Technical Assistance Partnership for Child and Family Mental Health |
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Preventing Tragedy: Bringing an End to Youth Suicide |
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“I’ve got a whole universe of suicide that I enter every so often and it’s got its own little villages where you kind of go, into wrist-slitting town and suffocate-yourselfville and jump-off-a-cliff town and everything. It’s like being stuck in it and you work really hard to get out of it …[but] suicide look[s] like the only way out” (Tania, 17, in Fullagar, 2003.) In America, the third leading cause of death in 15- to 24-year olds, behind unintentional injury and homicide, is suicide. In 1999, more youth died from suicide than from cancer, heart disease, AIDS, birth defects, stroke, and chronic lung disease combined (Centers for Disease Control and Prevention [CDC], 2002). In the past 10 years, even though the rates of serious suicidal ideation have declined for high school students, rates for all attempts and for injurious attempts have increased (see chart below).
Sources: National Center for Health Statistics (2003) and CDC (2004a) Over the past 50 years, the suicide rate among youth has varied substantially. From 1950-1990, the suicide rate among persons ages 5-19 more than quadrupled (National Center for Health Statistics, 2003). In recent years, the rates for completed suicides have declined, largely due to a substantial decrease in suicide by firearm (CDC, 2004c). The graph below shows the rate of completed suicides per 100,00 population from 1950 to 2000. Note that if expressed in percentages, these rates are very small, ranging from 2-3 ten-thousandths of one percent.
Source: National Center for Health Statistics (2003) Because suicide is often under-reported, these estimates are probably low. Some deaths classified as homicides may actually have been teens putting themselves in harm’s way, and other suicides are recorded as “accidental.” Similarly, an accurate recording of suicide attempts is difficult to achieve because some unsuccessful attempts go unnoticed (Lazear, Roggenbaum, & Blase, 2003) Recognizing the many barriers faced daily by youth and adults with mental illness, President Bush established the President’s New Freedom Commission on Mental Health. The President charged this commission with evaluating the United States’ mental health service delivery system and providing advice on methods to improve the system so that adults with serious mental illness and children with serious emotional disturbance can live, work, learn, and participate fully in their communities. The commission responded to the President’s request with a set of six goals, the first of which is for the public to consider mental health as an essential component to overall health. Accompanying this goal is a recommendation to develop a national strategy for suicide prevention (New Freedom Commission on Mental Health, 2003). With youth suicide under the national spotlight, suicidal behavior will hopefully begin to decrease. However, if we really want to see a meaningful decline in youth suicide, we need to empower youth, their families, teachers, and other professionals with knowledge and support. Death can be an uncomfortable subject, but it is important that youth feel comfortable discussing any concerns they may have, especially when it comes to suicide. This article supplies a knowledge base. It describes populations that are at risk and identifies some of the warning signs that may indicate that an adolescent is contemplating suicide. Further, it suggests next steps, how to talk to young people about suicide, and how to help yourself if you are thinking about taking your own life. Who Engages in Suicidal Behavior?
Although adolescent females are significantly more likely to think about and attempt suicide than adolescent males, adolescent males are more than four times more likely to complete a suicide attempt (Roggenbaum & Lazear, 2003). One theory behind this is that males are taught to suppress their feelings, and suicide is their cry for help (Portes, Sandhu, & Longwell-Grice, 2002). Harvard psychologist William Pollack argued, “Many boys have an exterior structure that looks healthy and happy, but behind it lies more pain than we can imagine. Often, they either feel too ashamed to talk about it or have no one they can really talk to” (Thomerson, 2002, pg. 3). With youth of color expressing more feelings of alienation, cultural and societal conflict, academic anxiety, and feelings of victimization, they are a high-risk group for suicide as well ( Institute of Medicine, 2002). In the general population, Whites and Native Americans have the highest suicide rates ( Institute of Medicine, 2002). Native American males have the highest suicide rate among youth of color (Poland & Lieberman, 2003), though young Native American females have suicide rates more than two times that of females in the general population ( Institute of Medicine, 2002). The high suicide rates for this population have been attributed to factors including the stress of acculturation, cultural conflict, loss of ethnic identity, and a lack of cultural and spiritual identity (Lazear et al., 2003). In the most recent National Youth Behavior Survey (which did not have enough data on Native Americans to report population statistics for them) data showed that the prevalence of having attempted suicide was higher among Hispanic (10.6%) than white (6.9%) and black (8.4%) students; higher among Hispanic female (15.0%) than white female (10.3%) and black female (9.0%) students; and higher among black male (7.7%) and Hispanic male (6.1%) than white male (3.7%) students (CDC, 2004a). Sexual minority youth—lesbian, gay, bisexual, and transgender (LGBT)—are considered to be at high risk for suicidal behavior because they are the targets of a great deal of victimization. 