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Understanding Suicide Risk Among Children and Preteens: A Synthesis Workshop


Mary Rooney: Welcome to our NIMH Synthesis Workshop on Risk, Resilience, and Trajectories in Preteen Suicide. I am Dr. Mary Rooney, a Program Officer at NIMH in the Division of Services and Intervention Research. Thank you all for taking time out of your day to join us. The large number of attendees here online attest to the concerns so many have about suicide. Let's start with the overview of today's events. We have two separate sessions planned for today, the first is an hour and 1/2 public session. The second is a closed session meeting that will allow the preteen suicide risk roundtable panelist to come together as a group and share their thoughts on short and long-term research needs.

The open session will include brief high-level summaries of the three roundtable workshops that preceded today sessions. These summaries will be presented by the NIMH staff who planned and led the roundtable series. Following the summary presentations, we are very fortunate to have NIMH Director Joshua Gordon and Assistant Secretary Rachel Levine talk about how this research can inform efforts to improve preteen and youth suicide prevention.

Their conversation will be followed by a 20-minute Q&A session. You may submit questions to Dr. Gordon and Dr. Levine in our email box at any time. The email address is posted in the Zoom chat box. They will answer as many questions as possible during the 20-minute Q&A sessions. We expect to receive more questions than they can answer in the time allowed. So please note that we will share the questions sent by our audience with our roundtable panelist for their consideration as well. As with all NIMH meetings, we will have a summary of today's open and closed sessions, as well as summaries from earlier roundtable meetings, posted on the NIMH website in the next month or so.

Before we get started, there are a few housekeeping items to cover. Participants will be muted in listen-only mode, and cameras will be turned off. If you have technical difficulties hearing or viewing the meeting, please note this in the Q&A box and our technical support team will assist you. Or you can send an email to the address shown on the screen. Now, let's begin with some background and context for today's meeting.

In the United States, suicide is the second leading cause of death among adolescents. As of 2019, it is the fifth leading cause of death among children. Suicide rates for children have been increasing over time and suicidal ideation and attempts account for an increasing proportion of emergency department and in-patient visits in children’s hospitals nationwide. The death of a child by suicide is a devastating event that has long-lasting effects on affected families, schools, medical providers, and communities. Although relatively rare, the tragic loss of a child from suicide is becoming more frequent and in some sectors of the population, including among black youth.

Yet, as a field, we know very little about how to measure and mitigate child suicide risk given the limited amount of research that is focused on this topic to date. In May 2019, NIMH along with co-sponsorship from NIH Office of Behavioral and Social Sciences convened the first NIMH workshop focused on child suicide risk. This initial workshop brought together researchers in the emerging field of child suicide research. Along with researchers from related areas within development of psychology, clinical psychology, and psychiatry, as well as practicing clinicians to identify priority areas for research related to child suicide risk. This initial workshop highlighted an urgent need for additional studies focusing on assessing child suicide related thoughts and behaviors. identifying malleable factors underlying suicide risk, and the development and testing of interventions poised to have a near term impact on clinical practice.

The workshop resulted in the call-to-action paper seen here and laid the foundation for the current preteen roundtable series. So, building on that initial workshop, the roundtable series has brought together experts in related fields to assess the state of science, and discuss the research gap areas related to understanding suicide risk, resilience, and trajectories, among preteens, with the goal of ultimately performing the identification of at-risk youth and the optimal timing of interventions. For the purpose of these roundtables, we define the preteen period as covering children who fall within the 7 to 12 age range, although all roundtables acknowledge that there may be differences in the presentations of suicide related thoughts and behaviors between children on the lower and upper ends of this range.

Roundtable One convened in January 2021 and focused on defining and refining our assessment of the dependent variables in preteen suicide research – and that is suicide related thoughts and behaviors. Roundtable Two convened in early March 2021, and examined risk and protective factors, and how they will influence suicidal thoughts and behaviors in preteens. Finally, Roundtable Three, which took place in late March 2021, focused on the challenges of understanding complex risk patterns and how they may interact to confer significant risk and identifying the key drivers of this risk.

We greatly appreciate the esteemed group of panelists who have participated in this Roundtable series. They’re commitment to advancing the science in this area is remarkable. We are very grateful to the many contributions of this workshop series and to the scientific field as a whole.

Now, I'm going to kick off our roundtable summaries by providing a summary of the topics covered during Roundtable One. This roundtable was focused on the phenomenology and assessment of suicide thoughts and behavior in preteen children, with an emphasis on gaining a better understanding of what, as a scientific field, we already know about suicide thoughts and behaviors in this age group as well as the key things we do not know currently, and strategies for closing this gap. Here, you see some of the panelists who are members of Roundtable One, all of whom contributed to outstanding presentations and discussion sessions.

There were three specific areas related to the phenomenology and assessment of suicide ideation and behaviors of preteens discussed during the roundtable meeting. These included Individual characteristics and developmental status; Development and refinement of screening and assessment measures; and Contextual and setting specific factors that may influence screening and assessment outcomes. A cross-focus theme that emerged and occurred throughout our roundtable series, is a focus on workforce diversity and capacity. Which is things like increasing diversity in the scientific workforce, engaging non-suicide researchers in child suicide research activities, and considering things like the available clinical follow-up services at research sites.

Now, let's take a few minutes to look at a few of the discussion topics covered during the roundtable that are related to the need to account for individual differences when developing reliable and valid preteen suicide risk training and assessment tools. We know that preteens vary in their ability to report on and express their own emotions and thoughts in a meaningful way. The ability to self-monitor and be aware of your own thoughts, as they are happening, is an ability that develops over time as you age. While it typically fully develops during adolescence, there is variability around the emergence of this capability during the preteen years.

Cognitive functioning, including the ability to understand more abstract concepts, like death, and the ability to understand some of the more complex questions that are included in adolescent assessments of suicide thoughts and behaviors is another individual characteristic that varies from preteen to preteen both as a function of age and as a function of developmental level.

Developmental level refers not just to the preteen’s chronological age but whether they are more or less advanced in a particular set of cognitive or emotional abilities relative to what would be considered average for their current age.

Cultural background was discussed in the context of differing beliefs across cultures, and the way in which death is or is not talked about within different families and cultures. A preteen’s exposure to death and suicide, either within their own family, or their neighborhood or their community, or through various forms of digital media was also a key focus for the session.

These and other individual factors provided useful context in our next discussion related to the development and validation of developmentally and culturally sensitive suicide risk assessments and screening measures. Some of the discussion topics covered within this focal area included recognizing that in some cases measures currently being used with adolescents can be adapted to meet the developmental needs of preteens. The specific aspects of these measures that need to be adapted, and the measure adaptation and validation strategies that can be useful were discussed.

Panelists acknowledged that gleaning a clear picture of a preteen’s current suicide risk level may often require input from multiple sources. It may require multiple assessment methods. For example, in addition to self-report information from the preteen, caregiver report will also be needed in many cases. In addition to self-report data, objective or behavioral measures of constructs related to suicide risk may also be useful and necessary. The strategies for integrating data from various sources to form a clear picture of a preteen’s suicide risk was also discussed.

