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.
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.
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.
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 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
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
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
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
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
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
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
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
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
* 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
* 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
* 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
* 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.
* 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
* 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.