Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine.

I'm Melanie Cole. And this is part one of our two-part series highlighting the signals we miss in youth suicide prevention. This first episode covers the signals a family can see, what parents can notice at home, and what the screen research actually shows. And a quick note before we start, this episode contains material of a sensitive nature, including discussions on suicide and teen mental health that some listeners may find disturbing. We know this can be a difficult subject, so please take care of yourself while listening.

Joining me today is Dr. Yunyu Xiao. She's an Assistant Professor of Population Health Sciences and Psychiatry at Weill Cornell Medicine. Dr. Xiao, thank you so much for joining us today. So, let's start a little bit with the landscape of mental health and our youth. Where do things stand for young people right now as far as mental health? What have you seen in your research, in what you've done, and what has changed? How have things evolved in the last few years?

Yunyu Xiao, PhD: Yeah. First of all, thank you, Melanie, for having me. It's my great pleasure and honor to be on this podcast. So for the first time in two decades, there's generally a good news that it comes to a little bit of that decline of the suicide rates. The newest CDC final data tells us around like 48,824 suicide deaths in 2024, down about 1% from the 2023.

So, the overall rates fell about 14 per 100,000. And the rates, however, for the 15 to 34 years old fell to 4%. So, this is a real progress in terms of our efforts, in terms of making efforts of the open conversations and prevention investment. However, the national rate is still 32% higher than the 2000s. And particularly for this podcast that we are paying attention to about the youth population, suicide remains to be the second leading cause of death for those aged 10 to 34 years old. And roughly one in five high school students do report seriously considering suicide in a year.

Melanie Cole, MS: Those are pretty sobering and sad statistics. Now, Doctor, parents hear consistently about screen time and mental health risk. Are the number of hours really the thing that we worry about? I mean, we used to say that if kids are watching or playing these violent first-person shooters, that it could contribute to violent behavior. Is hours on the screens what we're worried about, or is it more what they're looking at? Tell us a little bit about that.

Yunyu Xiao, PhD: Yeah, absolutely. So, the short answer is that no. In our data, the number of hours was the wrong signal to watch, and what matters was the relationship that kids have with the screen and not the time on it. So in our study in JAMA, published in 2024, we followed thousands of children for four years, and the total screen time at the baseline was not associated with suicidal behaviors, suicidal ideation, or mental health outcomes, full stop.

So, what was associated was what we plot and then quantified as the addictive patterns of use. And what addictive means is that the kids share that they can't stop, they have distress without it. They use it to escape the bad feelings that they have and the conflicts that they have of using screen time versus do other things.

So, why this matters for parents is because two children can spend each, like, three hours on the phone. Same hour, one is fine and one is struggling in terms of their mental health. So, counting time and hours and treating them identically, and missing the one who needs help while alarming the families of ones who doesn't is not helping. So, the short answer is that time is the wrong signal.

Melanie Cole, MS: Well then, expand a little on this paper because it's fascinating. Dr. Xiao, tell us a little bit about what you found as far as those addictive behaviors and suicidal ideation and behaviors and how that all associates with the mental health in our teens.

Yunyu Xiao, PhD: Yeah, absolutely. So, this is the first studies that we were able to using this machine learning approach to quantify the trajectories of addictive use of three platforms: social media, mobile phone, and video games. And this is a longitudinal study. We watched around 4,285 children growing from age 10 all the way to 14 years old. And this is from the ABCD studies, the largest study in the US of adolescent brain development. So, children use follows distinct paths. And then, the striking one is that we find nearly one in three developed an increasing addictive use trajectory for social media, and then one in four develop this type of increasing addictive use of their mobile phones. So mostly, they begin around the age 11, and then they did not start that way. It just grows.

So, that means that we cannot just stop, like, using the baseline to do the signal or the risk factors to determine who is at risk and who is not. We really needed to keep asking. This is also the innovative part of this study that we designed to say that a single checkpoint at age 10 would have missed most of it because the risk was the trajectories that they have. And besides the increasing trajectories that is having risk that's associated with two to three times of the suicidal behaviors, we also find that there are also very high volume of children who are in a highly addictive use of social media and also mobile phones. And for video games as well, this is also associated with their internalizing symptoms. And by the age of 14 years old, around 5% of the children would report suicidal behaviors, and around 18% reported that they have suicidal ideations. So, these are 10 to 14 years old.

