A Public Health Crisis: Suicidal Behaviors in Teenagers

Introduction

The Center for Disease Control and Prevention and the United States Surgeon General together has declared suicide to be a public health crisis (Whitlock, Wyman, & Moore, 2014). Teenagers and young adults are especially susceptible to suicidal behaviors and ideation due to the changes and challenges that are faced during adolescence. Suicidal behaviors include non-suicidal self-injury (NSSI) and plan making. Nearly 25% of all adolescents will engage in NSSI. NSSI is self-harm typically done through the burning or cutting of oneself. Those that engage in this behavior tend to be doing it as a coping mechanism to reduce feelings of tension, anger, or anxiety, and depression; some even self-harm to actually feel something rather than nothing. Research has found that those that engage in NSSI likely have a friend or family member that also engages in it (Steinberg, 2016).

How the media portrays suicide victims and how friends are behaving also influences an adolescent’s behavior. Studies of media reports of suicide have shown that adolescents are influenced by fictional and non-fictional instances of suicide and the way a victim is portrayed has a significant impact on whether a teenager will copy the behavior. For example, if a victim is show in a light that they have been “set free,” versus the fact that the victim was suffering from an illness, the influence becomes stronger. Suicide experts from the Centers for Disease Control and Prevention (CDC), Canadian Psychiatric Association and World Health Organization prefer that the media cover suicide with an emphasis on the fact that the victim was under duress, that it is not a solution and to encourage those that feel hopeless to reach out for help. Also, teens are more likely to commit suicide if a friend, family member, or member of their community committed suicide (Feuer, & Havens, 2017). This is known as suicide contagion, which teens are more susceptible to due to the fact that they imitate behavior in their environment (Steinberg, 2016).

This research and recommendation report discusses the different transitions that adolescents go through and how these transitions may affect their decision to commit suicide, a review of the current data and articles about suicide during adolescence, and recommendations on how to prevent suicide.

Theory

Adolescence is a trying time due to the amount of biological, cognitive, and social changes that an individual will go through. Hormonal changes that everyone goes through during puberty leads to changes in the body and sexual maturation and depending on when the individual goes through these changes, can lead to dissatisfaction in body image. Research has shown that early and late maturation compared to peers can lead to emotional difficulties. The intense pressure that adolescents are under to be attractive and thin can lead to depression, anxiety, the development of eating disorders, and even panic attacks. Two established risk factors for attempting suicide are having a psychiatric problem and being under stress (Steinberg, 2016).

In addition to the different changes that the body undergoes, adolescents’ brains are maturing and developing. Adolescents begin to think abstractly, hypothetically and in multiple dimensions. During this time, development of understanding other people’s personalities through mentalizing, that is understanding someone else’s mental state (Steinberg, 2016), takes place. Adolescents are also able to compare risk and reward and become more emotional and more responsive to stress. Although adolescents experience a maturing of thought processes, adolescents are more likely to engage in risky behavior than adults. These behaviors include reckless driving, unsafe sex, and substance abuse. These risky behaviors may develop into coping mechanisms in depressed individuals which increase the risk of a suicide attempt (Risk Factors and Warning Signs, afsp.org, 2018).

In social transitions, if there are discontinuous transitions, that is transitions that are not smooth and the entrance into new events in life is more sudden, adolescents are more at-risk at being under stress. Being under stress is another established risk factor for attempting suicide. The fourth and final is experiencing parental rejection, family disruption, or extensive family conflict. During the social transition period, it’s likely that adolescents will be separated from their parents more and more. Typically this is through summer camps or boarding schools. This separation, though not an inherently bad thing, can weaken relationships and make it difficult for adolescents to know where to turn for help.

Literature Review

Statistics

Suicide is the 10th leading cause of death in the United States and the 2nd leading cause of death of individuals ages 10 to 24. Approximately 157,000 of these individuals are treated in the Emergency Department for self-inflicted injuries and/or suicide attempts with 4,600 dying each year (Suicide Statistics, afsp.org, n.d.). 10% of female adolescents and 5% of male adolescents will attempt suicide with males being more likely to actually die from suicide. The current suicide rate is the highest it’s been in 10 years. Research suggests that the increase in availability of drugs, alcohol, and firearms could be a factor in this (Steinberg, 2016). In 2016 alone, firearms were used in 51% of suicides.

The American Foundation for Suicide Prevention (AFSP) estimates that suicide attempts are likely underreported due to the stigma surrounding mental illness (2018). There are several organizations with similar goals in raising awareness, educating the public about mental health, and providing resources and aid to those affected by suicide. AFSP and the Suicide Prevention Resource Center (SPRC) are two organizations that were referenced in this report.

Warning Signs

There are 3 categories of warning signs that someone may be considering suicide. The important warning signs to look out for are any changes in the way an individual is talking (e.g. speaking about killing themselves, wishing they were dead, feeling trapped or hopeless), behaving (e.g. increased drug or alcohol use, isolating oneself, saying goodbye, or giving away prized possessions), or any drastic or sudden changes in mood (e.g. depression, loss of interest, feelings of shame or humiliation, or very sudden improvement) (Risk Factors and Warning Signs, afsp.org, 2018).

Protective Factors

In an effort to bring an end to this epidemic, there are some protective factors or environmental characteristics that help protect people from suicide. These include effective behavioral healthcare, connectedness to individuals, family, and community, life skills, self-esteem and a sense of purpose in life, and cultural, religious or personal beliefs that discourage suicide (Risk and Protective Factors, sprc.org, n.d.).

In the article Connectedness and Suicide Prevention in Adolescents: Pathways and Implications, published in the Official Journal of the American Association of Suicidology, Whitlock, Wyman, and Moore for the Centers for Disease Control and Prevention launched an initiative to increase connectedness; connectedness is often used interchangeably with related contexts such as attachment, bonding, and social support (Whitlock et al., 2014). It’s important to note that connectedness with peers and friends is not sufficient enough to prevent suicidal thoughts and behaviors (STB). Disconnection from peers and connection to peers may increase the risk of STB due to groups that may be unconventionally supportive of STB. Whitlock et al., suggests that there are two areas of focus to improve connectedness: positive subjective cognitive and emotional experiences and appraisals of relationships with adults, peers, and social systems such as schools, and structural interrelatedness between networks in which youth are embedded (2014).

The article Emotionally Troubled Teens’ Help-Seeking Behaviors: An Evaluation of Surviving the Teens Suicide Prevention and Depression Awareness Program, which was published in the Journal of School Nursing and written by Strunk, Sorter, Ossege, and King, analyzes help-seeking behaviors among emotionally troubled teens. They outline the Surviving the Teens program which is geared towards high school-aged students and its secondary level, Steps to LAST. The Steps to LAST initiative uses a mnemonic tool to help troubled teens help themselves in times of crises. For the individual, LAST stands for Let someone know what is troubling you, Ask for and accept others’ support, Share feelings, and Tell an adult who can help. When reaching out and helping a troubled adolescent the Steps to LAST are Listen and look for signs of depression/suicide, Ask specific questions about suicide, Show support and Tell and adult who can help. This program also educates educators on how to look for warning signs in their students. Strunk et al., have found that this program has had promising results in schools (2013).

Finally, in the article Teen Experiences Following a Suicide Attempt by Holliday and Vandermause, found in the Archives of Psychiatric Nursing, there are two patterns of suicide attempts: attempting as communicating and attempting as transforming. In the pattern of suicide as communicating teens struggled with telling others about their suffering and the attempt was their “telling.” In this case, the attempt preceded language. In one case study, a girl named Jennifer explained that she attempted suicide due being unable to communicate her suicidal thoughts. She was quoted as saying she felt betrayed due to those close to her not picking up on the little signs she would put out. Steinberg wrote that adolescents who attempt suicide have usually made appeals for help and that they tend to feel trapped, hopeless, and worthless. The support they seek from friends and family is not received which coincides with Jennifer’s account (2015).

In the pattern of attempting as transforming, attempts created a shift between life before and after the attempt. Interviews conducted by Holiday and Vanermause found that interviewees felt that they were disconnected from their support group prior to their attempt. After the attempt, however, they experience a reconnection with family and initiation of connection with counselors. The connection with counselors helped the adolescents realize that the connection with family had been there all along (2015).

Real-Life Example

My family and I all thought my little brother Nathan was just a normal 13 year-old with normal struggles. He enjoyed video games and playing with LEGOs. He seemed happy though he had been struggling in school recently. He had been having issues with other students and some teachers, too, but he seemed to be holding it together well. Dr. Rachel Mallory, Ph.D., RPsych has said that it's sometimes difficult to see warning signs when warning signs are the norm (2014).

