Suicides in Adolescents


During the last decade there appears to have been a dramatic increase in attempted and completed suicides among the adolescent population (Emery, 1983). Among 15 to 19 year olds the suicide rate in 1950 was between 2.7 and 3.5 suicides per 100,000.

By 1977 this figure had risen to 14.2, the highest increase in the suicide rate of any group except 20 to 24 year olds. Further, the tendency not to attribute suicidal motives to young adolescents and the desire to spare families public embarrassment result in a number of suicides being officially recorded as accidents (Husain & Vandiver, 1984). As a consequence, some analyses estimate that the actual rates of adolescent suicide may be three times as high as the official government statistics, which show that, in 1983 alone, 6,000 young people killed themselves (Tugend, 1984). Some also contend that for every suicide there are ten unsuccessful attempts, most of which remain unreported. Yet, despite the likelihood of underestimating the actual number of suicides, suicide is still the third leading cause of death among adolescents.

According to the national centers for disease control, the increase in youth suicide is primarily due to the dramatic changes in the male suicide rate (Tugend, 1984). From 1970 to 1980 the male suicide rate increased by 50 percent, in comparison to a 2 percent rise for females. Almost 90 percent of the male suicide victims are white, although there are no significant racial differences among female suicide victims. Because males choose the most violent methods for killing themselves, like shooting and hanging, their suicide attempts are far more successful than females' attempts. In contrast to males, female typically employ methods that are less lethal and more time consuming, such as trying to poison themselves with pills.

The increasing concern about suicide has resulted partially from a number of apparent cluster suicides during recent years (Tugend, 1984; Coleman, 1987). For example, in three of New York's northern suburbs, 36 adolescents killed themselves in 22 months; in Houston suburbs, adolescents took their own lives in three months; and in Plano, Texas, seven adolescents committed suicide in one year. Although in some of these incidents the adolescents did not know one another, in others the friendship between the youths suggest that their suicides may have been related. In response to increasing public concern, the national centers for disease control began extensive research on cluster suicides in 1984. In the meantime, the uncertainty over whether too much publicity contributes to multiple suicides has made researchers proceed cautiously about directing too much public attention to the matter. (Coleman, 1987)

The suicide behavior of adolescents and adults is similar in several aspects (Husain & Vandiver, 1984; Weiner, 1980, 1982). Irrespective of age, three times as many males commit suicide as females, but females attempt suicide three times more often than males. There is more suicide among whites than blacks, more in urban than rural communities, more in higher socioeconomic groups than among poor, and more among Protestants than among Catholics or Jews. Older adolescents and adults usually kill themselves by hanging or shooting, while younger adolescents and children usually take a drug overdose. Most people who fail in a suicide attempt have taken poisonous drugs, a method that increases the chances that someone will discover them before death occurs.

Causes

Depression

Many adolescents who kill themselves do manifest symptoms of depression, but this is not always the case. To assert that depression is the prime cause appears to be overly simplistic. The preponderance of evidence indicates that a number of other variables seem to have an impact on a person's decision to commit suicide (Emery, 1983; Weiner, 1980, 1982)

Attempts are being made to identify the types of behavior that might be the cause of a youngster's suicide (Weiner, 1980,1982). Some psychologists contend that depression among young is often overlooked, because the symptoms are dismissed as a normal part of adolescence. For example, in a 1982 survey of 116 adolescent girls from different racial and socioeconomic backgrounds, attending San Francisco's public high schools, 23 percent were moderately to severely depressed as measured by the Beck Depression Inventory; and 39 percent reported occasional thoughts of suicide (Gibbs, 1983). Even among adolescent psychiatric patients, fewer than 20 percent are diagnosed as having problems primarily caused by depression, yet half of these young people manifest symptoms of depression including behavior such as self-deprecation, crying spells, suicidal thoughts, and experience feelings of sadness, pessimism, and worthlessness (Weiner, 1980). Data like these have led to the suggestion that adults should become more sensitive to adolescents' symptoms of depression.

Depression can be perfectly normal yet transitory reaction to negative events in the adolescent's life. To begin with, the type of depression that contributes to suicidal thinking often emanates from a serious loss in the adolescents life. The loss might be created by incidents like someone's death, parents' divorce, or a breakup with a boyfriend or girlfriend. In addition, feelings of loss can emanate from the loss of self-esteem. Hence, academic failure, social embarrassment, a disfiguring accident, or serious illness can contribute to suicidal thinking (Husain & Vandiver, 1984; Weiner, 1980). Further, chronic depression during adolescence tends to be characterized by excessive self criticism, feelings of powerlessness, inexplicable crying spells, and feelings of hopelessness about the future (Chartier & Ranieri, 1984).

