Adolescence is an exciting time when a child transitions into adulthood. Most people associate the transition to exciting moments in a person’s life like discovery oneself, increased independence, obtaining a driver’s license, participating in social events, and graduating from high school. While most adolescents enjoy this period in their life, there is a large portion that find this phase difficult to navigate and find themselves isolated and not knowing how to manage their negative thoughts. According to the Centers for Disease Control and Prevention, as of 2017, adolescent suicide is the second-leading cause of death among this population. Suicide is a preventable act when proper steps are taken. As of today, there has been limited research conducted to determine an effective approach when working with this group in a clinical setting.
Many adolescents engage in suicidal thoughts and those thoughts lead to action in alarming numbers. A study revealed that in the year 2011, thirteen percent of adolescents in the United States had thought about and planned to commit suicide and that as many as eight percent had followed through on those thoughts with actual attempts at suicide (Shain, 2016). While since 1990 the number of adolescents who died as a result of suicide seems to have slightly dropped there was a huge increase the adolescent suicide rate in this country in the previous four decades. From 1950 to 1990 the adolescent suicide rate for individuals of 15 to 19 years of age in the United States increased by 300% (Shain, 2016). While the rate of suicide may be on a slight decline the number of suicide deaths in the United States is still alarming. In 2013, for example, it is reported that 1,748 young people in this age group died as a result of suicide (Shain, 2016). An interesting note is that while adolescent boys are three times more likely to commit suicide, the rate of suicide attempts is twice as high among girls than it is among boys indicating that girls tend to choose methods of suicide that are less likely to actually result in their death than are boys (Shain, 2016). All suicidal attempts must be treated seriously though as it is estimated that suicidal attempts are successful as much as 50% of the time (Shain, 2016).
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Adolescent suicide affects all races and socioeconomic groups but some groups have much higher rates than other groups do. The highest rate of adolescent suicides is found in American Indian and Native Alaskan males while Black Females have the lowest rate of suicide. Lesbian, gay, bisexual or transgender young people are more than two times as likely to experience suicidal ideation as their heterosexual counterparts (Shain, 2016).
The 2013 Youth Risk Behavior Survey of students in the United States in grades 9 through 12 revealed that 39.1% of girls and 20.8% of boys felt sad or hopeless almost every day for at least two weeks in a row (Shain, 2016). The study reported that in the previous year 16.9% of girls and 10.3% of boys reported that they had planned a suicide attempt and that 10.6% of girls and 10.3% of boys had carried out these attempts (Shain, 2016).
While there seems to be some disagreement as to which method is the most highly used method of suicide most studies agree that suffocation/hanging and firearms are the two most common methodologies used by adolescents intent on ending their lives. One study indicated that in 2013 the four leading methods used by adolescents committing suicide were suffocation at 43%, firearms at 42%, poisoning at 6% and falling at 3% (Shain, 2016). The Center for Disease Control (CDC) has stated that in recent years there has been a substantial change in the suicide methods utilized by adolescents in the United States especially among females. The CDC reports that from 2003 to 2004 the rate of females committing suicide by hanging/suffocation went up by 119% in young girls aged 10 to 14 and by 44% in young girls aged 15 to 19 (Cash & Bridge, 2009).
Not only is adolescent suicide an obvious issue of concern among the adolescent population but there are studies that indicate that if suicidal thoughts are experienced during adolescence the risk of psychiatric problems and the possibility of adult suicide are greatly increased (Cash & Bridge, 2009). Researchers have suggested that this finding suggests that if ways can be found to identify adolescents who are experiencing or are likely to experience suicidal ideation and to treat or change that ideation it may reduce the risk of suicidal behavior later on (Cash & Bridge, 2009).
Identifying the Risk
Acknowledging that adolescent suicide is a major problem is the easy part, however. The next and more important part of the issue is trying to identify the causes of this behavior and the risk factors that may indicate that a young person is likely to experience such ideation.
Many risk factors have been identified as factors which can lead to the conclusion that an adolescent is likely to experience suicidal ideation or engage in suicidal behavior. The difficulty with this approach is realizing that the risk factors identified are fairly common in the population while, thankfully, suicide is not (Shain, 2016). Therefore, the use of risk factors alone in attempting to identify potential adolescent suicide victims would result in many false identifications. Further, the lack of one of the risk factors commonly identified does not mean that the individual is somehow safe from suicide as many victims of adolescent suicide do not exhibit one of the risk factors (Shain, 2016).
