Preventing Suicide in Adolescents - Tips for Parents & Teachers

INTRODUCTION

Suicide is one of the commonest causes of death among young people. Suicide is the sixth leading cause of death among children aged 5-14 years, and the third leading cause of death among all those 15-24 years old. The latest mean worldwide annual rates of suicide per 100 000 were 0.5 for females and 0.9 for males among 5-14-year-olds, and 12.0 for females and 14.2 for males among 15-24-year-olds, respectively. In most countries, males outnumber females in youth suicide statistics. Though female teens are much more likely to attempt suicide than males, male teens are four times more likely to actually kill themselves. A recent survey of high-school students in the US found that:

• Almost 1 in 5 had seriously considered attempting suicide;
• More than 1 in 6 had made plans to attempt suicide; and
• More than 1 in 12 had made a suicide attempt in the past year.

If you look around a class of 25 students, at least five are likely to have seriously considered suicide, and at least two are likely to have tried to kill themselves in the past year. There are far more suicidal attempts and gestures than actual completed suicides. One epidemiological study estimated that there were 23 suicidal gestures and attempts for every completed suicide. However, it is important to pay close attention to those who make attempts, as 10% of those who attempted suicide go on to a later completed suicide.

The suicide rate among young teens and young adults has increased by more than 300% in the last 3 decades. Social changes that might be related to the rise in adolescent suicide include an increased incidence of childhood depression, decreased family stability, and increased access to firearms.

The rising rate has also been explained as a reaction to the stress inherent in adolescence compounded by increasing stress in the environment. Adolescence is a time when ordinary levels of stress are heightened by physical, psychological, emotional, and social changes. Adolescents suffer a feeling of loss for the childhood they must leave behind, and undergo an arduous period of adjustment to their new adult identity. In single-parent families, this adjustment may be even more difficult. Yet society alienates adolescents from their new identity by not allowing them the rights and responsibilities of adulthood. They are no longer children, but they are not accorded the adult privileges of expressing their sexuality or holding a place in the work force. Our achievement-oriented, highly competitive society puts pressure on teens to succeed, often forcing them to set unrealistically high personal expectations. There is increased pressure to stay in school, where success is narrowly defined and difficult to achieve. In an affluent society which emphasizes immediate rewards, adolescents are not taught to be tolerant of frustration. Blurred gender roles can also be confusing and frustrating for teens.

Some researchers attribute teenage suicide to the weakening of the family unit. They argue that economic and political institutions have penetrated it, reducing it to a consumer unit no longer able to function as a support system, and no longer able to supply family members with a sense of stability and rootedness. Awareness of the existing state of the world, now threatened by sophisticated methods of destruction, can cause depression which contributes to the adolescent's sense of frustration, helplessness, and hopelessness. Faced with these feelings and lacking coping mechanisms, adolescents can become overwhelmed and turn to escapist measures such as drugs, withdrawal, and ultimately suicide.

RISK FACTORS FOR SUICIDE

Contrary to popular belief, suicide is not an impulsive act but the result of a three-step process: a previous history of problems is compounded by problems associated with adolescence; finally, a precipitating event, often a death or the end of a meaningful relationship, triggers the suicide. Long-term problems can include: losing a parent or close relative at a young age; coming from a family of divorce, or one in which there is much discord; being a victim of domestic violence or child abuse; or living with an alcoholic in the family. Hyperactivity or undiagnosed learning disabilities also pose serious long-term problems for adolescents. These problems can create further difficulties for the adolescent, causing social isolation and withdrawal, poor school performance and attendance, and repeated suicide attempts. The precipitating event which triggers a suicide attempt is usually a family crisis, a significant personal loss, or an upset to self-esteem (such as failing a course, losing one's place on a sports team or being fired from a part-time job). The anniversary of a loss can also evoke a powerful desire to commit suicide.

Personal Characteristics

Psychopathology: More than 90% of youth suicides and around 60% of younger adolescent suicide victims have had at least one major psychiatric disorder. The most prevalent disorder in adolescent suicide victims is depressive disorders. Depression that seems to quickly disappear for no apparent reason is a cause for concern, and the early stages of recovery from depression can be a high risk period. Substance abuse, conduct disorder, posttraumatic stress disorder and panic attacks are the other disorders detected to be common in this population.

Previous suicide attempts: A history of prior suicide attempt is one of the strongest predictors of completed suicide, especially in boys. One quarter to one third of teen suicide victims have made a previous suicide attempt.

