The Evaluation and Management of Suicide Risk in Adolescents in the Context of Interpersonal Violence
Abstract and Keywords
In this chapter, risk factors for suicidal ideation and behavior are reviewed, including sociodemographics, prior suicidal behavior, nonsuicidal self-injury, depression, anxiety, substance use, family factors, physical and sexual abuse, sexual orientation, and access to firearms. Special emphasis is placed on the intersection of suicidality and interpersonal violence in terms of reciprocal risk. A review of the core areas to address in the acutely suicidal adolescent or the adolescent who has recently attempted suicide is also provided. Clinical questions regarding the adolescent’s current emotional state, suicidal ideation/intent, reasons for suicidality, access to means, and capability of the environment to keep the adolescent safe are suggested. The chapter concludes with a discussion of safety planning.
Suicide incidence increases markedly in the late teenage years and continues to rise until the early twenties. Suicide represents the third leading cause of death for 10- to 24-year-olds (National Center for Injury Prevention and Control [NCIPC], 2014) and is the second leading cause of death for 15- to 24-year-olds (McIntosh & Drapeau, 2014). Suicide attempts are defined as any intentional, nonfatal self-injury, regardless of medical lethality, if intent to die was indicated (O’Carroll et al., 1996). Nationally, the most recent results from the Youth Risk Behavior Surveillance Survey (YRBSS) of youth in Grades 9 through 12 found that 16% of students reported seriously considering suicide, 13% reported creating a plan to kill themselves, and 8% reported trying to kill themselves in the 12 months preceding the survey (Kann et al., 2014).
Interpersonal violence (assault or homicide), the third leading cause of death among 15- to 24-year-olds and fourth leading cause of death for 10- to 14-year-olds (McIntosh & Drapeau, 2014; NCIPC, 2014), is defined as “the intentional use of physical force or power, threatened or actual, against another person or against a group or community that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002, p. 5). Interpersonal violence is divided into intimate partner violence (between current or former romantic partners), which is also referred to as dating violence (Centers for Disease Control and Prevention [CDC], 2012b), and peer nonpartner violence (e.g., fights at school, gang violence; CDC, 2012a). Many researchers and clinicians further differentiate bullying (which is defined as having a power differential) from other forms of peer violence. Nationally, 10.3% of adolescents endorse dating violence (being slapped, hit, or physically hurt on purpose) at the hands of a partner, with females (13%) endorsing higher rates of dating violence victimization than males (7.4%; Kann et al., 2014). Almost (p. 40) a quarter of adolescents surveyed endorse past-year peer physical fights (Kann et al., 2014), and 20% to 30% endorse past-year peer bullying (CDC, 2012c). Interpersonal violence, in all forms, is a significant risk factor for suicidality.
Accumulating evidence suggests strong links between dating violence and suicidality among adolescents. Adolescents who reported dating violence victimization had 3 times the odds of having attempted suicide within the timeframe of the abuse (CDC, 2006). Other studies (Silverman, Raj, Mucci, & Hathaway, 2001) suggest that adolescent female victims of dating violence are 6 to 8 times more likely to think about and attempt suicide than those who have not experienced dating violence. Among girls, experiencing dating violence at baseline was associated with suicidality at a one-year follow-up (Roberts, Klein, & Fisher, 2003), even after controlling for prior dating violence and other potential confounders. In a community sample of Latino youth 11 to 13 years of age, dating violence victimization among boys was associated with a history of suicidal ideation (Yan, Howard, Beck, Sattuck, & Hallmark-Kerr, 2010). Other studies show that both physical dating violence victimization and perpetration increased the odds of suicide ideation.
Peer violence is also strongly associated with risk of suicidality. For instance, adolescents reporting a past-year physical fight and weapon carriage have a higher likelihood of reporting past-year suicidal ideation and suicide attempts (Stack, 2014; van Geel, Vedder, & Tanilon, 2014). Studies suggest that there is a direct correlation between increasing frequency of physical peer victimization and rates of suicide ideation and suicide attempts (Kaminski & Fang, 2009; Turner et al., 2012). Interestingly, it is not just victimization that correlates with suicidality and suicide attempts. Mere exposure to violence—witnessing peer violence in the community—also correlates with higher rates of suicidal ideation (Lambert, Copeland-Linder, & Ialongo, 2008). Increased aggressiveness—for example, being a perpetrator of peer violence—predicts future suicidal behavior as well, particularly for girls (Juon & Ensminger, 1997; O’Donnell, Stueve, & Wilson-Simmons, 2005).
Reviews of the literature (e.g., Kim and Leventhal, 2008) suggest that adolescent perpetrators and victims of bullying are at increased risk for suicidal behavior. In a sample of 208 Swedish adolescents, any kind of bullying (victim, perpetrator, both) was associated with a history of suicide attempts (Ivarsson, Broberg, Arvidsson, & Gillberg, 2005). Likewise, Kim, Leventhal, Koh, and Boyce (2009) prospectively used a peer nomination design to study bullying and risk for suicide in a sample of 1,655 Korean seventh and eighth graders. Adolescent perpetrators and victims of bullying were at increased risk for suicidal ideation and attempts compared to adolescents not involved in any form of bullying. In addition, high school students who report being bullying victims and perpetrators are at higher risk of suicidal behavior than those who are only victimized or only bullied (Roland, 2002; Hepburn, Azrael, Molnar, & Miller, 2012).
Cyberbullying (i.e., bullying that takes place using electronic technology such as mobile phones and social media) is increasingly common. Confirming earlier single-site studies (e.g., Hinduja & Patchin, 2010), a recent meta analysis showed that cyberbullying is more highly correlated with both suicidal ideation and attempts than in-person bullying (van Geel et al., 2014). (See Chapter 7 of this volume by Samantha Pflum, Peter Goldblum, Joyce Chu, and Bruce Bongar for more information on bullying and suicide risk.)
Dating violence, peer violence, and suicidality tend to “cluster” in adolescents (Bossarte, Simon, & Swahn, 2008). Polyvictimization (e.g., experiencing a combination of peer and dating violence, sexual assault, and adverse childhood experiences such as child abuse) also predicts significantly higher rates of suicidal ideation (Turner, Finkelhor, Shattuck, & Hamby, 2012).
In this chapter, risk factors for suicidal ideation and behavior, including interpersonal violence, are reviewed. These background variables set the stage for the assessment of suicidal risk. Whenever possible, special emphasis is placed on the intersection of suicidality and interpersonal violence, both in terms of reciprocal risk as well as management.
Risk Factors for Suicidal Behavior
Sociodemographic factors related to suicidal behavior and their overlap with interpersonal violence are reviewed in the following.
Sex differences among 13- to 24-year-olds who die by suicide are pronounced (CDC NCIPC, 2013a). In 2011, more adolescent males (20.2 per 100,000) than females (5.4 per 100,000) died by suicide (McIntosh & Drapeau, 2014). Sex differences in the opposite direction exist with respect to suicide attempts. YRBSS (Kann et al., 2014) data indicate that female high school students (22.4%) (p. 41) were more likely than males (11.6%) to have seriously considered suicide in the 12 months preceding the survey. Moreover, they were also more likely (16.9%) than males (10.3%) to report having a suicide plan. Similarly, female respondents (10.6%) were more likely than males (5.4%) to have attempted suicide in the year preceding the study and were more likely (3.6%) to have made an attempt requiring medical attention compared to males (1.8%). In one study, being female doubled the odds of reporting suicidal ideation, even after controlling for dating violence (Nahapetyan, Orpinas, Song, & Holland, 2014).
