Gender role in adolescent suicidal behavior: observations and therapeutic implications

We analyzed the relative seriousness of suicide attempts by boys based on 430 hospitalized suicide attempters ages 13 to 19 years. A comparison by sex of adolescent suicide attempters with a school population of non-suicidal adolescents of the same age group shows greater differences in the areas of school failure, psychosomatic and distress-related symptoms and substance abuse between suicidal and non-suicidal boys than between suicidal and non-suicidal girls. These findings suggest that compared with non-suicidal boys and girls, suicidal boys show more deviant behavior than girls. The question then arises as to whether there are differences in the treatment received by male and female suicide attempters. On hospital admission, more boys than girls are sent to psychiatric wards, and boys are proposed follow-up care more frequently than girls. On the other hand, boys and girls are not treated differently with respect to psychiatric consultations during hospitalization or coordination with outside physicians (family doctor, school doctor, other physicians) and the social services. These findings could serve as the basis for the development of specific treatment plans to meet the needs of suicidal boys.     

Clinical characteristics of adolescent psychiatric inpatients who have attempted suicide

 The clinical characteristics of 191 adolescent inpatients were examined in relation to frequency of previous suicide attempts, predictors of suicide attempts prior to hospitalization, and lifetime suicide attempts. Overall, more than 50% of the adolescent inpatients had attempted suicide during their lifetime, and of these more than half (58%) had made more than one attempt. Approximately half of the suicide attempters had made a serious attempt prior to hospitalization. Girls reported higher levels of depressive symptoms and suicidal ideation than boys, in addition to having attempted suicide prior to hospitalization (33%) or during lifetime (37%) more often than the boys (13% and 26%, respectively). Although about two thirds of the adolescent inpatients reported that they had received some help after a suicide attempt, approximately half of the repeaters had not received any help. The results of multivariate analyses showed that suicide attempts made prior to hospitalization were predicted by depressive symptom levels and a clinical diagnosis of depressive disorder, whereas frequency of lifetime suicide attempts was predicted by suicidal ideation levels and having a family member or a friend who had attempted (or committed) suicide. The high prevalence of lifetime and repeated suicide attempts among the psychiatric inpatients underscores the importance of identifying risk factors in the clinical evaluation of adolescent suicide attempters. Accepted: 1 April 1998     

The neglected link between eating disturbances and aggressive behavior in girls.

OBJECTIVES: Research has linked eating disturbances with behavioral impulsivity. Little is known, however, about whether eating disturbances and aggressive behavior have a tendency to co-occur in the same girls. This article assesses the eating disturbance-aggressive behavior association and then examines the extent to which these factors confer a risk on drug use and attempted suicide. METHOD: Survey data were gathered from 3,630 girls in grades 6 through 12 in the upper Midwest. Girls responded anonymously to questions regarding binge eating and purging, dietary restriction, aggressive behavior, drug use, and attempted suicide. Logistic regression analysis was used to assess the unique contribution of demographic variables, eating disturbances, and aggression on drug use and attempted suicide. RESULTS: Eating disturbances were significantly associated with aggressive behavior. Girls who endorsed binge eating and purging or dietary restriction had odds of aggressive behavior 2 to 4 times higher than girls who did not endorse these items. Logistic regression revealed that eating disturbances and aggressive behavior were significantly associated with both drug use and attempted suicide. CONCLUSIONS: Eating disturbances are significantly associated with aggressive conduct in adolescent girls. The constellation of eating disturbances and aggressive behavior is associated with a greater risk of drug use and attempted suicide.     

Suicidal behavior among adolescents with conduct disorder--the role of alcohol dependence

Our aim was to investigate the association between alcohol dependence and suicidal behavior among adolescent girls and boys suffering from conduct disorder (CD). The original study sample consisted of 387 adolescents (age 12-17) admitted to psychiatric inpatient care between April 2001 and May 2005. DSM-IV-based psychiatric diagnoses and variables measuring suicidal behavior were obtained from the Schedule for Affective Disorders and Schizophrenia for School Aged Children--Present and Lifetime (K-SADS-PL). Of the total study population, 59 adolescent girls and 82 boys had CD according to DSM-IV criteria. Of all adolescents with CD, 24 (40.7%) girls and 24 (29.3%) boys were suffering from alcohol dependence. Among girls with CD, alcohol dependence increased the risk for suicide attempts up to 3.8-fold (95% CI 1.1-13.4). Among boys with CD, alcohol dependence increased the risk for life-threatening suicide attempt over nine-fold (95% CI 1.2-80.1). In addition, the risk for self-mutilative behavior was as high as 3.9-fold (95% CI 1.1-13.8) among girls and 5.3-fold (95% CI 1.1-26.5) among boys. The results indicate that, among adolescents suffering from CD, the risk of suicidal behavior is considerably increased by co-morbid alcohol dependence, which should therefore be carefully taken into account in clinical work.     

