In the note Aaron Williams wrote before dousing himself with gasoline, he explained that he’d wanted to become a doctor when he grew up. To help people.
Instead, the 16-year-old printed in stiff black letters, “I cant even help myself.”
He hoped that his high school’s faculty would realize kids like him “have feelings like I do right now.” Aaron himself couldn’t understand what he was feeling, or how he’d come to this moment.
He pulled onto the busy campus of his school, Academic Magnet High in North Charleston, and parked. Then, he lit himself on fire.
His autopsy report arrived at his Mount Pleasant home in an envelope. His father, Trace, read it right away. His mother could not bear to until months later.
Yet, it contained answers to why such a sweet and docile boy would end his life in this fashion.
Aaron had multiple lesions in his amygdala, structures in the brain’s limbic system that play critical roles in processing emotions — notably anxiety and fear.
His parents had no idea then, but his death in 2010 underscored a disturbing trajectory among adolescents on the one hand, the hope of modern brain imaging on the other.
Suicide deaths across all ages have risen nationwide for almost two decades, and South Carolina has seen the biggest jump in the Southeast at 38 percent, federal data shows. Suicide is now the second-leading cause of death among teens and young adults here.
In 2007, 13 youth ages 10 to 19 in South Carolina took their lives, state data shows.
Help is available for people contemplating suicide.
A decade later, 51 did in a year's time.
Yet, as those figures rise, modern imaging also is opening critical new views into the living brain. Scientists are discerning far more about the biology of suicide, a key factor to knowing why this is happening. And how to address it.
Researchers can track different paths that the concept of "death" travels through the brains of people who have considered suicide — and those who have not. They can see which areas of the brain play critical roles in suicidal thoughts versus actions.
One key area is the amygdala, where Aaron’s brain suffered damage.
The next frontier
In the beginning, there was an x-ray. Then a CT scanner. Then an MRI. And then an fMRI, or functional magnetic resonance imaging, a machine invented in the early 1990s that allows researchers to peer inside the skulls of living people to measure tiny changes in the brain's blood flow as it functions.
They can watch a brain think.
Just as the fMRI stepped onto the world's scientific stage, a young Dr. Mark George, trained in psychiatry and neurology, arrived at the National Institutes of Mental Health in D.C. He became fascinated with brain imaging and was among the first to use it to spot differences in the brain activity of people who have depression and mania.
George returned to his native South Carolina and opened an imaging and research division at MUSC. The Brain Stimulation Lab has since been at the forefront of using brain stimulation to study and treat neuropsychiatric disorders, evidence of the practical treatments imaging technology has helped to yield already.
We now know that disorders like depression and anxiety, once seen as character flaws (If he’d only buck up and get over it!), often result from malfunctioning biology, much like we know about cancer and cells.
From his MUSC office, George explains.
Think of the limbic system, nestled deep within the central brain, as a hub where emotions like fear and pleasure emerge. The amygdala is part of this system. When those emotional responses head up into a healthy prefrontal cortex, particularly its orbitofrontal cortex just behind your eyes, that region acts like a braking system to the emotions. In people who suffer depression and suicidal thoughts, those brakes can be faulty.
In adolescents, already grappling with hormones and heightened emotions, the prefrontal cortex typically isn't fully developed yet, one reason they're known for impulsive decision-making. This also could put them at greater risk of acting on suicidal thoughts.
“It makes total sense why adolescents are so vulnerable," George said.
But how can we tell normal teenage rates of brain maturity from chronic deficiencies that put some youth at greater risk of acting on suicidal thoughts?
We can't, not yet. Most of what we have learned from modern brain imaging is based on scans of people over 21, not adolescents.
“It’s a big hole," George said.
And the next frontier.
The lives of teens
Biology, however, isn't the only factor that drives suicidal ideation. Environment also plays a role, experts say, and the reality is: adolescent life has changed.
For almost 20 years, the federal government’s Youth Risk Behavior Surveillance System survey has provided glimpses into the lives of teenagers. And among South Carolinians who responded over the past decade, every measure that relates directly to suicide has risen, especially among girls. (Boys are far more likely to die of suicide while girls more often attempt it.)
The most recent survey, done in 2017, found that nearly one in four high school girls said they had seriously considered it over the past year. That was up 6.5 percent in a decade.
More than one in 10 of them had attempted suicide in the previous year, up 5 percent. Only six states had higher rates.
Expand that to include young people ages 10 to 24, and state mental health officials estimate that attempts have risen 43 percent over just the past couple of years.
Family conflicts, onset of puberty, social media and bullying play roles. So does a huge spike in substance abuse rates, said Alex Karydi, head of the S.C. Department of Mental Health's suicide prevention center.
Then there's the ever-bubbling cauldron of pressure they face.
Used to be, most adolescents wanted to marry one day, land stable jobs, have children and settle down. Then, it would be time to feel content, accomplished. Life had goals and finish lines.
Today's teens feel pressure to have great experiences all the time. What's Instagram without new pictures of fun times to post?
Then there's mounting stress to get into top colleges, themselves more competitive. There's pressure to land the perfect job — fulfilling and well-paying — all while hundreds or thousands of their closest social media friends watch and critique.
“It’s the treadmill of, I’ve got to stay competitive," explained Dr. Kevin Gray, MUCS's director of child and adolescent psychiatry.
Among the national survey's most striking findings is the steep rise in high school girls who reported feeling sad or hopeless over the past year almost every day for two weeks or more in a row, to the point they stopped doing some usual activities. It is a key indicator of depression.
A stunning 43 percent of girls said they'd experienced this — an 11 percent increase over a decade. About one-third of boys did, too.