Within these assessments it was acknowledged that context will play an important role when evaluating reports for preteen suicide thoughts and preteen suicide behavior. Panelists discussed which contextual factors may be most important to evaluate during assessments. Lastly, panelists discussed the need for developmentally sensitive risk thresholds that can be used to make a determination about whether a preteen is currently low-risk, moderate risk, or high risk for suicide.

The final focal area centered around the setting and context surrounding the assessment itself, and how this context may affect the sensitivity and reliability of the assessment. Panelist discussed the need to consider whether the assessment or screening was planned in advance or if it is occurring in the context of the crisis situation. Panelists also acknowledged that the setting where the evaluation occurs may influence the responses provided by the preteens or caregivers. For example, responses given in emergency department may be different from those given in the pediatric primary care setting.
Similarly, the level of trust the preteen or caregiver has in an evaluator or setting may also affect assessment sensitivity and should be considered within the overall sensitive context itself.

Overall, panelists’ discussions, feedback and recommendations provided during Roundtable One will help ensure that reliable and valid measures of suicide thoughts and behaviors will be developed for this previously understudied preteen population. The goal is that these measures will result in robust data that can ultimately inform state-of-the-art science, scientific strategies for identifying high risk youth, and developing well-timed, well-targeted interventions to alter the recent upward trend in preteen suicide rates.

We appreciate the valuable insight and contributions that have been provided by the roundtable panelist to support NIMH and the suicide research field at large as we collectively work to advance this high priority goal. Now, am going to pass things over to my colleague, Stacia Friedman-Hill, for presentation of the topics discussed during Roundtable Two.

Stacia Friedman-Hill: Thank you Mary. So it is my pleasure to present a brief summary of Roundtable Two. In March we held a meeting focused on Measuring Preteen Suicide Risk and Protective Factors across Multiple Domains. I would like to start by thanking the fantastic group of researchers who presented at the second roundtable. This is a screenshot of one of the discussions. We were not able to capture everyone's image, but you can see the whole list of participants on the screen.

There were three key areas of focus for Roundtable Two. First, we asked panelist to identify key risk and protective factors that may be especially important for pre-teen suicide. Second, we wanted to know the best ways to measure these risk and protective factors: the setting for assessment, for example, out-patient specialty care, primary care, or school; considerations relative to who is reporting – the child, the parent, or teacher; and how often risk and protective factors should be assessed.

Third, a significant focus on our discussions was consideration of populations that may be at higher risk levels and how to tailor assessments so that they are culturally sensitive and appropriate. We asked participants to consider if there were some risk and protective factors that are common across different groups, and also if there were some factors that were unique to specific groups.

So, we would like to give you a very high-level overview of some of the topics discussed in roundtable two. The first session focused on risk factors at the individual and family level and peer interactions. One area that several panelists agreed was understudied but malleable in middle childhood were our cognitive processes. Dr. Christine Cha and Dr. Arielle Sheftall presented evidence that suicidal thoughts and behaviors in preteens have been associated with weaker episodic future thinking, lower cognitive flexibility, and weaker cognitive control.

Family processes were also identified as playing a large role in elevated risk. Dr. Anthony Spirito noted that low parental monitoring and high family conflict were very strong predictors of poor outcomes in youth with co-occurring psychiatric and substance use disorders. Dr. Rebecca Schwartz Mette discussed how peer interactions can be an important risk factor. Specifically, friend groups can share internalizing and externalizing behaviors through co-rumination. This is a mediator in contagion, or the spread of mood or thoughts within a group. Peer interactions may discourage youth from seeking help from adults. Dr. Rhonda Boyd discussed family interaction in clinical settings and how the divergence of parent and child reports of clinical symptoms and suicidality is, in itself, a potential indicator of risk.

The second panel in Roundtable Two examined community risk factors and social and structural drivers of mental health. Dr. Ellen-ge Denton presented data from Guyana, a middle-income country with one of the highest rates of suicide in the world and a history of trauma and family separation. In Guyana there are high rates of youth suicide attempt, but ideation is underreported and not predictive. Instead, somatic symptoms like sleep disturbance may be more predictive of who is at risk.

Dr. Brian Mustanski and Dr. Dorthy Espelage presented research on sexual and gender minority youth. Bisexual, transgender, and non-binary youth have higher rates of suicidality, lower family support, and high rates of victimization. These risk factors can be counterbalanced with protective factors like school affiliation, self-esteem, parent and school support and positive messaging and most LGBTQ youth are thriving. Dr. Brendesha Tynes discussed how black youth experience discrimination and victimization in online media through symbols, videos, and text. They can be individually directed or experienced vicariously. Exposure to online racism and victimization is associated with increased mood and anxiety symptoms, lower self-esteem, and decreased academic motivation. Lastly Dr. Allison Barlow talked about factors influencing very high rates of suicide in American Indian communities including inter-generational transfer of trauma from the boarding school era and multiple adverse childhood experiences. However, the White Mountain Apache are a model for how community engagement, surveillance and strengths-based interventions can greatly reduce suicide rates.

The third panel focused on proximal risk factors. Dr. Richard Liu walked us through the literature noting that life stress, sleep disturbance and poor neurocognitive function are all associated with suicidal thoughts and behaviors. But most studies assessed suicidality over months and years even though the 24 hours before an attempt might be most predictive. Dr. Cassie Glenn discussed the utility and feasibility of real-time monitoring with wearable sensors and smart phone data. Dr. Randy Auerbach discussed how interpersonal loss and targeted rejection may activate underlying vulnerability and hasten the transition from suicidal ideation to attempt. Dr. Adam Miller reviewed how atypical stress response can be assessed by measuring cardiac rhythms, cortisol, and neuroinflammatory markers, and puberty can affect systems relating to stress response and these, in turn, can be modulated by the preteen’s experience and environment. Lastly, Dr. Lauren Gulbas reminded us how few studies of suicide are focused on Latinx youth in spite of higher rates of ideation, especially in girls. Family separations, immigration stress and intergenerational trauma heighten risk. A different approach to capturing acute stress has been the use of a body mapping technique that includes drawing and painting to measure somatic symptoms.

We ended Roundtable Two on a more positive note by discussing protective factors. Dr. Arin Connell talked about how family training including psychoeducation, emotion regulation, and problem-solving, mitigates suicide ideation and attempts. Religiosity is a complex protective factor for black youth. Dr. Sean Joe discussed how church participation and subjective religiosity both contribute to feelings of optimism, hope and persistence against adversity. Religiosity also affects attitudes about suicidal acceptability. Dr. Holly Wilcox discussed how a youth’s relationships with trusted adults can reduce suicidal ideation or attempt. We also considered two examples of multilevel systemic programs for culturally sensitive, community driven suicide prevention. Dr. Lakshmi Vijayakumar shared the success of a program in India and Dr. Lisa Wexler presented programs from Alaska native communities.

