Erik Loraas, MD
Program Director, Child and Adolescent Psychiatry Fellowship, Psychiatry Residency Spokane
Sacred Heart Children’s Hospital
Medical Director, Providence RISE Program at Providence Holy Family Hospital
Adolescent suicide and suicidal behavior has increased significantly in the past decade and remains the second leading cause of death in adolescents. From 2007 to 2015, the suicide rate in adolescents increased by 31% nationally, from 10.8 to 14.1 per 100,000. 1
Individuals, communities, and large systems have taken steps to address this public health crisis. In “Saving Holden Caulfield: Suicide Prevention in Children and Adolescents,” David A. Brent, MD uses the story of J.D. Salinger’s protagonist, Holden Caulfield, as a metaphor to explore alternative approaches to addressing youth suicide.2 Holden imagines “thousands of little kids” playing in a rye field near a cliff, and he has to “catch everybody if they start to go over the cliff.” The real-world prevention strategies effectively lead children away from the cliff. The strategies tend to be cost effective and target common risk factors. Such interventions include preventing maltreatment of children, addressing adverse childhood experiences, and building safe parent-child relationships. School-based programs, such as The Good Behavior Game; Question, Persuade, and Refer; Signs of Suicide; and Youth Aware of Mental Health have proven to be effective preventative measures.
We can improve access to care when we join children in the rye field. A clear evidence-based strategy is collaborative care in which mental health providers are co-located in a primary care setting and work closely with psychiatrists. Changing the rules of the field inspires us to examine the culture and strategies of care delivery. Zero Suicide is a comprehensive team-based approach gaining traction nationally and is supported by a number of positive studies. Finally, a fence around the cliff represents restricting access to lethal means. Clear examples include removing firearms from home or ensuring safe storage and limiting access to immediately lethal items (medications, cleaning agents, sharps, and ligatures).
As providers who work with children, adolescents, and families we can find ourselves, like Holden, alone in a field of rye desperately trying to catch children. As the above approaches suggest, we will be most successful when we join one another in the field to lead children to safety, create new rules, and at the very least build a fence so all can play safely without the fear of falling.
- Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999-2014. NCHS Data Brief. 2016;241:1-8.
- Brent DA. Master Clinician Review: Saving Holden Caulfield: Suicide Prevention in Children and Adolescents. J Am Acad Child Adolesc Psychiatry. 2019;58(1):25-35.