Some experts blame social media. But research shows mixed results.
In some, social media appears to heighten loneliness and affect sleep. Yet, it helps others feel connected to peers. And, although one in five girls reported being bullied through texting or social media over the past year, those rates are actually down very slightly since 2011, the federal survey shows.
Some experts speculate social media could play a key role in suicide contagion, the phenomenon of one act sparking a series of them. Given news outlets typically don’t report on individual deaths by suicide, adolescents in the past might not have heard when someone died far outside their social circle. Today, word spreads across Instagram and Snapchat.
When Netflix released its hugely popular "13 Reasons Why," a show about a teenage girl who dies by suicide, debate erupted: Would it lead to copycat deaths?
Indeed, over the month after the show's 2017 debut, suicide deaths among children aged 10 to 17 rose 29 percent, according to a federal study.
But ultimately, these are statistics.
They don't tell us why.
Learn the ABCDs
A massive new study of children across the country aims to answer that question, and many others.
The federally funded Adolescent Brain Cognitive Development study is the largest long-term study of child brain development in America. Known as the ABCD study, it will follow an enormous cohort of children who are now 9 and 10 years old for at least the next decade.
Researchers at 21 sites across the country, including MUSC, have enrolled 11,874 children, measuring everything from their time on social media to suicidal thoughts. Along with extensive interviews, each child underwent a brain scan. They will get new ones every other year.
Those results will help explain how much biology versus environment play in suicidal ideation.
Last fall, MUSC finished enrolling the 381 children who will participate here and began interviewing them. Lindsay Squeglia, co-principal site investigator, began getting a text when any child reported suicidal thoughts. Given these are nine and 10 year olds, she didn’t expect many.
Instead, “I was getting texted all the time."
More than 13 percent of the children reported at least one suicide-related thought or behavior. But is that better or worse than past years?
“We don’t really know what’s normal and what isn’t,” Squeglia said. “We’re still learning so, so, so much.”
A pipe dream
There is, in all of this, a central question: Why do some people act on suicidal thoughts, while others don’t?
Follow the concept of “death” as it traverses the brain, and a clue emerges. In a recent study, researchers used a computer algorithm to measure that path in patients and discovered they could tell, with 91 percent accuracy, those who had considered suicide from a control group who had not.
The two groups processed the concept of death differently. They also processed other concepts related to life and suicide — ones like “cruelty” and “carefree” — differently.
“The valuation of what is important and good in life and what is not appears to be altered,” according to the 2017 study by researchers at Carnegie Mellon, University of Pittsburgh and others.
The brains of people struggling with suicidal ideation lit up more when they thought about concepts related to self. And they associated self with the concept of death more than control groups.
Within the group that had considered suicide, the algorithm also distinguished with 94 percent accuracy those who had thought about it from those who'd actually attempted it.
“It’s the thinking that is the cause of the change,” said Marcel Just, a psychology professor at Carnegie Mellon and lead author of the study. He's now working with a $3.8 million federal grant to advance the research.
Ultimately, it could elicit life-saving information.
Suicidal ideation is treatable. Yet the only way to know people are grappling with it is if they say so. And most people who die by suicide had denied these thoughts the last time they had contact with a mental health professional.
What if doctors could routinely connect patients to a machine and detect who is at risk?
Right now, that's not possible. fMRI machines are expensive, $1 million or more, and not readily available to the average patient.
Changing that is Just’s goal.
He studying ways to transfer this approach to an electroencephalogram, or EEG, a much cheaper machine available in most neurologist's offices.
For now, it’s a pipe dream.
“But it could happen,” Just said. “That's exactly the hope.”
'He wasn't in control'
Aaron Williams’ parents worried about issues teens everywhere face. But they were listening for the wrong alarm bells.
Aaron, their first child, was born prematurely with a rare condition of the central nervous system called neurocutaneous melanosis. It is characterized by a proliferation of moles, or large deposits of melanin, the pigment that colors skin. These can occur on the skin — and in the brain.
Aaron had a mass of them down his back. An MRI early in life showed an inoperable one in his brain, on his thalamus. Given the thalamus’ role as a relay station for sensory messages, his doctor warned his parents to watch for declines in their son's balance, coordination and speech.
But Aaron grew up to become a straight-A student, a lanky boy who ran track.
When he first entered Academic Magnet High, he fared well. But then he struggled more with anxiety. During sophomore year, he mentioned hurting himself. He wasn’t eating well, didn’t sleep well and hung back from his peers. His 6’4” frame slimmed to 135 pounds.
Aaron tried to explain what he couldn’t understand himself.
Sometimes, he felt good. Then overwhelming anxiety gripped him.
His parents worried he was being bullied. Or ostracized. Or that his workload at school was too taxing.
A psychiatrist put him on Prozac, and he improved. The summer before junior year, he even began to ween himself from the medication.
Then he didn’t finish a heavy load of summer reading in time for school to start, a big departure from his normal behavior. He began the year behind. He described his anxiety level at home as around a 3. At school, closer to a 10.
In early December, he drove there with the gasoline.
After he died, guilt and shame wracked his parents. They obsessed asking: How could the child they called Safety Man, because of his cautious nature, do this?
Then came his autopsy. At first, his mother, Beth, didn't want to read a clinical description of his injuries.
Five months later, she pulled it out.
"A section of the left amygdala shows a mass of cells engorged with chunky brown pigment consistent with melanin," it read.
She pondered what that meant.
“There was biological proof that he really, really struggled with something bigger than him,” Beth recalled. “It would have helped to know that what he was feeling wasn’t his fault.”
Or anyone else’s.