Preventing Suicide

“I am so embarrassed because I know I can do better they will never allow me to get out of that bad school. They won’t allow me to succeed I’m stuck and I’m embarrassed I can’t look anyone into their eyes I can’t […] I want to live up to my last name. But this country won’t let me. Won’t give me the option and the opportunity to succeed.  I just hope I didn’t do this in vain …” This is a nightmare any mother would like to avoid. Seeing the dead child is one of the greatest tragedies parents can face in their lives. Suicide remains one of the most contentious social issues in today’s world. The complexity and complications of adolescent suicide can hardly be overstated. Despite the growing suicide awareness and numerous preventive measures, the controversy surrounding adolescent suicide continues to persist. Children and adolescents who have just entered this life are not expected to throw themselves into the hands of death. They seem to be full of optimism, plans, future dreams and expectations. Why do adolescents commit suicides? Why do they swallow pills and shoot themselves? Is adolescence so unbearable that it lends itself to death? These are just some of the questions to be answered in this work.

Suicide remains one of the most popular objects of present day social, mental health, sociological and medical research. Possible reasons why adolescents kill themselves have been described in abundance. Unfortunately, contemporary researchers persistently disregard the moral and emotional sides of adolescent suicide. How many mothers spend their lives crying for their children? How many parents fail to survive the loss of their adolescent children? Official statistics do not answer these questions, but the unbearable pain of losing a child should not be disregarded. This study aims to fill the emotional gap in the analysis of adolescent suicide, its causes, consequences and implications. Whether or not suicide is moral and permissible is beyond the scope of this analysis. With the help of a personal story of suicide, this study will create the foundation for the development of relevant suicide prevention strategies and provide recommendations to parents and professionals in the analysis of adolescent behaviors and intentions.

The seriousness and complexity of adolescent suicide issues should not be overestimated. More often than not, suicide is claimed to be a serious violation of the fundamental laws of morality and ethics. Werth (2000) writes, “it is not irrational to avoid hard – including pain and suffering – if there is some purpose to be served undergoing it […] committing suicide would be irrational as well as immoral, because it would evade that suffering” (p.19). Put simply, everything has its higher purpose, and avoiding pain and suffering is the same as avoiding life. Yet, these moral premises are not always feasible and logical. Not all pain and sufferings are necessarily constructive and useful. There is pain that does not serve any emotional purpose (Werth, 2000). This is particularly the case of adolescents who, due to the lack of life experiences, cannot envision their future clearly and optimistically. When pain becomes severe and long-term, enduring it is no longer possible. The longer is the pain, the more likely it is to interfere with adolescents’ mental and emotional functioning. In this state, adolescents cannot develop an outlook for pain-free recovery (Werth, 2000). The prospects to avoid pain by suicide become even more probable.   

It is not within the scope of this paper to judge adolescents for their decisions. Judgment and criticism will not do any good to them. Life is the greatest gift bestowed upon human beings, and it is within human abilities and skills to preserve and protect this life. Adolescents are extremely vulnerable to external influences and events. They tend to exaggerate the seriousness of their problems. Their emotions are difficult to control. This is why parents, school and mental health professionals play a crucial role in the development of suicide prevention instruments. The goal of this study is to prove that preventing adolescent suicide is absolutely possible. The most important is the amount of attention paid by adults to adolescent problems and concerns. This study will explore and critically appraise the current state of literature regarding adolescent suicide, to confirm the seriousness of the issue and urge the development of broad suicide prevention programs.

Goals and Objectives

The main goal of this study is to provide recommendations to prevent suicidal intentions and attempts in adolescents. The following research questions will have to be answered:

-         What is suicide?

-         What are the main global suicide trends?

-         How common is adolescent suicide?

-         What are the factors that affect and predispose suicidal intentions in adolescents?

-         How are adolescent suicide and immigration related?

-         How to prevent adolescent suicide?

Suicide: Definition and Trends

The meaning of suicide is often taken for granted. More often than not, suicide is the way individuals use to leave life prematurely. In other words, committing suicide is the same as killing oneself. In reality, however, suicidal behaviors are as diverse as their meanings. There is still no single, universal definition of suicide. Suicidal behaviors begin with individuals’ thinking to end their lives (Krug, 2007). Suicidal behaviors also include planning a suicide, getting means to realize these plans, attempting self-murder and, eventually, completing the task (Krug, 2007). The nature of suicide varies considerably, depending on the conditions and circumstances in which suicide occurs. It is no wonder that defining suicide is extremely problematic. The term ‘suicide’ is directly associated with aggressiveness and violence (Krug, 2007). The first time the term ‘suicide’ appeared in literature was in 1642, when Sir Thomas Browne, a famous philosopher and physician, used two Latin words, caedere (to kill) and sui (of oneself) to coin the word ‘suicide’ (Krug, 2007). Sir Thomas Browne sought to distinguish between the acts of homicide against another person and the acts of homicide against oneself. It was not before the 20^th century than an official definition of suicide was coined.

In 1973, the Encyclopedia Britannica published the first official definition of suicide: “the human act of self-inflicting one’s own life cessation” (Krug, 2007, p.185). Again, as in case with Sir Thomas Browne, human intention to die was at the heart of suicide definition and description. However, even this definition does not reduce the controversy surrounding the issue of suicide. The fact is that, when the person is dead, it is virtually impossible to reconstruct his (her) thoughts and decide with confidence that the death was nothing but an act of suicide. If the person made no clear statements regarding suicidal intentions and thoughts, distinguishing suicide from a murder or accident may become extremely problematic. Not all those who survive suicidal attempts want to live, and not all those who want to die plan to realize their suicidal intentions. Therefore, it is not always possible to define suicide as somebody’s voluntary intention to leave. Reasons behind suicides are so complex, and their outcomes are so devastating that defining suicide may become an unachievable task. For the purpose of this study, suicide will be defined as “completed suicide that refers to death which directly or indirectly results from an act that the dead person believed would result in this end” (Fonagy et al., 2010, p.304). This definition implies that suicide is (a) lethal; (b) nonhabitual; and (c) intended. In other words, suicide is an act of self-harm that always leads to death, is nonhabitual (unusual for a person) and planned.

