Every day, some 13 Americans aged 15 to 24 kill themselves. There are no typical stories. They come from every segment of society -- from affluent suburbs to urban ghettos, from Indian reservations to rural communities.
But there are two qualities they all share: youth and hopelessness. Consider:
A 14-year-old honor student swallows a soda bottle full of vodka and jumps in front of an approaching freight train. The Prince William County girl left behind a diary that chronicled three years of sexual abuse by her adoptive father.
A 17-year-old boy hangs himself in a county jail cell.The previous night he was arrested for drunk driving after having failed a Marine Corps entry test.
A 15-year-old girl, on PCP and alcohol, tells a friend that she has "messed up her life." Later she kills herself with a shotgun.
A 17-year-old boy argues with his girlfriend, and threatens to kill himself if she walks out on him. She says, "You're crazy." He pulls a gun from his pocket and shoots himself.
These teen-agers are among the 5,000 American adolescents who commit suicide each year. Alan L. Berman, American University psychology professor and past president of the American Association of Suicidology, outlined three of these incidents for the U.S. Senate Committee on the Judiciary's Subcommittee on Juvenile Justice in October 1984.
"No vignette can portray adequately the dynamics behind such life stories," Berman said during his testimony. "Had the opportunities presented themselves, we can only wonder how many of these decisions might have been redirected toward alternative, life-sustaining choices. That this is possible is without question."
Over the last three decades, the adolescent suicide rate has tripled, while rates for the rest of the population have remained stable, according to the National Center for Health Statistics. In addition to the 5,000 young people who succeed in killing themselves, an estimated half a million more try and fail.
As alarming as they are, these figures are generally considered low. Many suicides among the young go unreported, experts say, often to protect families from the stigma attached to the act. Some deaths recorded as accidents -- particularly fatal car wrecks -- may have been suicides.
Currently, suicide ranks as the third cause of death among Americans aged 15 through 24. Only accidents, the leading cause of death, and homicides claim more victims. Together, these violent ends account for 75 percent of deaths among teen-agers and young adults.
"People have been attending to the problem of youth suicide for many years," Alan Berman says. "But it's only recently that we're beginning to see really serious attention and a lot more study. We're finding that completed suicides have been giving off messages: trouble with authority, drug and alcohol use, and clear verbal signals, too."
Suicidal adolescents, Berman says, typically "feel like islands in the sea. They feel that they alone carry the burden of whatever their problem is, and suicide seems to be the only solution. They get irrational; they get rigid. They feel bad about themselves, and hopeless about the future. They become immune to influence, and all their data looks of one kind."
Berman and other experts believe that such hopelessness can be counteracted. "It probably requires some therapeutic intervention," he says. "We can't provide false hope. It takes helping someone learn to problem solve, to see that there are options, and that suicide is only one of them. They can learn that, with a bit of time and a second head to help, the world can look a little brighter."
Suicidal fantasies and thoughts are common in adolescence, Berman says. But, he adds, "thoughts don't equal behavior, and depression is not the same as suicide -- although there is considerable overlap."
Roughly two thirds of adolescents who commit suicide show signs of depression. But, Berman says, "it's tough to assess. We have depressed kids who are not suicidal, and suicidal kids who do not appear depressed. For one to be suicidal requires more than just being depressed. Hopelessness is more of an indicator."
In June 1985, then-secretary of Health and Human Services Margaret Heckler -- herself upset by the suicide of a close friend's teen-age child -- launched a national Task Force on Youth Suicide. Its first findings -- on risk factors -- will be reported next month at a conference at the National Institutes of Health.
Task force chairman Dr. Shervert Frazier, director of the National Institute of Mental Health, says it is difficult to find reasons for the burgeoning numbers of youth suicides. Among the factors involved, he says, are changes in family structure and the declining influence of religion.
Religion, he says, "is a built-in future concept. A belief system was what tided a lot of us over as adolescents. We had a belief in the future, that there was somebody up there watching out for me and taking care of me. That was a bridging mechanism until I got more experience."
