Although suicide rates in the general population have remained stable over the last three decades, they have increased threefold among adolescents.1 Second to accidents, suicide is the most common cause of death in 15- to 24-year-olds in the United Slates.2
The situation becomes even more alarming when suicide attempts are taken into account. Each year, approximately one half million adolescents and young adults attempt suicide. A recent Menninger foundation Suicide Fact Sheet indicated that as many as 1 I % of all normal high school students can be expected to have made at least one suicide attempt, while approximately 25% have thought about suicide to the point of having an actual plan in mind. It is estimated that for every completed suicide there are 50 to 150 attempted suicides.5
This article presents a comprehensive and critical review of the literature on the psychosocial factors of suicide in adolescents. Also presented is a summary of the findings of a study conducted by Husain and Vandiver, who have analyzed 167 cases of suicidal behavior presented in the literature.
In 1968. the number of completed suicides in the United States among 5- to 1 4-year-olds was 1 1 8, rising to 200 in 1982 and representing 0.5% oí suicides in all age groups. These figures for I 5- to 24-year-olds were 2557 in 1968 and 5025 in 1982. accounting for 12% of all suicides.2 These trends suggest that suicide rates increase over time and are age-specific.4'6 Young children seem to be relatively immune to suicide.
A number of factors may explain the low suicide rate in children. Children are said to lack the psychological sophistication required to make a decision to commit suicide. Depressive illnesses, which have a high association with suicide, are less prevalent in children. Also, families tend to provide more support to younger children because they are so dependent.7
Percentage increase in the populaof adolescent and young adults contributes to suicide by incompetition for desirable and the subsequent increase stress.8,10
Women attempt suicide three more often than men," but as many men actually comit. A similar trend is observed the adolescent population.12 increase in completed suicide in is partly attributed to their use more potent and foolproof methods.
Racial, religious, and cultural variables play important roles in youth Although whites succeed in suicide more often, blacks make more suicide attempts. suicide rates in adolescents of both races, however, are the same.14 Urban blacks of both sexes have consistently higher suicide rates than whites.15 Rage and violence seem to be underlying factors in this group6
Social and religious attitudes toward suicide also are important. Ordinarily, in societies in which suicide is regarded as an honorable and noble way to die, suicide is more common than in cultures in which it is considered sinful, cowardly, or a sign of mental illness. However, no significant relationship between religious beliefs and suicidal behavior is found in children and adolescents. I(1 These studies conclude that the effect of religion on adolescent behavior is more complex and may depend on the strength of religious conviction.
ROLE OF THE FAMILY
Suicidal behavior in adolescents is frequently a symptom oi' prolonged and progressive family disruption, disturbed parent-child relationships, and inadequate communication.17 A suicidal adolescent may feel isolated from important family members and may experience a loss of love. The adolescent may have feelings of hostility and rejection and may be al a loss for a constructive way of dealing with them.18 Suicidal adolescents often have a history of suicidal behavior in their immediate and extended families.19
A poignant interpretation of suicidal behavior in multiple family members is that suicide is a "language" that is understood, whereas other methods of communication fail.20 Thus, suicide is an effort at communication used in place of normal methods of communication in nonsuicidal families.
The child or adolescent suicide attempt is considered by some authors as a "cry for help."21'23 An adolescent may use a suicide attempt to communicate, when other communication attempts have failed and the child sees no other way of obtaining help.22 If repeated attempts are ignored by those within the adolescent's immediate environment, a final fatal attempt may result.
Actual physical or psychological loss, such as death, separation, or emotional distancing oï a family member, is considered by some as the most significant environmental factor in the life histories of suicidal adolescents.24·25 The context in which the loss occurs is also important. After the death of a parent, children and adolescents usually do better when social support and adequate surrogates are present than when these elements are absent.26
DEPRESSION AND SUICIDE
Suicide is the most serious complication of depression, although depression does not always underlie suicide.27 Severe depression is the most prevalent characteristic of the suicidal adolescent.19,27 Studies comparing suicidal with nonsuicidal children have shown that suicidal children arc significantly more depressed than their nonsuicidal counterparts. Often, however, adults fail to notice depressive symptoms in their children until after a suicidal act.28
Clinical symptoms of depression as seen in adults may be more difficult to identify in adolescents. Acting out behaviors, such as outwardly expressed hostility, stealing, running away, acting out sexually, and school dysfunction, are by far more commonly seen in depressed adolescents. Depression in adolescents frequently may be manifested as conduct disorder29 and therefore may be missed as a suicide risk factor.