41.7% of LGBT youth report not feeling safe in their schools. More than two-thirds report experiencing some form of verbal, physical, or sexual harassment or violence (SIECUS cited in Hetrick-Martin Institute, 2002). LGBT youth also suffer from high rates of depression (Committee on Adolescence, 2000)—a risk factor for youth suicide—perhaps due to factors such as the abuse they receive, the confusion they feel about their sexuality, or the difficulty in “coming out” to family and friends. Nevertheless, despite a widespread perception that LGBT youth are at higher risk for suicide than their peers, data do not uphold this perception (Rutter & Soucar, 2002). For completed youth suicides, the sexual orientation of the youth is often unknown to others before the tragic event. Research on suicide attempts reveals only a slightly different conclusion. When researchers are very careful to identify who is a sexual minority and what constitutes a suicide attempt, they have concluded, “the assertion that sexual minority youths as a class are at increased risk for suicide is not warranted” (Savin-Williams, 2001, p. 989). Epidemiological research has shown that same-sex sexual behavior, rather than same-sex attraction (which is much more common among youth), is the only factor that predicts higher rates of suicide attempts (Wichstrom & Hegna, 2003). A final group to consider is youth in the juvenile justice system. Of the more than 11,000 incarcerated youth, over half suffer from diagnosable, yet untreated mental illnesses (Teplin & McClelland, 1998). Within this group, more than 17,000 incidents of suicidal behavior are recorded in juvenile facilities each year (Hayes, 2000). Youth Risk Factors
Suicide does not typically have a sudden onset. There are a number of stresses that can contribute to a youth’s anxiety and unhappiness, increasing the possibility of a suicide attempt. A number of them are described below. Mental illness and substance abuse: One of the most telling risk factors for adolescents is mental illness. Mental or addictive disorders are associated with 90% of suicides (Poland & Lieberman, 2003). One in ten youth suffers from mental illness serious enough to be impaired, yet fewer than 20 percent receive treatment (Thomerson, 2002). In fact, 60% of those who complete suicide suffer from depression (Poland & Lieberman, 2003). Alcohol and drug use, which clouds judgment, lowers inhibitions, and exacerbates depression, are associated with 50-67% of suicides. The high rates of substance use may be due to the combination of the increasing accessibility to these substances and the young age at which youth are now able to acquire them (Dying Young, 2002). Aggression and fighting: Recent research has identified a connection between interpersonal violence and suicide. Based on a nationally representative survey of youth in grades 9-12, students who reported attempting suicide in the past 12 months were nearly four times as likely to report involvement in physical fights. Further, one in 20 high school students reported both suicide attempts and involvement in physical fights in the past year. 61.5% of students who attempted suicide also reported engaging in physical fights, compared with only 30.3% of students who did not attempt suicide. Suicide is associated with fighting for both males and females, across all ethnic groups, and for youth living in urban, suburban, and rural areas. Researchers hope that efforts to reduce violence can also reduce suicides (CDC, 2004b). Home environment: Within the home, a lack of cohesion, high levels of violence and conflict (Poland & Lieberman, 2003), a lack of parental support, alienation from and within the family (Portes, Sandhu, & Longwell-Grice, 2002), a lack of communication, and a failure to meet parental expectations are all risk factors for suicide (Butler, Novy, Kagan, & Gates, 1994). Any number of these can create a hostile environment that does not meet the needs of adolescents or serve as a much-needed support system. Moreover, this type of family atmosphere can result in youth having low self-esteem, depression, and behavior problems (Butler et al., 1994). Community environment: Adolescents with high levels of exposure to community violence are at serious risk for self-destructive behavior (Vermeiren, Leckman, Deboutte, & Schwab-Stone, 2002). This can occur when an adolescent models his or her own behavior after what is experienced in the community. Additionally, more youth are growing up without making meaningful connections with adults, and therefore are not getting the guidance they need to help them cope with their daily lives (Thomerson, 2002). School environment: Youth who are struggling with classes, perceive their teachers as not understanding them or caring about them, or have poor relationships with their peers have increased vulnerability (Shaffer et al., 2001). Previous attempts: Youth who have attempted suicide are at risk to do it again. In fact, they are eight times more likely than adolescents who have never attempted suicide to make another suicide attempt (King, 1999). Cultural factors: Changes in gender roles and expectations, issues of conformity and assimilation, and feelings of isolation and victimization can all increase the stress levels and vulnerability of individuals (Lazear et al., 2003). Additionally, in some cultures (particularly Asian and Pacific cultures), suicide may be seen as a rational response to shame (Lester, 1997; Lewin, 1986; Sachdev, 1990). Family History/Stresses: A history of mental illness and suicide among immediate family members places youth at greater risk for suicide (Poland & Lieberman, 2003). Exacerbating these