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Section 15
Adolescent Suicide Risk

Question 15 | Test | Table of Contents

Suicide is a leading cause of death among adolescents. This study examined the suicidal ideation, behavior, and attempt history of 100 adolescents ages seventeen to nineteen. Four psychosocial factors were found to be important for overall suicide risk: hopelessness, hostility, negative self-concept, and isolation. It is suggested that focusing on these four psychosocial factors would enhance suicide assessment and prevention efforts with adolescents.

Suicide is a leading cause of death among those aged 15-24 (Berman & Jobes, 1995; Centers for Disease Control, 2002). Consequently, in the U.S., a National Health Objective (National Institute of Mental Health, 2001) urges researchers to focus on ways to decrease the adolescent suicide rate by more than 25% within the decade.

Adolescent suicide research has, by and large, focused on demographic risk factors (Brent, Baugher, & Bridge, 1999; Levy, Jurkovic, & Spirito, 1995). This approach provides descriptive data and correlates demographics with suicide risk. Numerous studies have examined the incidence of suicidal thoughts and suicide attempts by age, race, educational level, family background, religion, socioeconomic level, sexual orientation, and other demographic variables (D'Augelli, Hershberger, & Pilkington, 1996; Levy, Jurkovic, & Spirito, 1995). Such studies focused on who is at risk, but did not explain why certain youths may be at risk for suicide. For example, adolescents with substance abuse problems, psychiatric disorders, family disruption/stress, antisocial behavior, or family suicide history are said to be at greater risk for completing suicide. This does not explain the context of an adolescent's propensity for suicide, and is problematic in the formulation of effective intervention strategies (Grholt, Ekebrg, & Wichstrom, 2000).

This approach also suggests that adolescents of a certain demographic may be at higher risk for suicide, but focusing on demographics alone may lead to misidentifying those not at risk, as well as bypassing those who are actually at risk for suicidal behavior (Pfeffer, Klerman, Hurt, Lesser, Peskin, & Seifker, 1991). For example, D'Augelli and Hershberger (1995) suggested that gay, lesbian, and bisexual adolescents exhibit greater suicide risk than their heterosexual peers. However, Rutter (1998) found that sexual orientation alone did not impact suicide risk. Rutter and Soucar (2002) reported that adolescents who endorsed items citing the presence of social support from peers and family displayed less suicide risk, regardless of their sexual orientation.

The majority of suicides occur among Caucasian adolescents; consequently, most interventions are based on Caucasian adolescents' suicidal behavior. Yet, rates among Native American, Hispanic, and African American adolescents have increased dramatically in the past decade. Recent research suggests that racial and ethnic minority adolescents exhibit suicide risk differently, are unlikely to be assessed accurately, and are often overlooked as "at risk" (Canino & Roberts, 2001; Choquet, Kovess, & Poutignat, 1993; Scouller & Smith, 2002).

Blum, Beuhring, Shew, Bearinger, Sieving, and Resnick (2000) have suggested that researchers look within more proximal social contexts to understand what predisposes some adolescents to increased suicide risk. In keeping with the aforementioned National Health Objective (National Institute of Mental Health, 2001), examining the psychosocial correlates within a particular demographic group may be a more efficacious approach to predicting who is at highest risk for suicide. The purpose of the present study was to ascertain the salience of combining four psychosocial variables as potential predictors of suicide risk.

Method
Participants
A sample of one hundred adolescents, with an equal number of male and female participants, was recruited from a sexual minority support agency (n = 50) and an urban university (n = 50). Fifty-three percent of the participants were Caucasian, 25% African American, 6% Asian, 3% Hispanic, and 13% identified themselves as either biracial or Native American. Fourteen percent were 17 years old, 37% were 18 years old, and 49% were 19 years old. In terms of sexual orientation, 26% self-identified as homosexual, 24% as bisexual/questioning, and 50% as heterosexual. This was a nonclinical sample and participation was voluntary.

Procedure
The exploration of psychosocial factors in relation to suicide risk is by no means new. There is extensive literature on how certain individual factors can affect suicidal behavior. The current study explored adolescent suicide risk across multiple psychosocial factors (hopelessness, negative self-concept, hostility, and low social support). The instrument combined the Suicide Probability Scale (SPS; Zachary, Roid, Cull, & Gill, 1983), the Beck Hopelessness Scale (BHS; Beck, Brown & Steer, 1989), the Suicide Questionnaire (SQ; Meehan, Lamb, Saltzman, & O'Caroll, 1992), and a demographics form (Rutter, 1998).

