Adolescent Suicide Risk: Case Study Assessment and Treatment

Introduction

Today, alarming numbers of young people are contemplating taking their own lives, and many follow through on their suicidal ideations to actually kill themselves or to make an attempt. Suicide represents the second-leading cause of death for people aged 15 to 34 years and is the third-leading cause of death among young people aged 10 to 14 years (Suicide facts at a glance, 2015). To gain some additional insights into these issues, this case study provides a description of a hypothetical 14-year-old runaway Caucasian adolescent, "Jane," who was referred from a homeless shelter with suicidal ideations. The study aims to determine what screening and testing should be performed, to discuss current recommended treatment protocols including pharmacological and non-pharmacological interventions, and to describe expected treatment outcomes along with a corresponding time frame and follow-up plan.

Patient Assessment and Screening Tools

Case Description and Anticipated Examination Findings

The subject in this case study is Jane, a representative teenager who ran away from home two months ago to escape an abusive stepfather and a noncommittal biological mother. Since that time, Jane reports having engaged in sexual acts in exchange for food and drugs, as well as several instances of shoplifting for food, though she claims she has never been caught. The client appears malnourished, dehydrated, dirty, and disheveled, with torn clothes and matted hair. She also admits to contemplating suicide before she ran away and notes that the frequency of these ideations has increased significantly in recent weeks. When asked whether she had made any firm plans for carrying out a suicide, Jane concedes that she does not have any concrete ideas but has alternatively considered jumping in front of a fast-moving car or taking an overdose of a drug that "could do the job." The client presents seeking help to "turn her life around" and to address her suicidal thinking patterns.

Unfortunately, Jane's case is certainly not unique or even uncommon. According to the U.S. Centers for Disease Control and Prevention, in 2013 nearly one-quarter (22.4%) of female adolescents and just over one in ten (11.6%) of male adolescents had seriously considered taking their own lives at some point during the previous year (Suicide facts at a glance, 2015). Moreover, nearly as many male adolescents (10.3%) and even more female adolescents (16.9%) had made plans concerning how they would commit suicide at some point during the previous year.

More troubling still, many adolescents act on these suicidal ideations. Approximately twice as many female adolescents as male adolescents (5.4%) had made at least one suicide attempt during the previous year, and about the same ratio — 3.6% of female adolescents and 1.8% of male adolescents — suffered an injury, overdose, or poisoning episode as a result of a suicide attempt that required medical intervention. These rates are even higher for minorities in the United States (Suicide facts at a glance, 2015), making the need for timely and accurate assessment essential.

Assessment Instruments

The assessment of adolescents such as Jane for suicide includes determining their individual needs in order to formulate an efficacious intervention (National Action Alliance for Suicide Prevention, 2013). Patient assessment is needed to identify the reasons that adolescents are contemplating suicide, with a specific focus on the various social and clinical factors that must be taken into account in any type of intervention (National Action Alliance for Suicide Prevention, 2013). Several assessment tools are available, some in the public domain, that are specifically designed for use with adolescents. Three key instruments are described below.

Suicidal Ideation Questionnaire (SIQ). The SIQ was developed for use with high school-aged youth, and a slightly different version (the SIQ-JR) is available for ages 12–14 years. The questionnaires are presented as paper-and-pencil tasks or by computer-assisted administration. There are 30 items in the SIQ and 15 in the SIQ-JR, all focusing on suicidal ideation. Youth are asked how often they experience the thoughts described in each question, selecting from six responses ranging from "never" to "almost every day." Norms are available indicating the scores that should raise concern about suicide risk. The SIQ has been studied with a wide range of youth in varied clinical and non-clinical settings, as well as with different cultural backgrounds. Substantial research has demonstrated its good psychometric properties and its ability to identify youth who have histories of suicide attempts or who may make future attempts.

Suicidal Behaviors Questionnaire-Revised (SBQ-R). The 14-item SBQ-R and the 4-item version were originally developed for use with adults but have subsequently been studied and used with adolescents. On the more frequently used version, youth check any of five responses to whether they have experienced thoughts about killing themselves, whether they have told anyone about it, and how likely they believe it is that they will attempt suicide someday. The SBQ-R's brevity makes it the quickest screening method available for suicide risk assessment. Validation research has been favorable, though use in juvenile justice settings has been limited. The SBQ-R's greatest value lies in its validation with adolescents in general, its simplicity and ease of administration, and the absence of cost for materials because it is in the public domain.

