|Preventing Suicide: A Resource for Teachers and other School Staff (WHO, 2000, 34 p.)|
Suicidal behaviour under particular circumstances is more common in certain families than in others, owing to environmental and genetic factors. Analysis shows that all the factors and situations described below are frequently associated with attempted and completed suicide among children and adolescents, but it must be remembered that they are not necessarily present in every case.
It must also be remembered that the risk factors and risk situations described below vary from one continent and country to another, depending on cultural, political and economic features that differ even between neighbouring countries.
Cultural and sociodemographic factors
Low socioeconomic status, poor education and unemployment in the family are risk factors. Indigenous people and immigrants may be assigned to this group, since they often experience not only emotional and linguistic difficulties but also the lack of social networks. In many cases, these factors are combined with the psychological impact of torture, war injuries and isolation.
These cultural factors are also linked with low participation in societys customary activities, as well as with conflict between various group values. Specifically, this conflict is a powerful factor for girls born or brought up in a new and freer country, but who retain strong roots in their parents even stronger conservative culture.
Each individual young persons growth is intertwined with collective cultural tradition. Children and adolescents who lack cultural roots have marked identity problems and lack a model for conflict resolution. In some stressful situations, they may resort to self-destructive behaviour such as a suicide attempt or suicide.5
There is a higher risk of suicidal behaviours in indigenous versus non-indigenous people.
The attributes of gender nonconformity and identity issues relating to sexual orientation are also risk factors for suicidal behaviours. Children and adolescents who are not openly accepted in their culture, by their families and peers, or by their schools and other institutions have serious acceptance problems and lack supportive models for optimum development.
Family pattern and negative life events during childhood
Destructive family patterns and traumatic events in early childhood affect young peoples lives thereafter, especially when they have been unable to cope with the trauma.6
Aspects of family dysfunction and instability and negative life events often found in suicidal children and adolescents are:
· parental psychopathology,7 with the presence of affective and other psychiatric disorders;
· alcohol and substance abuse, or antisocial behaviour in the family;
· a family history of suicide and suicide attempts;
· a violent and abusive family (including physical and sexual abuse of the child);
· poor care provided by parents/guardians, with poor communication within the family;
· frequent quarrels between parents/guardians, with tension and aggression;
· divorce, separation or death of parents/guardians;
· frequent moves to a different residential area;
· very high or very low expectations on the part of parents/guardians;
· parents/guardians inadequate or excessive authority;
· parents/guardians lack of time to observe and deal with the childs emotional distress, and a negative emotional environment featuring rejection or neglect;
· family rigidity;8
· adoptive or foster family.
These family patterns often, but by no means always, characterize cases of children and adolescents who attempt or commit suicide. Evidence suggests that young suicidal people often come from families with more than one problem in which risks are cumulative. Since they are loyal to their parents and sometimes unwilling, or forbidden, to reveal family secrets, they frequently refrain from seeking help outside the family.
Cognitive style and personality
The following personality traits are frequently observed during adolescence, but are also associated with the risk of attempted or completed suicide (often in conjunction with mental disorder), so that their utility in predicting suicide is limited:
· unstable mood;
· angry or aggressive behaviour;
· antisocial behaviour;
· acting-out behaviour;
· high impulsivity;
· rigid thinking and coping patterns;
· poor problem-solving ability when difficulties arise;
· an inability to grasp realities;
· a tendency to live in an illusory world;
· fantasies of greatness alternating with feelings of worthlessness;
· a ready sense of disappointment;
· anxiety, particularly at signs of mild physical ailment or minor disappointment;
· feelings of inferiority and uncertainty that may be masked by overt manifestations of superiority, rejection or provocative behaviour towards schoolmates and adults, including parents;
· uncertainty concerning gender identity or sexual orientation;9
· ambivalent relationships with parents, other adults and friends.
