Recurrent Adolescent Suicidal Behavior

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significant number of the children in both studies had straight eyes played a part in the delay of diagnosis and subsequent treatment.

During 1975, visual screening was carried out in schools and screening clinics in Fulton County, Georgia, the county which contains Atlanta. The screening was carried out by the Fulton County Health Department using both public health nurses and volunteer parents. The vision in each eye was tested carefully while the fellow eye was

occluded with an occluder paddle. Picture charts and the illiterate E game are used for preschool children. Regular letters are used for school-age children. A total of 54,778 children were tested. The majority were from the public schools, while 2,200 were from private and parochial schools. Of the total, 5,400 were screened in 24 local health department clinics for preschool children; 7.9% of those screened failed the vision test. Only 50% of those who failed kept follow-up appointments with eye physicians. Because only 50% kept follow-up appointments, an accurate accounting of false-positives is not available. By rescreening the same children every other year any false-negatives will have another chance to be

diag-nosed. The cost of this type of program is not excessive, because a significant part of the work was and will continue to be done by volunteers such as the parents of the children.

Preschool eye screening is a vital part of the health care of a child. Pediatricians should actively participate to detect amblyopia at an early age. The combination of pediatricians in private practice and community health programs such as that carried out in Fulton County will give more children a better chance of going through life with two good eyes.

REFERENCES

1. Moody EA: Amblyopia, in Harley RD (ed): Pediatric Ophthalmology. Philadelphia, WB Saunders Co, 1975, p 185.

2. Reinecke RD, Miller D: Strabismus, A Programmed Text. New York, Meredith Publishing Co, 1966, p 90.

3. Parks MM: Amblyopia, in Parks MM (ed): Ocular Motility and Strabismus. New York, Harper & Row, 1975, p 85.

4. Pollard ZF, Manley DM: Long-term results in the treatment of unilateral high myopia with amblyo-pia. Am JOphthalmol 78:397, 1974.

Recu rrent

Adolescent

Suicidal

Behavior

Matilda S. Mclntire, M.D., Carol R. Angle, M.D., Richard L. Wikoff, Ph.D.,

and Marilyn L. Schlicht

.

From the Department of Pediatrics, University of Nebraska Medical Center and Creighton University School of Medicine, and the Department of Psychology, University of Nebraska at Omaha

Suicide is the third leading cause of death among people in the age group 15 to 25 years.’ Self-destructive behavior in children and adoles-cents is a continuum that ranges from drug intoxications to gestures of low lethality to suicide attempts with high lethality of intent. In our survey of 1,100 self-poisonings in people aged 6 to 18 who were seen at poison control centers we found an incidence of 220 self-poisonings for every fatality.2 This is higher but comparable to other estimates of 50 to 150 suicide gestures for every reported death from suicide in the adoles-cent.36 Suicide attempts may account for 12% of

all emergency room visits.7 This represents a public health problem of the first magnitude.

It is ironically tragic that many of the adoles-cent suicide deaths are unintentioned-the victim

Received May 19; revision accepted for publication September 16, 1976.

Supported by U.S. Public Health Service grant MH 19588 from the Division of Special Mental Health Programs. ADDRESS FOR REPRINTS: (M.S.M.) Department of Pedi-atrics, Creighton University School of Medicine, Tenth and Castelar, Omaha, NE 68108.

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606 RECURRENT SUICIDAL BEHAVIOR

did not really intend to die. In our collaborative poison study, for example, none of the six deaths could be called intended. The adolescents were not victims of suicide but of pharmacologic roulette.

The single best correlate of suicidal risk appears to be lethality of intent. A diagnosis of suicide attempt, as contrasted to a gesture, implies both a lethality of intent coupled with a mature concept of death as an irreversible state. Lethality is defined by Shneidman’ as the proba-bility of an individual’s killing himself in the immediate future. In classifying all deaths as intentioned, subintentioned, and unintentioned as contrasted to the traditional classifications of natural, accidental, suicidal, and homicidal he has used the dimension of lethality to cut across the terms attempted, threatened, and completed suicide. Imputed lethality can be rated from high to absent based on the specific acts and life style of the individual: high, the subject definitely wants to die and anticipates that his actions will result in death; medium, the individual is ambiv-alent, playing some partial, covert, or uncon-scious role, as in drug abuse, foolhardiness, care-lessness, or outright disregard of lifesaving medical care; low, the subject plays some small but not insignificant role, such as the adolescent “inhalers,” who have no conscious wish to die and yet are willing to take unknown risks; absent, no lethal intent.

