Suicide involves the intentional act a person takes to end their own life.  Suicide among adolescents, specifically 10 to 24 years old, has become a serious public health concern in the United States.  Risk factors include hopelessness, biological factors, social factors, depression, substance abuse, and non-suicidal self-injury (NSSI).  Since suicide accounts for more deaths among adolescents in the United States than all natural causes combined, it is imperative that effective prevention programs be implemented in schools, communities, and through all forms of media.  Prevention efforts also include therapy and treatment for suicidal thoughts and behavior (STB) such as connectedness, attachment based family therapy (ABFT), integrated cognitive behavioral therapy (I-CBT), and dialectical behavior therapy (DBT).  It is crucial to establish effective and evidence-based programs in all communities to reduce the risk factors, attempts, and deaths of suicidal adolescents.

Adolescent Suicide as a Serious Health Concern

Suicide accounts for more deaths among 10-24 year olds than all natural causes combined (Joshi, Hartley, Kessler, & Barstead, 2015).  The Center for Disease Control (CDC) reports suicide rates in adolescents has increased 25% over the last 15 years.  “As the second leading cause of death among adolescents in the United States, suicide remains a serious health concern” (Bloch, 2016, p. 773).  A possible solution to the problem involves first understanding why the suicide rates in adolescents has increased to such proportions.  Adolescents tend to display behaviors that are impulsive and egocentric to the point where they do not believe bad things can happen to them (Martin, 2018). Consider these natural tendencies of behavior while studying the risk factors affecting adolescent suicide.

Risk Factors Affecting Adolescent Suicide

Hopelessness
One in every seven youths has considered suicide and one out of every thirteen youths has attempted suicide in the last 12 months (Bloch, 2016).  The leading factor differentiating the youths considering suicide from those who attempt suicide is the level of hopelessness they feel (Taliaferro & Muehlenkamp, 2014).  Many youths today feel undervalued, unworthy, and unwanted which tends to leave them feeling like a burden on their family or community.  When they feel disconnected from peers or family, feelings of hopelessness tend to overwhelm them, leading to negative thoughts and negative tendencies.  Hopelessness can be linked with biological factors as well.

Biological Factors
“A prolonged sense of negative emotional states and social disconnection contribute to neurophysiological imbalances linked to many of the known precursors to suicide, such as depression, substance abuse, and persistent feelings of hopelessness” (Whitlock, Wyman, & Moore, 2014, p. 263).  Padurariu et al. (2016) describes how serotonin amounts within blood platelets of tested suicide attempters reported considerably lower levels than a person with suicide ideation or without suicidal tendencies.  Serotonin helps regulate mood and social behavior, as well as appetite, sexual desire, sleep, and memory.  Abnormal levels of serotonin, usually lower levels, derive from stress, trauma, personality disorders, and alcohol abuse.  Scientists have also found strong evidence supporting the association of dopamine receptors and oxytocin in the brain to suicidal ideation and suicide attempts (Padurariu et al., 2016).  Another biological factor involves familial transmission. Children of suicide attempters have been shown to have more impulsive aggression and carry comorbid personality disorders that result in suicidal thoughts and behavior (STB).  The family history tends to interfere with their ability to create stable, long-lasting relationships with family and friends, as well as health care professionals providing treatment (Rajalin, Hirvikoski, Salander, Asberg, & Jokinen, 2016).

Social Factors
Numerous social factors have been identified that increase the risk for suicidal ideation and suicide attempts in adolescents, including divorce, bullying, peer victimization, family dysfunction, same-sex sexual attraction, and childhood physical and sexual abuse (Taliaferro & Muehlenkamp, 2014).  The family environment can often predict STB when adolescents live within a low socioeconomic status or live with only one parent.  In fact, female adolescents not living with their parents, or only one parent, and with a low income socioeconomic status are at an elevated risk of suicide (Im, Oh, & Suk, 2017).  In addition, youth who experience a lack of connectedness with their parent(s), friends, or other social groups suffer one of the primary triggers for suicidal behavior: feelings of rejection and isolation.  Interpersonal problems have been the most reported causes of suicide attempts in adolescents (Rajalin et al., 2016).  In 1897, sociologist Emile Durkheim argued that suicide resulted from lack of social connection to others and low behavioral control.  Apparently, this theory remains the same today.  When an adolescent’s desire for warmth, affection, attachment, and support are unsatisfied, then their negative tendencies and thoughts increase and can lead to depression (Whitlock et al., 2014).

