Behavioral and Psychological Adjustment

With all of these brain changes and novel experiences, we expect to see adolescents undergo significant behavioral and psychological adjustments. Adolescents are facing strong emotions, changing peer relationships, more independence, expectations to be more adult-like, and a desire to take risks, all while lacking a fully mature brain or the life experience to navigate these situations. It is inevitable that some mistakes will occur along the way, as well as a great deal of learning. We will examine some typical adjustment issues encountered by adolescents: driving, aggression, drug use, anxiety, depression, and self-violence.

In a 2017 National Children’s Health poll, parents report that one of the top concerns is teen driving (C.S. Mott Children’s Hospital, 2017). Driving gives teens a sense of freedom and independence from their parents and can free up time for parents as they are not shuttling teens to and from school, activities, or work. However, with higher levels of risk-taking behavior and lower levels of experience, parents are concerned with their teen’s safety on the road.

The National Highway Traffic Safety Administration (NHTSA) reports that in 2014 young drivers (15 to 20 year-olds) accounted for 5.5% (11.7 million) of the total number of drivers (214 million) in the US (National Center for Statistics and Analysis (NCSA), 2016). However, almost 9% of all drivers involved in fatal crashes that year were young drivers (NCSA, 2016), and according to the National Center for Health Statistics (2014), motor vehicle accidents are the leading cause of death for 15 to 20 year-olds. “In all motorized jurisdictions around the world, young, inexperienced drivers have much higher crash rates than older, more experienced drivers” (NCSA, 2016, p. 1). The rate of fatal crashes is higher for young males than for young females, although, for both genders, the rate was highest for the 15-20 years-old age group. For young males, the rate for fatal crashes was approximately 46 per 100,000 drivers, compared to 20 per 100,000 drivers for young females. The NHTSA (NCSA, 2016) reported that of the young drivers who were killed and who had alcohol in their system, 81% had a blood alcohol count past what was considered the legal limit. Fatal crashes involving alcohol use were higher among young men than young women. The NHTSA also found that teens were less likely to use seat belt restraints if they were driving under the influence of alcohol, and that restraint use decreased as the level of alcohol intoxication increased.

In an AAA study of non-fatal, but moderate to severe motor vehicle accidents in 2014, more than half involved young male drivers 16 to 19 years of age (Carney, McGehee, Harland, Weiss, & Raby, 2015). In 36% of rear-end collisions, teen drivers were following cars too closely to be able to stop in time, and in single-vehicle accidents, driving too fast for weather and road conditions was a factor in 79% of crashes involving teens. Distraction was also a factor in nearly 60% of the accidents involving teen drivers. Fellow passengers, often also teenagers (84% of the time), and cell phones were the top two sources of distraction, respectively. This data suggested that having another teenager in the car increased the risk of an accident by 44% (Carney et al., 2015). According to the NHTSA, 10% of drivers aged 15 to 19 years involved in fatal crashes were reported to be distracted at the time of the crash, the highest figure for any age group (NCSA, 2016). Distraction, coupled with inexperience, has been found to greatly increase the risk of an accident (Klauer et al., 2014).

The NHTSA did find that the number of accidents has been on a decline since 2005. They attribute this to greater driver training, more social awareness to the challenges of driving for teenagers, and to changes in laws restricting the drinking age. The NHTSA estimates that the raising of the legal drinking age to 21 in all 50 states and the District of Columbia has saved 30,323 lives since 1975.

Several major theories of the development of antisocial behavior treat adolescence as an important period. Patterson’s (1982) ‘early versus late starter model’ of the development of aggressive and antisocial behavior distinguishes youths whose antisocial behavior begins during childhood (early starters) versus adolescence (late starters). According to the theory, early starters are at greater risk for long-term antisocial behavior that extends into adulthood than are late starters. Late starters who become antisocial during adolescence are theorized to experience poor parental monitoring and supervision, aspects of parenting that become more salient during adolescence. Poor monitoring and lack of supervision contribute to increasing involvement with deviant peers, which, in turn, promotes adolescents’ own antisocial behavior. Late starters desist from antisocial behavior when changes in the environment make other options more appealing.