Sex differences in youth who die by suicide are related, in part, to the greater likelihood of males having multiple risk factors for suicide, including comorbid mood and alcohol abuse disorders and a higher likelihood of choosing more lethal suicide attempt methods (Gould, Fisher, Parides, Flory, & Shaffer, 1996; Shaffer & Pfeffer, 2001). Greater levels of aggressive behavior in males compared with females may also increase risk for eventual death by suicide (Brent, Baugher, Bridge, Chen, & Chiapetta, 1999).
Adolescent boys are more likely to be both victims and perpetrators of non-self-directed forms of violence as well, although sex differences in rates of peer violence are narrowing. Notably, between 19% and 27% of adolescent females participating in national surveys reported having been in a serious fight in the past year (Substance Abuse and Mental Health Services Administration, 2009), and 40% of assaulted adolescents seen in the emergency department in 2012 were female (CDC NCIPC 2013b); these rates parallel that of adolescent males. Like males, the majority of assaults among adolescent females are reported to be caused by peers, not dating partners (Mollen, Fein, Localio, & Durbin, 2004; Cheng et al., 2006; Walton et al., 2009).
Similarly, sex differences in dating violence are minimal, with mutual dating violence being commonplace among this age group (Chiodo et al., 2012). Most studies report comparable rates of dating victimization and perpetration among the two sexes (Archer, 2000; Foshee, Linder, MacDougall, & Bangdiwala, 2001; Jain, Buka, Subramanian, & Molnar, 2010; Rothman, Johnson, Azrael, Hall, & Weinberg, 2010; Foshee et al., 2011), although recent longitudinal study among high school students in the southeast region of the United States found that males were more likely to report dating violence victimization than girls, girls reported more perpetration than boys (Nahapetyan et al., 2014). A longitudinal dating prevention study (Chiodo et al., 2012) found that 30% of 11th-grade adolescent girls endorsed being in a romantic relationship where they had experienced physical dating violence, of whom 26% reported being exclusively perpetrators and 53% reported being both perpetrators and victims. Severity of dating violence perpetration is also similar among adolescent females and males. One study (Rothman et al., 2010) conducted among a sample of adolescents with a history of alcohol use screened in a pediatric medical emergency department found that 55% of girls and 45% of boys endorsed at least one incident of dating violence perpetration; about a third (29%) of the girls endorsed severe dating violence perpetration compared to 15% of the boys. Severe dating violence included at least one incident of attempting to choke, causing an injury that necessitated medical attention, hitting with a fist or object, beating up, and/or assaulting with a knife or gun in the past six months (Rothman et al., 2010). Moreover, victimization and perpetration of this kind of violence was equally distributed among the girls (29% endorsed each), whereas 23% of the boys endorsed being victims of this kind of violence versus 15% perpetrators (Rothman et al., 2010). (See Chapter 4 of this volume by Randy Broum for more information about youth violence.)
In 2011, suicide rates among 15- to 24-year-olds were lower among Asian/Pacific Islanders (6.39 per 100,000), non-Latino Blacks (7.22 per 100,000), and Latino/as (7.04 per 100,000) than non-Latino Whites (13.52 per 100,000), according to National Vital Statistics data available from the CDC’s NCIPC (2013b). American Indian/Alaska Natives (AI/AN) had the highest suicide deaths rates (29.33 per 100,000) among this age group. Among young adult females, AI/AN (12.02 per 100,000) had the highest suicide rates followed by non-Latino White females (4.83 per 100,000), Asian/Pacific Islander females (2.92 per 100,000), Latinas (2.91 per 100,000), and non-Latina Black females (2.36 per 100,000). Similarly, AI/AN males had the highest suicide rates among this age group (46.08 per 100,000), followed by non-Latino White males (21.85 per 100,000), non-Latino Black males (12.02 per 100,000), Latinos (10.81 Latino per 100,000), and Asian/Pacific Islander males (9.75 per 100,000).
In contrast to data regarding suicide deaths, YRBS (Kann et al., 2014) data shows higher rates of past-12-month suicide attempts among Latino/a (11.3%) and Black (8.8%) adolescents, as compared (p. 42) to White adolescents (6.3%). Latino/a (18.9%) students also reported higher rates of having seriously considered suicide than their White (16.2%) and Black counterparts (14.5%) and higher rates of having made a plan for how they would attempt suicide (Latino/a 15.7%, White 12.8%, Black 10.4%). Across race groups, females (22.4%) were more likely than males (11.6%) to report having seriously considered attempting suicide 12 months prior to the study and having made a suicide plan (16.9% vs. 10.3%; Kann et al., 2014).
Although recent YRBS race-based data reported by the CDC does not include comparisons for AI/AN students (due to small numbers), aggregate data (Rutman, Park, Castor, Taualii, & Forquera, 2008) suggests that AI/AN are at elevated risk for suicide. Aggregated YRBS data from 1997 to 2003 for AI/AN high school–age youth (1% of the aggregate sample) indicated (a) 27.9% of AI/AN youth endorsed seriously considering suicide in the year preceding the study compared to 18% of White students; (b) 25% of AI/AN compared to 14% of White students made a suicide plan; (c) 20.8% attempted suicide compared to 6.7% of their White counterparts; and (d) 10.9% of AI/AN youth compared to 1.9% of White youth made a suicide attempt that resulted in injury (Rutman et al., 2008). However, other studies have found that these rates vary considerably by tribe and by where these youth were raised (i.e., in urban areas vs. on a reservation; Freedenthal & Stiffman, 2004; Goldston et al., 2008).
Previous YRBS (CDC, 2012c) data indicate dating violence and peer violence disparities between adolescents of color and their White counterparts; White adolescents were less likely than their Black and Latino peers to have been the victims of dating or peer violence. Non-YRBS data sets show that Black and Latino youth are also more likely to witness peer violence than their White peers (e.g., Zimmerman & Messner, 2013). Although more Black students (34.7%), than Latino/a (28.4%) and White students (20.9%) reported being in a physical fight in the prior year (Kann et al., 2014), this relationship may be a function of poverty, exposure to violence, and exposure to delinquent peers (CDC, 2012a) rather than of race/ethnicity. Racial/ethnic disparities in prevalence of dating violence have decreased, with higher victimization rates among females across all race groups in the most recent YRBS data (Kann et al., 2014). Although there is no recent YRBS-based dating violence rates for AI/AN youth, analyses of prior YRBS years (Rutman et al., 2008; Pavkov, Travis, Fox, King, & Cross, 2010) show that AI/AN high school–age youth experience higher rates of both dating and peer physical violence.
Dating violence and peer violence have been strongly linked to suicidal behavior in ethnic minority adolescents. The 2004 Youth Violence Survey, which gathered data among mostly ethnic minority adolescent (45% Latino, 28% non-Latino Black, 23% non-Latino White) public high school students in a high-risk urban school district, found that a combination of victimization and perpetration—for either peer or dating violence—was the strongest correlate of reporting a past-year suicide attempt (Swahn et al., 2008). These findings did not vary by race/ethnicity, nor did researchers find an elevated association between suicide attempts and victimization or perpetration alone. Although studies cited did not find race differences in the relationship between dating or peer violence and suicidal behavior, most studies either do not report sociodemographics in their analyses (Klomek, Marrocco, Kleinman, Schonfeld, & Gould, 2008; Kaminski & Fang 2009; Chiodo et al., 2012), conflate heterogeneous ethnic minority groups into homogeneous groupings, or are not sufficiently powered to find these differences.
Age of Onset
Suicidal thoughts escalate significantly around age 12 and then continue to increase across adolescence (Nock et al., 2013). After puberty, rates of suicide increase with age until they stabilize in young adulthood (Heron et al., 2009). Psychological explanations for the onset of suicidality in early adolescence include the increase in psychopathology that emerges during adolescence, particularly mood disorder and substance abuse combinations (Shaffer, Gould, Fisher, & Trautman, 1996; Groholt, Ekeberg, Wichstrom, & Haldorsen, 1998; Brent et al., 1999). In addition, older adolescents have more autonomy and less parental supervision, which may make recognition of imminent risk from adults less likely.
