What nurses can do to understand and prevent youth suicide

Imagine your busy household, on a Tuesday evening. Your children are watching TV, you are tidying away the dishes after the evening meal. Your mind drifts to the pile of laundry waiting from the weekend sports, the homework that needs be supervised. You wonder carelessly if your 13-year-old will walk the dog this evening. He has been quiet these past few days. The phone rings. It is your mother, you chat for a while. Suddenly you hear your 8-year-old daughter scream. You drop the phone, you race to your son’s bedroom and he is hanging from the top bunk bed, limp and blue, with froth in his mouth. You cut him down and dial for an ambulance.

Your family will never be the same again.

Understanding the great change

During the teenage years, there are changes in physical characteristics, but more so in behaviour. This is compounded by the surge in hormone levels. It is a time of great change for young people. They may become rebellious, argumentative, stubborn, impulsive and occasionally violent. They often display risk-taking or experimental behaviour.

Adolescents are usually preoccupied with their mates, who may influence their decision-making. They desperately want to fit in with their peers, from music to clothing and so on. Ultimately, they are trying to assert their independence and find their identity and purpose.

However, the teenage years should be a time of opportunity, of psychological and cognitive growth. Society entrusts older teenagers with certain privileges and responsibilities (driving and voting for example) which promotes their independence. As parents, the ideal is to nurture their strengths, navigate their challenges with them, talk with them about alcohol responsibility, and help them deal with bullying, handle money and manage technology. Most importantly, be a role model, provide appropriate supervision, listen to them actively, set clear family house rules of acceptable behaviour with consequences that are calm, firm and consistent. Encourage them to realise their own potential, to cope with the normal stresses of life, to work productively and to contribute to society.

At our major trauma centre in Brisbane, we have seen an increase in risk-taking behaviour, such as exceeding red-lining limits (the fastest, furthest, highest point considered safe), driving in excess of the speed limits, travelling unrestrained, drug abuse, chroming (inhaling fumes from chrome-based paint), alcohol abuse and experimenting with homemade explosives.

New computer-mediated technological trends are always of concern; for example, recording yourself while planking (lying flat and holding yourself on your toes and elbows in precarious places), or the more recent online dare or challenge games which induce vulnerable teenagers to enact formidable exploits.

One ongoing craze is the online choking game. By definition, choking is the mechanical obstruction of air flow from the atmosphere into the lungs. Choking prevents oxygen and carbon dioxide gas exchange and can be partial or complete. Partial choking allows some, though inadequate, flow of air into the lungs, while complete choking, results in asphyxia, which leads to anoxia and is potentially fatal.

Asphyxia may be defined as a state in which the body lacks oxygen because of some mechanical interference with the process of breathing, usually associated with an excess of carbon dioxide in the blood. The usual causes of non-violent asphyxia are suffocation or smothering, whereas violent asphyxia includes choking, strangulation (constant application of pressure to the neck) and hanging.

Judicial hanging, a form of execution is no longer prevalent, as capital punishment was abolished in all jurisdictions in Australia. The last execution by hanging was in Victoria in 1967. In judicial hanging, death is instantaneous due to the fall of the body for a few metres in the air, causing fracture and/or a dislocation of cervical vertebrae with vasovagal shock.

Suicidal hanging is a form of ligature strangulation in which the force applied to the neck is derived from a gravitational drag by the weight of the body or part of the body. The ligature is the material used to strangle the patient usually below the thyroid. Death is often a slow process, taking eight to 10 minutes.

Strangulation is the constriction of the airway, or trachea, by manual means (for example, an arm lock) or by ligature or hanging. These three methods inhibit normal respiratory function or impede circulation; there is vascular outflow obstruction or an occlusion resulting in a lack of blood supply and oxygen to the brain.

Australian law has changed over the past 100 years. It has decriminalised suicide. People who attempt suicide are no longer excommunicated from the Church and those who die by suicide are permitted a Christian burial. However, apart from the tragic and complex factors involved with suicide, the stigma remains.

