SUICIDE 

Suicide is the second leading cause of death among teenagers, 
after automobile accident. Many of the signs and symptoms may go 
ignored which is why many of these teens are not taken seriously, 
until it is too late. This posses additional problems for the 
survivors, who usually are burdened with excessive guilt. 

SYMPTOMS 
Most of us have at least considered suicide at some point in our 
lives, although most of us will quickly dismiss the notion. For some, 
however, suicide can seem to be a very viable option. The following 
symptoms usually will indicate that the potential for suicide is 
serious enough to require professional intervention.

Depression: 
These individuals are usually severely depressed. Usually, the 
depression has lasted for an extended period of time.

Feelings of Hopelessness: 
These individuals usually consider the situation to be hopeless. In 
other words, the individual does not see any way that the problem can 
be resolved. In such cases, suicide becomes the "only way out" of the 
situation, or the emotional "pain" that the individual has endured. 

Previous attempts: 
Most individuals who will commit suicide have made previous attempts. 
This increases the likely hood that the attempt will be lethal. 

Changes in personality.
A person may suddenly began to lose weight for no apparent reason. 
He or she may lose sexual desire, or be unable to sleep through the 
night. They may also withdraw from family and friends.

Preparing for death.
Many of these individuals will give away prized possessions to friends, 
and relatives. They may also make vague, or even more direct, 
references to committing suicide. 

Threats.
Threats of suicide should ALWAYS BE TAKEN SERIOUSLY. They may be 
merely a means of getting back at someone, or may be simply a "cry for 
help", they should be taken seriously. Three times out of every four, 
a person who threatens suicide will make an attempt.

Developing a Plan. 
Often they will buy a gun, or a rope to make a noose etc. They may 
also may tell someone of a potential plan. "If I were going to 
commit suicide this is how I'd do it ........." 

Women more often than men. 
Women more often than men attempt suicide; however, men tend to be 
more successful than women in actual lethality. Men succeed about 
66% of the time, while women succeed about 33% of the time. This is 
because women tend to select more passive means such as "pills" etc. 
Men, on the other hand, tend to use more violent means such as guns, 
etc., which makes it much less likely to have a change of mind. 

ACTIONS TO TAKE: 

1. Always take a suicide threat seriously! It is usually at least a 
"cry for help" which should not be ignored. Refer the 
individual for counseling to an appropriate mental health agency. 

2. Do not leave the individual alone if the threat is deemed to be 
life threatening. 

3. Develop a network of support for the individual to turn to in 
case a crisis occurs. This support group can be made up of 
selected family members, relatives, friends and/or church 
personnel. 

4. If the threat is mild (i.e., distinct possibility of failure) 
educate parents as to the common suicide indicators and 
behaviors. Parents should consider initiating counseling with an 
appropriate mental health professional and consultation with the 
family physician. 

5. If the threat is moderate, general suicide precautions should be 
taken. Parents should be notified of the availability of and 
access to psychiatric hospitalization. 

6. If the threat is severe (i.e., very small probability of 
failure), extreme suicide precautions should be taken. Notify 
the parents and provide one-to-one monitoring at all times. 

7. Stress future events. Focus on activities that will be occurring 
in the next few days. 

8. A suicidal agreement may be presented and signed by the 
individual, whereby the pupil agrees to contact a hotline crisis 
phone number if suicidal thoughts become severe within the next 
24 hours (or specific period of time). 

9. Provide frequent monitoring. Do not leave the individual alone 
during a crisis or following an argument. 

10. If appropriate counseling is not initiated in the near future (3 
days), individual protective officials should be contacted and a 
referral submitted to this agency. 

11. Provide the individual with the necessary coping skills to 
establish plans for carrying out alternatives to self-destructive 
behavior. 

12. Bibliotherapy may be used to demonstrate how others solved 
problems related to suicide. The problem-centered fictional 
books should be read by an adult prior to suggesting them to the 
individual and then discussed on an individual basis. 

13. Parents should consider treatment for depression if persistent 
suicidal ideation appears to exist without evidence of 
situational stress. 

14. With young children, review the concept of death, since the 
individual may have misconceptions about death in relation to 
personal suicidal behavior. 

15. An attempt should be made to decrease the intensity and amount of 
perceived stressors. 

16. The availability of family counseling may need to be considered 
in view of the complexity of the dynamics involved. 

17. Parents should consider follow-up monitoring by a mental health 
professional in consultation with the child's physician. 

18. When discussing suicide intent, the therapist should attempt to 
determine what the individual is communicating by this suicidal 
threat and for whom. 

19. Avoid arguments and challenges. Do not try to win arguments 
about suicide by logic. 

20. Promote thinking of alternatives and provide emotional support 
for living. 

21. Encourage the individual to talk and think of alternatives. 

22. Remove all weapons and pills from the house. 

23. The individual should not be left home without supervision due to 
current emotional state. 

24. Acknowledge the individual's perceived problems and give 
assurance that they won't last. Stress that suicide is 
irreversible. 