With the development of cognitive skills, adolescents also become more capable of planning and executing a suicide attempt (Groholt et al., 1998; Brent et al., 1999). Indeed, the increase in suicidality and death by suicide across adolescence is likely a function of changes in the developing brain. Desmyter, Bijttebier, and van Heeringen (2013) conducted a review of studies that compared brains of individuals with and without suicidal behavior. Findings demonstrated differences in areas of the brain in the same network as decision-making (p. 43) processes for suicidal individuals, relative to nonsuicidal individuals. This finding resonates with impulsivity research by Klonsky and May (2010) that found that adolescents and young adults who have attempted suicide demonstrate a diminished ability to think through their actions relative to those with suicidal ideation only. Another recent review by van Herringen and Mann (2014) found impairments of the serotonin neurotransmitter system and the hypothalamic-pituitary-adrenal axis stress-response system that manifest as deficits in mood regulation and problem solving, as well as a tendency toward aggressive traits, overreactivity to negative social signs, and heightened emotional distress, leading to suicidality. (See Chapter 20 of this volume by Victoria Arango and Mark Underwood for more information on neurobiological factors in suicide.)
The trajectory of youth violence is very similar to that of suicidality. Both peer and dating violence become fairly common during adolescence and has been shown to increase with age (CDC, 2012c). The highest rates are reported in midadolescence with this developmental period being a particularly vulnerable time when interpersonal violence is usually initiated (Smith, White, & Holland, 2003). This trajectory is thought to be due to the slow maturing of the frontal lobe, which is accompanied by an increase in impulsive and risky behaviors. Significant decreases in rates of both peer and partner violence occur by the late teens and early twenties.
Prior Suicidal Behavior
A prior suicide attempt is one of the best predictors of eventual death by suicide (Shaffer et al., 1996; Brent et al., 1999; Bridge, Goldstein, & Brent, 2006), as well as future suicide attempts (Prinstein et al., 2008; Goldston et al., 2009) among adolescents. Goldston et al. found the number of prior attempts was the strongest predictor of a post-hospitalization suicide attempt. A Scandinavian study (Groholt, Ekeberg, & Haldorsen, 2006) found that approximately two-thirds of adolescents who were hospitalized for a suicide attempt reported a repeat attempt within two years. The risk of a repeat attempt is estimated to range from 10% at six-month follow-up to 42% at 21-month follow-up, with a median recurrence rate range of 5% to 15% per year (Goldston et al., 1999; Hawton, Zahl, & Weatherall, 2003).
The rates of subsequent death by suicide are low, from 0.5% to 1% per year, but these rates are much higher than the general population (Hawton et al., 2003). In a sample of more than 5,000 adolescents and young adults treated in a hospital in the United Kingdom following an act of deliberate self-injury (with or without suicidal intent), the risk of death by suicide in the following year was 35 times the annual population risk in males and 75 times the annual population risk in females (Hawton et al., 2003).
Escalations in suicidal ideation, as well as the presence of suicide planning, are also important aspects of suicidal behavior that may increase the likelihood of an attempt. Longitudinal studies indicate that elevations in suicidal ideation (Prinstein et al., 2008) and/or frequent and long lasting suicidal ideation that is accompanied by the planning of a suicide attempt increases the likelihood of an eventual suicide attempt (Lewinsohn, Rohde, & Seeley, 1996), as well as increases risk for making another attempt among adolescents who have attempted suicide (Goldston et al., 1999).
Nonsuicidal self-injury (NSSI), defined as self-harm without suicidal intent, is highly prevalent among adolescent suicide attempters and may differentiate repeat from first-time attempters (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Prinstein et al., 2008; Hamza, Stewart, & Willoughby, 2012). Nock et al. found that 70% of psychiatrically hospitalized adolescents with a history of NSSI reported a lifetime history of a suicide attempt and 55% reported a history of multiple suicide attempts. Studies have also found that a longer history of NSSI is associated with a higher lifetime rate of suicide attempts (Nock et al., 2006; Asarnow et al., 2011).
Esposito, Spirito, Boergers, and Donaldson (2003) found greater severity of NSSI among multiple than first-time adolescent suicide attempters. Guan, Fox, and Prinstein (2012) found that a history of NSSI led to a seven-fold increase in risk for future suicide attempts, after controlling for past attempts, sex, and depressive symptoms among high school students. Further, Prinstein et al. (2008) found greater frequency of NSSI to be associated with slower remission of suicidal ideation among previously hospitalized adolescents, suggesting that NSSI may also be associated with a poor outcome among suicidal youth. (See Chapter 27 of this volume by Joseph Franklin and Matthew Nock for more information about the relationship of NSSI and suicidal behavior.)
Few studies have examined the role of interpersonal violence on NSSI or whether NSSI puts an adolescent at risk for dating or peer violence, or vice versa. However, one cross-sectional study (p. 44) (Weismoore & Esposito-Smythers, 2010) conducted with a clinical sample of adolescents on an inpatient unit found that NSSI was associated with a history of assault in adolescence, including physical and sexual victimization at the hands of peers and dating partners, but not childhood abuse (physical or sexual) at the hands of caretakers. The authors also found that those adolescents with the most cognitive errors (i.e., overgeneralization, selective abstraction) and most negative self-views had higher odds of reporting NSSI.
Why do prior suicidal behavior, NSSI, and interpersonal violence increase risk for a repeat suicide attempt? It is possible that the underlying mechanism that drives an adolescent to attempt suicide is common to both types of intentional injury (i.e., self-directed vs. directed at others). Joiner (2005) emphasizes that a capacity to engage in lethal self-injury must be acquired over time and that people become capable of suicidal behavior only after they have habituated to dangerous behavior. Therefore, prior suicidal behavior lowers the threshold needed to precipitate future suicidal behavior. Both suicidal behavior as well as youth violence exposure may result in the experience of injury and pain over time, which may also lead individuals to lose their innate fear of pain, thus allowing them to engage in progressively more damaging and potentially lethal self-injurious acts and/or acts of violence against others (Joiner, 2005; Van Orden, Witte, Gordon, Bender, & Joiner, 2008).
Depressed Mood and Mood Disorders
There is a strong association between depressed mood and adolescent suicidal behavior in clinical and community samples (Evans, Hawton, & Rodham, 2004). Greater severity of depressed mood has been associated with slower remission of suicidal ideation (Prinstein et al., 2008). Goldston, Reboussin, and Daniel (2006) followed 180 adolescents discharged from a psychiatric inpatient unit for a median of 11 years and found that self-reported depressive symptoms predicted future suicide attempts. In a representative sample of 2,464 high school students, disturbed concentration, middle insomnia, and hopelessness, all symptoms of depression, were related to suicide attempts at baseline, but only worthlessness was prospectively found to predict suicide attempts between 15 and 20 years of age (Nrugham, Larsson, & Sund, 2008).
The relationship between severity of depressed mood and adolescent suicidality may vary by history of suicidality. Esposito, Spirito, Boergers, and Donaldson (2003) found that adolescents with a history of more than one suicide attempt had more severe depressive symptoms than first-time attempters. In a similar study, repeat suicide attempters but not first-time attempters reported more severe depressive symptoms than adolescents with no suicide attempt history (Goldston, Daniel, Reboussin, & Kelley, 1996). Thus a severe depressed mood may be a particularly salient risk factor for a repeat attempt among adolescents with a prior attempt history.