The SPS is a reliable 36-item Likert-type self-report inventory focusing on hopelessness, hostility, suicidal ideation, and negative self-concept. The BHS is a psychometrically sound self-report measure that has 20 true-false statements to assess negative beliefs about the future. Scores range from 0 to 20, with higher scores indicating greater levels of hopelessness. The SQ was modified from its original form as an inpatient clinical interview. Reliability and validity have yet to be established, although the SQ has been reported to exhibit high face validity and to offer a nonthreatening method of assessing suicidal ideation, plans, and attempts (Muehrer, 1995). The demographics form contains questions about the adolescent's ethnicity, sexual orientation, and education level, as well as questions about the level of social support received from friends, family, and school staff.

Findings
To assess suicide risk across demographic and psychosocial variables, participants were first grouped into a lowest quartile (Group 1; n = 25) and a highest quartile (Group 2; n = 25) according to their scores on the SPS. Participants in Group 2 has a significantly higher score (M = 7.72, SD = 3.59) on the BHS than those in Group 1 (M = 2.44, SD = 1.66). A statistically significant positive relationship was found between SPS and BHS scores (p < .01).

Groups 1 and 2 (lowest and highest SPS quartiles) were compared across responses to three items (7,8,and 9) from the SQ. These items asked participants if they experienced injury resulting from their suicide attempt (item 7), if their attempt was serious enough to require medical care (item 8), and whether hospitalization was required after their suicide attempt (item 9). A t test indicated a statistically significant difference (p < .01) between the two groups on their responses to item 7. Group 1 experienced much lower injury from their suicide attempt (M = 2.00, SD = 1.98) than Group 2 (M = 2.76, SD = 2.76). The comparison of the two groups on item 8 (attempt serious enough to require medical care) and item 9 (hospitalization required after suicide attempt) suggested differences between groups, but results were not statistically significant (item 8:F = 4.00, p = .051, and item 9:F = 1.39, p = .24). Results from t tests approached statistical significance regarding a relationship between perceived social support and SPS scores (p = .057).

Finally, demographics were explored using the two groups. No statistically significant correlation between any one demographic and suicide risk was found. Analysis included comparing SPS scores across race (F = .03, p = .855), gender (F = .88, p = .352), and sexual orientation (F = .02, p = .887).

Discussion
Limitations of this study should be noted. First, the sample included a group of sexual minority youth recruited from a support agency. This support may have skewed their responses in a positive direction. Second, while the data can serve as impetus for a larger project, the current findings are exploratory in nature and may not be generalizable. Third, the assessment of support could have been more comprehensive. With this said, the data do offer insight into the significance of psychosocial factors in assessing adolescent suicide risk.

A higher SPS score was related to a higher level of hopelessness and to greater seriousness of the suicide attempt. High and low scores on the SPS differed significantly in their BHS scores and their responses to item 7 of the SQ (injury resulting from suicide attempt). While the two SPS groups differed in terms of social support (high scores reported low social support and low scorers reported high social support, this difference was not quite statistically significant.

These data are consistent with and build upon previous research that focused on the individual psychosocial factors of hopelessness (D'Augelli, Hershberger, & Pilkington, 1997), hostility (Cull & Gill, 1989), poor self-concept (Cetin, 2001; Harter & Marold, 1994), and low social support/isolation (Rutter & Soucar, 2002). What emerges from the data in the present study are that these four factors (hopelessness, hostility, negative self-concept, and isolation) collectively correlate with increased suicide risk.

Hopelessness is a significant indicator of adolescent depression and potential for suicide. Hopelessness and its clinical manifestations can be situational or transient (Beck, Brown, & Steer, 1989). Combined with adolescents' impulsive nature, the presence of hopelessness can be quite dangerous (Hollander, 2000). Therefore, accurate assessment of adolescent suicide risk should include an indication of current levels of hopelessness (Dori & Overholser, 1999).

Hostility has long been associated with suicide. Schneidman (1969) defined self-injury as hostility turned inward. More recently, hostility among adolescents has been associated with punitive self-injury aimed at an external person, such as a parent or peer (Meehan et al., 1992).

Self-concept is also a psychosocial factor that warrants inclusion. Research indicates that adolescents incorporate personal, school, and social failures as elements of their self-concept (Berman & Jobes, 1995; Harter & Marold, 1994). Researchers exploring this variable have maintained that poor self-concept can lead to self-loathing and to an adolescent's consideration of suicide (Grholt et al., 2000; Harter & Marold, 1992).