The subject matter experts discussions and feedback and recommendations that were provided during Roundtable Two will help us: understand the similarities and differences that exist in risk and protective factors across diverse populations; highlight the most important research questions and challenges regarding risk and protective factors related to social connectiveness, social media and technology; suggest ways to collect data from multiple perspectives to better understand preteen suicide risk and protective factors; and suggest ways to increase involvement of parents, local leaders, and trusted adults to understand risk and prevention factors. Now I would like to introduce my colleague Dr. Chris Sarampote who will present a summary of Roundtable Three.

Christopher Sarampote: Hello, I am Christopher Sarampote. I am Chief of the Biomarker and Intervention Development for Childhood Onset Disorders Branch in the Division of Translational Research at NIMH. I was the lead of Roundtable Three- Risk States and Risk Trajectories for Suicide and Preteen Children.

To assess the needs, opportunities, and challenges in studying risk states and risk trajectories in suicide in young children, we specifically sought the perspectives from a scientifically diverse group of researchers. The goal was not only to research youth suicide but to consider how different approaches and methods might be adapted to study our problem. In addition to those whose work was squarely within the study of youth suicide we invited researchers with expertise in analyzing large longitudinal data sets, developing new analytical and methodological approaches, and those studying what might be called adjacent themes - researchers who grapple with challenges that are similar to those seen in the suicide field, such as bipolar disorder, substance use and abuse, lifespan development, and child welfare. Again, we want to thank our panelists for their time and hard work and insights.

So, over our two-day roundtable at the end of March we focused the presentations and discussions on four topics. First, sampling and methodological approaches - what tools and strategies do we have to study youth suicide trajectories? Second, leveraging data from multiple streams - how do we synthesize and analyze different types of data from multiple informants? Third, model development – how do we best model trajectories of suicidal risk? Finally, current opportunities and priorities for data collection – what do we have now and what we need for the future?

During our first panel Drs. Christine Cha, Jeff Bridge, Glen Coppersmith, and James Allen discussed the challenges inherent to studying youth suicide and approaches to managing them. Suicide in young children is a relatively rare event as such, available samples are small and may not provide adequate power analyses to detect meaningful predictive variables and group differences. Furthermore, the study of youth suicide is challenged by sampling biases, inadequate inclusion of communities of color, theoretical complexity with multiple moderators and mediators, a reliance on theories of suicide in adults, and many more. Panelists discussed approaches to address these hurdles using, for example, epidemiological analysis of birth cohort data, suicidal and self-harm surveillance, psychological autopsy studies, and alternative complementary approaches like meta-and secondary data analyses of health services patterns, and child welfare involved suicide. One example Glenn Coppersmith provided examples of how automated machine learning might be used to analyze youth social media data. Panelist also drew on research conducted within small populations, not only as an example of research strategies that maximize small sample data but as an opportunity to better understand and address health inequities between culturally distinct groups.

In our second panel, Drs. Alex Crosby, Andres de los Reyes, Anna Van Meter, Kai Larsen, and George Howe discussed approaches to leveraging data from multiple informants and multiple sources. Specifically, panelists identified the critical assumptions underlying analyses that integrate multi-informant data and how to select the procedures that allow for both common and unique variants. Similarly, this panel discussed not only the integration of multi-informant data, but the harmonization of data from related constructs and how we should interpret the variability between informants. For example, if we have a construct that is a measure of hopelessness do we in fact have the same construct when we see variability? Are we not measuring it well or are these different constructs based on the informant? Panelists also examined risk calculators and automated machine learning approaches and how such strategies can integrate multiple factors that could lead to high-impact predictors for individual and group suicide risk.

In our third panel Drs. Regina Miranda, Devin English, Bengt Muthen, and Antonio Morgan Lopez discussed approaches to incorporating intersectionality into models of preteen suicide risk and what types of criteria can be used to ensure appropriate model selection for longitudinal studies. As noted previously, alarming increases in suicide have been observed in children of color and those from sexual and gender minority groups. How do we construct models that avoid simply documenting group differences but rather identify factors derived from the communities at risk, including sources of power and oppression and those that promote action?

In our fourth panel Drs. Arielle Sheftall, Andrea Hussong, Ana Ortin Peralta, Yaron Finkelstein, and Emily Haroz examined what is currently possible with existing data sets as well as outlining future approaches that can be pursued to better understand preteen suicide. Data sets that track child welfare, abuse and neglect as well as big data derived from electronic health records and other healthcare administrative databases were identified as potential resources, with presenters discussing what has been accomplished to date. For example, Ana Ortin Peralta and colleagues recently analyzed data from two datasets – the Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) and the Fragile Families and Child Well-being Studies – to identify specific factors for self-harm and suicidal ideation in young children exposed to neglect. Panelists also discussed useful data pulling strategies such as integrative data analysis, to leverage power for low base rates and small subsample questions as well as harmonization techniques like moderated nonlinear factor analysis. These are approaches that take into account measurement differences across studies, procedures, participants and instruments and item response patterns to create scores portable to a broad range of hypothesis testing in the frameworks.

In summary, Roundtable Three panelists identified many challenges in modeling predicting suicidal behavior in young children. Approaches derived from small population studies, machine learning, epidemiological studies and others may be used to leverage existing data sets, but each has their own limitations. Development of new harmonization in existing data sets should include methodologists who can guide activities that minimize those limitations while maximizing statistical efficiency. As an aside, I would mention that as a group it was very exciting to have folks who represented quite a breadth of science, all kind of coming together to address this problem of high public health significance from their own unique perspectives. Thank you for the opportunity to summarize and to lead the group. I will turn it over to Doctor Jane Pearson to introduce the next steps and our keynote panel.

Jane Pearson: Thank you Chris. So, as you have heard the summaries from these roundtables showed some progress in our understanding of suicide risk among teens, but our research gaps still remain. The goal for our next hour here is to help our audience understand why we need this research to build the science. About children at risk for suicide. For this session, we are going to include Dr. Joshua Gordon who is our National Institute of Mental Health (NIMH) Director and our Health and Human Services Assistant Secretary for Health Dr. Rachel Levine. I invite each of them to turn on their cameras if they are online now. Maybe as they are… We are and minute ahead so they might be still getting ready to enter here.

I guess I should introduce myself as we are waiting for Dr. Levine and Dr. Gordon. I work in the Office of the Director of NIMH looking at strategic research needs for suicide prevention. This topic was clearly one of those areas as Mary introduced, it is a very difficult area to determine risk factors for such a very low base rate unfortunately. Very low numbers of children who died by suicide that are 12 and under but we know it has been a growing number. So the effort to start working understanding the risk factors and the risk trained to meet the rest before these children act on their thoughts is really important. So let's see if Dr. Gordon and Dr. Levine are here and if they are, they can put their cameras on.

Yea, welcome! I do not know if Dr. Gordon is here or not. If not, I can go ahead and start introducing you, Dr. Levine. He will be on shortly. I know that both of you had a chance to talk earlier, I think last week, so that is great! Well, let me introduce you, Dr. Levine. As our 17th Assistant Secretary for Health in the U.S. Department of Health and Human Services we are so happy to have you here. Dr. Levine is a physician trained in pediatrics and adolescent medicine.