Mental health issues tend to top the list of factors which indicate the risk of suicide (Shain, 2016). A strong link has been found between suicide and clinical depression (Cash & Bridge, 2009). One autopsy study indicated that 60% of adolescent suicide victims had a depressive disorder when they died (Cash & Bridge, 2009). There seems little doubt that depression is the main factor predicting that an adolescent will have suicidal thoughts (Cash & Bridge, 2009). Clinical studies have revealed that as many as 85% of people with major or chronic depressive disorder will experience suicidal ideation (Cash & Bridge, 2009). Other mental health issues are also frequently noted as risk factors for suicidal ideation. Adolescents with sleep disorders, bipolar disorders, psychosis, substance abuse issues, bipolar disorder, or a history of aggression or severe anger problems are also at risk for suicidal ideation (Cash & Bridge, 2009). While adolescents who cut or otherwise self-harm are not attempting suicide, such behaviors, identified as non-suicidal self-injury actions, have been identified as a substantial risk factor indicating and adolescent likely to experience suicidal ideation (Cash & Bridge, 2009). In fact, as many as 90% of the victims of adolescent suicide have been estimated to meet the criteria for a psychiatric disorder (Cash & Bridge, 2009).
There are other risk factors which have also been cited as helping to identify those adolescents who may be expected to experience thoughts of suicide. The abuse of alcohol and/or drugs also contributes to the risk of suicide (Cash & Bridge, 2009). A study found that adolescents 13 years of age or younger who engaged in instances of heavy drinking were 2.6 times more likely to engage in suicidal behavior than those who didn’t engage in such drinking (Cash & Bridge, 2009). Family problems can also be indicative of suicidal behavior risk. Family problems such as a history of suicidal behavior in the family, death of a parent or divorce, or mistreatment or a poor-quality parent-child relationship are associated with a greater risk of adolescent suicidal ideation and/or behavior (Cash & Bridge, 2009).
There are also a number of risk factors in the adolescent’s social or environmental background which are seen as indicative of suicidal ideation. Such things as bullying, living outside of the home, whether by homelessness, a corrections facility or a group home, problems at school, being isolated socially or any number of stressful live events can lead to suicidal thoughts and behaviors (Shain, 2016). Bullying has been defined as aggressive or deliberately harmful behavior between peers which is repeated over time and involves a power imbalance (Shain, 2016). Bullying is a fairly prevalent issue in adolescence. The 2013 Youth Risk Behavior Survey of students revealed that 23.7% of girls and 15.6% of boys reported having been bullied at school (Shain, 2016). Other studies have shown a clear relationship between suicidal ideation and behavior among adolescents who were both the victims and those engaged in bullying behavior and were highest yet in individuals who had been both the victim and the perpetrator of bullying (Shain, 2016). The internet has also been cited as a serious risk factor leading to adolescent suicide ideation and behavior. The internet is a frequent location for bullying with 21% of girls and 8.5% of boys reporting that they were electronically bullied on the internet in the 2013 Youth Risk Survey (Shain, 2016). Further, internet use for more than 5 hours a day has been associated with increased levels of depression and suicidal thoughts (Shain, 2016). The use of the internet to search suicide-related topics and even sites advocating suicide or discussing methods of suicide can also be a significant risk factor (Shain, 2016). Also, an issue leading to suicidal thoughts is learning of the suicide of another. The internet may be a frequent source of such information through news and networking sites (Shain, 2016).
Evidence Based Practices
Currently there is not a clear-cut choice in the method of treating adolescent suicide. Most studies concerning suicide have been conducted with adults as the main focus. Although the studies that have been conducted focused on adults, practitioners believe Cognitive Behavioral Therapy (CBT) more specifically Cognitive Behavioral Therapy Suicide Prevention (CBT-SP), Dialectical Behavior Therapy (DBT), with the addition of Family Therapy in each practice are the most beneficial approaches when working with suicidal adolescents.