If defining and describing suicide is not possible, it is better to look at the nature, types and consequences of various suicidal behaviors. Categorizing suicidal behaviors may shed some light on the analysis of suicide, its nature and implications. Although suicidal behaviors differ greatly across individuals, it is still possible to systematize the current knowledge of suicide and create the basis for the development of preventive strategies. Suicide is rarely accidental. In most cases, the act of self-inflicting death is preceded by the thoughts and considerations of dying. This is suicidal ideation, which refers to the thoughts and dreams of killing oneself (Krug, 2007). Suicidal ideation also covers the feelings of being tired of life and pessimistic about the future, feeling that life is not worth living, and thinking that it is better not to wake up from sleep (Krug, 2007). However, the fact that individuals think of suicide does not mean that they will actually attempt to die. Thousands of people experience similar feelings from time to time but, once their troubles are over, immediately forget about their worst feelings.

When suicidal intentions become permanent, self-mutilation may follow. Individuals with suicidal thoughts and intentions may apply to major self-mutilation, stereotypical self-mutilation or superficial-to-moderate self-mutilation (Krug, 2007). Self-mutilation differs greatly from suicide and is not discussed in this study. However, at times, self-mutilation may help in the analysis of suicidal behaviors and suicides, especially among adolescents. The current state of research and statistics helps to understand the seriousness and extent of the problem. In this chapter, the extent of suicide in general, including adults and adolescents, is discussed and analyzed.

Suicides represent one of the major causes of deaths among adults and adolescents. In the developed world, suicide remains one of the central causes of deaths among males 15-24 years of age (Fonagy, 2010). Although national rates of suicide vary considerably, it is clear that the highest rates of suicide are in Eastern European countries, including Belarus, Estonia and Lithuania, as well as the Russian Federation (Krug, 2007). In 2011, Lithuania had 61.3 male suicides per 1,000 of residents, compared to 10.4 suicides per 1,000 Lithuanian women (WHO, 2012). As of today, Lithuania is fairly regarded as the leader in the global suicide race. Sri Lanka is also well-known for high suicide rates (Krug, 2007). The lowest suicide rates are in Latin America, especially in Paraguay and Colombia (Krug, 2007). In Asia, the Philippines and Thailand are mostly free from suicides (Krug, 2007). These statistical data suggest that the rates of suicide depend on and change under the influence of numerous social and environmental factors. More surprising is the fact that, despite their advanced economic and social status, the countries of Europe have consistently failed to cope with the problem of suicide among all population groups. As of today, countries of Europe are somewhere in between the highest and lowest suicide extremes (Krug, 2007).

The rates of suicide and the risks of suicidal behaviors vary greatly across population groups. Age is one of the major factors of suicidal intentions in the general population. The incidence and prevalence of suicides increases with age, but young people aged 15-24 years are the most susceptible to the risks of committing suicide (Krug, 2007; Fonagy et al., 2010). Only those aged 75 and older face the risks of suicide three times higher than those in the 15-24 age group (Krug, 2007).

In England and Wales, suicide is the second common cause of death among 15-24 year olds, after motor vehicle accidents (Fonagy et al., 2010). In the United States, suicide is the second major cause of death among 15-19 year olds and the third major cause of fatalities among young people who have achieved 15-24^th year of age (Fonagy et al., 2010). Children under 12 rarely complete their suicide intentions; more common suicide intentions and acts become during the age of puberty, and their rates increase in each adolescent year (Fonagy et al., 2010). This information has profound implications both for this study and the analysis of adolescent suicides. On the one hand, if so many adolescents in the developed world commit suicide, then the reason may lie in their emotional and mental state after puberty. On the other hand, it is possible to assume that high rates of adolescent suicides reflect the lack of social conditions that favor adolescents’ emotional development and maturation, as well as the lack of effective prevention strategies against suicide. However, these are merely assumptions that need further analysis. What is certain is that adolescents, especially young girls and women, are prone to commit parasuicide, which is largely an adolescent phenomenon (Fonagy et al., 2010).

Here, parasuicide deserves special attention and becomes a good point of analysis in the study of adolescent suicide. The term “parasuicide” was created to help professionals and researchers to differentiate among deliberate self-harm and attempted suicide (Welch, 2001). The fact is that deliberate self-harm and attempted suicide are absolutely different behaviors. Many people, including adolescents, apply to self-harm with no intention to die (Welch, 2001). Yet, due to the existing confusions in terminology, these people are also referred to as “suicide attempters”, which distorts the overall picture of adolescent and adult suicide. The term “parasuicide” is applied to situations involving nonfatal self-injurious behaviors without any clear intent to cause death (Welch, 2001). Today, parasuicide is a common term used by mental health and sociology professionals in Europe and the United States. Whether or not the term ‘parasuicide’ is applicable in this study is to be decided later. At this moment, brief information on parasuicides completes the picture of the global suicide trends among adults and adolescents. The importance of parasuicide in the study of adolescent suicide should not be disregarded, since adolescent women display the highest rates of nonfatal self-injurious behaviors among all population groups (Fonagy et al., 2010; Welch, 2001).

Back to adolescent suicide, the postwar period in Europe and the United States was marked with an unprecedented increase in the prevalence and incidence of self-inflicted deaths among males (Fonagy et al., 2010). In the meantime, the rates of suicide in the oldest population groups rapidly decreased (Fonagy et al., 2010). Again, these changes in the global suicide trends suggest that environmental and social conditions play a huge role in the development of suicidal intentions and the number of self-inflicted deaths. What factors are responsible for the growing number of self-inflicted deaths among adolescents is to be discussed later. Unfortunately, even extensive statistics cannot expose the real tragedy of suicides among adolescents.

Adolescent suicide is a tragedy that can be prevented. Stories of teen suicides in the developed world are not uncommon. Reasons why adolescents choose to kill themselves are numerous, but it is clear that all these youngsters experience unbearable pain, so unbearable that only death can reduce it. Statistical data on suicides should be treated with great caution: since ways in which suicides are recorded in different countries vary substantially and make relevant comparisons difficult and extremely problematic. The changing conditions of performance, environment, globalization and technological advancement, including migration, place new demands on teenagers. Many of them cannot cope with their emotional troubles without external help. The role of parents and school systems in suicide prevention is crucial. As previously mentioned, statistics regarding suicide rates across countries and population groups are abundant. More scarce is the information which exposes the emotional and spiritual background of adolescent suicide. Not all parents can successfully and timely denote the risks and signs of suicide in their adolescent children. Consequences of parents’ failure to detect suicidal ideation in children may be tragic. This paper pays a tribute to all adolescents who have deceased prematurely and, as a result, have exposed the danger of suicide affecting all adolescents. Most, if not all, adolescent suicides could have been prevented. However, everything that happens in this world has its destiny and purpose. Hopefully, all those deaths have been in vain, teaching a good lesson of caution and emphasizing the need to keep adolescents from taking irrational decisions. This study will attempt to change the situation with adolescent suicides to the better, by learning the main factors and predictors of adolescent suicide and providing recommendations to prevent family tragedies similar to that which happened to Miss Sevin Elmas.

Literature Review

Statistics and global trends

Adolescent suicide is a popular object of contemporary research. Reasons and risk factors of adolescent suicide have been researched in abundance. Nevertheless, the issues and misunderstandings surrounding the issue of teen suicide continue to persist. The tragedy of adolescent suicide cannot be ignored. Parents and family members suffer the loss of their children. More tragic, however, is the realization that they could have prevented the loss, by being more attentive and thorough in their analysis of various precipitating events.

The current state of literature provides a brief insight into the history of suicide trends in the United States and the rest of the world. Researchers explore changes and variations in adolescent suicide statistics and, additionally, explore the relationship between completed suicides and attempted adolescent suicides. In 1991, Andrus et al. confirmed that suicide was the third leading cause of death among adolescents and youth, but for every completed suicide, between 30 and 200 suicides were attempted. Attempted suicide has far-reaching implications for understanding the nature of adolescent suicide, since ten percent of adolescents who already attempted suicide will try to repeat their attempt within one year (Andrus et al., 1991). Andrus et al. (1991) specifically focused on attempted adolescent suicides in Oregon, suggesting that during the 1980s, suicide accounted for at least 16% of deaths in Oregon adolescents aged 13-19. Today, repeated suicide attempts continue to stir the hearts and minds of professional researchers. Almost 20 years later, Gryedanus, Bacopoulou and Tsalamanios (2009) explored the repeated suicide phenomenon and concluded that at least one suicide attempt would raise the probability of another attempt 15-fold. Statistically, 30% of adolescents aged 13-18 who already tried to commit suicide have 2-3 attempts per year, and 17% of “attempted” adolescents have 4 or more attempts during one year (Gryedanus et al., 2009). Reasons why adolescents commit repeated suicide attempts are numerous, from depression and violence to sexual assault, weight gain in girls and substance abuse (Gryedanus et al., 2009). Repeated suicide attempts have far-reaching consequences for adolescents’ emotional and psychiatric state of being, and the analysis of factors leading to attempted suicide can shed light on the reasons and possible prevention strategies in the context of adolescent suicide.

Contemporary researchers explore the global and national statistics of adolescent suicide. Greydanus et al. (2009) calculated that as many as 200,000 adolescents ended their lives through suicide every year in all parts of the world. In the United States, the rates of adolescent suicide varied throughout the 20^th century and reflected the changes and pressures of greater societal forces on young people (Greydanus et al., 2009). The 1930s witnessed the highest rates of teen suicide, partially due to the Great Depression and serious economic difficulties faced by young people and their parents (Greydanus et al., 2009). In the 1940s and 1950s the rates of teen suicide in the U.S. decreased dramatically, but increased again in the 1960-1990s (Greydanus et al., 2009). Since the beginning of the 1990s, the rates of adolescent suicide in the U.S. steadily declined (Greydanus et al., 2009). McKeown, Cuffe and Schulz (2006) support these findings. Like Greydanus et al. (2009), McKeown et al. (2006) cannot explain the reasons behind the rapid changes in adolescent suicide rates in the U.S. during the latter half of the 20^th century. McKeown et al. (2006) are confident that broader societal forces have nothing to do with the rapid fluctuations in teen suicide rates in the country. Most probably, and Greydanus et al. (2009) propose this explanation, it is due to the rapid development of medicine and increased use of serotonin reuptake inhibitors to deal with adolescent depression that the rates of teen suicide in the country have decreased. However, if medicine helps to reduce adolescent suicide rates, it is not clear why Japan is still at the forefront of the global adolescent suicide landscape. Japan is well-known for its suicide problems, and the rates of self-induced death among Japanese adolescents continue to increase (Gryedanus et al., 2009). Suicide rates among the 20-24-year-old group are twice as high as those among the 15-19-year-old Japanese (Gryedanus et al., 2009). The situation in Turkey is no better: Uzun et al. (2009) examined suicide among children and adolescents in one Turkish province and discovered that the prevailing majority of teen suicides were completed by adolescents 15-19 years of age. These data support the global trend. Possible reasons why adolescent suicide rates increase globally may include the loss of social cohesion, unemployment and economic instability, depression, etc. (Wasserman, Cheng & Jiang, 2005).

Unfortunately, using global statistics as the basis for the analysis of the teen suicide phenomenon is not always appropriate. Researchers recognize the difficulties obtaining and using adolescent suicide statistics. Basically, not all countries report their suicide data (Wasserman et al., 2005). For example, Wasserman et al. (2005) were able to find the data for only 90 countries out of 192 nations available. Even then, the reliability of adolescent suicide statistics is questionable, since suicides tend to be underreported for various religious and cultural reasons (Wasserman et al., 2005). Relatives of suicides may not be willing to disclose the true reason of death, masking it by other, similar death categories (Wasserman et al., 2005). Simultaneously, death from suicide in adolescent populations may be masked or misclassified unintentionally, making the global picture of teen suicide misbalanced and statistically dysfunctional (Wasserman et al., 2005). All these difficulties further complicate the international comparability of suicide data: given that doctors and police in different countries follow different routine procedures; these differences may further affect the validity of the national and international suicide statistics (Wasserman et al., 2005).

