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Malia-Grace Bush never knew their names, but she can still picture their faces: the kids on her middle school campus who seemed somehow off, the ones who made her think, “something’s wrong.”

Bush, now 19 and a member of the statewide , says she didn’t know anything about depression in the eighth grade. She didn’t have the skills or knowledge she needed to reach out to her classmates.

Chances are, a lot of them needed reaching out to.

Last year nearly a quarter of middle school students in Hawaii said they had seriously considered suicide, according to the 2015 Youth Risk Behavior Survey. One in eight said they tried to take their own lives.

The biennial survey, conducted by the and the , is slated for release in June, when national results are also available for comparison. It was previewed for the earlier this month.

Middle school students in Hawaii have been reporting high rates of suicidal feelings since the state started surveying kids on the topic in 1997. Despite the alarming numbers, education and prevention efforts historically have focused on older teens.

That’s in part because, for several years, Hawaii had the highest rate of high school students who said they had seriously considered suicide, according to the . (In the most current available data, from 2013, Hawaii reported the in the nation.) 

There’s also a sense among some adults that kids in elementary and middle school are too young for such a heavy topic, that they should “just be happy,” said state Department of Health  Nancy Deeley.

That needs to change, the youth leadership council says. 

Formed last year, the council had a clear message after reviewing the state’s : Hawaii needs to start talking to kids about mental health and suicide sooner. Much sooner.

Why Is Middle School So Hard?

Experts say it’s difficult to pinpoint specific reasons why so many teens in Hawaii report feeling suicidal.

Anxiety, which might be an even bigger contributor to suicide attempts than depression, is a more prevalent issue for youth in Hawaii than in other states, said t, a professor and associate director of research at the  John A. Burns School of Medicine.

But it’s unclear why anxiety levels are higher in Hawaii.  

Teens in high school may face as many — or more — stressors as they did in middle school, but they are also more likely to have developed a range of coping strategies.

There are also some groups within the state that seem particularly at risk for depression, anxiety and suicidal feelings, including Native Hawaiians, kids living in rural or economically depressed areas and military children. Risk factors are complex, however. 

Many experts say that middle school is just a uniquely tough time for kids anywhere.

Middle school students are undergoing enormous transitions. Their bodies are changing. Their hormones are changing. And for kids getting on social media for the first time, the way they interact with their peers is changing.

Bullying is more prevalent in middle school. In 2015, one in four middle school students in Hawaii said they had been electronically bullied in the previous year, and 45 percent said they had been bullied on campus, according to the preliminary youth survey results.

In high school, those figures dropped to 14.7 percent coping with electronic bullying and 18.6 percent experiencing bullying on campus.

There’s also the maturity factor. Teens in high school may face as many — or more — stressors as they did in middle school, but they are also more likely to have developed a range of coping strategies.

Click on the various options in the graphic below to see what the 2015 risk-behavior middle school survey results would look like in a class or 28 students.

Finally, depression in middle school can be hard to identify.

The youth survey asked students if they have felt sad or hopeless for an extended period of time. Asking students if they’ve been feeling angry every day might be a better indicator of depression, Goebert said.

“In the school system if someone is angry and acting out, they are not necessarily referred to mental health,” Goebert said. “That’s usually a referral for the vice principal to take care of, and not necessarily seen (as a sign) that someone is struggling.”

Changing Strategies

One of the biggest statewide efforts in preventing youth suicide has been focused on “gatekeeper” training — helping peers, teachers, parents and community members learn to identify and reach out to at-risk youth. 

“If youth don’t feel supported, if they can’t identify what’s going on internally, it’s really hard to get them help,” said Mara Pike, Pono Youth Program manager at . “So the idea is to get the trainings going so they can identify when they need help or if someone else looks like they are having a hard time they can talk to them as peers.”

Much of the training was funded by a federal grant that ended in 2014, for a partnership between UH and Mental Health America focused on high school students.

The training has continued without grant funding, although resources are tight. One way that Mental Health America is trying to make the effort sustainable is by creating the youth leadership council to facilitate more peer-to-peer outreach.

This year, because of the suggestions of young adults on the youth council, the group modified its suicide prevention training curriculum so that it can be used at middle schools, Goebert said.

During the council’s first meeting last year, members said the biggest state need was for student education in elementary and middle schools about mental health and suicide. Many members said they received some training in developing coping skills in high school, but learning the skills earlier would have allowed them to support each other and themselves, Pike said.

State curriculum benchmarks for middle and high school have requirements for emotional and mental health education. But young people on the council are saying that more teachers and adults need to really use the word “suicide” and be comfortable talking about it, Pike said.

The group also said more adults need to be trained on how to work with youths effectively, Pike said. For example, crisis workers who man the state suicide hotline don’t necessarily have specific training in youth counseling, she said.

Hawaii has had challenges with professional development training on suicide prevention in schools. According to a 2014 national study by the , only 17.7 percent of lead high school health teachers in Hawaii had received professional development on suicide prevention over the prior two years — the second-lowest rate in the nation.

In January, the  rolled out a statewide training program, open to both school officials and community members, as part of a new mental health pilot program.

Project HI AWARE (Advancing Wellness and Resilience in Education), which is being piloted in three school complex areas in Hawaii, aims to increase awareness of childhood mental health issues and improve coordination between schools, the Department of Health and community resources, said Chad Farias, superintendent for the complex on Hawaii Island.

The goal is also to identify strategies that can be used throughout the state, including  training.

The department hopes to train 3,000 youth mental health “first aiders” over the next four years. 

“These are issues that need to be addressed, but these are issues that are treatable if they are approached properly,” Farias said.

Lawmakers are also expected to soon calling for the state’s suicide prevention task force to create a plan for reducing suicides in the state by 25 percent in the next decade.

The subcommittee in charge of coming up with the strategic plan would include at least two members of the youth leadership council.

In the meantime, schools like  are working to address mental health issues by targeting campus bullying and monitoring student behavior and academic progress through early intervention systems.

Sometimes, academic performance is nine-tenths of the problem, Kailua Principal Lisa DeLong said.

“If they are feeling successful, that helps,” DeLong said.