Similarly, Moffitt’s (1993) ‘life-course-persistent versus adolescent-limited model’ distinguishes between antisocial behavior that begins in childhood versus adolescence. Moffitt regards adolescent-limited antisocial behavior as resulting from a “maturity gap” between adolescents’ dependence on and control by adults and their desire to demonstrate their freedom from adult constraint. However, as they continue to develop, and legitimate adult roles and privileges become available to them, there are fewer incentives to engage in antisocial behavior, leading to discontinuation of these antisocial behaviors.

Children and adolescents sometimes argue, are aggressive, or act angry or defiant around adults. A behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child’s age at the time, persist over time, or are severe.  Because disruptive behavior disorders involve acting out and showing unwanted behavior towards others they are often called externalizing disorders.

When children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with Oppositional Defiant Disorder (ODD). ODD usually starts before 8 years of age, but no later than by about 12 years of age. Children with ODD are more likely to act oppositional or defiant around people they know well, such as family members, a regular care provider, or a teacher. Children with ODD show these behaviors more often than other children their age.

Examples of ODD behaviors include

• Often being angry or losing one’s temper
• Often arguing with adults or refusing to comply with adults’ rules or requests
• Often resentful or spiteful
• Deliberately annoying others or becoming annoyed with others
• Often blaming other people for one’s own mistakes or misbehavior

Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers.

Examples of CD behaviors include

• Breaking serious rules, such as running away, staying out at night when told not to, or skipping school
• Being aggressive in a way that causes harm, such as  bullying, fighting, or being cruel to animals
• Lying, stealing, or damaging other people’s property on purpose

Treatment for Disruptive Behavior Disorders

Starting treatment early is important. Treatment is most effective if it fits the needs of the specific child and family. The first step to treatment is to talk with a healthcare provider. A comprehensive evaluation by a mental health professional may be needed to get the right diagnosis. Some of the signs of behavior problems, such as not following rules in school, could be related to learning problems that may need additional intervention. For younger children, the treatment with the strongest evidence is behavior therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child’s behavior. For school-age children and teens, an often-used effective treatment is a combination of training and therapy that includes the child, the family, and the school.

Being healthy is important for all children and can be especially important for children with behavior or conduct problems. In addition to behavioral therapy and medication, practicing certain healthy lifestyle behaviors may reduce challenging and disruptive behaviors your child might experience. Here are some healthy behaviors that may help:

• Engaging in regular physical activity, including aerobic and vigorous exercise
• Eating a healthful diet centered on fruits, vegetables, whole grains, legumes (for example, beans, peas, and lentils), lean protein sources, and nuts and seeds
• Getting the recommended amount of sleep each night based on age
• Strengthening relationships with family members

It is not known exactly why some children develop disruptive behavior disorders. Many factors may play a role, including biological and social factors. It is known that children are at greater risk when they are exposed to other types of violence and criminal behavior, when they experience maltreatment or harsh or inconsistent parenting, or when their parents have mental health conditions like substance use disorders, depression, or attention-deficit/hyperactivity disorder (ADHD). The quality of early childhood care also can impact whether a child develops behavior problems.

Although these factors appear to increase the risk for disruptive behavior disorders, there are ways to decrease the chance that children experience them. Learn about public health approaches to prevent these risks:

• Positive parenting strategies for young children
• Child maltreatment prevention
• Youth violence prevention
• Bullying prevention
• Mental health in adults
• Finding high-quality child care

Substance Use

Adolescence is a time of rapid change and maturation. It is also a time of experimentation—with new hairstyles, clothes, attitudes, and behaviors. Some of these experiments are harmless. Others, such as using alcohol or other drugs, can have long-lasting harmful consequences. There are several reasons why it is important to identify and treat adolescent substance use.

