I'm writing this in October, which happens to be National Mental Health Awareness month and October 10th is World Mental Health Day. However the real reason I'm writing this post is because I had a few mothers see me in the clinic who made me aware of a recent teenage suicide at a local high school. Many of you may be aware of the cluster of teen suicides at Gunn High School in Palo Alto.
Palo Alto is one of the most affluent cities in the country, yet their teen suicide rates are 4 times the national average.
Every suicide is different and I want to say from the beginning that I have no details on the circumstances of this recent suicide and nothing I write in this post implies any assumptions about why I think such a tragic death occurred. However, as a result of me doing podcasts and lectures on this topic, many of them accompanied by my pediatrician wife, I do get a fair number of messages from teenagers who are clearly struggling and suffering and their parents have absolutely no idea of what their “good intentions” are doing to them.
In this post I want to highlight what I think are some of the key issues based on direct feedback from teenagers, discussions with mental health experts, and also open discussions with adult patients who are struggling with their own mental health, and relate some of those root causes to their experiences early in life.
I want to be clear that I'm not covering inner city or overt trauma-related suicides in this post. These include cases of severe mental health issues that stem from adverse socioeconomic stress, sexual/physical abuse, drug abuse, etc. I have very limited experience in this area and would defer to others who are in the trenches dealing with these issues on a daily basis. My deepest respect for front line workers who do this important work.
This post is more about what I call affluent teen suicide. Affluent doesn't necessarily mean rich, although some of the families I've interacted with are quite wealthy, but simply families who have more than sufficient access to resources (food, housing, health care, high level education, etc.).
Affluent teen suicide and mental health issues are the most difficult to detect because they represent emotional suffering that is camouflaged by status and countless opportunities, something lacking in the inner cities.
Parents, neighbors, friends, and teachers are usually completely oblivious to the burden these teenagers are facing, so when the suicide occurs, it comes as a complete shock to the community.
At the end of this post are some recent interviews I've done on this topic to help open up the conversation with others about this important topic, in addition to some links to resources and tools to help manage mental health for adults and teens.
Some Potential Causes
CHILDREN ARE AN EXTENSION OF OUR EGO
We may hate to admit this, but our children are an extension of our ego. Even the most modest individuals can go on and on about the achievements of their children. I'm not saying this is bad, but it is important to acknowledge that if we brag to our friends when your kids accomplish great feats, we send a message to our children that their value is proportional to the weight of their achievements.
It is really important for us to make children feel valuable and loved, independent of what they accomplish. My brother and I had an incredibly accomplished father. An MD, PhD who was fluent in Sanskrit, wrote beautiful poetry, and was the life of every party. He wanted my brother to be a doctor and really wanted me to specialize in a field like cardiology.
Despite these expectations which neither of us met, he was incredibly loving along the way and once he realized we weren't going to hit his preset bar, he accepted it and expressed incredible amounts of pride at what we did accomplish. Even if I never went into medicine and chose a job even further below the bar he set, I know he would still express tremendous pride at whatever path I chose because that was the type of father he was.
As a result of the above experience, we do gently nudge our boys to explore different fields to find their genuine area of interest, but we have never told them…”you should be a doctor, an entrepreneur, etc.” If they make decisions that may not meet our expectations, we discuss their reasoning, reset our expectations and fully embrace the decisions they make.
WE COMPENSATE FOR OUR OWN INSECURITIES BY PILING THEM ON OUR CHILDREN
If you are a parent of teenagers, you will find yourself reflecting consciously and subconsciously on your own experiences as a teenager. Perhaps you were not very athletic, but you saw how the athletic kids were top of the food chain and got all of the attention while you were barely noticed. Wouldn't it be great if your child could be a star athlete so they could benefit from extra attention and you could live somewhat vicariously through their success?
Maybe you were shy and introverted as a teenager, but you noticed how the outgoing kids had more friends and often took up leadership positions in school. Wouldn't it be great if your own child could be extroverted and popular and maybe even be class president even if he/she is not naturally an extrovert? Wouldn't that make up for some of your own childhood experiences?
