PolicyLab

Blogger's Note: With youth suicide in the cultural spotlight we must all work to fill in the gaps in education. In response to criticism of the initial season of “13 Reasons Why,” this season Netflix will include more warnings before particularly graphic episodes. But in public health, we know that warning statements are not sufficient by themselves to change individual attitudes and behaviors around a health-related issue. Furthermore, the show underestimates the impact of suicide on children and adolescents in our country by not appropriately highlighting that the youth suicide rate in the U.S. continues to increase. In fact, among high school students, approximately 12 percent of girls and 6 percent of boys attempt suicide over a 12-month period. In addition, adolescent girls consider suicide and plan suicide attempts at rates almost double adolescent boys; however, males are more likely to die from suicide.

With suicide being the second-leading cause of death in 2016 for young people in the United States ages 10-24, it should be no surprise that there is increased attention on the Netflix series “13 Reasons Why.” Based on a book by the same name, “13 Reasons Why” follows a teen character explaining events that led to her suicide. The release of the first season in 2017 took parents and health care providers by surprise, and we have since had many discussions with patients and families in our clinics about the show. As we await the release of season two on May 18, it’s crucial to examine the show’s impact on youth and how parents can prepare their families for the new episodes.

Why are health care professionals concerned with youth watching “13 Reasons Why”?

“13 Reasons Why” is popular for covering many adolescent issues such as bullying, peer and family conflict, sexual assault, drinking and peer pressure. Of the patients that I’ve (Rhonda Boyd) spoken to, most enjoyed the series and watched the entire first season. Anecdotally, a few discussed how the show triggered negative emotions, memories of past experiences and desires to kill or harm themselves. While this level of emotional understanding can be difficult to endure, it’s positive that those patients were aware of how the show could impact their emotions and we could discuss care plans to address those emotions.

However, some youth could not understand how the series had negatively influenced their feelings and actions, which is quite normal as cognitive skills are still developing in adolescence. This creates an important role for parents and caregivers to help children and teens comprehend the themes and impact of a series such as “13 Reasons Why.” Parents and other adults in their lives can help them process their reactions and discuss them in a safe context.

With youth suicide in the cultural spotlight we must all work to fill in the gaps in education. In response to criticism of the initial season of “13 Reasons Why,” this season Netflix will include more warnings before particularly graphic episodes. But in public health, we know that warning statements are not sufficient by themselves to change individual attitudes and behaviors around a health-related issue. Furthermore, the show underestimates the impact of suicide on children and adolescents in our country by not appropriately highlighting that the youth suicide rate in the U.S. continues to increase. In fact, among high school students, approximately 12 percent of girls and 6 percent of boys attempt suicide over a 12-month period. In addition, adolescent girls consider suicide and plan suicide attempts at rates almost double adolescent boys; however, males are more likely to die from suicide.

Finally, the show only highlights some of the multiple factors that may increase a teenager’s risk for suicide, including behavioral health conditions, alcohol and substance use, history of trauma, stressful family and peer interactions and LBGTQ status. Other risk factors include whether a youth has made a previous attempt at suicide or knows of someone who made a suicide attempt or died by suicide, whether it’s a friend, community member, stranger, celebrity or even a fictionalized character. Awareness of a person attempting or dying by suicide can trigger suicidal thoughts and attempts in others. This phenomenon, known in the literature as “suicide contagion,” is one of the primary reasons health care providers and others are concerned about the upcoming season of “13 Reasons Why.”

What can parents do to prepare for the upcoming season?

Health care professionals at Children’s Hospital of Philadelphia have been actively thinking about suicide prevention and treatment, but we cannot overlook the impact of parents and caregivers as the key figures in the lives of adolescents. Unfortunately, research has shown that parents are often unaware of their children’s true emotional state and, more troubling, often unaware their children may be thinking about death or having thoughts of wanting to die by suicide. The second season of “13 Reasons Why” gives parents a renewed opportunity to minimize the potentially harmful impact of this series on their child or teen. Below are a few considerations for parents to help get the conversation started and some resources for youth suicide prevention:

1. Although many youth who are interested in watching “13 Reasons Why” may be developing greater independence and spending more time apart from their parents, we recommend that parents and youth watch the series together.  Doing so may create natural opportunities for parents to appreciate their child’s understanding of the program’s content and messages, and become aware of concerning reactions at an early stage.
2. It is vital for parents to establish an open dialogue about the show and its content. In order for parents to feel comfortable engaging in such a conversation, we recommend that parents learn as much as they can about the show, prevalence and risk factors of youth suicide and what steps they can take if they are concerned about the well-being of their child. It’s important to understand that talking with your child about suicide does not make them more at risk for suicide. Rather, talking openly and honestly in a caring and nonjudgmental manner is important and mitigates the risk of missing important information about your child’s emotional state.
3. If you are concerned about your child or teen, seek professional help. You can obtain behavioral health referrals from your insurance company and/or your primary care physicians. 
4. Be aware of helpful resources and pass them along to teens and other parents. For more information on suicide prevention, contact the following organizations:
   1. National Suicide Prevention Lifeline:  1-800-273-8255
   2. Trans Lifeline: 877-565-8860
   3. Trevor Project: 866-488-7386
   4. Text “START” to Crisis Text Line at 741-741
   5. Visit Lifeline Crisis Chat online

Jason Lewis, PhD, is a psychologist and associate director of outpatient services in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at CHOP.

Stephen L. Soffer, PhD, is a psychologist and director of outpatient services in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at CHOP.

This piece also ran on the Delco Daily Times website here.