In medical college, I once wrote a story for the college magazine. It was a simple though stark story about a medical student’s suicide. The week before the magazine was published unfortunately there indeed was another suicide. The unfortunate student’s friends were incensed that I had written about their friend. They had to be reassured that the article had been submitted months ago and was not personal. The author had merely stated the typical course of circumstances and events that usually led to this.?

Though suicides are not always predictable, the sad truth is that there are easily recognisable factors that may enhance their likelihood and that open them up to prevention. In my story, though the underlying theme was the intense competition for post-graduate seats and the trigger was heartbreak, the real reason was the gloomy mood of increasing isolation and desolation of a teenager in a world that recognised success and prioritised academic excellence over nurturing and rewarding relationships marked by instant shifts in attention and commitments. The premise was that you were only as good as your last viva voce marks.?

That such typical situations can be the cause of tremendous tragedy is stupefying. According to statistics from the Centers for Disease Control and Prevention, suicide is the second leading cause of death in the 10–34 age range. More than 47,000 people killed themselves in 2017, one suicide every 11 minutes, while 10.6 million adults seriously thought about suicide.?

A recent review by the Indian Academy of Pediatrics by Galagali, Gupta, et al, on Prevention and Management of Suicidal Behavior in Adolescents informs us that adolescents form 18 per cent of India’s population, and suicide is the third leading cause of adolescent mortality. The number of reported student suicides in the year 2015 alone was 8,934. In 2020, one adolescent committed suicide approximately every hour with more girls than boys. The actual figures may be higher as in most cases there is inaccurate reporting.

Essential Red Flags to Look Out For?

I saw a boy?who was referred to me for his undiagnosed headache and stomach pains. Since there was no evidence of any medical illness, the paediatrician wanted me to have a look. When asked in detail, the mother shared that her teenage son’s behaviour had changed in the past couple of months. His sleep and eating habits had become erratic. He had stated avoiding his friends and extra-curricular classes and was withdrawn and isolated recently.?

We found that he had been depressed after a series of events wherein he had a relocation of residence, a change of schools, lost a grandparent whom he was extremely close to, missed scoring well in some key exams and was subjected to bullying in his new school. He had not shared the latter with his parents as he thought they were undergoing stress as well. He had attempted to swallow some sleeping pills but didn’t muster the courage to go through it, he said.?

Subtle unexplained changes in baseline behaviour can often be a clue to something going drastically wrong in the child’s mind; similarly, symptoms unexplained by medical evaluations (psychosomatic) need to be looked at in detail.?

One or multiple events like the death of a dear one, including a pet, change of schools with disruption of peer group, examination-induced stress and bullying are all too common but their impact may be missed. Social isolation and feeling of hopelessness are giveaway signs that should alert every parent. Softly spoken statements like “I don’t want to be a burden on you anymore”, or “No one really cares or misses me” may be far more sinister than they seem, suggesting a preoccupation with death, suicidal thoughts or even ways to die. Giving away loved possessions, like a prized scrapbook or a camera or a favourite jacket may not be altruistic as much as a sign of innocent bequeathing of possessions.?

While a sudden drop in academic performance may signal recent hopelessness; a chronically poor school performance may indicate an unrecognised learning disability. Children continue to be the butt of disparaging comments from teachers. When they see the shame in their high-achieving parents’ eyes, children may end up blaming themselves for their parents’ humiliation, even for the disagreements between them. A sibling who is an extraordinary achiever can further the cause of shame and worthlessness. Smaller children may be unable to express their frustration in words and may resort to drawing; a mother once showed me a picture drawn by her daughter showing a stick figure hanging from a fan. Scribbled lines, drawings, photographs, letters tucked away in the cupboard, internet history—may all indicate hopelessness and a preoccupation with suicidal thoughts.

Relationships matter more than worldly issues. A study in the reputed journal Pediatrics reported younger children were more affected by relationship issues with family and friends, whereas relationship issues with boyfriends or girlfriends mattered more to adolescents.?

Children with existing mental health disorders like depression or ADHD were subject to higher risk; hence, red flags must be immediately attended to. Similarly, children from homes with family discord and domestic violence, academic failure, disadvantaged or abused children, any recent death in the family are at higher risk. Bullying and now, cyberbullying and internet addictions, especially gaming, need special attention; there has been a rise in reports of suicide-provoking sites. Suicide has been shown to “run” in families, and while a genetic predisposition to depression and substance abuse may play a role, the awareness that someone else chose that outcome may also influence suicidal ideation.

Building an Arch?

Recognising red flags, respecting high-risk factors and seeking dependable help are the three most important things that parents should keep in mind.?

