Risk Behaviors

School-age children can engage in many behaviors of concern to adults as a function of their development as well as the changing culture and environments in which they live. Perhaps the most concerning and baffling of these risk behaviors are the tendencies in some to consider ending their own lives at so young an age. Why children and adolescents consider these self-destructive actions is a complicated puzzle to understand and solve. Such behaviors must be considered in light of young people's vulnerability to external models, their increased anxiety related to issues of social acceptance, their desire to develop a unique identity, and the existence of unstable and abusive families.

In 1999 the surgeon general of the United States, David Satcher, issued a call to action to prevent suicide. Satcher noted the continuing increase in suicide rates among the young, with the rate tripling from 1952 to 1996. He stated that Americans under the age of twenty-five accounted for 15 percent of all completed suicides and that risk factors for suicide attempts among the young included depression, alcohol or drug use disorders, and aggressive and disruptive behaviors. Suicide was not just a mental health problem but a public health problem as well.

Occurrence

Suicide rates for children and adolescents are regularly reported by the National Center for Health Statistics in the U.S. Department of Health and Human Services. These reports count only those for whom suicide is listed as the cause of death. For this reason it is believed that suicides may be underreported. Those who sign death certificates (family physicians, emergency room staff, and medical examiners) may not always list the cause of death as intentional in order to avoid stigma for the family or because evidence of suicide may not be immediately present. It is suspected that vehicular accidents and deaths related to substance abuse, for instance, may in some cases be suicides, but they may not be recorded as such.

A review of statistics regarding rates of suicide reveal a number of facts. For those aged fifteen to twenty-four, suicide stands as the third-leading cause of death behind accidents and homicides. As of 1996, the rate of suicide deaths for Americans aged ten to fourteen was 1.6 deaths per 100,000 population (2.3 per 100,000 for males and 0.8 per 100,000 for females). For fifteen-to nineteen-year-olds the rate was 9.7 deaths per 100,000 (15.6 per 100,000 for males and 3.5 per 100,000 for females), and for those aged twenty to twenty-four the rate was 14.5 deaths per 100,000 (24.8 per 100,000 for males and 3.7 per 100,000 for females). Young males (aged fifteen to nineteen) are more likely to succeed at killing themselves than females by a ratio of at least five to one. Reports from the surgeon general also suggest that gay and lesbian youth may be two to three times more likely to commit suicide. Although accomplished suicide rates were highest for white males, young African American males showed the greatest increase during the 1980s and 1990s. White females had the next highest rates, followed by African-American females. Research on Hispanic populations indicated that rates of suicide in young men and women may be higher than for whites.

Suicides can be completed using a variety of means. Nearly 63 percent of suicides occur using firearms. Most other deaths are a result of more passive means such as drug poisonings or hangings. Suicide attempts are less likely to involve firearms and may, therefore, provide opportunities for discovery and rescue.

In addition to completed or accomplished suicides, many young people attempt suicide. Accurate rates for this group of attempted suicides, often called parasuicides, are even more difficult to obtain. Hospitals and emergency rooms may identify attempters, but many parasuicides go completely undetected or are confided only to the closest of friends. Possible ratios of attempts to completions may range from 10:1 to 150:1, depending upon the research and the definition of attempts. The continuum of suicidal behaviors, which includes actual suicide on one end and attempted suicides in the middle, includes on the other end the least severe form of self-destructiveness, usually identified as suicidal ideation or intent. The idea of killing oneself may occur quite frequently in young people, but it becomes serious only when there is intent to actually act. Such suicidal intent often includes a plan and a timetable in the person's mind.

Risk Factors

Many factors have been examined as contributors to the likelihood that a school-age child will become suicidal. Some factors appear to be historical or situational whereas others are psychological. A large percentage (perhaps as high as 90 percent) of those who are victims of suicide have diagnosable psychiatric disorders at the time of death. Many suffer from mood disorders, and a large percentage have made previous suicide attempts. Risk factors may include: psychiatric disorder, previous suicide attempt, co-occurring drug use and mental disorder, family history of suicide, impulsive or aggressive tendencies, feelings of hopelessness, loss of significant relationship, loss of job, physical illness, stress, lack of access to mental health treatment, availability of lethal means (e.g., guns or drugs), feelings of isolation and alienation, influence of peers or family members, unwillingness to seek help, cultural or religious beliefs or traditions, influence of the media, current epidemics of suicidal behaviors, and being a victim of bullying.

In the case of children and adolescents, two major themes related to increased risk for suicide are fears of humiliation by others and feelings of invisibility. Additional themes may also include general levels of stress, breakdown of psychological defenses, self-deprecatory thoughts, and a negative personal history.

Protective Factors

Just as some factors seem to increase the incidence of self-destructive suicidal intent, so also there appear to be conditions that make these thoughts and behaviors less likely. Such circumstances or characteristics are considered to be protective. Among those cited by the surgeon general in 1999 were: effective and appropriate clinical care; access to treatment and support for seeking help; restricted access to lethal means; family and community support; ongoing medical and mental health care relationships; learned skills in problem solving, conflict resolution and nonviolent dispute management; and a belief system, either cultural or religious in nature, that discourages suicide. Skills in anger management, impulse control, and appropriate action in the face of victimization have been also cited as protective factors.

Warning Signs

The warning signs of imminent suicidal behaviors can appear in many forms. They can be verbal, spoken to others; written as poems, songs, diary entries, or suicide notes; or made as threats directly ("I am going to kill myself") or indirectly ("You won't have me to kick around anymore"). Other warning signs include social withdrawal, getting things in order, giving things away, constant crying, or an angry or hostile attitude. Some signs occur in the person's environment, such as the death of someone close, family problems, or failure in school or at work. Lastly, some signs are those characteristic of depression or general mental and emotional difficulties. These latter signs might include sleep disturbance, feelings of despair, appetite change, or radical and abrupt changes in behavior or personality.

Formulation of the Problem

According to Jerry Jacobs, writing in 1971, early research into suicide examined five major stages seen in suicidal children. These included a history of problems, an escalation of problems, the failure of coping, the experience of helplessness, and finally, a justification for taking a self-destructive action. Although these stages may be present, in many cases adults do not observe them, but rather they are shared with peers. Adults may merely see the final behaviors.

It is important to realize that suicidal behavior can best be seen not as a disease (although it may in some cases be the manifestation of one), but rather as a symptom with many different possible underlying causes. Just as a headache could be caused by many things, so the action to end one's own life can be a result of any number of causes: depression or other mental illness, stress, grief or loss, unresolved conflict, substance use, unexpressed anger or rage, social pressure, lack of problem-solving or conflict resolution skills, hopelessness or frustration, chronic victimization, a desire for visibility or respect, the need to avoid humiliation, or the desire to be noticed.

Prevention

The best strategies for the prevention of suicide are those that reduce the number of risk factors and increase protective factors. This means making resources available to families and schools to aid in this process. In some cases early intervention is needed. Prevention or primary interventions need to: develop strategies for detecting suicidal individuals, treat all threats seriously, educate those who work with kids about suicide, increase peer education about suicide, teach families and communities to look for warning signs, reduce the availability of lethal means, make twenty-four-hour hotlines available, and use the media to teach the public how to recognize those at risk.

Finally, it must be acknowledged that the problem of self-destructive behavior affects everyone. Parents, schools, and communities must make a commitment to work to end this behavior and its causes.