Cognitive and personality factors: Hopelessness, poor interpersonal problem solving ability and aggressive impulsive behaviour have been linked with suicidality.

Biological factors: Some teens are at greater risk for suicide because of their biochemical makeup. Abnormalities in the function of serotonin, a neurotransmitter, have been associated with suicidal behaviour.

Family Characteristics

Family history of suicidal behaviour: Teens who kill themselves have often had a close family member who attempted or committed suicide.

Parental psychopathology: High rates of parental psychopathology, particularly depression and substance abuse, have been found to be associated with completed suicide and suicidal ideation and attempts in adolescents. Moreover, family cohesion has been reported to be a protective factor for suicidal behaviour among adolescents.

Adverse life circumstances

Stressful life events: Life stressors such as interpersonal losses, and legal or disciplinary problems are associated with completed suicide and suicide attempts in adolescents.

Common problems preceding self harm:

• Difficulties or disputes with parents
• School or work problems
• Difficulties with boyfriends or girlfriends
• Disputes with siblings
• Physical ill health
• Difficulties or disputes with peers
• Depression
• Bullying
• Low self esteem
• Sexual problems
• Alcohol and drug abuse
• Awareness of self harm by friends or family

Physical abuse: Childhood physical abuse has been found to be associated with increased risk of suicide attempts in late adolescence and early adulthood.

Socioeconomic and contextual factors

School and work problems: Difficulties in school, neither working nor being in school, dropping out of hog school and not attending college pose significant risks for completed suicide.

Contagion/Imitation: Teens are more likely to kill themselves if they have recently read, seen, or heard about other suicide attempts. Evidence continues to amass from studies of suicide clusters and the impact of the media, supporting the existence of suicide contagion. The impact of suicide stories on subsequent competed suicides appears to be greatest for teenagers.

PREVENTION STRATEGIES

Youth suicide prevention strategies have primarily been implemented in within three domains – school, community, and health are systems.

SCHOOL-BASED SUICIDE PREVENTION PROGRAMS

School based suicide prevention programs include both curricula components to teach students about these warning signs and what to do, as well as non-curricula components such as peer groups, hot lines, intervention services and parent training. The goals of school based suicide prevention programs are to:
• Increase awareness
• Promote identification of students at high risk of suicide and suicide attempts
• Provide knowledge about the behavioral characteristics ("warning signs") of teens at risk for suicide.
• Provide information to students, teachers and parents on the availability of mental health resources
• Enhance the coping abilities of teenagers

Prevention includes education efforts to alert students and the community to the problem of teen suicidal behavior. Intervention with a suicidal student is aimed at protecting and helping the student who is currently in distress. Postvention occurs after there has been a suicide in the school community. It attempts to help those affected by the recent suicide. In all cases it is a good idea to have a clear plan in place in advance. It should involve staff members and administration. There should be clear protocols and clear lines of communication. Careful planning can make interventions more organized, and effective.

Education
Education may be done in a health class, by the school psychologist, guidance counselor or outside speakers. Education should address the factors that make individuals more vulnerable to suicidal thoughts. Education regarding the ill effects of drug and alcohol abuse would be useful. PTA meetings can be used to educate parents about depression and suicidal behavior. Parents should be educated about the risk of unsecured firearms in the home. Outside mental health professionals can discuss their programs so that students can see that these individuals are approachable. Education on the following areas will be useful:

Warning signs of suicide

• Suicidal talk
• Preoccupation with death and dying
• Signs of depression
• Taking excessive risks
• Increased drug use
• Previous suicide attempts
• The verbalizing of suicide threats
• The giving away of prized personal possessions
• The collection and discussion of information on suicide methods
• The expression of hopelessness, helplessness, and anger at oneself or the world
• Themes of death or depression evident in conversation, written expressions, reading selections, or artwork
• Statements or suggestions that the speaker would not be missed if he or she were gone
• The scratching or marking of the body, or other self-destructive acts
• Recent loss of a friend or a family member (or even a pet) through death or suicide; other losses (for example, loss of a parent resulting from divorce)
• Acute personality changes, unusual withdrawal, aggressiveness, or moodiness
• Sudden dramatic decline or improvement in academic performance, chronic truancy or tardiness, or running away
• Physical symptoms such as eating disturbances, sleeplessness or excessive sleeping, chronic headaches or stomachaches, menstrual irregularities, apathetic appearance

The majority of the population at any one time does not have many of the warning signs and has a lower suicide risk rate. But a lower rate in a larger population is still a lot of people - and many completed suicides had only a few of the conditions listed above. Sudden changes in behavior that are significant, last for a long time, and are apparent in all or most areas of his or her life (pervasive) are more specific than presence of isolated signs. However, all indications of suicidality need to be taken seriously in a one person to another person situation.

