Letter of Intent 1. Final Project Letter of Intent. The Exploration of Adolescent Suicide: A Suicide Awareness Booklet for Parents

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1 Letter of Intent 1 Running head: LETTER OF INTENT Final Project Letter of Intent The Exploration of Adolescent Suicide: A Suicide Awareness Booklet for Parents Shelley Marie Smysnuck (Garneau) Campus Alberta Applied Psychology Program Supervisor: Dr. Mary Dyck Submitted: February 19, 2007

2 Letter of Intent 2 The Exploration of Adolescent Suicide: A Suicide Awareness Booklet for Parents Problem Statement Researchers have indicated that suicide among the adolescent population is considered a major health problem (Canadian Association for Suicide Prevention [CASP], 2004; Spirito, 2003). Canadian statistics indicate that suicide rates among youth aged years have increased to be the second leading cause of death for this population (CASP, 2004; Sofronoff, Dalgliesh, & Kosky, 2005). In addition, researchers have proposed that certain characteristics are common within the family environment where adolescents have attempted suicide (Maris, Berman, & Silverman, 2000). Only recently, have researchers looked directly at the family as a protective factor in adolescent suicide. Psychiatric research has not sufficiently explored the interrelationships among family variables and how this relates to adolescent suicidality (Bureau of Psychiatric Services, 2005). Based on these findings, it is crucial for parents to increase awareness of adolescent suicidal behavior, to understand the family s role in suicidal behavior, and to recognize the protective factors that exist or can be developed within the family unit to build resiliency for adolescents. The present proposal aims to (a) provide an overview of literature on adolescent suicide familial characteristics and protective factors, and (b) develop a booklet for parents in order to address the importance of family functioning as it relates to adolescent suicidality. Rationale Numerous studies support that family dysfunction, in combination with other identified risk factors, plays a critical role in adolescent suicidal behavior (Hollenbeck, Dyl, & Spirito, 2003). In the past decade, researchers have examined these multiple risk factors and have worked diligently in developing prevention programs in an attempt to address adolescent suicidality (Gould, Greenberg, Velting, & Shaffer, 2003). However, according to Gould et al. (2003), there

3 Letter of Intent 3 is a need for future research to increasingly identify factors that protect against suicidal behavior so that they may be enhanced (p. 400). There are a limited number of studies that have focused on the protective factors related to adolescent suicidal phenomena (Evans, Hawton, & Rodham, 2004). Currently, there is a need for the development of an integrated model, which will help measure the relationships among adolescent suicidal risk factors (Reinecke & Didie, 2005). In an attempt to explain the many factors associated with adolescent suicide, an ecological model can be a useful tool for understanding the existence of these factors (Ayyash-Abdo, 2002). The ecological model applied to adolescent suicidal behaviors provides a framework that attempts to view such behaviors as part of a complex interaction of personal, interpersonal, and sociocultural dynamics. Interactions between the adolescent and their primary settings occur at the microsystem level. The most important microsystems that have been identified for adolescents appear to be family, peers, and school (Henry & Stephenson, 1993; Hoge, 1999). This writer will focus on the familial characteristics of family psychopathology (i.e., mental illness, substance abuse, and history of suicide), family relationships (i.e., parent-child connectedness and family conflict) and the protective factors relating to adolescent suicidal behavior. Conducting a thorough literature review will assist this writer in the development of an adolescent suicide awareness booklet for parents. This booklet will assist parents in becoming more informed about this important health issue among the adolescent population. Research on parents ability to identify adolescent suicidal behavior is limited. Stanley (2004) reports that many parents who had lost an adolescent to suicide were unable to differentiate between normal adolescent behavior and suicidal behavior. The Bureau of Psychiatric Services (2005) discusses how researchers have neglected paying closer attention to family as being a primary prevention

4 Letter of Intent 4 source for suicidal adolescents, yet it is the family who has a powerful influence on adolescent development. Most adolescents live at home; therefore, it makes sense to explore whether the home environment and the related familial interactions contribute to adolescent suicidal behavior (Henry & Stephenson, 1993; Hoge, 1999). Overall, this final project will assist parents and families in recognizing the impact family functioning has on adolescent suicidal behavior and will provide a means to identify appropriate support services to address areas of impaired family functioning. Literature Review The period of adolescence has been previously viewed as a time of turbulence and turmoil where enormous responsibilities are placed on adolescents (Compas, Gerhardt, & Hinden, 1995). All adolescents are faced with new experiences and unexpected developmental challenges (Judge & Billick, 2004). More recently, literature has indicated that the majority of adolescents are able to move through this developmental period without major behavioral, emotional, or social difficulties (Steinberg, 1999). Nonetheless, many adolescents continue to experience and display suicidal behavior. Risk factors relating to suicide ideation and attempted suicide in adolescents have been researched extensively and include age, gender, lethality method, sexual orientation, and crosscultural variation (Gould, Shaffer, & Greenberg, 2003). However, the relationships among the many factors that are thought to promote suicidal behavior are still unknown. An ecological analysis can assess the relations among the systems whereby the multilevel determinants of suicidal behavior are evident (Potter, 2001). Therefore, suicidal behavior is not linked to one specific factor, but rather it is the interaction of many factors which may influence an adolescent to engage in this behavior. It is clear that suicidal behavior is complex and the prevention of adolescent suicide requires a multidimensional approach. One component of this approach

5 Letter of Intent 5 focuses on the interconnectedness of family variables in order to gain a better understanding of how family functioning may impact suicidal behavior (Ayyash-Abdo, 2002; Henry & Stephenson, 1993). Research literature has established that there is an increased risk for adolescent suicidal behavior when there is a family history of suicide (Brent, Bridge, Johnson, & Connolly, 1996; Fergusson, Beautrais, & Horwood, 2003; Gould & Kramer, 2001; Roy, Nielsen, Rylander, & Sarchiapone, 2000), parental psychiatric illness, parental substance abuse (Bongar, Goldberg, Cleary, & Brown, 2000; Brent, 1995; Wagner, 1997), family conflict (Fergusson & Lynskey, 1995; Reinherz, Giaconia, Silverman et al., 1995), poor parent-child relationships (Connor & Rueter, 2006), and an unsupportive family environment (Fergusson et al., 2003; Fergusson & Lynskey, 1995; Perkins & Hartless, 2002). These findings suggest that within the area of family functioning there exists many factors associated with family psychopathology and family relationships which can play an integral role in adolescent maladjustment and suicide. Family Psychopathology There are many pathways that contribute to adolescent suicidal behavior. Adolescents who are suicidal often have parents with significant psychopathology (Wagner, 1997). One pathway, from a biopsychosocial perspective, supports that some illnesses such as psychiatric disorders may be genetic or inherited (Roy et al., 2000). It is possible that an adolescent may inherit a predisposition to a specific psychiatric disorder that could increase the level of risk for suicidal behavior. Brent and Mann (2005) found evidence that suicidal behavior is related to ancestry. Thus, the transmission of this behavior may be linked to genetics even after controlling for psychiatric disorders. Additional pathways, that may play a role in adolescent suicidal behavior, include adolescents using methods of coping based on modeling the abnormal behavioral patterns of their parents. Some adolescents may be subjected to neglectful parenting

6 Letter of Intent 6 practices, which contributed to poor self-esteem and the development of psychopathology (Wagner, 1997). Parental psychopathology can affect parents abilities to offer clear and consistent expectations and consequences for children in the home (Lochman, 2004). Researchers view psychiatric disorders as one of the many possible factors associated with adolescent suicidal behavior and that additional research is required to further identify factors that predispose to suicide (Apter, 2003). Therefore, the pathways linked to suicidal behavior are not linear. Parental substance abuse has also been examined as a familial risk factor for adolescent suicide (Bongar et al., 2000). Fernquist (2000) found a connection between suicidal behavior in adolescents aged years and parental problem drinking. Research on alcoholism and the impact on children have revealed that children of alcoholics can be exposed to deviant parental role models, disrupted child-parent relationships, and inadequate parenting which can lead to abnormal psychological development and functioning (Sher, 1997). Family Relationships Children who move through their early childhood meeting significant developmental milestones in a supportive and nurturing environment with others will likely develop the necessary skills or mindset to adapt to stressful events in adolescence (Compas et al., 1995). Adolescence is often coined as the time when an individual s identity is formed. The failure to construct a healthy identity is viewed as an underlying concern of adolescent suicide (Portes, Sandhu, & Longwell-Grice, 2002). In Erikson s (1963) theory of psychosocial development, adolescence is the stage where an individual engages in the exploration of identity versus identity confusion. At times within this transition an adolescent may experience challenges and social limitations that create a confusion of roles. The confusion of roles coincides with some research which shows interpersonal conflict

7 Letter of Intent 7 and loss, whether it is real or imagined, increases stress and suicidal ideation (Arensman & Kerkhof, 2004; Huff, 1999). The less successful an adolescent is in developing intimacy with others and a healthy identity, the more likely he or she will engage in self-destructive behavior (Portes et al., 2002). Certain conditions relating to familial characteristics are thought to negatively affect psychosocial development in adolescence. Hence, individuals who are exposed to conditions relating to family conflict and a poor family environment are considered to be at risk for poor developmental outcomes such as psychological maladjustment (Hauser, Vieyra, Jacobson, & Wertlieb, 1985). Many studies have explored the connection between family relationship factors and adolescent suicidal behavior (Adams, Overholser, & Lehnert, 1994; Conner & Rueter 2006). Suicidal adolescents aged years perceived their families as being poor problem solvers, having difficulty adapting to change, poor communicators, and were often involved in many crises (Adams et al., 1994). In addition, family relationships with suicidal behavior were described as being enmeshed or emotionally detached (Adams et al., 1994). Reinherz et al. (1995) found that suicidal adolescents aged years reported their family environments as being more disruptive and unstable where family arguments were common when compared to other adolescents. The identification of family risk factors can provide valuable information on how impaired family functioning may impact adolescent suicidal behavior. However, it is equally important to identify, examine, and develop protective factors within the context of the family (Bureau of Psychiatric Services, 2005). Protective Factors Resiliency in psychosocial development from early childhood, during adolescence, and into adulthood is shaped by many different circumstances, some of which are based on the individual s innate strengths and vulnerabilities (Hauser et al., 1985). Protective factors relating

8 Letter of Intent 8 to familial characteristics are thought to buffer against individual and family adversity during adolescence. The following protective factors have been identified: parental warmth (Conner & Rueter, 2006; White, 1998), positive communication (Conner & Rueter, 2006; Evans et al., 2004), modeling of healthy adjustment (White, 1998), supportive family environment (Evans et al., 2004; Flouri & Buchanan, 2002; WHO, 2000), and close parent-child relationships (Evans et al., 2004; WHO, 2000). An important consideration is that these protective factors are not assumed to eliminate all risk factors associated with adolescent suicide, since suicidal behavior is related to many factors. Instead, these protective factors have a protective effect on adolescent adjustment and functioning within the family environment (Evans et al., 2004). From an ecological perspective, the utilization or development of familial protective factors are related to prevention at the microsystem level. Research on whether parents and families understand how to recognize, utilize, or develop protective factors is limited. Primary prevention measures to address adolescent suicidal behavior have begun to include parents and families as an integral part of prevention (Ayyash-Abado, 2002). Primary prevention that has been found to be effective includes educating parents about the major health problem of adolescent suicide; teaching parents how to recognize risk indicators; and providing resource lists so that parents can access appropriate support services (CPA, n.d.; Maris et al., 2000). Furthermore, raising awareness relating to the importance of protective factors may assist parents or families in engaging services, including family therapy, where there is a focus on improving whole family functioning (Ayyash-Abado, 2002). Families need to learn about dysfunctional family patterns, suicide and psychiatric disorders, and parental psychopathology so that there are opportunities to increase awareness and access appropriate interventions (Brent, 2001). Family involvement is a key factor in addressing adolescent suicidal behavior.