Video 5.7.1. Adolescent Substance Use, Addiction, and Treatment discusses the prevalence of substance use and teens’ susceptibility to abuse.

Substance use is common among adolescents. Alcohol, marijuana, and tobacco are the substances most commonly used by youth (Johnston et al., 2014), and alcohol often is the first substance to be used (Johnston et al., 2010). The percentage of young people who have used alcohol increases with age. By eighth grade, 28% of students have tried alcohol, and 12% have been drunk at least once; by twelfth grade, 68% of students have tried alcohol, and more than half have been drunk at least once (Johnston et al., 2014). In 2012, 45% of students in grades 9 through 12 reported ever having used marijuana, and 24% reported having used marijuana in the preceding 30 days. Between 2008 and 2012, the proportion of teens who used marijuana daily increased from 5% to 8% (PDFA, 2013). According to a survey published in 2014, 41% of students in grades 9 through 12 reported having tried cigarettes. Nearly one-quarter said they had used tobacco in some form in the past 30 days (Kann et al., 2014). A substantial percentage of adolescents, including 15% of 12th graders, report misuse (i.e., use without a prescription) of prescription medication, especially stimulants and pain medications (Johnston et al., 2014).

Why do Adolescents use Drugs?

Risk Factors for Substance Abuse

Substance use has its own risks and also is associated with other risky behaviors. Adolescent substance use poses both short-term and long-term risks. In the short term, drinking, for example, can result in unintentional injuries and death, suicidal behavior, motor vehicle crashes, intimate partner violence, and academic and social problems (Brown et al., 2008; Cole et al., 2011; Weitzman  Nelson, 2004). These outcomes occur because excess alcohol consumption leads to decreased cognitive abilities, inaccurate perception of risk, and impaired bodily control. These effects, in combination with the fact that compared to adults, adolescents tend to be more physically active when under the influence of alcohol, put adolescents at greater risk of harm. For example, at blood alcohol concentrations greater than zero, adolescents are at increased risk of being fatally injured or involved in fatal crashes in single, two, and more vehicles compared with sober male drivers ages 21-34 (Voas et al., 2012). Marijuana use is associated with diminished lifetime achievement (Meier et al., 2012). Tobacco use results in poor health in the short and long term, and it can be a gateway to the use of other drugs (Sims, 2009). The risk of substance use is compounded because it is associated with other risky behaviors, such as unplanned, unprotected sex, which can result in pregnancy (Brown, 2008; Levy et al., 2009; Tapert et al., 2001). Adolescents who misuse prescription opioids are at high risk of transitioning to injection drugs and overdosing (McCabe et al., 2012). Any level of substance use can be harmful to adolescents—no amount is safe.

Adolescence is a particularly vulnerable period for brain development and maturation. Adolescence is a long period of intense neurodevelopmental growth and maturation. As a result, the adolescent brain is particularly vulnerable to the toxic effects of alcohol and other drugs and to the potential for addiction. Persistent marijuana use in adolescence, for example, is associated with neuropsychological impairments across a range of functional domains (Meier et al., 2012). Moreover, stopping use does not fully restore neuropsychological functioning, suggesting particular harm to the adolescent brain.

Use tends to increase over time. National estimates of the prevalence of drinking indicate that older youth drink more and drink more heavily than do younger youth (SAMHSA, 2010). This fact makes it all the more important for pediatricians to start early with screening and brief intervention so as to prevent or delay alcohol use for as long as possible.

Substance use in adolescence is associated with harm in adulthood. The earlier an adolescent begins using substances, the greater are his or her chances of continuing to use and of developing substance use problems later in life. For example, compared to people who do not start drinking until they are young adults, people who begin to drink before age 15 are 5 times as likely to develop alcohol dependence or abuse (Chambers et al., 2003; Grant & Dawson, 1997; Hingson & Zha, 2009). Compared with adolescents who first try marijuana at age 18, those who begin using at 14 or younger are 6 times as likely to meet the criteria for illicit drug dependence or abuse later in life (SAMHSA, 2010). More than 80% of adults who smoke tobacco began before they were 18 (Sims, 2009).