Signs of depression in teens

• Sad, anxious or "empty" mood
• Declining school performance
• Loss of pleasure/interest in social and sports activities
• Sleeping too much or too little
• Changes in weight or appetite

Possible motives or reasons underlying self harm

• To die
• To escape from unbearable anguish
• To change the behaviour of others
• To escape from a situation
• To show desperation to others
• To change the behaviour of others
• To "get back at" other people or make them feel guilty
• To gain relief of tension
• To seek help

Features of self harm that suggest high suicidal intent

• Conducted in isolation
• Timed so that intervention is unlikely (for example, after parents have gone to work)
• Precautions to avoid discovery
• Preparations made in anticipation of death (for example, leaving indication of how belongings to be distributed)
• Adolescent told other people beforehand about thoughts of suicide
• The act had been considered for hours or days beforehand
• Suicide note or message
• Adolescent did not alert others during or after the act

Factors associated with repeated self harm

• Previous self harm
• Personality disturbance
• Depression
• Alcohol or drug misuse
• Chronic psychosocial problems and behaviour disturbance
• Disturbed family relationships
• Alcohol dependence in the family
• Social isolation
• Poor school record
How to support a student with suicidal thoughts and a low self-esteem?
• Listen actively. Teach problem-solving skills
• Encourage positive thinking. Instead of saying that he cannot do something, he should say that he will try.
• Help the student write a list of his or her good qualities.
• Give the student opportunities for success. Give as much praise as possible
• Help the student set up a step-by-step plan to achieve his goals.
• Talk to the family so that they can understand how the student is feeling.
• He or she might benefit from assertiveness training
• Helping others may raise one's self-esteem.
• Get the student involved in positive activities in school or in the community.
• If appropriate, involve the student's religious community.
• Make up a contract with rewards for positive and new behaviors.