Another problem is that the death category ‘suicide’ is questioned continuously (Mohler & Earls, 2001). Nonrandom bias and random error lead to serious misclassifications in suicide statistics (Mohler & Earls, 2001). The lack of suicide-specific information, especially concerning attempted suicides, leads to underreporting of data (Mohler & Earls, 2001). Again, Mohler and Earls (2001) mention religious and cultural considerations of suicide, which further affect the degree to which adolescent suicides are reported officially. Despite these problems, the current state of research provides abundant information regarding the most prevalent reasons and risk factors of suicide among adolescents.

Reasons why adolescents commit suicides

Needless to say, different adolescents face different barriers to realizing their dreams. A young person experiences serious emotional pressures that naturally accompany the process of his (her) maturation.  School problems, low grades, the lack of parental support and family cohesion, abuse and violence, and other reasons may readily result in the development of suicidal intentions and behaviors. Certainly, not all teenagers who experience these problems will want to kill themselves. More often than not, suicide is a complex result of multiple influences. Researchers have no consensus with regard to the most common suicide reasons, but it is still possible to delineate certain trends in the development and realization of teenagers’ suicide decisions.

It should be noted that, in most cases, adolescent suicide is preceded by one or a series of precipitating events, which fuel the hidden forces of stress and depression and push teenagers to complete the act of self-induced death. Hill et al. (2012) discussed various precipitating events in adolescent suicidal crises, and their findings provide a vast landscape for exploring the main causes of adolescent suicide. Earlier researchers found that various events could become a major precipitating factor leading to teen suicide (Hill et al., 2012). The nature of these events varies considerably, from a stressful situation to broken relationships and the loss of a significant other (Hill et al., 2012). More interesting, however, are the causes and drivers of teen suicide in the absence of precipitating events, and this is what Hill et al. (2012) tried to explore. Really, only 40-90% of adolescents experience a precipitating event leading them to suicide. The act of teen suicide in the absence of a precipitating event suggests that adolescent suicide is much more complicated than previously established. Self-induced death which is not attributed to a precipitating event may take place as a result of adolescents’ heightened sensitivity, stress reactivity or cognitive reactivity, all of which lead to the subsequent activation of suicidality in adolescents (Hill et al., 2012).

The fact that Hill et al. (2012) refer to stress reactivity and sensitivity is not surprising, as stresses are believed to be at the heart of most suicidal intentions and behaviors in teenagers. Paulson and Everall (2001) reviewed the results of the Teen Suicide Research Project and found that the most common reasons why adolescents committed or attempted suicide included: (a) “major negative life events as divorce, death, or extreme difficulty at school; (b) many daily stresses that contributed to feeling overwhelmed; and (c) few or no social supports” (p.93). Teachers’ negative reactions at school make it even more difficult for adolescents to cope with their suicidal intentions (Paulson & Everall, 2001). By contrast, teachers who react positively to adolescents and their classroom problems can successfully erase the pain of distress experienced by teenagers for various reasons (Paulson & Everall, 2001). These results are suggestive of the huge role which educators play in preventing suicidal intentions in adolescents. Very often, adolescents may experience the feelings of loss, stress and entrapment, which result in suicidal ideation and, later, suicidal attempts and completed suicide (Taylor et al., 2011). The concepts of entrapment and defeat are rooted in the developmental models of depression and explain the state when individuals have a powerful motivation to escape the difficult situation but are blocked from doing it (Taylor et al., 2011). The feeling of defeat emerges when individuals fail to achieve their status-related goals (Taylor et al., 2011). This is also the feeling experienced by adolescents, when they persistently try but fail to escape a difficult situation. In other words, the feeling of entrapment, if it persists during lengthy periods of time, can readily become the basis for the development of defeat perceptions.

Whether or not family can generate the feelings of entrapment and defeat is difficult to define, but it is clear that family, or the lack of cohesive family relations, can become the main driver of suicidal intentions in teenagers. This is the issue that was explored by Au, Lau and Lee (2009). Au et al. (2009) analyzed the effects of family cohesion and social self-concept on suicide ideation in adolescents and found that better family support and positive peer relationships were negatively related to suicidal ideation in teenagers. That is, the better were the family support and peer relationships the less likely were adolescents to experience suicidal intentions (Au et al., 2009). The fact is that low family cohesion and the lack of peer support, as well as family dysfunction and familial conflict, contribute to the development and aggravate depressive symptoms (Au et al., 2009). They increase the risks of suicidal ideation in adolescents (Au et al., 2009). These can be followed by neglect, dissociation and abuse in families. Zoroglu et al. (2003) examined the relationship between self-mutilation, suicide attempts, abuse, dissociation and neglect among Turkish high school students and discovered that self-mutilation and suicidal attempts were directly associated with abuse, dissociation and neglect. Among adolescents who reported at least one type of abuse were 2.7 times more likely to engage in self-mutilation and 7.6 times likely to attempt suicide (Zoroglu et al., 2003). These findings suggest that the prevention of suicide among adolescents should start with screening for abuse, neglect, depression and dissociation.

The presence or absence of giftedness and its implications for adolescent suicide should not be disregarded. It appears that giftedness places adolescents at increased risks for developing suicidal moods (Delisle, 1986). The mechanisms of the giftedness-suicide relationship are poorly understood, but Delisle (1986) reports that gifted individuals are extremely susceptible to suicide attempts. One possible reason is that advanced intellectual development in teenagers increases the gap between their emotional and cognitive demands and the social, physical and emotional realities in which they live (Delisle, 1986). Very often, gifted students who experience excessive popularity in elementary years lose this popularity in high school (Delisle, 1986). These readjustments may generate anxiety and depression in adolescents, leadings to suicides (Delisle, 1986). Finally, giftedness is not a guarantee in the development of sustained peer ties (Delisle, 1986). More often than not, gifted students outpace their peers in intellectual development and, therefore, fail to find good friends and establish effective social networks. This isolation may also be responsible for the development of suicidal moods (Delisle, 1986). Yet, reasons why adolescents commit suicides differ greatly from the risk factors of suicidal moods in adults. While reasons may be extremely different and diverse, the knowledge of risk factors for adolescent suicide can enhance the quality of screening and adolescent suicide prevention procedures.