Adolescents who report weekly or more frequent substance use are likely to have a severe substance use disorder. In some cases, by the time an adolescent has reached this point, parents are already aware of the drug use, although they may underestimate the seriousness of the problem. Adolescents with serious substance-use disorders require more-intensive care as soon as possible, including a comprehensive evaluation by a substance use specialist, assessment for co-occurring mental health disorders, and referral to treatment.

Prevention of Substance Abuse

Prevention of substance abuse during adolescence should be a multipronged and long term approach that involves the education of youth, families, and the community. Prevention education should begin as early as preschool and be specific to the target population (i.e., ethnicity, gender), establishing a culture against substance abuse. Effective programs for teens involve interactive education, such as peer discussions and role-playing, and focus on risk-reduction and fostering good decision-making skills.

Anxiety, Depression, And Self-Directed Violent Behavior

Developmental models of anxiety and depression treat adolescence as an important period, especially in terms of the emergence of differences and prevalence rates that persist through adulthood (Rudolph, 2009). Although the rates vary across specific anxiety and depression diagnoses, rates for some disorders are markedly higher in adolescence than in childhood or adulthood. For example, prevalence rates for anxiety disorders are about 19% in adults, but 32% in adolescents (NIMH, 2017). Adolescents are also more likely to experience depression (13%) compared to adults (7%) (NIMH, 2019). Rates of self-directed violence are also higher among teens (17%), followed by college students (15%), adults (5%), and children having the lowest rates (1.3%) (APA, 2015).

Occasional anxiety is an expected part of life. You might feel anxious when faced with a problem, before taking a test, or when making an important decision. But anxiety disorders involve more than temporary worry or fear. For a person with an anxiety disorder, the anxiety does not go away and can get worse over time. The symptoms can interfere with daily activities such as job performance, school work, and relationships.

The wide variety of anxiety disorders differ by the objects or situations that induce them but share features of excessive anxiety or worry about a variety of things. Fear and anxiety can cause significant problems in areas of their life, such as social interactions, school, and work. Anxiety also manifests in physiological and psychological responses, such as feeling restless, fatigued, difficulty concentrating, irritability, muscle tension, and sleep problems.

Video 5.7.2. Fight, Flight, Freeze–Anxiety Explained for Teens identifies symptoms and responses to the experience of anxiety.

The following data pertains to the compiling of statistics for any anxiety disorder including, panic disorder, generalized anxiety disorder, agoraphobia, specific phobia, social anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and separation anxiety disorder. An estimated 31.9% of adolescents have an anxiety disorder. Of adolescents with any anxiety disorder, an estimated 8.3% had severe impairment. The prevalence of any anxiety disorder among adolescents was higher for females (38.0%) than for males (26.1%). The prevalence of any anxiety disorder was similar across age groups.

Figure 5.7.1. Prevalence of any anxiety disorder among adolescents (2001-2004). Data from the National Comorbidity Survey Adolescent Supplement (NCS-A).

Anxiety disorders are generally treated with psychotherapy, medication, or both. Psychotherapy or “talk therapy” can help people with anxiety disorders. To be effective, psychotherapy must be directed at the person’s specific anxieties and tailored to his or her needs. Medication does not cure anxiety disorders but can help relieve symptoms. Medication for anxiety is prescribed by doctors, such as a psychiatrist or primary care provider. The most common classes of medications used to combat anxiety disorders are anti-anxiety drugs (such as benzodiazepines), antidepressants, and beta-blockers. Some people with anxiety disorders might benefit from joining a self-help or support group and sharing their problems and achievements with others. Talking with a trusted friend or member of the clergy can also provide support, but it is not necessarily a sufficient alternative to care from a doctor or other health professional. Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. Research suggests that aerobic exercise can help some people manage their anxiety; however, exercise should not take the place of standard care, and more research is needed.

