Clinical Psycholo~ Review, Vol. 9, pp. 335-363,
Printed in the USA. All rights reserved.
0 1989 Pergamon
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ATTEMPTED SUICIDE IN ADOLESCENCE:
A REVIEW AND CRITIQUE
Anthony Spirito, Larry Brown, lames Overholser,
Rhode Island Hospital
Brown University Program in Medicine
its frequency, coexisting physical and psychiatric problems, and economic toll. Attempters are also
a high-risk group for eventual completed suicide. This review covers three major areas pertinent to
attempted suicide in adolescence: characteristics of the attempt (lethality, intent, and precipitants),
psychological factors associated with suicidal behavior, and follow-up
there exists a significant a!egree of individual andfamily dysfunction among a large proportion of
adolescent suicide attempters. However, strong evidence for the speczficity of this dysfunction to
suicide attempts, rathr than to general emotional disturbance, was found only for hopelessness,
family conflict, and contagion. In addition, the ability to devise effective interventions for adolescent
suicide attempters is significantly compromised by limited knowledge of the natural course follow-
ing a suicide attempt. Therefore, the needfor comprehensivefollow-up
should be the immeduzte focus of research efforts with this high-risk group.
Attempted suicide among adolescents is a significant public health concern’due to
course. Findings suggest
studies of suicide attempters
found that a significant
9% in New York City (H ar k avy-Friedman,
frequency of suicide attempts
cant physical and psychological
care system, and the increased
Although the majority
suicide among adolescents
in the past: 8.4%
is a surprisingly
of high school students
in the Midwest
risk for completed
of suicide attempters
magnitude of nonfatal
had made one or more
is of great concern
its economic burden
do not complete suicide,
due to signifi-
on the health
there is an
Island Hospital, 593 Eddy Street, Providence,
to Anthony Spirito, Ph.D., Child and Family Psychiatry, Rhode
A. Sjhito et al.
go on to complete
to more lethal methods.
of death by overdose.
suicide is the second leading
creasingly focus on the related
cent suicide attempters
study, a nonrandomized
worker was to help the adolescents
support, and to explore
an educational curriculum
sonnel, and the police
Results of this study
controls to comply
sions for suicidal
However, the program
attempts after adjustment
teristics and knowledge
cence: (a) characteristics
course of recovery.
clinical work conducted
ambiguities or disagreements,
clarify the possible
relevant, the type of setting
since results may vary from
settings to psychiatric
ples. This is important
child or adult suicide
1985) who completed
follow-up studies show that a significant
suicide (Goldacre & Hawton,
suicide is affected by a variety of factors beyond
intent on committing suicide
parents come home unexpectedly)
behavior can result in accidental
adolescent suicides can be described
Angle, & Schlicht, 1980):
The overlap between
partly related to chance
cause of death in persons
& Conn, 1987),
of effective interventions
there have been descriptions
attempter seen in an emergency
keep their follow-up
potential services available
were also conducted
with medical recommendations,
behaviors were reduced
did not have
for prior history
will await more thorough
from three areas
An effort will be made to clarify issues relevant
details of the research
effects of age and setting
in which the research
we will focus on research
since it may be inappropriate
attempters to adolescents.
Beck, & Mitchell,
in studies using clinical
Nelson, & Sainsbury,
had made a prior
the desire to die. An
may be rescued due to unusual
or because of limited
even when the adolescent
as a “pharmacologic
risk-taking behavior with a high probability
15 to 24 years (Rosenberg,
efforts to understand
of attempted suicide.
& Motto, 1984), we are aware of only one
Hsieh, Joshi, & McNamara,
trial, assigned a social worker
for the adolescent.
human service workers,
in the targeted
these adolescents were
a demonstrable effect
of suicidal behavior.
data on psychological
course. Thus, this review will evaluate
related to suicidal behavior
attempts, (b) psychological
indicates in two ways.
does not desire to
& Angle, 1970,
given the fact that
completed suicide in-
is also inade-
to each ado-
role of the social
twice as likely
to a control
in order to
will be specified
on the results
studies on children
of the study. When
will be clarified,
and adults will be
Attempted Suicide in Adolescerue
behaviors are common during adolescence
rect forms of self-destructive
differ from adults in terms of their typical financial
stressors to which they are commonly
have an impact on suicidal behavior,
effects across different age groups.
and do not necessarily
it would be inappropriate
Since all of these variables
to ignore their
FACTORS ASSOCIATED WITH SUICIDAL BEHAVIOR:
LETHALITY, PRECIPITANTS, AND INTENT
complete suicide (e.g., Otto,
rate the medical lethality of an attempt (e.g., Goldacre
Conroy, & Ehler, 1984). The Risk-Rescue
1972) has been a commonly
used in several studies with adolescents (Brent,
1982). In Brent’s (1987) study of 13 1 suicide attempters
room, those adolescents who had made a medically lethal attempt were similar to
those who completed suicide (i.e. they were predominantly
diagnosed with an affective disorder, demonstrated
history of drug abuse).
Others examining medical lethality of adolescent suicide attempts have found a
restricted range of variability on the Risk-Rescue
Overholser, & Fritz, 1988). Of 130 subjects
room, 65% made attempts of low risk, 33% were moderate
were high risk. Similarly, Garfinkel et al. (1982)
attempts were of low lethality, 21% were moderately
highly lethal. Also, 51% made attempts with a high likelihood of rescue, and 36%
with a moderate likelihood. Of concern in all these studies with adoIescents
fact that lack of variability makes it difficult to reliably score an instrument
as the Risk-Rescue Rating Scale.
The method of suicide attempt has also been investigated
variable among adult attempters. However, once again there is a restricted range
of methods in adolescents. A number of studies (Spirito,
Owens-Stively, 1987; Hawton,
demonstrate that 75 to 90% of all adolescent
dose. At times, the attempt may be unrecognized
scribed for the adolescent’s medical condition (e.g., an insulin overdose by diabet-
ic adolescents) (Kaminer & Robbins, 1988). Overdoses are nearly equally divided
between over-the-counter and prescription
ence that may be useful to examine in future research.
suicide attempters are more likely to use over-the-counter
drugs are readily available, whereas the more hopeless and dysphoric attempters
are more likely to use a combination of drugs (Brent,
Although most overdoses are not fatal, it does not necessarily
cents who take overdoses do not want to die. Limited access to different methods
may account for the use of nonlethal drug overdoses by adolescents.
Burn&ox, Pocock, and Pottle (1975) have documented
of active or violent suicide attempts
1972). A number of approaches
are at high risk to eventually
have been used to
Rating Scale (Weisman
used method with adults, and the scale has also been
Froese, & Hood,
seen in an emergency
male, most often were
high suicidal intent, and had a
Rating Scale (Spirito,
to the emergency
risk, and only 2 %
also found that 78% of the
lethal, and only 1% were
as an important
suicide attempts are by drug over-
because it involves drugs pre-
drugs (Spirit0 et al., 1987), a differ-
It may be that impulsive
drugs, or whatever
mean that adoles-
that adolescents most
A. Spirit0 et al.
intention is the same between the adults and adolescents,
prescription drugs, one would expect more completed
adults, which has indeed been found (Centers
larly, the finding that females attempt suicide by overdose may not be a reflection
of less lethal intentionality, but rather a sex difference
Shaffer and Bacon (1986) refer to a study by Sathyavathi
contention. This study, conducted in India, where access to effective medical care
may be less readily available, found female adolescents
completed suicide as males.
method want to die. One study (Peterson,
has shown that among a group of 30 adults with self-inflicted
all had intended to die. Rather, many of these attempters
attempt with a method that for them was readily available.
The precipitants of suicide attempts in adolescents
several investigators. Tishler, McKenry,
ing precipitants in a study of 108 adolescent
gency room: parental problems (50%),
school problems (30 %), sibling problems
Girlfriend/ boyfriend problems, family problems,
three most common precipitants reported by Otto (1972).
(aged 5 to 14 years), family problems (45%)
most common (Kienhorst, Wolters, Diekstra,
group was not used in either study, thus failing to provide a normative
son on the stressors common to most adolescents.
(in press) studied th e precipitants
of suicide attempts among adolescents
ized on a general pediatrics floor compared
problem that made them very anxious or depressed (distressed
dents who reported a problem which did not make them very anxious
pressed (nondistressed controls). All three groups reported four problems
curring most frequently (school, parents,
problems), The suicide attempters and distressed controls reported problems with
parents more frequently than nondistressed
ported problems in school more frequently,
ters are not a distinct group from other distressed adolescents.
Given the limited range of suicide precipitants,
(and consequent lethality)
tant area to investigate may be suicidal intent. The Suicide Intent Scale (Beck,
Schuyler, & Herman,
1974) has been used in studies both with adults and adoles-
cents (Rrent, 1987; Garfinkel et al., 1982).
attempters hospitalized on a general medical unit, a strong relationship
found between depression, suicidal intent,
Boeck, & Kurzon, 1987). Unlike adults, it is common for a significant
of adolescent suicide attempters to deny their overdose had any suicidal implica-
tion. Gispert, Wheeler, Marsh, and Davis (1985) found that 24% of their sample
of 82 adolescent suicide attempters seen on a general medical unit denied ever
having any suicidal intent, and 27 % admitted they wanted to kill themselves at the
time of the attempt but were no longer suicidal the day following the attempt.
drugs are used by adults. As Shaffer and Bacon (1986)
drugs in suicide attempts whereas more danger-
then, based on access to
suicides by overdose in
for Disease Control, 1985). Simi-
in suicide attempt method.
