like a,
52:28you know, quiet, hush thing.
52:29No one was really scared to
52:31talk about it or like say big
52:32words like suicide anymore.
52:36We're building the efficacy evidence
52:37behind it in a wait list control
52:39trial in 40 schools in California.
52:41We are in the middle of, we've done that,
52:43recruited a first cohort of 14 schools.
52:45This is funded by the William T
52:47Grant Foundation and we're focusing
52:48on Latin X kids and LGBT plus kids
52:50because these are kids at risk.
52:52And all of this work,
52:53both the weak care study that's
52:55funded by NIH and directing change are
52:57part of the Center called Arcadia.
52:59And I'll just end with this
53:01and one last point,
53:02so it's called a Research Center
53:04for adolescent interconnected
53:05approaches for suicide prevention
53:07is named after Tom Stoppard.
53:08Play is one of the plays my
53:10daughter read in high school,
53:11which for those of you might know not know,
53:13it's a story about a girl who sort of.
53:18Makes progress in actually math by
53:20bringing together math and nature
53:21sort of a century ahead of her time.
53:23But it's also about the juxtaposition
53:25of past and present,
53:26where we're trying to learn what happened
53:28to this girl in the past through
53:30looking what happened in the present.
53:31And there's a number of really important
53:33themes for suicide prevention.
53:34It's about integrating across disciplines,
53:37it's about looking back for answers,
53:39and finally it's about acknowledging
53:40tragedy and death.
53:41So the title of the play Arcadia
53:44comes from this painting in Arcadia
53:46Ego which which is referring to.
53:49Which means in Arcadia,
53:50I am the I refers to the presence of death,
53:54which is a tombstone in the middle
53:55of a country scene. Arcadia.
53:57And the notion is is that we have to
53:59acknowledge tragedy and knowledge
54:01hard things in order to address them.
54:04And I think that's really critical
54:06in suicide prevention.
54:07So that's all this work that I'm
54:09trying to do is layer approaches to
54:11this this cheese model and because
54:13you're at the beginning taught me
54:14about the value of being a scientist
54:16and the size and doing a lot of
54:18public work as well.
54:19And I'll end with this picture.
54:20So that little post it wall that
54:23you saw a few screens ago when
54:25kids return post COVID,
54:28they a kid who is a freshman
54:29when Frankie was a senior,
54:30decided to permanently remake it
54:31and made it into a love saloon,
54:33which I think every place should have
54:35a love saloon and every school with
54:36an affirmation station where they can.
54:38Make new post-its and talk about their
54:40own mental health and then with a
54:42love picture that has all their faces on it.
54:44So I just wanted to share
54:45that with you as well.
54:47So with that, taking all of my colleagues,
54:50Rachel Navali, Yashas Potoski,
54:51Stan Collins, David Zaragoza,
54:53Harris on the we care as well,
54:55Michael Lindsey,
54:55Child King,
54:56an amazing team that I have at NYU,
54:58and of course funders William T Grant
55:01Foundation and National Institute
55:02of Mental Health for funding.
55:04So thank you very much.
55:06Umm.