Preventing Youth Suicide

1
Preventing Youth Suicide

• Pre-Service Workshop

2
Suicide PreventionPre-Test

1. Nationally, suicide is the second leading cause
   of death among teenagers, whereas in the West, it
   is the third leading cause.
2. The lethality from suicide attempts by younger
   boys is higher than post-puberty boys.
3. Differences between suicide rates of adolescent
   boys and girls vary according to numbers, suicide
   methods, and ways of handling stress.
4. Suicide was accepted in previous historical
   times. A strong feeling of empathy was given to
   the victim's family.
5. The four levels of suicidal behavior are
   statements, gestures, attempts and completion.
6. The number one triggering event in youth suicide
   is the break up of a romantic relationship.
7. It is better to over react than under react when
   a youth presents any suicidal behaviors within
   the four levels.
8. 10 of all hospitalizations for suicide attempts
   are considered environmental manipulation.
9. The commonly accepted rate of suicide in the
   United States among youth age 15-24 is 12.9 to
   100,000.
10. A youth may attempt suicide to obtain freedom,
    achieve control or end pain.

3
Gender Differences

• NUMBERS
• GIRLS ATTEMPT SUICIDE THREE TIMES AS OFTEN AS
  BOYS
• BOYS COMPLETE SUICIDE THREE TIMES MORE OFTEN THAN
  GIRLS (SUDAK, FORK, AND RUSHFORTH, 1984)
• METHODS
• GIRLS TEND TO USE LESS LETHAL METHODS
• BOYS TEND TO USE 'QUICKER AND MORE LETHAL METHODS
• STRESS
• GIRLS TEND TO VERBALIZE EMOTIONS, THUS INCREASING
  SUICIDAL INTERVENTION
• BOYS TEND TO RESORT TO AVOIDANCE AND
  DISPLACEMENT, THUS ISOLATING THEM AND INCREASING
  CHANCES OF EXPLOSIVE SUICIDAL RESPONSE

4
Depression and Suicide

• Suicide and suicide attempts may follow periods
  of depression
• Depression may be genetic or result from
  traumatic events in a persons life
• Almost 75 of all adolescents suffer from some
  form of depression for a period of time before
  adulthood

5
12 Indicators of Depression

• SLEEP DISTURBANCE
• SOCIAL WITHDRAWAL
• CHANGE IN SCHOOL PERFORMANCE
• SOMATIC COMPLAINTS
• EATING DISTURBANCE
• SUDDEN ELATION
• ANHEDONIA
• TEARFULNESS
• SELF-DEPRECIATION
• INABILITY TO FIGHT BACK
• HOPELESSNESS
• MASKED DEPRESSION

6
Stages of Suicidal Behavior

• Suicidal behavior is best viewed in stages
• There are four stages of suicidal behavior
• Most youth who engage in suicidal behavior are
  level 1 or level 2 which are non-lethal
• Youth can progress from being non-lethal to
  lethal so all suicidal behavior, even if it is
  attention-seeking or to avoid a negative
  consequence, must be taken seriously

7
Level I

• SUICIDAL IDEAS ARE INFERRED FROM BEHAVIORS THAT
  SUGGEST SUCH THOUGHTS
• IF A YOUTH MAKES PREPARATIONS FOR SUICIDE, IT
  MUST BE ASSUMED THAT HE/SHE IS SERIOUS
• SUCH IDEAS / PREPARATIONS MAY BE INDICATIVE OF
  POSSIBLE VIOLENCE TOWARD OTHERS
• REGARDLESS OF THE SITUATION, ADULTS CARING FOR
  YOUTH MUST ACT IMMEDIATELY

8
Level II

• SUICIDAL GESTURES ARE SELF-DESTRUCTIVE BEHAVIORS
  THAT CALL ATTENTION TO THE FACT THAT YOUTH MAY BE
  CONSIDERING SUICIDE
• NATURE OF THE GESTURE INDICATES WHETHER SUICIDE
  WAS INTENDED
• DISTINCTION BETWEEN SUICIDE GESTURE AND SUICIDE
  ATTEMPT DOES NOT DICTATE WHETHER THERE SHOULD BE
  INTERVENTION, BUT RATHER HOW TO INTERVENE

9
Level III

• SUICIDE ATTEMPTS ARE LIFE-THREATENING BEHAVIORS
  THAT JEOPARDIZE LIFE OR GIVE APPEARANCE OF SUCH
  AN ATTEMPT (FREESE, 1979)
• INTERVENTION IS A MUST
• SEEK MEDICAL ATTENTION IMMEDIATELY

10
Level IV

• SUICIDE COMPLETION REPRESENTS TRAGIC SUCCESS OF
  SUICIDE ATTEMPT
• PERSON WHO ACTUALLY COMPLETES SUICIDE GENERALLY
  INTENDS TO DIE WHILE PERSON WHO ATTEMPTS SUICIDE
  MAY WANT HIS / HER LIFE TO IMPROVE
• SOMETIMES ATTEMPTS TURN INTO COMPLETIONS BY
  MISTAKE

11

• ALWAYS REACT AS THOUGH AN ATTEMPT IS POTENTIALLY
  DEADLY AND ONLY DETERMINE DEGREE OF SERIOUSNESS
  AFTER CHILD IS SAFE

12
Suicidal Warning Signs

• BEHAVIORAL - VERBAL OR NONVERBAL ACTS THAT
  SUGGEST SUICIDAL INTENTIONS 80 OF THOSE WHO
  COMMIT SUICIDE GIVE WARNING SIGNS (BLACKBURN,
  1982)
• ENVIRONMENTAL - LIFE EVENTS THAT MAY TRIGGER A
  SUICIDE ATTEMPT

13
Behavioral Warning Signs

• VERBAL STATEMENTS EXPRESSING DESIRE TO DIE
• HISTORY OF PREVIOUS ATTEMPTS
• SUBSTANCE ABUSE
• GIVING AWAY PERSONAL POSSESSIONS
• PREOCCUPATION WITH DEATH
• SLEEP DISTURBANCE
• SOCIAL WITHDRAWAL
• CHANGE IN SCHOOL PERFORMANCE
• SOMATIC COMPLAINTS
• EATING DISTURBANCE
• SUDDEN ELATION
• DEPRESSION

