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Risk factors for adolescent suicidal behavior: loss, insufficient familial support, and hopelessness. Christopher D. Morano; Ron A. Cisler; John Lemerond.
Adolescence, Winter 1993 v28 n112
p851(15)
Author's Abstract: COPYRIGHT Libra Publishers Inc. 1993
Upon admission to an inpatient psychiatric facility, 20 adolescent serious suicide attempters and 20 nonattempters matched on depression scores were asked about their perceived hopelessness, social support, and loss preceding hospitalization. Attempters and nonattempters were similar in psychiatric status, gender, age, race, and socioeconomic status. Measures included Reynold's (1987) Suicidal Ideation Questionnaire (SIQ) and assessment for recent loss of a significant other. Also included were versions of the Beck Depression Inventory (Beck, 1967), Beck Hopelessness Scale (Beck, Schuyler, & Herman, 1974), Suicide Intent Scale (Beck et al., 1974), and Sarason's Social Support Questionnaire (Sarason, Levine, Basham, & Sarason, 1983) modified to retrospectively assess the period of time just prior to hospitalization. Classification of serious suicide attempt using both staff screening and the Suicide Intent Scale was validated by attempters' high scores on the SIQ. Data show that loss and low family support were the best predictors of an adolescent's suicide attempt. Also, suicide attempters reported more hopelessness than did nonattempters. The influence of recent loss on serious suicide attempts, especially when paired with a perceived lack of family support and hopelessness, provides evidence for a "stress-vulnerability" model of adolescent suicide behavior.
Full Text: COPYRIGHT Libra Publishers Inc. 1993
The precipitous increase in the adolescent suicide rate over the past three decades has been well documented (Berger & Thompson, 1991; Den Houter, 1981). This rapid rise has led to much research aimed at determining high-risk groups and predictors (Adcock, Nagy, & Simpson, 1991; Gispert, Wheeler, March, & Davis, 1985). Many variables, notably depression (Robbins & Allesi, 1985) and gender (Kosky, Silburn, & Zubrick, 1986), have been found to differentiate adolescent suicide attempters from nonattempters.
However, many seemingly key variables associated with adult suicide attempts have not been explored adequately with adolescents; three such variables are hopelessness, loss, and social support. For example, Beck and his colleagues (Beck, Brown & Steer, 1989) found that hopelessness was the best predictor of adult serious suicide attempts, but to date it has not been reliably linked to adolescent attempts. Another predictor of adult suicide attempts that has not been firmly established with adolescents is loss of a significant other (Slater & Depue, 1981). Finally, a third plausibly related variable, though not fully explored, is social support. This present study investigated the relationship between hopelessness, loss, social support, and inpatient psychiatric adolescent serious suicide attempts.
Though depression has long been considered the hallmark sign of risk for youths, the relationship is neither simple nor linear (Carlson & Cantwell, 1982). Not all severely depressed adults or adolescents requiring hospitalization resort to suicide, and many who attempt, and complete, suicide were not previously diagnosed as globally depressed (Kazdin, French, Unis, Esvelt-Dawson, & Sherick, 1983). Indeed, Beck and others (Beck, Steer, Kovacs, & Garrison, 1985; Cole, 1988; Emery, Steer, & Beck, 1981; Schotte & Clum, 1987) have shown that hopelessness, one facet of depression, is a better predictor of suicide intent among adults than is global depression. In terms of adolescent suicide, however, further study on this hopelessness-suicide intent relationship is needed because existing evidence is based on studies which (1) used weak measures of suicidal intention (Rotheram-Borus & Trautman, 1988; Topol & Resnikoff, 1982), and (2) asked about hospitalized subjects' current state of hopelessness rather than about their perceived sense of hopelessness before their suicide attempt (Spirito, Williams, Stark, & Hart, 1988).