Today, he says, "kids have the feeling that they're not connected with many people. They don't have a sense of affiliation, they don't have an adequately developed sense of caring for other people in the community. There is a lack of affiliative bonds. It seems to me that that's a serious shortage in our society now."
Another problem, Frazier speculates, may be that popular culture leads young people to look for easy answers to the inherent problems of adolescence.
"Life's expectation's are built in 30-minute segments," he says. "You can pretty well see the biggest problems in the world come to a solution or to the end of consideration in half an hour. That leads young people to believe that they ought to get an answers to anything in 30 minutes. And if you don't get the short-term answer, what do you do? You don't have mechanisms for bridging that immediacy issue. It's almost as if you've got to have the answer within immediate vision."
In addition to the television generation's focus on 30-minute solutions, says Frazier, there is the ever-present threat of nuclear holocaust. "I talk with a lot of adolescents, and I think that there's a sense of resignation to the fact that the world may not last very long," he says. "They live with a feeling of the immediacy of the end. It almost takes away meaning, it makes you easily swayed. The urgency of the moment takes over."
As an example of this common feeling of being stuck in the present, Frazier cites a scenario often repeated among adolescents who commit suicide. "There's a whole syndrome of adolescent boys who end up in jail, drunk," he says. "And as they dry out and wake up, they hang themselves. There's a powerful sense of the immediacy of the whole thing, the humiliation, the shame. It's almost as if there's not a connection with the other world at that point."
Studies of adolescent suicide show that alcohol consumption is often involved -- as it also is among adults who commit suicide. Adolescence, says Frazier, "is so very painful. You tend to be impulsive, to have a sense that desperation is greater than it is. Every incident is major one. And everything is in excess.
"It's also a time of experimention with alcohol and drugs. You have individuals who don't have good control mechanisms to begin with, and then they take substances that cause further discontrol -- and that may lead to a concatenation of out-of-control events."
There are several theories of adolescent suicide. One theory explains self-destructive behavior as the culmination of guilt, anger and resentment resulting from a perceived loss of love, or of rejection by significant people. This view is held by proponents of psychodynamics, who assume that much of one's behavior is determined by past experience.
Developmental psychologists, who focus on the stresses people experience at the various phases of life, emphasize the inherent problems of adolescence. This view attributes suicidal behavior to such precipitating events as a move, a change in schools, the end of a romance, the death of a loved one, or parents' divorce.
Cognitive theory, which focuses on thought processes rather than emotional reactions, suggests another view: That the adolescent has little sense of the finality of death. This attitude is thought to result from incomplete intellectual development, coupled with our culture's denial of the reality of death.
Sociologists look to alienation, isolation, and loss of social contact, a situation in which a secure world seems to crumble, leaving the adolescent without support.
Recently, a theory has emerged proposing that biological factors contribute to suicidal behavior. This research underscores the relationship between sucide and depression. Recent studies suggest that there may be a deficiency of serotonin, a chemical messenger in the brain, in people who commit suicide.
But despite the wide range of theories and continuing research on the topic, experts caution that any single explanation is too simplistic a response to such a complex subject.
While many adults recall their teen-age years as a period of happiness and hope, adolescence is in fact a time of profound loss and stress. During this important developmental stage, new desires surface; the sense of identity forged in childhood changes. Teen-agers begin to sever their attachment bond to parents, and experience an increased sense of separateness. Loneliness is a common source of stress at this age; one study conducted at the Human Systems Institute in Boulder, Colo., suggests that a sense of isolation and loneliness peaks at age 16.
For some adolescents, the normal sadness and stress of this part of their lives spills over, and causes serious mental health problems -- specifically depression. An American Academy of Child Psychiatry glossary of mental illnesses describes adolescent depression as a disease in which victims' moods are seriously disturbed for at least two weeks, and which can lead to serious disability and death.
In addition to feelings of sadness, hoplessness and irritability, adolescent depression includes at least four of the following symptoms, says the AACP:
Noticeable change of appetite with either significant weight loss when not dieting, or weight gain.