What can be done to help someone who may be suicidal?
1. Take it seriously.
Myth: "The people who talk about it don't do it." Studies have found that more than 75% of all completed suicides did things in the few weeks or months prior to their deaths to indicate to others that they were in deep despair. Anyone expressing suicidal feelings needs immediate attention.
Myth: "Anyone who tries to kill himself has got to be crazy." Perhaps 10% of all suicidal people are psychotic or have delusional beliefs about reality. Most suicidal people suffer from the recognized mental illness of depression; but many depressed people adequately manage their daily affairs. The absence of "craziness" does not mean the absence of suicide risk.
"Those problems weren't enough to commit suicide over," is often said by people who knew a completed suicide. You cannot assume that because you feel something is not worth being suicidal about, that the person you are with feels the same way. It is not how bad the problem is, but how badly it's hurting the person who has it.
2. Remember: suicidal behavior is a cry for help.
Myth: "If someone is going to kill himself, nothing can stop him." The fact that a person is still alive is sufficient proof that part of him wants to remain alive. The suicidal person is ambivalent - part of him wants to live and part of him wants not so much death as he wants the pain to end. It is the part that wants to live that tells another "I feel suicidal." If a suicidal person turns to you it is likely that he believes that you are more caring, more informed about coping with misfortune, and more willing to protect his confidentiality. No matter how negative the manner and content of his talk, he is doing a positive thing and has a positive view of you.
3. Be willing to give and get help sooner rather than later.
Suicide prevention is not a last minute activity. All textbooks on depression say it should be reached as soon as possible. Unfortunately, suicidal people are afraid that trying to get help may bring them more pain: being told they are stupid, foolish, sinful, or manipulative; rejection; punishment; suspension from school; written records of their condition; or involuntary commitment. You need to do everything you can to reduce pain, rather than increase or prolong it. Constructively involving yourself on the side of life as early as possible will reduce the risk of suicide.
4. Listen.
Give the person every opportunity to unburden his troubles and ventilate his feelings. You don't need to say much and there are no magic words. If you are concerned, your voice and manner will show it. Give him relief from being alone with his pain; let him know you are glad he turned to you. Patience, sympathy, acceptance. . At times everyone feels sad, hurt, or hopeless. You know what that's like; share your feelings. Let the child know he or she is not alone.Avoid arguments and advice giving. If the child's words or actions scare you, tell him or her. If you're worried or don't know what to do, say so.
5. ASK: "Are you having thoughts of suicide?"
Myth: "Talking about it may give someone the idea." People already have the idea; suicide is constantly in the news media. If you ask a despairing person this question you are doing a good thing for them: you are showing him that you care about him, that you take him seriously, and that you are willing to let him share his pain with you. You are giving him further opportunity to discharge pent up and painful feelings. If the person is having thoughts of suicide, find out how far along his ideation has progressed.
6. If the person is acutely suicidal, do not leave him alone.
If the means are present, try to get rid of them. Detoxify the home.
7. Urge professional help.
Persistence and patience may be needed to seek, engage and continue with as many options as possible. In any referral situation, let the person know you care and want to maintain contact.
8. No secrets.
It is the part of the person that is afraid of more pain that says "Don't tell anyone." It is the part that wants to stay alive that tells you about it. Respond to that part of the person and persistently seek out a mature and compassionate person with whom you can review the situation. (You can get outside help and still protect the person from pain causing breaches of privacy.) Do not try to go it alone. Get help for the person and for yourself. Distributing the anxieties and responsibilities of suicide prevention makes it easier and much more effective.
Crisis Services (hotlines)
Crisis centers and hotlines are based on the premise that suicide is often associated with a critical stress event, it is usually approached with ambivalence, and the wish to commit suicide is seen as a way to solve an immediate problem. Crisis centers and hotlines are designed to deal with the immediate crisis, and use the individual's ambivalence to convince them that there are other means of solving the problem other than suicide. Central Institute of Psychiatry, Ranchi, has been successfully running a 24-hour helpline for last few years (Toll free no: 1600451116).
Interventions with a suicidal student
Schools should have a written protocol for dealing with a student who shows signs of suicidal or other dangerous behavior. Some schools have automatic expulsion policies for students who engage in illegal or violent behavior. It is important to remember that teens who are violent or abuse drugs may be at increased risk for suicide. If someone is expelled, the school should attempt to help the parents arrange immediate, and possibly intensive psychiatric and behavioral intervention.
1. Calm the immediate crisis situation. Do not leave the suicidal student alone even for a minute. Ask whether he or she is in possession of any potentially dangerous objects or medications. If the student has dangerous items on his person, be calm and try to verbally persuade the student to give them to you. Do not engage in a physical struggle to get the items. Call administration or the designated crisis team. Escort the student away from other students to a safe place where the crisis team members can talk to him. Be sure that there is access to a telephone.
2. The crisis individuals then interview the student and determine the potential risk for suicide.
a. If the student is holding on to dangerous items, it is the highest risk situation. Staff should call an ambulance and police and the student's parents. Staff should try to calm the student and ask for the dangerous items.
b. If the student has no dangerous objects, but appears to be an immediate suicide risk, it would be considered a high-risk situation. If the student is upset because of physical or sexual abuse, staff should notify the appropriate school personnel and contact the police. If there is no evidence of abuse or neglect, staff should contact parents and ask them to come in to pick up their child. Staff should inform them fully about the situation and strongly encourage them to take their child to a mental health professional for an evaluation. The team should give the parents a list of telephone numbers of crisis clinics. If the school is unable to contact parents, and if the police cannot intervene, designated staff should take the student to a nearby emergency room.
c. If the student has had suicidal thoughts but does not seem likely to hurt himself in the near future, the risk is more moderate. If abuse or neglect is involved, staff should proceed as in the high-risk process. If there is no evidence of abuse, the parents should still be called to come in. They should be encouraged to take their child for an immediate evaluation.
d. Follow-Up: It is important to document all actions taken. The crisis team may meet after the incident to go over the situation. Friends of the student should be given some limited information about what has transpired. Designated staff should follow up with the student and parents to determine whether the student is receiving appropriate mental health services. Follow-up is crucial, because most suicides occur within three months of the beginning of improvement, when the youth has the energy to carry out plans conceived earlier. Regularly scheduled supportive counseling should be provided to teach the youth coping mechanisms for managing stress accompanying a life crisis, as well as day-to-day stress.
Role of the school counselors
School counselors can act as liaisons between the community and the school, between mental health professionals and teachers, and between suicidal teens and parents. They can also:
• Alert school officials to the seriousness of the issue
• Present educational films to the school population
• Offer stress management workshops to teens
• Train peer counselors
• Establish support groups for teens
• Staff drop-in centers, providing a counseling atmosphere of support and acceptance
• Construct a referral network of psychiatrists, psychologists, and social workers to contact in case of emergency
• Advocate that the school offer a wide variety of extracurricular activities to youth
• Encourage more personalized teacher-student relationships
In a counseling situation, a contract can be an effective prevention technique. The adolescent signs a card which states that he or she agrees not to take the final step of suicide while interacting with the counselor.
Role of the teachers
Teachers play an especially important part in prevention, because they spend so much time with their students. Along with holding parent-teacher meetings to discuss teenage suicide prevention, teachers can form referral networks with mental health professionals. They can increase student awareness by introducing the topic in health classes. Students should learn how to identify those at risk of suicide, how to intervene with good listening and communication skills, and where to turn for help.
Role of the peers
Peers are crucial to suicide prevention. According to one survey, 93% of the students reported that they would turn to a friend before a teacher, parent or spiritual guide in a time of crisis. Peers can form student support groups and, once educated themselves, can train others to be peer counselors.
Adolescents often will try to support a suicidal friend by themselves. They may feel bound to secrecy, or feel that adults are not to be trusted, and this may delay needed treatment. Ideally, a teenage friend should listen to the suicidal youth in an empathic way, but then insist on getting the youth immediate adult and professional help.