Loss is another event which may precede adult and child/adolescent suicide attempts. Loss of someone who provides emotional, informational, and/or material support has been shown to leave adults seriously vulnerable to suicide (Conroy & Smith, 1983; Hart & Williams, 1987; Wasserman, 1988). Also, divorce, separation, and chronic family discord, but not the death of a parent, were related to suicide attempts in children and adolescents (Crook & Raskin, 1975). This latter study, however, did not differentiate children from adolescents. Taken together there is some reason to believe that the loss of a significant other could be a precursor to adolescent suicide attempts.
Relatedly, much research has explored the role of social support in general adolescent health (Blyth, Hill, & Thiel, 1982; Boyce, 1985; Buruda, Vaux, & Schill, 1984; Clark & Clissold, 1982). However, only two studies report a relationship between social support and adolescent suicidal behavior, one of which suffers from methodological problems (Dubow, Kausch, Blum, Reed, & Bush, 1989) and the other has not been published (Reynolds & Waltz, 1986). Dubow and others (1989) found that suicidal ideation and suicide attempts were associated with low family support. However, the findings were based only on anonymous self-report; no independent verification of important variables was assessed, such as whether a subject had actually made an attempt. Further, no distinction was made between serious and nonserious attempts. Reynolds and Waltz (1986) presented nonpublished data, derived from a nonclinical sample, that linked lack of social support and increased risk of suicide in adolescence. Overall, the dearth of research in this area is particularly compelling when one considers that adolescence is an especially tumultuous time when individuals are arguably more sensitive to social systems and support.
Some studies suggest that family support is a particularly crucial part of overall social support with respect to adolescent health (Boyce, 1985; Clark & Clissold, 1982). Boyce (1985) concluded that mutual, interactive social support is evident in the child's earliest experiences with the family, and that this interaction is critical to the maintenance and normal development of the child. Clark and Clissold (1982) examined the general adaptation of adolescent boys, and found that support from family and friends was the most powerful predictor of healthy adjustment in this population. Neither of these studies, however, examined the effects of varying degrees of family support on adolescent suicidal behavior.
Clearly, because adolescent suicidal behavior is a complex problem with many possible determinants, more research is needed to identify these factors more fully. Several of these factors were discussed as integral to the problem and in need of further examination: hopelessness, loss of significant others, and social support. Few studies focused directly on these variables and their relationship to adolescent suicidal behavior, and the existing data appear incomplete.
The present study examined the impact of these factors on serious suicidal attempts of adolescents. It was hypothesized that psychiatric inpatient adolescents who have made serious suicide attempts would report more experience with recent loss of significant others (termed "exit events" by Slater & Depue, 1981), perceived lack of social and family support, and perceived hopelessness than would a control group of their psychiatric inpatient peers, comparable in age, gender, socioeconomic and psychiatric status, and level of depression.
METHOD
Subjects
Subjects were 40 white, middle-class adolescents, aged 13-18, recruited from one of two fully accredited adolescent inpatient psychiatric treatment facilities in Milwaukee, Wisconsin. Subjects were similar in psychiatric status in that only nonpsychotic disorder subjects were asked to participate. Twenty Suicide Attempters (SA) who had made a serious suicide attempt as judged by the facility admissions officer and who had a confirming score on a suicide intent measure were also assessed for depression. Twenty Non-Suicide Attempters (NSA) comprised a comparable group of adolescents who had not made a suicide attempt. Ten male and 10 female SA subjects were recruited, and then 20 NSA subjects, closely matched for gender (i.e., eight females and 12 males), were found with similar depression scores. Table 1 contains summary demographic data on SA and NSA subjects.
Measures
Six measures were administered to subjects. Because the primary
objective of this study was to identify variables that precede
adolescent suicide attempts, three standardized measures--Beck
Depression, Beck Hopelessness, and Sarason Social Support Questionnaire--were
modified to have SA subjects focus on the period just prior to
the suicide attempt; the NSA subjects were asked to focus on their
experiences in the few weeks just prior to hospitalization. A
fourth measure asked if subjects experienced a significant loss
also in the period prior to treatment. Another measure was administered
only to SA subjects to confirm their suicide attempt by tapping
their intention to commit suicide. Finally, a sixth measure determined
the degree of suicidal ideation in all subjects. All five standardized
measures have appreciable reliability and validity.
