By Lisa Freda, Psy.D.
Suicide is the third leading cause of death among adolescents and young adults ages 12 to 24. In particular, thoughts of suicide are relatively common among high school students, and of those who act on these thoughts, risk of successfully completing a suicide rises greatly. There are approximately 50-100 attempts for each completed suicide and 10% of adolescent attempters will make further attempts within 1 year.
September 2010 Vol. 26, No. 9
This article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.
As mental health professionals, our efforts need to focus on reducing risk factors in an effort to prevent attempts.
Suicide is universally rare before age 12. Due to cognitive immaturity and limited access to means, a young child is not generally able to design and carry out a realistic suicide plan. When assessing adolescents who have suicide plans, it is helpful to remember that although the vast majority of attempts by adolescents are by overdose (75.5%), for completed suicides the most common method is firearms (72.3%). Thus, removing access to firearms is one of the most protective actions we can take to
Boys tend to use more lethal methods than girls, with aggression and substance abuse commonly linked to completed suicide. In addition, boys are 5 times more likely to complete suicide than girls; although girls are 6 to 9 times more likely to make suicide attempts than boys. In terms of race, adolescent suicide rates are highest among American Indians/Alaskan Natives. Hispanic adolescent females are also at especially high risk for suicide attempts.
Psychological autopsy studies are the source of most of our knowledge about adolescent risk factors. One of the strongest predictors of completed suicide is the number of prior attempts and their lethality. While youth with lethal plans clearly need immediate intervention, it is also important to consider that due to developmental and cognitive factors, young people's perception of dangerousness is often inaccurate. We need to judge intent carefully, understanding that adolescents with high risk and serious intent to die frequently devise nonlethal plans.
Psychiatric risk factors: Psychiatric diagnosis is a significant risk factor; more than 90% of youth suicides have at least one diagnosis. This statistic highlights the prevention and intervention needs among our own clinical populations. Depressive disorders are most prevalent, and depression alone is a more serious risk factor for girls. Substance abuse is also strongly linked with suicide attempts, especially when combined with mood or anxiety symptoms. Recent research (Epstein & Spirito, 2009) highlights drug use, along with victimization by peers and health problems as critical risk indicators.
Also of note, panic attacks increase suicidal behavior risk for girls, while for boys, disruptive disorders-often comorbid with mood, anxiety, and/or substance abuse- are common. Self-mutilative behavior is also associated with increased risk, contrary to popular thought. Lastly, schizophrenia poses a high risk for suicide attempt, although accounts for a small number of youth suicides overall.
Family risk factors: Family history of suicidal behavior greatly increases risk of attempted and completed suicide; risk doubles for first degree relatives of suicides. Adolescents whose parents have a history of depression or substance abuse are at increased risk, as are children who have been physically or sexually abused.
Internal/external resources: Consideration of adolescent's internal resources, such as coping and problem-solving skills and self-esteem, are important in assessing suicide risk. In assessing cognitive factors, it is important to consider adolescents' beliefs about dying, death, and suicide. In general, a more positive and less shameful view of suicide, and lower fears of death increase risk of suicidal behavior. External resources, particularly availability of social supports, are also a critical risk mitigation factor. Social support systems are especially important for already vulnerable adolescents, such as those with serious mental illness or disability.
Stress: Another important risk factor to weigh is level of stress, with a particular focus on the adolescent's perception of stressful events. In terms of types of stressors, suicidal behavior is linked to interpersonal conflict or loss, typically parent-child conflict for young adolescents and romantic problems for older teens. Given teens' impulsivity, even short-term stressors may prove critical. In addition, cultural and family factors are important.
For example, an argument with a parent might be perceived as an everyday event or a catastrophic occurrence, depending on the meaning assigned to it.
