Suicide: Specific Adolescent Risk Factors

Demographic Risk Factors

Completed suicides in adolescence remain a primarily Caucasian male occurrence, with 73% of suicides in this age range committed by white males. However, rates are rising among African American males, doubling in the past 20 years, making them the population with the greatest increase in risk.   Additionally, there is concern that suicide rates among young African American males may be masked by high homicide rates, with some research suggesting that many of the homicides may include elements of suicide (Lyon et al., 2000).

Although suicide completion in adolescence is primarily the purview of males (who complete suicide four to five times as often as females), suicidal ideation and attempts are much more common in females. Over one third of adolescent females rate themselves as significantly depressed or hopeless almost every day for more than two weeks during the past 12 months, compared with 22% of males. Female adolescents (24%) were significantly more likely than males (14%) to have considered suiccide in the past year, and females were significantly more likely (18%) than males (12%) to have developed a plan (Centers for Disease Control and Prevention, 2004).

Emotional Risk Factors

Adolescent suicide attempters and completers have overall higher rates of psychological distress than their nonsuicidal peers. All major classifications of mental health disorders are represented in the at-risk population at higher rates than in the population of those not at risk (Wetzler et al., 1996), and approximately 90% of completers have at least one major psychiatric disorder. A review of autopsy studies (Brent et al., 1993) found the most prevalent mental health disorders among adolescent suicide completers were as follows:

• Affective disorders: Studies show that a range of 35-76% of adolescent suicide completers suffered from an affective disorder, most commonly depression followed by bipolar disorder and anxiety.
• Schizophrenia: Studies show that from 0-17% of adolescent completers have schizophrenia. However, most research demonstrates that individuals with schizophrenia are at the highest risk for suicide during their thirties and forties.
• Substance abuse: Typically between one third and two thirds of me sample in most studies of adolescent completers have a substance abuse disorder. Substance abuse is more likely to be a risk factor when it occurs in the presence of a coexisting affective disorder.

Other psychological risk factors include problems with identity, fluctuating mood states, hopelessness, anger and impulsivity (Wetzler et al., 1996), and antisocial personality disorder/conduct disorder (Apter, Bleich, Plutchik, Mendelsohn, & Tyano, 1988; Brent et al., 1993). Anxiety (Sareen, Cox, Clara, & Asmundsen, 2005; Strauss et al., 2000) also has been linked to suicidal behaviors, particularly when a person has both anxiety and depression.

As with all age groups, the depressive factor of hopelessness appears to be the most salient in moving from a general depression to a high risk for suicide (Beautrais, Joyce, & Mulder, 1999). Adolescents who have no hope for the future or cannot envision a future, a more and more common occurrence among inner-city youths, appear to be at very high risk.

The psychological trait of impulsivity is particularly disturbing and has only recently received attention in the literature. A 2001 study found that among nearly lethal suicide attempts of young people (ages 13-34 years), almost one quarter (24%) of the attempts occurred with less than five minutes between the decision to attempt suicide and the actual attempt (Simon et al., 2001).

Substance abuse increases the suicide risk in adolescents. Youths who reported alcohol or illicit drug use over the past year are much more likely to be at risk for suicide. Those who use alcohol have more than double the risk, and those who use illicit drugs have nearly three times the risk of suicide than those who do not (National Household Survey on Drug Abuse, 2002).

Chemically dependent adolescents have been found to have higher rates of suicide attempts before treatment than chemically dependent adults (36% versus 26%) (Holland & Griffin, 1984). Further studies have shown that chemical abuse or dependence may be secondary to an affective disorder in determining suicide risk. That is, adolescents who are depressed and use substances appear to be more at risk than those with depression or substance abuse alone.

