In recent years, Staten Island (SI) has taken up the nationwide call to action to address suicidal behaviors among youth. During a May 2018 roundtable discussion on mental health issues facing youth, hosted by local elected officials and attended by a multisectoral group of professionals from schools, mental health providers, community-based organizations, and city agencies, anecdotes from clinicians at pediatric behavioral health outpatient clinics raised concerns about the increasing acuity of suicidal behaviors among children as young as 7 years old. Although these instances among young patients were considerably rare, clinicians cited the extent to which some patients went, sharing that some patients reported tying objects around their necks like a noose or testing if certain curtain rods were strong enough to support their weight. Clinicians connected these behaviors with increasing numbers of kids at younger ages talking about feelings of vulnerability, anxiety, and lack of control. Bullying was also prominently discussed at the roundtable, with stories about how a rise in bullying, especially electronic bullying, has contributed to similar feelings of vulnerability, anxiety, and lack of control. This connection between bullying and suicide has been well documented, but this roundtable highlighted the urgent need for our community to delve deeper at the local level to better understand how bullying and suicide affect SI youth, and assess our community’s capacity to meet these challenges.
Following the roundtable, the Staten Island Partnership for Community Wellness (SIPCW), which serves as the backbone organization for TYSA, a collective impact initiative focused on addressing the behavioral health needs of SI youth, took the lead in conducting an assessment. SIPCW completed eight key informant interviews (KIIs) with adolescent mental health service providers on SI, including staff from school-based health centers (SBHC) and outpatient behavioral health clinics. Interviewees shared their insights on bullying, suicide, and the relationship between the two, and offered recommendations on community-led approaches to address these issues. SIPCW will use these recommendations as a roadmap to engage partners from various sectors in affecting systemic changes in the way that families, schools, and communities address bullying and suicide.
During the KIIs, the experts identified specific risk and protective factors that contribute to bullying and suicide. Identified risk factors for bullying included low sense of self-esteem and self-worth, weak social support systems, and could coincide with belonging to one or more marginalized groups based on sociodemographic factors like age, race/ethnicity, sexual orientation, gender identity, disability, and family income. Identified risk factors for suicidal behaviors included feelings of sadness, hopelessness, depression, anxiety, and social isolation, past suicidal behavior, history of substance use, loss of a loved one, and barriers to accessing mental health and other supportive services. A young person’s home life, including if there is a family history of mental illness or substance use, negative parent-child relationship, and/or involvement with child services are also important factors to consider. It may not be any single factor that causes a child to exhibit suicidal behaviors, but rather, the aggregation of several factors.
When discussing protective factors against bullying and suicide, the shared overlap in these protective factors was apparent, namely strong resiliency and problem-solving skills, a strong support system that fosters a sense of connectedness, and adequate access to mental health services. The following recommendations were identified through the KIIs and focus on strengthening these key protective factors by giving youth the skills to navigate challenging situations like bullying and suicide and affecting environmental strategies that focus on changing the community landscape.
Building Resiliency and Problem-Solving Skills
Strong coping, resiliency, and problem-solving skills equip children to navigate and communicate through challenging situations. By adopting and implementing formalized Social-Emotional Learning (SEL) curricula early in a child’s development (during elementary and middle school), children will develop the social emotional regulation skills they need to meet life’s challenges and thrive in their social and learning environments. SEL provides a strong foundation that enables children to identify and understand their own feelings, regulate their emotions, effectively communicate their thoughts and feelings, and assess situations to respond appropriately. By developing these SEL skills early on and reinforcing this instruction throughout their development, generations of youth will learn to treat themselves and each other better.
Empowering Bystanders to Stand up Against Bullying
Bystanders may feel helpless and unsure of how to stop bullying, or they may fear that by stepping up, they could become the bully’s next target. Strong SEL skills will help youth to feel more empowered to help their peers, but it is still necessary to provide the appropriate skills to de-escalate tough situations when faced with bullying. Bystander intervention trainings at school can help to build these skills and show youth how to support others in solidarity.
