What Parents and Teachers should Know about Suicide in
Adolescents (Part 1)
INTRODUCTION
Suicide is one of the commonest causes of death among young
people. The latest mean worldwide annual rates of suicide per
100,000 are 0.5 for females and 0.9 for males among
5-14-year-olds, and 12.0 for females and 14.2 for males among
15-24-year-olds. Suicide is the sixth leading cause of death
among children aged 5-14 years, and the third leading cause of
death among all those 15-24 years old. In most countries, males
outnumber females in youth suicide statistics. There are far
more suicidal attempts and gestures than actual completed
suicides. One epidemiological study estimated that there were 23
suicidal gestures and attempts for every completed suicide.
Though female teens are much more likely to attempt suicide than
males, male teens are more likely to actually kill themselves.
The suicide rate among young teens and young adults has
increased by more than 300% in the last three decades. Social
changes that might be related to the rise in adolescent suicide
include an increased incidence of childhood depression and
decreased family stability. Some researchers argue that economic
and political institutions have penetrated the family unit,
reducing it to a consumer unit no longer able to function as a
support system, and no longer able to supply family members with
a sense of stability and rootedness. Awareness of the existing
state of the world, now threatened by sophisticated methods of
destruction, can cause depression which contributes to the
adolescent's sense of frustration, helplessness, and
hopelessness. Faced with these feelings and lacking coping
mechanisms, adolescents can become overwhelmed and turn to
escapist measures such as drugs, withdrawal, and ultimately
suicide.
The rising rate has also been explained as a reaction to the
stress inherent in adolescence compounded by increasing stress
in the environment. Adolescence is a time when ordinary levels
of stress are heightened by physical, psychological, emotional,
and social changes. Adolescents suffer a feeling of loss for the
childhood they must leave behind, and undergo an arduous period
of adjustment to their new adult identity. Yet society alienates
adolescents from their new identity by not allowing them the
rights and responsibilities of adulthood. They are no longer
children, but they are not accorded the adult privileges of
expressing their sexuality or holding a place in the work force.
Our achievement-oriented, highly competitive society puts
pressure on the teens to succeed, often forcing them to set
unrealistically high personal expectations. There is increased
pressure to stay in school, where success is narrowly defined
and difficult to achieve. In an affluent society which
emphasizes immediate rewards, adolescents are not taught to be
tolerant of frustration.
RISK FACTORS FOR SUICIDE
Contrary to popular belief, suicide is not an impulsive act but
the result of a three-step process: a previous history of
problems is compounded by problems associated with adolescence;
finally, a precipitating event, often a death or the end of a
meaningful relationship, triggers the suicide. The major,
empirically proven risk actors for suicide among adolescents are
detailed below.
PERSONAL CHARACTERISTICS
Psychopathology: More than 90% of youth suicides and
around 60% of younger adolescent suicide victims have had at
least one major psychiatric disorder. The most prevalent
disorder in adolescent suicide victims is depressive disorders.
Depression that seems to quickly disappear for no apparent
reason is a cause for concern, and the early stages of recovery
from depression can be a high risk period. Substance abuse,
conduct disorder, posttraumatic stress disorder and panic
attacks are the other disorders found to be common in this
population.
Previous suicide attempts: A history of prior suicide
attempts is one of the strongest predictors of completed
suicide, especially in boys. One quarter to one third of teen
suicide victims have made a previous suicide attempt.
Cognitive and personality factors: Hopelessness, poor
interpersonal problem solving ability and aggressive impulsive
behaviour have been linked with suicidality.
Biological factors: Some teens are at greater risk for
suicide because of their biochemical makeup. Abnormalities in
the function of serotonin, a neurotransmitter, have been
associated with suicidal behaviour.
FAMILY CHARACTERISTICS
Family history of suicidal behaviour: Teens who kill
themselves have often had a close family member who attempted or
committed suicide.
Parental psychopathology: High rates of parental
psychopathology, particularly depression and substance abuse,
have been found to be associated with completed suicide and
suicidal ideation and attempts in adolescents. Moreover, family
cohesion has been reported to be a protective factor for
suicidal behaviour among adolescents.
ADVERSE LIFE CIRCUMSTANCES
Stressful life events: Life stressors such as
interpersonal losses and legal or disciplinary problems are
associated with completed suicide and suicide attempts in
adolescents. The anniversary of a loss can also evoke a powerful
desire to commit suicide.