Not all adolescents manifest their depression in the same way. Many will be persistently tired, behave like hypochondriacs, or have problems concentrating at school. In their efforts to escape depressing thoughts, depressed youngsters sometimes become engaged in the quest for continual stimulation and entertainment. They appear excessively restless and become easily bored. They tire quickly of new activities and of former friends, searching for more entertaining substitutes. Still others withdraw into solitary activities, where they need not fear human rejection. Older adolescents often express depression through delinquency, drug abuse, sexual promiscuity, and rebellious behavior at home and at school. A few attempt to cope with depression be joining groups that attract attention to themselves for their unconventional values.

The study by Angold (1988) reviewed the literature on depression in children. This author is the developer of the Childhood Depression Inventory. Angold reports on the different meanings of the term depression and the differing symptoms which constitute the condition. He also reports on the risk factors which tend to predispose children to depressive symptoms. This is relevant given that the objective of the measurement techniques employed in both assessing depression must make reference to factors which can be identified as high risks for suicide. Angold states that it is the adolescent which is more prone to develop depression. Children younger than 10 years old do not have as high depressive ratings as do children from 12 to 19 years old. Girls also have more depressive states than do boys, although this is a controversial issue (Butcher, 1988). Depressive symptoms also have been found equally in low and middle income families, and in black as well as white families. The one significant issue in the development of depression is the family history of depressive disorders. Children with depressive parents tend to develop depressive personality trait characteristics.

Angold (1988) also reviews studies which indicate that certain precipitating factors can lead children to develop depressive symptoms, these include divorce and the loss of a love one. Although there is some controversy about the long range effects of these stressful events on a child's life, there is increasing evidence that some children never get over the divorce and often go into depressive states which last up to 10 years after the stressful event.

The study by Deykin et al. (1987) directly relates to the issue at hand. The diagnostic Interview Schedule was used to determine the prevalence of depressive disorders in children aged 12 to 19. The results of the study found that adolescents who reported a history of alcohol and drug abuse were four times as likely to have a history of depressive disorders than controls. This was particularly true with females who were six times more likely to have experienced depressive symptoms. However, the use of alcohol along with the depression was more prevalent among males than females. Because of the pseudo longitudinal nature of the study the authors concluded that the depressive disorder was present prior to the alcohol abuse.

Another study ( Holmes & Robins, 1987,1988) found that depressive disorders in adulthood could be predicted from parental disciplinary practices. The study assumed that disciplinary actions meant misbehavior in the children who later developed depression. However, the study also found that women were more likely to develop depression and men were more likely to develop alcoholism. The interesting point from this study is that depression and alcoholism were disorders which were most

predictive from knowledge about a child's misbehavior. This would tend to imply that parental influences have a strong and lasting effect on the development of disorders, somewhat supporting the contention that early experiences have effects on symptomatology in a normal population.

The ability to measure depression in children has been discussed by Angold (1988). The relationship of depression to childhood experiences has also been investigated and supported by a number of studies (Carrison et al., 1988). In addition, the contributing factors which parental concordance of affective disorders with that of the children has been investigated Merikangas, et al. (1988). These authors found that depressive disorders present in parents are also at risk of being found in their children. This is not only true of depression but of other psychopathologies and of alcoholism. This finding is not new but it helps to support the contention being laid here that the presence of depression in youths can be measured, is a reliable construct to use in identifying children who might be at high risk of developing alcohol abuse, and can be used to predict alcohol abuse using expectancy testing as well as depressive scores.

Unrealistic Conceptions of Death

It has also been suggested that adolescents with unrealistic conceptions about death are prone to suicidal thoughts (Husain & Vandiver, 1984; McKenry, Tishler, & Christman, 1980). According to this view, the cognitive limitations of early adolescence an distort young people's understanding of death. In our culture, where death is often presented in euphemistic, vague, or exaggerated terms, the realities of death are too often hidden from the young. The melodramatic or emotionless portrayals of death in the media often sustain the image that suicide is an instructive act that can teach one's enemies and careless loved ones a lesson.

The argument has also been offered that rock stars can create a glamour about death that appeals to the young (Attig, 1986). Record albums and stage shows sometimes depict mock hangings and suicidal gestures in an effort to entice the audience. such acts might create genuine confusion among young adolescents, whose views of fantasy and reality may be influenced by the drama of stage limits and illusive images on photo albums. Although the relationship between suicide and our society's portrayals of death in the media or in the entertainment world is still uncertain, the assistant chief of the National Centers for Disease Control states that there is evidence that possible people imitate suicides they view on television or through other media sources. (Tugend, 1984)

Several studies confirm the hypothesis that suicidal youths tend to engage in wishful, magical thinking about death (Husain & Vandiver, 1984) These unrealistic thoughts about death reflect the limitations of children's cognitive development, which include egocentric thinking, the imaginary audience, and the personal fable, as cogently described by Piaget and Elkind. For example, a disproportionate number of suicidal youths have been found to believe in reincarnation and to believe that they will remain cognitively aware of events on earth after they die. Adolescents whose suicide attempts failed have explained that they imagined how good it would feel to observe the effects of their act on those here on earth. Some imagined that their suicides would radically transform the world or would cause their lovers who rejected them to feel forever guilty. Suicide is sometimes envisioned as a chance to be reunited with a deceased loved one. Conceiving of death as an escape from problems rather than as a permanent end to life, suicidal youths tend to differ from nonsuicidal children in their belief that death is temporary.

