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  • 1. Adolescent suicide risk: four psychosocial factorsFindArticles > Adolescence > Summer, 2004 > Article > Print friendlyPhilip A. RutterSuicide is a leading cause of death among those aged 15-24 (Berman &Jobes, 1995; Centers for Disease Control, 2002). Consequently, in the U.S.,a National Health Objective (National Institute of Mental Health, 2001) urgesresearchers to focus on ways to decrease the adolescent suicide rate by morethan 25% within the decade.Adolescent suicide research has, by and large, focused on demographic riskfactors (Brent, Baugher, & Bridge, 1999; Levy, Jurkovic, & Spirito, 1995).This approach provides descriptive data and correlates demographics withsuicide risk. Numerous studies have examined the incidence of suicidalthoughts and suicide attempts by age, race, educational level, familybackground, religion, socioeconomic level, sexual orientation, and otherdemographic variables (DAugelli, Hershberger, & Pilkington, 1996; Levy,Jurkovic, & Spirito, 1995). Such studies focused on who is at risk, but did notexplain why certain youths may be at risk for suicide. For example,adolescents with substance abuse problems, psychiatric disorders, familydisruption/stress, antisocial behavior, or family suicide history are said to beat greater risk for completing suicide. This does not explain the context of anadolescents propensity for suicide, and is problematic in the formulation ofeffective intervention strategies (Grholt, Ekebrg, & Wichstrom, 2000).This approach also suggests that adolescents of a certain demographic maybe at higher risk for suicide, but focusing on demographics alone may lead tomisidentifying those not at risk, as well as bypassing those who are actuallyat risk for suicidal behavior (Pfeffer, Klerman, Hurt, Lesser, Peskin, & Seifker,1991). For example, DAugelli and Hershberger (1995) suggested that gay,lesbian, and bisexual adolescents exhibit greater suicide risk than theirheterosexual peers. However, Rutter (1998) found that sexual orientationalone did not impact suicide risk. Rutter and Soucar (2002) reported thatadolescents who endorsed items citing the presence of social support frompeers and family displayed less suicide risk, regardless of their sexualorientation.The majority of suicides occur among Caucasian adolescents; consequently,most interventions are based on Caucasian adolescents suicidal behavior.Yet, rates among Native American, Hispanic, and African Americanadolescents have increased dramatically in the past decade. Recent researchsuggests that racial and ethnic minority adolescents exhibit suicide riskdifferently, are unlikely to be assessed accurately, and are often overlooked
  • 2. as "at risk" (Canino & Roberts, 2001; Choquet, Kovess, & Poutignat, 1993;Scouller & Smith, 2002).Blum, Beuhring, Shew, Bearinger, Sieving, and Resnick (2000) havesuggested that researchers look within more proximal social contexts tounderstand what predisposes some adolescents to increased suicide risk. Inkeeping with the aforementioned National Health Objective (NationalInstitute of Mental Health, 2001), examining the psychosocial correlateswithin a particular demographic group may be a more efficacious approach topredicting who is at highest risk for suicide. The purpose of the present studywas to ascertain the salience of combining four psychosocial variables aspotential predictors of suicide risk.METHODParticipantsA sample of one hundred adolescents, with an equal number of male andfemale participants, was recruited from a sexual minority support agency (n= 50) and an urban university (n = 50). Fifty-three percent of theparticipants were Caucasian, 25% African American, 6% Asian, 3% Hispanic,and 13% identified themselves as either biracial or Native American.Fourteen percent were 17 years old, 37% were 18 years old, and 49% were19 years old. In terms of sexual orientation, 26% self-identified ashomosexual, 24% as bisexual/questioning, and 50% as heterosexual. Thiswas a nonclinical sample and participation was voluntary.ProcedureThe exploration of psychosocial factors in relation to suicide risk is by nomeans new. There is extensive literature on how certain individual factorscan affect suicidal behavior. The current study explored adolescent suiciderisk across multiple psychosocial factors (hopelessness, negative self-concept, hostility, and low social support). The instrument combined theSuicide Probability Scale (SPS; Zachary, Roid, Cull, & Gill, 1983), the BeckHopelessness Scale (BHS; Beck, Brown & Steer, 1989), the SuicideQuestionnaire (SQ; Meehan, Lamb, Saltzman, & OCaroll, 1992), and ademographics form (Rutter, 1998).The SPS is a reliable 36-item Likert-type self-report inventory focusing onhopelessness, hostility, suicidal ideation, and negative self-concept. The BHSis a psychometrically sound self-report measure that has 20 true-falsestatements to assess negative beliefs about the future. Scores range from 0to 20, with higher scores indicating greater levels of hopelessness. The SQwas modified from its original form as an inpatient clinical interview.
  • 3. Reliability and validity have yet to be established, although the SQ has beenreported to exhibit high face validity and to offer a nonthreatening method ofassessing suicidal ideation, plans, and attempts (Muehrer, 1995). Thedemographics form contains questions about the adolescents ethnicity,sexual orientation, and education level, as well as questions about the levelof social support received from friends, family, and school staff.FINDINGSTo assess suicide risk across demographic and psychosocial variables,participants were first grouped into a lowest quartile (Group 1; n = 25) and ahighest quartile (Group 2; n = 25) according to their scores on the SPS.Participants in Group 2 has a significantly higher score (M = 7.72, SD =3.59) on the BHS than those in Group 1 (M = 2.44, SD = 1.66). Astatistically significant positive relationship was found between SPS and BHSscores (p < .01).Groups 1 and 2 (lowest and highest SPS quartiles) were compared acrossresponses to three items (7, 8, and 9) from the SQ. These items askedparticipants if they experienced injury resulting from their suicide attempt(item 7), if their attempt was serious enough to require medical care (item8), and whether hospitalization was required after their suicide attempt (item9). A t test indicated a statistically significant difference (p < .01) betweenthe two groups on their responses to item 7. Group 1 experienced muchlower injury from their suicide attempt (M = 2.00, SD = 1.98) than Group 2(M = 2.76, SD = 2.76). The comparison of the two groups on item 8(attempt serious enough to require medical care) and item 9 (hospitalizationrequired after suicide attempt) suggested differences between groups, butresults were not statistically significant (item 8:F = 4.00, p = .051, and item9:F = 1.39, p = .24). Results from t tests approached statistical significanceregarding a relationship between perceived social support and SPS scores (p= .057).Finally, demographics were explored using the two groups. No statisticallysignificant correlation between any one demographic and suicide risk wasfound. Analysis included comparing SPS scores across race (F = .03, p = .855), gender (F = .88, p = .352), and sexual orientation (F = .02, p = .887).DISCUSSIONLimitations of this study should be noted. First, the sample included a groupof sexual minority youth recruited from a support agency. This support mayhave skewed their responses in a positive direction. Second, while the datacan serve as impetus for a larger project, the current findings are exploratoryin nature and may not be generalizable. Third, the assessment of support
  • 4. could have been more comprehensive. With this said, the data do offerinsight into the significance of psychosocial factors in assessing adolescentsuicide risk.A higher SPS score was related to a higher level of hopelessness and togreater seriousness of the suicide attempt. High and low scores on the SPSdiffered significantly in their BHS scores and their responses to item 7 of theSQ (injury resulting from suicide attempt). While the two SPS groups differedin terms of social support (high scores reported low social support and lowscorers reported high social support, this difference was not quite statisticallysignificant.These data are consistent with and build upon previous research that focusedon the individual psychosocial factors of hopelessness (DAugelli,Hershberger, & Pilkington, 1997), hostility (Cull & Gill, 1989), poor self-concept (Cetin, 2001; Harter & Marold, 1994), and low socialsupport/isolation (Rutter & Soucar, 2002). What emerges from the data inthe present study are that these four factors (hopelessness, hostility,negative self-concept, and isolation) collectively correlate with increasedsuicide risk.Hopelessness is a significant indicator of adolescent depression and potentialfor suicide. Hopelessness and its clinical manifestations can be situational ortransient (Beck, Brown, & Steer, 1989). Combined with adolescentsimpulsive nature, the presence of hopelessness can be quite dangerous(Hollander, 2000). Therefore, accurate assessment of adolescent suicide riskshould include an indication of current levels of hopelessness (Dori &Overholser, 1999).Hostility has long been associated with suicide. Schneidman (1969) definedself-injury as hostility turned inward. More recently, hostility amongadolescents has been associated with punitive self-injury aimed at anexternal person, such as a parent or peer (Meehan et al., 1992).Self-concept is also a psychosocial factor that warrants inclusion. Researchindicates that adolescents incorporate personal, school, and social failures aselements of their self-concept (Berman & Jobes, 1995; Harter & Marold,1994). Researchers exploring this variable have maintained that poor self-concept can lead to self-loathing and to an adolescents consideration ofsuicide (Grholt et al., 2000; Hatter & Marold, 1992).Finally, social support is related to healthier adolescent functioning. Support,as a construct, has been defined as a sense of belonging, specifically amongpeers, teammates, community, or family members (Grholt et al., 2000).Adolescents reporting strong social support (low isolation) exhibit higher
  • 5. levels of resilience and lower levels of suicide risk. Adolescents are also lesslikely to be suicidal if they perceive their family, friends, and peers to bemore accepting, and if they have more positive friendships (Harter, Marold,Whitesell, & Cobbs, 1996). Those who feel supported by counselors, parents,or peers exhibit healthier coping mechanisms and maintain a more positiveoutlook about their future (DeWilde, Kienhorst, Diekstra, & Wolters, 1993).In contrast, adolescents who lack social support and experience isolation maybehave in self-injurious ways (Himmelman, 1993; Remafedi, Farrow, &Deisher, 1991; Spruijt & de Goede, 1997).These four psychosocial variables, taken collectively, appear to improve theability to assess and predict adolescents suicide risk. This should be verifiedthrough additional research using a larger sample, a variety of schoolsettings, and with additional items to assess social support.Future work could clarify whether improving any one of the four psychosocialfactors will influence the other factors and decrease overall suicide risk. Forexample, clinical strategies aimed at increasing levels of social support mayreduce an adolescents level of hostility, hopelessness, or negative self-concept. The results of this and prior studies warrant exploring the individualand collective impact of these variables in reducing levels of suicide risk. Wespeculate, for example, that the gay and lesbian participants in the presentstudy may have exhibited lower suicide risk because they were members of acommunity-based youth center for sexual minorities. Their membership mayhave contributed to less isolation, hopelessness, and hostility, and to feelingbetter about themselves.While many today conceptualize suicide as an experience located within theindividual, pioneering work on suicide focused on underlying social factorsthat impact individuals, leading them to be more, or less, suicidal. Durkheim(1897/1951) stressed the importance for individuals to feel connected and tobe socially integrated. Those with weaker social ties and those suffering froma bewildering sense of not belonging, what he referred to as anomie, aremore likely to commit suicide. This is consistent with the four psychosocialfactors that the present study has found to correlate with suicide risk amongsome adolescents.This perspective suggests the need to design dual-approach interventionsthat work with both the individual and within society. The individual maybenefit from strategies to reduce hopelessness, hostility, negative self-concept, and isolation. Social policy makers wishing to reduce suicide mightconsider strategies that would combat anomie by encouraging small groupparticipation for marginalized individuals. Further, while our study examinedadolescents, the findings may have implications for other groups (e.g., theelderly).
  • 6. Other factors should not be ignored in assessing adolescent suicide risk,including previous suicide attempts, a history of others in the family whohave been suicidal, mental illness, alcohol and drug use, and other self-destructive behaviors. Nevertheless, school counselors, therapists, andothers in the helping professions will be better equipped to intervene andreduce suicide risk when they focus on adolescents level of hopelessness,hostility, negative self-concept, and isolation.The authors wish to thank the School of Education Research Center, LauraGoodwin, and Kimberly White for their assistance.REFERENCESBeck, A., Brown, G., & Steer, R. (1989). Prediction of eventual suicide inpsychiatric inpatients by clinical ratings of hopelessness. Journal ofConsulting and Clinical Psychology, 57, 309-310.Berman, A., & Jobes, D. (1995). Suicide prevention in adolescents (ages12-18). Suicide and Life Threatening Behavior, 25, 143-154.Blum, R., Beuhring, T., Shew, M., Bearinger, L., Sieving, R., & Resnick, M.(2000). The effects of race/ethnicity, income, and family structure onadolescent risk behaviors. American Journal of Public Health, 90, 1879-1884.Brent, D. A., Baugher, M., & Bridge, J. (1999). Age- and sex-related riskfactors for adolescent suicide. Journal of the American Academy of Child andAdolescent Psychiatry, 38(12), 1497-1505.Canino, G., & Roberts, R. (2001). Suicidal behavior among Latino youth.Suicide and Life Threatening Behavior, 31, 122-130.Centers for Disease Control. (2002). Health, United States, Table 60.Retrieved July 8, 2003, from http:/w/wwww.cdc.gov/nchs/data/husables/2002/02hus060.fCetin, F. C. (2001). Suicide attempts and self-image among Turkishadolescents. Journal of Youth & Adolescence, 30, 641-651.Choquet, M., Kovess, V., & Poutignat, N. (1993). Suicidal thoughts amongadolescents: An intercultural approach. Adolescence, 28(111), 649-659.DAugelli, A., & Hershberger, S. (1995). Lesbian, gay and bisexual youth andtheir families: Disclosure of sexual orientation and its consequences.Manuscript submitted for publication.
  • 7. Daugelli, A., Hershberger, S., & Pilkington, N. (1996). Predictors of suicideattempts among gay, lesbian, and bisexual youth. Manuscript submitted forpublication.DeWilde, E., Kienhorst, E., Diekstra, R., & Wolters, W. (1993). The specificityof psychological characteristics of adolescent suicide attempters. Journal ofthe American Academy of Child and Adolescent Psychiatry, 32, 51-58.Dori, G. A., & Overholser, J. C. (1999). Depression, hopelessness, and self-esteem: Accounting for suicidality in adolescent psychiatric inpatients.Suicide & Life Threatening Behavior, 29, 309-318.Durkheim, E. (1951). Suicide. New York: Free Press. (Original work publishedin 1897).Grholt, B., Ekeberg, L., & Wichstrom, L. (2000). Young suicidce attempters:A comparison between a clinical and an epidemiological sample. Journal ofthe American Academy of Child and Adolescent Psychiatry, 39, 868-875.Harter, S., & Marold, D. (1992). Psychosocial risk factors contributing toadolescent suicidal ideation. In G. Noam & S. Borst (Eds.), Child andadolescent suicide: Clinical developmental perspectives. Rochester, NY:University of Rochester Press.Harter, S., & Marold, D. (1994). The directionality of the link between self-esteem and depressed affect: Beyond causal modeling. In D. Cicchetti & S. L.Toth (Eds.), The self and its disorders: Rocheseter Symposium onDevelopmental Psychopathology. Rochester, NY: University of RochesterPress.Harter, S., Marold, C., Whitesell, N., & Cobbs, G. (1996). A model of theeffects of perceived parent and peer support on adolescent false selfbehavior. Child Development, 67, 360-374.Himmelman, T. (1993). Gay and lesbian youth: Contributing factors toserious attempts or considerations of suicide. Journal of Gay and LesbianPsychotherapy, 2(1), 77-89.Hollander, G. (2000). Questioning youths: Challenges to working with youthsforming identities. School Psychology Review, 29(2), 173-179.Levy, S., Jurkovic, G., & Spirito, A. (1995). A multi-systems analysis ofadolescent suicide attempters. Journal of Abnormal Child Psychology, 23,221-234.
  • 8. Meehan, P., Lamb, J., Saltzman, L., & OCaroll, P. (1992). Attempted suicideamong young adults: Progress toward a meaningful estimate of prevalence.American Journal of Psychiatry, 149, 41-44.Muehrer, P. (1995). Suicide and sexual orientation: A critical summary ofrecent research and directions for future research. Suicide and LifeThreatening Behavior, 25(suppl.), 72-81.National Insitute of Mental Health. (2001). Interventions for suicidal youth.Retrieved December 12, 2002, from http://grants.nih.gov/grants/guide/ pa-files/PA-00-077.html.Osman, A., Downs, W., Kopper, B., Barrios, F., Baker, M., Osman, J., Besset,T., & Linnehan, M. (1998). The Reason for Living Inventory for Adolescents(RFL-A): Development and psychometric properties. Journal of ClinicalPsychology, 54(8), 1063-1078.Overholser, J. C., Adams, D. M., Lenert, K. L., & Brinkman, D. C. (1995).Self-esteem and suicidal tendencies among adolescents. Journal of theAmerican Academy of Child and Adolescent Psychiatry, 34, 919-928.Pfeffer, C. R., Klerman, G. L., Hurt, S. W., Lesser, M., Peskin, J. R., &Siefker, C. A. (1991). Suicidal children grow up: Demographic and clinicalrisk factors for adolescent suicide attempts. Journal of the AmericanAcademy of Child and Adolescent Psychiatry, 30, 609-616.Remafedi, G., Farrow, J., & Deisher, R. (1991). Risk factors for attemptedsuicide in gay and bisexual youth. Pediatrics, 87, 869-875.Rutter, P. (1998). Adolescent suicidal behavior across sexual orientation: Anassessment of suicidal ideation, risk and history of attempts. DissertationAbstracts International. Temple University, December, 1998.Rutter, P., & Soucar, E. (2002). Youth suicide risk and sexual orientation.Adolescence, 37 (146), 289-299.Sehneidman, E. (Ed.). (1969). On the nature of suicide. San Francisco, CA:Jossey-Bass.Scouller, K., & Smith, D. (2002). Prevention of youth suicide: How well-informed are the potential gatekeepers of adolescents in distress? Suicideand Life Threatening Behavior, 32(1), 67-79.Spruijt, E., & de Goede, M. (1997). Transitions in family structure andadolescent well-being. Adolescence, 32(128), 897-911.
  • 9. Zachary, R., Reid, G., Cull, J., & Gill, W. (1983, November). Relationshipbetween a brief suicide risk scale and the MMPI. Paper presented at themeeting of the Western Psychological Association, San Francisco, CA.The authors wish to thank the School of Education Research Center, LauraGoodwin, and Kimberly White for their assistance.Philip A. Rutter is an assistant professor within the Counseling Psychologyand Counselor Education program at the University of Colorado at Denver.Andrew E. Behrendt is a consultant and private practitioner in Philadelphia,Pennsylvania.COPYRIGHT 2004 Libra Publishers, Inc.COPYRIGHT 2004 Gale Group