SUICIDAL BEHAVIOR IN ABUSED CHLDREN
Physical and sexual abuse is commonly found in the histories of suicidal adolescents. Seiden15 frequently encountered a history of violence in parents of suicidal young blacks. These adolescents were flooded with angry homicidal impulses and were overwhelmed by the fear of losing control. They considered suicide a means of controlling these violent impulses.
In a study of 15 male victims of homosexual incest. Husain50 found that all had strong suicidal thoughts and that six had actually made suicide attempts. These adolescents had strong homicidal impulses toward the perpetrator of the sexual abuse; four had already killed their molesters. The rest attributed their suicidal thoughts to their frustration at not being able to carry out their homicidal impulses.50
In an effort to explore psychosocial factors of children and adolescents who threaten, attempt, or complete suicide, the investigators conducted a statistical analysis of 167 case studies of suicide behavior reported in the literature from 1955 to 1980. The details of methodology, statistical analysis, and findings are published elsewhere.27
This analysis uncovered significant age and sex differences based on the categories for suicidal behavior rates and for propensity to complete suicide rather than threaten or attempt suicide. Sixty-five percent of suicide completers were male, and all but one suicide completer fell in the 16- to 20-year-old age category.
We found that boys were involved in suicidal incidents more frequently than gills. Although suicidal behaviors in children I 1 years of age and younger were low. young boys were much more likely to have suicidal behaviors than young girls and comprised 76% of the suicidal behavior. The suicide rates among girls increased significantly during puberty. Girls comprised 63% of the suicidal behavior in the 12- to 15-year-old age category.
Children who engaged in suicidal behavior often were characterized as bright, but their environment and personal lives were in turmoil. Many IeIt a great deal of hostility directed at them, while many also experienced overt or covert rejection. They often reacted by exhibiting behavior problems and delinquency or depression and withdrawal. They possessed a great deal of anger and despair. Some had experienced separations and deaths, primarily in their younger years, and for some these experiences had formed a pattern of separation and bereavement occurring throughout their childhood. The parents and the environment of these children and adolescents were often overwhelmingly rejecting.
Boys who were I I years old and younger showed hyperactivity, aggression, and disobethence as their behavior characteristics; the girls showed only disobethence. Both boys and girls demonstrated an affect of anger and despair. Withdrawal, delinquency, drug abuse, and truancy became more common in the 12- to 15-year-old age group. Depression was the single most frequem precipitating factor in the 16-to 20-year-old age group. Problems with alcohol and drug abuse increased, whereas behavior problems decreased in the older group.
Those who completed suicide were characterized in our analysis as being more depressed, more frequently involved with illicit drugs or alcohol, and having more rejecting fathers than the suicide attempters. They also more often experienced the loss of their mothers by suicide before their own suicide.
A variety of psychosocial factors contribute to suicide behavior in adolescents. Age. sex, and race are all involved. However, familyrelated factors appear to be the most significant contributors in youth suicide. Family turmoil, disturbed parent-child relationships, physical and sexual abuse by family members, and hostile and rejecting attitudes of the parents directed toward the children have all been found to promote suicide behavior.
In reviewing the literature, it appears that a teenager does not make the decision to complete suicide overnight. The suicide is usually completed alter a long and progressive struggle, when all other efforts (including previous suicide attempts) have failed to bring a relief from stress and despair.
In a typical scenario, the struggle between a child and the environment mav begin early in childhood. The child may react to loss, rejection, hostility, and abuse with anger and despair, and may manifest behaviors such as hyperactivity, aggression, and suicide threats. As the child grows older and does not sec any relief from turmoil, anger and desperation may be acted out through delinquent and antisocial acts. The child may resort to the use oi drugs and alcohol to feel better and may gravitate toward peers who are experiencing similar situations. At this stage, suicide attempts become more common than threats. Depression begins to set in. with a feeling ol helplessness and hopelessness dominating the child's moods. The decision to commit suicide is then made as a last resort.
The phenomenon of "cluster suicide"' also can be explained on the basis of this scenario. Adolescents who kill themselves after a muchpublicized suicide are most often those who have gone through a similar lengthy ordeal. They have often contemplated or even attempted suicide in the past. The publicized suicide offers them a model for the final solution.
Suicide is preventable and opportunities for intervention are numerous. It is up to the family and professionals to recognize the risk and to develop preventive strategies.