The main focuses of CBT-SP are risk reduction and relapse prevention. This approach has two phases: acute and continuation with each phase lasting around 12 weeks. The acute phase has an initial, middle, and end phase. The initial phase relates to the first three sessions and focuses on: the events that lead to the suicidal attempt or suicidal behaviors, safety planning, psychoeducation, reasons for living and hope, case conceptualization. The middle phase, sessions four through nine places its emphasis on behavioral/cognitive skills training in either individual or family sessions. The end phase, sessions ten through twelve focuses on relapse prevention. The relapse prevention portion has five parts: preparation, review of suicidal attempt/behavior(s), review of the attempt using skills learned in previous sessions, review of potential high-risk scenarios, and debriefing/follow-up (Stanley, et al., 2009).
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The continuation phase is also 12-weeks and this phase could include an additional six individual sessions with the potential of three family sessions. The focus of the continuation phase is to teach new skills or revisit previous skills while providing the client an opportunity for closure. Additionally, the continuation phase allows for the client to discuss other mental health concerns they may have (Stanley, et al., 2009).
As previously stated, there is little evidence to support the effectiveness of any form of treatment related to adolescent suicide. The TASA (Treatment, Retention, Acceptability and Adherence) Study took place in 2009 to measure the usefulness of the CBT-SP model. The subjects of the study were 110 individuals ranging in age from 13-19 who had attempted suicide within the previous 90 days and had received a diagnosis of depression. The majority of the participants were Caucasian females in high school. 100% of the individuals reported that they believed that the method (CBT-SP) was helpful. The participants had a couple issues with the treatment stating it was long-lasting and that they didn’t like how the approach focused on the suicidal event. One of the biggest issues clinicians had with the trial was the number of participants who didn’t complete the treatment in its entirety (Stanley, et al., 2009).
Those utilizing any form of CBT should be cognizant of their approach to the client and the matter at hand and remember that it is a team approach between the client and practitioner. It is also important for the clinician to remember the source of the client’s involvement in therapy and maximize the time spent together.
“The problems DBT treats in suicidal adolescents include emotion dysregulation, interpersonal conflict, impulsivity, cognitive dysregulation, and self-dysregulation” (Salsman & Arthur, 2011). DBT has two fundamental aspects: Biosocial Theory, which states the issues mentioned above are a consequence of biological factors and a nonnurturing home setting and the Treatment Theory- which focuses on change and acceptance. The Biosocial Theory believes most suicidal adolescents have increased emotional sensitivity, have extreme reactions, and struggle with returning to their normal state after an incident. The Treatment Theory change aspect utilizes chain analysis (events that lead to the negative action), skills training, contingency management (positive behavior = positive outcome), and exposure (Salsman & Arthur, 2011). The acceptance part of the Treatment Theory focuses on mindfulness and accepting reality as it is in that moment (Salsman & Arthur, 2011).
DBT typically ranges from twelve to sixteen weeks and has four parts of treatment: individual/group therapy, skills training, telephone consultation, and weekly consultation meetings. The individual therapy portion focuses on: eliminating life threatening behaviors, preventing therapy-interfering behaviors, changing behaviors that get in the way of the client’s quality of life, and the improvement of client’s skills. The therapist has the client use cards to track daily behaviors and thoughts to help navigate the sessions and specific behaviors (Salsman & Arthur, 2011). The skills training emphasizes: emotional regulation, mindfulness, interpersonal effectiveness, distress tolerance, and “walking the middle path” (building strong communication skills between the adolescent and their parent(s) (Salsman & Arthur, 2011). The telephone consultation is limited to five to fifteen minutes to: increase the probability of positive actions/thoughts, utilization of skills, and limit negative actions/thoughts. Parents of adolescents receiving treatment are encouraged to utilize phone consultation as well to ensure the transition of skills into the home (Salsman & Arthur, 2011). Consultation team meeting take place weekly. The purpose is to provide support and offer a platform to staff the case with additional practitioners.
In 2002, a study was conducted utilizing DBT. Twenty-nine individuals who had attempted suicide in the previous sixteen weeks and had three or more Boderline Personality Disorder features were assigned DBT, while eighty-two individuals who only had one of the above circumstances received treatment as usual (TAU) (Salsman & Arthur, 2011). “Patients treated with DBT had fewer hospitalizations (13% in TAU vs 0% in DBT) and a lower dropout rate (60% in TAU and 38% in DBT)” (Salsman & Arthur, 2011).