Before coming to HHS, Dr. Levine was a professor of pediatrics and psychiatry at Penn State College of Medicine. She has had a number of leadership positions. Most recently, in 2018, she was named by the state of Pennsylvania as the Secretary of Health. She is an expert in adolescent medicine including mental disorders. And Dr. Levine is very familiar with suicide preventions of youth. So, let's see. Has Dr. Gordon joined us yet?

Speaker: Not yet.

Jane Pearson: Will I would say, Dr. Levine, if you want to go ahead and start talking about some things- Efforts going on within HHS that are relevant to this topic, we can certainly start there. I know there's been a lot of legislation that has come through in the last few months, or anything from your prior experiences, as a pediatrician adolescent expert that you would like to raise on adolescent suicide.

Rachel Levine: Thank you for that very kind introduction. I would like to thank you and Dr. Gordon for inviting me to participate in this very important discussion. So, as were mentioning, I am an academic medicine physician and I am a pediatrician, and adolescent medicine specialist. Before I became to public service, I was at the Penn State College of Medicine and the Penn State Hershey Medical Center. And saw many particularly troubled teenagers with eating disorders, and other conditions. Particularly, what always interested me is that intersection between physical health issues and mental health issues.

So, I saw many teams with eating disorders and other related illnesses. And, you know, what I have always felt very gratified about was my ability to help people. Right? To help patients, and families, and students. That is what we do in public health, now. As the Secretary of Public Health of Pennsylvania and now as the Assistant Secretary at HHS, we are trying to help people and children, and their families, our communities, and our nation. That is what you all do at the NIH, so you are helping people from the very very important medical and health perspective.

Before I dive into this topic, I want to briefly talk about the topic that has been on everyone's mind. Which is of course, COVID-19. It is such a pressing issue. Particularly though, what I want to reference is the impact that COVID-19 has had on children and adolescents. Both directly and indirectly. You know, we have seen children and adolescents who have become infected with COVID-19, thankfully, we have seen less deaths than we have seen in other populations.

But, we have seen very sick children. And very sick adolescents that require hospitalization and intensive care. That is children that have had COVID-19 symptoms, but also children that have had what is called MIS-C, or Multisystem Inflammatory Syndrome in Children disorder, who have been quite ill.

There is also, you know, it is significantly impacted children in terms of their lives. It is impacted children in terms of their families. In their parents. And illnesses and families, that particularly may be grandparents. Possibly deaths in families. But also the impact of their lives in general, whether it was their families and their economic security, their housing security, their food security. Of course, their lives in terms of school. And their interaction with their peers. Which has been, significantly impacted.

I don’t think that it surprises any of us that they are trying to go to school on these platforms is not quite the same as being in kindergarten or being in first, second, or third grade. I think that schools have tried to manage in the challenging environment, but it has been very difficult. So, I just want to throw the word out in terms of the vaccinations. You know, to put the pandemic behind us. We need COVID vaccines, and they are safe, effective, and they are so important. We can vaccinate individuals 12 and above in the United States. There are studies being done right now about vaccinations for younger children.

So, whether that is a six month to five years of age, and then 5 to 12. So, we will wait the results of those clinical trials. Certainly, we need everyone 12 in the above to be vaccinated. We need your help! As trusted, medical providers, in your community and states and nationally to help us build confidence in these COVID-19 vaccines so that we can get more people vaccinated and put this pandemic behind us. You know, you can go to and help us get people vaccinated.

As I was saying, we were just beginning to understand the impact of COVID-19 on youth mental health changes and routines, breaks and continuity of learning, missed life events, loss of security and safety, disease, and even death of loved ones. There are some troubling findings that the CDC released in their MMWR. In May 2020, during this COVID-19 pandemic, emergency department visits for suspected suicide attempts began to increase among adolescents aged 12 to 17.

During February to March 2021. Suspected suicide attempts were higher among girls. And, actually, even higher among boys as well. And this, the concern is that this is going to have significant public health consequences both in the short-term but also in the long term. In terms of their overall health and well-being of children and teenagers. You can almost think of this as a collective trauma to children in our country. They are going to need immediate support and then ongoing support. One of the things that I have not mentioned in terms of the school issue, though, is that even for kids who had great access to platforms like this, had difficulty in terms of their schooling. But what about, you know, the quote unquote digital divide? Not everyone has access to computers. Not everyone has access to the internet.

You know, this is put a burden on parents, some parents have been able to try to cope and other parents have been very severely challenged. It gets into a health equity issue in terms of, we do not want the ability of kids to go to school and equity issue. We are going to need to address those mental health issues, including adolescent suicide that you have talked about previously. And even, you know, suicide attempts and tragically completed suicide in children.

The Surgeon General has a call to action to implement strategies for suicide prevention. It is to understand the upstream factors that influence suicide, particularly, those that involve ACEs, you can think of COVID-19 as one gigantic ACE. One gigantic adverse childhood experience. Also ways to strengthen protective factors and resilience factors. You know, one of the things that Dr. Gordon and I talked about in our conversation before this meeting was, how that impacts specific groups and the literature that particularly black children have suicide rates that are increasing. Why that might be so, and how we would work in terms of prevention to do that. So you know, the call to action is to broaden perceptions of who is impacted, and who might be at risk, and what the influences might be. Whether that is individual issues. Whether that is relationship issues. Family issues. Community issues. Social issues. We talked a lot about social disturbance of health and the how that might impact things. And we want to expand the national narrative. To talk about those social determinants of health and environmental factors that might influence this. You know, Health and Human Services Secretary Becerra has established the Behavioral Health Coordinating Council, the BHCC. I am learning all the new federal acronyms. To focus on collaboration and strategic planning across the department.

I am honored to co-chair the BHCC with the Assistant Secretary for Mental Health and Substance Use. Right now, I'm working with Tom Coderre, who is the Acting. I know that it is imminent that we will have confirmation, knock on wood as I say that the Secretary for Mental Health and Substance Use. I really looking forward to working with her and to co-chair the Behavioral Health Coordinating Council with her.

We want to make sure that for this issue and others that the Americans that we see in prevention and early intervention retreatment recovery for these mental health and substance use disorders. We are going to make sure that this issue, as others, are prioritized both in terms of research also in terms of treatment and recovery. I'm going to say one more statement.

It is for all of you not to forget your own mental health and physical health during these really challenging times. These are challenging times for everyone. So, please take care of yourself. We know that you cannot take care of others unless you take care of yourself. I am so looking forward to collaborating with you all. Because we all make a difference in people's lives. And we are going to face these challenges of these very difficult times together. And we are going to build a safer, healthier world for all of us together.

Thank you so much! Now I will send it over to Dr. Gordon.

Jane Pearson: Dr. Gordon, you want to introduce yourself and keep rolling? I don’t have to provide you an introduction, perhaps? We will just keep it more conversational.