While there is much interest in the relationships between the extensive array of personality and cognitive factors and risk of suicidal behaviour in young people, the available research evidence for any specific trait is generally sparse and often equivocal.
Suicidal behaviour is overrepresented in children and adolescents with the following psychiatric disorders.
The combination of depressive symptoms and antisocial behaviour has been described as the most common antecedent of teenage suicide.10,11 Several surveys have established that up to three-quarters of those who eventually take their own lives show one or more symptoms of depression, and many suffer from a full-blown depressive illness.12
School students suffering from depression often present physical symptoms when they seek medical advice.13 Somatic complaints, such as headache and stomach-ache and also shooting pains in the legs or chest, are frequent.
Depressed girls have strong tendencies to withdraw and become silent, despondent and inactive. Depressed boys tend, instead, towards disruptive and aggressive behaviour and demand a great deal of attention from their teachers and parents. Aggressiveness can lead to loneliness, which is in itself a risk factor for suicidal behaviour.
Although some depressive symptoms or depressive disorders are common among suicidal children, depression is not a necessary concomitant of either suicidal thoughts or suicide attempts.14 Adolescents can kill themselves without being depressed, and they can be depressed without killing themselves.
Studies have shown a consistent correlation between anxiety disorders and suicide attempts in males, while a weaker association has been found in females. Trait anxiety appears to be relatively independent of depression in its effect on the risk of suicidal behaviour, which suggests that the anxiety of adolescents at risk for suicidal behaviour should be assessed and treated. Psychosomatic symptoms are also often present in young persons tormented by suicidal thoughts.
Alcohol and drug abuse
Abusers of alcohol and illicit drugs are overrepresented among children and adolescents who commit suicide. In this age group, one in four suicidal patients has been found to have consumed alcohol or drugs before the act.15
Owing to dissatisfaction with their bodies, many children and adolescents try to lose weight and are concerned about what they should and should not eat. Between 1% and 2% of teenage girls suffer from either anorexia or bulimia. Anorexic girls very frequently also succumb to depression, and suicide risk among anorexic girls is 20 times that for young people in general. Recent findings show that boys, too, can suffer from anorexia and bulimia.13,17
Although few children and adolescents suffer from severe psychiatric disorders such as schizophrenia or manic-depressive disorder, suicide risk is very high in those affected. Most psychotic young people are, in fact, characterized by several risk factors, such as drinking problems, excessive smoking and drug abuse.
Previous suicide attempts
A history of single or recurrent suicide attempts, with or without the above-mentioned psychiatric disorders, is an important risk factor for suicidal behaviour.
Current negative life events as triggers of suicidal behaviour
A marked susceptibility to stress, with the cognitive style and personality traits mentioned above (due to inherited genetic factors but also to family patterns and negative life stressors experienced in early life), is usually observed in suicidal children and adolescents.16 This susceptibility makes it difficult to cope with negative life events adequately, and suicidal behaviour is therefore often preceded by stressful life events. They reactivate the sense of helplessness, hopelessness and despair that may bring thoughts of suicide to the surface and lead to attempted suicide or suicide.17
Risk situations and events that may trigger suicide attempts or suicide are:
· situations that may be experienced as injurious (without necessarily being so when evaluated objectively): vulnerable children and adolescents may perceive even trivial occurrences as deeply injurious and react with anxiety and chaotic behaviour, while suicidal young people perceive such situations as threats directed against their self-image and suffer from a sense of wounded personal dignity;
· family disturbances;
· separation from friends, girl-/boyfriends, classmates, etc.;
· death of a loved one or other significant person;
· termination of a love relationship;
· interpersonal conflicts or losses;
· legal or disciplinary problems;
· peer-group pressure or self-destructive peer acceptance;
· bullying and victimization;
· disappointment with school results and failure in studies;
· high demands at school during examination periods;
· unemployment and poor finances;
· unwanted pregnancy, abortion;
· infection with HIV or other sexually transmitted diseases;
· serious physical illness;
· natural disasters.