It was late when my mom called. My husband and I were just hanging out at home when she told us that we needed to get to the hospital as soon as we could; Nathan had been in an accident. My stomach dropped and I immediately knew there was more to the story. I asked if he had hurt himself. My mom paused, "Yes, hurry."

Nathan is the youngest of our family, so it’s just him and my other brother that live at home. One of my little sisters was visiting from college that weekend since Sunday was Mother’s Day. It had been a busy Friday night and everyone was out of the house. Nathan had cleaned his room and once he was alone, he went into his closet with a belt. A short time later, my parents and another sister got home and my dad went to go check on Nathan. If you ask my parents, they will tell you everything was in slow motion. They worked quickly to get him down, start CPR and call for help. By the time my dad was able to revive Nathan, an ambulance was there to take him to the hospital and not a moment too soon as he began to have seizures. Nathan hadn’t written a note.

My dad greeted my husband and I at the Emergency Department when we arrived. He had been crying. My mom was with Nathan and my little sister who was with them when they found him. My other siblings were in a waiting room. Once everyone had arrived, we went into the room. Nathan was still with us, though he was strapped down on his hospital bed and there were tubes everywhere. I was angry, sad, confused, and but mostly heartbroken. I couldn’t understand how we couldn’t have known this would happen? Why didn't he come to us for help? Were we not there for him? Why would he do this?

After only a few short hours at that hospital, he was transferred to Primary Children's Medical Center in the Pediatric Intensive Care Unit. We would later find out that the staff at the first hospital didn't think he was going to make it and had Nathan travel in an ambulance rather than be airlifted. He was put into a medically induced coma so his brain could heal from the lack of oxygen and the resulting seizures. He was in this coma for over a day. Through some miracle, he had survived. But we all wondered “would he be in a wheelchair and need diapers? When will he wake up? Would he be the same? How could we ever be the same?”

Naters spent several days in the PICU recovering from his attempt. We visited him every day we could. On Sunday, we all signed a card for my exhausted mom. Nathan wrote “Happy Birthday!” While it provided some much needed levity during a very difficult time, we all wondered how could think it was our mom’s birthday when we had told him just that it was Mother’s Day. Was he going to suffer permanent memory loss?

Later, my parents spoke to him privately about why he thought he was in the hospital; he kept saying it was due to a car accident that happened 5 years prior. My mom told him how he got hurt and why he was in the hospital. Nathan was distraught and kept asking why he would do that. We didn't know. We still don't know. With time, we stopped focusing on why it happened and started to focus on how to prevent it from happening again. We also know that he was in need of friendship and feeling loved. On top of struggling with depression, ADHD, and bullying, Nathan’s relationship with me and our siblings was very casual. He's the youngest child in our family so it used to be difficult to connect.

Our family visited Nathan as often as we could throughout his 3 week stay between PCMC and at the University of Utah Health University Neuropsychiatric Institute (UNI). At UNI, he was watched over and we did group family therapy in addition to him receiving individual therapy. We wrote letters to him to let him know how much we love him and how happy all of us were that he was still with us. He recovered well and returned home. We all made personal promises that we would make an effort to become closer to one another and especially to Nathan.

Today, I’m thrilled to share that Nathan is a thriving almost 16 year-old. He hasn’t had any lasting cognitive, physical, or even emotional effects of his attempt. We are so lucky to have him with us.

I spoke with him earlier this month about his experience and I asked him if he still struggles with suicidal ideation or self-harm. He told me since his attempt he hasn’t thought about it. I asked him why that would be the case and he told me it was because of the family’s and some of his friends’ responses to the situation. He told me he felt loved and needed and when my sister had her baby and I had our babies, he said that it made me him want to live to see them grow up. I asked what he does for his friends when they have similar struggles. He told me that always being there for them and letting those that are struggling know you love them and care about them will go a very long day and can mean the difference between seeing them another day or not.

Could we have prevented Nathan from attempting suicide? There was clearly a transformation in Nathan’s and our lives after the attempt, just as the literature states. Perhaps his attempt was communication since he felt he didn’t have an adult who could help. The SPRC’s education piece lists connectedness and support, which Nathan needed, as an important factor in their 9 faceted prevention program.