Joshua Gordon: Sure, thank you so much. I will introduce myself; I am Joshua Gordon; I am the Director of the National Institute of Mental Health. As many of you know, suicide prevention research has been a priority of mine since I came to the NIMH just over four years ago.

Before I go into that, let me just say a deep thanks to Dr. Levine, for joining us today. I think her presence here, talking about youth suicide, and what we need to do to increase our understanding of this problem and develop interventions to increase resilience and decrease risk, the fact that she is here talking about that with us demonstrates the importance that HHS places on mental health in general and in the context of the pandemic, I'm sure that Dr. Levine is busy that she eloquently spoke about playing an important role in the COVID response. And that fact that she recognizes that mental health and suicide prevention is an important aspect of that response and a priority for HHS is very important.

So, for those of you who do not know, what is the NIMH? The NIMH, the National Institute of Mental Health, is one of the National Institutes of Health. We are the principal federal agency within HHS that is responsible for conducting research on mental illnesses. And developing novel interventions and preventative measures to reduce the burden of mental illnesses throughout the United States and indeed throughout the globe. Why are we here today talking about youth suicide prevention?

Well, this is a culmination, really, of a couple years’ worth of work recognizing that the fastest rising risk group for death by suicide is teenagers and preteens. Further recognizing that although, NIMH has supported a broad range of research efforts and develop some phenomenal approaches to reducing risk for suicide, including universal screening, including systems based preventive measures including both psychotherapeutic and pharmacological approaches to reducing suicide risk in individuals, there are some gaps in our understanding that we need to address the research.

And primary amongst those gaps is our understanding of the factors that lead to suicide in the youngest victims. So, with that increase, an alarming increase in preteen and early teen suicide deaths, we knew we had a job in front of us. Furthermore, I want to credit the Congressional Black Caucus and their ring the alarm report which highlights what the CDC and others have been telling us for a couple of years now, which is that the rate of suicide of black youth has been increasing at a faster rate than the rest of the general population. So this particular health disparity is one that we need to address.

So the subject for the day is youth suicide prevention. Those of you who participated in the preceding symposia on individual issues within the area know that one important factor to consider are the risk factors, in particular, identifying which factors placed young people at risk of suicide is really crucial. As are, what Dr. Levine mention is resilience factors. To what if the individual community level factors that confer resilience to suicide.

I will just mention that, previously, there were factors in the black community that provided tremendous resilience. And the suicide deaths as among black children were lower than the general population. That is what is changing and that is what we have to understand. What is the combination of the risk and resilience factors that are leading to these rapid increases? In order to understand risk and resilience, especially in young people we need to understand what we would call the trajectory of risk. How things change in an individual over time. Why is that important? Because we are learning more and more that mental illnesses in general and expressions of those illnesses through behaviors such as suicide attempts, these occur in stages and phases and different approaches are necessary to intervene at different stages. Number two, the earlier one intervenes and then illness the better the chance one has as changing the course of that illness. While it is well and good that we can take someone who is experiencing suicidality and reduce their risk acutely through a range of different therapeutic approaches, it is clearly much more efficacious if we intervene earlier. Understanding the trajectory that leads from risk factors through challenges and other symptoms to suicide attempts is really, really crucial.

Finally, as Dr. Levine mentioned, in terms of risk factors we have to recognize that we are going through an unprecedented period of time in our society with the effects of the COVID-19 pandemic and as the CDC indicated and Dr. Levine illustrated, it is not over when the pandemic recedes into the background and goes off the front pages. We see the increasing need for mental health services, increasing suicide attempts amongst young people as the pandemic has worn on and even as it began to abate in early spring. What we have to do is understand the persistence of risk factors like economic risk factors and disruption in schooling and challenging in social interactions that may be playing a role in youth suicide. Then developing interventions that will mitigate these risk factors and build resilience. That’s the last piece that I will talk about.

A big responsibility to NIMH is looking for opportunities for intervention. Developing and testing interventions that build resilience and decrease risk. Understanding how to apply what we already know to younger children is important but even more important is developing specific approaches that will work in these younger populations. That is what we have been working on for the last year so this conversation we are having today is really to capstone or culminate the discussions we have been having and I'm really pleased to be here. With that, if that is OK, I will start a conversation between myself and Dr. Levine. There will be questions as well coming in from the audience?

Jane Pearson: There are some coming in already and I am tracking them so we will make sure we leave sometime at the end to have those questions brought to you and so the audience knows, we are tracking all of these questions and we will bring it to our expert panels as well. Even though we can't answer all of them, we are tracking what you’re asking about and will bring that to our next part.

Joshua Gordon: Let me start Dr. Levine with the personal. You spoke about your background as a pediatrician, to me there is nothing more tragic than a life cut short by suicide in teenage years. Can you tell us some about your experience working with troubled teens and how that has informed your commitment to these issues?

Rachel Levine: Thank you for that question, I trained in pediatrics in adolescent medicine many years ago at Mount Sinai in New York City. I actually did my research in my fellowship on adolescent suicide. I saw many teens in the emergency department called in for suicide attempts. Looking at different psychological factors and many of the different ideological factors we have been talking about. After a number of years at Mount Sinai I left New York and went to Central Pennsylvania, which is quite a difference, I practice at the Penn State College of Medicine and the Penn State Hershey Medical Center and Pediatrics and particularly adolescent medicine. I saw a lot of troubled teens. And young adults. Particularly with eating disorders. That would be with anorexia nervosa, bulimia nervosa and related illnesses. We see more children with eating disorders now. The DSM diagnosis is often ARFID which is avoidant restrictive food intake disorder which is a little different than anorexia bulimia. But a lot of children with significant eating disorders and we would see them outpatient and we had a partial program as well as inpatient. Of course associated with eating disorders we saw a lot of other mental health issues like mood disorders, anxiety disorders, PTSD and some teens and we had many teens that had significant suicidal ideation some of which would require hospitalization. I think that the etiological factors were varied, and we saw teens that had significant family issues, but it is a misconception that teens with eating disorders are all the teens with anorexia or bulimia or other mental health issues all had dysfunctional families. It is not true. We saw some but others had other social issues and others, it was not as clear from an environmental point of view what might be triggering their suicidal ideation. We saw everything from some family issues. We saw teens that unfortunately had experienced trauma and sexual abuse and etc. that triggered a lot of their symptoms. Many teens that wasn't exactly clear why they might have anorexia or bulimia or why they might be suicidal. One of the things I wanted to ask you Dr. Gordon is from the research I did, and if I tell you when it was, it was a long time ago… What I found when I was reading some of the literature about this was that a lot of the children and teens aren't always chronically depressed. You would think that someone who is suicidal would probably be chronically depressed but the role of impulsiveness and the co-association with attention deficit disorders was prominent. I was wondering your thoughts about that. I will turn around and ask you a question.

Joshua Gordon: I am glad to have some give and take. In my own research fellowship I worked on related issues to this in mouse models quite a little different than teens. What we learned from both studies of individuals who had died by suicide and mouse models as well is that there are neurotransmitter systems in the brain that regulate impulsivity. Those are disrupted in many individuals who have died by suicide. Moreover that impulsivity as a personality factor can be found at higher levels in individuals who died by suicide through a process called psychological autopsies. Which is an interesting thing and were pioneered in Pennsylvania at a university in Pittsburgh. I think it is fair to say that there is a very tight linkage between impulsivity and death by suicide in a portion of individuals who have died by suicide.