I remember talking to a mother who left her job as a tech executive to focus on raising her kids. She admitted to me that she felt insecure around working mothers who in subtle or not so subtle ways made her feel inadequate. She openly admitted that raising her children and getting them to the best colleges became almost like a work project and she might have overcompensated because of her insecurities about no longer being employed. This is where I got the title for one of our parenting talks: “Is Your Child a Start-Up?”
I think you get the picture here. I'm not immune to this either, so I constantly have to reflect as a parent whether what I'm recommending to my kids is something that's truly good for them, or is it fulfilling some unfulfilled need in me or some subtle insecurity that I had at their age.
WE ARE INNATELY COMPETITIVE…SOME MORE THAN OTHERS
Many of us learned from birth to be intensely competitive. Survival of the fittest may have been instilled from living in an overcrowded city where you had to fight for everything to get ahead. A school system where your ranking was attached to your name….”Hi I'm Taj Bengal and I was ranked 25th in a school of 25,000 students.”
We then immigrate to the US and shower our children with all the opportunities we never had growing up, but somehow we expect them to be as competitive as we were when we were fighting in an environment with extremely limited resources. When our children don't express natural competitiveness, we try to push them as hard as we can.
We tell them you have to be the best. That if they don't work harder, they will be out on the streets and trampled by their more driven peers. Even worse, we compare them to their own peers or their siblings, by either directly telling them “why can't you be more like your brother, sister, or friend,” or in subtle ways by bragging more about one child than another.
I would say this constant comparative behavior is one of the most common themes I've heard teens and adults talk about that inflicted emotional damage, insecurity and low feelings of self-worth.
On top of that now, social media is a constant reminder of how teens might feel less popular and less valued. One teenager told me that his parents made him feel worthless at home by constantly comparing him to his sister who is at Stanford, and his peers make him feel worthless at school due to social media and them constantly talking about all of their achievements.
WE EQUATE BUSYNESS WITH PRODUCTIVITY AND FUTURE SUCCESS
We cannot sit still and we don't let our children do the same. Many of our children need open space and free time to allow their brains to rest and recuperate from all of the academic and social stimulation they receive on a daily basis. If we pile on the AP classes and extracurricular activities we rob them of that precious time and we push their bedtimes so late that they can barely function.
Ignore your peers who love to list off the 20 different activities their kids are involved in, making you feel like an inadequate parent and your child like a lazy, unproductive member of society with no hope for the future. My wife and I constantly see the health effects of overscheduled children, like obesity, early onset prediabetes or type 2 diabetes, fatty liver, PCOS (Polycystic Ovarian Syndrome) which is becoming an epidemic in girls, in addition to chronic stress and emotional disorders. Plug your ears and focus on the unique needs of your own child rather than trying to keep up with someone else's.
WE DO NOT TEACH CHILDREN THE ART OF SELF-CARE
If there is one area we as parents put most of our time into with our boys, it's the importance of self-care. Most of the adults I see in my clinic have no idea how to take care of their mind and body. They are obsessed with productivity and outperforming their peers/competitors in the pursuit of material goals to the point that they are damaging themselves in ways they are unaware of.
There are some days our sons come back from school and it's clear they are exhausted and need time to tune out. They might have the impulse to hit their books right away if they have an approaching deadline or an exam, but we encourage them to go outside and shoot baskets, play their keyboard or just “veg” in their room.
The one academic skill we do work on continuously with them is time management and organization, but the purpose isn't so they can pile on more extracurriculars. The goal is so they can finish their work in a timely fashion so they can get to bed earlier and have more time for physical activity, socialization, and hobbies they do enjoy like music.
Our boys also see my wife and I constantly engaging in self-care activities. Getting to bed early on most nights, working out, attending yoga classes together, preparing healthy meals, practicing gratitude and mindfulness, connecting with friends separately and as families, etc.
CULTURE AND COMMUNICATION GAP
Many of the teens who reach out to me and a few who are my patients, are the children of immigrant parents. They tell me middle school and especially high school is when they really start feeling a huge gap with their parents. Their Western friends tend to have a tremendous amount of freedom, while they are supervised day and night and restricted from participating in various activities.