Noticeable change in sleeping patterns, such as fitful sleep, inabilty to sleep, or sleeping too much.
Loss of interest in activities formerly enjoyed.
Loss of energy; fatigue.
Feelings of worthlessness, feelings of inappropriate guilt.
Inability to concentrate or think; indecisiveness.
Recurring thoughts of death or suicide, wishing to die, attempting suicide.
Depressed adolescents may behave in the ways outlined above, but they may also have some other symptoms. "Adolescence and Depression," a publication of the National Institute of Mental Health, reports that few studies have been done to identify specific symptoms of the disorder in adolescence. However, the NIMH booklet does outline some symptoms specific to adolescents suffering from depression, including fluctuation between indifference and apathy and talkativeness; anger and rage expressed in verbal sarcasm; sensitivity and tendency to overreact to criticism; intense ambivalence between dependence and independence; feelings of helplessness and decreased peer support.
A Public Health Service survey of research literature indicates that young adults who experience depression and attempt suicide are typically undergoing an increase in negative events -- perhaps the end of a romance, or a failure in school -- in concert with family stress and illness, especially psychiatric illness. Studies indicate that adolescents who commit suicide have recently experienced a confrontation over some event such as poor grades, and have been involved in truancy and antisocial behavior, with subsequent humiliation.
David A. Brent, assistant professor of child psychiatry at the University of Pittsburgh, compared completed suicides to attempted suicides among children and adolescents in Allegheny County, Pennsylvania. Attempters were likely to be younger, non-white and female, he discovered. Completers were much more likely to use firearms, hanging, or carbon monoxide, whereas attempters resorted primarily to drug overdose.
Completers were more likely to be intoxicated on alcohol, whereas attempters were more likely to show evidence of having used tranquilizers. The single most common drug overdose the attempters took, he found, is one commonly found in a home medicine cabinet: acetominophen, a pain reliever.
Suicide completers showed higher intent, were more likely to have left a note, to have expressed prior intent, to have made an effort to conceal their activity, to have chosen a remote location, and to have planned the suicide, Brent found.
In another study, Brent examined methods used in 159 suicides and 38 "likely suicides" between 1960 and 1983 -- a period that saw a marked increase in the youth suicide rate in Allegheny County. In spite of the fact that pills -- particularly tranquilizers -- became easier to obtain during this time, overdoses were infrequent. Firearms were consistently the most common means of suicide. And the suicide victims were likely to have been drinking at the time.
Brent's data, presented to the American Academy of Child Psychiatry's annual meeting in October 1985, suggest that alcohol and firearms work together to produce suicides. "Perhaps ready access to both these agents has contributed to the rise in suicide among our youth," he reported. "It is not difficult to imagine some of the youngsters, despondent, intoxicated, uninhibited, and with judgment impaired, for whom the ready availability of a firearm made a lethal outcome all too likely."
Among adolescent suicide attempters and completers, a sense of loss is a pervasive theme. The loss may be internal -- loss of face, loss of self-esteem. Or the loss may be external -- the death of a relative or friend, a move, a change in schools, even the canceling of a favorite television show or the death of a beloved pet. To adults, the loss may seem insignificant; to the adolescent, it appears monstrous, and recovery from it impossible.
For some District adolescents an experimental course in death education offers a chance to vent feelings about the losses adolescence brings. The course was designed by the St. Francis Center, a nondenominational, nonprofit organization that helps people cope with loss in general, but especially with death and grief issues.
"The basic emphasis of the program is to give students a safe place to talk about feelings related to separation and loss," says the Rev. William A. Wendt, an Episcopal priest and director of the center. "Adolescence is the worst time of grieving, yet they're told that these are the best years of their lives.
"Teen-agers are already experiencing the loss of childhood, the loss of a benign world, the loss of innocence. Add a death, or a divorce, or a separation, and you've got the whammies coming out all over the place. The school system isn't prepared to deal with that stuff; nor is our culture.