14
Environmental Warning Signs

• The three environmental warning signs are
• Unstable family history
• Loss of a significant relationship--particularly
  within the last year
• Recent suicide within the environment

15
Increasing Deterioration

• SUICIDE IS NOT A SPONTANEOUS ACTIVITY
• THERE IS NO SINGLE CAUSE OF SUICIDE
• SUICIDE IS A MALADAPTIVE FORM OF COMMUNICATION
• AMBIVALENCE IS THE FEELING MOST CLOSELY
  ASSOCIATED WITH SUICIDAL BEHAVIOR
• HOPELESSNESS AND A PERCEIVED LACK OF OPTIONS ARE
  FREQUENTLY PRECURSORS TO SUICIDAL BEHAVIOR

16
Unstable Family History

• SUICIDE IN THE FAMILY
• FAMILY INSTABILITY
• FAMILY CONFLICT

17
Loss of Significant Relationship

• THE PRIMARY EVENT WHICH TRIGGERS SUICIDE IN
  ADOLESCENTS IS THE BREAKUP OF A ROMANTIC
  RELATIONSHIP

18
Suicide within the Environment

• SUICIDAL BEHAVIOR CAN BE LEARNED OR IMITATED
• ADULTS NEED TO KNOW THAT ANY ACTIVITIES WHICH
  SENSATIONALIZE OR DRAW UNDUE ATTENTION TO SUICIDE
  MAY INCREASE THE LIKELIHOOD OF SUICIDE CONTAGION
  AMONG YOUTH

19
Four Types of Youth Most likely to Imitate
Suicidal Behavior

• EXTREME ATTENTION SEEKERS
• STATUS SEEKERS
• YOUTH UNDER STRESS WHO POSSESS LIMITED
  PROBLEM-SOLVING SKILLS
• YOUTH UNDER STRESS WHO HAVE HIGH RISK PROFILES
  FOR SUICIDE

20
Autoerotic Asphyxia Attempts

• WARNING SIGNS
• There can be warning signs that a teen-age boys
  is experimenting with autoerotic asphyxia,
  according to experts in the field. They include
• Marks on the neck - abrasions, rope burns,
  bruises, pressure marks.
• The discovery of padded ropes, baits or knotted
  sheets or pillows or towels or underclothes that
  seem to have been hidden.
• Bloodshot eyes.
• Disoriented behavior after the teenager has gone
  somewhere alone.
• Possession of or fascination with ropes or other
  paraphernalia that could Induce partial
  asphyxiation, such as plastic bags, gas or
  inhalation devices.

21
Autoerotic Asphyxia Attempts

• WARNING SIGNS
• Ell Coleman, an associate professor In the
  University of Minnesota Medical School's program
  In human sexuality, said parents who suspect an
  adolescent is experimenting with autoerotic
  asphyxia should prepare for that possibility -
  and any number of others - by creating a candid
  atmosphere in which children feel free to discuss
  sexual matters.
• "Our assumption is that people, given greater
  knowledge, will become more responsible with
  their sexual behavior. -Gordon Slovut

22
Suicide Prevention Techniques

• KNOWING THE WARNING SIGNS
• KNOWING THE SIGNS OF DEPRESSION
• TREATING ALCOHOL AND DRUG ABUSE
• REFUSING TO KEEP SUICIDAL BEHAVIOR SECRET
• REVIEWING THE YOUTH FILE OR HISTORY FOR A NEWLY
  ADMITTED YOUTH
• ESTABLISHING A BASELINE FOR TYPICAL YOUTH
  BEHAVIOR
• BUILDING STRONG, POSITIVE RELATIONSHIPS WITH
  YOUTH AND ENCOURAGING THE DISCLOSURE OF EMOTIONS
• SETTING REASONABLE GOALS AND EXPECTATIONS FOR
  YOUTH TO ACHIEVE

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• TEACHING PROBLEM-SOLVING SKILLS
• PROMOTING RELIGIOUS AND MORAL VALUES
• DOING INCIDENTAL TEACHING ABOUT SUICIDE
• ESTABLISHING REPORTING OF SUICIDE BEHAVIOR
• BY YOUTH PEERS
• ESTABLISHING REPORTING OF SUICIDE BEHAVIOR BY
  OTHER ADULTS
• MONITORING ROMANTIC RELATIONSHIPS OF YOUTH
• INCREASING VIGILANCE WHEN A SUICIDE OCCURS
• MONITORING OR RESTRICTING HOME VISITS IF
• THEY ARE A MAJOR PROBLEM SOURCE FOR YOUTH
• TRUSTING INTUITIONS

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When Talking about Suicide with Youth Discuss

• THE TRAGEDY AND FUTILITY OF SELF-INFLICTED DEATH
• THE MYRIAD OF ALTERNATIVES THE VICTIM HAD
• THE KINDS OF SITUATIONS THAT MERIT PEER CONCERN
  AND REPORTING
• HOW TO REPORT A DANGER SIGN
• SUICIDE WARNING SIGNS

25
Addressing the Immediate Crisis

• ENSURE SAFETY FIRST
• STAY WITH YOUTH
• DO NOT ARGUE
• AFFIRM LIFE AND OTHER OPTIONS
• DO NOT ANALYZE
• ASSESS LETHALITY
• MAKE A VERBAL CONTRACT
• CONTACT SUPERVISOR
• CHECK FOR SUICIDE NOTES
• FOLLOW POLICIES AND PROCEDURES

26
Self Harm Inventory

• This is a tool used to attempt to describe the
  youth's state of mind whenever a warning sign of
  potential self harm is observed by the treatment
  provider. The information is to be communicated
  to the legal guardian immediately so that s/he
  may decide what intervention to require.
• Has the child had trouble getting to sleep or
  waking up early?
• Has the child had poor eating habits? Not eating
  enough?
• Has the child made expressions of low
  self-esteem?
• Does the child smile much?
• Has the child withdrawn from friends and family
  and from regular activities?