Societal Factors

According to some cross cultural data, in societies with a high degree of anomie, suicide rates are higher than in countries with low anomie. Anomie is a condition that manifests itself as a feeling of alienation and detachment from other individuals and from society. Anomie is said to arise in situations where personal bonds are discouraged. Societies with the most anomie are those that stress such values as competitiveness, mobility, rapid change, and materialism at the expense of family intimacy and dedication to interpersonal relationships. According to cross cultural comparisons, adolescents in highly industrialized, modern countries like Japan and the United States commit suicide more often than those in more rural, religious and traditional countries. Such suicides are thought to occur partly in response to adolescents' feelings of culturally induced anomie.

It has also been suggested that modern society creates feelings of anomie and insecurity in adolescents through overemphasizing competition and financial success (Husain & Vandiver, 1984). In a society where self esteem and social status are often derived through money, many adolescents grow up under the pressure of having to be number one in social, athletic, and academic pursuits. Pressured on the homefront to succeed, young people may feel overwhelmed by the economic instability, high mobility, competitiveness, and rapid change operative in our technological society. Feeling powerless and lonely in the midst of these pressures, some youngsters may feel so overwhelmed that they opt for suicide.

In support of this argument, data regarding rates of American Indian youths are particularly instructive (Berlin, 1984). Reported suicides among Native American youths have increased by almost 1,000 percent during the past two decades, becoming the second leading cause of death in the 10 to 20 year old age group. Environmental factors contributing to the suicide escalation include a breakdown of tribal tradition, the increasing incidence of divorce, and a decline in the importance of religion. As Indian communities have become more acculturated, the factors contributing to the feeling known as anomie have grown. In support of this analysis, it has been noted that the lowest anomie rates exist in tribes with the most traditional customs and in areas where opportunities for employment and education exist within the tribal community.

Sex Roles

Because three times as many females of every age attempt suicide than do males and use less lethal methods in their attempts, it has been suggested that gender stereotypes may be influencing suicidal behavior (Husain & Vandiver, 1984). According to this view, society offers males certain outlets for expressing their aggression and frustration that are typically denied to females. For example, disobedience to elders, sexual promiscuity, and physical aggression are generally condemned more severely in females than in males. Girls tend to learn to turn their hostility inward rather than to express them overtly. This anger directed toward the self contributes to suicidal thinking; although the reasons underlying the higher rate of suicide attempts among the female population are debatable, girls are clearly at a higher risk than boys. Recognizing this, special attention might be directed toward adolescent girls who manifest symptoms of depression.

Family Factors

Among the variables associated with adolescent suicide a number are related to the adolescents family (Husain & Vandiver, 1984) It appears that drug abuse, marital discord, and physical abuse are more common in the families of suicidal than nonsuicidal youths. Suicidal youth often report feeling unloved and unwanted, suggesting that their parents have been unable to create an accepting, loving atmosphere in the home. Many suicidal children also report that their parents are excessively critical and have high expectations in regard to vocational and academic goals.

Preventing Adolescent Suicide

Some states have assumed legislative initiative in suicide prevention programs (Folk, 1984; Tugend, 1984). In 1984 California and Florida enacted state laws requiring suicide prevention programs in high schools. The programs are aimed at teaching students to recognize suicidal tendencies in themselves and in their friends and to seek help when suicidal thoughts occur. Given the stigma attached to the word suicide some schools are presenting the information under the guise of student stress programs. Brochures are also being provided for parents and teachers. The Florida law further requires that to be eligible for teacher certification, college graduates must receive suicide prevention training in order to recognize the signs of depression and stress in their students. There have been cases where an English teacher would grade an essay by a student- on suicide and return it corrected for grammar (Tugend, 1984).