"The schools tend to say, 'We teach only reading, writing and 'rithmetic; we don't handle what the family, the church and the community should be handling. But family, church and community don't handle this stuff anymore. So where does a kid go? I'm saying that the one place right at the moment that's most helpful for suicide prevention is the schools. That's the kids' turf; it's their world."
At a recent meeting of the American Association of Suicidology in Atlanta, Wendt and his associate Elaine Cummings, a registered nurse, presented their findings on the efficacy of their death education curriculum as a suicide prevention device. The St. Francis Center has conducted the course for the past seven years. For the evaluation, 120 students from six high schools in the Washington area were studied. The teen-agers come from a wide sampling of socio-economic and ethnic groups, and from public and private schools.
Wendt and Cummings cited these five findings:
A "significant number" of the students reported having made at least one suicide attempt in their lives. The attempt was unknown to anyone else except possibly a peer.
A high percentage of the students perceived themselves to have experienced a significant loss and reported not having a sufficient emotional outlet until their experience in death education class.
As a result of the course, students reported a change in their concept of school support and the kinds of communication that can happen there.
Most reported a very positive change in their perception of the value of life.
Many students reported feeling better prepared to deal with a suicidal peer.
The St. Francis Center's program discusses death head on. Another prevention program, this one in the Fairfax County public schools, provides adolescents with a chance to talk about stress. The subject of suicide does come up; the students bring it up themselves.
Myra Herbert, coordinator of school social work services for the Fairfax County schools says, "it's my feeling that jumping into a crisis is not the place to start for suicide prevention . We need to learn to manage and handle those kinds of circumstances that bring adolescents to a point of despair. Parents are very uneasy talking about suicide with kids. It's so threatening and frightening a topic that you scare many of them away if you give programs labeled 'suicide.' "
School systems in California, Louisiana, Florida and New Jersey have ordered high schools to set up suicide prevention programs. Other school systems have set up such programs voluntarily, as Fairfax County did.
The Fairfax County system, 10th largest in the nation, has 124,000 students in its 162 schools. In the 1980-81 school year -- including summer vacation -- there were 20 suicides in the system. The suicide prevention program was initiated in reponse to that tragedy. The suicide rate dropped the following year, and has stayed low.
"Our faculties are tremendously alert," Herbert says. "Referrals for counseling have quadrupled. There's tremendous awareness of the problem, and that has formed a kind of safety net for these kids. The schools have created an awareness, and hopefully with that, people will turn themselves and their own communities to developing supports for adolescents."
American University's Berman recalls a private patient who came to him through a school referral. "This teen-ager was despondent over the break up of a relationship," Berman recalls. "There was an antagonistic relationship with parents, and school problems in spite of great pressure to do well. The child began harboring pills, thinking that death was the only way out, but happened to communicate to a friend what was going on. The friend managed to raise questions to an adult, who then referred the child to a school counselor. The school counselor referred privately, and suggested that the family get help."
He pauses. "And a long way down the road, all is well."
Berman's patient is living one of the happy endings to a potential suicide story. Luckily, another teen-ager had the presence of mind to take a friend's suicidal talk seriously, and to get help. Such peer interventions, says Charlotte Ross, president and executive director of the Youth Suicide National Center in the District, can be a valuable step on the road to prevention.
When she was working as director of the San Mateo Suicide Prevention and Crisis Center in California, Ross set up a class called "peer befriending." Such programs, Ross says, can "help kids get a clear understanding of suicidal feelings, and help them become better able to respond to each other. One of the things we can try to do with kids is teach them how to be therapeutic friends. Not counselors, but helpful friends. The first lesson is to think about the things you'd like your friends to do if you're feeling down. You'd want someone to hang in with you; you want someone to talk to you." It's important, too, says Ross, to impress upon teen-agers that they're not solely responsible for the information their friends share with them. This is a time when keeping a secret may lose you a friend. Telling someone may be necessary -- and can help. Kids may not find the appropriate adult counselor on the first try, however.
"It's up to us to make systems in the adult world that kids will use," says Ross. "Youth suicide prevention is not the problem of medicine, of psychiatry, of schools, of the government. It's everybody's problem."