Depressive disorders have consistently been reported in attempted suicide and death by suicide in adolescents (Gould, Greenberg, Velting, & Shaffer, 2003; Evans et al., 2004). A review of the literature suggests that rates of depressive disorders range from 49% to 64% among adolescent suicide victims (Gould et al., 2003). Further, the odds ratios of death by suicide among adolescents with mood disorders ranged from 11 to as high as 27.
A formal diagnosis of major depression disorder also is common in attempted suicide. In the Goldston et al. (2009) naturalistic, prospective study described previously, after controlling for demographic variables and prehospitalization suicide attempts, major depression disorder was associated with more than a five-fold increase in risk for suicide attempts, with this relationship increasing in strength with age. Major depression disorder and dysthymia were also found to be more common among repeat attempters than first-time attempters. An association between mood disorders and suicide attempts was found in a large community-based sample of 2,464 high school students (Nrugham et al., 2008), but only dysthymia diagnosed at age 15 was found to prospectively predict suicide attempts between 15 to 20 years of age, even after controlling for depressive symptoms. One study on pediatric bipolar disorder and suicide attempts in a clinical sample of 405 children and adolescents, ages 7 to 17 years, found approximately one-third of youth reported a history of suicide attempts (Goldstein et al., 2005).
The correlation between mood disorders and suicidal behavior may be explained, at least in part, through cognitive processes associated with depression, that is, cognitive errors (e.g., overgeneralization, catastrophizing, selective abstraction), the cognitive triad (i.e., negative views of self, world, and future), and depressive automatic thoughts (e.g., “I don’t deserve to be loved”; Shirk, Boergers, Eason, & Van Horn, 1998; Jacobs, Reinecke, Gollan, & Kane, 2008). With repeated stressful events, these dysfunctional cognitions can become more stable (p. 45) and pervasive, especially if left untreated, and may result in suicidal ideation and an eventual attempt. Indeed, cognitive errors, hopelessness, and worthlessness have all been associated with suicidality among adolescents (Brent, Kolko, Allan, & Brown, 1990; Kingsbury, Hawton, Steinhardt, & James, 1999).
Depressive symptoms are also strongly associated with exposure to peer and partner violence (Kilpatrick et al., 2003; Robinson, Paxton, & Jonen, 2011; Ranney et al., 2013). Many correlates of depression—such as irritability, poor self-esteem, and poor self-regulation of emotions—are also commonly related to physical violence (Cyranowski, Frank, Young, & Shear, 2000; Goldsmith, Chesney, Heath, & Barlow, 2013). Violence may increase stress reactivity and reinforce maladaptive coping skills, thereby worsening depressive symptoms (Seiffge-Krenke, 2000). Whether sex mediates the interaction between violence and depression is undetermined. Some studies suggest that females are more likely than males to develop depression after violence exposure (Ranney et al., 2013), while other studies suggest that sex differences in depression are attenuated by violence exposure (Dunn, Gilman, Willett, Slopen, & Molnar, 2012; Javdani, Jaleel, Suarez, Nichols, & Farmer, 2014).
Anxiety Symptoms and Disorders
A large body of research suggests that adolescent suicide attempters report higher levels of anxiety and anxiety disorders than those without an attempt history, though results are not always consistent (Evans et al., 2004). Goldston et al. (1999, 2006) found that self-reported symptoms of anxiety, particularly trait anxiety, predicted future suicide attempts in adolescents over 5 to 11 years of follow-up. In a clinical sample, generalized anxiety disorder and panic disorder predicted future suicide attempts, though only panic disorder remained significant in a multivariate model. Generalized anxiety and panic disorder were also found to be more common among repeat attempters compared to first-time attempters (Goldston et al., 2009). Mazza (2000) found an association between posttraumatic stress symptomatology and suicidality (current ideation and attempt history) among a group of high school students. Students reporting higher posttraumatic stress symptom severity reported more suicide ideation and were more likely to have a suicide attempt history than those in the average severity group. Posttraumatic stress symptoms were positively and independently related to suicide ideation but not attempt history, once depression and sex were controlled for (Mazza, 2000).
Similar to mood disorders, cognitive distortions in anxiety disorders are associated with suicidality. Adolescents with anxiety disorders have a lower threshold for perceived threat, expect negative outcomes in threatening situations, underestimate their competency in dealing with perceived threat, and experience higher levels of anxious automatic thoughts in comparison to children and adolescents without anxiety disorders (Barrett, Rapee, Dadds, & Ryan, 1996; Bögels & Zigterman, 2000). Because anxiety and depressive disorders often co-occur, if these cognitions are combined with depression-related cognitive distortions, such anxious thoughts may become overwhelming. Under such conditions, suicidal behavior may be considered as a means of escape.
There is also a strong link between violence exposure and anxiety disorders, particularly posttraumatic stress disorder (PTSD; Boccellari et al., 2007; Cisler et al., 2012; McLaughlin et al., 2013). This relationship is likely a dose–response relationship (Hedtke et al., 2008; Cougle, Resnick, & Kilpatrick, 2009). Adolescents who develop acute stress disorder immediately after an emergency department visit for a violent injury are likely to progress to full-blown PTSD (Fein et al., 2002; Pailler, Kassam-Adams, Datner, & Fein, 2007). Whether gender influences the risk of post-violence PTSD is under debate, with some authors suggesting different types of PTSD symptoms between the two genders (Langeland & Olff, 2008; McLaughlin et al., 2013; Steven Betts, Williams, Najman, & Alati, 2013; Javdani et al., 2014). The association between trauma experience, PTSD, depression, and suicidality is complicated, with some studies suggesting that PTSD may act as a mediating variable between violence and depression (Mazza & Reynolds, 1999; Kerig, Ward, Vanderzee, & Arnzen Moeddel, 2009) or that it may simply be a marker of general mental distress (Adams et al., 2013).
Anger, Impulsivity, Aggression, and Conduct Disorders
Disruptive behavior disorders are strongly associated with attempted suicide and death by suicide among adolescents, particularly in the presence of comorbid mood disorders (Gould et al., 2003; Evans et al., 2004). There is an especially strong association between disruptive behavior disorders and repeat suicide attempts (Esposito et al., 2003). Approximately one-third of males who died by suicide have been (p. 46) found to have had a conduct disorder diagnosis (Gould et al., 2003), and conduct disorder has been found to predict future suicide attempts among psychiatrically hospitalized adolescents (Goldston et al., 2009) but only in the presence of major depressive disorder. In a large epidemiologic sample of 1,420 children and adolescents (9 to 16 years old), disruptive behavior disorders were found to predict suicidality (ideation, plans, and/or attempts) over the course of three-month follow-up, even after adjusting for other disorders and covariates (Foley, Goldston, Costello, & Angold, 2006).
The association between anger and suicidality varies as a function of suicide history. In one study (Stein, Apter, Ratzoni, Har-Even, & Avidan, 1998), repeat attempters, first-time attempters, and nonsuicidal inpatient controls reported more trait anger than community controls, but only repeat suicide attempters reported more anger than nonsuicidal inpatients. Esposito et al. (2003) found that repeat adolescent suicide attempters evaluated in a general hospital emergency department or pediatrics floor reported higher levels of trait anger than first-time attempters. In a third study (Goldston et al., 1996), higher levels of self-reported trait anger were found among adolescent inpatients with a previous suicide attempt compared to those who recently made a first attempt and those who never made a suicide attempt. No differences were found across groups on degree of state anger. Overall it appears that adolescents with more significant suicide histories report particularly high levels of trait anger. However, the work of Goldston et al. suggests that recent suicidal behavior may have a cathartic effect with respect to anger. A suicide attempt may also effectively reduce anger-related emotional arousal and/or temporarily remove adolescents from situations that promote intense anger. In another study that examined self-reported levels of anger before and after a suicidal crisis, anger was found to increase from the time of the precipitant stressor to the time of the suicidal crisis for all adolescents. However, those who carried through with an attempt during the suicidal crisis reported a greater decrease in anger than those who only reported suicidal ideation (Negron, Piacentini, Graae, Davies, & Shaffer, 1997). Thus it is possible that some adolescents may attempt suicide as a maladaptive means of coping with unresolved anger.