According to research from the US-based Zur Institute, teen suicides were the third leading cause of death for adolescents and young adults (2016). Our major trauma centre paediatric injury data supports this. From 2012 to 2016, strangulation was the third most common fatal mechanism of injury for all ages (0–16 years). During this period, 40 per cent of children aged 12-16 died because of strangulation. Eight teenagers used a ligature around their necks and, whether intentional or not, it resulted in death. The ligatures used were predominately of nylon or leather, most often ropes, cords or belts. Ninety per cent were males and all were aged 12–16. These strangulations took place in or near the home (five were in the home, two in the garden and one in an adjoining building). During the same period, three teenagers survived a potential strangulation by hanging (two 14-year-olds and a 16-year-old).

Data from the Queensland Family & Child Commission highlights a larger burden of teen suicides by hanging. Over the same five-year period, 94 children died by hanging and 94 per cent of these were found to be suicide or probable suicide. All were aged 12–17, and 29 per cent were female. These patients did not necessarily present to any hospital.

Whether these adolescents are experimenting with sexual gratification or completing a dare, whether their intention is suicide or not, it is impossible to say with certainty.

As a nurse caring for these patients and witnessing the tragic outcomes, I urge you if you know a parent or if you are a parent of a prepubescent child to take the time to connect with them, to listen attentively, to refrain from belittling them, to encourage them to be courageous with your unremitting support. If neurosurgeon and writer Paul Kalanithi is correct and life’s meaning has “something to do with the depth of the relationships we form”, let us develop and nurture enduring relationships.

Building interpersonal relationships

There are many theories relating to interpersonal relationships. The vital first close bond is called "attachment". A secure close relationship between an emotionally available parent and child is essential for healthy relationships during childhood and this translates positively into adulthood. It promotes strong social and emotional wellbeing.

Adolescents may experience low moods, poor motivation and sleeping issues as they change their sense of identity, find their place in the world, and move towards independence. Conflict is inevitable during this time, as teens have different views on the world. This can undermine the parent-child relationship. However, it is important to remember that a bad day is not catastrophic and resolution is possible if approached with good humour and sensitivity. As a parent, be readily forgiving and maintain clear, consistent, positive communication. As the 13th century poet Rumi wrote: “Raise your words, not your voice – it is rain that grows flowers, not thunder.”

Acknowledge the teen’s concerns, their ideas and their feelings. Recognise their struggles and their achievements. This will shape their future, help them feel safe, deal with stress, rebound from disappointments and create positive healthy connections with those around them.

A well-designed versatile program may help identify causative factors. The Australian mental health organisation, beyondblue, is campaigning to end the stigma associated with mental illness by promoting conversation – talking to family, friends, peers and professionals. Combined with appropriate education, increased parental and sibling vigilance, awareness of signs to look for, monitoring the portrayal of suicidal news in the media and restricting access to ligatures, this may lessen the number of teen suicides.

Peer camaraderie with the involvement of young people in positive activities, specific psychotherapy preventive strategies, including care with self-talk, promoting self-esteem, incorporated with a physical exercise program, may reduce the rate of suicidal death by hanging.

In 2011, Queensland had the highest incidence of youth suicide in Australia, according to the Australian Bureau of Statistics. One strategy the Queensland government put in place to change this is Mental Health Week, which takes place in the second week of October. It coincides with World Mental Health Day (10 October).

About 25 per cent of all adults will experience mental health issues during their lifetime. Mental Health Week is a prompt to connect with family, friends, peers and co-workers and is an opportunity to engage with others, to have open discussions without the stigma attached to mental health. The aim is to provide psychological and mental health first aid.

Will Carrigan’s suicide sparked the Where There’s A Will campaign for mental health programs in schools. Carrigan was a 24-year-old football star with a close-knit family and a thriving business as an electrician who died by suicide on Christmas Day in 2015. The campaign will introduce what is known as “positive education” to try to “immunise” young people against anxiety and depression.

Mental health will be the greatest health burden to humankind by 2028, according to the World Health Organization. About 26 per cent of young Australians have some form of mental illness or anxiety now. These are staggering statistics. They are preventable deaths. We need to support these young people as they try to find meaning and a sense of responsibility in their existence.

Tona Gillen is nurse manager, trauma, at Lady Cilento Children’s Hospital in South Brisbane.

If you or someone you know is struggling with mental illness, contact Lifeline at 13 11 14, beyondblue at 1300 22 4636, Headspace at 1800 650 890 or Kids Helpline on 1800 551 800.

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