Suicide method runs in families: a birth certificate cohort study of adolescent suicide in Taiwan

Suicide method used by adolescents was examined to determine if it was the same as that employed by their suicidal parents. Six hundred eighty adolescents completed suicide between 1997 and 2007, of whom 12 had parents who had previously died by suicide. The suicide method used by these adolescents was compared with that employed by their suicidal parent and that of a matched peer control adolescent with no exposure to parental suicide and living in the same area. In 10 of the 12 suicidal parent-adolescent dyads, the same suicide method was employed by parent and adolescent. Of seven adolescents whose age at parental suicide was 15 years or above, six used the same suicide method as their suicidal parent had. On the contrary, of 12 exposure-nonexposure suicidal adolescent dyads, the same method was used in only four. Adolescents exposed to parental suicide are more likely to use the suicide method employed by their suicidal parents than the method used by adolescent peers with no exposure to parental suicide.     

The Unified Protocols for Children and Adolescents in Partial Hospitalization: Using Implementation Science Frameworks to Guide Adaptation

Partial hospitalization programs (PHPs) and other acute mental health treatment programs, which are becoming increasingly common, may help divert children and adolescents from inpatient psychiatric care and provide a concentrated dose of intervention to individuals living in low-resource areas. However, there have been relatively few examinations of the effectiveness of PHPs in addressing emotional concerns (e.g., anxiety, depression, irritability) and functional impairment in youth. Further, evidence-based treatments originally designed for delivery in an outpatient weekly format may require significant adaptation to be appropriate for delivery in acute mental health settings, which differ significantly from weekly outpatient care in program structure, patient acuity, and staffing. In this intervention development and adaptation report, we present the rationale for adapting a transdiagnostic approach to treating emotional disorders—the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A)—for a hospital-based, general psychiatric partial hospitalization program. We use implementation science frameworks to describe our iterative approach to treatment adaptation and testing and to describe in detail proactive, planned adaptations to the UP-C/A for partial hospitalization that occurred prior to initial implementation and pilot testing. Three case examples (child, preadolescent, adolescent) are presented to illustrate how a transdiagnostic approach to care such as the UP-C/A can be used intensively in an acute mental health setting to address emotional and behavioral concerns, including safety.     

Peer Victimization and Suicidal Thoughts and Behaviors in Depressed Adolescents

Suicide is a leading cause of death among youth worldwide, and depressed adolescents are at a significantly elevated risk to report suicidal ideation, planning, and attempts. Peer victimization is a robust predictor of adolescent suicidal thoughts and behaviors (STBs), but little research has focused on why bullying leads to suicidal thoughts and behaviors. To address this empirical gap, we recruited 340 (246 female) depressed adolescents ages 13–19 (M = 15.59, SD = 1.41) within 48 h of admission for acute psychiatric treatment. At the initial assessment, participants were administered clinical interviews characterizing psychopathology, nonsuicidal self-injury, and STBs (ideation, plans, and attempts). Further, they completed questionnaires assessing 3 forms of victimization (overt, relational, and reputational), recent risky behavior engagement, and psychiatric symptom severity. Controlling for internalizing symptoms and age, overt and reputational bullying were associated with more frequent past month suicide attempts, but not suicide ideation. Past month risky behavior engagement, but not NSSI, mediated the relation between victimization and attempts. However, sex differences revealed that this effect only held for males whereas bullying was directly associated with suicide attempts among females. In contrast, overt and relational bullying were non-linearly associated with suicide plans, and these relations were not mediated by risky behaviors or NSSI. Results highlight the complex network of factors that lead victimized adolescents to engage in STBs and may inform targeted suicide prevention and intervention programs.     

Suicidal adolescents' perceptions of their family environment.

This study examined the extent to which adolescents' perceptions of their family environments were associated with suicidal behavior. Fifteen suicidal adolescents, 14 psychiatric controls, and 14 normal controls rated their families on cohesiveness, adaptability, parent-adolescent communication, parental caring, and parental over-protectiveness. Suicidal adolescents rated their families as the least cohesive and most rigid of the 3 groups, suggesting that adolescent suicidal behavior may occur when isolation is experienced within an inflexible family system. Suicidal and psychiatric control adolescents rated their families as similarly dysfunctional along the remaining variables, and as more dysfunctional than families of normal control adolescents. The implications of these findings are discussed, and it is suggested that several characteristics commonly attributed to families of suicidal adolescents may actually be general risk factors for adolescent psychopathology, rather than for suicidal behavior specifically.     