(1975) to support this
have as high a rate of
who use a very lethal
O’Shanick, & Swann,
gunshot wounds, not
had made an impulsive
not all persons
have also been of interest to
(1981) reported the follow-
g ir if riend/ boyfriend
(IS%), and peer
and school problems
In a younger sample
and school problems
& Otte, 1987). However, a control
seen in an emer-
(17 %) were
to high school students reporting a
controls) or stu-
friends, or boyfriend/ girlfriend
Again, it appears that suicide attemp-
while this latter group re-
the restricted range of methods
suicide attempters, a more impor-
I n a study of adolescent
and discharge disposition
Attempted Suicide in Adolescence
get relief from a terrible state of mind,” “escape,” “make people feel sorry for you,’
and “seek help”). Such finer discriminations
useful and are worthy of further investigation.
In summary, adolescent attempters vary greatly in their intent to die, and
indications of intent may have some prognostic
deny suicidal intent, and clinicians need to be alert to other significant
signs (e.g., specifically buying pills for the attempt).
lethality of the attempt is a poor discriminator
attempters. Studies of precipitants to the attempt commonly point to conflict with
parents, although this may be an indication of general distress, rather than suicide
have tried to look beyond the wish to die and identify
for suicidal behavior. For example,
(1982) asked adolescents to choose a reason for their attempt (e.g., “to
Hawton, Cole, O’Grady, and
of suicide intent may prove clinically
significance. Many adolescents
of the medical
between relevant of
It is important
tempts to determine
attempt, continued psychiatric
variables suggested to be strongly related to adolescent
emotional states; cognitive variables;
mental factors. Studies investigating
factors that increase the likelihood of a repeat
difficulties, and/ or treatment refusal. Predisposing
variables associated with suicide at-
suicide attempts include:
interpersonal, and behavioral,
these domains are discussed below.
have been found in many, but not all attempters,
psychiatric admission, future attempts,
and affective arousal.
The relationship between depression
been well-investigated. Studies conducted in psychiatric
tion between depression and suicide attempts.
and Clarkin (1984) found that 27 of 28 hospitalized
suicide attempt had an affective disorder. Robbins
suicidal behavior to be highly associated with depressed mood among 64 adoles-
cent inpatients. Carlson and Cantwell (1982)
inpatient children had made a prior suicide attempt,
nondepressed children. Crumley (1979) reported that 24 (60%) of 40 adolescent
suicide attempters seen in a private psychiatric
major depressive disorder. Two large studies have been conducted with outpatient
samples. One study of black children
psychiatric services (Bettes & Walker, 1986) found that a depressed
more common among the subjects who made suicide attempts than among those
with suicidal ideation. The other study (Marks & Haller, 1977) found depression
to be more prevalent among suicide attempters than a nonsuicidal,
disturbed control group. When suicide attempters are examined in the emergency
room following an attempt, high rates of both dysphoria and the associated vege-
depression or depressive illness, hopelessness,
emotional states have been associated with adolescent
and anger. These factors
and their presence may predict
or be associated with general behavioral
and suicide attempts in adolescents has
hospitals find an associa-
Friedman, Corn, Aronoff,
and Alessi (1985)
who had made a
found that 30% of 102 depressed
in contrast to 18% of the
practice were diagnosed with a
and adolescents referred for outpatient
A. Spirits et al.
sample of 210 adolescent
Bennett, 1988) and 69% of a sample of 173 adolescent
clinically depressed (Withers
In contrast to patients seen in the emergency
depression is less prevalent in medically
feld (1984a), in studying 50 adolescents
suicide attempt, found that only 26% of their sample met strict criteria for depres-
sive disorder. This rate was, however, significantly
parison group of adolescents (2%) seen in an out-patient
Of adolescents admitted to a medical unit following a suicide attempt,
common diagnosis was adjustment reaction with depressed mood, with a few of
these adolescents meeting the criteria for major depressive disorder (Schrieber
Johnson, 1986). In a pediatric unit in which all suicide attempters
for psychiatric evaluation, scores on the Children’s
equivalent in a group of suicide attempters
for a variety of other emotional difficulties (Spirit0 et al., 1987).
From the studies cited above, it appears that depression
substantial proportion, but not all, of adolescent
depression may vary depending upon the population
rates found in psychiatric hospitals and the lowest in medical units. Depending
admission criteria, affective disorders may be over-represented
unit (Friedman et al., 1984; Lawler, Nakielny, & Wright,
1985). Schreiber and Johnson (1986) comment
assessment of the degree of depression
whether a psychiatric referral is even made and the presence of clinically
cant depression may be a criteria for transfer to in-patient
adolescent attempters are not depressed
attention. Other affective variables need to be investigated
Hopelessness has been found to mediate the relationship
and suicide with adult psychiatric inpatients
1973). In addition, a recent study (Beck, Steer, Kovacs, & Garrison,
hopelessness to be the best predictor of eventual
follow-up in a group of adults originally hospitalized
ies of hopelessness in adolescence have, for the most part, used psychiatric
ples. In younger children, Kazdin, French,
(1983) found a relationship between hopelessness and suicidal ideation and behav-
ior. Another study of young psychiatrically
strated that feelings of hopelessness are positively correlated
ior (Asarnow, Carlson, & Guthrie,
1987). A small (N= 11) study with teenage
outpatients demonstrated that suicide attempters
future” when compared to non suicidal psychiatric
Corder, 1974). T wo recent studies with larger samples demonstrated
ized adolescent suicide attempters had significantly
than nonsuicidal psychiatric and normal control groups (Spirito,
& Hart, 1988; Top01 & Reznikoff, 1982). Marks and Haller (1977),
outpatient sample, found that hopelessness
attempters than male suicide attempters,
are reported (Garfinkel
room studies based on chart review data have found that 82% of a
suicide attempters (Christoffel,
et al., 1982; Tishler et al., 1981). Two
were felt to be
& Kaplan, 1987).
room or psychiatric
hospitalized samples, Taylor and Stans-
admitted to a medical floor following a
higher than a matched com-
child psychiatry clinic.
as compared referred
is characteristic of a
with the highest
in the psychiatric
1963; Robbins & Alessi,
that the pediatric
following an attempt
psychiatric care. Many
and thus do not come to psychiatric
in these teenagers.
Bergman, Beck, & Beck, (Minkoff,
with suicidal ideation.
suicide at 10 year
Unis, Esveldt-Dawson, and Sherrick
hospitalized children has also demon-
with suicidal behav-
had a “lack of investment
(Corder, Shorr, &
higher levels of hopelessness
using a large
was more prevalent in female suicide
male nonsuicidal adolescents, or female
Attempted Suicide in Adolescence
across ages and in a variety of evaluation
Anger is another variable
with adolescent suicide attempts
ninger (1938) conceptualized
urge to kill (i.e., aggressive/ sadistic
have been collected
Mizruchi (1983) have presented
suicidal children: one displaying
other displaying suicidal
large study of out-patient
was found to be the most common symptom among nonsuicidal
& Walker, 1986).
Some adolescent suicide attempters
found to report intense anger prior to the attempt (Withers
to have exhibited a wide range of aggressive
Furthermore, increased anger has been associated
the attempt (Gispert et al.,
1985) and increased
(Gispert, Davis, Marsh, & Wheeler,
was noted to take several forms,
intense verbal outbursts and another third demonstrating
Only 15 % of these suicide attempters
When investigated systematically,
are found in a substantial proportion
irritability may at times be a component
tion may be less indicative of character
affective arousal which culminates
(1983) found that a large proportion
assaultivelaggressive behavior independent
suicide attempters are diagnosed as conduct disordered,
oppositional behavior seems evident in many childhood
attempts. Anger may be equally important
dered groups; however, its underlying
the data presented
Although depression and hopelessness
above suggest that hopelessness
behavior. It is consistently
are closely related
is more strongly
with suicide attempts associated
that has been prominently
suicide as stemming from either the urge to die (i.e.,
the urge to be killed (i.e.,
about anger in suicidal adolescents.
behavior without aggressive
black children referred for psychiatric
discussed in connection
1987). Indeed, 1987; Khan, Men-
the idea of two subtypes
seen in an emergency room have been
et al., 1982).
probability of re-attempting
1987). Among first time attempters,
with one third of the sample demonstrating
significant acting out.
denied any feelings of anger (Gispert et al.,
it appears that anger and aggressive behavior
of adolescent suicide attempters.
of depressive disorders.
pathology and more a function of strong
in a suicide attempt. However, Pfeffer et al.
of childhood suicide
anger as a component
in the depressed and character
basis may be very different.
Since many adolescent
display less adequate
have been observed in suicidal patients of all ages: children (Asarnow et al., 1987;
Cohen-Sandler, 1982; Orbach, Rosenheim,
man, 1987), and adults (Schotte & Glum, 1987). Orbach et al. (1987) studied 27
psychiatrically hospitalized children between the ages of 6 to 12 years who demon-
and cognitive distortions.
to suicidality in&de
In many studies, suicide attempters
abilities than either psychiatric
O’Riordan, & Taylor,
problem-solving deficits, im-
Such deficits 1987).
& Hary, 1987), adolescents (Traut-
A. S$rito et al
strated either suicidal ideation or behavior.
children with chronic medical illnesses and 23 normal controls on a test designed
to assess the ability to generate alternative
death. Suicidal children generated fewer alternatives
ill children. In the suicidal group, those most attracted to death were least capable
of generating alternative solutions.
(1982) found that psychiatrically hospitalized
generated fewer active coping strategies
(1987) also found that adolescent suicide attempters
problems than nonsuicidal psychiatrically
Neuringer (1971) d
a ministered the Rokeach
requires finding short-cuts on a map and thus presumably
flexibly reorganize problem elements. A group of 13 suicide attempters
test more often than nonsuicidal psychiatrically
suggesting inflexibility in the problem solving of suicidal adolescents.