Melanie Cole, MS: This is really interesting. And for parents that need this broken down just a little bit, Doctor, what does addictive use actually mean in a child in plain terms parents can understand? Because we used to hear from the AAP two hours of screen time, that's what it means. But I know what that addictive behavior kind of looks like when my son was, you know, younger and playing the games and on social media, my kids were doing that. But what does that really look like when we're thinking of our children and that screen time?

Yunyu Xiao, PhD: Yeah, absolutely. We always count the time, right? Set the clock for kids to, say, two hours or three hours. But honestly, it looks less like a clock and more kind of like psychological feelings and the struggles from the children.

So basically, I would say in plain language for the parent, you could look at like four signals. First, that the kids can't stop, like tries to cut back, but fails to stop using the phone. And second, they have the distress without it, like they feel restless, they feel irritable, anxious when the phone is away. And the third one is called escape. That means they use it to specifically to get away from some kind of like painful feelings that they have. And the final one, the fourth one, is conflict and loss, that they would have like fightings within the families at homes, and then they would drop their activities from the schools, not hanging out, or potentially lose their sleep in order to use it.

So, the story is that what happens when the screen is off, not what happens when it's on, in fact. And this map to the validated scales in our studies that we use, that children answer themselves, and the parents can also ask the same questions gently. Say, "Do you ever try to use it less and find that you can't?" Something like that.

Melanie Cole, MS: Wow. So, what you just said made so much sense, that it's more about what we're looking for when those screens are off than when they're on. Because of course, the kids are focused, and you and I both know that screen time has changed over the years, because school requires more screen time than it used to. So, we can't always quantify the way that it used to be, two hours of screen time on television or whatever. But now, kids have to do these things online for school in so many different ways, so that is quantified differently. What should parents be looking for in those off times, Doctor, that would send up red flags, things that we should not really let go, things that we should know about, and then we can look to them?

Yunyu Xiao, PhD: Absolutely. I think the first thing for the family and for the mom and dad is that do not panic about the quantity that kids use screens. Watch for the change that kids have, and also the displacements, like what instead that the kids are using. And, Melanie, you mentioned about ordinary teen behaviors. I would say they might have lots of hours of spending times on the screen, but they still, say, preferring friends to parents. And then, they would say that they close the doors and then also have the group chat at midnight or at the weekends. And that is adults and adolescents, and it is their behaviors. And usually, that is their normal trajectories of development and social lives.

And instead, parents should watch for what? They have lack of sleep, deficiencies during the school nights, right? And also, quitting things they really love. For example, I just recently developed behaviors of baking, but then suddenly I give it up. And then, my kids started scrolling like all the TikTok videos and then never pick up their hobbies. And then, they use screens to escape the stress rather than trying to connect with their friends. And also, they have some secret feelings that drive them to keep it private and then never talk about it, and want it to disappear from their parent, from their family, from their friends, from teachers.

So, the single most useful question is not how long were you on your phone, but what were you doing on it, and how did it make you feel? So, the connections use and escape use look identical from it.

Melanie Cole, MS: So Dr. Xiao, sleep has come up a few times in what you've been telling us as a factor and a changeable factor. And we know that those blue lights and our kids are up later, and as you say, they're on TikTok and social media, so they could lie there for hours and hours on those things instead of sleeping. Why does it matter so much when we're talking about this type of behavior and risk and ideation?

Yunyu Xiao, PhD: Yes. This is a great question, because sleep is where the screens and also the suicide risk, like these two element physically like connect with each other in the same three hours of the night. Like, short and disrupted sleep in our studies show that it is one of the most consistent proximal correlates of suicidal ideations in adolescents. And it is the pathway through which the nighttime use does much of its damage, right? The phones takes the hours, and then the loss of sleep takes the emotional regulation, impulsivities. And then, the despair of like death would increase a lot.

It is also the most changeable factors, which is a good news for the family controls. Like, you can't really say legislatively or algorithms from your kitchens or just talk to the tech companies about how to change the device settings. But for parents, with the good communication, we will be able to set the house rules. Say, what is the time to go to the bed, and then not really having too much of this efforts of changing a lot of things. So, talking and communication with kids about sleep is the most changeable factors that can help both the screen time use and also the mental health.

