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Wilfredo Lee, Associated Press
A student walks past signs outside Marjory Stoneman Douglas High School during the one-year anniversary of the school shooting, Thursday, Feb. 14, 2019, in Parkland, Fla. A year ago, 14 students and three staff members were killed when a gunman opened fire at the high school.

SALT LAKE CITY — Following the deaths by suicide of three people with ties to mass school shootings — two student survivors and the father of a child who was killed — families, friends and others are wondering what to watch for and how to help those who might wrestle with post-traumatic challenges.

"It is very important that everyone have a mental health checkup routinely, tragedy or not," said psychologist Mitch Prinstein, director of graduate studies and professor in the Department of Psychology and Neuroscience at the University of North Carolina at Chapel Hill. "We should be thinking about mental health and checking in with one another about symptoms of mental health all the time."

That's especially true now given the "remarkably high prevalence of depression and suicide" among adolescents, he said. Whether they've experienced a tragedy or not, one-fifth "think seriously about suicide within a given 12-month period," he added.

"If this was a physical illness, we would have screening clinics with inoculations on every street corner, but it's mental health," he said, "and I think we sometimes forget we should be screening and intervening for depression and suicide among adolescents all the time."

Suicide is far from unique to adolescents. Jeremy Richman, 49, was the father of Avielle Richman, one of the first-graders murdered at Sandy Hook Elementary School in Newtown, Connecticut, in December 2012. Richman, the cofounder of a nonprofit named for his daughter that used research and community education for violence prevention, was found dead on Monday of apparent suicide in the foundation's building.

Heather Tuttle

The other two believed to have taken their own lives were students who survived last year's massacre at Marjory Stoneman Douglas High School in Parkland, Florida. Sydney Aiello, 19, graduated last year and was attending college, but her mother told reporters she had been diagnosed with post-traumatic stress disorder. The other student, a 16-year-old male, has not been publicly named.

It's not clear what — if any — role the school shootings played in the suicides. Mental health experts caution against making assumptions and emphasize there's never just one cause for a suicide. But they also acknowledge each of these three experienced severe trauma that could have lasting effects.

"People who attempt suicide are often struggling with really extreme levels of emotional distress. They feel trapped, they feel depressed, they feel hopeless. And maybe they feel they are without options for how to solve that and how to feel better," Prinstein said. "They may have limited capacity because of extreme distress to be able to think about their options."

What happens when youths struggle

Adolescence is a particularly vulnerable time of which adults should take note, said Andrew J. Smith, a clinical psychologist at the University of Utah School of Medicine's Department of Psychiatry. School shootings hit teens at a "developmental period that's explosive and fragile at the same time."

Psychologist Joel Dvoskin of the University of Arizona agrees. "It's anxiety-inducing to be a teenager. Your hormones are out of control, schools can be challenging places, and in the aftermath of a trauma, it’s just so much worse. Trying to figure out what’s due to trauma and what's due to normal teenage life in America is both impossible and probably fruitless. You treat what you see and you’re guessing the reason for it," he said.

Most people overcome trauma — terrible events that run a gamut from serious accident to sexual assault, natural disaster, or even a mass shooting. But for some kids, trauma sends the message that "it doesn't matter what I do; unpredictable, dangerous things are going to disrupt my life," Smith said. That can lead to depression, PTSD or both. They often coexist.

" I think we need to become a culture that asks directly about suicide. "
Mitch Prinstein, director of graduate studies at the University of North Carolina at Chapel Hill

Trauma can also damage one's self-image and sense of worthiness, said Kim Metcalfe, retired professor of early childhood education and psychology and author of "Let's Build ExtraOrdinary Youth Together," whose daughter died by suicide. For a human being to believe they deserve "happiness, success and a good life, they must believe they are worthy." Feeling helpless or hopeless "are painful thoughts for any human to harbor for long time periods," she said.

Most people who experience trauma don't generalize it beyond the event itself. But a portion do, telling themselves, "I can't go to school," then "I can't go to the store," and then "I can't go out," said Smith. If someone becomes so frightened they cannot go outside, their world shrinks and becomes unhealthy.

Warning signs a person might be spiraling include mood changes, increased sadness, irritability and loss of interest in activities that had been important or enjoyable, Prinstein said. Even fleeting or seemingly joking comments about death or wishing one's life was ending could indicate danger, while gathering the means to hurt oneself, making a plan or giving away possessions and saying what could be farewells are "signs that need to be taken immediately seriously." Never ignore those as just a plea for attention.

