Youth Suicide

Abstract

This article delves into the tragic subject of youth suicide. Issues related to childhood suicide are introduced, including elements of Jean Piaget's developmental theory, myths surrounding childhood suicide, childhood depression and other preemptive characteristics of suicide, as well as a potential treatment option (play therapy). After segueing into the subject of adolescent suicide, Piaget's theory is once again broached by highlighting a concept known as adolescent egocentrism and its corresponding manifestations (e.g., imaginary audience, the personal fable). Predisposing factors that contribute toward teen suicide and a brief commentary on treatment are included. Finally, gender-related matters are covered, including statistical information and a gender-identity theory, which correlates "event centered" stage of development with suicide.

Overview

Suicide is the second leading cause of death for people between the ages of 10 and 34 years old, according to the National Institute for Mental Health (2021). Bereaved family members who lose loved ones to suicide are left to scrutinize the emotionally agonizing and mystifying details that contributed toward their child's untimely death. Therefore, research and clinical professionals are often bewildered by child suicide cases. Perhaps one of the reasons why childhood suicide is underestimated relates to the romanticized notion people tend to extend toward childhood itself. Most people view childhood as a carefree, buoyant existence brimming with promise and possibility.

Piaget's Stages of Development. Additionally, many people deem childhood suicide as cognitively unfeasible, given that the brain is still in the process of developing and cannot comprehend concepts that are categorically irrevocable, let alone contrive such destructive schemes. For example, according to renowned child psychologist Jean Piaget, children in the preoperational stage of development (i.e., ages 2–7) are still unable to grasp certain intellectual principles such as reversibility and decentration (Burger, 1991; Gainotti, 1997; Siegler & Ellis, 1996; Sigelman & Rider, 2006; Singer & Revenson, 1996; Favre & Bizzini, 1995), which mentally conceptualizes the multidimensional aspects of problems. By the time children reach the concrete operations stage, which roughly lasts between the ages of 7 and 12, they have made significant strides in their thought processes and can master sequential relationships and classify objects in accordance with their various physical properties (i.e., types of cars; types of dogs) (Mareschal & Shultz, 1999).

However, it is not until children reach adolescence, or the formal operations stage, when they are able to fully enter into the complex realm of abstract thinking. At this age, they can derive conclusions to hypothetical ideas, whereas beforehand they were limited to that which they could tangibly grasp through their five senses. These intellectual augmentations allow the adolescent to "think outside" of the conventional box that had been placed before them throughout their formative years, namely the rules and values that had been imposed upon them by parents, teachers, and society as a whole. It makes "neurological sense," therefore, that the adolescent era is inexorably linked with suicide, as teenagers are more apt to be rebellious and can examine their dilemmas from a variety of angles, thus believing that they had exhausted all options before settling on suicide as a final determination.

Myths of Youth Suicide. According to Greene (1994), there are many myths that accompany childhood suicide, and these myths ultimately serve as barriers toward conquering such a devastating phenomenon. Many people mistakenly presume that children under the age of 6 do not die by suicide. They also think that children in their latent period of growth (i.e., 6–12 years of age) are not capable of suicide. In reality, Greene alludes to the existence of several documented cases of young children within these age ranges who have died by suicide. Although evidence on this is unclear, Dervicet al. (2006) indicate that children cannot quite grasp the permanence of suicide until age 10. Or, as Fritz (2004) indicates, children may be drawn to the prospect of their own mortality but do not possess the intellectual skill set to interpret and verbalize their destructive motivations. Instead, they habitually choreograph death-defying activities to increase their fatal odds. As Greene (1994) points out, when young children make resolute statements such as "I'm going to jump off the house!," they are often perceived as eliciting attention-seeking behavior; but when such misdeeds are actually implemented, they are often regarded as accidental.