Impulsive aggression (i.e., quickly responding with heightened levels of hostility/anger to frustration or confrontation) may be more important than either impulsivity or aggression alone in contributing to suicidal behavior and may be genetically transmitted (Brent & Melhem, 2008; Bronisch & Lieb, 2008). A number of family studies suggest that impulsive aggression in adolescent offspring (Melhem et al., 2007) or both parent and adolescent offspring (Brent et al., 2002), increases risk for an adolescent suicide attempt. Brent et al. (2003) found that impulsive aggression among adolescent offspring was the most powerful predictor of the transmission of suicidal behavior from parent to child.
After controlling for depressive symptoms, impulsivity predicted suicidality for juvenile offenders but not for the psychiatrically hospitalized adolescents (Sanislow, Grilo, Fehon, Axelrod, & McGlashan, 2003). Thus the association between impulsivity and suicidality may vary as a function of the population under study with a stronger relationship found among adolescents with conduct/externalizing problems.
There is also a connection between aggressive and suicidal behaviors. O’Donnell et al. (2005) followed a community sample of 769 African American and Latino adolescents over the course of three years. Aggressive behaviors reported by adolescents in the eighth grade (i.e., fighting, carrying a weapon, use of a weapon) were found to predict suicidality (ideation, plan, and/or attempt) in the 11th grade for females but not for males. In a study of informant reports of aggressive behaviors in a sample of 55 child and adolescent suicide victims, compared to a community control sample of 55 nonsuicidal adolescents, history of aggressive behavior was found to be significantly greater among adolescents who died by suicide than community controls (Renaud, Berlim, McGirr, Tousignant, & Turecki, 2008). However, in a multivariate model controlling for psychiatric factors, the relation between aggression and suicide was reduced to nonsignificance. In a psychiatrically hospitalized sample of 270 adolescents, youth, but not parent, report of aggression was found to be associated with suicidal behavior among youth with internalizing symptoms (Kerr et al., 2007).
Substance Use Disorders
Substance use disorders (SUDs) have been associated with both attempted suicide and death by suicide among adolescents. In a review conducted by Esposito-Smythers and Spirito (2004), rates of any SUD among adolescents who died by suicide were found to range from 27% to 50%, alcohol use disorder ranged from 22% to 27%, and rates of illicit drug use disorders ranged from 13% to 25%. Among suicide attempters, rates of alcohol and/or cannabis (p. 47) use disorders were found to range from 27% to 50% in the Esposito-Smythers and Spirito review. Across studies reviewed, the presence of a SUD was associated with a three- to six-fold increase in likelihood of a suicide attempt. Additional research suggests that rates of alcohol and cannabis use disorders increase along with repetitive suicidal behavior (D’Eramo, Prinstein, Freeman, Grapentine, & Spirito, 2004).
In the Goldston et al. (2009) longitudinal study in which 180 adolescents were followed for up to 13 years post-psychiatric hospitalization, SUDs predicted future suicide attempts in univariate analyses and the relation between SUDs and suicidality strengthened as adolescents grew older. However, this association was nonsignificant in multivariate analyses, suggesting SUDs primarily confer risk for suicidal behavior in the presence of other mental health disorders. Similar results were found in a large epidemiologic sample of 1,420 children and adolescents ages 9 to 16. SUDs only predicted suicidality (ideation, plans, and/or attempts) in the presence of other mental health disorders, particularly depression, over the course of a three-month follow-up (Foley et al., 2006).
Bagge and Sher (2008) note that there are two dimensions of this association: directionality (alcohol leads to suicidal behavior, suicidal behavior leads to alcohol use, or a spurious relation) and temporality (proximal vs. distal effects of alcohol use and suicidal behavior). For example, Hufford (2001) suggests the acute effects of intoxication may heighten psychological distress, increase aggressiveness (toward self and others), enhance suicide-specific alcohol expectancies (e.g., “alcohol will give me the courage to make a suicide attempt”), and inhibit the generation and implementation of adaptive coping strategies. Among individuals contemplating suicide, this concurrent increase in psychological distress, aggressiveness, and cognitive distortion may be sufficient to propel suicidal thoughts into action. With respect to distal effects, alcohol use disorders may be associated with increases in stress and co-occurring psychopathology, which in turn increases risk for suicidal behavior. Over time, stress resulting from substance-related social, academic, and/or legal problems, when combined with depressive symptoms, may result in a suicide attempt.
Both peer and partner violence are associated with high rates of alcohol and other drug use (Yan et al., 2010; Cunningham et al., 2014). Substance use may increase the risk of violence, may co-occur due to clustering of risky behaviors, or may be a means of coping with post-violence consequences. For example, a longitudinal study of African American youth (Xue, Zimmerman, & Cunningham, 2009) found that early peer violence predicted later alcohol use; early alcohol use predicted later violent behavior; and decreases in alcohol use and violence were concurrent. This relationship was not modified by gender. Similarly, Yan et al. (2010) showed evidence for the link between alcohol and dating violence among a community sample of Latino youth. When compared to those who had not experienced dating violence, victims were more likely to experience adverse psychological outcomes like depression and suicidality and engage in alcohol related risk-behavior (heavy drinking). Specifically, girls who engaged in binge drinking were at about 27 times greater odds of experiencing dating violence victimization when compared to girls who did not report a binge-drinking history. For boys, those who reported dating violence victimization also reported high-risk behaviors, such as carrying a weapon, suicide ideation, and alcohol consumption.
Studies suggest that youth with a history of violence and alcohol and other drug use are at the highest risk of suicidality. For example, Silverman et al. (2001) found elevated odds of having a lifetime prevalence of sexual and physical dating violence among a nationally representative adolescent female sample when endorsing (a) past 30-day binge drinking (double the odds); (b) a history of cocaine use (triple the odds); (c) considering suicide in the 12 months prior to the study (six times the odds); and (d) suicide attempts (nine times the odds), independent of each other.
Various combinations of comorbidity, within and between internalizing and externalizing disorders, increase risk for attempted suicide and death by suicide. The likelihood of adolescent suicide attempts increased greater than two-fold with each psychiatric disorder that was diagnosed in one study (Goldston et al., 2009). Mood disorders, in combination with disruptive behavior and/or SUDs, seems to greatly increase risk for suicidal behavior (Brent, Perper, Moritz, Baugher, Schweers, & Roth, 1993; Shaffer et al., 1996; Goldston et al, 2009). Foley et al. (2006) found that risk for suicidality (ideation, plans, and/or attempts) was greatest for adolescents when general anxiety disorder or oppositional-defiant disorder was diagnosed on top of a major depressive disorder. In a large epidemiologic sample of youth ages 9 to 16, anxiety disorders (p. 48) were found to predict suicidality (ideation, plans, and/or attempts) over the course of three-month follow-up, but this association was reduced to a trend level after adjusting for other disorders and covariates. Generalized anxiety disorder did predict suicidality when comorbid with major depressive disorder (Foley et al., 2006).
Among patients with a history of violence, exposure to multiple forms of violence also heightens risk. This finding may be explained in two ways. First, we see a high rate of overlap between perpetration and victimization, both for partner and nonpartner youth violence. Thus most perpetrators are also victims and vice versa. Second, for those youth who are exclusively victims or exclusively perpetrators, the relationship may be mediated by internalizing disorders (for victims) versus externalizing disorders (for perpetrators).