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Self Harm Inventory

• Has the child been involved in violent or
  rebellious behavior or running away?
• Has the child been neglectful of personal
  hygiene?
• Has the child made any radical personality
  changes?
• Has the child been persistently bored, had
  difficulty concentrating, or had a decline in the
  quality of school work?
• Has the child made frequent complaints about
  physical symptoms, often related to emotions,
  such as stomachache, headache, fatigue, etc.?
• Has the child had a sudden loss of interest in
  pleasurable activities?

28
Self Harm Inventory

• Has the child had trouble accepting praise or
  rewards?
• Has the child made any suicidal statements?
• Has the child complained of being "rotten
  inside?"
• Has the child made verbal statements such as? "I
  won't be a problem for you much longer," "Nothing
  matters," "It's no use," or "I won't see you
  again"?
• Has the child put his or her affairs in order
  (e.g., giving away favorite possessions, cleaning
  his or her room, throwing things away, etc.)?
• Has the child become suddenly cheerful after a
  period of depression?
• Is this the anniversary of the death of a loved
  one?
• Is it the season or time of year when the child
  would normally associate feelings with traumatic
  events?
• Has the child abused alcohol or drugs?
• Is the child under the influence of alcohol or
  drugs?
• Has the child been under the influence of alcohol
  or drugs for some "weeks"?

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During Hospitalization

• VISIT EVERY DAY OR EVERY OTHER DAY
• TALK WITH THE CHILD'S THERAPIST EVERY DAY
• MAINTAIN NORMAL ROUTINE AT HOME
• DO INCIDENTAL TEACHING WITH OTHER YOUTH, STRESS
  CONFIDENTIALITY
• DISCOURAGE YOUTH VISITATION
• UPDATE THE CONSULTANT AND CASEWORKER

30
Post Hospitalization

• DECIDE IS CONTINUED THERAPY IS NECESSARY
• TEACH YOUTH HOW TO ANSWER QUESTIONS ABOUT
  HOSPITAL STAY
• RE-ESTABLISH NORMAL ROUTINE
• WATCH FOR RISK FACTORS
• FOCUS ON RELATIONSHIP
• TEACH PROBLEM SOLVING
• KEEP CONSULTANT UPDATED

31
Practical Exercise

• Identify the type of behavior or environmental
  warning sign of suicidal behavior in the slides
  following this one. Then, explain which option
  from those listed below you would use to address
  the behavior
• Effective praise
• Corrective teaching
• Preventive teaching
• Non-responsive/Intensive teaching
• SODAS method of counseling
• Call consultant immediately
• Discuss with consultant during next meeting
• Family Teacher stays with youth and does not
  allow them to be alone
• Each situation may have more than one warning
  sign and Family Teacher response.

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Practical Exercise

1. While monitoring study hour, you notice that a
   youth has gotten off task and is doodling in a
   notebook. The doodling contains the words death,
   Satan, and has a picture of a monster with bloody
   teeth.
2. A youth returns home from school, looks at you
   with a sad face, and says, "My girlfriend broke
   up with me today.
3. A new youth in your home has shown no interest in
   participating in family activities during the
   first two weeks. Today, he said, "I can't wait
   for tonight when we all get to go swimming. I
   used to be on the swim team in 9th grade."
4. A youth mentions that a girl at her old school
   committed suicide last year. She says that she
   didn't know the deceased girl, but said, "She was
   really popular."

33
Practical Exercise

• During an intensive teaching episode, you hear
  the youth say, "I don't care, it just doesn't
  matter. She then walks to her room and climbs
  into bed. Previous intensive situations with this
  youth included hours of verbal aggression and
  occasional throwing of small objects in the room.
• While reading a youth's file in preparation for
  placement later this week, you notice that he
  attempted suicide three times in the past using a
  small number of aspirins, drinking shampoo, and
  cutting on his wrist with a comb, creating a
  scar.
• A youth begins crying and says "I want to die"
  after you have delivered a large negative
  consequence for using alcohol at school.

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Practice Exercise

1. A youth who earned a 3.2 grade point average
   during the first quarter in your home delivers
   her mid-term progress reports to you. Two of
   seven classes indicate grades below passing
   level.
2. A youth says "I can't do anything right" while
   you are helping them prepare dinner
3. A younger youth who has had relatively few
   behavioral problems while in your home begins to
   lie, steal, and disobey rules on a daily basis.
   After a week of increased frequency of these
   behaviors, the youth does not return from school.
4. A youth who usually has a difficult time sleeping
   greets you in the morning by saying, "I slept
   really well last night and didn't wake up once.

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Practical Exercise

• 12. A youth tells his roommate that he may have
  his stereo because "I won't be needing it
  anymore." You receive a peer report about this
  thirty minutes after the incident.
• 13. A youth who normally wishes to be alone in
  her room is seen pleasantly playing Monopoly with
  the other youth.
• 14. A youth's parents are going through divorce
  proceedings. The youth receives a phone call from
  his father. After he is finished speaking on the
  phone, he says to a peer in a calm voice tone,
  "My dad is moving to New York after the divorce
  is done." The young man walks towards his
  bedroom.
• 15. After a youth returns from a home visit, you
  notice bruises on her arms and shoulders.