Adolescent suicide attempters presenting to a pediatric facility

This study profiles the characteristics of adolescent suicide attempters and the treatment they received in a pediatric emergency room (ER). A retrospective chart review of 4,072 adolescents seen in the ER at a children's hospital (CH) from July 1984 to June 1985 was undertaken. Twenty-seven adolescents who had deliberately injured themselves were identified. The average age was 14 years 7 months (range 11-19 years). Fifty-two percent of the patients were white and 78% were female. Ingestion was the most common method (78%), followed by attempted hanging (11%), and wrist laceration (7%). After evaluation by a pediatrician in the ER, 30% of the patients were treated and released, 11% were transferred directly to a psychiatric hospital, and 59% were admitted to the CH, with an average hospital stay of 1.88 days. Once hospitalized, consultations from psychiatry (81%), social service (50%), psychology (19%), and neurology (6%) were obtained. At the time of discharge from either the ER or CH, the patients had a variety of plans for ongoing care, with 52% being referred to outpatient counseling, 37% being transferred to a psychiatric hospital, and 11% having no documented plan for ongoing care. These results demonstrate that the evaluation of suicidal adolescents cared for in a pediatric facility may be episodic and suggest the need for a comprehensive program to approach the problem.     

A Brief Alcohol Intervention During Inpatient Psychiatric Hospitalization for Suicidal Adolescents

Alcohol use and suicide-related thoughts and behaviors are common in psychiatrically hospitalized adolescents and each problem can exacerbate the other. Despite knowledge about the functional relationship between alcohol use and suicide-related thoughts and behaviors, inpatient psychiatric units only cursorily address alcohol use because suicide risk is considered primary. In this paper we provide theoretical and empirical rationale for the inclusion of brief motivational interventions for alcohol use in inpatient treatment settings for suicidal adolescents. We give a case example of the brief intervention in practice, including when and how to use specific techniques. Following the case example, we discuss the flexibility of this intervention and how it can be adapted for adolescents with varying risk profiles. We conclude with recommendations for future research, including the development and testing of technology-based boosters following hospital discharge.     

Adolescent suicide and defensive style.

This empirical study investigated the relation between ego defense mechanisms, diagnoses, and suicidality among 200 adolescent psychiatric patients ages 12 to 16 years. Based on a structured diagnostic interview, adolescents were divided into three groups: suicide attempters, suicidal ideators, and nonsuicidal patients. Using the Defense Mechanisms Inventory (DMI), suicidal adolescents scored higher on the defense of turning-against-self and lower on reversal, as compared to nonsuicidal adolescents. Although suicide was significantly more common among adolescents with an affective disorder, turning-against-self remained significantly associated with suicide attempt even when diagnosis was controlled for. Results demonstrate the importance of defense mechanisms in understanding adolescent suicidal behavior.     

Working With the Suicidal Client Who Also Abuses Substances

Substance use disorders and suicidal thoughts and behaviors commonly co-occur in adolescent and adult psychiatric populations and are often functionally interrelated. Although the evidence base for treatment of this population is sparse, integrated cognitive behavioral treatment (CBT) protocols, or those that rely heavily on CBT techniques, hold promise. In this paper, we provide an overview of the evidence-based literature for interventions that target suicidal behavior and substance use disorders with adults and adolescents. We then discuss the manner in which these behaviors may be functionally interrelated and offer a conceptual framework (S-O-R-C) to guide case conceptualization and treatment planning for clients with co-occurring suicidality and substance use disorders. Next, we provide a case example of a client with suicidal behavior and an alcohol use disorder and demonstrate how to apply an integrated CBT treatment protocol to this case. This case example is followed by a more general discussion about the potential advantages of integrated CBT protocols for suicidality and substance use disorders, guidelines for prioritizing treatment targets and skill selection for each individual client, and other important treatment considerations. We conclude with recommendations for future research in this area.     

The Rorschach test for predicting suicide among depressed adolescent inpatients.

With the decreasing length of psychiatric hospitalizations, identification of test indicators of suicide risk becomes critically important. This Rorschach study was designed to model a clinical decision-making scenario concerning adolescent suicide risk. Using Psychiatric Evaluation Form (PEF) scores, we selected a sample of 25 severely depressed and suicidal adolescents; 26 severely depressed, not suicidal adolescents; and 28 not suicidal, not depressed adolescent inpatients at The Sheppard and Enoch Pratt Hospital. A Rorschach Index using the Exner (1986) Comprehensive System for scoring was developed to predict group membership. Four of six of the features on this index selected 64% of suicidal subjects. This constellation included traditional affective variables (vista responses, color-shading blends, color dominated responses, and morbid content) as well as measures of cognitive distortion (inaccurately perceived human movement responses [M-] and special scores). We discuss the implications of these findings for the diagnosis and treatment of the suicidal adolescent.     