We are hearing about more and more teens, including those of Asian and Indian background, who are turning to alcohol and drugs to insulate themselves from the restrictions their parents put on them. This happens either in high school or later in college where teens feel liberated from the shackles of oppressive parenting and engage in compensatory reckless behaviors.
For others, there is no culture gap, but more of a personality gap or a gap in expectations around the purpose of high school. Parents may be highly academic and perceive high school as almost exclusively a platform to launch their kids into a coveted institute of higher education, while the teen looks at it as being a time for exploration, socialization, and having fun, in addition to learning a few things along the way.
Finding middle ground between the academic and socialization spectrum can be a challenge, but forcing a social and extroverted child to become an introverted academic who just focuses on school can have immediate and downstream adverse consequences (or vice versa). A process of compromise rather than top-down parenting is the only way to find this illusive middle ground. We have frequent family discussions in a “safe” environment where we withhold any judgment or criticism so we can hear what our sons are feeling so they don't suppress their innate desires.
If teens don't feel comfortable discussing their stressors with their own family, they will emotionally suppress and ruminate.
Rumination itself is a powerful precursor to chronic mental health conditions like anxiety and depression and if you haven't read it, please read my detailed post on rumination here. It continues to be a post I get so much positive feedback on.
MODEL THE BEHAVIORS YOU EXPECT FROM YOUR CHILDREN
If we as parents don't take care of our physical and mental health on a daily basis, our children are unlikely to do the same. It is incredible how as I get older, I start subconsciously engaging in certain behaviors that are similar to my parents. It's almost as if I had been “programmed” with some software which is now being activated decades later.
My late father practiced daily meditation and tried to push me to do that in high school and I was not interested at all. He gave me various spiritual books to read and he would play these teachings on cassette tapes, while he narrated alongside on long drives which to me felt like torture at that time. He was literally teaching me the art of mindfulness long before mindfulness became hip, mainstream, and commercialized.
Now here I am decades later, meditating regularly and literally reading the very books my father recommended on my kindle. My mother also was very regular with exercise, even though she was busy running her own school and managing my father's medical practice. I remember her driving to the gym, joining exercise classes, and always making time to serve us a salad with healthy meals in the midst of her busy schedule.
My parents instilled the art of self-care in both my brother and I from an early age. My father was incredibly busy, at one time being the only pulmonary and critical care doctor in Bakersfield, rounding on multiple hospitals and taking night call several times a week. In the midst of that chaos, he made time for art, music, social connection, physical activity mostly in the form of gardening and golf, and daily mindfulness practices.
They both modeled habits and behaviors that exhibited the art of self-care in the midst of a very busy professional and family life, which are lessons I've brought into my own life and my life's work.
BOYS VS GIRLS
Traditionally the male suicide rate has been higher than females, but the gap is starting to close as rates in females are increasing at an alarming pace. This Time magazine article reports that:
“Starting in 2007, suicide rates for girls ages 10 to 14 began increasing annually by about 13%, compared to about 7% for boys, according to the new study. For teens ages 15 to 19, rates among girls and boys increased by about 8% and 3.5%”
My conversations with parents and experts points to social media being a major cause for this. Girls tend to spend more time on social media platforms, and thus have greater exposure to the toxic emotional effects of social comparison pressure. I have also noticed here in Silicon Valley that the average teenage girl is considerably more driven and motivated than the average boy. They tend to take more AP classes, join more clubs and extracurricular activities, and as a result are more overscheduled.
Girls are also more conscientious and detail-oriented with school work, so will typically spend more hours than the average boy on similar tasks. These are generalizations that obviously don't apply to all cases.
I haven't seen studies on this, but many parents and students I've talked to report that girls tend to go to bed much later which is a byproduct of being more overscheduled. What has been noted is that teenage girls are more negatively impacted by sleep deprivation (fatigue, daytime sleepiness, etc.) than boys as noted here
Teenage boys are often more susceptible to social isolation, loneliness and the ill effects of emotional suppression since they have more difficulty openly discussing complex emotions and feelings. Many of us adult men are guilty of the same. As parents of teenage boys, my wife and I often engage in all types of creative tactics to get them to open up about challenges they are facing. Some days we get spontaneous outpourings and other days it's like pulling water out of a rock, but we are committed to the practice because emotional internalization can be a major predictor for mental health issues.