Non-suicidal self-injury and suicidal ideation as predictors of suicide attempts in adolescent girls: A multi-wave prospective study

Although both suicide ideation (SI) and non-suicidal self-injury (NSSI) are known risk factors for suicidal behavior, few longitudinal studies have examined whether having a history of one or both of these factors prospectively predicts increased risk for suicide attempts. According to the theory of acquired capability for suicide, engagement in NSSI may reduce inhibitions around self-inflicted violence, imparting greater risk for suicide attempts among those with SI than would be observed in those with SI who do not have a history of NSSI. We used prospective data from the Pittsburgh Girls Study, a large community sample, to compare groups of girls reporting no SI or NSSI, SI only, or both NSSI and SI between early to late adolescence on any lifetime or recent suicide attempts in late adolescence and early adulthood. As compared to girls with no SI or NSSI history and those with only an SI history, girls with a history of both NSSI and SI were significantly more likely to subsequently report both lifetime and recent suicide attempts. Results are consistent with the acquired capability theory for suicide and suggest that adolescent girls who have engaged in NSSI and also report SI represent a particularly high-risk group in need of prevention and intervention efforts.     

Gender differences in suicide attempts from adolescence to young adulthood

OBJECTIVE: To examine associations of age, gender, and psychosocial factors during adolescence with risk of suicide attempt between ages 19 and 23 years. METHOD: Initial assessments were conducted with 1,709 adolescents (aged 14-18) in western Oregon between 1987 and 1989. One year later, 1,507 participants returned for a second assessment. A subset of participants (n = 941; 57.2% women) had a third diagnostic assessment after turning 24 (between 1993 and 1999). Information on suicidal behavior, psychosocial risk factors, and lifetime DSM-III-R psychiatric diagnosis was collected at each assessment. RESULTS: The suicide attempt hazard rate for female adolescents was significantly higher than for male adolescents (Wilcoxon chi 2(1)[n = 941] = 12.69, p < .001). By age 19, the attempt hazard rate for female adolescents dropped to a level comparable with that of male adolescents. Disappearance of the gender difference for suicide attempts by young adulthood was not paralleled by a decrease in the gender difference for major depression. Adolescent suicidal behavior predicted suicide attempt during young adulthood for female, but not male, participants. Adolescent psychosocial risk factors for suicide attempt during young adulthood were identified separately for girls and boys. CONCLUSIONS: Unlike depression, the elevated incidence rate of suicide attempts by adolescent girls is not maintained into young adulthood. Screening and prevention implications are discussed.     

Multimethod assessment of suicidality in adolescent psychiatric inpatients: preliminary results

OBJECTIVE: To examine agreement among multiple assessments of adolescent suicidal ideation and suicidal behavior for adolescent psychiatric inpatients, including pencil/paper checklists; structured and unstructured interviews; and adolescent, clinician, and parent reports, and to provide suggestions for the accurate and reliable assessment of suicidality in adolescence. METHOD: Participants included 153 adolescent psychiatric inpatients (54 boys, 99 girls) between the ages of 12 and 17 years. Measurement of suicidal ideation and behavior included common assessment instruments and standard clinical practices, including the Suicidal Ideation Questionnaire, NIMH Diagnostic Interview Schedule for Children, clinician interview, and parent report (Behavior Assessment Scale for Children). RESULTS: Results revealed significantly different rates of suicidality across each instrument and poor to moderate agreement between similar measures of adolescent suicidal ideation and suicidal behavior. Agreement between measures was generally best for boys, for older adolescents, and for assessments relying on a single informant. Reporters were most likely to agree on the presence of suicidality for more severely suicidal adolescents; this finding suggests that agreement in itself may be a useful marker for adolescent suicide. CONCLUSIONS: Results of this preliminary study supported the use of multiple measurement approaches when examining adolescent suicidality, particularly those that rely on clinician judgment and adolescents' own reports. Implications for future research and for clinical practice are also discussed.     

The relationship between adolescent suicidal behavior and life events in childhood and adolescence.

OBJECTIVE: Although the relationship between experience of problematic life events and adolescent suicidal behavior has frequently been recognized during the past decade, few studies of life events have been initiated that discriminated between adolescent suicide attempters and depressed adolescents. Therefore, the authors compared adolescent suicide attempters with both depressed and nondepressed adolescents who never attempted suicide with respect to life events that happened in two periods: childhood (defined as the period up to age 12 years) and adolescence (age 12 and older). METHOD: Using a semistructured interview, the authors gathered life event data about childhood and adolescence from three groups of adolescents: 48 suicide attempters, 66 depressed adolescents who had never made a suicide attempt, and 43 nondepressed adolescents who had never made a suicide attempt. RESULTS: The group of adolescents who attempted suicide differed from both of the other groups in that they had experienced more turmoil in their families, starting in childhood and not stabilizing during adolescence. During adolescence, they were more often sexually abused. During the last year before the attempt, further social instability, such as changes in residence and having to repeat a class, occurred. CONCLUSIONS: For suicidal adolescents, the suicide attempt seems embedded not just in the problems every adolescent has to deal with but in greater turmoil in their families, rooted in childhood and not stabilizing during adolescence, in combination with traumatic events during adolescence and social instability in the year preceding the attempt.     

The relationship between parental marital status and suicidal ideation and attempts by gender in adolescents: Results from a nationally representative Korean sample

Objective

Suicide in adolescents is a major problem worldwide. The purpose of this study was to identify differences in suicidal behaviors with respect to parental marital status.

Methods

The data used in this study were obtained from the Korea Youth Risk Behavior Web-based Survey (KYRBWS) of middle and high school students in 2010. Using a national representative sample, this study analyzed data from 73,238 subjects. With respect to gender, the odds ratios of suicidal behavior were calculated based on the parental marital status, living situation, and family affluence scale (FAS).

Results

After adjusting for age, achievement, sadness, and substance use, the prevalence of suicidal ideation in adolescents with a remarried parent significantly increased among boys to 1.364 [95% confidence interval (CI) = 1.027–1.813] and among girls to 1.511 (95% CI = 1.215–1.879). The odds ratio of suicide attempts increased to 1.808 (95% CI = 1.119–2.923) for adolescent boys and to 1.947 (95% CI = 1.609–2.356) for adolescent girls. However, having a single parent did not affect the prevalence of suicidal ideation in either gender. In girls, as family affluence decreased, the odds ratio of suicidal ideation notably increased. For girls whose families were in a low tier of the FAS, the odds ratio of both suicidal ideation and suicide attempts increased.

Conclusions

Both boys and girls were more likely to report suicidal ideation and attempts after a parent’s remarriage, whereas family affluence was inversely related to suicidal ideation and attempts in girls.     

Summary of the practice parameters for the assessment and treatment of children and adolescents with suicidal behavior

These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed.     

Peer suicidal behavior and adolescent risk behavior

The relationship between adolescent suicide attempts and death by suicide and psychosocial functioning of peers remains poorly understood, especially in the myriad ways that these suicidal behaviors might impact friends. This study explored the relationship between peer suicidal behavior and adolescent risk behavior using a large, nationally representative sample of adolescents (N = 5852). Results indicate that youth exposed to peer suicidal behavior are significantly more likely to have their own suicidal ideation and attempts, and to smoke cigarettes and marijuana, binge drink, be involved in a serious physical fight, and have inflicted injuries that require medical attention. These results highlight the need for professionals to be aware of these risks in friends of those who have attempted or died by suicide. Assessment and intervention for peers is appropriate and required for this at-risk group.     

Brief report: Suicidal ideation in adolescent girls: Impact of race

In the present study, we examine the unique and interactive effects of race (African American or European American) and depression on suicidal ideation, controlling for poverty, within a representative sample of adolescent girls. A community sample of 2450 girls (43.9% African American) participating in the longitudinal Pittsburgh Girls Study (PGS) was interviewed annually about depression symptoms and suicidal ideation, from ages 10–15 years. Caregivers reported on the girls' racial/ethnic background and the family's receipt of public assistance. Race and depression scores explained unique variance in suicidal ideation; receipt of public assistance did not. Endorsement and recurrence of suicidal ideation was more likely for African American than European American girls: there was a nearly two-fold increase in the likelihood of reporting frequent thoughts of death or suicide as a function of race. Of the 255 girls reporting recurrent suicidal ideation, 65.9% were African American. An interaction effect between race and depression symptoms was observed, such that African American girls were more likely to report suicidal ideation at lower levels of depression severity. The findings indicate that race is a critical factor for understanding, preventing, and treating suicidal ideation in girls.     

Adolescent coping behavior when confronted with a friend with AIDS.

The coping strategies employed by adolescents (n = 871) when presented with a hypothetical situation of a friend with AIDS were examined. Adolescents reported a wide range of imagined responses that were generally adaptive. Girls more than boys and distressed students more than nondistressed students were likely to endorse adaptive coping items. Comparison of the students with a separate sample (n = 472) that responded to a hypothetical situation of a suicidal peer revealed more distress in girls for the AIDS problem and more distress in boys for the suicide problem, contrary to expectations. Adolescents were more distressed and endorsed a wider variety of coping strategies in response to the AIDS scenario than to the suicide problem. Implications for care of adolescents dealing with these significant issues are discussed.     

Are children and adolescents who have suicidal thoughts different from those who attempt suicide?

In this study we inquire whether children and adolescents with suicidal ideation can be differentiated from children who attempt suicide on the basis of clinical symptoms or social grounds. From a total of 2181 consecutive outpatient referrals to a child and adolescent psychiatry service, 258 young persons who exhibited suicidal ideation are compared with 82 who had actually attempted suicide. We were unable to differentiate children with suicidal thoughts from those who attempted suicide on the basis of clinical symptoms alone. Both groups had similar high levels of symptoms of depression, anxiety, sleep disorder, and irritability. Conduct disorders were less common in both groups but 22% of the attempters abused illicit drugs or alcohol. Suicide attempts were more likely to be associated with chronic family discord and substance abuse. For boys, the odds of suicidal attempts were substantially increased if the subject had experienced loss. Results are discussed with reference to antecedents that may increase the odds of suicidal attempt and suggestions for future research are outlined.     

Diagnosis of childhood and adolescent suicidal behavior: unmet needs for suicide prevention.

This article highlights strategies for diagnosing risk for childhood and adolescent suicidal behavior. Empirical studies identifying risk factors for childhood and adolescent suicidal behavior guided recommendations for suicide risk assessment. Diagnostic assessment involves identification of multiple factors including demographic characteristics, suicidal behavior, psychopathology, interpersonal problems, family discord, family psychopathology, accessibility of lethal suicide methods, exposure to suicide, and protective factors. Interview methods and self-report questionnaires are reliable and valid in identifying suicidal risk but are limited by low base rates of suicide. Identification of risk factors as foci for intervention is important for suicide prevention.     

Adolescent inpatient girls׳ report of dependent life events predicts prospective suicide risk

Adolescents with a history of suicidal behavior are especially vulnerable for future suicide attempts, particularly following discharge from an inpatient psychiatric admission. This study is the first to test whether adolescents? tendency to generate stress, or report more dependent events to which they contributed, was predictive of prospective suicide events. Ninety adolescent psychiatric inpatients who were admitted for recent suicide risk, completed diagnostic interviews, assessments of history of suicidal behavior, and a self-report questionnaire of major life events at baseline. Participants were followed over the subsequent 6 months after discharge to assess stability vs. onset of suicide events. Cox proportional hazard regressions were used to predict adolescents? time to suicide events. Results supported hypothesis, such that only recent greater dependent events, not independent or overall events, predicted risk for prospective suicide events. This effect was specific to adolescent girls. Importantly, dependent events maintained statistical significance as a predictor of future suicide events after co-varying for the effects of several established risk factors and psychopathology. Results suggest that the tendency to generate dependent events may contribute unique additional prediction for adolescent girls? prospective suicide risk, and highlight the need for future work in this area.     

Concurrent adversities and suicide attempts among Sami and non-Sami adolescents: the Norwegian Arctic Adolescent Study (NAAHS)

Background: Little is known about connections between adolescent suicide attempts (SA) and concurrent adversities.

Aims: In a cross-sectional study, the authors wanted to investigate prevalences, additive effects of adversities, family and peer relations, gender, divorce and poverty, and ethnic differences between Sami and non-Sami youth.

Methods: In an adolescent community population encompassing 4881 adolescents of 15–16 years of age, youth with and without self-reports of attempted suicide the last year were compared on 12 concurrent adversities, on scales assessing family and peer functioning, and on sociodemographic variables.

Results: The prevalence of attempted suicide the last year was 5.3%, and more girls (8.8%) than boys (1.8%). All 12 concurrent adversities were strongly related to SA. The suicide attempters reported two and a half times as many adversities as non-attempters. A strong multiple additive relationship was found. Multivariately, among boys, the strongest risk factors were suicide among friends (OR?=?9.4), and suicide in the family or in the neighbourhood (OR?=?4.8). Among girls, sexual abuse (OR?=?5.2) and parent mental problems (OR?=?4.6) were strongest related to SA. Suicide attempters reported more divorce and poverty, more conflicts with parents, and less family support and involvement. Totally, Sami youth reported more SA and more concurrent adversities than non-Sami peers.

Conclusion: Adolescent suicide attempters are heavily burdened with concurrent adversities. Clinicians should be aware of gender differences in risk factors, and should ask about abuse and suicide or attempts among relatives and peers. A family perspective in clinical work is needed.     

The associations between health risk behaviours and suicidal ideation and attempts in a nationally representative sample of young adolescents.

OBJECTIVE: To examine associations between health risk behaviours and suicidal ideation and attempts in Canadian adolescents aged 12 to 13 years. Young adolescents think about and attempt suicide. However, most existing research on suicide has been conducted on individuals aged 15 years and older. METHOD: The present study examined a nationally representative Canadian sample of adolescents aged 12 to 13 years (n=2090). Health risk behaviours included disruptive (shoplifting, physical fighting, damaging property, fighting with a weapon, carrying a knife, and gambling), sexual (petting below the waist and sexual intercourse), and substance use behaviours (smoking cigarettes, consuming alcohol, marijuana or hash, and glue or solvents). Unadjusted and adjusted (for all significant health risk behaviour and psychiatric symptoms) models were tested. RESULTS: All health risk behaviours were common among male and female adolescents. In unadjusted models, almost all health risk behaviours were associated with suicidal ideation and attempts among adolescent boys. In adjusted models, only damaging property, sexual intercourse, and smoking cigarettes remained statistically associated with suicidal ideation, while smoking cigarettes and using marijuana or hash remained statistically associated with suicide attempts among adolescent boys. All health risk behaviours were statistically associated with suicidal ideation and attempts among female adolescents in unadjusted models. In adjusted models, only carrying a knife remained statistically associated with suicidal ideation, while shoplifting and gambling remained statistically associated with suicide attempts among adolescent girls. CONCLUSIONS: Health risk behaviours among young adolescents are associated with suicidal ideation and attempts among young adolescents. Recognizing health risk behaviours among young adolescents may be one means of understanding who among them is at increased risk of suicidality.     

Suicidal thoughts and depressive feelings amongst Estonian schoolchildren: effect of family relationship and family structure

Depressive feelings and suicidal ideation in a non-clinical sample of adolescents in Estonia were analysed in the context of family structure, mutual relationships amongst family members and schoolchildren’s preferences regarding intimate personal contacts with particular family members. Data from the WHO collaborative study ‘Health Behaviour in School-aged Children 2005/2006’ (HBSC) were used. A representative sample of schoolchildren aged 11, 13 and 15 years completed the semi-structured questionnaire. The analyses included only adolescents living in households with at least one birth parent. The subjects were 4,389 schoolchildren (2,178 boys and 2,211 girls), who were divided into three groups based on: (1) suicidal thoughts, with or without depressive feelings; (2) depressive feelings; and (3) neither suicidal thoughts nor depressive feelings. Multinomial logistic regression was used. The proportion of depressive feelings increased with age for both boys and girls. Girls expressed depressive feelings more frequently than boys from ages 13 and 15 years, and suicidal thoughts from age 15 years. Self-reported satisfaction with relationships in the family reduced the likelihood of depressive feelings and suicidal thoughts. Good communication with the parents reduced the likelihood of suicidal thoughts in all age groups. Adolescents who were satisfied with their family relationships suffered less frequently from depressive feelings and suicidal thoughts. The best environment for an adolescent was a family with both birth parents. Of the adolescents in ‘non-intact’ families, those with a step-parent in the family showed suicidal thoughts more frequently than those in single-parent families. Associations between family-related variables and suicidal thoughts were significant even after adjusting for family economic deprivation score.     

Characteristics of cocaine-dependent patients who attempt suicide

OBJECTIVE: Although suicidal behavior is frequent among cocaine-dependent patients, it has been little studied. Therefore, the author examined the characteristics of cocaine-dependent patients who had attempted suicide. METHOD: Cocaine-dependent patients who had attempted suicide (N=84) were compared with cocaine-dependent patients who had never attempted suicide (N=130) on clinical, personality, psychiatric, and physical variables. RESULTS: Significantly more of the patients who had attempted suicide were female and had a family history of suicidal behavior; they reported significantly more childhood trauma and were significantly more introverted, neurotic, and hostile. They had also had significantly more comorbidity with alcohol and/or opiate dependence, major depression, and physical disorders. CONCLUSIONS: The clinical implications are that family, childhood, personality, psychiatric, and physical risk factors contribute to suicidal behavior in cocaine-dependent patients. Comorbidity appears to be an important determinant of suicidal behavior.