Bullying: Of special note, bullying has long increased the risk for suicidal thoughts and behavior. New research on peer victimization (Kaminski & Fang, 2009), including the increasing common phenomenon of cyberbullying, suggests that youth threatened or injured by peers were 2.4 times more likely to report suicidal thoughts and 3.3 times more likely to report suicidal behavior than nonvictimized peers. "Copycat" behavior: For adolescents, suicide exposure confers a real risk of "copycat" suicides. Risk is proportional to amount, duration, and prominence of media coverage. Gay, lesbian, and bisexual youth, at increased risk for suicide generally, are also particularly vulnerable when exposed to other sexual minority youth who have attempted suicide.
Assessing suicidal ideation is one of the most anxiety-provoking tasks for professionals. (Please note that assessing adolescents who have made a suicide attempt is a specialized task beyond the scope of this paper.) Predicting risk is difficult, particularly since so many factors can increase risk. In addition to assessing stated intent, it is important to evaluate self-harm and suicidal behaviors. These observations may be particularly important in cases where a verbal report may not be very meaningful, such as with a dramatic, silent, or minimizing teenager.
Interviewing families is also an important part of the process, keeping in mind that parents are often unaware of their child's ideas or may not link dangerous behaviors with increased suicide risk. Information gleaned from collaterals is often critical in identifying and removing unrecognized risks and planning treatment. Significant others aside from parents may be important, and as such attention should be paid to teens' identifications, both traditional (race, ethnicity, religion, sexual orientation) and nontraditional groupings (such as based on drug use, online groups, gangs).
In assessing suicidal ideation, there are some helpful self-report measures, but a clinical interview is still our best tool. Considering known risk factors for suicide, the following broad areas and sample questions are offered to guide the assessment process.
Specific, concrete, detailed information is best.
Sample interview questions:
How often do you have thoughts of hurting yourself? How strong are they?
How long ago did you first start to have these thoughts?
Have you thought about how you would do it? When?
Have you taken steps towards acquiring the "gun, pills," and so forth?
Have you made any plans for your possessions or to communicate with people after your death such as a note or a will? Extensive planning and preparation
is unusual for adolescents.
Have you talked to anyone about your suicidal thoughts/feelings?
Who can you turn to for help? Name support people and get permission to contact.
How have you coped with serious problems and stressful situations in the past? Look for evidence of adaptive as well as maladaptive coping strategies.
What would make it easier to cope now? Brainstorm about current problems and assess cognitive style (flexible, rigid). Ask directly how you can help.
What does it mean to you to be dead? To be alive? How would important others feel if you acted on your thoughts?
Why not kill yourself now? What's holding you back?
Do you think things can improve and your future will be happier?
Are there things you want to do that you haven't done yet? What are your hopes and dreams for the future? Assessing affect as well as content helps evaluate hopelessness.
Complete a Mental Status Assessment and Family Assessment, with focus on known risk factors.
It is important to take an action oriented approach to assessment findings. Given the impulsive nature of suicide acts, the most important intervention with high risk youth is environmental. Enlisting parents or caregivers in removing access to firearms, medication, or other dangers is critical. Families and friends need to be involved in making short-term crisis plans. In cases where supports are unavailable, hospitalization or involvement of state protective agencies may be warranted to keep kids safe.
Providers who have an ongoing relationship with an adolescent may be especially helpful in identifying at-risk youth and preventing attempts as their connection may help kids to delay impulses, and make honest safety contracts.
Although research on long-term work with suicidal adolescents is limited, best evidence suggests that cognitive-behavioral work is most helpful in preventing recurrence. Treating coexisting symptoms and reducing risk factors, along with bolstering family awareness and support, is our best hope in reducing the number of teen suicides.
Lisa Freda, Psy.D., is Senior Psychologist at the Bradley School, East Providence; and Clinical Assistant Professor in the Department of Psychiatry & Human Behavior at the Warren Alpert Medical School of Brown University.
References:Epstein JA, Spirito A: Risk factors for suicidality among a nationally representative sample of high school students. Suicide Life Threaten Behav 2009; 39(3): 241-251. Kaminski JW, Fang X: Victimization by peers and adolescent suicide in three U.S. samples. J Pediatr 2009; 155(5): 683-688