Should Kids Watch '13 Reasons Why'? Advice From a Pediatrician

Serializing or Sensationalizing Teen Suicide?

The latest teen viewing sensation is a dark, disturbing, serialized drama called 13 Reasons Why. The series explores a troubled teen's motivations for completing suicide.

School systems across the nation have sent letters home to families, warning of fears that the series could have a "contagion effect" in students at particular risk for self-harm. Others have suggested that rather than causing harm, the show provides the potential for discussions around what is often a taboo subject. The National Association of School Psychologists was sufficiently concerned to issue a first-ever guidance for school officials about a television show.

It's not only educators who will need to advise families about how to both monitor viewing and appropriately discuss the issues raised by the show. Healthcare professionals also should be aware of the show and be prepared to help families make a decision about whether to allow their teens or tweens to watch it. To provide this information, Medscape spoke with Cora C. Breuner, MD, MPH, an adolescent medicine specialist at Seattle Children's Hospital and chair of the American Academy of Pediatrics' Committee on Adolescence.

How Realistic Is It?

Medscape: Let's begin with the bottom line: In your view, does this show realistically explore the many issues that are recognized to factor into the tragedy of teen suicide?

Dr Breuner: I was asked by a number of different media outlets to comment on this before I had seen the series. So I watched the whole series over a weekend. And since then, I've done a lot of reading about how people have responded to it.

Cora C. Breuner, MD, MPH

My first understanding of the show itself is that it's a drama. It's definitely geared to a 15-year-old audience. But it's being watched by kids who are both younger and older. The director created an interesting, well-produced story about a girl who had been bullied and subsequently spiraled out of control. She wanted, in her last few days, to create a scenario in which she would exact revenge on everybody who had let her down, and do it in a way that would clearly be remarkable. From that standpoint, as a drama, it was riveting, although the scenes about rape, bullying, and fighting were very challenging to watch.

These were professional actors; the series was well done and well scripted, and it probably filmed with multiple takes until it was done perfectly. Looking at it as a show, as fictional, is very important.

Looking at it as a show, as fictional, is very important.

I don't think kids who are actively depressed or have been sexually traumatized or bullied should watch it without their parents or a responsible caregiver with them.

That's why kids should watch it with their families, who can stop, pause it, and have a discussion. Kids need to understand that these are actors with a script, and it was rehearsed. At the same time, we know that these things happen. Questions to pose to teens can being with, "Has it happened in your school? How did you respond?"

Medscape: Where does this show seem unrealistic to you?

Dr Breuner: I see a lot of depressed kids who intermittently have thought of self-harm or even have made suicide attempts. The level of organization displayed by this character does not make sense in someone who is actively depressed. In the series, she is depicted as deliberately coming up with an entire strategy to convey her reasons for suicide to others after the event, including obtaining a cassette recorder to record her thoughts.

From a mental health perspective, this is unlikely. People who are very depressed and despondent can't really get out of bed. They can't bathe. They can't interact. They aren't going to school. They aren't participating in social functions. And yet, this character was doing all of those things, which is not congruent with significant mental illness and depression, where the end result will be taking your life.

As a clinician and parent, it didn't make sense to me that this girl was portrayed as someone who was so organized and yet was also contemplating killing herself. And the fact that the organization was focused on revenge didn't make sense. For a kid to say, "I want to kill myself because I want to exact revenge on those who let me down," as a storyline—that was not completely believable or plausible.

Medscape: In the real world where you live and practice, would this girl probably have come to the attention of a pediatric or mental health professional?

Dr Breuner: Yes. In this series, there was little or no mental health involvement in this girl's life. In this series, depicting a teen with involved parents, it is more likely that they would have been saying, "I need to get my daughter in to see a therapist now." There was no real involvement of the mental health community, other than some involvement by a school guidance counselor.

Every day in my clinic, I probably have five or six kids and their families coming to see me because the child isn't eating, is sad, is not going to school, and won't leave their room. They want me to help them help their child somehow. These are very concerned parents of all socioeconomic strata. So, that part of the show wasn't totally congruent with what those of us in this field actually see.

Medscape: What about the issue of suicide contagion? Does that concern you?

Dr Breuner: That is a definite concern. That's why media typically avoid reporting that someone has killed him- or herself. They don't put it on the news. They just say the person died suddenly. This is because of the upticks that happen after a suicide. After Marilyn Monroe killed herself in the 1960s, there was a big uptick in suicide. To some extent, it seems to glorify it. So, there is some concern about contagion with this series.

Since it's been out, however, I don't think we have yet seen an uptick in suicides. There are more suicides in the spring anyway, related to the end of the school year and transitioning to summer. It will be hard to tease out whether there is an increase in suicide rates totally related to teens watching the show, but this will obviously be reviewed.

Netflix has put disclaimers at the beginning of the series noting that the content is disturbing and adult, but I think that warning should be placed at the beginning of every episode. The network should also, in my view, link to the discussion session after every episode and at the beginning and end of the series. But that's just my editorial about it.

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