This lack of flexibility and rigidity in problem solving (Neuringer,
be state dependent and not a stable personality
Whether acute or chronic, cognitive rigidity may underlie many problem-solving
deficits (Ellis, 1986). Finally, suicidal patients have been found to identify more
negative consequences for their problem
(Schotte & Clu m, 1987). The perceived negative consequences
the implementation of the few solutions they do generate.
Impulsivity has frequently been described
1983) and a personality characteristic of adolescent
1979; Haider, 1968). Shaffer and Bacon (1986) h ave reported that most completed
suicides among adolescents are preceded by a short period of planning.
impulse control has been found to differentiate
a control group of adolescents with an acute illness (Slap, Vorters, Chaudhuri,
Centor, 1988). However, impulsivity does not seem to characterize
attempters, since group comparisons have found no differences
patients and psychiatric controls on a measure of cognitive impulsivity
Clum, & Luscomb, 1979). Instead, impulsivity
high risk subgroups. A one-year follow-up of suicidal patients found the repeat
attempters to be more impulsive than nonrepeaters
thermore, it has been suggested that impulsive
families in which action supercedes verbal mediation
and that male adolescent suicide attempters
than female suicide attempters (Marks & Haller, 1977). Finally, impulsive suicide
attempters have been found to be less depressed and less hopeless than nonim-
pulsive attempters (Brown, Overholser,
son, & Montgomery, 1980). It is surprising
on the relation between impulsivity and adolescence,
to teenage suicide attempts as impulsive.
tion between impulsive cognitive style and impulsive
ered. Another problem is that the measures
often reflect angry and aggressive behavior as much as behavior suggesting a lack
of reflection or planning.
Cognitive distortions involve maladaptive
These children were compared to 25
solutions to scenarios
than normal or chronically
about life and
et al. (1987)
suicidal children (ages 8 to 13 years)
than nonsuicidal children.
generated fewer ways to solve
Map Reading Problem
taps the ability to
controls, hospitalized adolescent
1987). trait (Perrah & Wichman,
solutions than psychiatric controls
as a risk factor for suicide (Arffa,
suicide attempters (Crumley,
from adolescent suicide attempters
in identifying may be important
are more often described as impulsive
et al., 1979). Fur-
& Philip, 1972)
Spirito, & Fritz, 1988; Williams,
how few studies have been conducted
given the frequent reference
In those studies that do exist, the distinc-
of impulsivity used in these studies
must be consid-
information processing patterns that
Attempted Suicide in Adolescence
traits). Conversely, positive events are attributed to specific, external, and unstable
causes (e.g., luck). Adolescent suicide attempters have been found to display more
frequent attributional errors as compared to psychiatric controls (Hart, Spirito, &
Overholser, 1988). In this study, 66 adolescent suicide attempters were compared to
a group of 40 psychiatric~ly hospitalized
tional Style Questionnaire and the Children’s Depression
two groups did not differ on level of depression,
were more likely to view negative events as stable characteristics
ment than the nonsuicidal psychiatrically
In summary, three cognitive variables
attempters. Problem-solving deficits, impulsiveness,
pear more frequently in at least a subgroup
Whether these variables are temporary states or permanent
than whether professionals can learn to accurately
deficits when they are present. Identification
ly lead to more intensive intervention with this particularly
attempters. The clinician can expect that many attempters
style marked by a lack of flexibility, perception
and a tendency to feel overly responsible for those negative outcomes. Attempts at
enhancing problem solving will need to take these factors into account.
a person to focus on the negative
theory of depression argues that depression results from a tendency to
negative events to global, internal,
aspects of a situation. The
and stable causes (e.g., personality
adolescents on the Children’s Attribu-
Inventory. Although the
the adolescent suicide attempters
of their environ-
are relevant to the study of suicide
and cognitive distortions
traits is less important
will have a cognitive
of overly negative consequences
a suicide attempt in response to stress (Khan,
adolescent suicide attempters
more prone to use avoidant methods of coping, such as social isolation or sub-
stance abuse. Also, Jacobs (197 1) suggests that suicide attempters
ety of coping strategies prior to the suicide attempt,
successful. Only one study has examined
suicide attempters. In this study, 76 adolescents
rics unit following a suicide attempt were asked to complete a coping checklist in
order to assess which cognitive and behavioral
the stress which precipitated the suicide attempt (Spirito,
press). Two control groups that completed
personal problem, which they had experienced
on the basis of whether or not the problem made them seriously distressed.
suicide attempters employed wishful thinking,
than the nondistressed controls. When compared
suicide attempters were less likely to use wishful thinking and more likely to use
social isolation as coping strategies. These latter findings suggest that the use of
certain types of coping strategies,
prevent or dissuade distressed adolescents
coping strategies are among the main reasons that an adolescent makes
of coping in suicide attempters have focused primarily on
However, some researchers feel that deficient or maladaptive
1987). Curran (1987) suggests that
may lack effective coping strategies, or they may be
employ a vari-
but none of them is very
a broad range of coping strategies
hospitalized on a general pediat-
strategies they used in response to
the coping checklist in response to a
in the prior month, were formed
& Stark, in
and social isolation
to the distressed controls,
from moving toward suicidal behavior
or behavioral, may help
A. Spirito et al.
as a possible solution.
future research in this area should be encouraged.
Substance abuse may be an indication
substance abuse among adolescent suicide attempters
the United States have been reported at 23% (Headlam,
& Rauh, 1979), 25% (Withers
1986), and 42% (Christoffel
(Garfinkel et al., 1982; McKenry,
substance abuse significantly
al. (1987) found that the rate of substance
signi~cantly different from the rate in nonsuicidal
psychiatric evaluation (24%).
incidence of drug abuse among adolescent
different patterns of drug use across the countries.
al., 1982) has reported the rate of alcohol/ drug abuse at the time of the attempt
(11.3%). u f t
n or unately, adolescent
rooms are not consistently asked whether they use drug or alcohol on a regular
basis (Rockett, Spirito, Fritz, & Riggs,
cording information on substance abuse in less than l/ s of cases (Christoffel
The importance of drug abuse in lethal actions is underscored
and Allman (1987),
who found that adolescent suicide victims who used firearms
(a highly lethal method) were much more likely to have been drinking than those
who chose other methods. Strong correlations
alcohol/ drug abuse have been reported
settings (Robbins & Alessi, 1985).
The studies cited above suggest that substance
of adolescent suicide attempters. Drug and alcohol use may reflect a maladaptive
coping strategy, general psychopathology,
behavior, rather than being specific to suicidal behavior. Nevertheless,
of abuse are reported, and such abuse is correlated with highly lethal attempts,
that complete drug histories are mandatory
ter. Interventions targeted at reducing drug use, if successful,
rate of attempted suicide among adolescents.
Since interventions may be designed to enhance coping,
of a breakdown in coping. Rates of
seen in general hospitals in
& Johnson, & Kaplan,
et al., 1988). Two studies included control groups
Tishler & Kelly, 1983) and found rates of
higher in the attempter groups. However, Spirit0 et
abuse in attempters
Studies in Britain (Hawton,
Only one study (Garfinkel
1986) report very low
seen in typical emergency
1988), with emergency room charts re-
by Brent, Perper,
abuse is a salient characteristic
family disturbance, or self-destructive
in the evaluation of a suicide attemp-
may also lower the
and poor peer relationships
on a psychiatric
than a psychiatric
Reynolds, and Heald (1977)
being socially isolated before their suicide attempt,
the male attempters. Also, patients who re-attempted
from the hospital had reported
compared with one-time attempters
Barter, 1970). Psychiatrically
impressions and case reports have suggested that impaired
can lead to suicide attempts in adolescents
1987; Teicher, 1979). Adolescent
floor have been found to display less adequate peer relationships
control group (Stanley & Barter,
reported that 50% of a sample of 65 adolescent
seen in an emergency room described themselves as “loners” or
hospitalized suicide attempters
1970). Rohn, Sarles, Kenny,
a finding especially
suicide following discharge
less frequent peer interactions
Swaback, & Todd, 1968; Stanley &
adolescent suicide attempters
Attempted Suicide in Adolescence
cy of peer problems.
ties, with 72 to 87 percent
Sinay, and Nihira
friends than other
cents did report,
peer groups than
(198 1) found only 15 % of 108 adolescent
room reported experiencing
ple in Britain, social isolation
who made a suicide
Cole, 1982b). Fourteen
conflict. In another
self-report of social skills was found between
ison group of psychiatric
1988). However, social skill deficits
the suicide attempters
patients reporting greater
Thus, there is conflicting
the genesis of adolescent
factors may exert their influence
stressful precipitant of the actual attempt
sonal functioning (Curran,
strued as a form of interpersonal
ing more adaptive ways to satisfy
attempt may be the result primarily
uting to the depression
1975; Spirito, Overholser
serious peer problems
than either nonsuicidal
group of high
(Top01 & Reznikoff,
to a control
of peer problems
f ound no differences
of the adolescents
(1972) f ound
adolescents with psychiatric
however, that they were less interested
the other adolescents
in suicide attempters may be limited
had a very high rate of peer difficul-
reporting no friendships.
interviewed. In contrast,
suicide attempters seen in an emergency
social isolation. Similarly,
was present in only 28% of a sample
by drug overdose (Hawton,
percent of these adolescents also reported
general hospital sample of suicide attempters,
the suicide attempters
inpatients (Spirito, Overholser,
were a function
and the psychiatric patients,
social skill deficits.
literature regarding the relevance
suicide attempts. The mechanism
is a matter of speculation.
or a marker
1987). Alternatively, the suicide
coercion (Zich, 1984) used by individuals
of depression, with social skill deficits contrib-
rather than directly to the suicide
et al., 1988).
on the frequen-
that had more
in a general hospital
and a compar-
attempt Osborn, &
of level of depression
with the more
of social factors
Social failure may be a
of an adolescent’s
can be con-
needs. Finally, a suicide
Family The relation
has been explored
ior and also in their background
inent in samples
exposure to family
these studies did not use control
in many lines of research.
family functioning and adolescent
investiga- areas of clinical
and rates of separation/
behavior has been noted in both the suicide attempters’
of suicidal children (Kosky,
violence has been seen in suicide
Stone, & Sposto,
et al., 1983).