Depression

Sadness is something we all experience. It is a normal reaction to a loss or a setback, but it usually passes with a little time. Depression is different. Depression (major depressive disorder) is a medical illness that can interfere with a person’s ability to handle daily activities, such as sleeping, eating, or managing responsibilities. Depression is common, but that doesn’t mean it isn’t serious. Well-meaning friends or family members may try to tell someone with depression to “snap out of it,” “just be positive,” but depression is not a sign of weakness or a character flaw. Many people with depression need treatment to get better.

Depression is characterized by feelings of deep sadness and hopelessness that disrupts all normal, regular activities. However, teens may not identify feelings of sadness and instead report feeling more irritable and angry. Often, when depressed, people feel worthless and excessively guilty. They withdraw from activities that they normally enjoy and spend more time alone. Changes in appetite and sleeping habits (more or less than normal) are common. People with depression may experience fatigue, having low energy, and also feel restless. Physical aches and pains with no associated reason may occur, like muscle, stomach, or headaches. Cognitive functioning, such as attention, concentrating, memory, and decision-making, may be impaired. And while not necessary for a depression diagnosis, thoughts of death or suicide may be an issue.

Teens with depression may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. It can be difficult to determine whether an adolescent is depressed or just “being a teenager.” Consider how long the symptoms have been present, how severe they are, and how different the teen is acting from his or her usual self. Teens with depression may also have other disorders such as anxiety, eating disorders, or substance abuse.

Video 5.7.4. Adolescent Depression provides information on identifying symptoms of depression in teens and how to respond to concerns.

The figure below shows the prevalence of major depressive episodes among U.S. adolescents in 2017. An estimated 3.2 million adolescents aged 12 to 17 in the United States had at least one major depressive episode. This number represented 13.3% of the U.S. population aged 12 to 17. The prevalence of major depressive episodes was higher among adolescent females (20.0%) compared to males (6.8%). The prevalence of major depressive episode was highest among adolescents reporting two or more races (16.9%).

Figure 5.7.2. Prevalence of major depressive episode among US adolescents (2017). Data from SAMHSA.

Causes of depression include many factors such as genetics and early childhood experiences that predate adolescence, but puberty may push vulnerable children, especially girls, into despair. During puberty, the rate of major depression more than doubles to an estimated 13%, affecting about one in five girls and one in ten boys. The gender difference occurs for many reasons, biological and cultural (Uddin et al., 2010).

Developmental models focus on interpersonal contexts in both childhood and adolescence that foster depression and anxiety (e.g., Rudolph, 2009). Family adversity, such as abuse and parental psychopathology during childhood, sets the stage for social and behavioral problems during adolescence. Adolescents with such problems generate stress in their relationships (e.g., by resolving conflict poorly and excessively seeking reassurance) and select into more maladaptive social contexts (e.g., “misery loves company” scenarios in which depressed youths select other depressed youths as friends and then frequently co-ruminate as they discuss their problems, exacerbating negative affect and stress). These processes are intensified for girls compared with boys because girls have more relationship-oriented goals related to intimacy and social approval, leaving them more vulnerable to disruption in these relationships. Anxiety and depression then exacerbate problems in social relationships, which in turn contribute to the stability of anxiety and depression over time.

Depression, even in the most severe cases, can be treated. The earlier that treatment can begin, the more effective it is. Depression is usually treated with medications, psychotherapy, or a combination of the two. An estimated 19.6% received care by a mental health professional alone, and another 17.9% received combined care by a mental health professional and medication treatment. Treatment with medication alone was least common (2.4%). Approximately 60.1% of adolescents with major depressive episode did not receive treatment.

