Suicide Prevention For Schools

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Suicide Prevention For Schools

From the World Health Organiztion

Worldwide, suicide is among the top five causes of mortality in the 15- to 19- year age group. In many countries it ranks first or second as a cause of death among both boys and girls in this age group.
Suicide prevention among children and adolescents is therefore a high priority. Given the fact that in many countries and regions most people in this age group attend school, this appears to be an excellent place to develop appropriate preventive action.

Currently, suicide among children below the age of 15 years is generally uncommon. Most suicides among children aged up to 14 probably take place in early adolescence, while suicide is rarer still before the age of 12. However, in some countries there is an alarming increase in suicides among children aged less than 15, as well as in the 15- to 19- year age group.
Suicide methods vary between countries. In some countries, for example, the use of pesticides is a common suicide method, whereas in others intoxication with medicines and car exhausts and the use of guns are more frequent. Boys die from suicide much more often than girls; one reason may be that they resort to violent methods of suicide, such as hanging, firearms and explosives, more frequently than girls. However, in some countries suicide is more frequent among girls aged 15-19 than among boys in the same age group, and over the past decade the proportion of girls using violent methods has risen.

Whenever feasible, the best approach to school-based suicide prevention activities is teamwork that includes teachers, school doctors, school nurses, school psychologists and school social workers, working in close cooperation with community agencies.

Having suicidal thoughts now and then is not abnormal. They are part of the normal development process in childhood and adolescence, as are working on existential problems and trying to understand life, death, and the meaning of life. Questionnaire surveys show that morethan half of upper-secondary students report that they have entertained thoughts of suicide.
Young people need to discuss these topics with adults.
Suicidal thoughts become abnormal in children and adolescents when the realization of those thoughts seems to be the only way out of their difficulties. There is then a serious risk of attempted suicide or suicide.

AN UNDERESTIMATED PROBLEM
In some cases, it may be impossible to ascertain whether some deaths, caused for example by car crashes, drowning, falls and overdoses of illegal drugs, were unintentional or intentional. Adolescent suicidal behaviour is widely deemed to be underreported, because many deaths of this type are inaccurately classified as unintentional or accidental. Postmortem studies of adolescents who died from violent causes indicate that they do not constitute a homogeneous group. They show subtle manifestations of self-destructive and risk-taking tendencies4 and, while some of their deaths may be caused by unintentional acts, others are intentional acts resulting from the pain of living.

In addition, the definitions of attempted suicide used by students differ from those used by psychiatrists. Self-reported results show almost twice the number of suicide attempts revealed by psychiatric interviews. The most likely explanation is that the young people who responded to anonymous inquiries were using a broader definition of attempted suicide than that used by professionals. Moreover, only 50% of adolescents reporting that they had tried to kill themselves had sought hospital care after their suicide attempts. Thus, the number of suicide attempters treated in hospital is no real indication of the dimension of the problem in the community.

Generally speaking, adolescent boys suicide more often than girls do.
Nevertheless, the rate of attempted suicide is two to three times higher among girls. Girls develop depression more often than boys do, but they also find it easier to talk about their problems and to seek assistance, and this probably helps to prevent fatal suicidal acts.
Boys are often more aggressive and impulsive, and not infrequently act under the influence of alcohol and illicit drugs, which probably contributes to the fatal outcome of their suicidal acts.

PROTECTIVE FACTORS

Major factors that afford protection against suicidal behaviour are:

Family patterns
� good relationships with family members;
� support from family.

Cognitive style and personality
� good social skills;
� confidence in oneself and one�s own situation and achievements;
� seeking help when difficulties arise, e.g. in school work:
� seeking advice when important choices must be made;
� openness to other people�s experiences and solutions;
� openness to new knowledge.

Cultural and sociodemographic factors
� social integration, e.g. through participation in sport, church associations, clubs and other activities;
� good relationships with schoolmates;
� good relationships with teachers and other adults;
� support from relevant people.

RISK FACTORS AND RISK SITUATIONS

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 society�s 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 person�s 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 behavior such as a suicide attempt or suicide.

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 people�s lives thereafter, especially when they have been unable to cope with the trauma. 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 child�s emotional distress, and a negative emotional environment featuring rejection or neglect;
� family rigidity;
� 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;
� irritability;
� 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;
� self-righteousness;
� 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;
� 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.

Psychiatric disorders

Suicidal behaviour is overrepresented in children and adolescents with the following psychiatric disorders.

Depression
The combination of depressive symptoms and antisocial behaviour has been described as the most common antecedent of teenage suicide. 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.1 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. Adolescents can kill themselves without being depressed, and they can be depressed without killing themselves.

Anxiety disorders
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.

Eating disorders

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.

Psychotic disorders

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. This susceptibility makes it difficult to cope with negative life events adequately, and suicidal behavior 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.

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 selfimage 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.

School Suicide Prevention II

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