Global Appraisal of Individual Needs – Short Screener (GAIN-SS). The GAIN-SS is a screening companion to a more comprehensive tool called the Global Appraisal of Individual Needs (GAIN), which is widely used as a structured way to identify the behavioral and mental health service needs of youth. The GAIN requires up to two hours to administer; the GAIN-SS was designed to "screen out" individuals who might not need the more extensive GAIN evaluation. The GAIN-SS has four scales: Internalizing Disorder, Externalizing Disorder, Substance Use Disorder, and Crime/Violence. Each scale has five questions posed in an interview format. There is no dedicated suicide scale, but the Internalizing cluster inquires about depressed mood and includes one item on suicidal ideation. The GAIN-SS is in the public domain and therefore has no per-case cost (National Action Alliance for Suicide Prevention, 2013, pp. 5–6).

These assessment instruments typically evaluate various general risk factors such as low self-esteem, depression, substance abuse, and a history of childhood abuse, as well as situational factors such as the loss of a loved one or a failed close relationship (King & Price, 2009). Assessment should also take into account any verbal clues during the assessment session, such as "Things would be better without me around" or "I want to die" (King & Price, 2009, p. 255). While these types of verbal clues are clearly relevant to the thought patterns of young people who may be contemplating suicide, the diagnostic screening process can be far more complex and difficult to interpret accurately, given the tumultuous and unpredictable aspects of adolescent life that make distinguishing actual suicidal ideations from normal reactions to the human condition incredibly challenging.

Diagnostic Screening and Interpretation Challenges

One of the more challenging and confounding issues involved in diagnostic screening of adolescents concerns the turbulent period in their lives and their natural responses to seemingly major problems. It is reasonable to posit that everyone remembers just how important — and even earth-shattering — rejection or ridicule can be during adolescence. When taken to their extreme, these forces combine to create a sense of helplessness and hopelessness among young people. Indeed, even the aforementioned screening instruments, which have demonstrated reliability and validity, are unable to capture the entire range of psychological responses to the stressors that characterize adolescence, making accurate diagnostic screening and testing all the more important (Horwitz & Wakefield, 2007).

Notwithstanding this overarching consideration, many clinicians may easily misinterpret findings from even the best assessment instruments without taking into account other potential disorders that may be causing adolescent suicidal ideations. In this regard, Horwitz and Wakefield (2007) emphasize that "a second-stage diagnostic screening may eliminate many of these errors but also applies symptom-based DSM criteria to adolescents' labile emotions, possibly still yielding substantial false-positive identifications of depressive disorder and suicide risk" (p. 176). Furthermore, there is currently insufficient scientific evidence supporting the effectiveness of broad teen screening programs (Horwitz & Wakefield, 2007).

Conclusion

The research showed that young people such as the hypothetical Jane remain at risk of committing suicide unless and until they receive the evidence-based therapeutic interventions that have been proven effective in mitigating suicidal ideations. The research also showed, however, that young people's perception of the human condition may be highly exaggerated, and even seemingly major problems that would be disregarded later in life may combine to create a situation in which adolescents feel trapped, with suicide appearing to be their only escape. To the extent that clinicians understand these powerful emotions and reactions, they will be better equipped to help these young people overcome their problems and go on to become well-balanced adults.

References

Horwitz, A. V. & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. New York: Oxford University Press.

Interventions for suicide risk. (2017). Zero Suicide. Retrieved from

King, K. A. & Price, J. H. (2009, April). Preventing adolescent suicide: Do high school counselors know the risk factors? Professional School Counseling, 3(4), 255–257.

Maris, R. W. & Berman, A. L. (2000). Comprehensive textbook of suicidology. New York: Guilford Press.

National Action Alliance for Suicide Prevention: Youth in Contact with the Juvenile Justice System Task Force. (2013). Screening and assessment for suicide prevention: Tools and procedures for risk identification among juvenile justice youth. Washington, DC: Author.

Suicide facts at a glance. (2015). U.S. Centers for Disease Control. Retrieved from https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf.