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Children's Voice Article, November/December 2003

The Poison Within

by By Tegan A. Culler

For most parents, the most frightening idea imaginable is that serious harm could befall their child. For thousands of families each year, the reality is even worse--sometimes children come to harm by their own hands, intentionally. Sometimes they take their own lives.

By the Numbers

The adolescent suicide rate tripled between 1952 and 1995, and despite gradual decreases during the last eight years, suicide among American teens and young adults remains alarmingly high.

In 2000, the most recent year for which data are available, suicide was the third leading cause of death for youth ages 15 - 24, surpassed only by accidents and homicides, according to the Centers for Disease Control and Prevention (CDC). Of deaths among teens ages 15 - 19 that year, 1,621 were due to suicide, compared with 1,639 due to all less frequent cases combined.

Even more shocking is the rate of suicide among younger children. In 2000, suicide was the 11th most common cause of death among the general U.S. population, but the third leading cause of death among children ages 10 - 14.

The actual prevalence of adolescent suicide is likely even higher, as some are probably misreported as accidental deaths. And mortality figures don't account for nonlethal suicide attempts, which the National Institutes of Mental Health estimate to outnumber deaths at least eight to one, and probably much more.

Although the Substance Abuse and Mental Health Services Administration (SAMHSA) says there don't appear to be significant differences among urban, suburban, and rural youth in suicidal thoughts and behavior, differences do exist between the sexes and between some ethnic, racial, and cultural groups. For example, girls and young women attempt suicide about twice as often as boys and young men, according to the National Adolescent Health Information Center (NAHIC). But CDC says young males are much more likely to actually take their own lives--more than three times as many boys than girls committed suicide in 2000.

According to NAHIC:
  • Latino youth are more likely than other teens to have attempted suicide.

  • Suicide rates among African American youth, although historically low, increased dramatically between 1986 and 1994; like teen suicide rates overall, however, they have since declined.

  • American Indian and Alaska Native adolescents are twice as likely as their peers to commit suicide.

  • Boys in these ethnic groups are at particular risk--they are four times as likely to commit suicide than other boys.
In addition, sexual minority teens--youth who identify as gay, lesbian, bisexual, or transgendered--may be at increased risk for contemplating and attempting suicide, as may teens with disabilities.

As a society, we are slowly grasping the frightening reality that many of our children are falling victim to their own violent despair. But what can parents, professionals, and communities do to avoid losing one of their own to tragedy?

Teens in Danger

One starting point is knowing what factors put children at increased risk for harming themselves. Known risk factors do exist, and they tend to occur in clusters.

Depression or other mood disorders are probably the most significant--and most common--risk factors. Studies estimate some 20% of the U.S. adolescent population has some type of emotional problem, and depression affects as many as three-quarters of a million teens at any given time. But mood disorders in adolescents are easy to miss. When surveyed, 90% of parents believed they would recognize depression in their own children, but, according to SAMHSA, only 20% - 40% of depressed youth are ever diagnosed and treated.

Substance abuse has been linked to increased suicide risk in teens. A 1996 study found that alcohol played a role in 28% of suicides among children ages 9 - 15, and, according to SAMHSA, youth who reported using any illicit drug other than marijuana were almost three times more likely to report having considered suicide in the previous year. If a teen is depressed, many drugs, including alcohol, can exacerbate his mental state, making him even more desperate. And most drugs increase impulsive behavior and decrease inhibitions. A teen whose judgment is impaired by drugs or alcohol might rashly attempt suicide when he would not consider doing so sober.

Youth who are exposed to others' suicidal behavior may also be at increased risk of attempting suicide themselves. Teens with a family history of depression or suicide may be biologically predisposed to mental illness or suicidal thoughts or behavior. Teens who lose a family member, friend, or acquaintance to suicide may come to view suicide as a valid method of dealing with depression or other problems.