Depression
The life of a teenager can be stressful as they experience changes in hormones and physical body changes and irritability levels increase.  Roughly 80% of adolescents suffering from depression can also be classified with an anxiety disorder.  When an adolescent combines their natural impulsiveness and dramatic behavior with anxiety and depression, an increased risk of suicide may occur.  Fifty percent of suicide completers suffered from depression (Padurariu et al., 2016).  Other common risk factors associated with depression that adolescents experience include low self-esteem, eating disorders, and sleep deprivation.  These factors tend to manifest self-destructive behavior (Martin, 2018).

Substance Abuse
Mental health conditions combined with substance abuse attribute to 75% to 90% of the deaths caused by suicide.  Adolescents who participate in substance abuse are more likely to have suicide ideation, especially between the ages of 13 and 16 years old (Im et al., 2017).  Substance abuse can be the determining factor between suicide ideation and a suicide attempter.  74% of high school seniors have used alcohol and 40% have experimented with illegal drugs (Martin, 2018).  Within all age groups, 30% of completed suicides showed close to the legal blood alcohol limits, or higher (Padurariu et al., 2016).  Another epidemic sweeping across the United States effecting adolescent suicide rates involves opioid abuse.  Opioids include substances that act on the opioid receptors in the brain and have primarily been used for pain relief.  Between 2005 and 2010, there were 4,186 calls to poison centers across the United States as a result of opioid abuse in adolescents.  Out of the calls, 30% of the patients claimed to suffer from depression and the prescription medication being used did not belong to them.  Over 35% of adolescents admitted to abusing opioid prescriptions they were prescribed to treat headaches and admitted over-using the prescription medication to treat the anxiety they felt (Sheridan et al., 2016).

Non-Suicidal Self-Injury (NSSI)
Another type of self-destructive behavior that has been shown to lead to suicide ideation or suicide attempts is non-suicidal self-injury (NSSI).  NSSI involves hurting oneself without suicidal intent by use of scratching, cutting, burning, or hitting.  NSSI has very similar risk factors as suicidal behavior, including anxiety, depression, eating disorders, hopelessness, and physical and sexual abuse.  “Adolescents with a past suicide attempt report greater levels of anxious and depressed symptoms and are more likely to report a history of abuse than those with a history of NSSI” (Wolff et al., 2013, p. 1005).  Prior history of NSSI has been used to predict suicides. In fact, 70% of adolescents who engage in NSSI also have a history of a suicide attempts (Wolff et al., 2013).

Preventing Adolescent Suicide

Knowing and understanding the risk factors of adolescent suicide allow schools, parents, and human service professionals to be cautious of at-risk youth and focus on preventing STB and attempts.  The prime location to exert efforts of prevention is in schools where adolescents spend most of their time.

 Suicide Awareness Curricula
School-based suicide prevention programs efficiently provide cost-effective ways to influence adolescents since they spend most of their day inside a classroom.  Curriculum should include four components of health promotion, prevention education, intervention, and postvention.  The goal of school-based programs allows for students to become more aware of signs and symptoms of suicide where they can recognize suicidal behavior in themselves and their peers.  Understandably, adolescents will not seek treatment if they cannot recognize the symptoms.  The American Foundation of Suicide Prevention (AFSP) has created a 75-minute program developed for high school students and teachers that alerts both groups to common symptoms of depression and anxiety. The emphasis is on providing students with hope and options for treating depression and the importance of asking for help when they see symptoms in themselves or their friends (Katz et al., 2013).

Screening
When STB symptoms arise, an effective prevention method involves screening the adolescent to determine if they need treatment.  Screening consists of a questionnaire that analyzes the level of risk for suicide based on the adolescent’s answers.  Risk factors are determined from the screening, such as depression, substance abuse, past suicidal behavior, and physical abuse.  TeenScreen has been a leading program in the United States used by both outpatients and schools (Katz et al., 2013).

Skills Training
Skills training helps prevent suicide by increasing protective factors.  Programs teach adolescents coping skills, problem solving, decision making, and cognitive skills.  Skills training does not directly prevent suicide but instead attacks the risk factors of STB.  The Care, Assess, Respond, Empower (CARE) program identifies high-risk youth through a computer-based suicide assessment interview.  The program provides for a safe environment to share and encourage positive coping and help seeking behavior.  The goal of the CARE program is to reduce suicidal behavior and establish treatment options for adolescents.  CARE has shown to reduce levels of depression and anger in youth (Katz et al., 2013).  The Cincinnati Children’s Hospital Medical Center introduced a screening program in 2013 that delivers 93% accuracy in determining which patients are either suicidal, mentally ill but not suicidal, or neither.  The program addresses a patient’s level of hope and anger, and the responses help diagnose levels of depression.  The program detects signs of depression early so treatment can be provided before the patient becomes suicidal (Grose, 2016).