Familial Transmission of Suicidal Behavior and Abuse
Wagner, Silverman, and Martin (2003) published a comprehensive review of familial risk factors associated with adolescent suicidality. Low cohesion, high conflict, and unsatisfying parent–adolescent relationships, in particular, were more frequently observed in the families of adolescents who attempt and/or die by suicide than controls. Yet the relation between such family variables and adolescent suicidal behavior is often lessened or reduced to nonsignificance when other related factors, such as adolescent or parental psychopathology, are taken into account (Gould et al., 2003; Evans et al., 2004; Brent & Melhem, 2008). Here we focus on the relation between childhood physical and sexual abuse because it has been shown to be related to adolescent suicidal behavior as well as interpersonal violence.
A comprehensive review of studies examining the association between childhood abuse (sexual, physical, and/or neglect) and adolescent suicidality concluded that childhood abuse predicts suicidal thoughts and behavior among adolescents (King & Merchant, 2008). For example, in a large high school sample of 131,862 American adolescents, more than half with a history of sexual abuse reported a lifetime history of suicide attempt (Eisenberg, Ackard, & Resnick, 2007). Likewise, Fergusson, Beautrais, and Horwood (2003) examined the relationship between childhood sexual abuse and suicide attempts in 1,063 adolescents and young adults from New Zealand and found that adolescent victims of childhood sexual abuse had elevated rates of suicidal ideation and attempts compared to nonvictims. In a study comparing a community sample of women with and without a childhood sexual abuse history (Briere & Runtz, 1986), women reporting childhood sexual abuse were more likely to have a suicide attempt history than those not endorsing such abuse. A higher percentage (87%) of women reporting having first attempted suicide in adolescence also reported a history of childhood sexual abuse; this was not the case for women whose first attempt was in adulthood. Results also suggested that number of previous attempts were associated with a combination of physical and sexual abuse (Briere & Runtz, 1986).
In an Australian sample of 2,485 high school students, sexually abused adolescents were more likely to report suicidal ideation, plans, threats, and attempts than nonabused adolescents (Martin, Bergen, Richardson, Roeger, & Allison, 2004). After controlling for depressive symptoms, hopelessness, and family functioning, sexual abuse did not predict suicide attempts for females, but for male adolescents the risk of suicide attempt was 15 times greater for victims of sexual abuse. Thus, the relationship between sexual abuse and suicidal behavior is likely moderated by factors such as sex, age at the time of detection, and number of perpetrators (Evans et al., 2004). In these distressed families, both the environment and genetic factors likely increase risk for offspring suicidal behavior.
With respect to physical abuse, one study found that Flemish adolescents who self-injured with the intent to die were more likely to have a physical abuse history than their counterparts who engaged in NSSI (Baetens, Claes, Muehlenkamp, Grietens, & Onghena 2011). There also is evidence that abuse may influence suicidal behavior through an association with impulsivity and aggression (Baud, 2005; Brodsky & Stanley, 2008), affect change (Bebbington et al., 2009), or by negatively impacting neurobiological development. These pathways may be similar in those exposed to peer violence.
Sexual Orientation and Gender Identity
Lesbian/gay/bisexual/transgender (LGBT) youth are at increased risk for suicide ideation and attempts as compared to their non-LGBT counterparts. According to the analysis by Silenzio, Pena, Duberstein, Cerel, and Knox (2007), National Longitudinal Study of Adolescent Health study data revealed elevated past-year ideation (17.2%) and attempt rates (4.9%) in LGB identified youth as compared to non-LGB identified youth (6.3% (p. 49) ideation, 1.6% attempts) controlling for age, sex, and race. Although very few studies of suicidality have been conducted among transgender youth, the evidence that does exist suggests that they are at particularly high risk for suicide attempts and ideation (Grossman & D’Augelli, 2007). Specifically, Grossman and D’Augelli found that almost half (45%) of Transgender male and Transgender female adolescent participants sampled in their study had seriously thought about taking their lives in the year preceding the study, and a little over a quarter (26%) reported at least one lifetime suicide attempt. Moreover, 51% (8 of 14) of those with an attempt history agreed with the statement that their wish to be dead had to do with the difficulty associated with living as a transgender person. When comparing transgender attempters to nonattempters, those who attempted had more negative attitudes toward being LGBT, experienced more parental verbal and physical abuse, and reported lower body self-esteem (i.e., appearance and others disliking their bodies). (See Chapter 6 in this volume by Michael Hendricks for full discussion of LGBT youth and suicidal behavior).
LGBT youth also report almost double the incidence of peer violence and bullying compared with non-LGBT youth (Kann et al., 2011). The highest rates of peer violence are experienced by transgender youth (Kosciw, Greytak, Diaz, & Bartkiewicz, 2010). Multiple studies suggest a direct relationship between peer violence exposure and suicidality among LGBT youth (Savin-Williams, 1994; Kosciw et al., 2010; Nuttbrock et al., 2010; Toomey, Ryan, Card, & Russell, 2010). Interestingly, among LGBT youth with high levels of protective factors (e.g., supportive family relationships, absence of homophobic teasing), the rate of suicidal thoughts decreases to close to that of non-LGBT youth (Eisenberg & Resnick, 2006; Birkett, Espelage, & Koenig, 2009).
Exposure to Suicidal Behavior and Interpersonal Violence
A comprehensive review by Insel and Gould (2008) found that the majority of studies provide significant support for an association between exposure to the suicidal behavior of adolescent peers and an adolescent’s subsequent suicide attempts. For example, one study of more than 5,000 high school students found that adolescents exposed to a peer who made a nonlethal suicide attempt were 3.5 times more likely to report suicidal ideation, 3.6 times more likely to report a suicide attempt, and 1.8 times more likely to inflict injuries requiring medical attention in the next year than adolescents without this exposure history. Adolescents exposed to a peer who died by suicide were 5.4 times more likely to report suicidal ideation, 9.4 times more likely to report a suicide attempt, and 3.1 times more likely to inflict injuries requiring medical attention in the next year than adolescents who were not exposed to a peer who died by suicide (Cerel, Roberts, & Nilsen, 2005).
The media has a significant influence on suicidal behavior, more so for nonfictional descriptions of suicides (e.g., newspaper and television reports) than fictional portrayals of suicides on television or in movies (Insel & Gould, 2008). So-called cyber suicide pacts (suicide pacts among strangers who meet over the Internet) have also emerged in last decade (Insel & Gould, 2008). Although it is unclear why this cluster effect occurs, recent research by Gould, Kleinman, Lake, Forman, and Bassett Midle (2014) found that newspaper coverage of suicide that included specific story characteristics was significantly associated with the initiation of adolescent suicide clusters. Social modeling is another potential vehicle for transmission, but assertive pairing (i.e., youth with mental illness may be more likely to choose peers with similar problems) also may play a role in cluster suicides. Youth who are vulnerable to suicidality may belong to a group of like-minded peers prior to any suicidal acts.
The experience of violent, interpersonal stressors may increase risk in particular. For example, in a sample of 3,005 adolescents from Mexico City, the experience of any traumatic event, including a serious injury, being a victim of violence, and witnessing domestic violence, increased the likelihood of a making a suicide plan five-fold and making an attempt six-fold (Borges, Benjet, Medina-Mora, Orozco, Molnar, & Nock, 2008). Further, those who experienced three or more traumatic events were 13.7 times more likely to report a suicide attempt than those who did not experience any traumatic events.