Another myth involves the lack of weapons a child has within reach that may facilitate their suicidal pact. To some degree, this assumption has been squashed with the circulation of several media reports regarding the deadly recourse to which many youngsters resort (Children with Guns, 2000). Additionally, children often carry out their deadly, self-imposed intentions through accessible means such as consuming toxic concoctions or bolting into oncoming traffic. Additional myths that circulate around childhood suicide include the belief that children cannot fully understand the finality of death, and that depression, which is a likely antecedent to suicide, does not occur until adolescence (Brådvik, Mattisson, & Bogren, et al, 2008; Herskowitz, 1990). To rebut the first belief while operating in concurrence with Piaget's aforementioned premise, children do, in fact, cultivate an ability to distinguish between that which is reversible and irreversible by age 7. And with regard to depression, it is true that Sigmund Freud elaborated on the roots of adolescent depression, saying that it stemmed from a "diseased superego." Freud also posited that depression was a result of the grievances related to parental attachments that had not been properly resolved (Polmear, 2004). Thus, Freud's inference suggests that the onset of depression coincides with puberty. However, Freud's theories have largely been discredited by modern psychology.

Childhood Depression. A substantial amount of research proves that childhood depression and correlating suicide rates have significantly increased along with our understanding of the symptomatology of depression (Murphy, 2004). For example, because young children tend to discern life's pertinent lessons through the process of play, an absence of such recreational indulgence (i.e., anhedonia) carries tremendous ramifications and is a primary indicator of depression. Indeed, the literature surrounding childhood depression is quite expansive and covers the following categories:

• Utilization of the Berkley Puppet Interview as a diagnostic tool for childhood depression and anxiety (Luby, Belden, & Sullivan, et al., 2007);
• The adverse reactions that some children face when taking psychotropic medication (Bylund & Reed, 2007);
• Family factors that influence childhood depression (Wang & Crane, 2001);
• The concomitance between childhood depression and other ailments such as cancer (Koocher, O'Malley, Gogan, & Foster, 1980) and ADHD (Redy & Devi, 2007).

In addition to depression, specific motivations surrounding childhood suicide puzzle experts and the layperson alike. Many decades ago, Gunther reported on possible incentives for childhood suicide by accounts made on behalf of children who had previously planned suicide (1967; Cytryn & McKnew, 1998; Pelkonen & Marttunen, 2003; Stefanowski-Harding, 1990). A history of prior attempts and sudden personality changes (e.g., shy to talkative; submissive to aggressive) or behavioral changes (in sleep patterns, eating habits, or activity levels) are strong indicators of suicidal ideation, along with feelings of worthlessness, social isolation, hopelessness, and academic failure. These facts tend to couple with a specific trigger, such as the child's perception that he was recipient to undue punishment over a particular event. Family factors that contribute toward suicide consist of parental substance abuse, divorce or separation, physical or sexual abuse, rejection, parental psychopathology (e.g., depression, parental suicide or suicide attempts), as well as good parental intentions that have gone awry, including parents that are either overprotective or those who demand perfection. A child considering suicide may be hypersensitive, depressed, anxious, and angry. Such angst may manifest through health maladies, oppositional behavior, sleep disturbances, or an overriding aversion toward school. Additionally, young children often conjure up enigmatic portrayals to help comprehend the inexplicable nature of death, particularly if they had recently lost a love one. Oftentimes, death is explained to children in ethereal terms such as "Mommy is in heaven now," or "Grandpa is smiling at you from the clouds," and children select suicide as a means to reunite with their loved one.

Further Insights

Treating the Suicidal Child. Children who have demonstrated some form of suicidal ideation, such as those with a history of previous attempts, would highly benefit from therapy. Because children are ill equipped to both conceptualize and articulate their inner demons, nonverbal therapeutic alternatives such as play therapy (Landreth, 2012; Schaefer & O'Connor, 1983) should be considered. Play therapies have assisted children who have encountered a variety of psychosocial distress, including survivors of abuse or trauma, those in the throes of grief, and children experiencing terminal illness. The ways in which therapists elicit pertinent information from children via play therapy includes art (e.g., drawings, clay), as well as puppets, sand and water trays, and storytelling techniques. The premise behind this therapeutic modality is that although children cannot directly understand or articulate their feelings (e.g., "I'm lonely"), such sentiments will manifest throughout the process of play. For example, the lonely child might portray a solitary puppet who is consistently estranged from the other puppets. The suicidal child might draw graphic depictions of a person getting hit by cars or being held at gunpoint. From that point, the therapist encourages the child and the family to infuse change into the play characters that the child has created, which eventually seek to transcend into the child's life. The following passage describes the resolution of a young girl's school phobia through this process:

Ann and her parents negotiate new solutions via the puppet play. The gorilla agrees to be more patient with the puppy and the cat. When the puppy runs away, the gorilla does not yell at the cat, but they express their worries about the puppy and together go look for the puppy. When they find her, the puppy is excited and hugs the cat and the gorilla. They go home together, the gorilla carrying the puppy on his back. When the therapist processes the play with the family, the dad reports that he used to carry Ann on his back when she was younger and got tired during long walks. The family transfers the "new solution" from the puppet play to their "real" life by changing their morning routine. Dad gets up a little earlier and calmly helps Ann to get ready. Then the family has a brief breakfast together. When it is time to leave, Dad pretends to be the "good" gorilla and carries the "puppy" on his shoulder to the front door. There he lets her down, gives Ann a kiss, and sees her off to the school bus (which the parents did not do before, because Ann was a "big" girl). This way Ann feels safer in the transition from home to school and her school fear subsides quickly (Wittenborn, Faber, & Harvey et al, 2006, p. 341).

Adolescent Suicide. Suicide during the adolescent years is much more prevalent and therefore symptoms such as depression are more recognizable. Most people have probably encountered a sullen, disgruntled teenager and attributed such petulance to the influx of hormonal and physical changes that rapidly occur during this time. Furthermore, advancement into Piaget's formal operations developmental stage yields specific characteristics that exacerbate the difficult mood swings and insecurities that teenagers endure. For example, it is common for adolescents to undergo a phenomenon known as adolescent egocentrism, or the inability to operate outside of their internal mechanisms in order to truly align with divergent perspectives (Elkind, 1967). Additionally, the phenomenon of contagion-imitation has contributed to suicide clusters among teenagers, particularly those exposed to higher frequencies of suicides by similar others and/or repeated discussions or representations of it (Bilsen, 2018).

Adolescent Egocentrism. Two common manifestations that extend from adolescent egocentrism include the imaginary audience and the personal fable (Ryan & Kuczkowski, 1994; Vartanian, 2000). The imaginary audience revolves around the teenager's assumption that the world is preoccupied with their affairs and even garners the same level of attention that they extend toward such matters. To illustrate this premise, let us assume that on the way to school, Brian tripped and ripped the cuff of his pants. Embarrassed, he enters the cafeteria during lunchtime overwrought with fear that his classmates will ridicule his earlier miscalculation, and he modifies his behavior accordingly by quickly exiting the lunchroom. Adolescents who are naturally insecure or feel socially awkward based upon subjective or object criteria feel especially self-conscious during this cumbersome stage, even though in reality their peers are directing the same level of criticism toward themselves.

The personal fable, on the other hand, is the adolescent tendency to think that their thoughts, feelings, and experiences are unrivaled. Thus, when they fall in love, they believe it is a love like none that the world has ever seen. Likewise, when they suffer a broken heart, or when they receive the sharp denunciation of peer rejection, they believe that their heightened level of depression is unmatched. Certainly, this reveals insight toward the perplexing nature of adolescent depression and suicide, in that teenagers feel that their social blunders are held under a microscope for the rest of the world to scrutinize. At the same time, they feel that their anguish is unique and that nobody can possibly understand the concentrated level of torment that they encounter.

Predisposing Factors. Bridge, Goldstein, and Brent highlight a variety of predisposing factors that correlate with suicidal behavior (2006). Some of the adolescent family factors mirror those that are prevalent within children and include the following: poor family relations, previous suicide attempts, a family history of suicide or mental disorders, stressful life event or loss, abuse, alcohol and/or drug use, easy access to lethal methods (such as prescription drugs and firearms), and mental disorders. Examples of mood disorders that correlate with suicide are depression, anxiety, and bipolar disorder; other disorders that are risk factors for suicide include substance use disorder, personality disorder, conduct disorder, post-traumatic stress disorder, eating disorders, and schizophrenia. Therapeutic treatment plans assist teens who are considering suicide and vary among the various theoretical styles (e.g., psychodynamic, cognitive-behavioral). Personality can play a role as well, with impulsivity, passivity, rigidity, and poor problem-solving being other potential risk factors (Bilsen, 2018).