Gatekeeper
Gatekeeper training takes people who are considered natural helpers, including youth and adults, and trains them with knowledge and skills to detect symptoms of suicide within schools and communities.  The Question, Persuade, Refer (QPR) program has been used in schools and communities to refer adolescents with suicidal behavior to the appropriate source for analysis and treatment.  The drawback with this program is whether the gatekeeper feels comfortable referring the at-risk student to seek help.  It does increase awareness in schools and provides better connection between students (Katz et al., 2013).

Peer Leadership Training
Another program found within schools and communities, called peer leadership training, puts students in a position to help suicidal peers and direct them to a trusted adult if they experience suicidal risk factors.  Youth tend to feel more comfortable talking with peers about their suicidal thoughts.  Sources of Strength (SOS) is a prevention program that uses protective factors within schools and communities to decrease risk factors, such as social isolation and ineffective coping skills.  Peer leaders are selected by teachers and staff to encourage other students and build connectedness within the school environment where isolation would otherwise exist (Katz et al., 2013).

Social Media
In the last decade, youth have experienced a new influence in their lives with social media.  Between Facebook, Twitter, Instagram, Snapchat, or MySpace adolescents now build relationships through a screen and have drifted away from face-to-face interaction.  Social media has influenced people to post their feelings and life events, as well as relationship changes.  As a result, technology has been developed and is now being utilized by social media platforms that allows for detection of suicidal thoughts among its users.  When a person posts their feelings online, social media sites now use an algorithm as a way of identifying at-risk adolescents.  Facebook and Google have both created a mechanism to provide information on suicide support options.  As a result, when “suicide” is typed into the search engine, then a list of suicide and crisis hotline numbers will appear first on the page.  Other organizations, such as Inspire Foundation USA and ReachOut.com, have plans to use social networking sites to target those who post suicidal thoughts on their social media pages.  Fact sheets, web pages, and a youth advisory system are available to those who land on their search results when questioning suicide online (Cash, Thelwall, Peck, Ferrell, & Bridge, 2013).

Media and Television Influence
For several weeks during 2017, 13 Reasons Why held the ranking as one of the most popular shows watched on television and included a storyline about a teenage girl who killed herself.  The show was promoted throughout the United States and watched by youth on Netflix (Feuer & Havens, 2017).  The storyline involved a beautiful, smart, high school student who killed herself and left behind 13 tapes about how people contributed to her death.  This show provides an example of how television does not help prevent suicide, but could be utilized as a prevention method if changes were made in future broadcasts regarding suicide.  For six weeks following the release of 13 Reasons Why, clinicians reported a high level of calls and accounts of suicide attempts where children reported suicidal thoughts and behavior triggered by the series.  Emergency services reported increases in the volume of patients attempting suicide.   Copycat gestures were seen 30 days after the show’s release.  Children in emergency rooms reported making suicide attempts because of the show (Feuer & Havens, 2017).  Media and television have the potential of directing suicidal thoughts into positive coping behavior and hope for those with mental illnesses.  If media would not glorify suicide by describing the situation and death in detail, but instead connect the crisis to prevention and to groups and community-based services that can help, then adolescent viewers may see the alternatives to suicide.  Media outlets and the entertainment industry could play such a vital role in influencing suicide prevention, depression, and mental health issues to the public.

Modifying the Environment
Adolescent females are more likely to report suicidal ideation and have suicide attempts than males but adolescent males are four times more likely to die by suicide.  Males tend to use firearms to commit suicide which reduces the likelihood for surviving a suicide attempt, versus prescription drugs that females favor (Bloch, 2016).  Therefore, limiting the access to firearms and prescription drugs in a youth’s environment could help reduce the deaths by suicide.  Modifying the environment can also include providing a safe and sheltered environment for youth following a crisis or suicide in the community.  Offering a safe haven for youth to turn to for counseling and therapy following a crisis will lower stress levels and anxiety and help them through a difficult or sad situation.