Melanie Cole, MS: Well, so talking with our kids and communication is not only one of the most important aspects, I think, of what we're discussing here, but also can be for some parents, Doctor, the most challenging. So, how do we speak to our children? How do we work on that communication so that we don't seem like we're hovering over their social media and what they're doing and these types of things, because they don't want that, but also so that we know what they're doing online and so that we can talk to them. And you mentioned one question earlier about how it made them feel, but what do you say? What do you want us to say to our children to help keep those lines of communication open so we can identify those red flags should we need to?

Yunyu Xiao, PhD: Yeah, that is really important, because sometimes we have the willingness to help, but we don't have the tools to help, right? So, I would say that the most important things, and it's actually a common myth about suicide prevention, is that we always worry about asking about suicide would actually trigger the ideations. However, this is a myth because asking about suicide does not plant the idea. Like decades of research have always shown that asking directly is protective and silence is not. So, I would say in the calm and direct versions and say to your kids, like, "Sometimes when people feel this bad, they think about ending their life. Have you ever had the thought like that?" And then, stop and listen, because listening is very important for a person who have suicidal thoughts. And it is not advising and it is not shocking, instead you should also avoid some things such as panic and such as punishment or bargaining, saying that you have so much to live with, right? Sometimes we would, say, "Oh, why are you not satisfied?" So, these are not good words. And also, interacting the phones in the same conversation or promise secretly that you cannot keep. So, our data on who young people actually tell makes this urgent when intent is shared before the death. It is overwhelmingly shared with families and also their friends, and mostly never actually shared with professionals.

So, parents are not just attached to the safety system, but they are the safety system themselves. So if you think about it this way, then you are also feeling the responsibilities and also feeling the powers, and you are empowered to ask all these question.

And the final thing is that just keep all the means of death by suicide away from the kids. Like, secure the means. Like, firearms, guns should be really locked and safely stored and separated from the children. And the medication as well is also counted and put away, and time and distance really can save lives with a second thought.

Melanie Cole, MS: Well, first of all, you've made so many great points. And thank you for saying about the myth that if we talk to our children about suicide itself, that it's going to trigger that idea. These kids are not getting that idea from us discussing that type of safety and our concerns. So, thank you so much for that.

And then, getting the means out of there, because we know that some of those means such as firearms, can be a permanent solution to a temporary situation for a child. Maybe they're upset about something, and these things are so scary and dangerous. Now, before we wrap up, I would love your best advice for when those red flags go off in our heads, when should we be seeking that professional help? And what does that really look like for our teens and for the family that are all going through these times of crisis together?

Yunyu Xiao, PhD: Yeah, absolutely. And in fact, the threshold of seeking professional help is lower than most families and parents think. And the front door is easier than they can fear about. And I would say that any ask of like a death or being burdened, like showing from your kids, or like the signals of self-harm, like cutting, or a plan or a means that you have seen that they thought about planning about suicide, or disruptions about their sleep, appetite, withdrawal from something they're interested in, or the feeling of helplessness, that you do not really need any certainties, right, to make a call and then to worry.

So, always call. And then, it's very reachable right now to call and text 988 or go to the ED. And then, you can also reach out to pediatricians or school counselors as an entry point of seeking professional help. And also, ask specifically about suicide risk assessment. And if the risk is present, really, write down the safety plan and which is a brief evidence-based intervention. It's not a form, but it's a very rigorous evidence-based planning.

And what good care looks like, like directly asking ways, a structured tool like the Columbia Suicide Risk Assessment tool, a safety plan that the teenagers can really help writing ways, and then the means counselings from the home. And now, we also have like telehealth and some follow-up with the contacts. And families are always allowed to ask for each of these specifically. And with the tools of technologies right now, we're always empowered to ask any time as well.

Melanie Cole, MS: You've given us so much great information, Doctor. So much to think about and such an important topic. Not always easy to discuss. So, I thank you so much, and I'd like to just reiterate that the Suicide and Crisis Lifeline is 988. So, please don't hesitate to use that. And thank you so much for joining us today.

And this has been part one of our two-part series highlighting the signals we miss in youth suicide prevention. Please remember to check out part two for more great information. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcasts, Spotify, iHeart, and Pandora. For more health tips, go to weillcornell.org and search podcasts, and don't forget to check out Back to Health.