Teachers and other school staff can also benefit from these trainings. Since they interact with students on a daily basis, they should be considered frontline staff in identifying and addressing bullying. As trusted adults, they should be empowered to intervene whenever they see any child being bullied or treated unkindly and be aware of the mental health resources available at school to connect students to additional support. School staff need to reinforce these bystander intervention skills with their students whenever possible and can do so by establishing norms around caring for and respecting one another, both in and out of the classroom.
Promoting Family and Community Connectedness
Families do not always have the right tools to support their children emotionally and could benefit from resources that reinforce family connectedness through strengthening key parenting skills. These parenting skill programs will build caregivers’ knowledge of healthy and age-appropriate child development, effective communication methods, behavioral management, and conflict resolution. Such programs will help caregivers develop and improve critical skills in fostering a nurturing and supportive environment for their children, which studies have shown to be effective in reducing adolescent risk behaviors like bullying and suicide (Devid-Ferdon et al., 2016). Caregivers who can help their children work through challenges in a productive way can foster resiliency skills that will help in navigating, and hopefully, preventing, bullying and suicide.
Community-based programs should be safe and inviting spaces where all young people are accepted. These should be spaces where young people can build themselves up, feel valued and appreciated, interact with peers and mentors, and feel comfortable sharing their personal challenges. In stressful times, the connections forged through these communities can be critical lifelines to socioemotional support. One clinician emphasized that “if they are building themselves up, they’ll be too busy to let others bring them down,” stressing that these programs help to build resilience to weather the shock of external trauma like bullying. It is important to engage school- and community-based leaders like teachers, team coaches, and faith-based leaders, who are already working with youth, and train them to be ambassadors for general wellbeing and mental health. By providing school staff and community leaders with the skills to identify behavioral health challenges like bullying and suicidal ideation, and supporting them in helping these young people, we can reach youth with the support they need in more non-traditional spaces.
Building Pathways to Access Mental Health Services
SBHC clinicians noted how each school’s mental health resources and capacity can differ widely and may not necessarily be equipped to meet the needs of all students. SBHC clinicians may be adept at screening for mental health needs and making referrals to school- and community-based services, but oftentimes, there are not enough resources in schools and communities to meet students’ needs. For short-term mental health support, school social workers can provide services, but long-term treatment plans are not possible. All SBHC staff that we spoke with acknowledged the overwhelming shortage of local mental health providers, which poses a major barrier to treatment. Agencies simply do not have adequate staffing and resources to respond to all these urgent cases in a timely manner. Wait times for an appointment can take months, which strains the healthcare system and frustrates parents, children, and clinicians.
Increasingly, the task of managing mental health treatment is falling onto physician generalists, both in school and community settings, but they do not always have the confidence or comfortability to manage patients’ mental health needs, especially cases involving suicidal ideation. SIPCW recommends additional professional development for pediatricians to build confidence and competency in addressing milder cases to relieve pressure from the overstretched mental health outpatient clinics. Increased collaboration between pediatricians and psychiatrists through case conferencing would support exchange of best practices and facilitate more seamless patient-centered care. Additionally, the emergence of telehealth offers opportunities to close some of these gaps in services, and providers should be supported in building their tele-capacity moving forward.
Addressing the existing culture of bullying requires a community-wide realignment with a thoughtful, strategic approach. All stakeholders need to work collaboratively to address this deeply entrenched bullying culture through evidence-based strategies as a means to prevent suicides. If we can change the community norms around bullying and suicide through collective action, we can improve mental health and wellbeing for future generations of young people.
Steven Chan, MPH, is Evaluation Coordinator; Maralie Deprinvil, MPH, is Senior Coordinator of Behavioral Health and Contracts; Jazmin Rivera, MPH, is Director of Behavioral Health & Evaluation; and Adrienne Abbate, MPA, is the Executive Director at The Staten Island Partnership for Community Wellness.