Gender also bears tremendous relevance toward the conception and implementation of suicide. According to the Centers for Disease Control and Prevention, boys aged 10 to 14 were half again as likely to die by suicide as girls in that age range (3.1 per 100,000 deaths versus 2.0 per 100,000), and more than four times as many 15- to 24-year-old males died by suicide than their female age peers (22 per 100,000 versus 5.5 per 100,000) (cited by Hedegaard, Curtin, and Warner, 2021). Further, the suicide rate among preteen and young teen boys nearly tripled between 2007 and 2017 (cited by Jayson, 2020). The gender discrepancy between suicide attempts and actual suicide may be explained through the method of suicide, as more boys and men utilized guns in contrast with girls and women, who were more likely to attempt suicide through poisoning, suffocation, or other means (National Institute of Mental Health, 2021). Among US students in high school (grades 9 through 12) in 2019, about one in five (18.8 percent) reported seriously considering suicide in the previous twelve months, including 24.1 percent of girls and 13.3 percent of boys. About one in six respondents (15.7 percent) reported having made a plan about how they would attempt suicide, 8.9 percent reported attempting suicide one or more times, and 2.5 percent ((3.3 percent of girls and 1.7 percent of boys) reported making a suicide attempt that resulted in an injury, poisoning, or overdose that required medical attention, according to the 2019 Youth Risk Behavior Survey (Ivey-Stephenson et al., 2020).

In the early 2000s and 2010s, a string of high-profile LGBT (lesbian, gay, bisexual, and transgender) teen suicides were attributed to harassment and bullying, including those of 13-year-old Ryan Halligan in 2003, Rutgers student Tyler Clementi in 2010, and 14-year-old Jamey Rodemeyer in 2011. Indeed, in 2019, 40.2 percent of LGB teens and 23.9 percent of teens questioning their sexual identity had planned suicide while 23.4 percent of LGB youth and 16.1 percent of questioning teens had attempted suicide in the preceding year (Ivey-Stephenson et al., 2020). In response to such prevalence of suicidal ideation among LGBTQ youth, initiatives such as the It Gets Better Project spread messages that the difficult lives of LGBT teens will improve; the project started with video messages from LGBT adults and some celebrities and includes tens of thousands of videos from a diverse body of contributors. Additionally, policies and programs have been developed in communities and schools to protect LGBT youth from bullying and offer support and resources to prevent this form of youth suicide.

Race and racism appear to be another predisposing factor in youth suicide. For instance, Ivey-Stephenson et al. (2020) report that Black and Hispanic teens were more likely to have attempted suicide than their non-Hispanic White counterparts, although White youth were more likely to contemplate and make a suicide plan than Black and Hispanic youth were. Additionally, American Indian/Alaska Native (AI/AN) youth die by suicide 3.2 times more often than their non-Hispanic White age(Office of Minority Health, 2021).

Researchers also began investigating increases in social media and internet use and cyberbullying as potential reasons for a sudden spike in suicides among preteens and young teens that began in the late 2000s (Jayson, 2020). Social isolation, loss of school services, familial deaths or employment loss, and additional stressors during the COVID-19 pandemic of the early 2020s were also thought to have exacerbated the trend in suicidality (Chatterjee, 2021).

Prevention. By the early 2020s, a number of youth-suicide prevention programs were created for grade-school children (Chatterjee, 2021), and in the 2010s, culturally-based interventions were initiated in many places in an effort to prevent suicides specifically among AI/AN communities (National Indian Council on Aging, 2019). Psychiatrists also advocated for the implementation of in-school mental health screenings alongside physical health screenings, day treatment programs for youth, the expansion of remote and visiting psychiatric services, and increased insurance coverage for mental health services (Chatterjee, 2021). Indeed, there is some evidence that brief interventions in clinical settings and mental-health education alongside school screenings may be effective for youth suicide prevention (Robinson et al., 2018).

Conclusion

Suicide is preventable. The majority of individuals who commit suicide have a mental disorder at the time of their deaths, most commonly depression or bipolar disorder. Any talk of suicide and especially suicide attempts should be taken seriously and treatment should be sought immediately. A combination of therapy and medication can be highly effective in reducing the incidence rate of suicide.

Terms & Concepts

Adolescent Egocentrism: A teenager's inability to operate outside of his internal mechanisms in order to truly align with divergent perspectives.

Event-centered Stage of Development: The event-centered stage initially surfaces in infancy, but later re-emerges throughout subsequent stages in various forms, and revolves around the belief of omnipotence and creativity.