Common problems preceding suicide attempts:
* School or work problems
* Difficulties with boyfriends or girlfriends
* Physical ill health
* Difficulties or disputes with parents, siblings or peers
* Depression
* Bullying
* Low self esteem
* Sexual problems
Physical abuse: Childhood physical abuse has been found
to be associated with increased risk of suicide attempts in late
adolescence and early adulthood.
SOCIOECONOMIC AND CONTEXTUAL FACTORS
School and work problems: Difficulties in school, neither
working nor being in school, dropping out of high school and not
attending college pose significant risks for completed suicide.
Contagion/Imitation: Teens are more likely to kill
themselves if they have recently read, seen, or heard about
other suicide attempts. Evidence continues to amass from studies
of suicide clusters and the impact of the media, supporting the
existence of suicide contagion. The impact of suicide stories on
subsequent competed suicides appears to be greatest for
teenagers.
PREVENTION STRATEGIES
Youth suicide prevention strategies have primarily been
implemented within three domains - school, community, and health
are systems. This article reviews the school-based programs in
detail and briefly describes the community based interventions.
SCHOOL-BASED SUICIDE PREVENTION PROGRAMS
School based suicide prevention programs include both curricula
components to teach students about these warning signs and what
to do, as well as non-curricula components such as peer groups,
hot lines, intervention services and parent training. Prevention
includes education efforts to alert students and the community
to the problem of teen suicidal behavior. Intervention with a
suicidal student is aimed at protecting and helping the student
who is currently in distress. Postvention occurs after there has
been a suicide in the school community. It attempts to help
those affected by the recent suicide. In all cases it is a good
idea to have a clear plan in place in advance. It should involve
staff members and administration. There should be clear
protocols and clear lines of communication. Careful planning can
make interventions more organized, and effective.
The goals of school based suicide prevention programs are to:
* Increase awareness
* Promote identification of students at high risk of suicide and
suicide attempts
* Provide knowledge about the behavioral characteristics
("warning signs") of teens at risk for suicide.
* Provide information to students, teachers and parents on the
availability of mental health resources
* Enhance the coping abilities of teenagers
Education: Education may be done in a health class, by
the school counselor or outside speakers. Education should
address the factors that make individuals more vulnerable to
suicidal thoughts. Education regarding the ill effects of drug
and alcohol abuse would be useful. PTA meetings can be used to
educate parents about depression and suicidal behavior. Parents
should be educated about the risk of unsecured firearms in the
home. Outside mental health professionals can discuss their
programs so that students can see that these individuals are
approachable. Education on the following topics will be useful:
Warning signs of suicide:
* Preoccupation with death and dying
* Signs of depression
* Taking excessive risks
* Increased drug use
* The verbalizing of suicide threats
* The giving away of prized personal possessions
* The collection and discussion of information on suicide methods
* The expression of hopelessness, helplessness, and anger at
oneself or the world
* Themes of death or depression evident in conversation, written
expressions, reading selections, or artwork
* The scratching or marking of the body, or other
self-destructive acts
* Acute personality changes, unusual withdrawal, aggressiveness,
or moodiness
* Sudden dramatic decline or improvement in academic
performance, chronic truancy or tardiness, or running away
* Physical symptoms such as eating disturbances, sleeplessness
or excessive sleeping, chronic headaches or stomachaches,
menstrual irregularities, apathetic appearance
Sudden changes in behavior that are significant, last for a long
time, and are apparent in all or most areas of his or her life
(pervasive) are more specific than presence of isolated signs.
However, it should be noted that many completed suicides had
only a few of the conditions listed above, and that all
indications of suicidality need to be taken seriously in a one
person to another person situation.
Signs of depression in teens:
* Sad, anxious or "empty" mood
* Declining school performance
* Loss of pleasure/interest in social and sports activities
* Sleeping too much or too little
* Changes in weight or appetite
Features of self harm that suggest high suicidal intent:
* Conducted in isolation
* Timed so that intervention is unlikely (for example, after
parents have gone to work)
* Precautions to avoid discovery
* Preparations made in anticipation of death (for example,
leaving indication of how belongings to be distributed)
* Adolescent told other people beforehand about thoughts of
suicide
* The act had been considered for hours or days beforehand
* Suicide note or message
* Adolescent did not alert others during or after the act
(Article continued in Part II)