1. Hepworth DH. Farley OW. Griffith JK. Research capsules. In: Social Research Institute Newsletter. Salt Lake City. Utah: University of Utah. Graduate School of Social Works: February 1986.
2. National Center for Health Statistics. Madison. Wl: US Dept of Health Education and Welfare: 1984.
3. Mclntire M. Angle CR. Wikoff RL. Schlicht. Recurrent adolescent suicidal behavior. Pediatries. 1977 : 60:605-608.
4. Hellon CP. Solomon MI. Suicide and age in Alberta, Canada. 1951-1477: the changing profile. Arch (Jen Psychiatry. 1980: 37:505-510.
5. Murphy GE, Wetzel RD. Suicide risk by birth cohort in the United States. 1949-1974. Arch Lieu Psychiatry. 1980: 57:510-525.
6. Goldney RD. Katsikitis M. Cohort analysis of suicidal rates in Australia. Arch Gen Psychiatry. 1985: 40:71-74.
7. Shaffer D. Fisher P. The epidemiology of suicide in children and young adolescents, J Am Acad Child Adolesc Psychiatry. 1981; 20:545-5b5.
8. Hendon H. Youth suicide: a psychosocial perspective. Suicide Life Threat Behav. Summer 1987; 17:2.
9. Hollinger PC. Offer D. Prediction of adolescent suicide: a population model. Am J Psychiatry. 1982; 159:302-507.
10. Esterlin R. Birth and fortune: The Impact of Numbers on Personal Welfare. New York. NY: Basic Books: 1980.
11. Neiger BI., Hopkin RW. Adolesceni suicide: character traits of high risk teenagers. Adolescence. 1988; 23:90.
12. Miller ML. Chiles JA. Barnes V. Suicide atiempters within a delinquent population. J Consult Clin Psychol. 1982; 50:491-498.
13. Davis PA. Suicidal Adolescents. Springfield. Ill: Charles C. Thomas; 1983.
14. Malen BQ. Frandsen KJ. Youth Suicide: Depression and Loneliness. Provo. UT: Behavioral Health Associates: 1986.
15. Seiden RH. Death in the West: a regional analvsis of the vouthful suicide rate. West J Med. 1984; 140(b):969-976.
16. Petzel S. Riddle M. Adolesceni suicide: psychosocial and cognitive aspects. In: reinstein SC. ed. Adolescent Psychiatry. Developmental and Clinical Studies. Chicago. Ill: University of Chicago Press: 1981:545-598.
17. Hearings Before the Senate judiciary Subcommittee on Juvenile justice of the Senate Committee on Teenage Suicide. 98th Cong (1984) (testimony of M. Herbert on leenage suicide in the public school system).
18. Rosenberg I. Policy Forum: The Personal Stress Problems of Tanners and Rural Americans. Rockville. Md: NIMH: 1986.
19. Friedman RC. Corn R. Hurt SW, Sibel B, Schulick I. Swirsky S. Family history of illness in the seriously suicidal adolescent: a life cycle approach. Am J Orthopsychiatry'. 1984: 54:590-595.
20. fishier CL. McKenry PC. Morgan KC. Adolesceni suicide attempts: some significant factors. Suicide Life Threat Behav. 1981; 11:86-92.
21. Mclntire MS. Angle CR. The taxonomy of suicide as seen in poison control centers. Pediatr Clin Sortit Am. 1970: 17:697-706.
22. Richman J. Suicide and the family: affective disturbances and their implication for understanding diagnosis, and treatment. In: Lansky MR. ed. family therapy and Major Psyehopathology. New York. NY: Crune and Stratton: 1981.
25. Creen AH. Self-destructive behavior in battered children. Am I Psychiatry. 1978: 155:579-582.
24. Adam KS. Bouckoms A. Steiner D. Parental loss and family stability in attempted suicide. Arch Gen Psychiatry. 1980: 59:1081-1085.
25. Lee EE. Suicide and youth. Personnel and Guidance journal. 1978; 57(4):200-204.
26. Raphael B.- Anatomy of Bereavement. New York, NY: Basic Books: 1985.
27. Husain SA. Vandiver T. Suicide in Children and Adolescents. New York, NY: Spectrum Publication: 1984.
28. Shaffer D. Suicide in childhood and early adolescence. J Child Psychol Psychiatry. 1974; 15:275-291.
29. Husain SA. Depressive illness in children. Mo Med. 1979; 527-551.
50. Husain SA. Homosexual incest. Am J Psychiatry. In press.