I don't know although there is probably some known, and if people know they can speak up, whether that relationship is tighter in teenagers or in children. For lots of reasons I think it could be. One other thing I would say about your observations that might temper that relationship just a little bit, is that as you know from being a pediatrician in children, depression can be difficult to see. Even for parents. It can manifest in ways that are not typical of adults. You may not see someone withdrawing completely or see somebody who is looking sad or depressed or crying you may see a child who is more irritable or behaviorally acting out. As a symptom of what we think is as similar biological process although I still say we need more research. It does point to the challenges involved in recognizing risk and the reason why we need to study young children specifically for risk for suicide. Not just think that because we understand what young adults or adults do, they might apply there. There will be different ranges of risk factor. It is a great question and I'm glad you asked.

Rachel Levine: I certainly have seen and learned about and taught about the presentation of depression in children and adolescents as being irritability. That they do not have the anhedonia and other symptoms always that adults would have, and you have to be looking for other things, particularly irritability. Some parents would say that all teenagers are irritable, but this is quantitatively not qualitatively different.

Joshua Gordon: Since we are on the subject of what we understand and research that leads us to that understanding, I am curious, you progress from a practitioner to being in charge of the health of an entire state and really issues more around policy in addition to practice. Policy as it affects practice from a public health perspective. We are speaking to a mixed group but there are a lot of scientists here who do research on suicide prevention, and they are trying to come up with the findings and discoveries that will guide public health practice. What thoughts you have about how we bring understanding and novel approaches from the research world into the practice world through public health respectively?

Rachel Levine: I think that part of research is important. We usually think of translational research from the bench to the bedside but let me take it further, I have been at the bench and, not long time but I have certainly been at the bedside and now I am in the office. I am thinking about how to implement those policies from a public health perspective, previously just in Pennsylvania and now nationally. I think that all of that is important so what you learn at the bench in terms of maybe some of the biological factors that you have been discussing like the neurotransmitter factors but also thinking about other issues I deal with which is the disease of addiction and substance use disorders and opiate use disorders. We have learned a tremendous amount of the bench that has had specific applications to seeing patients. Then we have taken those to the public health arena. I will use the example of opioids, in terms of control of pain, the saga is well-known about how opioid pain medications have been overprescribed and may be a faulty application of bench research to the bedside and how we have tried to address that. The medication the locks own which we have had significant work and distribution and administration and medication for opioid use disorder that we are looking to implement from a public policy perspective. That has been an example. In terms of suicide, there is certainly youth suicide, there are certainly experiences that I have learned and taught at the bedside evaluating and treating children and teenagers that we are working to implement from a public policy point of view. One would be making sure that we have enough professionals. Making sure that we have enough child and adolescent mental health professionals to be able to evaluate and to treat those young people. We certainly don't. We have significant shortages of child and adolescent psychologist and psychiatrist and other types of master’s level and other therapists. The importance of implementation of school programs. School prevention programs and teaching resilience in schools. School evaluation programs and then referral programs. That would be something that we would learn at the bedside that we would want to implement from our public health perspective. So, we certainly value tremendously the gains from research and from NIMH and the research that you all sponsor and throughout the academic medical centers and other facilities throughout the country, that help people in the clinic and in the hospital that we can implement then from a public health, public policy perspective. -- ...

Joshua Gordon: Thank you for that. You mentioned schools and I think it is important to dwell on that for a while. Schools play an important role in mental health. Whether it be in identification of individuals at risk or having trouble. In many jurisdictions, actually delivering mental health care for troubled children. Certainly, as a referral source. To mental health care, where it is available. What are you seeing, what is the nation seeing in terms of the issues around mental health in the context of COVID in the schools being shut down, or hybrid, or limited in person? How is that affected our ability to deliver care? What are we doing at the HHS level to try to address that issue?

Rachel Levine: I think it is severely, significantly impacting the abilities of schools to play that role. For example, one thing that we have seen, I know one thing we saw in Pennsylvania, and we see throughout the country is a dramatic drop in referral to children research to child protective services. I would love to say that that is because those concerns do not exist. But it is not. It is because many of those concerns were observed in schools. By teachers, by guidance counselors, by administrators, by coaches, etc. That is eventually leading to a child protective services referral for evaluation and intervention. That does not happen when you are looking at a Zoom, or you are trying to do school for millions of kids remotely. Also, the student assistance programs that are throughout the programs, that are throughout the United States in terms of schools, they severely curtailed in a virtual environment. So, we are looking forward to schools coming back in the fall. The key to schools coming back in the fall is getting our population vaccinated, which goes back to one of the comments that I made before. That means, having teachers and school personnel vaccinated, but it also means vaccinating other adults, kid’s parents, and extended families. In the vaccinating, right now, teens, 12 to 18. Hopefully before the end of the year. Depending on the results of the clinical trials, younger children. We are significantly worried about the ability of those systems to function in this COVID environment ... we need to get her kids back to school.

Joshua Gordon: So vaccines are good for mental health?

Rachel Levine: Vaccines are good for mental health. It is exactly right. One of the keys for mental health country is getting people back to their lives, getting people back to school and the ways to do that is through vaccination programs.

Joshua Gordon: Let me ask you a question with regard to that, you talked about how schools plan important role. What are some things that we in the research community can do to try to respond to the challenges of the COVID pandemic and the lack of you know, school-based mental health approaches in that context?

Rachel Levine: Unfortunately, given the size and scope of COVID-19 it is a living laboratory. So, I think that I wish that we did not have that living laboratory over the past year and 1/2 but that is what we have seen. I think it is unique opportunity for you all at NIMH, and all the fantastic people on this call, to research the impact of such a global event on mental health. The impact upon our systems.

And then help us, as the President says build back better. Just get back to where we were before, but to build more resilient communities and schools and families going forward.

Joshua Gordon: That is great that you mentioned that I swear I did not plant this, but NIMH has a notice special interest out there asking investigators to do exactly that. To study the impact of the various disruptions and school processes on mental health and cognitive and emotional development in children. We partnered with the National Institute of Child Health and Human Development to do this. So, all you scientists out there, take a look at that ask if your interests overlap with that. We would love to see data that looks at the effects of hybrid learning environments. The looks of the effect of bringing kids back to school.

We recognize that there will be positive and negative effects and perhaps different children will be affected differently. And how that impacts on risk and suicide prevention is a really good question. We do rely on schools, to a certain extent, for screening, in addition to pediatrician offices and all sorts of other things.

Rachel Levine: The other thing that I would like to highlight, before the biggest crisis that we face was COVID-19, the biggest crises that we were facing was the overdose crisis. The impact of substance use disorders and the risk of completed and even aborted overdose attempts, the impact of that on children. You know, whose families were impacted by that. I think that is something to consider, and I would love to say that that is over, but it is not! If anything, things are worse because of COVID-19. That is going to continue to exist.