Smith calls warnings, including anger, "vital signs" and said teens might use alcohol and drugs as a coping mechanism.

Experts say you should do something

It isn't always easy to tell how at risk a person is. If danger of suicide seems imminent, Prinstein said to call 911. Most states allow for an emergency hold in a health care facility until an evaluation is completed. "No one wants to call 911 on a loved one, clearly. But the alternative is worse," he said.

Absent what seems like immediate danger, he suggests encouraging someone to use available tools ranging from crisis lines to trained mental health professionals. Some crisis lines use texting, which makes some teens more comfortable.

In all cases, ask what's going on.

"I think we need to become a culture that asks directly about suicide," said Prinstein. Some fear it will "plant" the suggestion, but science suggests that's a bogus worry. Someone may already be considering suicide. If not, the question's not going to prompt it.

Asking if someone feels so sad they've thought about hurting themselves and if they have a plan "is incredibly important," Prinstein said, adding he's done schoolwide screenings for years. "I can tell you personally that a tremendous amount of good can come from asking kids questions directly and then working with parents on what they can do in the presence of an affirmative response."

Parents, peers and others can help those who struggle, Dvoskin said. When kids are having trouble, his advice is to help them feel safe, physically and emotionally. He recommends getting them talking — "not to get them to spill their guts" about what's bothering them, but to engage them. It doesn't matter if they're talking music or sports, the point is they're talking.

Dvoskin warns against what he calls "pathologizing normal reactions" to trauma and other hard events. Fear, anxiety and depression are normal after a major community trauma, but they shouldn't interfere with long-term ability to function. The goal is to help those who can't function feel better, "not because there's anything wrong with the kid, but because the kid needs help," he added.

Help comes in many forms, and it doesn't have to always be a psychologist or psychiatrist, said Dvoskin. A religious leader or someone else may be easier to talk to than a mental health professional. "Kids don’t want to think they’re the only ones who feel that way or that there’s anything wrong with them."

Here's how you can help

Teens can help themselves, too. Some steps are simple, like getting enough sleep and focusing on self care.

Dvoskin said a good starting to point to combat suicide is learning what kind of help is available. People think going to a mental health professional means they'll get medication, but that may not be needed. "Often, talk therapy is as effective or more effective," he said.

He suggests learning who is available to provide care in your community, including who is covered by your insurance, where the nearest community health center is, whether there's a crisis team there and what you should do in crisis.

" Sometimes the right amount is just to answer their questions. "
Joel Dvoskin of the University of Arizona

With teens, "don't make it a case of 'You have to do this,'" said Dvoskin. "Suggest professional care might help them feel better, then circle back later: 'Have you thought about what we talked about?'" Forcing teens can prompt them to push back. "I would say to be more persuasive than bossy."

Loved ones sometimes respond to crisis in accidentally terrible ways, including "victim blaming" that can marginalize someone. After a sexual assault, for example, focusing on why the victim was there or whether they fought hard enough can divert the blame back to the person who was harmed.

"We unconsciously come up with ways to protect ourselves by finding a way to make the person who's suffering responsible for their suffering — because otherwise, the world is unpredictable and dangerous," Smith said. That leaves those who survive a trauma and develop deep problems at risk of being isolated and stigmatized.

Never lie, Dvoskin said, "especially after a traumatic event. They need to trust you more than they ever have in their whole life. ... Tell the truth to kids of all ages, but that doesn’t mean necessarily to flood them with too much information. Sometimes the right amount is just to answer their questions. Let them tell you how much they want to know."

Lies can seem reassuring, but they are still bad. For example: "There's nothing to be afraid of." Maybe there is.

Or: "Everything is going to be OK." "You don't know that," Dvoskin said.

"Simple truths are a lot better: 'I love you. I want the best for you. I'm scared for you. I want to know how I can help you.' Those are great things to say," he said.

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Many effective, evidence-based treatment options exist, and it's important to address issues as soon as they're spotted. In adolescents, development can be derailed if they don't receive treatment, said Smith.

If someone you know is struggling with thoughts of suicide, resources are available. In Utah, the SafeUT app provides a direct connection to a crisis line. Other resources include:

National Hotline: 1-800-273-8255 (TALK)

University Neuropsychiatric Institute Crisis line: 801-587-3000

National Suicide Prevention Lifeline: www.suicidepreventionlifeline.org/