Assessment of Suicidal Youth in the Emergency Department

Accurate evaluation of suicidal adolescents in the emergency department (ED) is critical for safety and linkage to follow‐up care. We examined self‐reports of 181 adolescents who presented to an ED with suicidal ideation (SI) or a suicide attempt (SA). Parents also completed self‐reports. Results showed fair agreement between parents and youth on the reason for the ED visit (e.g., SI vs. SA) and greater agreement between independent judges and youths than between judges and parents. In accordance with accepted definitions of suicide attempts (e.g., Crosby, Ortega, & Melanson, 2011; O'Carroll, Berman, Maris, Moscicki, Tanney, & Silverman, 1996, p. 237; Posner, Oquendo, Gould, Stanley, & Davies, 2007, p. 1035; Silverman, Berman, Sanddal, O'Carroll, & Joiner, 2007, p. 248), most youth with SA as the reason for the ED visit reported some intent to die associated with the attempt. Finally, youth presenting to the ED with SA did not differ clinically from youth presenting with SI, and almost half of youths with SI reported past suicide attempts. These results highlight the need to emphasize adolescents' reports in clinical decision making, suggest adolescents' defined suicide attempts similarly to published definitions, and show that assessment of past SAs, as well as present suicidal thoughts and behaviors, is critical in determining future risk.     

Racial disparities in mental health service use by adolescents who thought about or attempted suicide

Differences in rates and predictors of mental health service use among 2,226 Black, Hispanic, and White adolescents (aged 12-17) who reported recent suicidal thoughts or an attempt were examined. Black adolescents were 65% (OR = .65, p < .05), and Hispanic adolescents were 55% (OR = .55, p < .001), as likely as White adolescents to report service use, even when controlling for need for care and ability to secure services. Suicide attempt and psychiatric symptoms each interacted with race to increase the odds of service use uniquely for White adolescents. Results indicate that racial disparities characterize adolescents' mental health service use even when suicide risk increases.     

Occupational Therapist,Biomedical Science Corps Officer and Former Firefighter

Abstract

What the literature reports that adolescents need within their parent-adolescent relationships, as well as what adolescents with serious emotional disturbances may experience within their parent-adolescent relationships are discussed. A framework for providing parent-adolescent group intervention for psychiatrically hospitalized adolescents and their parents to promote positive interaction and co-occupation are provided. Summaries of the parent-adolescent activity group experiences of three families are provided to illustrate how different adolescent psychiatric issues and family dynamics might be addressed in a parent adolescent activity group.     

Parental Awareness and Monitoring of Adolescent Internet Use

This study focused on four aspects of parental monitoring of Internet use by their children: parental supervision, communication and tracking, and adolescent disclosure. Data were obtained from a SAFT (Safety Awareness for Teens Project) national survey of Singapore youths and parents regarding Internet safety at home. Study 1 examined 1,124 adolescents and 1,002 parents; Study 2 examined a subsample of 169 dyads of adolescents and their parents. Frequency of use and engagement in risky Internet behaviors such as visiting inappropriate websites were analysed. The results indicated that parents tend to underestimate adolescents’ engagement in risky Internet behaviors and overestimate the amount of parental monitoring regarding Internet safety that occurs at home. The study suggested that mothers have a better awareness of their adolescents’ Internet use than fathers. The findings were explained in the context of parental monitoring. The results suggest that parental monitoring needs to be reconceptualized and that parents need to improve the communication with their adolescents regarding Internet use.     

Suicidal Ideation and Behavior in Adolescents Aged 12–16 Years: A 17‐Year Follow‐Up

The prevalence of suicidal ideation/behavior in 1983 or 1987 and its association with future mental health in 2001 were evaluated in a provincially representative sample of Canadian adolescents (n = 1,248) aged 12 to 16 years. Approximately 13.3% (95% CI = 11.5–15.3) of adolescents self‐reported suicidal ideation/behavior. Adolescent agreement with parent (κ = .07) and teacher (κ = .05) reports at baseline was low because adults identified so few subjects. In adulthood, the associations between adolescent self‐reports of suicidal behavior/ideation and major depression and other mental health indicators were explained by respondent sex and adolescent emotional problems reported in 1983/1987. Adolescents with suicidal behavior/ideation often are not recognized by their parents and teachers and may be at risk for persistent psychiatric problems attributable to coexisting mental health problems early‐on.     

Family-Based Cognitive-Behavioral Treatments for Suicidal Adolescents and Their Integration With Individual Treatment

A considerable research base underscores the importance of family functioning in the risk for and treatment of adolescent suicidal thoughts and behaviors. This paper reviews the extant empirical literature documenting associations between features of the family context and adolescent suicidal thoughts and behaviors. A case example is provided to illustrate how family factors may guide case conceptualization and treatment planning for suicidal adolescents. In light of the growing support for treatment approaches predicated on the principles of cognitive-behavioral therapy (CBT), the paper focuses on many of the common family treatment elements, notably interventions with parents across treatment studies with adolescent suicidal populations. A specific treatment known as CBT for Suicide Prevention (CBT-SP; Stanley et al., 2009) serves as an exemplar for how interventions with parents may be applied in the context of an integrated intervention for teen suicide. The paper reviews issues salient to the implementation of key components of treatment with parents and addresses specific treatment considerations and challenges.     