25. Parents should be made aware of resources such as: private 
physicians; hospital emergency room; Child Guidance Emergency 
Department; Suicide Prevention Hotline or Teen Hotline. 

HELPING THE OTHER VICTIMS 

It has been said that the real victims of a suicide are the 
survivors. The behavior and attitudes of friends and relatives can
be greatly affected by a suicide. Bereavement is our response to 
loss. It usually refers to subjective feelings after the loss of 
someone we care about, usually death, but also after the dissolution 
of a relationship. Death of a loved one is never easy to accept, and 
a sudden loss can be especially distressing. There are five steps to 
recovery that are usually recognized in the bereavement processes: 

1. Shock and denial. Many individuals will state that they "just can't 
believe that the person is gone. 

2. Anger. A general feeling that life is not fair and that we have 
somehow been cheated in our loss of the individual. We may be 
angry at God, or at other people who were more closely associated 
with the person just prior to the suicide. Individuals in this 
stage may become very irritable, or moody. They often vacillate 
back and forth between depression and anger.

3. Depression and Guilt. This is what the individual has been 
attempting to avoid at all costs. Depression is the essence of 
grief. This is time to cry and it hurts. This stage of the 
process begins when we humbly surrender. It will be disappear, 
only when the process has been worked through. With any death, 
survivors usually feel at least some guilt. However, when the 

death is by suicide, especially someone young and in good physical 
health, this guilt is compounded. There is always the assumption 
that the death could have somehow been prevented. If only I had 
done something, told someone etc. For those who may have been 
close to the person just prior to the suicide, this is most 
troubling. Even for those somewhat more distant to the act, there 
are feelings of guilt associated with things they may have said or 
done to the individual when they were alive that they wish they 
could take back. 

4. Reflectiveness. During this stage the survivors emotions will 
become less intense. They can now begin evaluating the events and 
circumstances that lead to the suicide more objectively. 

5. Acceptance. This is it after we have closed our eyes, kicked, 
screamed, negotiated, and finally dealt with the pain of the lose, 
we arrive at the stage of acceptance. It is not just a hopeless 
giving up, but the end of a struggle. Acceptance is not really a 
happy stage, although the individual will begin to resume a more 
normal routine of activities. It is almost void of feelings. It 
is as if the pain is gone, and the struggle is over. The individual 
is now free to go on living. 

Those grieving over the loss by suicide of a someone close, should be 
encouraged to talk things out. There is sometimes a fear that talking 
about suicide, especially with someone who is depressed will may 
potentiate a suicide attempt in that individual. This is a myth. 
Talking things through is the best approach to working through the 
stages listed above. In the present situation, it would be helpful 
to allow students to openly discuss their feelings regarding the loss, 
and to understand, that the situation could not have been prevented no 
matter what they could have or should have done. This will go a long 
way in helping them relieve any guilt that they may be feeling. If 
individuals complain of eating, or sleeping problems, or express 
concern over personality changes they feel they are experiencing they 
should be referred to the guidance counselors or for outside 
counseling. There may also be tendencies toward what psychologists 
refer to as the "copy cat" effect, which can lead to more suicide 
attempts. These are usually by teens who are somewhat troubled to 
begin with, and who view the attention, and immortalization of the 
suicide victim as very positive. They may also see a suicide attempt 
as a means of getting back at their parents or a boyfriend of 
girlfriend for jilting them ("they will be sorry they treated me this 
way when I'm gone"), or they may simply want to gain some attention 
and sympathy for others. While these teens may in many cases not be 
seriously suicidal, they should be always be taken seriously. There 
have been frequent incidents especially in large high schools where 
successful "copy cat" suicides have occurred. These students should be 
referred to the guidance counselor, or school psychologist if they make 
have made threats or comments to their friends that they want to die. 

SUICIDE BEHAVIOR OF YOUTH: ASSESSMENT AND INTERVENTIONS 

While suicide is not a pleasant topic, the increased incidence has 
placed a demand on all professionals working with children to confront 
this tragedy. The enclosed review, Suicide Behavior of Youth: 
Assessment and Intervention, is intended to provide a summary of 
updated information and management approaches that could be applied at 
school and home. This could be copied and disseminated to school 
staff and parents when dealing with children suspected to be at risk 
for suicide. 

* Causes and Correlates. Most writers on this topic attribute the 
increased suicide rate in youth to the increased stresses of 
childhood (see earlier SPS for a review of children and stress). It 
is no accident that the skyrocketing adolescent suicide rate during 
the 1960's and 1970's was accompanied by increased drug and alcohol 
abuse in addition to family disorganization (e.g., both the suicide 
rate for youth and the divorce rate tripled from 1950 to present 
and drug overdose is most common method). A logical hypothesis is 
that youth suffer more stress and there is less availability of 
support systems. An additional cause often cited recently is 
modeling, where suicides occur in clusters. 