Role of parents
Parents need to be as open and as attentive as possible to their adolescent children's difficulties. The most effective suicide prevention technique parents can exercise is to maintain open lines of communication with their children. Sometimes teens hide their problems, not wanting to burden the people they love. It is extremely important to assure teens that they can share their troubles, and gain support in the process. Parents are encouraged to talk about suicide with their children, and to educate themselves by attending parent-teacher or parent-counselor education sessions and from the Internet. Once trained, parents can help to staff a crisis hotline in their community. Parents also need to be involved in the counseling process if a teen has suicidal tendencies. These activities may both alleviate parents' fears of the unknown and assure teenagers. that their parents care.
Postvention/crisis intervention
An attempted or completed suicide can have a powerful effect on the staff and on the other students. There are conflicting reports on the incidence of a contagion effect creating more suicides. However, there is no doubt that individuals close to the dead student may have years of distress. One study found an increased incidence of major depression and posttraumatic stress disorder 1.5 to 3 years after the suicide. There have been clusters of suicides in adolescents. Some feel that media sensationalization or idealized obituaries of the deceased may contribute to this phenomenon.
The rationale for school-based postvention/crisis intervention is that a timely response to a suicide is likely to reduce subsequent morbidity and mortality in fellow students, including suicidality, the onset and exacerbation of psychiatric disorders (for e.g., posttraumatic stress disorder, major depressive disorder), and other symptoms related to pathological bereavement. The major goals of postvention programs are
• To assist the survivors in the grief process
• To identify and refer those individuals who may be at risk following the suicide
• To provide accurate information about the suicide while attempting to prevent suicide contagion
• To implement a structure for ongoing prevention efforts
The school should have plans in place to deal with a suicide or other major crisis in the school community. The administration or the designated individual should try to get as much information as soon as possible. He or she should meet with teachers and staff to inform them of the suicide. The teachers or other staff should inform each class of students. It is important that all of the students hear the same thing. After they have been informed, they should have the opportunity to talk about it. Those who wish should be excused to talk to crisis counselors. The school should have extra counselors available for students and staff who need to talk. Students who appear to be the most severely affected may need parental notification and outside mental health referrals. Rumor control is important. There should be a designated person to deal with the media. Refusing to talk to the media takes away the chance to influence what information will be in the news. One should remind the media reporters that sensational reporting has the potential for increasing a contagion effect. They should ask the media to be careful in how they report the incident. Media should avoid repeated or sensationalistic coverage. They should not provide enough details of the suicide method to create a "how to" description. They should try not to glorify the individual or present the suicidal behavior as a legitimate strategy for coping with difficult situations.
It is imperative for crisis interventions to be well planned and evaluated; otherwise, not only may they not help survivors, but they may potentially exacerbate problems through the induction of imitation.
COMMUNITY BASED PREVENTION PROGRAMS

Restricting access to lethal means

The underlying rationale for means restriction is that suicidal individuals are often impulsive, they may be ambivalent about killing themselves, and the risk period for suicide is transient. Restricting access to lethal methods during this period may prevent suicides. The following steps may be useful:
• Safe storage of guns
• Fences on bridges
• Restricting drugs/poisons
• Other restrictions on guns
Educating the media

This includes educating media professionals about contagion, in order to yield stories that minimize them, and encouraging the media's positive role in educating the public about risks for suicide and shaping attitudes about suicide.

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