circumstances are changes in family structure such as death, divorce, remarriage, moving to a new city, and financial instability (Shaffer et al., 2001). Firearms: Guns are the most common method of suicide for both males and females, accounting for approximately 60% of youth suicides (Poland & Lieberman, 2003). Homes with guns are 4.8 times more likely to experience a suicide of a resident than homes without guns (Roggenbaum & Lazear, 2003). Removing firearms from the homes of suicidal youth is a great step in preventing suicide, as more than 90% of suicides involving firearms are fatal due to the minimal chance for rescue (Committee on Adolescence, 2000). Suffocation: Among youth aged 10-14, suffocation (mostly hangings) has replaced firearms as the most common method of suicide. In 2001, suffocation suicides in this age group occurred nearly twice as often as firearms suicides (CDC, 2004c). Self-Mutilation: Self-mutilation, or self-harm behaviors include head banging, cutting, burning, biting, and digging at wounds (Nichols, 2000). These behaviors are becoming increasingly common among adolescents, especially adolescent girls (Ross & Heath, 2002). While self-injury typically signals the occurrence of broader problems, the reason for this behavior can vary from peer group pressure to severe emotional disturbance. Other motives for this behavior can include relief of intolerable stress, poor coping skills, inadequate problem-solving skills, inability to express feelings in words, beliefs that are irrational and untrue, and suicidal ideation (Nichols, 2000). Although help should be sought for any individual who is causing self-harm, an appropriate response is crucial. Because most self-mutilation behaviors are not suicide attempts, it is important to be cautious when reaching out to the adolescent and not to make assumptions. Situational crises: Approximately 40% of youth suicides are associated with an identifiable precipitating event, such as the death of a loved one, loss of a valued relationship, parental divorce, or sexual abuse. Typically, these events coincide with other risk factors (Poland & Lieberman, 2003). Signs of Impending Suicide
Adolescents do not just wake up one day and decide to kill themselves. Although youth attempting suicide are seeking escape, it is not from life, but from some pain that is perceived as insufferable. Therefore, youth often exhibit warning signs in hope that someone will take notice of their situation and offer to help them. Approximately 9 out of 10 adolescents at-risk for suicide exhibit some form of identifiable signs prior to taking action (Hicks, 1990). However, healthy teens may also exhibit some of these signs, so it is important to look for a pattern and trust your instincts. Changes in self: These can include changes in behavior, appearance, thoughts, or feelings (Poland & Lieberman, 2003). For example, an adolescent may withdraw from friends and family, display changes in patterns of eating and sleeping, and show a loss of interest in pleasurable activities and things that he or she used to care about (Doan, Lazear, & Roggenbaum, 2003). Preoccupation with death: Excessive interest in death, including reading, writing, and talking about the subject. Anyone who hints of suicide or a suicide plan is at great risk and immediate action should be taken (Poland & Lieberman, 2003). Making final arrangements: Actions in this category might include giving away possessions or putting personal affairs in order (Doan et al., 2003; Poland & Lieberman, 2003). Medical symptoms: Especially in cases of depression, an adolescent may seek treatment for recurrent or persistent complaints, including abdominal or chest pains, headaches, lethargy, weight loss, and dizziness (Committee on Adolescence, 2000). Behavior problems: Actions that may be manifestations of depression include running away, truancy, vandalism, self-destructive behavior, drug or alcohol abuse, and sexual deviance (Committee on Adolescence, 2000; Doan et al, 2003). Verbal statements: Both direct and indirect statements may be heard from youth. It is important to take immediate action if they are ever spoken (Doan et al., 2003). Direct statements: “I want to die”; “Life sucks and I want to get out.” Indirect statements: “I want to go to sleep and never wake up;” “Soon the pain will be over;” “They’ll be sorry when I’m gone.” Taking Action: The DOs and DO NOTs
In talking to adolescents, it is important not to minimize or dismiss their problems. Instead, try to provide them with reassurance. Be sure to acknowledge their fear, sadness, and other emotions, and tell them you care about them and want to help them. Also, it is important to keep from encouraging feelings of guilt and being judgmental (Doan et al., 2003). It is important to know how in-depth an adolescent has thought about suicide. Do not be afraid to ask. Because suicide can be a crisis of non-communication and despair, asking about it may open up badly needed lines of communication (Capuzzi & Golden, 1998). Your first question should be whether or not he or she is having suicidal thoughts. If the answer is yes, then ask the individual if he or she has a plan of how to do it. If the adolescent answers yes again, ask if he or she has got whatever is needed to do it, and if so, if a time has been determined. Getting the answers to these questions can help you evaluate the mindset of the adolescent and get him or her the necessary help.
If someone is suicidal, he or she must not be left alone. Try to get the person to seek help immediately from his or her doctor or the nearest hospital emergency room, or call 911. It is also important to limit the person’s access to firearms, medications, or other lethal methods for suicide.
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