* Role of Schools. Legislation may be forthcoming which mandates 
schools to provide suicide prevention programs. Law suits have 
been filed by parents against schools in several states (e.g., CA, 
CT, NJ, and OR) claiming that school officials were negligent, not 
recognizing and referring youth with suicidal risk. In a recent 
editorial, Joanne Jacobs pointed out that this is unrealistic and 
that the role of schools is prevention through education. 
California has recently mandated school suicide prevention programs 
and Dr. Michael Peck has developed a five segment curriculum for 
that state. Such instruction is typically integrated into health 
education and includes such topics as coping with stressors, 
problem-solving skills, and death education. Teacher training, 
parent awareness, and administrative guidelines for management are 
also provided. 

* Role of the School Psychologist.

*Suicide as a Symptom. Most suicidal youth are not "normal," but 
rather are "handicapped" or "suspected handicapped" students (e.g., 
physical, emotional, learning, behavioral, and social problems 
result in higher risk). At the prereferral intervention assistance 
team level or as part of regular referral, students with suspected 
suicide behavior should be referred to the school psychologist 
(i.e., treat the "whole child" rather than suicide in isolation). 

*Suicide Specific Assessment. Our staff of school psychologists have 
been provided with new assessment instruments this year that enable 
them to gain a routine general screening of suicide ideation and 
attempts (i.e., Child Behavior Checklist parent and teacher ratings 
as well as self-report form) in addition to a comprehensive, 
specific, and standardized measure of suicide behavior (i.e., 
Suicide Probability Scale). 

*Interdisciplinary Consultation. In service training for our staff 
this year has focused on interdisciplinary approaches such as 
appropriate referral to primary care pediatricians. School 
psychologists could be in an opportune position to report results of 
suicide probability assessments to other professions (i.e., 
physicians, school counselors, and social service agencies). 

*Staff Development and Parent Education. We have a suicide slide 
presentation that could be reviewed with educational staff and 
parents by your school psychologist. We could also help with 
suicide prevention programs for students. 

*Crisis Intervention Counseling. Administrators, school counselors, 
and teachers could refer students to school psychologists for short-
term counseling when students experience a crisis or stressor that 
may result in suicidal behavior. 

DEFINITION Suicide is a deficiency disorder ranging from help-
seeking behavior and an impulsive stressor reaction to expression of 
despair and depression. Suicidal youth may not be seeking death as 
such as an escape from life. All suicidal expressions by youth, 
whether acts or verbal threats, should be taken seriously and referral 
to a child mental health professional should take place. Suicide 
usually does not occur suddenly but rather is viewed as a process of 
failure to resolve problems. 

INCIDENCE While suicide itself is a relatively infrequent event, it 
is estimated that about 12% of youth seriously think of suicide or 
attempt suicide. The suicide rate among youths is now the highest in 
history of the nation as reflected by the following statistics: 

* The U.S. suicide rate for 15-24 year olds has nearly tripled from 
1950 to 1979 and increased 44% from 1970 to present for 15-19 year 
olds. 

* Since 1984, there are about 5,000 recorded victims aged 15-24 years 
annually with estimates that at least twice that number are passed 
off as accidental deaths. 

* Suicide attempts among youths are estimated to be as high as 200,000 
- 400,000 annually with estimates of ratio for attempts to 
completion ranging from 10:1 to 100:1. 

* Suicide rates and methods very by sex, age, and race (e.g., white 
males are more likely to commit suicide and girls have more 
unsuccessful attempts. The rate is increasing for preadolescents). 

RISK FACTORS Although it is almost impossible to predict suicide for 
an individual, common risk factors are often reported in the 
literature. The red alert distress signal is thoughts of death or 
suicidal threats (e.g., "I wish I'd never been born"). Depression is 
the major correlate with this being present in about 60% of the cases. 
Other clusters of symptoms that may be relevant in determing suicidal 
risk are in the following categories: 

* Behavioral Symptoms - Loss of interest in social life and/or change 
in social behavior, truancy and a drop in school grades, alcohol 
and/or drug abuse, loss of interest in activities that were a source 
of pleasure, changes in eating and sleeping habits, giving away 
prized possessions, changes in energy level with sudden agitation or 
lethargy, increased risk taking, and behavior such as reckless 
dring, threatening others, irritability. 

* Emotional Symptoms - Depression (e.g., sadness, brooding, 
hopelessness, and worthlessness),,,, inappropriate or excessive 
guilt, loss of self-esteem, perturbation (e.g., upset, withdrawn, 
alienated, and excitable), sudden personality change, unexplained 
crying, apparent recovery from depression (i.e., energy to perform 
the act). 