This phenomenon of "suicide contagion," in which a single suicide precipitates others, is not necessarily limited to people with whom a teen is close. In fact, it is even triggered occasionally by media coverage of suicides in which teens do not know the victims. In the two weeks following the 1999 Columbine shootings in Littleton, Colorado, in which two students killed 13 others and themselves, six students in Los Angeles schools took their own lives.

Adolescents who have ready access to lethal means of self-harm, such as guns or dangerous medications, are more likely to commit suicide. Firearms are the most commonly used method of suicide among youth, and suicides by gun increased nearly 40% between 1981 and 1994, according to the CDC. Teens who kill themselves using guns are most likely to do so at home, and the risk of youth suicide in a home with a gun increases in proportion to the number of guns and their accessibility (loaded versus unloaded, locked up or not, and so on).

Other factors that can put teens at increased risk for suicidal thoughts and behavior include a history of abuse or neglect, especially sexual abuse; chronic illness in the adolescent or his family; dating violence; and stressful life events--such as the loss of a romantic relationship or close friendship; family problems such as divorce or heated arguments between teens and their parents; isolation that can accompany a family move, being the victim of bullying, or intense shyness; or disciplinary problems like arrest, pregnancy, or poor school performance.

Individually, these stressors aren't usually enough to put a teen at extreme risk for taking her own life, but they can precipitate suicidal behavior, particularly in conjunction with other stressors or serious risk factors. To an adult, an event in a teen's life, such as a fight with a girlfriend or boyfriend, or a poor grade on a test, may not seem significant, and parents may discount a youth's distress as histrionic or attention-seeking behavior. But a teen may experience a seemingly trivial event as intensely painful or humiliating.

An Ounce of Prevention

Many of the life factors that help protect teens against harming themselves are also facets of general good mental health for adolescents: open communication with parents, a strong support network of family and peers, learned coping skills, and high self-esteem and self-worth.

Some kids will have some or all of these factors, and some won't. But, according to Steve Hornberger, Director of Behavioral Health Services at CWLA, not all protective factors for suicide are just the luck of the draw. "Communities certainly have a role to play in making sure teens are supported," Hornberger says. "They need to ensure recreation, leisure time, and optimal youth development opportunities for youth."

Access to mental health treatment and a willingness to pursue it can also protect teens. Indeed, depression, the most common mood disorder among adolescents, can usually be treated through therapy, medication, or both. But even if a teen is willing to seek help, the availability of treatment is often a significant hurdle for parents to surmount. Hornberger points out that many insurers fund mental health treatment only partially, if at all, and uninsured families don't even have that minimal assistance. "While we are learning more effective ways to intervene in these situations all the time," he points out, "affordable, accessible, and comprehensive mental health care for children remains underfunded and underresourced."

Earlier this year, the President's New Freedom Commission on Mental Health--the first comprehensive study of mental health service delivery in nearly 25 years--recommended several improvements to the nation's mental health system, aimed at reducing the stigma on seeking care, ensuring access to care, and reducing fragmentation of services.

The commission's Subcommittee on Suicide Prevention recommended making the U.S. Department of Health and Human Services responsible for coordinating federal suicide research and prevention efforts, and called for national centers of excellence through the National Institute of Mental Health to support research on suicide prevention interventions, federal and state surveillance systems for reporting suicide and attempted suicide, and broad community suicide prevention coalitions.

Historically, organized suicide prevention efforts have tended to take a blanket approach, working to educate or affect all teens rather than just those who may be depressed or suicidal. But several legislative and grassroots efforts, broadly aimed at changing the context in which some suicides occur, have actually had some success in reducing suicide rates. For example:
  • As suicide contagion has become better understood, suicide prevention groups have partnered with media organizations to establish guidelines for reporting on suicides without sensationalizing them.

  • A correlation exists between raising the legal drinking age from 18 to 21 and a modest--but consistent and measurable--reduction in suicides.

  • Rigorous public awareness campaigns have alerted both parents and teens to the problem of suicide and illuminated the existence of crisis centers and hotlines.