36
RESOURCES
37
Suicide Warning Signs

• Eighty percent of those who commit suicide give
  warning of their intentions (Blackburn, 1982). It
  is a myth that most people who commit suicide do
  not talk about it or show signs of their intent.
• Warning signs can be behavioral (where the youth
  says or does something to suggest suicide
  intention) or environmental (events in the
  youth's life that could trigger a suicide
  attempt). Those caring for youth should be aware
  of both.
• Twelve behavioral warning signs are
• Making statements like "I want to die," "I feel
  dead inside," or "I want to kill myself'
• Previous suicide attempts
• Abuse of drugs or alcohol
• Giving away prized possessions, writing a will,
  or making other "final" arrangements
• Preoccupation with themes of death or expressing
  suicidal thoughts
• Changes in sleeping patterns--too much or too
  little
• Withdrawal from friends and family or other major
  behavioral changes
• Changes in school performance, lowered grades,
  cutting classes, or dropping out of activities
• Frequent complaints of physical symptoms such as
  stomachaches, headaches, or fatigue
• Sudden and extreme changes in eating habits, or
  losing or gaining unusual amounts of weight
• Sudden cheerfulness after a prolonged period of
  depression
• Depression (which includes signs 6-11 above, and
  other signs discussed later)

38
Environmental Warning Signs

• The three environmental warning signs are
• Unstable family history
• Loss of a significant relationship--particularly
  within the last year
• Recent suicide within the environment
• Family-Teachers and youth caretakers should
  remember that the presence of any one of these
  signs is sufficient to indicate increased
  monitoring and vigilance.
• Some of these behavioral warning signs may occur
  immediately before a suicide crisis. Others may
  lurk in the youth's past. For example, a youth
  may make outright statements of wanting to die
  just before a suicide attempt, or changes
  indicating depression may develop over many
  months and be traceable in time to a point well
  before an actual suicide attempt. Environmental
  warning signs also can be manifested either in
  the past or present.
• From a caretaker's viewpoint, the twelve
  behavioral warning signs are somewhat easier to
  detect than the three environmental signs.
  Family-Teachers are more likely to notice the
  changes hi behavior that will signal possible
  suicide intention. Others in the youth's circle
  of contacts (such as clergy or teachers) are more
  likely to notice changes outside the home and
  alert someone.
• Environmental warning signs may depend heavily on
  the completeness of the written or oral reports
  available about the youth's life before admission
  to Boys Town or to his or her care site. Once in
  the new care site, accuracy of information about
  the youth's environment away from Boys Town will
  depend on some factors outside the caregivers
  control.
• Fortunately, more than just one warning sign is
  usually given by a suicidal youth.

39
Behavioral Warning Signs

• Behavioral Warning Signs
• Caregivers should treat every one of these signs
  as a warning, and provide maximum protection for
  their youth.
• Verbal Statements of Wishing to Die
• A youth who says "I. want to die" or "I want to
  kill myself' is more likely to do it than a youth
  who never makes such statements.. Eighty percent
  of those who commit suicide give repeated
  warnings (Blackburn, 1982).
• History of Past Attempts
• One of the most widely recognized signs that a
  suicide attempt may be made is a record of past
  attempts. Almost one-half of those persons who
  complete a suicide attempt have attempted suicide
  before (Blackburn, 1982). The record of a past
  attempt generally increases the likelihood that
  such a youth may attempt suicide again. Follow-up
  studies of persons who attempt suicide suggest
  that about 10 will make another attempt within
  one year (Hawton, 1986).
• Once a youth has made one attempt, it is
  apparently easier to try it again (Johnson,
  1986). Even more worrisome is the clinical
  observation that the more times a youth attempts
  suicide, the more likely the attempts will be
  increasingly serious (Kenney, 1986).

40
Behavioral Warning Signs

• Alcohol and Drug Use
• Habitual substance abuse in and of itself is a
  major risk factor that can lead to suicide. In
  fact, substance abuse alone substantially
  increases a youth's chance of attempting suicide.
  One study found that 20 of youth who attempted
  suicide were using drugs or alcohol during the
  time of their attempt (Frederick and Lague, 1978)
• Another study closely examined the lives of youth
  who "succeeded" in committing suicide from 1980
  to 1983 (Holden, 1986). It was discovered that
  about 70 of the youth were chronic alcohol or
  drug abusers.
• The importance of drug or alcohol abuse as a sign
  of possible suicide requires that caregivers make
  every effort to detect substance abuse. The
  problem is widespread. Research such as that
  cited above (Frederick and Lague, 1978 Holden,
  1986) indicates that the prevention and treatment
  of substance abuse in and of itself are important
  steps in suicide prevention. Some researchers
  (Fowler, Rich and Young, 1986) implicate
  substance abuse as an equal or greater factor
  than depression in precipitating youth suicide.
• Giving Away Possessions
• Any type of "final preparation" is a warning sign
  of suicide. While adults tend to make out a will
  when planning to kill themselves, youth tend to
  give away prized possessions such as a stereo,
  albums, or posters. A similar warning occurs if a
  youth begins telling others that he or she will
  be "going away" or begins saying goodbye to
  friends and others.

41
Behavioral Warning Signs

• Preoccupation With Death
• Youth seem to think more about suicide or death
  than was true in the past. Anecdotal evidence
  indicates that high school youth now consider
  suicide as an option for troubled people much
  more than they did a few years ago. People over
  30 years old rarely can recall a classmate who
  committed or even attempted suicide. Students in
  the 1980's may frequently know youth who have
  tried or completed suicide.
• Youth caretakers need to watch for higher than
  usual rates of concern about death or suicide. Of
  special concern is the youth who seems to dwell
  on the subject of death and to speak often about
  it. A morbid preoccupation may not necessarily be
  linked to serious depression, but it is a danger
  sign.
• The attraction to "punk" or "death rock" groups
  may be merely the result of peer interest.
  However, when coupled with the drawing of death
  symbols, frequent discussion of morbid
  activities, and a near obsession with destruction
  and violence, it can be much more serious.
• Related to this warning sign would be any self
  injurious behavior such as cutting oneself,
  carving initials in an arm or purposefully
  burning one's hand. Any youth who threatens or
  harms himself or herself is to be considered a
  potential suicide victim (Fujimura, Weis, and
  Cochran, 1985).