A. Spirilo et al
to 17 % in neglected
an inner city general
subject to more severe disciplinary
la (1972) found
characterized by reasoning
In view of the significant
studies report a significant
Mizruchi, & Werner,
of conduct disorder
service. Of course,
attempt with 120 delinquent
1982). Female delinquents
levels of acting out were equally
A high rate of sexual
1987). This rate of abuse
(Levin & Schonberg,
kin, Alpert, and McNamara
ters admitted to a general
of physical or sexual abuse between
Other studies indicate
as well as substantial
ships were found
liams & Lyons,
al., 1988). In addition,
zninoff, 1982; Williams
atric samples have documented
of the adolescent
50% reported a family history
control group. Alcohol
ed by parents, a finding
King, 1982a; Rohn
not find a difference
inpatients in the rate of family
Green (1978) found a greater
children and 7 % in normal
medical unit (Levin
wife battering, a primary
percentage of self-destructive
controls. In a study conducted
& Schonberg, 1987),
to be exposed to a variety
family member convicted
(1971) found adolescent
techniques than normal
in the families of suicide
and exploration, as compared
levels of family aggression,
rate (approximately 30%)
suicide attempters (Pfeffer,
1982; Tuckman & Connon,
have also been found in 20% (Taylor
&Johnson, 1986) of adolescent
not all adolescents with conduct
One study compared 30 delinquents
were much more likely to attempt
when depressed. Males
likely to attempt
emergency rooms (Levin & Schonberg,
is higher than that of a nonpsychiatric
with even more dramatic
(1985). Spirit0 et al. (1987)
pediatrics floor, but did not find differences
for psychiatric evaluation.
overt conflict between
& Cole, 1982a; Wenz,
to differentiate suicide attempters
and adolescents hospitalized
a number of studies (Corder
& Kelley, 1982; Taylor & Stansfield,
& Lyons, 1976) using control
among family members.
of psychiatric disorders
and drug abuse were the most common
supported by other studies (Cohen-Sandler,
1977). Studies using clinical
inpatients compared to nonsuicidal
between the suicide attempters
compared suicide attempts, 59 physically (50%)
of a violent
it is understandable
who had made
less likely to be d iscipline
on a medical
go on to make
Chiles, & Barnes,
suicide than male
has also been
noted by Dey-
group of medical
and a control
parent and the suicidal
in the entire
with an acute illness (Slap
et al., 1974;
Top01 & Re-
in the families
with 16% of the
(Carlson & Cantwell,
et al. (1982)
Attempted Suicide in Adolescence
(1984) found that chronic psychiatric
age 14 was more common among depressed suicide attempters
depressed adolescents. Similar
attempters seen in an emergency
group (Tishler & McKenry, 1982). This study indicated that fathers of attempters
displayed higher levels of depression, a lower self-esteem,
than fathers of nonattempters. High rates of attempted suicide, for example 28%
in the Kienhorst et al. (1987) study, have been found in the family members
adolescent suicide attempters. These higher rates of suicide attempts and comple-
tions among family members have been confirmed
groups (Garfinkel et al., 1982; Jacobs,
(Stevenson et al., 1972). A number of studies indicate
attempters frequently have parents who have been divorced or separated (Barter
et al., 1968; Choquet, Facy, & Davidson,
Jackson, & Ripley, 1965; Hawton et al., 1982b;
Barter, 1970; Tishler et al., 1981; Walker, 1980). The observed rate is consistently
greater than that in control groups of normal
medical service (Garfinkel et al., 1982; Jacobs,
with other psychiatric difficulties are used as a comparison
have found no difference in the rate of family breakdown across groups (Mattson,
Seese, & Hawkins, 1969; Spirit0 et al., 1987; Stanley & Barter,
tion, these studies have not controlled for potential confounding
parent age (Shaffer, 1982). Nonetheless,
to be risk factors for the development
though not specifically suicidal behavior. Overall,
prominent in the histories of adolescent
family seems to be the major area that differentiates
psychiatric comparison groups. More in depth study of the patterns
conflict, such as that conducted by Taylor and Stansfield
higher rate of father/ daughter conflict
group, will be an important area of future research.
The above studies are very consistent in supporting the belief that the families of
adolescent suicide attempters are characterized
tion. This dysfunction includes physical
parent and adolescents) and excessive discipline;
family; marital conflict, such as communication
and remarriage; more disturbed overall family functioning.
tently indicate high rates of significant
extended family, including suicide attempts and completions,
quently predispose these families to the high rates of dysfunction
These findings underscore the importance
the evaluation and treatment of adolescent suicide attempters.
Corn, Hurt, et al., 1984).
illness of a parent before the child reached
Corn, Hurt, et al.
findings were obtained
room when compared
in a sample of 46 suicide
to a medical control
and greater alcohol use
in studies with normal control
1971) but not psychiatric
1980; Christoffel et al., 1988; Dorpat,
Rohn et al., 1977; Stanley &
1971). However, when adolescents
group, several studies
or adolescents on a
1970). In addi-
factors, such as
parental divorce and separation
of emotional distress in adolescents,
seems to be
Overt conflict in the
(1984a) which found a
than in a control in suicide attempters
sexual abuse of children in the
Studies also consis-
levels of dysfunc-
parents and between
which may subse-
of understanding in
related to increased
with adults has shown that suicide attempters
events as compared to depressed patients,
cantly more events than psychiatric
Life E ven ts.
and severity of stressful life events have been
and suicidality (Paykel,
and depressed patients report signifi-
controls (Paykel, Prusoff,
1980). Previous research
& Myers, 1975).
A. Spirit0 et al
to a suicide attempt.
Most of the research
od of stress
during this period
suggest that stresses
triggered by an unrelated
difficulties and social ostracism.
of emotional distress.
trol groups is especially
Increased levels of life stress
Gispert et al. (1985)
jor life events from early to mid-adolescence
Cohen-Sandler et al., (1982a)
between 5 and 14 years)
Records were assessed
logy. Results showed
psychiatric control children,
Consistent increases in stress were observed
for suicidal children.
the suicide attempt. Depressed
while the suicidal children
through death, divorce,
especially social exit events,
ing suicide attempts in children
Physical illness is an example
been associated with an increased
present in 34% of 3,338
disorder have been reported
(Cadman et al., 1987; Goldberg,
chronic illnesses and completed
ed, at least partially because
reports have noted relatively
and adolescent suicide
third” of their sample of 50 attempters
similar to that reported
emergency room records
cantly higher rate of physical
group (43%). 0 ne-third
reported a history of chronic
described the frequency
importantly, the frequency of such events tends to increase
of stressful life events may be an important
that prior to the suicide
of a high number
et al., 1975). This
on stress and suicide has been conducted
& Patsiokas, 1980).
and turmoil, the exact relationship
is unstudied (Compas,
that stresses are simply
For example, presence
elicit more negative
To better examine
important when examining
and are observed
(1971) found that adolescent
on adult samples
stress and adjustment
studies of adolescents
may set the style for
in an adolescent,
may lead to socialization
cycle may develop
which serve to exacerbate
stress in adolescents.
adolescents have been
even when adequate
than a sample
the medical records
who had been hospitalized
for the severity of life stressors
that the suicidal children, as compared
were found to experience
over the developmental
Stressors were especially prominent
children were more likely to suffer peer rejections,
experienced more social losses (the loss of a loved one
or relocation). Thus, presence
seems to have important
of a more enduring
risk of suicide. In adults,
completed suicides (Whitlock,
as higher in physically
& Weitzman, 1981). However,
suicide among children
the rates for both are low compared
high rates of physical
Hawton et al. (1982a)
had an unspecified
by Choquet et al. (1980)
in Canada, Garfinkel et al. (1982)
illness in their suicide
of 210 suicide attempters
disease (Christoffel et al., 1988).
of a particular physical disorder
Clum, Wh’l I e adolescence
use of relevant
had more ma-
of 76 children
the year prior to
of stressful life events,
for understand- implications
Pless, & Roghmann,
Rates of psychiatric
also found a signifi-
seen in a general
Only one study has
In a review
than a control
Attempted Suicide in Adolescence
bles that act as protective
effects of life stress (Rich,
a rate he calculated
but it tends to support
and social responses
research on stressful
suicide, more research
found that 9 of 126 consecutive
as 15 times
attempts with greater
greater than expected.
made than the other
research on the pediatric
to chronic illness has not been adequately
life events may
is needed to identify
mechanisms versus those which exacerbate
Fowler, Fogarty, & Young,
will be improved and the risk of suicide
in the central
is scant and
physical illness in
nervous or the
facilitate our understanding
1988). In this way, interven-
in adolescence may be
Contagion and Imitation.
clusters of adolescent
following two adolescent
suicides were separated
Bollen and Phillips
described a relationship
fatalities in California.
were 3 1% greater
(r= .46) with age of person
specifically on adolescents.
the increase was most noticeable
consistent with imitation
explanations such as: precipitation
person. A relationship
was found in Gould
such movies they reported
the New York City area.
cent suicides in California
unable to replicate
shown on one television
There is also a fair amount
behavior within the family and social networks
suicide or attempts,
by three months
threat, all in students
had of one another,
imitation was likely an important
suicide, or automobile
(1982) f ound
Three days after a front page story, automobile
than expected. More widespread
of fatalities. Also, age of the driver
in the suicide story. Several
Phillips and Carstensen
suicides following 38 televised
of the story was associated
as a factor in these suicides
seasonal effects, or the effect of grief over death of an admired
between suicide and television
and Shaffer’s study (1986).
an increase in both attempts
Phillips and Paight (1987)
and Pennsylvania following
the finding. It was postulated
station, effects were not likely to be widespread.
of data indicating
newspapers and magazines
there are few detailed
and Conroy (1983)
in the suburban
and then followed
in the same high
New York City area.
by live attempts
visiting other during
coverage of suicides
by several studies.