9 Letter of Intent 9 Methodology The purpose of this final project will be two fold. First, this final project will produce an extensive review of the literature on adolescent suicide. Secondly, this project will develop an adolescent suicide awareness booklet for parents that can be easily distributed by community professionals who are in contact with the parent population. The central focus of the review of literature will be on certain familial characteristics (i.e., family psychopathology and family relationships) that are common within the family environment where adolescents exhibit suicidal behavior. Furthermore, the review will look at literature pertaining to the protective factors within family functioning as they relate to suicidal behavior. This review will not include research related to completed adolescent suicide or therapeutic treatment methods utilized with adolescents as it is beyond the scope of this review. Research literature will be reviewed using the following search strategies: PsycINFO, Medline, Academic Search Premier, Expanded Academic ASAP, Ovid, Behavioral and Social Sciences, Psychology and Behavioral Sciences Collection, ScienceDirect, Google Scholar, Questia, World Wide Web, and Calgary Library Connection. Research literature that will be considered for review will include adolescents aged years, which are published between 1985 and Search terms will include: adolescent suicide, family dysfunction and adolescent suicide, parental psychopathology and adolescent suicide, family relationships and adolescent suicide, family functioning and adolescent suicide, protective factors and adolescent suicide, and resiliency and adolescent suicide. The adolescent suicide awareness booklet will include, but is not limited to the following sections: (a) adolescent suicide statistics, (b) overview of suicidal behaviors, (c) individual risk factors, (d) impaired family functioning, (e) protective factors within the family, (f) development and utilization of protective factors, (g) list of appropriate community resources, and (h) list of

10 Letter of Intent 10 suicide information websites. Sections of the booklet will be developed based on the findings from the literature review. As a result, this booklet will provide relevant information relating to adolescent suicidality and will serve as a primary prevention resource within the context of the family. The booklet will be disseminated by this writer to community service agencies in the Campbell River area which provide services to children, youth, and families in order to reach the parent population. Agency workers can offer this booklet as a resource or review the booklet with parents directly. Potential Implications By completing this final project and sharing the booklet with community professionals, it provides an opportunity for more parents to be exposed to new information which may help to further raise awareness about this important issue. With this increased awareness, parents may be better equipped to assist adolescents in coping and rising above the many unexpected challenges adolescents may face relating to suicidal behavior. This awareness can benefit adolescents as the suicide risk factors and indicators will be better known among the parents and families of adolescents who experience suicidal behavior. From the creation of this booklet, it is this writer s hope that increased suicide awareness for parents may also lead to increased motivation towards making potential improvements to existing family functioning. Furthermore, by enhancing parents level of suicide awareness and providing lists of available community resources will hopefully improve the parents ability to respond competently so that adolescents displaying suicidal behavior receive the help they require. Finally, the list of community resources listed in the booklet may provide support options for parents or family members to assist in addressing issues which impair family functioning and aid in the development or utilization of protective factors within the family in the hopes of increasing resiliency among adolescents.

11 Letter of Intent 11 References Adams, D. M., Overholser, J. C., & Lehnert, K. L. (1994). Perceived family functioning and adolescent suicidal behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 33(4), Apter, A. (2003). Biological factors influencing suicidal behavior in adolescents. In R. A. King & A. Apter (Eds.), Suicide in children and adolescents (pp ). UK: Cambridge University Press. Arensman, E., & Kerkhof, A. (2004). Negative life events and non-fatal suicidal behavior. In D. D. Leo, U. Bille-Brahe, A. Kerkhof, & A. Schmidtke (Eds.), Suicidal behavior, theories and research findings (pp ). Cambridge, MA: Hogrefe & Huber. Ayyash-Abdo, H. (2002). Adolescent suicide: An ecological approach. Psychology in the Schools, 39(4), Bongar, B., Goldberg, L., Cleary, K., & Brown, K. (2000). Marriage, family, family therapy, and suicide. In R. W. Maris, A. L. Berman, & M. M. Silverman (Eds.), Comprehensive textbook of suicidology (pp ). New York: The Guilford Press. Brent, D. A. (2001). Assessment and treatment of the youthful suicidal patient. Annuals of the New York Academy of Sciences, 932, Brent, D. A. (1995). Risk factors for adolescent suicide and suicidal behavior: Mental and substance abuse disorders, family environmental factors, and life stress. Suicide and Life-Threatening Behavior, 25, Brent, D. A., Bridge, J., Johnson, B. A., & Connolly, J. (1996). Suicidal behavior runs in families: A controlled family study of adolescent suicide victims. Archives of General Psychiatry, 53, Brent, D. A., & Mann, J. J. (2005). Family genetic studies, suicide, and suicidal behavior.