42
Behavioral Warning Signs

• Sleep Disturbance
• One study revealed that 85 of youth who had
  attempted suicide had repeated episodes of
  disturbed sleep patterns in the 30 days preceding
  their attempt (Kosky, 1983). Difficulties can
  include problems with falling asleep (i.e.,
  taking longer than 45 minutes), repetitive
  nightmares or staying asleep longer than normal.
  One typical indicator is waking up early, such as
  at 2 a.m. to 5 a.m., and being unable to go back
  to sleep.
• Teenagers typically are not eager to get up at
  615 a.m., or to go to bed early at night.
  Variations from this theme should be viewed with
  concern. Of course, youth care workers will take
  into account that not everyone's biological clock
  runs alike. The cue is change ... to watch for a
  change in sleeping patterns.
• Excessive sleeping can be another sign. Unusual
  napping during the day also is a possible warning
  sign. Nightmares are another sign. Recurring
  nightmares, particularly where themes of death or
  violence predominate, can be an important element
  of sleep disturbance and related depression.
• There is some evidence that these changes in
  sleeping patterns are biological in nature.
  Depression (often present in suicidal youth) may
  be linked to actual physical changes in the
  body's biochemistry, and make it nearly
  impossible to sleep normally.

43
Behavioral Warning Signs

• Withdrawal
• Withdrawal is displayed as marked reduction of
  youth-initiated contact with other youth, with
  the youth's' Boys Town family, with the natural
  family, teachers, and others. Withdrawal is most
  serious when it is withdrawal away from
  "significant others" in the youth's life rather
  than from casual acquaintances. One study of
  sixty-five adolescents indicated that one-half of
  the youth became "loners" in the months
  immediately preceding their suicide attempts.
  They stopped interacting with friends and
  participating in favorite activities because of
  loss of ambition and/or loss of interest
  (DenHouter, 1981).
• Caregivers should determine the cause of
  isolation, to discover whether a youth has
  initiated it (suggesting depression) or whether
  peers are responsible (suggesting social
  ostracism). If the isolation was caused by
  others, depression is less likely to be present
  but the youth may be displaying other behaviors
  that led to the ostracism.
• Decreasing School Performance
• An adult who is contemplating suicide may show
  poor work performance on the job. Suicidal youth
  tend to show increasingly poor school
  performance. Sudden changes in school performance
  thus should serve as a warning sign. Since many
  youth with problems have difficulties in school,
  poor performance alone does not appear to be a
  hint of suicide intention. Problems in school,
  when combined with other suicide warning signs,
  should be taken seriously.
• Some school behaviors to watch for include the
  following hostile or unruly behavior at school
  short, frequent absences from school for one or
  two days each time acting unusually bored or
  frustrated with school in general or with
  homework assignments and withdrawing from
  extracurricular school activities.

44
Behavioral Warning Signs

• Four teenage suicides in New Jersey in March,
  1987, showed clear evidence of several warning
  signs before the four died together. Included was
  poor school Performance "Officials also called
  psychologists to the high school from which three
  of the four had dropped out and the forth had
  been suspended."'
• Somatic Complaints
• Increased complaints about physical ailments also
  are indicative of underlying depression as well
  as the danger of suicide. Typical complaints are
  about stomachaches, headaches, and fatigue. The
  ailments may in fact have a biological basis,
  such as increased acid secretions in the stomach
  during heightened stress. On the other hand, a
  physician maybe unable to determine the cause of
  the complaint.
• Once again, the key component is frequency.
  Persistent complaints, especially in the absence
  of a verifiable medical cause, are reason for
  concern. This sign tends to occur more frequently
  in girls than in boys. It is possible that such
  complaints are more socially acceptable when made
  by girls rather than by boys.
• Perhaps due to a difference in social
  acceptability, the presence of such complaints
  from a boy is a better predictor of a possible
  suicide attempt than it would be for a girl. It
  is more unusual for a boy to make such
  complaints, and therefore more likely to indicate
  a serious problem. It is also a greater predictor
  of potential suicide when observed in younger
  children. Youngsters are typically less adept at
  talking about depression, feelings or problems
  than adolescents. When younger children voice
  physical complaints repeatedly, depression may be
  present.

45
Behavioral Warning Signs

• Eating Disturbance
• Another observable warning sign of suicide
  likelihood is a change in eating habits. AA cause
  for concern and action is a youth who no longer
  cares for favorite foods. It may be a sign of
  depression for a youth to stop seeking snacks.
• Conversely, overeating at mealtime or eating more
  frequently can also be a warning sign. Overeating
  at one meal may signal nothing other than extra
  exercise and a resultant hearty appetite that
  day. However, a youth stuffing himself or herself
  repeatedly would be a far more serious sign.
  Eating disorders such as bulimia or anorexia are
  not directly related to suicide but may be among
  a constellation of indicators.
• Major fluctuations in body weight can be a sign,
  whether the weight change is up or down. This can
  be a clue even if youth caretakers do not note
  changes in eating behavior. However, dieting is
  fashionable and teenage girls can be especially
  prone to dieting. Family Teachers should monitor
  abrupt weight changes to ensure that such signs
  are normal and not signs of depression.

46
Behavioral Warning Signs

• Sudden Elation
• One warning sign that occasionally shows up in
  suicide prevention literature is the sudden
  appearance of elation or general happiness after
  a period of depression. It can be a danger sign
  because the sufferer has figured out how to end
  suffering (i.e., by committing suicide). Clinical
  experience of Boys Town consultants, however,
  suggests that such sudden elation is more typical
  in manic depressive disease, when the manic cycle
  is beginning again. Manic depression, a serious
  illness that can have a biological basis, is
  typically not found in group home youth since the
  disease rarely manifests itself before adulthood
  (Kenney, 1986).
• Depression
• Some behavioral warning signs of suicide intent
  are also associated with depression (such as
  sleep disturbance or somatic complaints). Neither
  signs of depression nor a diagnosis of depression
  necessarily indicate suicide intent. Only about
  5 - 10 of all depressed persons attempt
  suicide.
• Before examining the two environmental warning
  signs of suicide, let's look more closely at the
  relationship between suicide and depression.