10 days. Phillips
of suicide and motor
with the effect lasting
other studies have focused
with a greater increase
rather than adults.
and did not support
that would have occurred
in suicide and
The data were
movies about suicidal
In the two weeks following
the same movies
that since the movies
that there are models
A. Spirito et al
et al. (1987)
likely to know a family member
al., 1981), while 11% reported
toffel et al., 1988). J acobs (197 1) found a much higher
completed suicide in the relatives
compared to normal controls.
behavior in the families of adolescent
that of medical patients. Sixty
sibling or friend who attempted
higher than the controls (12 %), a group
victim. However, there was no difference
of suicidal behavior. Further
needed to determine whether
characteristic of psychiatrically
mine whether family models play a primary
or if family psychiatric history
ing factors in an adolescent’s
than family models, differential
cent suicidal behavior.
In summary, there are some data that suggest
television) as a relevant factor
group “wax and wane” so that changes
for suicide, or the motivation
1986). The variation in suicide
impact on national trends is small.
identified suicide attempters
surveying high school students
of suicide in another
of adolescent suicide
et al. (1982) found
suicide attempters seven times higher
percent of completed adolescent
or completed suicide.
composed of the closest
between the two groups in family history
studies using clinical comparison
this is specific to suicide
disturbed adolescents. More
role in an adolescent’s
or family models are the more relevant
suicide attempt. If peer models
social aggregation may better
to know a friend or peer who had attempted
a so found that suicide
attempters were more
a rate of suicidal
22% of the adolescent
member who had exhibited
a family history
had a suicides
or a general
data will help deter-
play a larger
have a real impact
in adolescent impulses
in the opportunity
rates imply imitation its
POST ATTEMPT COURSE
will be elaborated
make a suicide
study, one half of the referral
a positive effect and no further
as well as frequent
hinderance to adolescents
1 summarizes follow-up
in the table is discussed
of completed suicide.
suicide attempters to attend
that, unlike adult
attempt in the hopes of obtaining
and Carroll (1984)
denial of the seriousness
conducted with adolescent
in this section.
suggest half of all suicide
the rate appears
do not receive
in younger adoles-
have been cited for this failure
that the emergency
was needed (Mattson
of the attempts by parents
In one care.
reported room visit had
of the parents
is a primary
T ABL E
1. F ollow-up Studies of Adolescent Suicide Attempters
% of Sample
7 to 18 yrs
s Otto (1972)
O’Grady, Osborn, &
10 to 21 yrs
3 to 34
53% of 30
6 months to
2 months or
A. Spirito et al
ceived and were thus reluctant
cents have been
Ryan, & Jaffe,
tempters are less compliant
(Goldacre & Hawton,
Berman, & King,
studies using longer
attempters who had been psychiatrically
to be associated with general
follow-up studies is compromised
centages noted in Table
initial attempt have received
few months after an attempt
acre & Hawton, 1985).
contacting a subject
may reflect better
greater the likelihood
When data from
nonrepeaters are more likely to have had difficulties
of life stresses, more serious
than nonrepeaters (Gispert
risk for repetition was associated
psychiatric disorder. The high risk group also had at least three of the following
variables operating in their lives: a large
turbed family interaction patterns, poor school performance,
dencies (Choquet et al., 1980). Other factors
included: males, especially older teenagers
Hawton, 1985); chronic difficulties such as conduct
turbance (Hawton, Osborn, O’Grady, & Cole,
of prior suicide attempts (Hawton, 1986).
Another reason for difficulties in prediction
is different than the suicidal state. Adolescents
evaluation setting than in future situations
and behavior (Rotheram, 1987). S ome degree
problematic to many investigators because
of the treatment
may also play a role in referral
& Rudd, 1983) suggest
who made a prior suicide
treatment may make
Mattson et al. (1969)
dissatisfaction with the original
shown to attend relatively
1988), controlled studies
that parental attitudes and
than of attendance
reluctant to seek additional
that 29% of the mothers
are needed to determine
than other adolescent
that referral is particu-
it is possible
rates are often found in studies
1985) and younger
1982b). The higher
rates tend to be associated
et al., 1969)
hospitalized, while the lower rates seem
samples. The methodological
by difficulties in successfully
1980) as reflected
and with suicide
hospital rigor of most
in some of the low per-
is the greatest
over a short follow-up
of a reattempt
It has been
period and thus the increased
Conversely, the longer
for future attempts
by the higher
that the first
to the longer
the first attempt are re-examined, repeaters compared to
anger levels and dysphoria
In a study conducted
with persons who were diagnosed
a greater number
family, alcoholism in the family,
and an established
have felt to characterize
from 16 to 20 years
may be that the post-suicidal
may present quite differently
which might result in suicidal
of the serious consequences
is not considered
of a false
Attempted Suicide in Adolescence
The third major
rate of and predictors
than girls (Goldacre
include an active (e.g.,
towards the initial diagnostic
Although suicide attempters
suicide, the characteristics
attempter is at much higher
or young adult without
cide ideators/ attempters,
exposure to suicide,
if the adolescents
studies of the course following
are to receive appropriate
means that many adolescents
which, in cost/ benefit
may terms, be
are the suicide attempt
interventions in a cost-effec-
area of interest
have been discussed.
Boys are much more likely to complete
1985; Otto, 1972).
shooting) method of attempting
Of the variables assessed during
the ones most predictive of eventual
of suicidal intent and fear of “going
apathy, and hypersomnia (Motto,
compose a high risk group for eventual
of suicide completers
follow-up studies should not only determine
of suicide, but also those at risk for continued
there is sufficient
risk for eventual
prior suicidal behavior.
adolescent suicide victims
range of psychiatric diagnoses,
and family history of psychiatric
studies has been to determine
prior suicide attempters.
(Otto, an initial psychiatric
completed suicide were poor
suicide are different from
who is at risk for
that a suicide
suicide than an adolescent
Brent et al. (1988),
overlap between the two groups
disorder and suicide.
to lack descriptive
cents take overdoses
intent and precipitants
of studies point to hopelessness
hopelessness places an adolescent
The family functioning
by disturbed family
the family. There
the suicide attempters
Thus, when evaluating
pattern of communications
of low lethality
may be useful in discriminating
There are only three psychological
and contagion) where an adequate
as a prominent
Although highly correlated
dimension to the evaluation
can be drawn
due to the restricted
from the studies
on adolescent suicide
of suicide attempts
to a problem
factor in the psychological
of suicide attempters
will be needed to determine
at high risk for further
with their parents,
basis exists. A variety
when the level of
attempted or completed
is some evidence
and a significant
to suggest that this family conflict
to other psychiatrically
attempter, it is important
and conflict resolution
is usually characterized
degree of overt conflict in
for is greater
that may precipitate
A. Spirit0 et al
ment of a brief family
suicide and suicide
Although the impact
certainly has a significant
occurs. The development
suicides, and should be another
There are also two additional
among suicide attempters
of the cognitive
eating the psychological
number of areas
reported rates of depression,
been found in the social realm.
exist, but deficits
do not appear to differentiate
parative studies have yet to be conducted
Such research is needed
associated with adolescent
Our knowledge of the adolescent
confounded by the heterogeneity
suicide attempters are studied
patients are being investigated.
and definitive conclusions
attempters by relevant
important in future research.
described (Brent, 1987; Choquet
ton et al., 198213; Khan,
examined the psychological
fication systems, or have tried to differentiate
attempters by other criteria.
suicide attempters (i.e.,
as support for the same mechanisms
cance of developmental
cy age suicide attempters
ters are rare (e.g., Triolo,
suicide attempt. Future research
focus on the develop-
these dysfunctional intervention
is the third major
seems to occur
area with significant
of social restraints
impact on the communities
of effective programs,
L amb & Dunne-Maxim,
in which at least one study has documented
characteristics of suicide attempters
in which research
or history of psychiatric
in the specific social skills which contribute
research support. Completed
seem to have a significant
that occurs with publicized
That is, imitation
suicide rates is relatively
may help halt imitation
in the future.
holds some promise
to suicide attempters.
has failed to identify
controls. The groups
abuse, history of sexual
that differences in peer relationships
area of research
specific are a
do not differ
to peer relationships
to several variables,
and family models
whether these risk variables
from psychiatric Com-
of family of suicide.
suicide attempter’s psychological status is
of the population.
in the emergency
or in a psychiatric
Some areas of overlap
are thus impossible.
et al., 1980; Greuling
1987; Ryan et al., 1987).
floor, at a
but there are many
in each clinical
Yet, few empirical
of suicide attempters
on a pediatric
clinic, groups of
of patients setting
using such classi-
below the age of 13) should not necessarily
change. Studies that compare
to mid-adolescent and older adolescent
also be taken into account. Findings with child
given the signifi-
& Blyth, 1984) and needed.