Again, these are some sex-specific trends and generalizations, but there are plenty of teenage girls for example who are emotional suppressors because they fear disapproval from parents or experience a huge cultural gap in values. Madeline Levine, a highly experienced practicing psychologist and author of The Price of Privilege, notes the following in this article:
What disturbs her most is that the teenagers she sees no longer rebel. A decade ago, she used to referee family fights in her office, she told me, where the teens would tell their parents, “This is bad for me! I’m not doing this.” Now, she reports, the teenagers have no sense of agency. They still complain bitterly about all the same things, but they feel they have no choice.
I've talked to parents of adults now who report that it was often their most rebellious child who is now the most emotionally resilient and living the life they envisioned, while the more silent, compliant ones are often emotionally struggling and questioning the career path they chose or were forced to choose.
Rebels can be difficult to tame and in many cases shouldn't be tamed, but instead their energy and defiance can be rechanneled into other pursuits which may not necessarily follow the path you envisioned. Rebelling against a rebel only creates more conflict and further energizes rebels to take on more defiant and in many cases risky behaviors.
If you have a child on the other hand who is silent and compliant, please be aware that he or she may be emotionally suppressing. Do everything you can to get that child to express their emotions and if they rebel in any way, praise them for having a sense of agency. If your child just can't express to you as a parent, be sure they are regularly connecting with other friends, relatives (close cousins, aunts, uncles, etc.) so they have some outlets for expression.
Remember, children who suppress early on because they fear parental disapproval or feel disconnected from them become future adult spouses, partners, workers, etc. who suppress and suffer without having the confidence or the voice to speak up for what they want or believe in.
CLOSING THOUGHTS AND RESOURCES
Parenting is a sensitive topic. No one wants to feel they are doing or have done damage to their own child's emotional health. Despite me feeling so passionate about this topic, I have come to accept that the act of parenting is intrinsically imperfect and despite my best intentions and efforts, there will be some wounds and injuries I will pass onto my own children. I often find myself reflecting on certain words I might have said to one or both of my sons on the drive to work, and find myself apologizing or explaining to my boys later.
Self-reflecting as a parent is absolutely essential to minimizing the damage we do to our children. If you have a simple narrative that I'll just drive and motivate my child, there will be sacrifices and wounds along the way, but once they achieve academic and professional success their wounds will magically heal and they will thank me later….guess again.
I discuss in my rumination post that many adults who were driven down this path resent the fact that they missed out on a normal childhood, and that their professional status and wealth have not healed the wounds of sacrificing their mind and body to achieve status.
Teenage suicide is the worst possible outcome of many of the behaviors I've discussed in this post. It's a really low bar if all high schools are doing is trying to prevent suicide or lower suicide rates. A few high schools and middle schools are integrating mindfulness programs into their curriculum. Visitacion Middle School is a remarkable example (read here) of how mindfulness transformed a student body regularly exposed to drugs and gang violence, including students finding 3 dead bodies dumped onto their schoolyard.
Despite the proven benefits of mindfulness, most schools are still resistant to introducing it into their curriculums. I hope that will change some day and it becomes a part of PE or a subject on its own. I think parents need regular education on how what they often perceive as “productive parenting” might be damaging to their kids. We need to continue more open discussions about this topic and I've done some recent interviews/podcasts focused on mental health in youth which are listed below.
If you would like my wife and I to come out to your school, workplace, community center, etc. to talk about this important topic, reach out to us here. We feel passionately about the mental health crisis in our youth and will do what we can to attend.
Peter Attia Drive Podcast: Although most of this interview focuses on insulin resistance root causes and impacts on high risk cultures, starting at 1:35, we discuss high stress parenting and some recommended interventions.
ZDoggMD Interview: This interview with Dr.Zubin Damania (aka “ZDogg”) is a more lighthearted, but thoughtful discussion on stress and its impact on adults, children and practical recommendations.
Stress Tools and Resource Page: This is where I'm posting my favorite content, Apps, short video tutorials and more to help you and your family manage stress.