47
Depression, Learning Theory and Suicide

• Depression is one of the major indicators of
  suicide in adolescents. It is thought to be
  present in two-thirds of all suicidal adolescents
  (Keidel, 1983). Further, some studies indicate
  that so many youth in group homes , have
  depressive symptoms that they are at special risk
  for suicide attempts or completions (Hawton,
  1986).
• From a statistical viewpoint, anyone who is
  depressed is 30 times more likely to attempt
  suicide than someone who is not (Stallone,
  Dinner, Ahearn, and Fieve, 1980). As a cautionary
  note, though, youth caregivers should keep in
  mind that "depression" refers to a constellation
  of symptoms over a period of time--not simply
  being "down" or sad one afternoon when things did
  not go well.
• Depression occurs when an individual's
  "reinforcers" (i.e., the rewarding values,
  persons, places, or things that motivate all of
  us to one degree or another) are either absent or
  no longer rewarding. Depression is most serious
  when the person becomes paralyzed by
  helplessness, passivity, hopelessness, and the
  inability to be assertive enough to get what he
  or she wants and needs in life (DenHouter, 1981).

48
Behavioral Indicators of Depression

• Behavioral Indicators of Depression
• From a therapeutic point of view, it is fortunate
  that there are some clear signs of depression.
  These behavioral indicators may manifest
  themselves during daily life in the home or
  elsewhere. Youth care workers may directly
  observe them, receive a report from another adult
  (e.g., priest or minister, school teacher), or
  learn of it from one youth worried about another
  youth (i.e., peer reporting).
• There are twelve indicators or signs of
  depression that youth caregivers must monitor
• Sleep disturbance
• Withdrawal
• Changes in school performance
• Somatic complaints
• Eating disturbance
• Sudden cheerfulness
• Anhedonia
• Tearfulness
• Self-depreciation
• Inability to fight back
• Hopelessness (the "catalyst" that can lead the de
  depressed youth to commit suicide)
• "Masked" depression
• Depression indicators 1 - 6 have already been
  discussed under the behavioral warning signs of
  suicide, indicators 7 - 12 will be further
  discussed here.

49
Behavioral Indicators of Depression

• Anhedonia is loss of interest or motivation in
  activities that formerly appealed to the youth.
  For example, a boy who used to love listening to
  music may no longer even pay attention to the
  radio, much less buy tapes of his favorite group.
  A youth who has been active in sports but
  suddenly stops playing, similarly. could be
  depressed. In general, any indication that a
  formerly enjoyable activity is no longer enjoyed
  could be an indicator of depression.
• Tearfulness. In a three-year study, 90 of
  suicidal youth were unhappy, sad, tearful, or
  depressed during an interview (Kosky, 1983).
  Girls often display their emotions more readily
  than boys. Such tears can be happy or sad.
  However, increased crying beyond what is normal
  for an individual girl should be watched as a
  possible sign of depression.
• Tearfulness in boys, however, is more unusual and
  therefore may be more likely to indicate
  depression (Kenney, 1986). This is especially
  true if an adolescent boy cries in front of other
  kids.
• Self-Depreciation. Depression can be signaled
  when a youth makes a statement that contains
  unwarranted guilt or discouragement. Such youth
  "put themselves C
• down." claiming that they are "useless" or "no
  good at anything." This behavior is often
  generated by assumed guilt for a major problem,
  such as a youth blaming himself or herself for
  the parents' divorce.

50
Behavioral Indicators of Depression

• Such guilt can become unbearable, especially for
  situations that appear to have no ready solution.
  The youth who assumes blame for causing a divorce
  is typically not going to be able to fix the
  problem (i.e., get Mom and Dad together again).
  Thus, the unjustifiable guilt may appear to the
  youth as inescapable and permanent, generating
  the self-depreciation.
• Inability to Fight. Kenney (1986) has reported
  from extensive clinical observations that one
  sign of depression in adolescents is loss of the
  ability to fight back. Normal adolescents are
  quick to protect and fight for ownership of
  possessions, privacy, independence, and other
  features of their lives. Youth like those at Boys
  Town are typically apt to assert themselves in
  this fashion.
• For example, youth in Boys Town's Family Homes
  usually have a history of antisocial outbursts or
  tantrums against authority figures such as
  parents and teachers. The youth may balk at
  following home rules or at following.
  instructions or guidance.
• Depression may be indicated when such a youth
  suddenly seems to "give up" and not resist
  anything. If a boy suddenly does everything he is
  told to do, without any display of affection or
  positive emotion, then there may be cause for
  concern. Of course, this must be distinguished
  from desirable improvements. It can be
  distinguished from appropriate cooperation when
  compliance or agreement is accompanied by
  mannerisms indicating a "who cares?" attitude.

51
Behavioral Indicators of Depression

• Hopelessness. The feeling of hopelessness is one
  that often precedes a suicide attempt and
  accompanies serious depression. For a youth in a
  group home, a perception that the youth could
  never return to his or her natural home--no
  matter what--can generate a feeling of
  hopelessness. This is one reason why Family
  Teachers quickly establish long-term goals like
  returning home for a newly placed youth and
  always have temporary goals related to that
  long-term goal.
• Most suicidal adolescents who kill themselves
  show signs of hopelessness before their death
  (Grueling and DeBlassie, 1980). Hopelessness is
  one of the major discriminators between
  uncomfortable depression and depression that may
  predict a suicide attempt. The suicidal depressed
  adolescent is pessimistic and sad ... and
  convinced that sadness will continue no matter
  what (Blackburn, 1982).
• Thus, hopelessness is the "final straw" in that
  it can lead the depressed person to attempt
  suicide. Depression without hopelessness is not
  nearly as serious, and can be more readily eased
  by therapy.

