1. Suicidal Behavior in Adolescence

2. Completed Suicide: Rates/100,000 (N) by Gender & Ethnicity, Ages 15-19, 2003 CaucasianBlackAm Indian/ Alaska Native Males12.65 (1,047) 6.55 (107) 24.65(37) Females2.91 (227) 0.88 (14) 8.97 (13)

3. U.S. Suicide Rates per 100,000 1990-2003, ages 15-24

6. Suicide rates by age group and sex United States, 1997 Source: Natl. Center for Health Statistics

7. International Comparisons Age 14 & under, US rate > 2x higher than other industrialized nations Age 15-24, compared with 47 other nations, US rate at ~66 th %ile. Some nations, suicide rate is flat across age groups– Australia, Canada, Ireland, Costa Rica (i.e., does not increase with age).

8. International Rates, C’t’d Males with highest rates in Russia 53.7/100,000, Lithuania (48.6), New Zealand (44.1) Females with highest rates Cuba 17.9, New Zealand 12.3, Singapore 11.6, Finland 8.4 Greatest increases in suicide rates: Males: 154% in Ireland, 95% New Zealand, 87% Northern Ireland, Females: N. Ireland 213%, Israel 175%,, Norway 91% Greatest Decreases: Males: 45% Japan, 38% Czechoslovakia & Israel Females: Denmark 87%, Costa Rica 65%, Japan 40%.

9. Variation in US States (ages 10-19) Alaska 20.74/100,000 Wyoming, S. Dakota, Idaho, New Mexico, Montana, ranged from 9-12/100,000 New Jersey, California, New York, Mass, 2- 3/100,000 Why?? Population density/ social isolation Rural states more poor Lower access to mental health services

10. Can We Predict Suicide? No. Why Not? Low base rates (e.g., ages 15-19 in US, approx. 1,700 suicides, of pop. = 20 million). Too many ‘false positives’ and ‘false negatives’ But, we have identified risk factors which help to place youth into ‘risk zones’ What we can do is assess risk in a reasonable, reliable, consistent manner, and document thoroughly

11. Risk Factors, Predisposing Factors (Percentages) Ethnic / racial differences: Females, 2003 CaucasianBlackHispanic Suicide Attempts 10.3%9.015.0 Suicide Plan 18.6%12.420.7 Seriously Consider Suicide 21.2%14.723.4 Sad/ Hopeless 33.3%30.844.9

12. Risk Factors: Predisposing Factors Ethnic / racial differences: Males, 2003 CaucasianBlackHispanic Suicide Attempts 3.7%7.76.1 Suicide Plan 13.9%8.414.6 Suicidal Ideation 12.0%10.312.9 Sad/ Hopeless 19.6%21.725.9

13. Rates by Grade: Females, 2003 Sad/ Hopeless IdeationAttempt 9 th Grade 35.722.214.7 10 th Gr36.923.812.7 11 th Gr35.920.010.0 12 th Gr32.618.0 6.9

14. Rates by Grade: Males, 2003 Sad/ Hopeless IdeationAttempts 9 th Grade 21.011.95.8 10 th Gr22.713.25.5 11 th Gr22.112.94.6 12 th Gr22.013.25.2

15. Overlap of Suicide Attempts and Completed Suicide Gender breakdown differs Methods used differ Most common method for completers: firearms, second most common = strangulation For attempters, most common = self-poisoning Considerable overlap for psychopathology, family history of psychopathology, precipitating events Roughly one-third to one-half of completed suicides have made a previous attempt

16. Presenting Symptoms Psychiatric disorder present in 80-90% of youth suicides MalesFemales Mood Disorders50%69% Conduct Disorder43%24% Substance Abuse38%17% Anxiety Disorders19%48%

17. Symptoms, continued… Depression Depressed mood, plus other symptoms on “Student Interview Worksheet” Irritable/grouchy mood Hopelessness Mania (Unusually happy/excited, energetic, sure of self for week or more) Panic Attacks Anger / agitation / impulsivity Self report: of urgent emotion and need for relief; feeling out of control? If yes, how did you cope deal with that? Objective: arguments, physical fights, risky behavior

18. Risk Factors: Predisposing Factors 2 Parental Psychopathology Youth history of suicidal behavior History of physical/sexual abuse, family violence, harsh discipline

19. Risk Factors: Precipitant Stress Recent significant loss Major academic failure Significant relationship conflict with family, friends, romantic partner Unsolvable impasse

20. Interpersonal Functions of Emotions in Suicidal Behavior Poor family communication: Avoid direct communication, including communication of emotions (Richman, Orbach, Pfeffer) Use more indirect, avoidant actions (looks, gestures, walking out, ignoring). Unexpressed hostility (Pfeffer 81). Suicidal act is a desperate attempt to communicate

21. Interpersonal Factors, Ctd. Scapegoating: The “Expendable Child” (Sabbath,’69). Parents perceive child as threat to their well-being, and wish (perhaps unconsciously) to be rid of child or for him/her to die. Child thus feels rejected and expendable. Scapegoating: Parental Rejection: (e,g, Richman, Orbach, others) One child (or other family member) must die, or fail, to ensure the success of other(s). Parental rejection internalized by child, becomes self hatred. Child feels burdensome, or that s/he has no right to live.