Since 2008, 18 children ages 10 to 14 - seven girls and 11 boys - have died by suicide in New Hampshire, according to the Office of the Chief Medical Examiner, including four just this year.
In that same period, 18 girls and 70 boys between the ages of 15 and 19 also took their own lives.
Typical changes that come with adolescence can sometimes mask signs of serious troubles, according to Elaine de Mello, supervisor of training and prevention services for NAMI New Hampshire (the National Alliance for Mental Illness).
"We say to folks, err on the side of caution if you see changes or see some unusual behavior," she said. "Even if it doesn't look negative, it could be a signal that something's going on."
If you're worried that a loved one might be thinking about suicide - or if you're at risk yourself - there are people who are ready to help.
About 20 years ago, de Mello and Ken Norton, now NAMI's executive director, developed the CONNECT program to train youth and adults to recognize the warning signs of suicide and take appropriate steps to help. The program has since become a nationally-recognized best practice, de Mello said.
Paying attention to youngsters is especially important, she said. "All young people are vulnerable just because they're youths," she said. "Their brains are still developing. Hormones are kicking in. They're subject to all kinds of things in their environment... ."
It can be tough to get kids to talk, she acknowledged. She recommends talking in the car, with your teenager in the back seat, or during an activity, to make the encounter less confrontational.
And, she urged, "Surround them with healthy people," including peers and adult role models. "That's why we try to train as many people as we can in suicide prevention," she said. "What a mother might not see at home, a teacher might see at school, or the bus driver might see on the bus ride."
In the 2017 Youth Risk Behavior Survey, 16 percent of New Hampshire high school students who responded said they had seriously considered suicide in the previous 12 months - about 12 percent of boys and 21 percent of girls. And hundreds of students said they had attempted suicide at least once.
Kids talk to other kids, de Mello said. So it's important to train students to turn to adults for help, she said.
"Sometimes it just takes one person who shows that they care and who is going to be there without judgment that can make the difference, I think, between life and death in some cases," she said.
Another program that's making a difference is Zero Suicide, a national initiative from the Suicide Prevention Resource Center to prevent suicide deaths among those under the care of medical and behavioral health providers.
One study found that three-quarters of those who died by suicide had had contact with their primary care physician in the year leading up to their deaths. And 45 percent had seen their doctor in the month before.
That means health care providers have an opportunity - and responsibility - to prevent suicides, experts say.
Debra Vasapolli is director of public relations at Exeter Health Resources, which sponsored a Zero Suicide training academy last fall. The model, she explained, involves screening individuals at every interaction.
And if someone is identified to be at risk, she said, there's an immediate transfer, what providers call a "warm handoff," to a behavioral health provider in the community.
EHR decided to open up its Zero Suicide training to other organizations. And it wasn't just health care providers who responded.
The room was packed with folks from VA medical centers, the National Guard, state police, corrections, as well as other health care organizations, Vasapolli said. "It really does take an entire community to be able to identify and screen and know what to do and how to get someone into treatment," she said.
The Mental Health Center of Greater Manchester sent a team to last year's training and is now implementing Zero Suicide in its practices.
Patricia Carty, chief operating officer at MHCGM, said everyone in an organization, from the clinical staff to those who work in billing, should be trained to recognize warning signs and take action. "You build it into your culture," she said.
Kristen Kraunelis, director of quality improvement at the center, said the key message to impart is that treatment works: "That there is hope. There are many, many ways that we can help people to feel better and create a life worth living for them if they have access to treatment."
For every death by suicide, there are 135 people who are affected by it, Kraunelis said. "It's not just about the person: it's about community and families," she said. "And our mission is to really reach people who are vulnerable and at risk."
Carty said she's already seen the training have an impact at her agency.
When a client was about to be discharged from the Cypress Center recently, a staff member who had attended the Zero Suicide training voiced concern that the man was at risk for suicide.
When they told the man, a veteran, that they wanted to keep him under their care, Carty said, he started to cry. "I think it was a realization that there was someone who cared about him and that had acknowledged his struggling and his suffering."
Carty said aiming for Zero Suicide "is an audacious goal, but it has to be."
"What else would you shoot for?" asked Kraunelis.
De Mello said she begins her prevention trainings with a message to anyone who has lost someone to suicide: "It's not your fault."
"Because if there was anything you could have done to prevent it, you would have done that."
The same is true of those who die by suicide, she said. "Most people don't want to die; they just want to end the pain," she said. "If there was anything they could have done to prevent it, they would have done that. They could not see any other way out."