Attempted Suicide in Adolescence
tween 5% to 40%
nal studies with suicide
at the time of the attempt
that are temporary
predict the most effective
important to advance
adolescents from further
morbidity and repeat
hinge on at least three major
determined; and (c) the collection
is a major problem;
can be related
and their families
review reveals a relative
suicide. In addition,
half of all adolescent
a suicide attempt.
will make another
one-half of adolescent
The need for more thorough
is crucial so that psychological
to future functioning
will help distinguish
states from the more enduring
between state and trait variables
Given the difficulties
in treatment, follow-up
who are most in need of psychiatric
absence of theoretical
Applying and testing
examination of the mechanisms
is of extreme interest.
are a high-risk group
Our ability to develop
developments in the area:
models of adolescent
comparison groups so that findings
of data from prospective
states can be related to future functioning.
and frequency of
the psychological variables
adolescent of keeping
studies will also help
to the prediction
(b) the use of
follow up. Development and Behavioral Pediatrics, 4, 83-87.
Arffa, S. (1983). Cognition
Asarnow, J. R., Carlson, G. A., & Guthrie,
ness, and perceived family environments
and Clinical Psychology, 55, 361-366.
Barraclough, B., Bunch, J., Nelson, B., & Sainsbury,
aspects. British Journal ofpsychiatry,
Barter, J. T., Swaback, D. 0.) & Todd, D. (1968). Adolescent
Beck, A. T., Schuyler, D., & Herman,
Beck, H. L. P. Resnik, & D. J. Lettiere
Beck, A. T., Steer, R. A., Kovacs, M., & Garrison,
lo-year prospective study of patients hospitalized
try, 142, 559-563.
Berman, A. L., & Carroll, T. A. (1984).
Bettes, B. A., & Walker, E. (1986).
Journal of Abnormal Child Psychology, 14(4), 591-604.
Bollen, R. A., & Phillips, D. P. (1982).
television news stories. American Sociological Reuiew, 47, 802-809.
Brent, D. A. (1986). Overrepresentation
C. R., O’Brien, T. P., & McIntire, M. S. (1983). Adolescent self-poisoning: A nine-year
and suicide: A methodological review. Suicide andLife-Threatening Behauior,
D. (1987). Coping strategies,
and suicidal children. Journal of Consulting
P. (1974). A hundred cases of suicide: Clinical
suicide attempts: A follow-up study of
Archives of General
Psychiatry, 19, 523-527.
Theprediction ofsui~ide (pp. 45-56).
of suicidal intent scales. In A. T.
B. (1985). H p 1
with suicidal ideation.
o e essness and eventual suicide: A
American Journal of Psychia-
Adolescent suicide: A critical review. Death Studies, 8, 53-
Symptoms associated with suicidal behavior in childhood and
Imitative suicides: A national study of the effects of
of epileptics in a consecutive series of suicide attempters
A. Spirit0 et al.
seen at a children’s hospital,
Brent, D. A. (1987).
cents. Jou;mnal ofAmerican Academy of Child and Adolescent P.yychiatry, 26, 87-91.
Brent, D. A., Perper, J. A., & Allman,
Temporal trends in Allegheny County,
As.roc&tion, 257, 3369-3372.
Brent, D., Perper, J., Goldstein, C., Kolko, D., Allan, M., Allman,
factors for adolescent suicide: A comparison
Archives of General
Psych&try, 45, 581-588.
Brown, L., Overholser, J., Spirito, A., & Fritz,
attempters. Poster presented at the 35th Annual
Psychiatry, Seattle, WA.
Cadman, D., Boyle, M. H., Offord, D. R., Szatmari,
J. (1987). Chronic illness and functional
Child Health Study. Canad& Medical Association Journal, 137, 761-767.
Carlson, G. A., & Cantwell, D. P. (1982).
Centers for Disease Control. (1985). Suicide surveillance. Atlanta,
Choquet, M., Facy, F., & Davidson, F. (1980).
France. In R. Farmer & S. Hirsch (Eds.),
Christoffel, K. K., Marcus, D., Sagerman,
attempts: A population study. Pediatric Emergency Care, 4, 32-40.
Cohen-Sandier, R. (1982).
Interpersonal problem-solving skills of ruicidal and nonsuicirial children: Assessment
and treatment. Unpublished manuscript, American
Cohen-Sandier, R., Berman, A. L., & King, R. A. (1982a).
Cohen-Sandier, R., Berman, A. L., & King, R. A. (1982b).
suicidal children. Journal ofthe American Academy ofchild
Compas, B. E. (1987). Stress and life events during childhood
Review, 7, 275-302.
Corder, B. E, Shorr, W., & Corder, R. F. (1974). A study of social and psychological
of adolescent suicide attempters in an urban, disadvantaged
Crumley, F. E. (1979). Adolescent suicide attempts.
Curran, D. K. (1987). Adolescent suicidal behavior. Washington,
Deykin, E. Y., Alpert, J. T., & McNamara, J. J. (1985).
child abuse and neglect on adolescent suicidal behavior.
Deykin, E. Y., Hsieh, C. C., Joshi, N., & M N c amara, J. J. (1986).
destructive behavior: Results of an intervention
Dorpat, T. L., Jackson, J. K., & Ripley, H. S. (1965). B ro k en homes and attempted
suicide. Archives of General
Psychiatry, 12, 213-216.
Dorpat, T. L., & Ripley, H. S. (1960). A study of suicide in the Seattle area. Comprehensive Psych&y,
Eisenberg, L. (1986). Does bad news about suicide beget bad news. New England Journal ofMedicine,
Ellis, T. E. (1986). Toward a cognitive therapy of suicidal individuals.
and Practice, 17, 125-130.
Friedman, R. C., Corn, R., Aronoff, M. S., Hurt,
suicidal adolescent: Affective and character pathology.
Rushforth (Eds.), Suicide in theyoung (pp. ‘209-226).
Friedman, R. C., Corn, R., Hurt, S. W., Fibel,
history of illness in the seriously suicidal adolescent:
0rthopsychiat7y, 54, 390-397.
Journal ofthe American Academy ofchild Psychiatry, 25, 242-
Correlates of the medical lethality of suicide attempts in children and adoles-
C. J. (1987).
1960 to 1983. ~Journal 4 the American Medical
firearms, and suicide among youth:
C., & Zelenak, J, (1988).
suicide victims with suicidal inpatients.
of the American
Zmpulsivity in adolescent suicide
Academy of Child
N. I., Crawford,
T., & Byles,
of the Ontario limitation
Suicidal b h e avior and depression in children and
Journal ofthe American Academy of Child Psychiatry, 21, 361-368.
GA: US Department of Health and
S uicide and attempted
The suicide sq’ndrome (pp. 73-89).
suicide among adolescents
S., &Bennett, S. (1988). Adolescent suicide and suicide
Life stress and symptomatology:
of suicidal behavior in children. Journal ofthe American Academy of Child Psychiatry, 21,
study of hospitalized
area. Adolescence, 9, l-16.
Journal of the American Medical Assoctition, 241,
A pilot study of the effect of exposure
American Journal of Psychiatry, 142, 1299-
Adolescent suicidal and self-
study. Journal ofAdolescent Health Care, 7, 88-95.
Professional Psychology: Research
S. W., & Clarkin,
In H. S. Sudak,
Boston: John Wright PSG,
J. F. (1984).
A. B. Ford, & N. B.
J., & Swirsky, S. (1984).
approach. American Journal of
Attempted Suicide in Adolescence
American J ournal ofPsych&y,
Gispert, M., Davis, M. S., Marsh,
in evaluation. Hospital and Community Psychiatry, 38, 390-393.
Gispert, M., Wheeler, K., Marsh,
Adolescence, 20, 753-762.
Goldacre, M., & Hawton, K. (1985).
cents who take overdoses.
British J ournal ofpsychiatry,
Goldberg, I. D., Regier, D. A., McAnganey,
role of the pediatrician in the delivery of mental health services to children.
Gould, M. S., & Shaffer, D. (1986).
imitation. New England J ournal OfMedicine, 315,
Green, A. H. (1978). Self-destructive
Greuling, J. W., & DeBlassie, R. R. (1980). Adolescent
Haider, I. (1968). Suicidal attempts in children
Harkavy-Friedman, J. M., Asnis, G. M., Boeck,
suicidal behaviors in a high school sample. American J ournal ofPsychiatry,
Hart, K., Spirito, A., & Overholser, J. (1988).
script submitted for publication.
Hawton, K. (1986).
Suicia’e and attempted sukide amonE children and adolescents. Beverly Hills, CA: Sage.
Hawton, K., Cole, D., O’Grady, J., 6i 0 b
s orn, M. (1982).
poisoning in adolescents.
British J ournal ofPscyh+y,
Hawton, K., & Goldacre, M. (1982). Hospital
(mainly self-poisoning) among adolescents in the Oxford region.
Hawton, K., O’Grady, J., Osborn, M., & Cole, D. (1982a).
characteristics, problems, and contacts with helping
Hawton, K., Osborn, M., O’Grady, J., & Cole, D. (198213). Classification
British J ournal ofPsychiatry, 140,
Headlam, H. R., Goldsmith, J., Hamenson, I. B., & Rauh, J, L. (1979). Demographic
tics of adolescents with self-poisoning. Survey of 235 instances
rics, 18, 147-154.
Hill, W. H. (1984). Intervention and postvention
Suicide in theyoung (pp. 407-416). Boston: John Wright.
Jacobs, J. (1971).
Adolescent suicide. New York: Wiley-Interscience.
Jessor, R. (1984). Adolescent development and behavioral
J. A. Herd, N. E. Miller, & S. M. Weiss (Eds.),
(pp. 69-90). N ew York: Wiley-Interscience.
Kaminer, Y., & Robbins, D. R. (1988). Attempted
Pedkztrics, 81, 526-528.
Kazdin, A. E., French, N. H., Unis, A. S.,
Hopelessness, depression and suicidal intent among psychiatrically
Consulting and Clintial Psychology, 51, 504-510.