I wonder about the impact of that on the suicide rate that you have been discussing.

Joshua Gordon: Absolutely, we know that acute intoxication with substances raises suicide risks, we also know that there is likely to be overlap in terms of, you know, some individuals being characterized as overdosing that might have been intentional. It has been a subject that we have been discussing with NIDA for a long time. Of course, the impact of the opioid epidemic on children. Not those that are using but those that are affected by it. Whether they are, you know, that those that are using with those that were affected by parents, or relatives, is significant.

Rachel Levine: I have seen those children. I have been to this great program in Pennsylvania of children who have lost both of their parents. Or at least one parent or both parents and talk to those families. And those children are significantly impacted from a mental health point of view. I cannot help having an impact on the rates that we are seeing.

Jane Pearson: I'm going to step in here because we have a lot of questions. Some of them, you have already addressed. We already know the families that have been facing stress and lost interfere that there is a program that is actually helping kids, you know, with grief. Those are risk factors. I think what we're working on now with our experts is understanding when this happens, given a child starting age, how do we best help them at that stage? So that they are not little adults. Or that they are not little teenagers. So because we are looking at a very young. I think those are some of the challenges. There are some key questions here about how we can figure out if a preteen has thoughts of suicide? Maybe without talking about it?

You mentioned, irritability. What would you recommend? Would you recommend going to a pediatrician? How would a parent check this out and to be certain that the child is not thinking about suicide? Or, if they are, what to do about it?

Joshua Gordon: Let me just turn on that and then if Dr. Levine wants to add anything, of course, absolutely talk to a pediatrician. It does not have to be a pediatrician; it can be another medical or mental health professional that you trust to have a conversation with. But, if you are suspecting something about your child, especially if your child has a pediatrician that knows that child could be a very helpful resource. You also heard from Dr. Levine that there is a shortage in mental health professionals, prepared to help with children. So, your pediatrician cannot just be an ally in terms of helping you understand whether something might go wrong but is also going to be an ally in terms of trying to help you get the treatment that you need for your child.

Doctor Levine, would you add anything to that?

Rachel Levine: I would agree that completely. I have spoken with children's hospitals as well as the director of training programs, and what they are finding is that pediatricians in training you need to be more trained about mental health issues. They are working to address that. So, pediatricians are not going to be child psychologist, but they need to be able to do that type of assessment, and then evaluation, and initial evaluation and referral. I think one of the promising things that we are seeing is the integration of mental health intro primary care.

So, I know that HRSA is working on that community health centers, but I know that I was at the Penn State College of Medicine, and they were working on that. I know that the University of Pittsburgh and the Children's Hospital of Philadelphia, I know the programs in Pennsylvania are best and Geiser was working on that, is integrating pediatric mental health professionals enter primary clinics, exactly for this reason. If a child comes in, their parents are concerned, or that pediatrician is also concerned, you do not have to call and get an appointment three weeks from now, but you have a mental health or professional in the clinic that can come or in the office, that can evaluate that child.

I think that integration, this is another public health measure, or health systems approach measure, integration of pediatric and adolescent mental health into the primary health care office is crucial.

Joshua Gordon: I'm sure some of the research is on the line would want me to make sure to let you know, as I'm sure you know already, that NIMH supported the research that make the groundwork for understanding collaborative care models integrating mental health professionals into primary care settings is an effective way to improve both mental and physical health care. For individuals with mental illness. Jane?

Jane Pearson: We had not really mentioned telehealth, I know there was a few questions about technology. And how telehealth could help extends the limited number of behavioral health researchers?

Joshua Gordon: That is a great question. We know that telehealth can work when done properly. We saw the effectiveness of telehealth over the past year. And many, if not all mental health provider shifted the majority of their patients to a telehealth situation. Dr. Levine, I was wondering if you might comment on the efforts that the HHS level to ensure that progress is built upon?

Rachel Levine: Sure, and then have a question for you. So, we are working to implement many of the telehealth practices that we incorporated during the pandemic into regular practice. So, this is complicated, it involves, really, all of HHS. It involves the course my office, but HRSA, SAMHSA, CMS, and many other actually offices as well. I think that telehealth is absolutely critical.

I think telehealth can take a number of different avenues. So one obvious one is, a mental health professional seeing a patient on platforms like this. The other is listening only telehealth. Because not everyone has platforms like this. Not everyone has computers. Not everyone has broadband and internet access. The other one though, and I know they implemented this in Pennsylvania, is that telehealth for pediatrician, if you do not have a mental health provider in the clinic, actually have access to a mental health provider.

I know that Penn State did this with practitioners, really throughout their area. It is that they had essentially, child psychiatry office hours and for pediatrician in Lancaster needed to talk to someone, they can call this number and speak to a child psychiatrist at Penn State. The other is Project Echo. Project Echo is designed in New Mexico, and it is a learning collaborative where, for instance mental professionals can work with primary care physicians talk about cases, do some webinars, and it can be very, very valuable.

What I wanted to ask you, Dr. Gordon, is what evidence is their telehealth with child psychiatry? Not to say adolescent, but school age kids or even younger using telehealth, is there evidence for that?

Joshua Gordon: That is a great question that I do not know the answer to. So I'm wondering if anyone else on the line might know the answer to? I know of lots of studies in adults, and particularly in studies and looking for example at the differential efficacy of the mental health providers seeing the patient directly. Versus collaborating with the primary health provider who then sees the patient in person. There is some evidence to suggest that that collaborative relationship and having the primary care provider be the front facing mental health professional, can be more efficacious especially for patients who develop long-term relationships.

Jane, do you know about what work we have in pediatric telehealth?

Jane Pearson: There might be something out there that we haven’t found yet. From what we understand, people are trying to figure out what model works best and are concerned about payment and the feasibility of getting it working. There has been some long-standing programs that haven't been evaluated. We are going state by state that have engaged in that to say what was the benefit? What was the return on investment? Some of them have to be sustained as well. We would like to know more about does the person need to observe the child especially if it is a young child because of the lack of capability of describing feelings and so on. This is always a challenge in these younger groups.

Joshua Gordon: So, scientists out there get those applications in. We need to know how to effectively use tele-mental health perhaps few -- through video or other means because we want to make sure we reach everybody and how to apply that in pediatric populations.

Jane Pearson: We have another question about what schools can do, there is a concern about kids picking up ideas from other kids by social media. So if there is a school awareness or assembly in terms of, what are we learning about that kind of contagion piece and what is best practices there? I don't know if either of you have any comments and I know some of our panelists, our research experts are looking at things like that.

Rachel Levine: Absolutely, I think that schools have to be very cautious if there is a suicide attempt in a school or a completed suicide in a school and having suicide contagion sounds dramatic, but I think it is real. I have seen it. I think that schools have to be careful about the big assembly where they eulogize the young person who tragically passed away because a young person who is feeling vulnerable and insecure, may not feel they get that attention. We also saw this not only in social media but on our TV program and I won't name it, so I don't get sued but a TV program which talked about a youth suicide where there were significant concerns about contagion from that. You have to be careful how the media depicts, and schools depict these things.