Imaginary Audience: The teenager's assumption that the world is grossly preoccupied with his affairs.

Personal Fable: The adolescent's tendency to think that his thoughts, feelings, and experiences are unique.

Piaget's Developmental Stages: Piaget's stages that directly pertain to childhood and adolescent suicide include preoperational, concrete operational, and formal operational.

Play Therapy: Although children might not be able to directly understand or articulate their feelings, a therapist can elicit such emotions through the process of play.

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Siegler, R. S., & Ellis, S. (1996). Piaget on childhood. Psychological Science, 7, 211–215. Retrieved August 22, 2008 from EBSCO online database Academic Search Premier: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9703041847&site=ehost-live

Sigelman C. K., & Rider, E. A. (2006). Life-span human development (5th ed). Belmont: Thomas and Wadsworth.

Singer, D. G. & Revenson, T. A. (1996). A Piaget primer: How a child thinks (Rev. ed.). New York: Penguin Group.

Singer, J. B., & Slovak, K. (2011). School social workers' experiences with youth suicidal behavior: An exploratory study. Children & Schools, 33, 215–228. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=67657308

Stefanowski-Harding, S. (1990). Child suicide: A review of the literature and implications for school counselors. School Counselor, 37, 328–340. Retrieved August 22, 2008 from EBSCO online database Academic Search Premier: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9607292163&site=ehost-live

Vartanian, L. R. (2000). Revisiting the imaginary audience and personal fable constructs of adolescent egocentrism: A conceptual review. Adolescence, 35, 639–662. Retrieved August 22, 2008 from EBSCO online database Academic Search Premier: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=4086875&site=ehost-live

Wang, L., & Crane, D. R. (2001). The relationship between marital satisfaction, marital stability, nuclear family triangulation, and childhood depression. American Journal of Family Therapy, 29, 337–347. Retrieved August 22, 2008 from EBSCO online database Academic Search Premier: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=5323144&site=ehost-live

Wherry, J. N., Baldwin, S., Junco, K., & Floyd, B. (2013). Suicidal thoughts/behaviors in sexually abused children. Journal of Child Sexual Abuse, 22, 534–551. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=89100792

Wittenborn, A. K., Faber, A. J., Harvey, A. M., & Thomas, V. K. (2006). Emotionally focused family therapy and play therapy techniques. American Journal of Family Therapy, 34, 333–342. Retrieved August 22, 2008 from EBSCO online database Academic Search Premier: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=20855210&site=ehost-live

Wong, I. C., Besag, F. M., Santosh, P. J., & Murray, M. L. (2004). Use of selective serotonin reuptake inhibitors in children and adolescents. Drug Safety, 27, 991–1000. Retrieved August 22, 2008 from EBSCO online database Academic Search Premier: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=15124063&site=ehost-live

Youth suicides rising, especially among young, teenage girls. (2007). Nation's Healthy, 37, 9. Retrieved August 22, 2008 from EBSCO online database Academic Search Premier: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=27330508&site=ehost-live

Suggested Reading

Carlson, T. (1995). The suicide of my son: The story of childhood depression. Duluth: Benline Press.

Gil, E. (2015). Play in family therapy (2nd ed). New York: Guilford Press.

Moskowitz, A., Stein, J., & Lightfoot, M. (2013). The mediating roles of stress and maladaptive behaviors on self-harm and suicide attempts among runaway and homeless youth. Journal of Youth & Adolescence, 42, 1015–1027. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=88060543

Pisani, A., Wyman, P., Petrova, M., Schmeelk-Cone, K., Goldston, D., Xia, Y., & Gould, M. (2013). Emotion regulation difficulties, youth-adult relationships, and suicide attempts among high school students in underserved communities. Journal of Youth & Adolescence, 42, 807–820. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=87551505

Scott, M., Underwood, M., & Lamis, D. (2015). Suicide and related behavior among youth involved in the juvenile justice system. Child and Adolescent Social Work Journal, 32(6), 517–527. Retrieved from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=110526719&site=ehost-live&scope=site

White, J. (2014). Expanding and democratizing the agenda for preventing youth suicide: Youth participation, cultural responsiveness, and social transformation. Canadian Journal Of Community Mental Health, 33, 95–107. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=97160638&site=ehost-live&scope=site