  • Many school districts have implemented suicide prevention programs for all students.
But such broad-based strategies, while they ameliorate the incidence of youth suicide to some extent, may have limited significance in the long run. Suicide contagion exists, but it affects a relatively small number of at-risk teens per year. The small correlation between suicide rates and the legal drinking age has remained steady since legislative changes went into effect. Hotlines get more use from adults in crisis than from troubled teens.

Consciousness-raising about the potential danger of suicide is helpful, and it is vital to educate teens not to dismiss suicide threats from their peers or keep them a secret, but some evidence exists that school-based suicide prevention programs--particularly those presented in assemblies rather than classrooms, that do not address suicide in the context of depression and other mental illnesses, or that describe suicide methods in detail--may not help teens. In fact, they may actually cause distressed adolescents to view suicide as an acceptable solution to their problems.

One school-based program takes a different approach, how ever: Since the most effective interventions seem to target the individual rather than teens in general, why not identify depressed and suicidal teens and treat them?

The program, Positive Action for Teen Health (PATH), uses a research-based model called Teen Screen. With their parents' consent, teens complete a computerized questionnaire, which screens for depression, mood disorders, suicidal thoughts and attempts, and substance abuse. Students found to be at risk go through a computerized interview for confirmation, which eliminates a number of false positives. Adolescents at risk then have a session with a counselor or caseworker, who contacts the teen's parents and helps the family form a treatment plan for the youth.

"Essentially, Teen Screen functions as a mental health checkup for youth," says PATH Director Laurie Flynn, who points out that former Surgeon General David Satcher called for regular mental health screenings for children and youth as part of school-based health services.

Unlike traditional school-based prevention programs, which are primarily informational in nature, students interviewed in Teen Screen disclose information about themselves and their feelings, rather than being told about suicide in a video or other presentation. And because of the computerized format, kids may reveal more than they would in a face-to-face interview with an adult.

It seems to work. Tested in 14 cities in 10 states, with up to 400 new sites slated to become operational by 2006, Teen Screen claims to identify all but 7% of teens with depression or suicidal thoughts or behavior. And six years after screening, 73% of youth picked up by Teen Screen had been diagnosed with a mood disorder; 64% had made at least one suicide attempt.

Without mental health treatment, Flynn admits, identifying a child who is depressed or suicidal is only modestly helpful. To maximize the program's benefit, PATH brokers and negotiates with public and private mental health providers in the community to ensure that children identified through the process receive the treatment they need.

Flynn, whose own daughter survived a suicide attempt as a teen, views the treatment component of PATH in the context of long-term advocacy. "Part of this is an effort to build a demand for child mental health," she says, describing what she hopes will eventually be part of a swelling demand for insured comprehensive mental health services, including substance abuse treatment. "Knowing about mental disorders in children and adolescents is not enough. We have to apply that knowledge."

Tegan Culler is an editor for CWLA and a contributing editor to Children's Voice.

Is Your Teen at Risk?

What are the warning signs of adolescent depression?

Although most parents say they would recognize depression in their own children, fewer than half of depressed youth are diagnosed and treated.

Why is mental illness in teens so difficult to catch? If you've parented or worked with teenagers, or even remember your own adolescence, you probably already know: Teens tend to be emotionally volatile, and they may be less likely to communicate their feelings to adults than at other points in their lives. Parents or caregivers may mistake the symptoms of clinical depression for the considerably more benign turbulence of adolescence. Also, the stigma of depression or other mood disorders may deter youth or their parents from seeking help. Adolescent boys, frequently conditioned to handle emotion with stoicism or aggression, may find it particularly difficult to ask for or accept help.