12 Letter of Intent 12 American Journal of Medical Genetics Part C, 133C, Bureau of Psychiatric Services. (2005). Families. Retrieved December 26, 2006, from Canadian Association for Suicide Prevention. (2004). CASP blueprint for a Canadian National Suicide Prevention Strategy. Retrieved October 20, 2005, from Canadian Psychological Association. (n.d.). Psychology works for suicide. Retrieved October 21, 2005, from http// Compas, B. E., Gerhardt, C. A., & Hinden, B. R. (1995). Adolescent development: Pathways and processes of risk and resilience. Annual Review of Psychology, 46, Conner, J. J., & Rueter, M. A. (2006). Parent-child relationships as systems of support or risk for adolescent suicidality. Journal of Family Psychology, 20(1), Erikson, E. (1963). Childhood and society (2 nd ed.). New York: W.W. Norton. Evans, E., Hawton, K., & Rodham, K. (2004). Factors associated with suicidal phenomena in adolescents: A systematic review of population-based studies. Clinical Psychology Review, 24(8), Fergusson, D. M., Beautrais, A. L., & Horwood, L. J. (2003). Vulnerability and resiliency to suicidal behaviors in young people. Psychological Medicine, 33, Fergusson, D. M., & Lynskey, M. T. (1995). Childhood circumstances, adolescent adjustment, and suicide attempts in a New Zealand birth cohort. Journal of the American Academy of Child and Adolescent Psychiatry, 34(5), Fernquist, R. M. (2000). Problem drinking in the family and youth suicide. Adolescence, 35(139), Flouri, E., & Buchanan, A. (2002). The protective role of parental involvement in adolescent

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14 Letter of Intent 14 Quarterly, 50(3), Maris, R. W., Berman, A. L., & Silverman, M. M. (2000). Comprehensive textbook of suicidology. New York: The Guilford Press. Perkins, D. F., & Hartless, G. (2002). An ecological risk-factor examination of suicide ideation and behavior of adolescents. Journal of Adolescence Research, 17(1), Portes, P. R., Sandhu, D. S., & Longwell-Grice, R. (2002). Understanding adolescent suicide: A psychological interpretation of developmental and contextual factors. Adolescence, 37(148). Potter, L. B. (2001). Public health and suicide prevention. In D. Lester (Ed.), Suicide prevention, resources for the millennium (pp ). Philadelphia, PA: Brunner-Routledge. Reinecke, M. A., & Didie, E. R. (2005). Cognitive-behavioral therapy with suicidal patients. In R. I. Yufit & D. Lester (Eds.), Assessment, treatment, and prevention of suicidal behavior (pp ). Hoboken, NJ: John Wiley & Sons, Inc. Reinherz, H. Z., Giaconia, R. M., Silverman, A. B. et al. (1995). Early psychosocial risks for adolescent suicidal ideation and attempt. Journal of the American Academy of Child and Adolescent Psychiatry, 34(5), Roy, A., Nielsen, D., Rylander, G., & Sarchiapone, M. (2000). The genetics of suicidal behavior. In K. Hawton & K. van Heeringen (Eds.), The international handbook of suicide and attempted suicide (pp ). New York, NY: John Wiley & Sons Ltd. Sher, K. J. (1997). Psychological characteristics of children of alcoholics. Alcohol Health and Research World, 21, Sorfronoff, K., Dalgliesh, L., & Kosky, R. (2005). Out of options: A cognitive model of adolescent suicide and risk-taking. New York: Cambridge University Press. Spirito, A. (2003). Understanding attempted suicide in adolescence. In A. Spirito &

15 Letter of Intent 15 J. C. Overholser (Eds.), Evaluating and treating adolescent suicide attempts (pp. 1-18). San Diego, CA: Academic Press. Stanley, N. (2004). Parents perspectives on young suicide. Children & Society, 19, Steinberg, L. (1999). Adolescence. Boston: McGraw-Hill. Wagner, B. (1997). Family risk factors for child and adolescent suicidal behaviors. Psychological Bulletin, 121(2), White, J. (1998). Youth suicide prevention: A framework for British Columbia. Retrieved December 14, 2006, from World Health Organization. (2000). Preventing suicide: A resource for teachers and other school staff. Retrieved October 18, 2005, from http// prevent/en/index.html