The subjective experience of problem irresolvability and suicidal behavior: dynamics and measurement.

This article presents the dynamics and measurement of a relatively unstudied concept in children's and adolescents' suicidal behavior: the subjective experience of problem irresolvability (SEPI). This concept relates to the youngsters' sense of lack of control due to being pressured to resolve irresolvable problems within the family circle. The first study describes the construction and factor analysis of the SEPI scale as well as its relationship to suicidal tendencies, perceived parental care, and self-esteem. The second study presents a repeated factor analysis and the association between the SEPI scale and suicidal tendencies, hopelessness, depression, anxiety, and commitment to parents. The results suggest that the scale has a 4-factor structure with sound psychometric properties that distinguish successfully between suicidal adolescents on the one hand, and psychiatric and normal adolescents on the other. The SEPI was also found to be associated with the various studied variables.     

A Multi-Informant Approach to Assessing Safety Behaviors among Adolescents: Psychometric Properties of the Subtle Avoidance Frequency Examination

Safety behaviors are subtle avoidance strategies for minimizing distress within social situations (e.g., avoidance of eye contact). These behaviors factor prominently in the development and maintenance of social anxiety concerns, and when patients use these behaviors within psychosocial treatments for social anxiety, this may impede treatment response. Prior work supports the need to include measures of safety behaviors within evidence-based assessments of social anxiety. Along these lines, researchers developed the Subtle Avoidance Frequency Examination (SAFE) to assess safety behaviors among adults. However, we know relatively little about the SAFE’s psychometric properties when administered to adolescents. We tested the SAFE’s psychometric properties using adolescent self-reports and parallel parent reports in a mixed-clinical/community sample of 96 14 to 15 year-old adolescents and their parents (33 clinic-referred; 63 community control; 59.4% African American). Adolescent and parent SAFE reports displayed moderate correspondence with each other. Both adolescent and parent SAFE reports related positively to well-established measures of adolescent social anxiety and depressive symptoms. Both reports distinguished adolescents on referral status as well as cut scores on well-established measures of adolescent social anxiety. Further, both adolescent and parent SAFE reports displayed incremental validity in relation to survey reports of adolescent social anxiety, over-and-above survey reports of adolescent depressive symptoms, which commonly co-occur with social anxiety. However, adolescent (but not parent) SAFE reports predicted adolescents’ social anxiety and state arousal as displayed within social interactions with unfamiliar peer confederates. These findings have important implications for leveraging multi-informant approaches to assessing safety behaviors among adolescents.     

Clarifying the Relationship of Parental Bonding to Suicide Ideation and Attempts

Suicide and suicidal behavior are major public health problems, especially among adolescents and young adults. Previous research has established links between parental bonding and suicidality; however, it remains unclear whether parental bonding is associated with suicide ideation, the progression from suicide ideation to suicide attempts, or both. This study examined the relation of parental bonding to suicide ideation and suicide attempts in adolescents from two settings: (1) acute psychiatric care (n = 172) and (2) high school (n = 426). All participants were administered validated measures of parental bonding, suicide ideation, and suicide attempts, as well as emotion dysregulation, loneliness, and self‐worth. In the psychiatric sample, lower parental care significantly differentiated adolescents with a history of suicide attempts from those with suicide ideation only or without histories of suicidality. This pattern remained even after controlling for other known correlates of suicidality (i.e., emotional dysregulation, loneliness, and low self‐worth). Similar effects were found in the community sample, although these findings failed to reach statistical significance. In both samples, parental overprotection was not associated with suicide ideation or suicide attempts. Results suggest that parental care may be an important risk factor for youth suicidal behavior and may help differentiate suicide attempters from suicide ideators.     

Adolescent suicide: character traits of high-risk teenagers

Adolescent suicide rates are increasing and are currently higher than ever recorded. Thus, it has become essential for health professionals, counselors, and parents to become familiar with characteristics of the high-risk teenager. This article examines personality traits and life circumstances which place an adolescent at higher risk for suicide. Among the variables examined are: depression, acute suicidal behavior, poor family relationships, alcohol and drug use, recent loss, failure in school, and other characteristics. As adolescents pass through difficult life stages successfully, teenage suicides will decrease. Professional helpers and parents must be able to recognize the signs which are discussed and take an active role in prevention and/or intervention.