52
Behavioral Indicators of Depression

• Masked Depression. "Masked depression" is a
  clinical term which Family-Teachers may find
  recorded in a youth's history. At Boys Town, this
  term is interpreted to mean that depression is
  suspected, but the usual outward signs are not
  there. The distinction between depression and
  "masked depression" is one that Family-Teachers
  need not be overly concerned about. They should
  treat it in much the same way as typical
  depression ... looking for other signs that
  signify a serious mood disturbance.
• However, one aspect of "masked depression" should
  be noted. Younger children tend to camouflage
  their true feelings (Fish and Waldhart-Letzel,
  1981). Adults who are depressed tend to look and
  act depressed. When a youngster becomes
  depressed, the visible signs may be more
  antisocial such as stealing, lying, running away,
  disobeying, abusing drugs, etc. If these
  behaviors did not occur often before, then it is
  possible that the youth is becoming depressed
  (Pettifor, Perry, Plowman, and Pitcher, 1983).
• Experience with adolescents has shown that,
  during the actual crisis of a suicide attempt, a
  youth may even display anger and heightened
  physical responses. This is in contrast to the
  commonly accepted meaning of "depression," and
  has been referred to as "masked depression."
  Nevertheless, suicide attempts are usually
  preceded over time by one or more of the signs of
  clinical depression discussed earlier.
• Any one of these signs of depression suffices as
  a reason to look for. other signs. Typically,
  however, four or five signs exist in a depressed
  adolescent.

53
Environmental Warning Signs

• Environmental Warning Signs
• In addition to the major warning sign of
  depression and the twelve behavioral signs
  previously described, there are environmental
  warning signs as well. These are events that
  occur in the youth's life, rather than behaviors
  or emotions directly observable in the youth. The
  three major environmental warning signs are
• Unstable Family history
• Loss of a significant relationship
• Recent suicide within the environment

54
Environmental Warning Signs

• Unstable Family History
• Suicide in the Family. Just as a record of
  previous attempts by a youth is a warning sign of
  another attempt, a record of suicides in the
  youth's family increases the risk that the youth
  also will attempt or commit suicide. It has been
  reported that 40 of those adolescents who
  attempted or committed suicide had a family
  member, relative, or close friend previously
  commit suicide (Pettifor, Perry, Plowman, and
  Pitcher, 1983). Another study found that
  one-third of the suicide victims had relatives
  who had attempted suicide (Holden, 1986).
• Some adolescents may even copy the methods used
  by family members who have attempted or committed
  suicide. In this sense, suicide can be viewed as
  a learned behavior, an approach taken by a
  distraught youth who has seen "a solution" and
  has learned how to do it ... either by trying it
  before or by learning from attempts by others.
• Some studies give clues about a youth's chances
  of attempting suicide by searching for common
  characteristics of mothers and fathers of
  suicidal youth. It has been found that fathers of
  suicidal youth tend to be depressed, have low
  self-esteem, alcoholic, and do not serve as
  effective father figures (Frederick and Lague,
  1978).

55
Environmental Warning Signs

• Of the parents of such youth, the mother is the
  most likely to have made a suicide attempt.
  Mothers who, model suicidal behavior indicate by
  their actions that suicide is an acceptable
  option to choose when dealing with stress
  (Pettifor et al., 1983).
• Family Instability. Sixty-eight percent of
  suicidal adolescents in one study were found to
  be without one or both of their natural parents
  (Paulson, Stone, and Sposto, 1978). While suicide
  can occur in caring families with no known
  serious problems (Keidel, 1983), most studies
  find that suicidal children come from families
  where divorce, separation, or death has occurred.
  Death of a loved one, particularly by suicide,
  can be dangerous for younger children who may
  fantasize that suicide is a way to be reunited
  with the deceased.
• Departure of a parent, either through divorce or
  death, may precipitate a crisis in a suicidal
  youth. Absence of a parent can worsen a crisis
  since he or she is no longer available to a youth
  contemplating suicide.
• Family Conflict. Family conflict, family
  disruption by divorce or death of a parent, high
  levels of familial arguing and youth perception
  of poor marital satisfaction are all related to
  youth suicide (McKenry, Tishler, and Kelley,
  1982 Topol and Reznikoff, 1982 and Kosky,
  1983). Another precursor to suicidal youth
  behavior is the alcoholic parent (Pettifor et
  al., 1983).

56
Environmental Warning Signs

• Youth at considerable risk for suicide attempts
  have been found often to be children of a
  depressed mother and an alcoholic father
  (Frederick and Lague, 1978). Such children are
  more likely to have been sexually abused by their
  father.
• Physical abuse definitely is a risk factor for
  suicide. Two-thirds of suicidal adolescents have
  been found to be physically abused by a parent or
  stepparent. Twothirds of suicidal youth also
  have witnessed physical abuse between the parents
  (Kosky, 1983).
• A youth can "learn" about suicide gradually,
  being desensitized by others close to him who
  talk about it, try it, or complete it. A family
  history of suicide increases the chance that a
  youth also might attempt it by a factor of eight
  (Garfinkel, Froese, and Hood, 1982).
• Loss of Significant Relationship
• The second major environmental warning sign of
  potential suicide is the loss of a significant
  relationship. The death of a loved one can pose a
  serious threat leading to a suicide attempt. Even
  if the loss is not death, it can be traumatic for
  a youth. The primary suicide trigger for youth is
  the breakup of a romantic relationship. This is
  true for boys and girls.

57
Environmental Warning Signs

• The loss of a significant social relationship
  within the year seems to be a much greater
  indicator of potential suicide than a loss
  occurring years previous. Youth caregivers should
  realize that almost every youth who comes to Boys
  Town has suffered some kind of loss, although not
  always during the year just prior to admission.
• Suicide by a Peer. A tragically clear example of
  peer suicide took place prior to the suicides of
  four youth in New Jersey who died together in
  March, 1987. One, 19-year-old Thomas Rizzo, not
  only suffered from the loss of his best friend,
  but the friend had committed suicide. Finally,
  not only had the loss been from another suicide,
  but Rizzo actually had watched his friend commit
  suicide.
• "Rizzo's mother, ... said one of the previous
  deaths involved her son's best friend, Joe Major,
  18, who in September fell from a 200-foot-high
  cliff overlooking the Hudson River. Her son saw
  Major fall and she said it was a suicide,
  although it was officially classified an
  accident."