Risk factors

 What increases the risks of suicide attempts and self-induced deaths in adolescents? Contemporary literature provides a wealth of information concerning the most prevalent risk factors of adolescent suicide. Shaffer and Craft (1999) explored the main risk factors of adolescent suicide and found that “much of what we know about the characteristics of adolescents who commit suicide is derived from epidemiologically based psychological-autopsy studies” (p.70). As a result, psychiatric disorders are rightly considered as one of the most solid predictors of suicidal intentions in teenagers, especially when adolescents report persistent symptoms for more than 2 years (Shaffer & Craft, 1999). Substance abuse and mood disorders also predict high risks of suicidal behaviors in teenagers (Shaffer & Craft, 1999). Suicide victims often display the symptoms of conduct disorder; unfortunately, only half of suicide victims are later reported to have been in contact with a psychiatrist (Shaffer & Craft, 1999). Most adolescents perceive suicide as a unique and extremely effective method to solve their problems (Laskite & Laskene, 2011). Few of them seek professional assistance, even when they realize the seriousness of the suicidal problem (Laskite & Laskene, 2011).

Stress is one of the central themes transcending all aspects of the adolescent suicide literature. Stress, depression and hopelessness are believed to be at the heart of most suicidal intentions and moods among adolescents (Wilburn & Smith, 2005). Stress is generally defined as a response of the human body to any external stimulus that results in the disruption of individual homeostasis (stability) (Wilburn & Smith, 2005). Stresses are neither escapable nor avoidable, and it is no wonder that, faced with another stressful stimulus, individuals inherently try to restore their emotional balance (Wilburn & Smith, 2005). In most instances, the degree to which adolescents experience stress depends upon the significance assigned to each particular event (Wilburn & Smith, 2005). The less significant is the event the less stressful it becomes. Here, self-esteem is one of the principal factors mediating the relationship between stress and suicidal intentions. In this sense, low self-esteem in adolescents may be readily considered as a serious risk factor of suicidal moods and decisions in adolescents. Self-esteem is a complex mechanism used by individuals to judge the significance of their self against the environment in which they live (Wilburn & Smith, 2005). Self-esteem issues in adolescents have been abundantly documented. Self-esteem and life stressors are inversely related (Wilburn & Smith, 2005). Positive self-esteem will help adolescents to cope with their life difficulties.

Stress alone can hardly be responsible for the high rates of suicide in adolescent populations. The lack of family support and cohesion is often cited among the most prevalent risk factors of adolescent suicide. In the context of adolescent suicide, the topic of family cohesion and support has been explored in abundance. Baumann, Kuhlberg and Zayas (2010) found that the rates of teen suicide among certain ethnic groups were directly related to the quality of the family contexts in which adolescents were raised. Baumann et al. (2010) defined familism as the emphasis on interdependence within families, family cohesiveness, loyalty and responsibility, caring and placing family interests before personal needs, and its effects on adolescent behaviors were mostly positive. Cohesive families protect adolescents from the negative influence of various social problems, enhance self-esteem in teenagers and, as a result, can predict and prevent suicide attempts in adolescents (Baumann et al., 2010). Mutuality (or the relationships among family members characterized by empathy, authenticity, engagement and empowerment) adds relevance to preventive strategies (Baumann et al., 2010). The lack of these aspects in adolescents’ relations with parents and other family members can put them at heightened risks for suicide, self-mutilation and suicide attempts (Baumann et al., 2010). Kwok and Shek (2010) confirmed those findings: suicidal ideation in adolescents is directly related to the quality of their communication with parents – improved father-adolescent communication reduces the risks of suicides in teenagers.

Not all researchers agree that family problems are responsible for the development of suicidal intentions in adolescents. Moskos, Achilles and Gray (2004) suggest that holding families and social stress responsible for adolescent suicide is one of the major mistakes made by researchers and practitioners. Any stressor can trigger suicidal intentions in adolescents, but most of these stresses are common in the lives of teenagers and rarely lead to such tragic outcomes (Moskos et al., 2004). Moskos et al. (2004) claim that not stressors but psychiatric disorders that are prevalent in adolescents, coupled with substance abuse and conduct problems, are responsible for the growing risks of suicide in this population group. In reality, Moskos et al. (2004) fail to account for the role which family stressors and social problems play in the development of conduct problems and substance abuse complexities. The latter, in turn, result in self-mutilation and suicide among teenagers. It is at least incorrect to say that psychiatric disorders are the only source of suicidal ideation in young people. Once adolescents make the first attempt to kill themselves, the risks of completing suicide increase dramatically (Dilli, Dallar & Cakir, 2010). Dilli et al. (2010) investigated the adolescent suicide situation in Turkey and confirmed that a previous suicide attempt is the most serious predictor of completed suicides in adolescents, and only cooperation among school, families and counseling professionals can reduce the risks of attempted and completed suicides among adolescents.

Suicide methods

 What methods do adolescents choose to commit suicide? An answer to this question can help to decide what strategies are the most effective in the prevention of adolescent suicides. As of now, literature discussing suicide methods among adolescents is rather scarce. However, it is clear that the most common suicide method used by adolescent males in the United States is firearms, followed by hanging and intentional motor vehicle accidents (Greydanus et al., 2009). By contrast, adolescent females are more prone to use self-cutting or a drug overdose (Greydanus et al., 2009). However, compared to the 1990s, adolescent females are turning towards more deadly methods of self-induced death, such as firearms (Greydanus et al., 2009). Simultaneously, there is a marked increase in the frequency of hanging suicides among all adolescents 10-19 years old (Greydanus et al., 2009). Yet, hanging is hardly the most lethal method of inducing death in adolescents.

The choice of suicide methods greatly depends upon the outcomes which adolescents are willing to achieve (Spicer & Miller, 2000). Like many years ago, firearms remain the most lethal method of committing suicide among teenagers (Shenassa, Catlin & Buka, 2003; Spicer & Miller, 2000). It is no wonder that those who seek to complete suicide choose firearms, whereas attempters are more likely to use drug overdose (Andrus et al., 1991). Drowning and hanging are further considered to be among the most lethal methods of suicide chosen by adolescents, whereas gas poisoning, self-cutting, and drug overdose are the least lethal (Spicer & Miller, 2000). The more frequent is the use of firearms as a method of suicide the higher the rates of suicide become (Spicer & Miller, 2000). Statistically, suicide attempts involving the use of firearms are 2.6 times more lethal than hanging (Shenassa et al., 2003).      