Symptoms in teens often manifest in marked personality changes, including
  • a significant change in appetite or weight;
  • withdrawal from or loss of interest in friends, family, social activities, or hobbies;
  • irritability, intense anger, continual crying, or aggressive/ problematic behavior;
  • risky behavior involving alcohol, drugs, sex, or delinquency;
  • chronic fatigue or drastic changes in sleeping habits;
  • unusual neglect of personal appearance;
  • frequent or unexplained aches and pains;
  • skipping school, or a drop in school performance;
  • running away;
  • expressing feelings of self-loathing, worthlessness, guilt, or helplessness; and
  • a prolonged sad or hopeless mood.
Many teens experience one or more of these symptoms periodically and briefly without being depressed or posing a risk to themselves. If you are a parent, try to be conscious of your teen's behavior without overreacting. If your child exhibits three or more of these symptoms for two weeks or more, seek professional help.

How do you know if a child poses a threat to herself?

Any child or youth who expresses suicidal thoughts to a peer or adult, even in an offhand, indirect, or joking manner, should be taken seriously. Parents and caregivers should seek professional help.

Any youth who attempts to harm himself, no matter how na´ve it may seem, should also be taken seriously and receive professional help immediately. Any youth who has previously made a suicide attempt should be considered at high risk for further attempts. Without professional intervention, half of all teens who have made one suicide attempt will continue to attempt to harm themselves--often as much as twice a year or more--until they succeed in taking their own lives. A third of all teens who die by suicide have attempted to end their lives at least once before.

Severe danger signs for suicide tend to occur in conjunction with prolonged symptoms of depression, and include
  • self-mutilation;

  • preoccupation with themes of death or suicide in written, artistic, or creative work;

  • direct threats of suicide, or indirect comments like, "I wish I was dead," "I want to go to sleep and never wake up," "You'll be sorry when I'm gone," "I won't be a burden to you much longer," or "Soon the pain will be over";

  • giving or throwing away treasured possessions, or other indications that the youth is putting her affairs in order; and

  • a sudden period of cheerfulness after a long period of depression--this may indicate the youth has settled on suicide as a "solution" to his problems.

If you think your teen may be depressed or considering suicide, what can you do?

  • Talk, ask questions, and commit to listening to your teen. Don't trivialize, dismiss, or poke fun at your child's problems. They may seem insignificant to you, but they are real to her, and they are causing her pain. Don't make assumptions about what the problem is, and be ready to hear what she has to say without judging her.

  • Share your feelings, and be honest about your concerns. If you are worried about him, let him know. Ask him whether he ever feels so bad that he wants to die. You will not instigate suicidal thoughts just by asking him openly and honestly about his feelings.

  • Assure your teen she is not alone and that many people experience depression. In fact, depression affects one-fifth of women and one-tenth of men, and may run in families. Let her know depression can be treated.

  • Make sure your teen has a trusted adult to talk to, even if it's not you. If your teen isn't comfortable confiding in you, suggest a more neutral person--a grandparent, member of the clergy, therapist, coach, or family friend, for example.

  • Let your child know you love him and you are committed to doing whatever it takes to support him and help him get well.

  • Get professional help for your child. Don't wait. The problem may go away without help, but it could also end in tragedy.

  • Seek support for yourself and other members of your family as well. For most parents, the realization that their child is depressed or suicidal sparks a wave of conflicting emotions, and parenting a depressed teen can be intensely draining. Be sure you are taking care of yourself during this difficult time, and seek professional services if you feel you need them. Other members of your family may also need professional guidance to deal with the situation.

Resources

American Association of Suicidology
4201 Connecticut Avenue NW, Suite 408
Washington DC 20008
202/237-2280
E-mail info@suicidology.org
www.suicidology.org

American Foundation for Suicide Prevention
120 Wall Street, 22nd Floor
New York NY 10005
888/333-AFSP
Fax 212/363-6237
E-mail inquiry@afsp.org
www.afsp.org

National Hopeline Network
Kristin Brooks Hope Center
201 North 23rd Street, Suite 100
Purcellville VA 20132
800/SUICIDE (800/784-2433, toll-free hotline)
800/442-HOPE or 540/338-5756 (business)
Fax 540/338-5746
Email info@hopeline.com
www.hopeline.com
www.livewithdepression.org

Positive Action for Teen Health (PATH)
c/o Columbia University
1775 Broadway, Suite 715
New York NY 10019
866/833-6727
E-mail path@childpsych.columbia.edu
www.pathnow.org

Teen Education and Crisis Hotline (TEACH)
PO Box 129
Clyde NC 28721
800/367-7287 (toll-free hotline)
828/627-1001 (business)
www.teachhotline.org

Child Maltreatment, Juvenile Delinquency, and Suicide

The most current research on adolescent suicide bears some discomforting--but not surprising--news for those who work in the child welfare system: Youth who have experienced trauma during childhood, particularly sexual abuse, are at significantly elevated risk for suicidal thoughts and attempts. For example:1
  • Adults with a background of childhood physical or sexual abuse may be up to 25 times more likely to attempt suicide than those who do not have such a history. Of several types of childhood traumas, child sexual abuse is linked most strongly with later suicide attempts, accounting for 9% - 20% of suicide attempts in adults.

  • The effect of trauma may extend beyond the victim of abuse: Children whose parents attempt suicide are more likely to attempt suicide themselves--and the risk is specifically increased for the children of suicide attempters who were sexually abused in childhood.

  • Childhood trauma of any type, such as physical, sexual, or psychological maltreatment or neglect; witnessing violence; having a parent with a substance abuse problem or other mental disorder; having a parent become incarcerated, die, or otherwise become separated from the child; or living in poverty, also renders youth and adults more vulnerable to low self-esteem, substance abuse, and depression and other mood disorders--all risk factors for self-harm.
This may offer a partial explanation for the high prevalence of suicidal thoughts and behavior among incarcerated youth. A 2000 study found the suicide rate among youth in the juvenile justice system is more than four times higher than among the general youth population, and a 1994 study found that 11,000 juveniles engage in more than 17,000 incidents of suicidal behavior in juvenile facilities each year.2 Suicide rates among teens incarcerated in adult facilities are even higher.

Children and adolescents in the juvenile justice system may be at increased risk for harming themselves for many reasons. First, there is a well-established link between child maltreatment and later juvenile delinquency. According to John Tuell, Director of CWLA's Juvenile Justice Division, individuals who are abused or neglected in childhood are 59% more likely than the general population to be arrested before age 18. Youth who have been abused or neglected and who are arrested tend to be younger at their first arrest, be arrested more frequently, and commit more offenses than adolescents in the justice system who have not been abused or neglected. Thus, a substantial number of incarcerated teens are likely to have experienced exactly the sort of childhood trauma that puts them at increased risk for suicidal thoughts or suicide attempts.

Second, whether or not it occurs as a direct result of early childhood trauma, incarcerated teens are highly likely to have depression or another mood disorder. According to Columbia University's Center for the Promotion of Mental Health in Juvenile Justice, the number of youth in the juvenile justice system who have severe mental health difficulties may be as high as 65%. Many also have substance abuse problems.

"The effects of childhood adversity and victimization can be staggering," says Caren Kaplan, CWLA's Program Manager for Child Welfare Services. "One in five children and adolescents may have a mental health problem, and individuals known to the child welfare or juvenile justice systems are at particularly high risk for self-harm. The prospective costs and consequences of inaction--the absence of essential mental health assessment, identification, and treatment of a child's pain--are unfathomable."

  1. Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide, Board of Neuroscience and Behavioral Health, Institute of Medicine of the National Academies. (2002). Childhood Trauma. In Reducing Suicide: A National Imperative. S.K. Goldsmith, T.C. Pellmar, A.M. Kleinman, and W.E. Bunney, eds. Washington, DC: National Academies Press.
  2. Hayes, L.M. (April 2000). Suicide Prevention in Juvenile Facilities. Juvenile Justice 7 (1). Available online at www.ncjrs.org/html/ ojjdp/jjjnl_2000_4/sui.html.

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