A child with a sudden or subtle change in behaviour could be a red flag. If a child suddenly shifts from calm and relatively happy to aggressive, completely withdrawn, or very anxious, it is important to address it. Signs of social isolation and hopelessness, failure to proactively engage with anyone or share affection, giving up without trying, preoccupation with death, prolonged grieving are late-stage red flags. Pay special attention to words or signs of helplessness and hopelessness. Finally, never ignore your gut feeling. Even if the so-called red flags aren’t obvious, if you have a bad feeling about something, don’t ignore it.

If risk factors exist, you should have an even lesser threshold for action. Death or suicide in the family, broken relationships, history of depression, domestic violence, substance abuse, chronic illness, financial burdens, screen addiction and bullying, and existing mental health disorders are all high-risk factors.

It transpires that any intervention is better than no intervention. Any attempt to connect with the child is better than masterly inaction. Any affection is better than no affection. Any ray of hope is better than darkness.

Unfortunately, we are socially averse to discussing this topic and our first reaction is either to brush it under the carpet—“No this can never happen” or to panic—“Oh my God, what am I to do?”, and that panic stuns us into inaction, till it is too late. Sometimes, especially with today’s generation, it is difficult to guess if the red flag is true or a blackmail tactic used by the child. “Doctor, you asked me to restrict screen access and gaming. My child threatens he will jump out the window if I don’t allow him right away!” Well, the real answer is—you can never be sure. But you have a clear course of action—begin to deal with it and seek help.

According to Katie Hurley, an author and psychotherapist, “Suicide might not feel like a family-friendly dinner conversation topic, but perhaps it should be.” A common misconception is that talking about suicides causes children to think about it. There is evidence now to dispel this myth. Besides parents can never know for sure what exactly is going on in the child’s mind. Avoiding the topic won’t help them learn how to get help if they need it. At the same time, it is important to stay calm and be nuanced rather than being dramatic or emotional as a parent. The child is already emotional and immature; your adding to the drama and emotion won’t help anyone. If you need to calm yourself or talk to anyone for support, please do it.

You may ask simple questions in a calm tone like, “Are you feeling depressed or very sad lately?” or “Are you thinking about hurting or killing yourself?” or even “Is anything bothering you?” Now your child at least knows that you understand and care. Conveying empathy in a time of emotional crisis is crucial. Your reaction to the child’s response is even more crucial. Regardless of whether your child answers or how he answers these questions, you need to maintain your calm because your reaction is going to mean the most to your child. Take care not to launch into a lecture on blame, behaviour, emotions and actions; a casual arm around the shoulder or a simple hug would be far more effective. Spending time with your child while not seeming judgemental or fussy are extremely important. A sudden overload of attention will perhaps overwhelm the child. ?
If this is first-aid, you need to remember that it is too serious a matter to be left to that. It is essential to seek an evaluation by a licensed mental health practitioner who specialises in working with children. Beware of numerous services that have sprung up of late that advertise well but may be completely unprofessional. If you’re not sure where to access help, schedule an immediate appointment with your child’s pediatrician who can then guide you. With proper support in place, children can work through the feelings and triggers that result in suicidal thinking and learn effective coping skills to deal with difficult life situations.

Stay calm and look after yourself. Remember, on an aircraft, they always ask you to “fasten your own mask before helping others”. Remember also, that you have an important role to play but the most vital role is of the child her/himself. Your job is to do the best you can, which includes seeking help for your child and yourself—this is Rule Number 1. If you find the task agonising for yourself, follow this rule. If you find yourself lapsing into the past and guilt, follow this rule. If you are a cinema buff, as am I, you would love watching Roberto Benigni’s Life is Beautiful–it would teach you more about parenting than any expert could!

During the Covid lockdown, our team at New Horizons Child Development Centre came up with an acronym ‘ARCH’ that many parents found useful, including in a small study at Sir J J Hospital, Mumbai. ARCH stands for Attempting to Adapt to change, fostering Resilience, enhancing Care and Cooperation between your child and others and, finally, inculcating Humor and Humility. Building an ‘Arch’ with your child may help you to bridge many stormy waters.?

In conclusion, don’t push this till you see red flags emerge. Parenting starts before you become a parent and never really stops. But parenting is an opportunity for self-development as much as a chore to perform—it matters most how you choose to accept it. The ultimate aim of parenting is to leave behind a child who can look after her/himself in your absence. Your life’s work is to prepare for your child after yours, not merely while you are with her/him. ARCH values can be a compass for you to steer your course. And if I had to choose one over the others, it would be resilience. Resilience is fostered by allowing your child to fail while standing by and taking over the wheel for a brief while as the child attempts to master it, with your support. Don’t let your child begin to drive alone, don’t continue back-seat driving either. Parenting is a beautiful opportunity to find yourself, as you gradually let the child find her own path with her own strength. ??

(Views expressed are personal)

Samir Dalwai Is a developmental pediatrician with expertise in contemporary interventions for children with special needs