Adolescent Suicide Therapy and Treatment

Connectedness
In order to reduce the impact of suicide, the Surgeon General of the United States and Center for Disease Control have recognized suicide as a serious public health concern and emphasized the need for implementing public health-based solutions for treatment and intervention.  They have identified connectedness as the focus for therapy and treatment for adolescents in the United States.  Connectedness involves the feelings of closeness by caring and belonging to a group of individuals by which they receive and give trust, value, and respect.  Children have a need for regular, positive experiences with others where stable and reciprocal care and concern are generously provided.  Specifically, all people want to be valued and to feel important.  When children are neglected, excluded, or ignored for long periods of time, depression usually develops.  Most of the treatments designed for suicidal behavior involve connecting the adolescent to peers, academic programs, sports, church groups and having them become involved in meaningful activities (Whitlock et al., 2014).  Involving the parents or family and training them to pay attention and communicate with their children becomes vital during treatment for STB.  Having “strong ties with adults in key social settings enhance adolescent willingness to seek help for emotional problems, and for suicide concerns” (Whitlock et al., 2014, p. 264).  Adolescents involved in school and social clubs feel they belong and are more likely to perceive social support as available.  Furthermore, connectedness reduces suicidal thoughts through expanding social networks, increasing opportunities for adolescents’ suicidal behavior to be recognized, exposing them to positive coping skills, increasing positive emotions, defining purpose and significance, and increasing experiences of belonging to a group (Whitlock et al., 2014).  Parental connectedness is an extremely powerful protective factor with adolescents.  Suicidal youths rate their parents as having less warmth and empathy and providing little support or attention.  Better quality relationships help adolescents cope with adversity and stress (Taliaferro & Muehlenkamp, 2014).

Attachment Based Family Therapy (ABFT)
A method of therapy that promotes relationships and designed to reduce depression and suicide risk in adolescents is Attachment-Based Family Therapy (ABFT).  This 12-16 week program strengthens the relationship and attachment between parent and child.  Most of the time, families begin therapy believing the child causes their depressive state and suicidal thoughts but they leave therapy understanding that the family is the solution.  Therapy connects the pain that both the adolescent and parents may be feeling and how they mutually desire a different and improved relationship and connection. The therapist helps the family with different ways of talking to and connecting with their child and parents receive emotion coaching.  Again, connectedness is the focus of the therapy to draw the adolescent out of STB.  As a result, suicide risks are reduced by increasing the adolescent’s sense of security, safety, and protection combined with the parent’s feelings of competence and connection (Singer, O’Brien, & LeCloux, 2016).

Integrated Cognitive Behavorial Therapy (I-CBT)
Integrated Cognitive Behavorial Therapy (I-CBT) confronts the combined risk factors of substance abuse and STB.  Regardless of the link between the two and the standard practice of treating them separately, I-CBT addresses them both simultaneously. The therapy targets the maladaptive behavior common to both problems of substance abuse and SBT.  For example, alcohol tends to cause disinhibition that increases the impulsiveness on suicidal thoughts.  Alcohol inhibits the coping skills to handle suicidal thoughts and elevates the risk of suicide attempts.  Drawing attention to the relationship between the two problems is important for therapists to clarify to adolescents.  Adolescents tend to participate in substance abuse to associate with the negative views they hold of themselves, distract their thoughts away from stress or anxiety they may feel, or numb themselves of negative emotions.  Again, parental involvement in I-CBT enhances the effectiveness of treatment in suicidal adolescents when therapists coach parents how to be buffers, rather than triggers.  Parents can monitor their adolescent’s location and activities, effectively communicate concern and compassion, and build support for their child’s treatment (Singer et al., 2016).

Dialectical Behavior Therapy for Adolescents (DBT-A)
Dialectical Behavior Therapy for Adolescents (DBT-A) was adapted from Dialectical Behavior Therapy (DBT) as a treatment that combines behavioral science, dialectical philosophy, and Zen practice but with focus on adolescents who struggle with suicidality, self-harm, or chronic emotion dysregulation.  DBT-A has been recently added to school-based curriculum but usually exists in inpatient or outpatient services with skill-based training groups.  DBT-A focuses on mindfulness by experiencing thoughts and feelings without attaching judgment or negative thoughts to them.  Through therapy, adolescents develop core skills to help them accept and tolerate pain better, as well as coping with difficult situations (Singer et al., 2016).  They learn how to tolerate difficult feelings without becoming overwhelmed.  Zen practice allows them to incorporate breathing exercises, positive imagery, prayer, and relaxation to convert negative thoughts to positive ones (Singer et al., 2016).

Conclusion

There remains a crucial need to provide evidence-based programs in communities and schools worldwide that will reduce risk factors, attempts, and deaths of suicidal adolescents. Clinicians seek more data from studies within schools and communities to better understand the risk factors, especially those that differentiate suicidal ideation from suicide attempts.  The focus on preventing STB involves understanding the risk factors, looking for the symptoms, and becoming connected to adolescents where they feel wanted and valued.  Offering parenting classes within communities could coach parents on ways they can connect with their children and improve awareness of their child’s emotions.  Further research on anti-depressants and serotonin inhibitors could provide more options for the adolescents who suffer from depressive symptoms.  Additional genetic testing and research could also allow for more answers on how adolescents could avoid familial transmission of STB.  Speaking to government officials and encouraging more funding for mental health research could also make a difference in saving the lives of adolescents.  If every person advocated for suicide awareness and prevention, more treatment options could be in the near future.

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