Table 1
Distribution of Gender, Age, and Beck Depression Inventory
(BDI) Score for SA and NSA Subjects
GROUP
Suicide Non-
Attempters Attempters
CHARACTERISTIC (n = 20) (n = 20)
Gender
Male 10 12 Female 10 8
Age
Mean 15.10 15.05 (SD) (1.37) (1.66) Depression (BDI Score) Mean 28.00 28.10 (SD) (10.07) (11.18) BDI Level of Depression Mild to moderate (11-17) 3 3 Moderate to severe (18-29) 8 8 Severe (!less than^30) 9 9
Beck Depression Inventory (BDI). The BDI has been used extensively in clinical research, in particular to match subjects on their level of depression (Beck, 1967; Dyer & Kreitman, 1984; Metcalfe & Goldman, 1965). The 21-item scale assessed both the number and severity of depressive symptoms the subjects experienced. Each item was rated from 0 to 3 reflecting depressive symptoms not present (0) to severe depressive symptoms (3), revealing a total depressive symptom score ranging from 0 to 63. As shown in Table 1, mean BDI scores were essentially the same for SA (M = 28.00; SD = 10.07) and NSA (M = 28.10; SD = 11.18) subjects. In addition, equal numbers of SA and NSA subjects were classified as mild to moderate, moderate to severe, and severe BDI depression (i.e., 3, 8, and 9, respectively).
Beck Hopelessness Scale (BHS). The BHS (Beck, Schuyler, & Herman, 1974) is a 20-item, self-related scale that has been useful in assessing risk for suicide attempt in adults (Beck et al., 1985; Minkoff, Bergman, Beck, & Beck, 1973). The BHS used here assessed the SA subjects' expectations of the future just prior to the attempt, and requested recent expectations for the future from NSA subjects.
Sarason Social Support Questionnaire (SSQ). The original SSQ (Sarason et al., 1983) is a valid, 27-item measure of perception of available social support (Compas, Slavin, Wagner, Vanatta, 1986; Sarason et al., 1983), and has been correlated with depression (Sarason, Shearin, Pierce, & Sarason, 1987). The SSQ used here assessed both the number of others available for support (SSQN) and the perceived degree of satisfaction with available support (SSQS). Further, because we believed that family support is inversely related to adolescent suicide attempts, we determined the ratio of family versus all other support provided (SSQF).
Exit Events Question (EEQ; Loss). Subjects were asked, "Have you lost anyone in the last three months whom you feel was important to you?" (This loss was termed "exit events" by Slater & Depue, 1981). Scoring was dichotomous: 0 losses = "No," !is greater than or equal to^ 1 loss = "Yes."
Suicide Intent Scale (SIS). The SIS (Beck, Schuyler, & Herman, 1974) consists of 20 items which tap details of a suicide attempt. It has well-established validity and reliability (Weissman, 1974). Administered only to the SA subjects, the SIS determined the seriousness of the attempt by their responses to questions such as their desire to be discovered after the attempt. The SIS was used in conjunction with the admissions officer screen to classify subjects as those who seriously attempted suicide or those who did not.
Suicidal Ideation Questionnaire (SIQ). The SIQ (Reynolds, 1987) consists of 30 items which assess the degree of suicidal ideation in all subjects. Subjects rated each of the 30 statements concerning their thoughts about suicide in the month prior to hospitalization on a 7-point scale where 0 = "I never had this thought" to 6 = "Almost every day." Thus, a subject's score could range from 0 to 180.
Procedure
Upon admitting an adolescent for treatment, an admissions officer contacted the experimenter. The assessment battery was administered as soon as possible, usually within one week of admission, but never more than two weeks. Admissions staff also assessed whether the adolescent had made a recent suicide attempt. This suicide assessment, paired with the adolescent's score on the SIS, determined whether the adolescent was classified as a suicide attempter.
