Suicide is now the second-leading cause of death among North Carolina youth between the ages of ten and seventeen, according to a new report from NC Child and the North Carolina Institute for Medicine.

The 2019 version of the annual Child Health Report Card—released Wednesday but made available to the INDY earlier under an embargo—focuses on suicide because of an alarming trend: The rate of youth suicide in North Carolina has nearly doubled over the previous decade. According to the report, mental health is just one factor leading to suicidal thoughts. Others include trauma, persistent stress, family violence, and bullying.

This is particularly acute for youth of color and LGBTQ youth. While 12 percent of heterosexual high schoolers reported seriously considering suicide, 43 percent of gay, lesbian, or bisexual students reported the same. African-American high schoolers were twice as likely as white students to have attempted suicide in the past year and were significantly less likely to get treatment for depression.

“The reality is that many kids have to cope with tremendous stressors and don’t have the supports they need to navigate them,” says Michelle Hughes, executive director of NC Child. “Dealing with things like discrimination because of their race or sexual identity, or experiencing abuse and neglect all contribute to a child’s likelihood of attempting suicide. These are all things that we can address with better public policy choices. We don’t have to accept this as a given.”

Strengthening North Carolina’s behavioral health system and its coordination with schools, making it harder for youth to access guns and prescription drugs, and ensuring adults—such as caregivers, schools nurses, and social workers—are trained to spot suicide risk factors can help prevent youth suicide, the report says.

The leading cause of death for children overall in North Carolina is infant mortality, the report says. According to the report, African-American babies are more than twice as likely to die in the first year of life as white babies. Children of color also have higher rates of poverty and obesity and lower rates of reading proficiency.

Another troubling trend highlighted by the report is a decrease in vaccination rates. While North Carolina has high vaccination rates compared to other states, the rate has dropped by more than 11 percent since 2014, and only three-quarters of children have had the appropriate vaccinations by age three.

The report’s authors say it’s unclear what exactly caused this dip; the percentage of parents without insurance has declined, reaching about 13 percent in 2016 and earning the state its only A, for insurance coverage, on the report card. But the anti-vaccination community does have a presence in North Carolina. Last year, an Asheville school with a high rate of families claiming a religious exemption to vaccination was the epicenter of the state’s worst chickenpox outbreak in two decades.

In addition to insurance coverage, the report gave the state high marks for the high number of newborns being breastfed, a declining teen birth rate, and a low number of children with diagnosed asthma.

The state earned straight Ds, however, for the percentage of children ages ten to seventeen who are obese (30.7 percent), how many kids live in food-insecure homes (20.9 percent), and alcohol, tobacco, and pain medication use among high school students. The state’s only F was for housing and economic security: 43 percent of children in North Carolina live in poor or low-income households.

“Children living in families that cannot afford the basics in life often have reduced access to safe living conditions, healthy food, and opportunities for exercise,” the report says, “all of which increase their risk for poor health.”

Contact staff writer Sarah Willets by email at swillets@indyweek.com, by phone at 919-286-1982, or on Twitter @sarah_willets.