58
Environmental Warning Signs

• Suicide Within the Environment
• A completed suicide by another youth--or even by
  a complete stranger--can be imitated. This
  phenomenon is referred to as a "contagious
  suicide," "ripple effect," "domino effect,"
  "copycat suicide," or as a "cluster phenomena."
  This type of suicide is believed to be learned
  and imitative in nature, similar to other kinds
  of learning that occur more naturally within
  families (Cantor, 1985).
• Adolescent copycat suicides have occurred
  throughout the country. In 1985 in Plains,
  Texas, seven youth in the high schools committed
  suicide. In 1986, eleven teenagers killed
  themselves in Jefferson County, Colorado, west of
  Denver. At an Omaha, Nebraska, high school in
  1985, three students killed themselves and two
  others attempted suicide ... all within one week.
• Once someone commits suicide, it increases the
  risk of suicide fourfold among others around that
  person (Hawton, 1986). School authorities have
  noted that when one student in a high school
  commits suicide, there is a high chance that
  another suicide will be attempted soon thereafter
  (Keidel, 1983).

59
Environmental Warning Signs

• Evidence suggests that media coverage of suicide
  leads to copycat suicides (Phillips and
  Carstensen, 1986). Following national coverage of
  the four New Jersey teenagers who committed group
  suicide in March, 1987, other copycat suicides
  were completed. Media professionals themselves
  began a debate that continues. "Some newspaper
  and broadcast editors have begun to downplay or
  even ignore individual suicides and focus
  attention on the causes of teenage suicide and
  the availability of counseling programs. Others,
  while stressing that journalists must act
  responsibly, say the first duty of the news media
  is to keep the public informed."
• Adults need to know that any activities which
  sensationalize or draw undue attention to suicide
  may increase the likelihood of suicide contagion
  among children.
• Types of Imitators. Suicide prevention experts
  feel that there are four types of youth most
  likely to imitate someone else's suicide. First,
  youth who are extreme attention seekers may
  imitate another's suicide. Second, adolescents
  who are seeking status may commit a copycat
  suicide. Third, a suicide can be imitated by an
  adolescent who is under stress yet has few
  problemsolving skills. Finally, imitators can be
  adolescents under stress who have high risk
  profiles for suicide.

60
Environmental Warning Signs

• The first two of these four types of imitators
  need not display any of the warning signs. These
  youth seek attention or status by attempting
  suicide. For such youngsters, the media and other
  attention surrounding the suicide appear to be a
  direct stimulus for their suicide. The last two
  of these four types of imitators display signs
  and warning signs for suicide. The media
  attention may be the trigger for suicides that
  are about to happen.
• Summary
• Eighty percent of persons who commit suicide
  give.' warning of their intention.

61
12 Behavioral Warning Signs

• There are twelve behavioral warning signs. Signs
  occur in the present as well as in the past. The
  twelve behavioral warning signs of a potential
  suicide attempt by a youth are
• Making statements like "I want to die," "I feel
  dead inside," or "I want to kill myself'
• Previous suicide attempts
• Abuse of drugs or alcohol
• Giving away prized possessions, writing a will,
  or making other "final" arrangements
• Preoccupation with themes of death or expressing
  suicidal thoughts
• Changes in sleeping patternstoo much or too
  little
• Withdrawal from friends and family or other major
  behavioral changes
• Changes in school performance, lowered grades,
  cutting classes, or dropping out of activities
• Frequent complaints of physical symptoms such as
  stomachaches, headaches, or fatigue
• Sudden and extreme changes in eating habits, or
  losing or gaining unusual amounts of weight
• Sudden cheerfulness after a prolonged period of
  depression
• Depression
• Depression, listed as one behavioral warning sign
  of suicide, is actually manifested in many
  different ways. Only about 5 - 10 of depressed
  persons attempt suicide, but about two-thirds of
  those who attempt suicide are depressed.

62
Six Additional Signs of Depression

• In addition to some suicide warning signs (6
  through 11 above, that also are symptoms of
  depression) there are six other signs suggesting
  depression. Although these signs do not
  necessarily indicate suicide planning, they do
  indicate depression. Depression alone is serious
  enough to warrant attention.
• These additional six signs of depression are
• Anhedonia
• Tearfulness
• Self-depreciation
• Inability to fight back
• Hopelessness
• "Masked" depression
• Of these six signs, hopelessness is the most
  serious. Most adolescents who actually commit
  suicide show signs of hopelessness prior to their
  suicide. This sign of depression acts as a
  "catalyst," leading the depressed youth to select
  suicide as the only way to solve his . or her
  problems.

63
3 Environmental Warning Signs

• In addition to behavioral warning signs, there
  are three environmental warning signs of possible
  suicide
• Unstable family history
• Loss of significant relationship
• Recent suicide within the environment
• It is worth noting that the second environmental
  warning sign (loss of significant relationship)
  need not involve death. Certainly, the death of a
  loved one can be a cause of a suicide attempt.
  However, the number one triggering event for an
  adolescent's suicide attempt is the breakup of a
  romantic relationship. Such a loss can be just as
  traumatic as loss from death.
• Finally, adolescents seem prone to committing
  "copycat" suicides, following someone else's
  suicide.
• The person copied need not be a close friend, but
  simply someone with whom the troubled youth can
  identify. It has been found that once someone
  commits suicide, it increases the risk of suicide
  fourfold among others around that person. _
• There are four types of "imitators" ... youth who
  are most likely to imitate someone else's
  suicide
• Extreme attention seekers
• Status seekers
• Stressed youth who have minimal problem-solving
  skills
• Stressed youth who have high-risk profiles

64
Footnotes

• 1 0maha World-Herald. Four New Jersey teens took
  way out in pact. March 12, 1987, p. 14 Reprinted
  by permission
• 2 Ibid.
• 3 Omaha World-Herald. Caution, duty to inform
  weighed in reporting of teen-age suicide. March
  22, 1987, 2-A. Reprinted by permission.