More specifically, potential SA and NSA subjects, as well as their parents, were informed of the study and asked to provide written consent to participate. Adolescents who were willing and permitted to participate were tested as soon as possible. Scores on the BDI for the NSA group were matched according to the BDI scores of the SA group. Serious suicide attempters were tested until 10 females and 10 males were recruited and assessed for depression. Concurrently, a total of 34 NSA subjects were assessed until 20, closely matched for gender (i.e., 8 females, 12 males), were matched on BDI scores. Subjects were then asked to complete the SIQ, BHS, SSQ, and EEQ. The measures were counterbalanced to control for order and fatigue effects. Adolescents determined by admissions staff to have made a suicide attempt were assessed on the SIS after completing all assessment instruments. Only subjects with a seriousness of intent score of moderate to extreme (i.e., SIS !is greater than or equal to^ 10) were ultimately classified as attempters (see Slater & Depue, 1981 for a similar procedure). Three adolescents who were assessed by the admissions officer as having attempted suicide were not confirmed by the SIS (i.e., SIS !is less than^ 10) and were replaced.
RESULTS
Validation of Suicide Classification
To validate the assignment of subjects to SA and NSA groups based on seriousness of suicidality (determined by an admissions officer and SIS score), analyses were performed on data from the Suicide Ideation Questionnaire (SIQ). As expected, the SA and NSA subjects differed significantly on their reports of suicidal ideation (F(1, 38) = 9.40, p !is less than^ .01). More specifically, SA subjects reported having more suicidal thoughts (M = 113.40, SD = 38.20) than did NSA subjects (M = 68.75, SD = 52.75).
Precursors to Serious Suicide Attempts
Discriminative function and regressive analyses revealed interesting relationships among the variables in this study. A discriminative function analysis determined that hopelessness (BHS), loss (EEQ), number of (SSQN) and satisfaction with (SSQS) social support, and family support (SSQF) collectively predicted SA and NSA group membership with 90% and 85% accuracy, respectively. More specifically, 18 of the 20 SA subjects and 17 of the 20 NSA subjects were correctly classified, given their scores on the primary dependent measures.
A multivariate (i.e., BHS, EEQ, SSQN, SSQS, and SSQF) regression analysis with serious suicide attempt or no attempt (i.e., 1 = SA and 2 = NSA) as the criterion was also performed. Both EEQ (!Beta^ = -.44) and SSQF (!Beta^ = .44) reliably predicted whether an adolescent would attempt suicide (Adjusted !R.sup.2^ = .42). In other words, loss and family support accounted for 42% of the variance in determining whether subjects attempted suicide; experience with loss and lower family support best predicted suicide attempt. Other measures did not reliably predict suicidality in this analysis (BHS !Beta^ = -.22; SSQN !Beta^ = -.20; and SSQS !Beta^ = .15).
Differences Between Attempters and Nonattempters
Table 2 contains means and standard deviations of suicide attempters and nonattempters on hopelessness (BHS), loss (EEQ), number (SSQN), and satisfaction (SSQS) with total supports, and family support (SSQF).
A one-way multivariate analysis of variance (MANOVA) was performed, which revealed a significant difference between SA and NSA subjects on the five (i.e., BHS, EEQ, SSQN, SSQS, and SSQF) aggregated dependent measures (Hotelling's Approximate F(5, 34) = 7.33, p !is less than^ .001). This further corroborates the finding that the measures selected for this study appropriately characterized those who did make a serious suicide attempt.
Further, independent univariate ANOVAs revealed that SA subjects
scored higher than did NSA subjects on the BHS (F(1, 38) = 4.47,
p = .041). Attempters (M = 14.10; SD = 5.02) reported feeling
more hopeless before their suicide attempt than did nonattempters
before their hospitalization (M = 10.95; SD = 4.47). In addition,
SA subjects, on average, scored higher on the EEQ than did NSA
subjects (F(1, 38) = 12, 93, p = .001). Significantly more attempters
(M = .50; SD = .51) reported the loss of an important person before
their suicide attempt than did nonattempters prior to hospitalization
(M = .05; SD = .22) In fact, 10 of the 20 suicide attempters reported
losing an important person in their life, compared to only 1 of
the 20 nonattempters.
Table 2
Breakdown of Suicidality on Hopelessness (BHS), Loss (EEQ),
Number of Supports (SSQN), Satisfaction with Supports (SSQS),
and Family Support (SSQF)
GROUP
Suicide Non-
Attempters Attempters
MEASURE (n = 20) (n = 20) F
Hopelessness
Mean 14.10 10.95 (SD) (5.02) (4.37) 4.47(*)
Loss
Mean 0.50 0.05 (SD) (0.51) (0.22) 12.93(**) Number of Supports Mean 43.35 46.70 (SD) (33.94) (28.12) 0.12 Satisfaction with
Support
Mean 103.60 103.10 (SD) (31.85) (25.31) 0.00 Family Support Mean 0.19 0.49 (SD) (0.22) (0.30) 12.98(**) Note: * p !is less than^ .05; ** p !is less than^ .001
Finally, no significant differences between groups were found on SSQN (F(1, 38) = 0.12, p = .736) or SSQS (F(1, 38) = 0.01, p = .956). However, a significant difference was found between SA and NSA subjects on the ratio of family supports to overall supports (i.e., SSQF). Here, the NSA subjects reported proportionately more familial support than did the SA subjects (M = .49; SD = .22 and M = .19; SD = .30, respectively; F(1, 38) = 12.99, p = .001). Though no differences were found in number and satisfaction of social support between SA and NSA subjects, the support received by the NSA subjects was more likely to be from family members than that received by SA subjects.
DISCUSSION
The rationale for this study was to explore several variables hypothesized to be precursors of serious suicide attempts in an inpatient psychiatric adolescent sample that have been previously linked to adult attempts. Data support hypotheses regarding the relationship between loss, family support, hopelessness, and suicidal behavior in adolescents. Experienced loss and low family support were the best predictors of serious suicide attempts by adolescents. Fully 10 of 20 suicide attempters reported losing a significant other before their suicide attempt as compared to only one of 20 nonattempters. Also, even though suicide attempters did not report fewer supports or less satisfaction with support than did nonattempters, they did report significantly less family support. Finally, as expected, suicide attempters reported more hopelessness than did the nonsuicide attempting adolescents who were matched on their reported depression.
Analyses revealed the importance of loss and insufficient family support in the etiology of inpatient adolescent suicide attempts. Subjects who experienced a loss and perceived that they had relatively little family support were highly likely to have attempted suicide. The value of family support as a buffer against serious vulnerability is strongly suggested. Indeed, lower levels of family support have been associated with suicidal ideation in a normal high school population (Dubow et al., 1989). However, it is equally likely that the lower perceived family support reported by suicide attempters could be a product of actual absence of family members in the home. Therefore, these adolescents could be lacking an adequate familial support structure which might normally thwart their vulnerability to stressful events such as loss.
On a theoretical level, Ball and Chandler (1989) have argued, using a developmental psychopathology approach, that adolescents who make serious suicide attempts have had faulty identity formation and have failed to achieve a sense of personal continuity in time. The authors further suggest that some adolescents, when they experience change (and these changes are inevitable, irreversible, and dramatic), have pronounced difficulty justifying why they should persist as persons. They see their identity as formed at least in part by exogenous factors, such as a best friend, a peer group's approval, or a first automobile. It is therefore possible that the loss experienced by a large segment of the suicidal group in this study constituted such a profound change that they were unable to find a reason for living.
Further, Bonner and Rich's (1987) "stress-vulnerability" model of suicidal behavior posits that socioemotional alienation and deficient adaptive resources combine to produce a predisposition to self-harm. They elaborate that stressful life events (such as loss), along with a lack of support from family and peers, and emotional alienation (depression) may be associated with adolescent suicidal behavior. The present research suggests that a negative outlook on the future (e.g., hopelessness) may also contribute significantly to adolescent suicidal behavior.
In fact, this study also provided seminal empirical evidence for Beck's (Beck et al., 1989; Emery, Steer, & Beck, 1981) claim that hopelessness is a stronger predictor of suicidality than is depression. Suicide attempters reported more hopelessness than did the nonsuicide attempting adolescents, over and above their reported depression. A review of research on this question revealed that, until now, none of the studies with adolescents controlled for depression.
An important feature of this study was the validation of the degree to which hospital admissions staff and a suicide ideation scale correctly assessed the seriousness of the adolescent's suicide attempt. Subjects judged to have made a serious attempt at suicide scored nearly twice as high on the Suicidal Ideation Questionnaire (Reynolds, 1987) than did those judged as nonattempters: M = 113.40 for attempters and M = 68.75 for nonattempters. In fact, the difference in SIQ scores between SA and NSA subjects was rather dramatic, especially when compared to hospitalized suicidal adolescents assessed by Spirito (1987) and a standard sample of nonsuicidal teenagers (Reynolds, 1987). The SA subjects in this study reported a higher degree of suicidal ideation (i.e., M = 113.40) than did Spirito's (1987) hospitalized suicidal adolescents (i.e., M = 69.90). Moreover, the nonsuicidal subjects in this study scored similarly (i.e., M = 68.75) to Spirito's (1987) suicidal teens (i.e., M = 69.90), and substantially higher than Reynold's (1987) nonsuicidal norms (i.e., M = 17.65). These data suggest that the methods used in the present study for assigning subjects to serious suicide attempter or nonattempter categories were effective, and the suicidal subjects in this study were, in fact, highly vulnerable to attempting suicide prior to their hospital stay and were serious in their attempt.
Ostensibly, this study made at least four major advances over previous research: (1) in order to identify precursors to suicide attempts, the self-report instruments were modified to ascertain information about adolescents' perceptions just prior to the important events surrounding the suicide attempt and hospitalization; (2) the relationships among loss, familial support, and hopelessness were all examined in the same study; (3) the effects of loss, support, hopelessness, and suicidal ideation on suicide attempt were assessed while controlling for depression; and (4) the degree to which hospital admissions staff and a suicide intent scale correctly assessed the seriousness of the adolescent's suicide attempt was substantiated by the predicted differences in attempters' and nonattempters' scores on a measure of suicidal ideation.
However, even though a self-report, retrospective design used in the present study is useful, it is not the most desirable approach for investigating the problem. Given the obvious and incontrovertible ethical considerations of prospective studies, the prototype design for the examination of the predictors of suicide attempts is probably cross-sequential (La Francois, 1986) or longitudinal, such as that employed by Beck (Beck et al., 1985). Either of these methods obviate retrospective self-reports, and are likely to lead to more reliable and valid data. Still, this study, with its focus on the period just prior to a suicide attempt, represents an advance over past research in the area. In terms of the specific measures used to identify precursors to suicide attempts, however, future research could improve on the present study by obtaining more detailed information about the support network that is available and utilized by adolescents. Also, more information should be gathered about the loss of a significant other such as the nature of the relationship, its meaningfulness, impact, and timing. This information is likely to shed light on the interrelationships between stressful life events and social support in predicting adolescent suicide attempts.
Finally, to substantiate and extend the findings of this research, future studies could include a nonclinical control group and groups from other ethnic and racial backgrounds (see Bettes & Walker, 1986, for a study on African-American adolescent suicidal behavior). Cross-sectional or longitudinal research could also examine the relationships between loss and identity formation and adolescent suicide attempts.
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Christopher D. Morano, Ph.D., Milwaukee County Mental Health Complex, Child and Adolescent Treatment Center, 9501 Watertown Plank Road, Milwaukee, Wisconsin 53226.