One of the most important questions is whether limiting adolescents’ access to suicide methods can become an effective method of preventing adolescent suicide. “Because youth suicide is often an impulsive act, it is reasonable to expect that limiting access to commonly used methods could prevent its occurrence in some instances” (Rutter & Taylor, 2002, p.545). For example, in Great Britain, the decision to replace poisonous domestic coal gas with natural gas led to considerable reductions in suicide rates (Rutter & Taylor, 2002). A decrease in the number of deaths attributed to coal gas asphyxiation led to the subsequent decrease in adolescent suicide rates by approximately 26% (Rutter & Taylor, 2002). Notably, no compensatory increase in adolescent suicides by other methods was noted in Britain (Rutter & Taylor, 2002). These results do not support the findings reported by Ohberg, Lonnqvist, Sarna, Vuori and Penttila (1995), who found that restriction of a suicide method for adolescents reduced its use during suicides, but other methods emerged and replaced them. Therefore, it is difficult to say that the restriction of suicide methods can stop adolescents from committing suicide. Here, the heritability of suicide methods should be also considered. Lu et al. (2011) found that suicide methods used by adolescents were the same used by their suicidal parents. Adolescents who seek to commit suicide and have the family history of suicidal ideation are more likely to choose the method used by their suicidal parents than by their peers with no history of suicide in families (Lu et al., 2011). This information can become a serious driver in the development and implementation of preventive mechanisms. In other words, adolescents who had suicidal parents should be constantly monitored, and their access to the suicide methods used by their parents should be severely restricted. As of today, parents, school professionals and counselors have free access to the wealth of information concerning the most popular risks and methods of suicide prevention in teenagers. Unfortunately, the effects and implications of immigration for the development of suicidal intentions in teenagers are persistently disregarded.

Gender, immigration, and adolescent suicide

 Gender and immigrations can potentially elevate the risks of suicide moods and attempts among adolescents. The significant gender differences in adolescent suicide trends suggest that gender is an important predictor and, simultaneously, an essential factor of adolescent suicide prevention. Jegannathan and Kullgren (2011) suggest that considerable gender differences in how adolescents address and express their suicidal ideation, highlight the critical value of gender-specific suicide prevention programs for teenagers. Gender greatly affects the prevalence of suicidal expressions, life skills, mental health profiles and frequency of exposure to suicide intentions and risks (Jegannathan & Kullgren, 2011). The presence of internalizing syndrome raises the risks of serious suicidal expression in women (Jegannathan & Kullgren, 2011).

Immigration is no less serious. Migration and immigration are frequently associated with the risks of suicide among adolescents and adults (Stack, 2000). Wadsworth and Kubrin (2007) write that social structure, culture and suicide are intricately related, but all these factors have unique effects on immigrant populations. Native-born citizens have greater resilience and emotional stability fighting with the major social life issues, whereas immigrants undergoing the difficulties of assimilation and economic disadvantage, the lack of affluence and ethnic inequality are more susceptible to suicide risks (Wadsworth & Kubrin, 2007). Even when adolescents do not migrate personally but are simply born in immigrant families or have the family history of immigration, the risks of suicide become increasingly high: immigrant generation status, problematic alcohol use, repeated drug use and other factors altogether exemplify an important determinant for suicide attempts among foreigners (Pena et al., 2008). Ponizovsky, Ritsner and Modai (1999) explored suicidal ideation and suicide attempts among immigrant adolescents from the U.S.S.R. to Israel, and the prevalence of suicides in the immigrant sample was much higher than in the nonimmigrant control group. Here, reasons why immigration subjects adolescents to increased suicide risks should be explained in more detail.

Anthropology and the study of culture play one of the central roles in today’s analysis of adolescent suicide. In anthropology, adolescence is categorized as a distinct life stage, characterized by preparation for adulthood and serious social transitions (Buchholz, 2002). Many anthropologists describe adolescence as the period of transition and crisis, and these perceptions occur everywhere across cultures (Buchholz, 2002). Modernization, urbanization, and economic growth give rise to new psychological stressors in the developing world, similar to those affecting youth in industrialized countries (Buchholz, 2002). The situation is particularly difficult in societies that are just entering a new stage of cultural development, since this situation is frequently associated with a conflict of traditions and innovations (Buchholz, 2002). From the anthropological viewpoint, adolescent suicide is more a cultural than individual or family phenomenon, and the conflict of traditions and innovations can potentially reinforce suicidal behaviors in teenagers (Buchholz, 2002). New cultures disrupt traditional socialization processes and social roles, leading to the rapid expansion of suicidal intentions in youth (Buchholz, 2002). Needless to say, immigration amplifies these influences. Immigration is associated with the rapid and dramatic transitions to a new level of cultural existence, and suicidal behaviors come to represent a unique form of resisting to the pressures brought on teenagers by the new culture (Buchholz, 2002).

Another explanation of the immigration-adolescent suicide relationship is rooted in the theory of social integration. The latter is a popular instrument of research in the context of adolescent suicide. Immigration is the process of relocating an individual from the country of birth to a new country (Wadsworth & Kubrin, 2007), and it is not difficult to see that immigrants naturally lose their domestic country connections and ties. Immigration and domestic migration can break the important ties between the immigrant and the social system in which he (she) used to live (Stack, 2000). These may include relative bonds, neighbors and familiar geography, friends and co-workers, etc. (Stack, 2000). Stack suggests that the loss of social cohesion is further complicated by changes in dress conventions, language and residential dwelling, new traditions and diets. It is no wonder that faced with the alien environment, adolescents may feel depressed and choose suicide as a method of escaping the unbearable reality of the new life. However, the magnitude of immigration effects on adolescent suicide rates varies by ethnic background and religion (Stack, 2000). For example, Catholic communities offer considerable support and are characterized by strong community ties in all parts of the world; as a result, immigrants with Catholic backgrounds have greater chances to easily assimilate in a new country and environment (Stack, 2000). There is a popular assumption that the risks of suicide in immigrants are directly associated with the degree to which immigrants mourn their respective cultures (Stack, 2000). Depending on the culture, religion and ethnic background, individuals may have stronger or weaker coping mechanisms and, consequentially, lower or higher suicide rates when coming to live and work in a foreign country (Stack, 2000).