Khan, A. V. (1987). Heterogeneity of suicidal adolescents.
Adolescent Psychiatry, 26, 92-96.
Kienhorst, C. W. M., Wolters, W. H. G., Diekstra,
Korella, K. (1972). Teenage suicide gestures:
students. Dissertation Abstracts Intel-national, 32, 5039A.
Kosky, R. (1983). Childhood suicidal behavior. J ournal oj Child Psychology and Psychiatry, 24(3),
Kotila, L., & Lonnquist, J. (1988). Adolescent suicide attempts:
Acta Psychiatrica Scandanauia, 77, 264-270.
B. D., Froese, A., & Hood, J. (1982).
L., & Wheeler,
S uici ‘d e attempts
in children and adolescents.
K. (1987). Adolescent suicide repeaters: Factors
L., & Davis, M. S. (1985). Suicidal adolescents: Factors in
Repetition of self-poisoning
T. K., Pless, I. B., & Roghmann,
and subsequent death in adoles-
K. J. (1978).
Pediatrics, 63, 898-
Th e impact
of suicide in television movies: Evidence of
in battered behavior children.
American J ournal of Psychiatry,
suicide. Adolescence, 15, 589-601.
British J ournal of PJ -ychia@,
M., & DiFiore, J. (1987). Prevalence
Attributional style in adolescent suicide attempters. Manu-
Motivational aspects of deliberate self-
admissions for adverse effects of medicinal
British J ournal of Psych&try, 141,
who take overdoses: Their
British J ournal of Psychiatry, 140,
of adolescents who take
in Cincinnati, OH.
in schools. In H. Sudak, A. Ford, & N. Rushforth
health. In J. D. Matarazzo,
Behavioral health: A handbook ofhealth enhancement and
S. M. Weiss,
suicide by insulin overdose in insulin-dependent
Esveldt-Dawson, K., & Sherrick,
R. B. (1983).
J ournal of
J ournal ofthe American Academy oj Child and
R. F. W., & Otte, E. (1987). A study of the
of suicidal behavior in children aged 5 to 14. J ournal of Child Psycholou and Psychiatry, 28,
A study of suicidal behavior among high school
Sex differences predicting suicide.
A. Spirit0 et al.
Lamb, F., & Dunne-Maxim,
T. L. McIntosh,
survivors (pp. 245-260).
Lawler, R. H.,
Lester, D., Beck, A. T., & Mitchell,
suicides: A test.Journal
Levenson, M., & Neuringer,
Consulting and Clinical Psych.ology, 37, 433-436.
Levin, L., & Schonberg,
Soczeg ojAdolexent Medicine. (Abstract,
Lewinsohn, P. M. (1975). The behavioral
Eisler, & R. M. Miller
Litt, I. F., Cuskey, W. R., & Rudd,
attempts suicide: Compliance
Luscomb, R. L., Glum,
between life stress and suicide attempting.Journal
Marks, P. A., & Hailer, D. L. (1977).
attempts.~~~r~~ ~~~~~~~~~ Psy~ho~o~, 33, 390-400.
Mattson, A., Seese, L. R.,
Archives of General Psychiatry, 20, 1 OO- 109.
McCulloch, J, W., & Philip, A. E. (1972). Suicidal behavior. Oxford:
McIntire, M. S., &Angle, C. R. (1970). The taxonomy
Pedkztric C1inic.r ofNorth America,
McIntire, M. S., & Angle, 6. R. (197 1). Suicide
McIntire, M. S., Angle, C. R., & Schlicht,
Resident and Sk@ Phystcian, 26, 72-85,
McIntire, M. S., Angle, C. R.,
Pediatrics, 60, 605-608.
McKenry, P. C., Tishler, C. L., & Kelley, C. (1982). Adolescent
ters and nonattempters in an emergency
McKenry, P. C., Tishler, C. L.,
Suicide and Life- Threatening Behavior, 13, 166- 175.
McLeavey, B. C., Daly, R. J,, Murray,
problem-solving deficits in self-poisoning
Mchr, M., Zeltzer. L. K., & Robinson,
cent suicide attempters: Part I.Jourplal a~A~~esce~t Health Care, 1, 269-274.
Mehr, M., Zeltzer, L. K., & Robinson,
cent suicide attempters: Part II.,,Joural
Menninger, K. A. (1938). Man agaznst himself. New York: Harcourt,
Miller, M. L., Chiles, J. A., & Barnes,
Minkoff, K., Bergman, E., Beck, A. T., & Beck,
tempted suicide. American Jaurnal of Psyc~~t~,
Morgan, H. G., Burns-Cox, C. J., Pocock, H. J., & Pottle, S. (1975). Deliberate
and socioeconomic characteristics of 368 patients.
Morrison, G. C., & Collier, J. G. (1969).
adolescents. Journal of the American Academy of Child Psychiatry, 8, 140-153.
Motto, J. A. (1984). Suicide in male adolescents.
(Eds.), Suicide in theyoung (pp. 227-244).
Nardini-Maillard, D., & Ladmane, F. G. (1980).
adolescents.~our~~ ofAdolescence, 3, 253-260.
Neuringer, C. (1964). Rigid thinking in suicidal individuals.
K. (1987). Postvention
& K. Dunne-Maxim
New York: W. W. Norton.
Nakielny, W., & Wright,
in schools: Policy and process. In E. J. Dunne,
(Eds.), Suic& and its aftermath: Understanding and counseling the
N. A. (1963). Suicidal attempts in children.
B. (1979). Extrapolation from attempted suicides to completed
ofAbnormal Psychalagy, 88, 78-80.
C. (1971). Problem-solving behavior in suicidal adolescents. Journal of
K. (1987). F amilial
study and treatment
Progress Ela ~~~~~07 ~dl~at~~
violence among adolescents who attempt suicide.
In M. Hersen,
New York: Academic
S. (1983). Emergency
Journal ojAdolescent Health Care, 4, 106-108.
A. T. (1980). Mediating
ofNer~ous andMental Disease, 168, 644-650.
Y 1 ow I lay me down for keeps: A study of adolescent
room evaluation of the adolescent who
R. A., &z Patsiokas, factors in the relationship
& Hawkins, J. W. (1969). Suicidal behavior as a child psychiatric
of suicide as seen in poison control centers.
as seen in poison control centers.
M. L. (1980). Suicide and self-poisoning in pediatrics.
Wikoff, R. L., & Schlict, M. L. (1977). Recurrent adolescent
Pediatrics, 21, 266-270.
Th e role of drugs in adolescent
A comparison of attemp-
& Kelley, C. (1983).
C. M., O’Riordan,
J., & Taylor, M. (1987).
Suicide and Lzj&Threatening
Behauior, 17, 33-
R. (1981). Continued self-destructive behaviors in adoles-
ofAdolescent Health Care, 2, 182-187.
Continued self-destructive behaviors in adoles-
Brace & Worid.
attempters V. E. (1982). Suicide within a delinquent
Journal of Consulting and Clinical Psychology, 50, 491-498.
R. (1973). Hopelessness, depression, and at-
BritishJournal of Psychiatry, $27, 564-574.
approaches to suicidal children
F amily treatment
In H. S. Sudak, A. B. Ford, & N. B. Rushforth
Boston: John Wright PSG,
The results of a follow-up
study of suicidal
Joum~l $ ConsuEtinp Ps$wEo~, 28, 54-
Attempted Suicide in Adolescence
children. Journal of& AmeriGan Academy of Child and AaSscent Psychiatry, 26, 181-185.
Otto, U. (1972). Suicidal acts by children
Scandinavia Su,qblement, 233, 5-123.
Paerregaard, G. (1975). Suicide among attempted
Patsiokas, A. T., Clum, G. A., & Luscomb,
attempters. Journal of Consul&~ and Clinical Psychology, 47, 478-484.
Paulson, M. Jo, Stone, D., & Sposto, R. (1978).
12 years. Suicide and L~e-Th?ea~n~~~ Behavior, 8, 225-242.
Paykel, E. S. (1980). Recent life events and attempted
The suz’cicie gmdrome (pp. 105-l 15). London:
Paykel, E. S., Prusoff, B. A., & Myers, J. K. (1975).
controlled comparison. Archives of General Psychiatry, 32, 327-333.
Perrah, M., & Wichman, H. (1987). Cognitive
ThTea~n~n~ Re~via7, 17, 251-255.
Peterson, L. G., Peterson, M., O’Shanick,
wounds: Lethality of method versus intent. AmericanJ ournal ofPsychiatry, 142, 228-231.
Pfeffer, C. R., Plutchik, R.,
children: Classification, measurement, and interrelations.
Pfeffer, C. R., Solomon, G., Plutchik, R.,
behavior in latency-age psychiatric patients:
American AC&~ of Child Psych~t~, 2 1, 564-569.
Phillips, D. P. (1979). Suicide, motor vehicle fatalities
theory of suggestion. American J ournal of Sociology, 84, 1150-l 174.
Phillips, D. P., & Carstensen, L. L. (1986).
stories about suicide. New England J ournal OfMedicine, 315, 685-89.
Phillips, D. P., & Paight, D. J. (1987). Th e impact of televised movies about suicide: A replicative
study. New E n~la~four~l ojMed~c~~, 317, 809-811.
Reuben, N., Boeck, M., & Kurzon, M. (1987, March).
disposition in aablescent suicide attimpters. Paper presented
ference, Seattle, WA.
Rich, C. L., Fowler, R. C., Fogarty, L. A., & Young, D. (1988).
Relationships between diagnoses and stressors.
Robbins, D. R., & Alessi, N. E. (1985). Depressive
AmericanJ ournal ~~~ch~t~, 142, 588-592.
Robbins, D., & Conroy, R. C. (1983). A cluster of adolescent
gious? Journal ofAdolescent Health Care, 3, 253-255.
Rockett, I., Spirito, A., Fritz, G., & Riggs, S. (1988). A trauma center study ofadolescent suicide attempters
and motor vehicle crash victims. Manuscript subrnitted
Rohn, R. D., Sarles, R. M., Kenny, T. J., Reynolds,
attempt suicide. Tk J ournal of Ped&rks, 90(4), 626-638.
Rosenberg, M. L., Smith, J. C., Davidson, L. E., & Conn, J. M. (1987).
suicide: An epidemiologic analysis and public health perspective.
Ross, C. P., & Motto, J. A. (1984). Group counseling
B. Ford, & N. B. Rushforth (Eds.), Suicide in theyoung (pp. 367-392).
Rotheram, M. J. (1987). Evaluation of imminent danger for suicide among youth. A~rica~~ur~L
~rt~~ch~t~, 57, 102-l 10.
Ryan, N. D., Puig-Antich, J., Ambrosini, P., Rabinovich,
S., & Twomey, J. (1987). The clinical picture of major depression
Archives of General
Psych&try, 44, 854-861.
Sathyavathi, K. (1975). Suicide among children in Bangalore.
Schotte, D. E., & Glum, G. A. (1987). Problem-solving
oj Consulting and Clinical Ps~cholo~, 55, 49-54.
I., Rosenheim, E., & Hary, E. (1987). Some aspects of cognitive functioning in suicidal
and adolescents: A follow-up study. A& Psych~tT~ca
suicide: A lo-year follow-up. Suicide, 5, 140-
R. L. (1979). Cognitive characteristics of suicide
Suicide potential and behavior in children ages 4-
suicide. In R. Farmer, & S. Hirsch (Eds.),
Groom Helm Ltd.
Suicide attempts and recent life events: A
rigidity in suicide attempters. S&i& and Life-
G. J., & Swann, A. (1985). Self-inflicted gunshot
M. S. (1983). S uici a and assaultive d 1
American J ournal ofpsychiatry, 140, 154-
M. S., & Werner,
A. (1982). Suicidal
Journal qf th.e
and the mass media: Evidence toward a
Clustering of teenage suicides after television news
Relation between suicidal intent, depressiolt, and
at the Society of Adolescent Medical Con-
San Diego Suicide Study III.
Archives ofGenera Psychiatry, 45, 589-592.
symptoms and suicidal behavior in adolescents.
suicide attempts. Is suicide conta-
B. J., & Heald, F. P. (1977). Adolescents who
Annual Reuiew ofPublic Health, 8,
for suicidal adolescents. In H. S. Sudak, A.
Boston: John Wright PSG,
H., Robinson, D., Nelson,
Indian J aunalofPaiz&ks, 42, 149-157.
skills in suicidal psychiatric patients.JournaZ
A. Spirit0 et al.
Shaffer, D. (1974).
try, 15, 275-291.
Shaffer, D. (1982).
Journal @-American Arnd~my of Ghiin F.~~h~t~~. 2 1) 4 14-4 16
Shaffer, D., & Bacon, K. (1986, June).
particular r&ence to youth .&i&.
Group of the HHS Task Force on Youth Suicide,
Shafii, M., Carrigan, S., Whittinghill,
completed suicide in children and adolescents.
Slap, G., Vortcrs, D., Chaudhuri,
uft~rnp~~~. Poster presented at the Society of Adolescent Medicine,
Smith, K., Conroy, R. W., & Ehler, B. D. (1984).
and Lifi- Threatening Behauior, 14, 215-242.
Smith, K., & Crawford, S. (1986).
and Life-Threatinq Behavior, 16, 3 13-325.
Spirito, A., Brown, L., Overholscr,
adolescents: A cautionary note. Manuscript
Spirito, A., Ovrrholser, J., H art, K.,
&presrion in adolescent .ruici& attempters. Manuscript
Spirito, A., Overholser, J., & Stark,
Findings with adolescent suicide attempters.
Spirito, A,, Stark, L. .J., Fristad,
attempters hospitalized on a general pediatrics
Spirito, A., Williams, C.. Stark,
Psychometric properties and clinical utility with normal and emotionally
Journal of Abnormal Child Pqxholog~, 16, 445458.
Stanley, E. J., & Barter, J. T. (1970).
Stevenson, E. K., Hudgcns, R. W., Held, C. P., Meredith,
L. (1972). Suicidal communication
L)Uecrres of& jvgrvous @s&en, 33, 112-122.
Taylor, E. A., & Stansfeld, S. A. (1984a).
with psychiatric controls.
Taylor, E. A., & Stansfeld, S. A. (1984b).
attendance for treatment.
Brituh Journal ofPsychiatry,
Teicher, J, D. (1979). Suicide and suicide attempts.
Prychlatry (Vol. 2, pp. 685-697). New York: Basic Books.
Tishler, C. L., & McKenry, P. C. (1982).
~o~r~i ojthr! Amerxan Ac&my of Child Psychiatry, 2 1, 404-408.
Tishler, C. L., McKenry, P. C., & Morgan,
significant factors. Suicide and L$-Threatening
Tolan, P., Ryan, K., & Jaffe, C. (1988).
process, and recipient characteristics.
Topol, P., & Reznikoff, M. (1982). Perceived peer and family relationships,
of control as factors in adolescent suicide attempts.
Trautman, I’. D. (1987, October).
Adolescent r&i& attempters: Deficits in co~cnitive .rvEe OT am&do&x? Poster
presented at the Annual Meeting of the American
Los Angeles, CA.
Trautman, P. D., & Rotheram, M. J. (1987, October).
Poster presented at the Annual Meeting of the American
Trioio, S. J,, McKenry, P. C., Tishler, C. L., & Blvth,
discriminants of adolescent suicide: Age and sex differences.
T. J., &Johnson, R. L. (1986).
medical service. ,jnural of the National Medical Association, 78, 101-108.
Suicide in childhood and early adolescence.
The evaluation and treatment of adolescent overdoses in
Journal of Child PSycholog, and Prychia-
Diagnostic considerations in suicidal behavior in children and adolescents.
A critical review ojplzuention and &rue&on
Paper presented at the Prevention
J. R., CL. Derrick,
American Journal ofP,rychriztry, 142, 1061-1064.
S., & Centor, R. (1988, March).
ej+rtx in .suicidc with
and Intervention Working
A. (1985). Psychological autopsy of
Lethality of Suicide Attempt Rating Scale. Suicide
Suicidal behavior among “normal” high school students.
J., & Fritz,
Use of thf RiJk-Rescue Rating Scale with
The ~e~ot~~ship $ social ski& and
problems and coping
Journal ofAbnormal Child Psycho&.
K., & Owens-Stively, J. (1987).
lloor.~fiurnal o~ppdiu&jc Pgchology,
L. J., & Hart, K. (1988). The Hopelessness
L. J. (in p ress). Common styles II:
M., Hart, Adolescent
Scale for Children:
Adolescent suicidal behavior. American Journal of Orthoprychiatry,
C. H., Hendricks,
Study of two matched groups of 60 teenagers.
M. E., & Carr, D.
Children who poison themselves
i ten who poison
In J. D. Noshpitz (Ed.), Baste Handbook of Child
I. A clinical
themselves II. Prediction of
Parental negative self- and adolescent suicide attempts.
K. C. (1981).
Behavior, 11, 86-92.
Journal ojClinica1 Child Psychology, 17, 229-236.
Adolescent suicide attempts: Some
mental health service use and provider,
hopelessness and locus
Szricide and L~~-~hrea~ni~~
Academy of Child and Adolescent Psychiatry,
Rej rra If ‘1
at ure among adolescent suicide attempters.
Academy of Child Psychiatry, Los
D. A. (1984).
Social and psychological
of Early Adolescenm, 4, 239-
Attempted Suicide in Adolescence Download full-text
Walker, D. K.,
among children in Genesee County. Boston,
Walker, W. L. (1980).
Adolescence, 3, 217-228.
Weisman, A., & Worden,
PsychkztTy, 26, 553-560.
Wenz, F. V. (1979).
ceflce, 14, 19-30.
Whitlock, F. A. (1986).
more: Williams & Wilkins.
Williams, C., & Lyons,
Williams, C. L., Davidson,
Clinical Psychology, 36, 90-94.
Withers, L. E., & Kaplan,
chart review of hospitalized
Yusin, A., Sinay, R.,
Am&an Journal of Psychiatry, 129, 574-577.
Zich, J. M. (1984). A reciprocal
and Life- Threatening Behautir, 14, 36-5 1,
J., & Connon, H. E. (1962). Attempted suicide in adolescents.
American Journal ofPsych&
Gortmaker, S. L., & Weitzman, M. (1981).
Ch raic illness and psychosoczizl problerm
Child Health Studies, MA: Community Harvard School of
Intentional self-injury in school age children: A study of fifty cases. Journal ti
W. (1972). Risk-rescue rating in suicide assessment.
Archives of General
Sociological correlates of alienation among adolescent suicide attempts. A&es-
Suicide and physical illness. In A. Roy (Ed.), Suicide (pp. 151-170). Balti-
C. M. (1976).
Australian and New Zealand Journal ofpsychiatry,
J. A., & Montgomery,
F amily interaction
and adolescent suicidal behavior: A
I. (1980). I m u sive suicidal behavior. Journal of
D. W. (1987).
Professional Psychology: Research and Practice, 18, 391-393.
K. (1972). Adolescents in crisis:
who attempt suicide. A retrospective clinical
Evaluation of a questionnaire.
control approach to the treatment of repeated parasuicide. Suicide