Access to Firearms
The most recent data available indicate that firearms account for 38% of deaths by suicide for youth ages zero to 19 (CDC NCIPC, 2013a). Research demonstrates that youth who live in a home with a loaded gun are more than 30 times more likely to die by suicide than those who live in homes without a loaded gun (Brent et al., 1993). Additionally, suicide attempts using a firearm are more likely to be fatal (Wadman, Muellerman, Coto, & Kellermann, 2003). A recent observational study showed that (p. 50) 60% of youth with past-year suicidal ideation, past-year peer violence, and past-year alcohol use had immediate access to a firearm (Ranney et al., 2013). However, few psychiatrists, family physicians, internists, pediatricians, or emergency physicians currently query high-risk patients about firearm access (Grossman, Mang & Rivara, 1995; Price, Kinnison, Dake, Thompson, & Price, 2007; Betz, Barber, & Miller, 2010; Betz et al., 2013; Butkus & Weisman, 2014).
Assessment of Acutely Suicidal Adolescents and Adolescents Who Have Attempted Suicide
Suicidal adolescents and their parents should be interviewed separately and together when assessing for suicide risk. Even with their parents out of the room, eliciting suicidal intent, a key component of the risk evaluation, can be challenging. It is critical to ask both open-ended and detailed questions about the adolescent’s suicidality, including the “who, what, when, where, why, and how.” In general, the interview should result in a thorough description of the current problem and precipitants to the attempt including understanding current symptoms and their severity, specifically about the extent of hopelessness and irritability/anger as well as substance use, especially heavy drinking episodes.
A thorough discussion of recent suicidal thoughts and behaviors (as well as prior suicide attempts) is critical. The extent of suicidality should be determined by asking about ideation, method/plan, the presence of threats (e.g., suicide note), and actual behaviors. In an adolescent who endorses suicidal ideation, it is essential to assess the risk that the patient will move from low to higher risk. If an attempt has already occurred, it is critical to determine its nature and to assess future risk. The following lists the critical questions a clinician should consider when assessing a suicidal adolescent based on material coalesced from a variety of sources, including Brent, Poling, and Goldstein (2011), Rudd (2006), Shaffer and Pfeffer (2001), and Spirito and Overholser (2003).
Current Emotional State
- What is your urge to harm yourself right now?
- Are you having thoughts of killing yourself right now?
- How often do you think about killing yourself?
- How well can you control your thinking about suicide right now?
- How well can you keep yourself from trying to kill yourself right now?
Were There Any Precipitating Events?
Precipitating events (e.g., bullying, fight with girl/boyfriend/parent, break-up) and stressors, and whether or not they are acute (e.g., recent humiliation) or chronic (e.g., school, illness, poverty, abuse/neglect), are important to assess.
- Ask whether anything triggered the suicidal ideation (e.g., break up with significant other, death of a loved one, or fight with parent).
- Determine whether these circumstances still hold.
- If a conflict or fight with a partner or peer was the precipitant, consider addressing the underlying causes of conflict and violence and ensuring safety. If cyberbullying or cyberfighting was present, consider advising the adolescent on reducing involvement in social media, texting, and so on.
Does the Adolescent Give Any Specific Reasons for Attempting?
The Reasons for Overdose Scale (Hawton, O’Grady, Osborn, & Cole, 1982) can be administered for adolescents who have a difficult time articulating the reason for the attempt and may help to clarify for the adolescent the underlying motive.
What Does the Adolescent Say About the Frequency and Severity of His or Her Suicidal Ideation?
Current ideation should be assessed, as well as suicidal ideation at the time of a suicide attempt, for adolescents who have recently attempted suicide. Having changes in suicidal ideation frequency and severity is one of the best predictors of a suicide attempt (Prinstein et al., 2008). A number of measures are also available to assess suicidal ideation, such as the Suicidal Ideation Questionnaire (Reynolds, 1987).
- How much of the day do you have suicidal thoughts?
- In a given hour, how much do you think about killing yourself? (p. 51)
- How well can you push away suicidal thoughts and think about something else (on a scale of 1 to 10)?
- How much do you think you can resist the urge to kill yourself (on a scale of 1 to 10)?
Does the Adolescent Endorse Suicidal Intent?
The intent of an adolescent suicide attempt has been found to be strongly related to the seriousness of a suicide attempt, often more so than the lethality of an attempt (Spirito, Sterling, Donaldson, & Arrigan, 1996). The Suicide Intent Scale (Beck, Schuyler, & Herman, 1974) is a useful tool to assess intent after a suicide attempt.
- At the present moment, do you want to die?
- If yes: People have different reasons for wanting to die. What are the reasons you want to die?
- If the adolescent has trouble generating ideas: Other teens have mentioned things like they didn’t particularly want to die but rather wanted to escape an intolerable situation or wanted to communicate something to someone like asking for help, getting attention, making someone feel sorry, or trying to get someone to change his or her mind.
- Is killing yourself something you think you might do?
- In an adolescent who has made a recent attempt, ask: Do you still feel the same way about wanting to die?
Was the Attempt Planned or Impulsive?
If the adolescent made an attempt, determine to what extent it was planned versus impulsive. Planned attempts have been found to be associated with greater depression and hopelessness than impulsive attempts (Brown, Overholser, Spirito, & Fritz, 1991).
- How long have you been thinking about killing yourself?
- If the adolescent has attempted suicide before, ask how long the adolescent had been thinking about suicide before making the attempt.
- What have you done to prepare for suicide?
- Have you made any plans to kill yourself?
- Have you written a goodbye letter, a suicide note, or a letter of explanation?
- Have you thought about what you might say in such a note?
Does the Adolescent Have a Preferred Method and Access to Means? Is There Firearm Access?
As with the risk assessment, the parent(s) and child should be interviewed separately about access to lethal means. Although overdoses accounted for only 6% of youth suicide deaths in 4 (CDC NCIPIC, 2013a), ingestion represents one of the most common adolescent suicide attempt methods (O’Brien & Berzin, 2012), and therefore access to pills needs to be discussed. Due to the lethality of attempts with firearms, access to firearms should always be assessed, even if the adolescent does not endorse guns as a preferred method. If the adolescent reports one method initially, always ask what other ways he or she has considered—adolescents will often start by disclosing the least lethal method first.
- Begin with an open-ended question but consider asking about hanging, jumping, drowning, stabbing, carbon monoxide, car crash, and cutting.
- Does the adolescent have a preferred plan or method he or she would use? Has he or she thought of more than one way to attempt suicide?
- Always ask about the availability of firearms and pills not only at home but also at relatives’ and friends’ houses. When asking about firearms or pills, ask specifically about type, how many, how stored (e.g., locked up or not), and, for firearms, how stored (e.g., locked up or not) and availability of ammunition.
- Assess for the youth’s access to over-the-counter medications, household cleaning supplies, and even the youth’s own prescription medications.
- Assess the parents’ knowledge of the lethality of different means and provide psychoeducation whenever possible.
- For adolescents who have attempted suicide, assess the adolescent’s perception of the lethality of the method.
What Is/Was the Potential for Discovery?
Inquire about the method and/or location/situation chosen to attempt suicide in order to determine if they would allow time for an intervention to reverse potentially lethal effects.
(p. 52) How Effective Is the Environment for Keeping the Adolescent Safe?
Can the Adolescent Give Any Reasons for Living?
Ask specifically what keeps the adolescent from killing him or herself, including reasons for living and adverse impact on other people.
The Reasons for Living Inventory for Adolescents (Osman et al., 1998) can also be administered to prompt adolescents on reasons they may have not considered.
Screening for Other Risk Factors Including Substance Use and Interpersonal Violence
As discussed previously, alcohol use and interpersonal violence increase risk for suicidal behavior.
- Ask about future intent to use substances and their availability. Ask whether drugs or alcohol have been known to worsen mood or increase risk for impulsive actions.