Finally, in adolescent lives, immigration is always a serious, stressful event. “Immigration as an apparently uncontrollable life situation often leads to either exacerbation of preexisting problems of emergence of new ones that are usually considered risk factors for suicidal behavior among adolescents” (Ponizovsky et al., 1999, p.1434). Adolescents face barriers to assimilation and adaptation, and difficulties in relations with parents are cited as the principal obstacle to easy adaptation in a new country (Ponizovsky et al., 1999). Suicidal ideation is further linked to the hardships experienced by immigrant adolescents in their relationships with peers (Ponizovsky et al., 1999). Expressed hostility to immigrant adolescents and malevolence greatly contribute to the development and expansion of suicidal moods in immigrant teenagers (Ponizovsky et al., 1999). Knowledge of these mechanisms is extremely important for the development of effective preventive strategies.

Adolescent suicide prevention

Present day literature provides a wealth of information concerning possible ways to prevent adolescent suicide. Methods of suicide prevention proposed by researchers vary from school-based screening to more complex counseling and medical interventions. Contemporary researchers can freely access any information needed to develop effective models of intervention, and Shaffer and Craft (1999) developed a heuristic model for suicide prevention among adolescents. Based on their model, adolescents commit suicide only when an underlying condition, such as substance abuse or a mood disorder, should be present (Shaffer & Craft, 1999). Moreover, for suicide to take place, a stressful event should activate the underlying condition (Shaffer & Craft, 1999). For adolescents, the loss of a relationship or a disciplinary crisis can readily turn into a serious stressful condition (Shaffer & Craft, 1999). Shaffer and Craft (1999) ground their model on the assumption that stresses often result in the development of anticipatory anxiety, and suicide is nothing but an avoidant response to this stress.

The complexity of the discussed model cannot be ignored. Its effectiveness and implications for adolescent suicide need further validation and empirical support. In the meantime, school remains one of the most promising media of dealing with the problem of adolescent suicide. The main reason why schools can become the major instrument of preventing teen suicides is because schools often become the principal source of emotional and cognitive controversies for the young people. Schools are pressured to provide social and psychological support to adolescents (Speaker & Petersen, 2000). Schools are expected to offer health screening and cooperate with probation officers and police in the prevention of substance and sexual abuse (Speaker & Petersen, 2000). Schools are expected to actively promote safety, good nutrition, social skills and general health in children and adolescents (Speaker & Petersen, 2000). In light of all these complexities, the connection between school violence and adolescent suicide often falls beyond the realm of research and professional attention in public schools. Apparently, schools possess enormous adolescent suicide prevention potentials. Proactive and comprehensive reorganization of public schools could give adolescents another chance to avoid the risks of suicide (Speaker & Petersen, 2000). Schools must provide a broad range of additional services, aimed to enhance cohesion in adolescents’ families, improve adolescents’ relations with parents and peers, and alleviate the burden of violence and hostility, especially against immigrant children, in order to prevent potential suicides (Speaker & Petersen, 2000). To prevent adolescent suicides, schools need to be staffed with personnel who are both pedagogically proficient and professional in providing comprehensive values education (Speaker & Petersen, 2000). For example, social skills curriculums could empower adolescents to shape quality relationships and networks with peers. Additionally, teachers should use inclusive strategies to address every student’s developmental needs, including alternative reading materials, classroom communications and informed choices, and reaching out parents to make informed curriculum design decisions (Speaker & Petersen, 2000).

Certainly, all these recommendations have a broad and public character. Simply stated, implementing these recommendations can be extremely difficult, especially in public schools, due to serious financial and social constraints. That, however, does not mean that schools cannot do anything to deal with the problem of adolescent suicide. Scott et al. (2010) recommend that school-based screening mechanisms are used to identify and timely address suicide risks in adolescents. Scott et al. (2010) assert that the Columbia Suicide Screen can be used to reduce suicide risks and intentions in the target population, save time and costs and, simultaneously, identify almost all students facing high risks of suicide. This is the model public schools could use to detect children who think of committing suicide. At times, teachers may simply need to ask their students about how they feel about their academic performance (Martin et al., 2005). The importance of this simple question is justified by the fact that perceived academic performance and students’ perceptions of ‘failing’ grades predict the development and realization of suicidal intentions among teenagers (Martin et al., 2005). Depending on the answer, teachers may initiate an in-depth clinical assessment of adolescents for the risks of suicide (Martin et al., 2005). The results of clinical assessments will either indicate the need for or deny the relevance of psychiatric or counseling treatment.

A variety of counseling and medical strategies can be used to address the risks of suicide in adolescents. Goodkind, LaNoue and Milford (2010) examined the implementation of Cognitive Behavioral Therapy for American Indian adolescents with predisposition for suicidal ideation and risks. The intervention was intended to address violence trauma in American Indian adolescents, and was culturally adapted to suit the needs of the target population (Goodkind et al., 2010). At each school involved in the program, two facilitators were responsible for program implementation, and CBT was the foundational ingredient of the discussed intervention, leading to significant decreases in adolescents’ anxiety, avoidant coping and posttraumatic stress (Goodkind et al., 2010). CBT also helped to reduce depression in teenagers (Goodkind et al., 2010). Here, Diamond, Wintersteen and Brown (2010) also used attachment-based therapy to reduce suicidal ideation in children and adolescents. Again, the therapy reduced considerably the depressive symptoms in adolescents who participated in the program (Diamond et al., 2010).