* Cognitive or Thinking Symptoms - Rigid thinking with expression of 
the "only" solution, Ambivalence with thinking of escape and at same 
time seeking attention and rescue, clear and specific plan of 
suicide, lack of cognitive problem-solving abilities (overestimating 
problems and not considering solutions), diminished ability to 
concentrate and think. 

* Situational Factors - Experience of loss as in death of significant 
person, recent stressor such as physical illness, divorce, and 
disruption of relationship(s), history of suicide among family or 
friends, prior suicide attempts, clear intention to repeat (most 
give ample warning), teenage girls who become pregnant and runaways 
are high-risk groups. 

ASSESSMENT OF SUICIDE PROBABILITY A comprehensive approach is needed 
that encompasses the context at the client's total life situation. An 
extensive background review by questionnaire and/or interview with 
parents is suggested that would include such data as onset and 
severity of presenting problem(s), presence of psychosocial stressors, 
family environment, and family history or client's experience with 
death and suicide. There should also be interview of the child and 
family concerning suicide-specific issues such as the above risk 
factors. Like other disorders, a multifactored and multimethod 
assessment of personal-social and all areas of functioning should be 
provided. An especially relevant standardized measure is the Suicide 
Probability Scale (Cull & Gill, 1982) which is a self-report measure 
for adolescents 14 years of age and older. For younger children (4-16 
years), the Child Behavior Checklist (Achenbach and Edelbrock, 1983, 
1986) provides parent and teacher ratings of suicidal ideation and 
attempts in addition to global adjustment. 

ASSESSMENT OF SUICIDE ATTEMPTS In practice, assessment of suicide 
risk often follows an attempt. In order to determine appropriate 
interventions (e.g., hospitalization), it is critical to determine the 
degree of risk since it is estimated that as many as half repeat 
attempts and 5-10% are ultimately successful. The following is a 
listing of high-risk factors or lethality: (a) clear plan and intent 
to repeat; (b) lethal overdose of 30 or more pills; (c) method of 
shooting and jumping are higher risk than ingestion or cutting; (d) 
attempts at remote site with little probability of rescue; (e) lack of 
social support systems. 

INTERVENTIONS (Trautman & Shaffer, 1984). There is no single 
validated approach to the treatment since suicidal youth may present 
different problems or risk factors. Hence, there is a wide variety of 
interventions recommended. Problem-solving techniques, family 
counseling, and follow-up monitoring by a mental health professional 
using prescriptive treatments are most often suggested. The 
suggestions provided below reflect basic considerations and techniques 
that could be applied when combined with a knowledge of individual 
needs confronting suicidal youth and their family. Interdisciplinary 
approaches are often needed. 

Suicide-Specific Guidelines:

* Address Suicide Directly. If a risk is suspected, ask the 
client. This is found to not increase risk but rather provide 
relief by giving permission for the client to let it out and open 
up. 

* Intent. When reviewing suicide, try to determine what the client 
is communicating by this act and for whom. 

* Avoid arguments and challenges. Don't try to win arguments by 
logic about suicide. Rather, promote thinking of alternatives and 
provide emotional support for living. Avoid answering questions 
which may be a trap and rather encourage the child to talk and 
think of alternatives. (Advise parents to remove all firearms 
and pills from house). 

* Avoid false reassurance. Acknowledge problems and give assurance 
that it won't last and stress that suicide is irreversible. 
"Suicide is a permanent solution to a temporary problem." 

* Frequent monitoring. Don't leave the client alone during a 
crisis or following an argument. Weekly or more frequent visits 
with a mental health professional should take place. 

* Review concept of death. Younger children may have 
misconceptions about death as related to their suicide behavior. 

* Referral (for risk or following attempts). Appropriate referral 
is critical such as physicians, emergency rooms, and suicide 
prevention centers (e.g., HELP hotline). 

Social Problem Solving. This approach is most often suggested and 
involves teaching coping skills and establishing plans to carrying out 
alternatives to negative behavior (see guidelines form entitled 
Problem Solving Techniques for Discipline and Guidance). 

Bibliotherapy. Reading problem-centered fiction with youth which 
demonstrates how others solved problems related to suicide can be 
helpful. These should be read by the adult prior to suggesting them 
to youth and discussed to be made more personalized. A book that is 
especially recommended is: Arrick, F. (1981). Tunnel Vision. NY: 
Dell. (See Craver, 1984, for a more complete listing). 

Depression Treatments. Depression is the most frequent symptom 
associated with suicide and this underlying problem needs to be 
identified as to degree and treated if present (see guidelines for 
Managing Childhood Depression). 

School Programs. Prevention efforts at schools should not focus 
directly on suicide but rather broad issues such as coping with 
different types of stressors.

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