CINCINNATI – Just before Christmas 2015, child psychiatrist Daniel Nelson noticed an unusual number of suicidal kids in the hospital emergency room.
A 14-year-old girl with a parent addicted to opioids tried to choke herself with a seat belt. A 12-year-old transgender child hurt himself after being bullied. And a steady stream of kids arrived from the city's west side, telling him they knew other kids – at school, in their neighborhoods – who had also tried to die.
"I think there's an increase in suicidal kids in Cincinnati," Nelson told a colleague. "We need to start mapping this out."
So Nelson and his colleagues collected the addresses of 300 children admitted to Cincinnati Children's Hospital with suicidal behavior over three months in early 2016, looking for patterns. Almost instantly, a disturbing one emerged: Price Hill, a poor community with a high rate of opioid overdoses, was home to a startling number of suicidal kids.
"This is who is dying from opiates – people in their 20s and 30s. Think about what that population is," Nelson said. "It's parents."
Now Nelson is working with county coroners across the nation to try to corroborate his theory, that trauma from the nation's opioid epidemic could help explain an extraordinary increase in suicide among American children. Since 2007, the rate of suicide has doubled among children 10 to 14, according to the Centers for Disease Control and Prevention. Suicide is the second-leading cause of death between the ages of 10 and 24. The suicide rate among older teenage girls hit a 40-year high in 2015, according to newly released data from the National Center for Health Statistics.
Cincinnati has been particularly hard hit. In 2015, five children died from suicide in Hamilton County, where Cincinnati is located. Last year, 13 children under 18 were lost to suicide – a rate nearly three times the national average. This year, nine kids have died by suicide, a majority of them under 15. The youngest, a resident of Price Hill, was 8 years old.
Nelson, who has been practicing for two decades, says many of his patients come from families with addiction problems. In a program he runs for preschoolers who have been severely abused, over 60 percent have an opioid-addicted parent.
"At any given time, at least 25 percent of my hospitalized kids have a parent actively struggling with addiction," Nelson said. "Early childhood trauma has been proven to set the stage for a lot of mental and physical illness. It's a pretty simple scale."
The epiphany about Price Hill came unexpectedly, when he saw a map of overdoses in Hamilton County. The overdoses clustered in the same places as his suicidal kids. "They laid over each other almost exactly," he said.
"We do worry that a neighborhood with a high rate of opioid overdoses is also seeing this suicide cluster," said Marilyn Crumpton, Cincinnati's interim health commissioner. In particular, she is concerned about the increasing number of children being orphaned by the opioid epidemic and the despair it is causing in communities. "It's very easy to see the relationship."
Price Hill overlooks the basin of downtown Cincinnati. Once a buzzing, wealthy suburb with its own cable railway, it is now pockmarked with shuttered businesses and boarded-up homes.
Nelson drove a reporter to Carson Elementary School, and its playground was desolate during summer break.
"I'm thinking if I live in a community where my friends' parents are dying, if I'm in a class of 25 with 15 families challenged by addiction, even if my family isn't directly challenged, I suddenly become affected," he said. "Kids are coming in with all these traumatic experiences. Resources are stretched. Teachers aren't able to teach the same. It could be a contagion effect in a community."
In January, 8-year-old Gabriel Taye, a third-grader at Carson, died by suicide at his home in Price Hill. He had been bullied by kids at the school.
The coroner initially asked police to investigate the death as a murder because she didn't think an 8-year-old could hang himself. Now, she was trying to figure out from Gabriel's iPad where he learned how to do it.
"They called me in when Gabriel died," Nelson said. "It's the youngest kid who completed suicide that I can remember in a long while."
Nelson drove a few blocks to Western Hills High, a 1,200-student school that had two suicides last year: A 16-year-old sophomore boy and a girl who had just finished school. In March, the school lost another teen. About a dozen of the suicidal kids on Nelson's map went to this school, which shares grounds and a medical clinic with Dater High, which had another student die of suicide recently.
"They've had four kids that died of suicide in the last two years between the schools," Nelson said. "Across the street from here, there is a junior high called Midway, where a 12-year-old died last year."
Inside Western Hills, a group of students were painting the long wall by the school gym gold. Rihanna blared from a boombox.
Nelson walked into a classroom where a strike team addressing the school's suicide problem was seated at a long table.
Susan Shelton, a founder of MindPeace, a youth mental-health organization that has brought professional mental-health services to nearly 100 Cincinnati schools over the past 15 years, was helping train school staffers to spot childhood trauma – a strong predictor of future depression and suicide risk.
Others around the table represented Lighthouse, a youth and family service agency whose psychologists and counselors work with students out of a room just down this corridor.