At times, medication and psychiatric hospitalization may help adolescents to reduce their anxieties and suicidal intentions. Boekamp and Martin (2010) recommend using psychiatric partial hospital treatment for young children with severe behavioral problems, whereas Olfson, Shaffer, Marcus and Greenberg (2003) suggest the presence of a strong relationship between depression medication and suicidal intentions in adolescents. The older is the age the stronger is the relationship between medication and suicidal ideation in young people (Olfson et al., 2003). However, even the most effective treatments cannot reduce the pressure of social influences, unless teachers and school principals act to destigmatize depression in adolescents and support them as they are going through the major life changes (Cash, 2003). Based on these findings, schools should become the major platform for the development and implementation of suicide prevention initiatives for adolescents.

Other considerations

While adolescent suicide remains one of the major problems in the developed world, it is at least surprising that the emotional and social consequences of adolescent suicide remain beyond the scope of professional research. Only Lindqvist, Johansson and Karlsson (2008) described the psychosocial consequences of adolescent suicide for the surviving family members. Lindqvist et al. (2008) confirm the major suspicion that teenage suicide is a devastating trauma for all family members. The scope of grief experienced by the surviving family members as a result of teenage suicide is difficult to estimate. For years following teenage suicide, parents and relatives struggle to come to terms with the question “why?” (Lindqvist et al., 2008). Parents try to find a rational and relevant answer as to why their child committed suicide and what they can do to proceed with their own lives (Lindqvist et al., 2008). In most cases, parents who have other children have no choice but to continue their lives against all odds (Lindqvist et al., 2008). Parents and family members try to find the meaning in the act of suicide committed by their children; suicide notes left by adolescents provide little assistance in demystifying the meaning of their suicidal choices (Lindqvist et al., 2008). Helplessness is one of the most prevalent feelings pervading all families which have undergone the loss of a child through suicide (Lindqvist et al., 2008). Even in their daily activities, families keep being preoccupied with their loss (Lindqvist et al., 2008).

What Lindqvist et al. (2008) write in their article exposes the emotional complexity and tragedy of teenage suicide. Some parents feel deceived by their children, whereas others experience aggression towards the child who committed suicide (Lindqvist et al., 2008). Some parents even think of committing suicide themselves, but being familiar with the emotional consequences of suicide, they are reluctant to pursue the same tragic path (Lindqvist et al., 2008). It goes without saying, that parents need qualified medical support, in order to cope with the feelings of loss, guilt, aggression, and disbelief. Yet, even with the presence of sophisticated social assistance networks and medical care, it is difficult to imagine that loving parents will ever reconcile with losing their child, until the end of their lives.

Teenage suicide is associated with profound short- and long-term changes in family members’ perceptions of the reality. However, is it at all abnormal for adolescents to experience suicidal intentions? The current state of research builds on the philosophy that suicidal intentions and ideation are medically and psychologically abnormal, and numerous intervention strategies are developed to tackle with and prevent the issue. The abnormality of adolescent suicide is taken for granted, but Marcenko, Fishman and Friedman (1999) suggest that suicidal behaviors may be part of adolescence and maturation. Marcenko et al. (1999) found that the nature of suicidal ideation and low self-esteem did not vary significantly across gender, ethnicity or other psychosocial variables, which raises the question of reconceptualizing the relationship between suicidal ideation and normal adolescent development. Yet, even if suicidal intentions are an important ingredient of adolescence and transition to adulthood, that does not mean that they should not be prevented. Despite the growing body of literature, future research is needed to identify the most effective strategies to prevent suicide in teenagers.

Objectively, there is no treatment for adolescent suicide. Everything written and said about suicidal adolescents offers strategies that deal with teenage suicide indirectly, through the treatment of depression and related mood disorders. Cognitive Behavioral Therapy, Attachment Based Therapy, Dialectical Behavior Therapy, and other instruments have the potential to reduce the scope of the adolescent suicide tragedy (Apter, 2010). Future researchers should focus on defining adolescent suicide and improving the existing definitions of suicidal behaviors. Gender and immigration status affecting suicidal behaviors in adolescents should be better understood. Future research is needed to understand how biological, social and psychological factors interact to result in suicidal behaviors and assess the validity and reliability of the existing prevention programs and their applicability in different settings.

Miss Sevin Elmas: The Tragic Story of Life

Developing effective preventive strategies for adolescents at high risks of suicide is impossible without understanding what exactly pushes young people to commit suicide. Adolescents are believed to have everything ahead. They face unlimited prospects to realize their dreams and strivings. Unfortunately, adults do not always understand the complexity of feelings and situations adolescents naturally undergo in their transition to adulthood. Actually, adolescence by itself is the process of painful transition to new experiences and responsibilities, and it is a pity that adults, who used to be adolescents, easily forget their own difficulties and problems during adolescence. Tragic and painfully brief was the life of Miss Sevin Elmas. Despite the pain and sorrow caused by her loss, her life and death can teach a good lesson to thousands of adolescents, parents and educators around the world. As her niece and person who treasures Miss Sevin’s memories and contribution, I sincerely hope that both her life and death were not in vain.

Miss Sevin Elmas was born in 1969 in Istanbul. She was the second child of her parents and the first daughter born to her parents. She had three other brothers and sisters and, for the most of her childhood, the life of Miss Sevin was overfilled with joy and happiness. She was loved by everyone. Her kindness and empathy drew friends to her. Everybody considered her to be a sweetheart, and it is no wonder that she was very popular among her relatives and friends. As a child, she never hesitated to share her lunch with others. She was always willing to help. She showed deep respect for the elderly people and was extremely polite with her teachers. She was as perfect as her life, in a family with loving parents and siblings; but not until her parents decided to immigrate to Germany.

In 1982, the whole family relocated to Germany. Looking back into her life, it is clear that 1982 became the beginning of Miss Sevin’s tragic death. The pain and sorrow she experienced upon being separated from her friends and relatives were enormous. No words can describe what a 13-year-old adolescent girl felt, when she realized that relocation, adjustment and assimilation were inevitable. Most probably, her life at that time was filled with the fear and anxiety about the unknown future. One of the biggest problems faced by Miss Sevin was the lack of language proficiency. She was 13 and she did not speak German. That was the main reason why Miss Sevin was placed to a school for low performers, with the hope that she would have greater chances to improve her grades and catch up with the knowledge and disciplines to move to a better educational facility.

The decision