Cognitive Risk Factors

A primary cognitive risk factor in adolescents, just as in children, is a rigid cognitive structure with poor coping skills. Adolescents who have an inability to generate solutions to problems may find themselves more likely to fixate on suicide as the only possible option. Adolescents have fewer life experiences to draw on than adults do, and the ability to problem solve by generating options, rather than relying on past experiences to generate ideas, appears to be of particular importance. Cognitive distortions (e.g., overgeneralizations, preoccupation with a single thought or idea, all-or-nothing thinking) are often present. A study of suicide notes of adolescents found a high incidence of cognitive constriction (e.g., rigidity in thinking, narrowing of focus, tunnel vision, concreteness). They seem preoccupied with one trauma (e.g., rejection of a boyfriend or girlfriend, conflict with a parent), and their notes contain words such as always, no-one, all, and never (Leenaars, de Wilde, Wenckstern, & Kral, 2001, p. 53). They appear to choose suicide because of a lack of perceived options.

Another cognitive risk factor is the presence of a learning disability. Adolescents with learning disabilities have high rates of emotional and behavioral problems and generally perceive themselves as less socially competent than their peers (Svetaz, Ireland, & Blum, 2000). It is impossible to determine from the current research whether the learning disability is in and of itself a risk factor or is simply correlated with suicide because of the associated emotional, behavioral, social, and cognitive strains. Nevertheless, adolescents with learning disabilities, particularly those with accompanying psychological distress and poor coping skills, are at particular risk.

Other cognitive risk factors that have been identified are an external locus of control and an absence of future-time perspective (Beautrais, Joyce, & Mulder, 1999). Individuals with an external locus of control believe that they have limited-or no- ability to determine their own outcomes in life. External events, people, and the environment dictate their actions, and they are simply reactive, rather than proactive, in their lives. Thus, people with an external locus of control might believe that that they are "led" to suicide and cannot live out other options.

A final cognitive risk factor is perfectionism. Ironically, there are some adolescents who are academically high-achieving, socially successful, and appear to be very future-oriented who are at risk for suicide if they are also perfectionistic. Perfectionism, which can be adaptive when used appropriately for goal orientation, also can be extremely maladaptive. Perfectionism is maladaptive "when one fails to meet personal expectations or standards are set too high" (Donaldson, Spirito, & Farnett, 2000, p. 100). Individuals with high levels of perfectionism may respond to failure—or anticipated failure—with depression or anxiety. These people typically fear disapproval from either "self" or from "others," and experience enormous amounts of inappropriate guilt. They use suicide or suicidal behaviors as coping mechanisms. Perfectionism that leads to suicidal behaviors is most prevalent in adolescence and does not appear to be a significant risk factor in adults. It appears that it is at this stage of development that early personality and cognitive traits of perfectionism become more locked in, leaving fewer alternative paths. Inability to adjust to change or to adapt is a hallmark of perfectionism, and this ties in with a rigid cognitive style that is also a risk factor for this age group. Adolescents who are striving for an identity seek identity as a perfect—or nearly perfect—person. Thus, some adolescents who appear to "have it all" may be at particular risk, yet they seldom receive mental health assistance. Parents, teachers, school counselors, and other adults perceive these students as models of success and happiness, and their mental health problems often slip under the radar.

Environmental Risk Factors

Among suicidal adolescents, there is a higher incidence of family dysfunction of all types compared to their nonsuicidal peers. Common familial risk factors for adolescent suicide include coming from highly conflicted families that are unresponsive to the adolescent's needs, families with parental alcoholism or substance abuse, and families with physical or sexual abuse. Families of suicidal teens also have higher levels of medical and psychiatric problems (Garfinkel, Froese, & Hood, 1982). Finally, families who have had a suicide completion are at higher risk for another.

Social isolation and poor peer relationships are two additional environmental risk factors. Suicidal adolescents often feel alienated, both within the family and with their peers (Stillion & McDowell, 1996). They are more likely to have poor social skills, to have ineffective peer relationships, to be nonjoiners, and to be generally unpopular.

Now that you have read about risk factors in adolescents, you can see how many risk factors Lucinda had that contributed to her death: depression, inability to envision a future, family dysfunction, and many more. Reread the case, and try to identify these specific risk factors.