Antidepressants are medicines that treat depression. They may help improve the way the brain uses certain chemicals that control mood or stress. Trying several different antidepressant medicines may be necessary before finding the one that improves symptoms and has manageable side effects. Antidepressants take time – usually 2 to 4 weeks – to work, and often, symptoms such as sleep, appetite, and concentration problems improve before mood lifts, so it is important to give medication a chance before reaching a conclusion about its effectiveness.

Several types of psychotherapy (also called “talk therapy” or, in a less specific form, counseling) can help people with depression. Examples of evidence-based approaches specific to the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy. CBT can help an individual with depression change negative thinking and interpret the environment and interactions in a positive, realistic way. IPT is designed to help an individual understand and work through troubled relationships or major issues that may cause depression or make it worse.

Teenagers usually rely on parents, teachers, or other caregivers to recognize their suffering and get them the treatment they need. Many teens don’t know where to go for mental health treatment or believe that treatment won’t help. Others don’t get help because they think depression symptoms may be just part of the typical stress of school or being a teen. Some teens worry about what other people will think if they seek mental health care.

Self-directed violence (SDV) encompasses a range of violent behaviors, including acts of fatal and nonfatal suicidal behavior, and non-suicidal self-injury (i.e., behaviors where the intention is not to kill oneself, as in self-mutilation). Recognizing signs of self-directed violence and interventions to help people engaging in this behavior can save a life and help get them treatment.

Non-suicidal self-injury (NSSI), also referred to as self-harm, self-mutilation, or cutting, is a “deliberate, self-inflicted injury without suicidal intent or for socially sanction purposes (such as tattoos or piercings).  NSSI is most often associated with ‘cutting,’ but means of self-harm often also include scratching, punching, punching oneself, banging objects with the intention of injury, biting, tearing of the skin, or burning. The location of the injury may also be an indicator of the severity of the psychological disturbance. Injuries to the face, eye, jugular, or genitals may be more concerning.  Although not a suicide attempt, NSSI is associated with suicide and can result in an accidental fatality (Whitlock, 2010).

The average age of the first NSSI is between 11 and 15 years old. The prevalence of at least one incident NSSI is estimated to be 12-37% in high school populations and 12 to 20% in late adulthood and early adulthood cohorts, with 6-7% of adolescents reported repetitive NSSI in the last year. Of those reporting repetitive incidents, 40% reported stopping the behavior within a year of starting, and the vast majority (79.8%) stopped within five years (Whitlock, 2010).

While we might presume that NSSI behavior is associated with mental illness, like depression and anxiety, that is not always the case. Forty-four percent of people that engage in common NSSI do not have any co-morbidity. This type of NSSI includes self-injurious behaviors that are (1) compulsive or ritualistic (like trichotillomania), (2) episodic or occasional, with no identification as a person that self-harms, (3) repetitive with a self-harming identity.  Common NSSI can be mild, moderate, or severe, depending on the severity of the injuries (Whitlock, 2010).

The reasons for NSSI are psychological, social, and biological and often step from a history of childhood adversity, comorbid psychological disorders, and emotional dysregulation. The psychological reasons are the most common and involve reducing psychological pain, expressing distress, and distracting oneself from other negative stimuli. Fewer teens report social reasons for NSSI, such as seeking attention or copying peers. Social factors, like peer reinforcement of the behavior, can increase the likelihood of repetitive NSSI. Those reporting “getting a rush” or “feeling normal” from NSSI may have biological reasons for the behavior. These individuals may have chronically low levels of certain neurotransmitters in their brains. The neurochemical response to injury may bring these neurotransmitter levels to a more normal level and help them regulate emotions. This may be the reason that some people are dependent on NSSI (Whitlock, 2010).

The correlation between NSSI and suicide-related behaviors is well known, but the nature of that relationship is rather paradoxical. Moving from NSSI to suicide-related behaviors may appear to be a predictable progression in severity—without intervention, those engaged in NSSI may get worse and eventually become suicidal. However, experts agree that NSSI may actually help alleviate the distress that could lead to suicide-related behavior, at least temporarily. NSSI could be a tool for coping with distress and avoid suicide (Whitlock, 2010).