Nelson had met with the group this spring, when they raised the alarm about students reporting suicidal thoughts. He'd shown his suicide and opioid overdose maps on a large-screen television. "They got it immediately," he said.
Weeks after that meeting, Western Hills lost another teenager to suicide.
"The worst thing a principal can face on any given day is to come into their school building and find out one of the students has committed suicide," said Kenneth Jump, the school principal.
Nelson said: "When a child dies, everybody is affected. No matter how hard you try, you feel like you're failing."
One of Nelson's patients, Samantha Potter, came to his clinic at age 12, after the first of two suicide attempts and two years after her father killed himself.
"We were celebrating my 10th birthday at Grandma's house when my dad passed away from suicide," Samantha said over tea in a bookshop cafe just across the river from Cincinnati in Florence, Kentucky.
"When they told us, we were sitting together on the loveseat," her sister Emma said. "I remember we held hands because we were scared."
Suicide – especially among children – can be contagious. Research suggests that about 5 percent of youth suicides are influenced by contagion from suicidal peers or cultural depictions of suicide. That's one thing that worried Nelson about his patients in Price Hill and across the region.
After she attempted suicide, Samantha said, "that night I slept with my mom and had horrible nightmares. I didn't know what to say to the nurses and doctors. I was terrified. Because when you're trying to commit suicide, some people forget this, but there's still a part of you that doesn't want to. Not only are you scared of dying, but you're scared of yourself. You're scared of what's possible at that moment in time."
After Sam was diagnosed and treated for post-traumatic stress disorder in her early teens and became more comfortable speaking out about suicide, she turned into a magnet for others in crisis.
"Suicide notes, calls for help started falling out of my locker," she said. "Some said, 'I have pains in my chest from anxiety.' Others would tell me they were cutting themselves. Some would just say, 'So-and-so needs a friend.' "
Now 19 and just starting college, Sam has an armory of coping skills, and she started Rob's Kids, named after her dad, to help other children deal with their trauma.
Like Nelson, she'd been puzzling over the cause of this tidal wave of depression and suicide among her peers. "Multiple classmates of mine at school had tried," she said. Emma, who is 17, nodded in agreement.
"Have you seen that show '13 Reasons Why'?" Sam asked. She was incensed about the series. The Netflix TV show about a high school teenager dying by suicide has become the focus of alarm for school superintendents and doctors.
Their fear is that it will stoke the problem of youth suicide through contagion, particularly among kids already struggling with depression. A study published in July found a 19 percent increase in internet searches about suicide, including "how to commit suicide," after the series debuted.
In addition to his pediatric practice at the children's hospital, Nelson runs an addiction clinic that serves poor families. The waiting room is crammed.
One patient, a father addicted to opioids, had walked for more than two hours from Kentucky to be there. An anxious couple were waiting to get a prescription and ask advice on what to do about their child, who had been taken away by protective services.
A young mother in recovery chastised her toddlers, who were happily exploring the office on all fours. "Can I give them a C-R-A-C-K-E-R today?" Nelson asked with a smile.
Then he walked out to greet the next family.
"I encourage them to bring and talk about their children," he said, during a short breather between patients. "Treating the addiction helps reduce psychosocial stress for the kids."
One of Nelson's patients, Scott Emmon, was born and raised in Price Hill, where he now works in security. He's been clean for about a year.
Last year, his brother died of a heroin overdose. He left behind two daughters, a 19-year-old who attended Western Hills and a 4-year-old who is now in foster care.
"I've been to 24 funerals and only two weddings," said Emmon, 37. "It's so sad to say, but it's the truth. I see people die all the time. It's like a normal thing now."
Price Hill locals have seen the epidemic of overdoses in their neighborhood, and many worry about how it is affecting their children.
Jeremy Bauer, parish operations manager at Holy Family Church in East Price Hill, witnessed three overdoses within the span of three weeks – a woman slumped across the street from the church; a second woman curled up in a McDonald's parking lot when he was with his two children; and a man in an alleyway behind the church.
In June, Bauer decided to hand out kits of Narcan – an antidote to acute opioid overdose – to families at a church community event, in an effort to combat the heroin epidemic in the area.
Bauer says kids are certainly aware of what they are seeing. "They see the overdoses. They hear about it – on the news, on Facebook. They see the squads," he said. "I can be out in my front yard with my kids working on my flower beds, I see people walk up and down and I can see they're high."
He continued: "Imagine being a young person in this community who looks around and sees this devastation, people in the throes of addiction, people slumped over or high on the street. That's got to sap their energy and passion. If they're living in this community, where walking down the street they see so many people trapped in a lifestyle, how can they have an ambition to be something bigger?
"How can we expect them to process it when we can't even process it as adults?"