Finally, social support is related to healthier adolescent functioning. Support, as a construct, has been defined as a sense of belonging, specifically among peers, teammates, community, or family members (Grholt et al., 2000). Adolescents reporting strong social support (low isolation) exhibit higher levels of resilience and lower levels of suicide risk. Adolescents are also less likely to be suicidal if they perceive their family, friends, and peers to be more accepting, and if they have more positive friendships (Harter, Marold, Whitesell, & Cobbs, 1996). Those who feel supported by counselors, parents, or peers exhibit healthier coping mechanisms and maintain a more positive outlook about their future (DeWilde, Kienhorst, Diekstra, & Wolters, 1993). In contrast, adolescents who lack social support and experience isolation may behave in self-injurious ways (Himmelman, 1993; Remafedi, Farrow, & Deisher, 1991; Spruijt & de Goede, 1997).

These four psychosocial variables, taken collectively, appear to improve the ability to assess and predict adolescents' suicide risk. This should be verified through additional research using a larger sample, a variety of school settings, and with additional items to assess social support.

Future work could clarify whether improving any one of the four psychosocial factors will influence the other factors and decrease over-all suicide risk. For example, clinical strategies aimed at increasing levels of social support may reduce an adolescent's level of hostility, hopelessness, or negative self-concept. The results of this and prior studies warrant exploring the individual and collective impact of these variables in reducing levels of suicide risk. We speculate, for example, that the gay and lesbian participants in the present study may have exhibited lower suicide risk because they were members of a community-based youth center for sexual minorities. Their membership may have contributed to less isolation, hopelessness, and hostility, and to feeling better about themselves.

While many today conceptualize suicide as an experience located within the individual, pioneering work on suicide focused on underlying social factors that impact individuals, leading them to be more, or less, suicidal. Durkheim (1897/1951) stressed the importance for individuals to feel connected and to be socially integrated. Those with weaker social ties and those suffering from a bewildering sense of not belonging, what he referred to as anomie, are more likely to commit suicide. This is consistent with the four psychosocial factors that the present study has found to correlate with suicide risk among some adolescents.

This perspective suggests the need to design dual-approach interventions that work with both the individual and within society. The individual may benefit from strategies to reduce hopelessness, hostility, negative self-concept, and isolation. Social policy makers wishing to reduce suicide might consider strategies that would combat anomie by encouraging small group participation for marginalized individuals. Further, while our study examined adolescents, the findings may have implications for other groups (e.g., the elderly).

Other factors should not be ignored in assessing adolescent suicide risk, including previous suicide attempts, a history of others in the family who have been suicidal, mental illness, alcohol and drug use, and other self-destructive behaviors. Nevertheless, school counselors, therapists, and others in the helping professions will be better equipped to intervene and reduce suicide risk when they focus on adolescents' level of hopelessness, hostility, negative self-concept, and isolation.
-Rutter, Philip A., Behrendt, Andrew E., Adolescence, Summer2004, Vol. 39, Issue 154

Suicide Risk Factors and Risk Assessment: A Systematic Review

- Evidence-based Synthesis Program (ESP) Center. (2012). Suicide Risk Factors and Risk Assessment: A Systematic Review. Department of Veterans Affairs.

Crisis intervention for people with severe mental illnesses

- Murphy, S., Irving, C. B., Adams, C. E., & Driver, R. (2012). Crisis intervention for people with severe mental illnesses. The Cochrane database of systematic reviews, 5(5), CD001087. doi:10.1002/14651858.CD001087.pub4.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about four psychosocial factors to be considered regarding adolescent suicide risk.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Preventing Youth Suicide: Potential "Crossover Effects"
of Existing School-Based Programs

Ayer, L., Stevens, C., Reider, E., Sims, B., Colpe, L., & Pearson, J. (2023). Preventing Youth Suicide: Potential "Crossover Effects" of Existing School-Based Programs. Prevention science : the official journal of the Society for Prevention Research, 24(2), 382–392. https://doi.org/10.1007/s11121-022-01473-2


Peer-Reviewed Journal Article References:
Ali, A., & Gibson, K. (2019). Young people's reasons for feeling suicidal: An analysis of posts to a social media suicide prevention forum. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 40(6), 400–406.

Braun, M., Till, B., Pirkis, J., & Niederkrotenthaler, T. (2020). Suicide prevention videos developed by and for adolescents: A qualitative study. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication.

Finan, L. J., Ohannessian, C. M., & Gordon, M. S. (2018). Trajectories of depressive symptoms from adolescence to emerging adulthood: The influence of parents, peers, and siblings. Developmental Psychology, 54(8), 1555–1567.

QUESTION 15
What are the four psychosocial factors to be considered regarding adolescent suicide risk? To select and enter your answer go to Test.

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