Clinicians applying DBT should utilize a strength-based approach. Clinicians should emphasize the small victories and avoid elaborating on any “set-backs.” Practitioners should emphasize building a strong therapeutic rapport with the client to keep them invested in their progress. Meanwhile the client should be encouraged to use face-to-face and telephone interactions to build and increase the client’s self-esteem.
Both CBT and DBT are great tools for practitioners. They are widely accepted and applied in numerous situations. Additional, prolonged studies should be conducted to determine the true efficacy of both treatments when used to treat suicidal adolescents.
Implications on Social Work
Adolescent Suicide relates directly to the ethical principle of “Service” of the National Association of Social Workers specifically, “Social workers draw on their knowledge, values, and skills to help people in need and to address social problems” (NASW Code of Ethics, 2017). The fact the Adolescent Suicide is the second-leading cause of death among this population and little-to-no lengthy studies have been conducted to determine a suitable treatment approach is alarming. This is a vulnerable population experiencing multiple changes physically, mentally, and socially. Social workers need to utilize their platform to advocate for additional resources to support the nation’s youth.
Adolescents have enough on their plate while they go through the largest transition of their life. As a society and as professionals we need to do better. We need to recognize the concern, put some serious resources to use and define the best option for treatment. In my opinion the treatment should consist of an intensive-condescended version of CBT-SP. The feedback from the participants of the limited trial was that it was too lengthy. I don’t want to discredit DBT but it would be difficult to condense a treatment style that has so many moving parts. CBT-SP is focused on the client, clinician and at times family involvement. It is much easier to manage the approach and care when the team is limited. Nonetheless, studies need to be completed to ensure the best option and allow clients to live in the moment and enjoy an exciting part of their life.
- About. (n.d.). Retrieved from https://www.socialworkers.org/about/ethics/code-of-ethics.
- Cash, S. J., & Bridge, J. A. (2009). Epidemiology of youth suicide and suicidal behavior. Current Opinion in Pediatrics, 21(5), 613–619. doi: 10.1097/mop.0b013e32833063e1
- Dirks, A. (2017). Treatment for the Suicidal Adolescent: A Critical Analysis of the Cognitive-Behavioral Approach. Acta Psychopathologica, 03(04). doi: 10.4172/2469-6676.100110
- Evans, R., White, J., Turley, R., Slater, T., Morgan, H., Strange, H., & Scourfield, J. (2017). Comparison of suicidal ideation, suicide attempt and suicide in children and young people in care and non-care populations: Systematic review and meta-analysis of prevalence. Children and Youth Services Review, 82, 122–129. doi: 10.1016/j.childyouth.2017.09.020
- FastStats - Adolescent Health. (2017, May 3). Retrieved from https://www.cdc.gov/nchs/fastats/adolescent-health.htm.
- Kennebeck, S., & Bonin, L. (2017, June). Suicidal Ideation and Behavior in Children and Adolescents: Evaluation and Management. Retrieved from https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-children-and-adolescents-evaluation-and-management.
- Salsman, N. L., & Arthur, R. (2018, December 11). Adapting dialectical behavior therapy to help suicidal adolescents. Retrieved from https://www.mdedge.com/psychiatry/article/64223/depression/adapting-dialectical-behavior-therapy-help-suicidal-adolescents.
- Shain, B. (2016). Suicide and Suicide Attempts in Adolescents. Pediatrics, 138(1). doi: 10.1542/peds.2016-1420
- Spirito, A., Esposito-Smythers, C., Wolff, J., & Uhl, K. (2011). Cognitive-Behavioral Therapy for Adolescent Depression and Suicidality. Child and Adolescent Psychiatric Clinics of North America, 20(2), 191–204. doi: 10.1016/j.chc.2011.01.012
- Stanley, B., Brown, G., Brent, D. A., Wells, K., Poling, K., Curry, J., … Hughes, J. (2009). Cognitive-Behavioral Therapy for Suicide Prevention (CBT-SP): Treatment Model, Feasibility, and Acceptability. Journal of the American Academy of Child & Adolescent Psychiatry, 48(10), 1005–1013. doi: 10.1097/chi.0b013e3181b5dbfe
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