- Assess exposure to peer/partner conflict; although there are no short, standardized screens for peer dating or nondating violence, modified versions of adult screens (e.g., “Has anyone hit, kicked, or punched you in the past year?”) are clinically effective. It is important to assess the frequency and type of violence, as well as its simple presence. A pattern of recurrent fights, cyberbullying, or dating violence implies higher risk than a single episode.
- Discuss emotional responses to interpersonal violence; explicitly discuss the relationship between violence exposure and thoughts of self-harm.
- Assess safety (of self, of friends, and of the other party in the violent episode).
- Consider explicitly discussing fight-avoidance strategies and emotional self-regulation in the face of future violence exposure.
Determining Overall Suicide Risk
Rudd, Joiner, and Rajab (2001) recommend assigning patients levels of risk based on the following criteria:
1. None to Mild = infrequent, low-intensity ideation, no intent or plan; supportive environment; youth can be managed in the community; focus of treatment is on underlying concerns and not suicide risk.
2. Moderate = suicidal ideation, some intent, no plan; youth may or may not be able to be maintained in the community based on the balance of risk versus protective factors; presence of supportive and healthy home, school, and neighborhood environment; focus of treatment is the current suicidal crisis and efforts to minimize risk factors and enhance protective factors.
3. High = frequent and disruptive ideation, strong intent, and specific plan; youth cannot be maintained in the community and is admitted to an inpatient facility; focus of treatment is ensuring safety, identifying and gathering environmental supports, and developing a discharge plan to ensure continuity of care.
The Columbia Suicide Severity Rating Scale (Posner et al, 2011) also has an algorithm to classify suicide risk that may be useful to clinicians (http://www.cssrs.columbia.edu/scales_practice_cssrs.html).
Inpatient Psychiatric Hospitalization
If overall suicide risk is determined to be high, inpatient psychiatric hospitalization is frequently deemed necessary. Inpatient psychiatric hospitalization is needed when the adolescent demonstrates suicidal thoughts or behaviors that are so unstable and unpredictable that there is serious short-term risk (Shaffer & Pfeffer, 2001). It is not uncommon for a suicidal adolescent to be psychiatrically hospitalized. In one study, suicidal thoughts and behaviors were the most common reason youth were admitted to an inpatient psychiatric hospital (Wilson, Kelly, Morgan, Harley, & O’Sullivan, 2012). Inpatient psychiatric hospitalization represents the most restrictive level of care available to suicidal adolescents and is frequently used in cases where a decision needs to be made quickly to keep the (p. 53) adolescent safe. Ideally, adolescents who need hospitalization will be admitted voluntarily. However, there are situations in which adolescents are admitted involuntarily because their caregivers and/or clinicians feel that they are at imminent risk and the adolescent does not agree to admission.
One study compared the effectiveness of inpatient psychiatric hospitalization in reducing suicidality compared to outpatient multisystemic therapy for adolescents, primarily African American, presenting with a psychiatric emergency (Huey et al., 2004). Multisystemic therapy resulted in fewer suicide attempts at one-year follow-up compared to hospitalization, but because there was a higher rate of prior attempts in the multisystemic therapy group, this finding may have been related to regression to the mean. There is no data available for determining which adolescents who are at high risk for suicide would be better served in the community versus an inpatient psychiatric setting (Lamb, 2009). Nonetheless, because there is no evidence that psychiatric hospitalization prevents suicide, alternatives to inpatient care should be considered for adolescents who can be safely managed by a less restrictive level of care. In many cases, a crisis intervention that incorporates a safety plan can be used to stabilize the current suicidal crisis and serve as an alternative to hospitalization if it is accompanied by immediate participation in an intensive outpatient program or individual plus family treatment (Singer, 2005).
After conducting a thorough suicide risk assessment and determining a return home is indicated, a safety plan should be developed with the adolescent and caregivers. Adolescents should be involved in the planning as much as possible in order to identify supports that are available at home, school, and through the therapist, as well as positive coping strategies. Parents/caregivers should be involved to limit access to means. The safety plan is not a “no-suicide” contract; it is designed to identify strategies to help adolescents cope with suicidal urges. No-suicide contracts are ineffective because they ask clients to promise to stay alive without providing a strategy on how to do so. No-suicide contracts provide clinicians with a false sense of security when in fact such contracts do not reduce the client’s risk for suicide and do not reduce the clinician’s risk for a lawsuit following a client’s suicide (Wortzel, Matarazzo, & Homaifar, 2013).
Overview of the Safety Plan
The safety plan includes an agreement between the adolescent, parents/caregivers, and therapist that should the adolescent have suicidal thoughts or impulses, he or she will inform a responsible adult and/or call the therapist or an emergency number. By agreeing to the plan, the adolescent is not promising he or she will never feel suicidal but rather that he or she will remain “safe” and not engage in further suicidal behavior without contacting someone. In addition, part of the plan is to collaboratively identify specific steps the adolescent and family would take if a suicidal crisis resurfaces. Specific steps should be written and easily available such as on a mobile phone for the adolescent to refer to in times of stress. Reaffirming the safety plan should be a part of every subsequent therapy visit until the crisis has passed.
Formulating the Safety Plan
The safety plan is developed and tailored to each adolescent and includes a hierarchically arranged list of coping strategies, developed collaboratively by the adolescent and the therapist. Whenever possible, the parent/caregiver should be informed of the coping strategies the adolescent reports are most effective, so that the parent/caregiver can help to coach the adolescent in those skills in a suicidal crisis. At a minimum, the safety plan should include the telephone numbers of social supports, the treating therapist, the on-call therapist, and the national suicide prevention lifeline (1-800-273-8255). The safety plan should also include an agreement between the adolescent, parents/caregivers, and therapist that, should the adolescent become suicidal, he or she will inform a responsible adult and/or call the therapist or emergency numbers. If partner/peer violence is a risk factor for suicidal ideation, the safety plan should include coping statements specific to this risk factor, as well as other alternative behaviors that might help in such situations (e.g., reporting the threat to a school guidance counselor).
Parents/caregivers are a party to the discussion of precipitants and motivations to the suicide attempt and to all aspects of the safety plan. The therapist must also obtain agreement for removal of firearms and lethal methods from the parents. Parents often are unwilling to remove knifes and razors from the household, so the therapist should take particular care to discuss this aspect of safety planning, especially when the adolescent has also engaged in NSSI. In circumstances where the parent is one of the adolescent’s triggers for suicidal ideation, the therapist facilitates a “truce” with adolescent and parent around hot topics/possible precipitants to future suicidality with the promise that these issues will be addressed in future therapy sessions.
(p. 54) Conclusions
There are a number of important risk factors to consider in evaluating adolescents with acute suicidality or those who have recently attempted suicide. Much of this information is obvious on presentation, including age, sex, and ethnic-minority status. Other information can be obtained in the interview of the adolescent and/or a collateral interview with a parent/caregiver, including history of self-injurious behavior (with and without suicidal intent) and its age of onset, history of mood and anxiety disorders, impulsivity, substance use, family history of suicidal behavior, sexual identity issues, and exposure to suicidal and violent behavior. Interpersonal violence is an equally if not more important area to assess given its close association with suicidality, especially with respect to its role as a potential trigger for suicidal behavior.
Once a history has been obtained, there are a series of important questions to ask with respect to the adolescent’s current emotional state that need to be integrated with historical information in order to determine the appropriate disposition. These include the precipitating events/reasons for suicidal thoughts/behavior for the current suicidal crisis/attempt and their current status in the adolescent’s life, the severity of the adolescent’s suicidal ideation/suicidal intent, access to means, exposure to interpersonal violence at discharge, and the capacity of the family/social environment to keep the adolescent safe. All interviews must conclude with a comprehensive safety plan to ensure that both the adolescent and parent have a comprehensive, structured plan to manage the resurgence of suicidal thoughts.
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