In 2017, suicide was the second leading cause of death for people aged 10-19. After a stable period from 2000 to 2007, suicide death rates for teens are now increasing.  Distressing thoughts about killing oneself become most common at about age 15 (Berger, 2019) and can lead to a variety of suicide-related behaviors.

Suicide-related behaviors include the following:

• Suicide: Death caused by self-directed injurious behavior with any intent to die.
• Suicide attempt: A non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury.
• Suicidal ideation: Thinking about, considering, or planning for suicide.

Suicide-related behavior is complicated and rarely the result of a single source of trauma or stress. Youth who are at increased risk for suicide-related behavior are dealing with a complex interaction of multiple relationships (peer, family, or romantic), mental health, and school stressors. Often, people who engage in suicide-related behavior experience overwhelming feelings of helplessness and hopelessness. Involvement with bullying behavior is one stressor that may significantly contribute to feelings of helplessness and hopelessness that raise the risk of suicide.

Youth are at higher risk for suicide-related behaviors if they experienced violence, including child abuse, bullying, or sexual violence, and cannot cope with problems in healthy ways and solve problems peacefully. Teens with disabilities, learning differences, sexual/gender identity differences, or cultural differences are often most vulnerable to being bullied. Teens who report frequently bullying others are at high, long-term risk for suicide-related behavior. Youth who report both being bullied and bullying others (sometimes referred to as bully-victims) have the highest rates of negative mental health outcomes, including depression, anxiety, and thinking about suicide.

The behaviors listed below may be signs that someone is thinking about suicide.

• Talking about wanting to kill themselves or making a plan to kill themselves
• Talking about feeling empty, hopeless, or having no reason to live
• Talking about great guilt or shame
• Talking about feeling trapped or feeling that there are no solutions
• Feeling unbearable pain (emotional pain or physical pain)
• Talking about being a burden to others
• Using alcohol or drugs more often
• Acting anxious or agitated
• Withdrawing from family and friends
• Changing eating and/or sleeping habits
• Showing rage or talking about seeking revenge
• Taking great risks that could lead to death, such as driving extremely fast
• Talking or thinking about death often
• Displaying extreme mood swings, suddenly changing from very sad to very calm/happy
• Giving away important possessions
• Saying goodbye to friends and family
• Putting affairs in order, making a will

If these warning signs apply to you or someone you know, get help as soon as possible, particularly if the behavior is new or has increased recently. Call the National Suicide Prevention Lifeline (Lifeline) at 1-800-273-TALK (8255), or text the Crisis Text Line (text HELLO to 741741). Both services are free and available 24 hours a day, seven days a week. The following recommendations are five action steps to help someone in emotional pain:

• ASK: “Are you thinking about killing yourself?” It’s not an easy question, but studies show that asking at-risk individuals if they are suicidal does not increase suicides or suicidal thoughts.
• KEEP THEM SAFE: Reducing a suicidal person’s access to highly lethal items or places is an important part of suicide prevention. While this is not always easy, asking if the at-risk person has a plan and removing or disabling the lethal means can make a difference.
• BE THERE: Listen carefully and learn what the individual is thinking and feeling. Research suggests acknowledging and talking about suicide may reduce rather than increase suicidal thoughts.
• HELP THEM CONNECT: Save the National Suicide Prevention Lifeline’s (1-800-273-TALK (8255)) and the Crisis Text Line’s number (741741) in your phone, so it’s there when you need it. You can also help make a connection with a trusted individual like a family member, friend, spiritual advisor, or mental health professional.
• STAY CONNECTED: Staying in touch after a crisis or after being discharged from care can make a difference. Studies have shown the number of suicide deaths goes down when someone follows up with the at-risk person.

Figure 5.7.3. Five action steps for helping someone in emotional pain.