Several authors have outlined the situation and behaviors that often indicate depression leading to adolescent suicide (McKenry & Christman, 1980; Husain & Vandiver, 1984):

1. Changes in eating or sleeping habits

2. Increasing isolation from friends and family

3. Behaving more aggressively or more belligerently

4. Giving away valued possessions or making comments about getting my life in order

5. Talking or asking questions about suicide

6. A sudden interest in religion and afterlife

7. Experiencing recent losses: a parent's divorce, breaking up with a boyfriend or girlfriend, the death of a friend or relative, a personal injury or chronic illness, the death of a pet

8. Making lower grades at school

9. Complaining often about being bred

10. Breakdowns in communication with parents or other important people

11. A history of repeated 'accidents'

12. Truancy, delinquency, drug abuse, or sexual permissiveness

13. Appearing excessively bored, restless, and hyperactive

14. Verbalizing feelings of helplessness

15. Expressing excessive shame or guilt

Recognizing the need for more data to aid suicide prevention and rehabilitation, the National Centers for Disease Control and the National Institutes of Mental Health instituted suicide research programs in the early 1980s. Through these federally funded programs studies are being conducted on the possible genetic, biological, and family causes of suicide. Since children who come from a family where suicide has been committed are six times as likely to kill themselves than are other young people, researchers are simultaneously examining genetic data and investigating the interpersonal interactions within these families. In addition, researchers are continuing to examine the relationship between suicide and the body's chemicals. For example, low levels of the brain chemical, serotonin, have been correlated with aggressive, impulsive behavior. Since males almost always have less serotonin than females, this finding suggests a possible link between the high attempted suicide rate of females and chemically related impulsivity. Such data should eventually yield a clearer profile of suicidal youth and provide a sounder basis for prevention and treatment.

From the available data it appears that depression, misconceptions about death, a sense of anomie, family factors, and sex role influences contribute to suicidal thoughts, but two important caveats must be pointed out. First, although crises like losing a job, having a violent fight with a parent, to getting pregnant may appear to account for a suicide, a single incident is seldom the primary motivator. Adolescents who attempt suicide have typically been wrestling for some time with conflicts and concerns that they cannot resolve. (Weiner, 1980)

A second caveat is that researchers do not agree that suicides could be prevented if only someone had taken heed of the youngsters cries for help., Some psychologists who have worked with suicidal youths feel that suicide is not clearly enough related to depression to permit us to identify suicide prone adolescents. Most suicides in adolescents come totally out of the blue; either many adolescents give no warning before their suicide or their symptoms are too imperceptible to cause adults much alarm. (Husain & Vandiver,,l 984)

References

Angold, A. (1988). Childhood and adolescent depression. British Journal of Psychiatry 152, 601-617.

Attig, T. (1986). Death themes in adolescent music: The classic years. Adolescence and Death. New York: Springer.

Berlin, I. (1984, March). Suicide among American Indian adolescents. Washington, DC: National American Indian Courts Judges Association.

Butcher, J. (1988). Introduction to the special series. Journal of Consulting and Clinical Psychology 56(2),171.

Carrison, C., Schluchter, M., Schoenbach, V., & Kaplan, B. (1988). Epidemiology of depressive symptoms in young adolescents.

Chartier, G., & Ranieri, D. (1984). Adolescent depression: Concepts, treatments, prevention. In Karoly & Steffen, Eds. Adolescent Behavior Disorders. Lexington, MA: Lexington Books.

Coleman, L. (1987). Suicide Clusters. Boston: Faber and Faber.

Deykin, E., Levey, J., & Weels, V. (1987). Adolescent depression, alcohol and drug abuse. AJPH 77(2) 178.

Emery, P. (1983). Adolescent depression and suicide. Adolescence 18, 245-257.

Folk, J. (1984). Preventative legislation. Psychology Today 18, 9.

Gibbs, J. (1983). Psychosocial factors associated with depression in urban adolescent females. San Francisco: Western Psychological Association.

Holmes, S., & Robins, L. (1987). The influences of childhood disciplinary experience on the development of alcoholism and depression. Journal of Child Psychology 28(3), 399-415.

Holmes, S., & Robins, L. (1988). The role of parental disciplinary practices in the development of depression and alcoholism. Psychiatry 51, 24.

Husain, S., & Vandiver, T. (1984). Suicide in children and adolescents. New York: SP Medical and Scientific Books.

Merikangas, K., Pursoff , B., & Weissman, M. (1988). Parental concordance for affective disorders: Psychopathology in offspring. Journal of Affective Disorders 15, 278-290.

McKenry, P., Tishler, C., & Christman, K. (1980). Adolescent suicide and the classroom teacher. Journal of School Health 50, 130-132.

Tugend, A. (1984, October 31). Researchers begin to examine youth suicide as a national problem. Education Today, 11-12.

Weiner, I. (1980). Psychopathology in adolescence. In Adelson, Ed. Handbook of Adolescent Psychology. New York: Wiley.

Weiner, I. (1982). Child and Adolescent Psychopathology. New York: Wiley.

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