Joshua Gordon: There is something known about contagion, and more being done to look at it. There are some successful programs and again I would say we are in the phase of evaluating them, but school districts can pair with local mental health providers to develop responses. I think that is one method to try to combat these issues. Jane you have anything else on that?

Jane Pearson: From that perspective you're trying to reach the kids that are most acute, how can you help them without taking them to the emergency room but getting them into care right away. An emergency evaluation then trying to get them to care. There is another level of kids already known at risk and if you talk to school personnel they are worried about a number of kids. How are they being helped? Schools are now asking questions like has social emotional learning built in some protective factors. Again our expert panels are thinking about what specific mechanisms of action… What have certain interventions done that actually do protect kids and for how long? Through what kinds of situations? We know not everyone reacts to stress the same way – but in a school where you have to think about the broader population more from a public health perspective there are some really important questions. We've had so many questions. Here is one that is more international in scope because Dr. Levine was talking about not everyone has technology here and we know actually more of the world's suicides are among lower and, lower income countries. Is there anything we are learning from those examples or cultures that could be brought here to help us with low resourced efforts to help our youth? If either one of you have ideas or we can bring it to the panelists.

Joshua Gordon: It is a great question and NIMH sponsors researchers throughout the world in lower- and middle-income countries including some suicide prevention. One thing we have learned through some of the efforts to reduce suicide in lower- and middle-income countries is that a very effective way of doing so is means restriction. In countries like India where fertilizer was a means often used for suicide, the laws restricting access to fertilizers and pesticides.

Jane Pearson: Both could be poisonous.

Joshua Gordon: It dramatically decreased suicide rates. That could be applied to the United States broadly both in lower income areas and throughout the US looking at how people died by suicide and trying to reduce access to means. I think another lesson that we are learning from our work is that some of the most innovative things happen in low resource settings because of the necessity for innovation. We are seeing the use for example, of text-based communications because in lower- and middle-income countries almost everyone has a cell phone but it is not usually a smart phone but it might be a text based solution or apps for non-smart phone telephones. Their use in monitoring individuals. Lots and lots of innovation. There is also social innovation, the use of community members as individuals who can identify and treat such as the friendship bench developed in Zimbabwe that has been brought back to areas in the United States where you have community members sitting on the benches outside doctors’ offices asking people about their mood. A number of practices that science has developed in these lower- and middle-income settings have the potential to be translated back to the US and indeed are already being done.

Rachel Levine: I wanted to build on something you said about means prevention. I think it is important in the United States as well. I will bring up a provocative topic and that is guns. If child overdoses, it can be very serious, but we are pretty good at that. Not always but pretty good at treating that. But a gunshot wound we are less successful. There are many things and almost everything in our country that we can disagree on, but I think that we can agree on is gun safety at home. There are well-defined, well accepted gun safety mechanisms for people who have guns at home that have been accepted by all sides of this issue and I think that gun safety at home is one way that we can prevent completed suicides among children and adolescents.

Joshua Gordon: I agree with that Dr. Levine, and I will point out that one of our partners, the American Association for Suicide Prevention has been working with gun dealerships to promulgate safe gun ownership to reduce suicide risk in children and others for that matter. Indeed, it is an important issue about ensuring safety and guns are responsible for about half of all suicides in the United States. I don't know, Jane maybe you do, do we have that data specifically for children about most frequent means?

Jane Pearson: I think we are still waiting to see evaluation of some of these efforts and fortunately it is still a low base rate but to have enough households that have acted in safe way to have stored things. There are some promising directions and efforts in Alaska, but we would like to see more.

Joshua Gordon: We funded work such as work that gives out safety locks for guns, etc. to look at the effects on suicide effects and suicide deaths. So there is a lot of opportunity to do science in this area.

Jane Pearson: One thing that has come across all of these roundtables and then we will wrap up pretty soon, is that there are highly diverse youth and we have talked about youth facing trauma but there is sexual minority youth, intersectional youth who might be racial minorities as well as sexual minorities. I'm wondering if you want to speak to some of the challenges we face in terms of trying to help all these diverse groups and trying to reach them in meaningful ways that don't cause more harm and what is… What kind of research could be used to improve all of that?

Rachel Levine: I will start. Certainly, I think the data is better for teenagers than for children but sexual and gender minority youth, youth that are about of the LGBTQ community are certainly at risk of increased mental health issues and increased risk of suicide. I want to emphasize though that it is not being LGBTQ that increases your risk of having mental health issues such as depression, anxiety, PTSD, suicidal ideation, it is the bullying, harassment, and overt discrimination that LGBTQ youth face that lead to those mental health outcomes whether from home or at school. There is evidence that having one supportive adult and doesn't have to be a parent or doesn’t have to be in the family but having one supportive adult really attenuates that risk. The other last word I will say is that there is significant evidence that trans youth that are treated with a well-established guideline that are accepted by the American Academy of Pediatrics, the American Psychiatric Association, the American Psychological Association, and the Endocrine Society, etc., our evaluation and treatment according to well-established standards of care, those youth do absolutely great. They do well socially and well in the communities and in their schools and have very little mental health issues. Young people that face is discrimination, harassment, nonacceptance by either home or school and do not have access to those standards of care, actually have more mental health issues and I want to emphasize that in the light of several state laws that have been passed and are being considered.

Joshua Gordon: I think that is an excellent point that gets to a significant chunk of the issue here. I will point out that it is mechanistic in approach. We see an observation of a mental health disparity and try understanding what are the mechanisms that lead to the disparity and in this case as you stated the evidence is very clear that it is about the discrimination and bullying and harassment that is faced by individuals in the context of their communities. That also points, of course, to interventions that you might want to use to reduce that risk. Such as providing the opportunity for mentoring from understanding adults. This would be one pathway forward. I will add in that it is important to think about the context, the community context, the individual level context as one is trying to reach the youth in trouble. Whether they be LGBTQ or other youth and of course as we mentioned there is now an increase risk in black youth. Considering that context and looking for innovative ways to reach those populations. One quick example from a slightly different aspect of the NIMH research portfolio in HIV risk we have funded a number of studies to look at ways to reach intersectional youth and to reach black youth to reduce their risk of HIV and ensure that they get tested and get care if they are at risk. I think taking some of those lessons learned and applying it to the problems of suicide prevention and other mental health issues in marginalized populations is something that we really need to look at.

Jane Pearson: I think it also speaks to the partnerships we need across agencies and across HHS, so it has been great to get your level of viewing all of this Doctor Levine and thank you for joining us today it has been a pleasure. I think with that, I will wrap this up and I want to let the audience know that there were many, many questions and we will be looking at them as we go forward and we really appreciate your attention today, your attending. Bringing up some really important questions. And again let me thank both Dr. Levine and Dr. Gordon for joining us today and I think we will wrap this up, the public session.

(Multiple speakers) Thank you so much for the opportunity.