Since most self-destructive behavior by adoles-cents is of low lethality,36 we have attempted to arrive at more significant predictors of repeated self-destructive behavior. The goal was to distin-guish those at risk for repeated self-destructive behavior of low lethality from those at risk for

gestures of increasing lethality of intent. This is a report of the correlation of recidivism with the initial assessment of risk as based on interview plus a personality questionnaire, and of the failure to improve when psychotherapy was not coupled with environmental change.

METHODS

An initial group of 50 subjects (40 females and 10 males) aged 14 to 18 who were successively admitted to one of three psychiatric services in Omaha following self-destructive behavior were evaluated as previously reported.9”#{176} Of the 50 subjects, 42 were admitted to one institution, the Nebraska Psychiatric Institution. The group had a high mobility but we were able to obtain a follow-up 6 to 24 months after the initial interview in 26

subjects (2 at 6 months, 13 at 1 year, and 1 1 at 24

months).

A structured interview of the 50 subjects was

conducted by a paraprofessional with special training in suicidology, employing the methods previously described. Each subject was rated on a scale of 0 to 9 for (1) circumstantial lethality (and the probability of rescue), (2) prior self-destructive behavior, (3) depression (negative self-concept), (4) hostility, (5) stress, (6) reaction of parent or parent surrogate, (7) loss of communica-lion, (8) lack of supportive resources, and (9) extremes of parental expectations and control.

Based on the interview and the circumstances of the original event, each subject was then categorized according to (1) lethality of intent-low, medium, or high-based on the probability of rescue; (2) diagnostic category-in-toxication, manipulative gesture, depressive ges-hire, true attempt; (3) functional and social inca-pacitation-none, mild, moderate, high; and (4) estimated risk for repeated suicidal behavior. Risk was rated high if lethality of intent was medium or high or if a gesture of low intent was coupled with prior suicidal behavior, significant depres-sion, or thought disturbance.

Prior ‘ ‘ of independent numerical

ratings of the 32 subjects by the paraprofessional and the psychiatrist showed a significant correla-tion of estimates of lethality of intent at r = .40

(P < .05), future suicidal risk at r = .60

(P < .001), and functional incapacitation at

r = .57(P< .001).

The follow-up interview used a format iden-tical to that of the initial interview to document interval events and responses, plus a tabulation of therapy, institutionalization, and environmental change, and questions as to whether the subjects considered their conditions improved.

RESULTS

The 26 adolescents with follow-up evaluation were representative of the original 50 subjects. None of the original or follow-up subjects were judged to have a high lethality of intent. Social incapacitation, defined as moderate to severe difficulties in functioning, was noted in 62% of the original group and 70% of those reevaluated. Of the original 50, 52% had made prior gestures, compared to 50% of the follow-up subjects. Of the original group, 44% had an alcoholic parent, similar to the 50% incidence for the follow-up gioup. Thought disturbances were present in 10% of the original and 15% of the follow-up group.

Of the follow-up group of 26 subjects, risk was predicted as low for 6 subjects and high for 20 subjects by both the suicidologist and the

psychia-trist (Table I). The six “low-risk” subjects had all made gestures of negligible lethality of intent-predominantly drug and alcohol

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TABLE I TABLE II

PREDICTED RISK FOR RECIDIVISM IN 26 ADOLESCENTS

No. (%) of

Subjects With

Predicted Risk

Low High

No. of subjects 6 20

Lethality of intent

Minimal 6 (100) ...

Low-moderate .. . 20 (100)

Depression/negative self- 0 13 (65) concept rating > median

Hostility rating > median 5 (87) 6 (30)

Prior gestures 1 (15) 12 (60) Thought disturbance 0 4 (20) Alcoholic parent 2 (33) 1 1 (55) Social incapacitation 4 (67) 14 (70)

doses. They had a high incidence of social incapa-citation with antisocial, delinquent behavior and high ratings for hostility. Only one had made a prior gesture, none were significantly depressed, and none had disturbed thinking.

A prediction of high risk of recurrent self-destructive behavior had been made for 20 of the 26. Predicted risk correlated best with the lethality of intent or probability of rescue in the original event, with prior suicidal gestures and with high ratings for depression or depression-hostility. The presence of moderate to severe functional incapacitation was unrelated to the prediction. Prior suicidal gestures had been made by 60%. Disturbed thought was diagnosed in 20%.

As shown in Table II, the overall recurrence rate was 31%, with eight repeated attempts in 26

subjects. The six subjects considered at low risk had no recurrences.

The low-risk group, however, had significant problems, particularly alcoholism and conflict with the law, but half of the low-risk group improved.

Of the 20 high-risk subjects, 40% made repeated gestures-five within six months, two more by one year, and one by the second year. Only three were improved. Acting out and delin-quent behavior and alcoholism persisted in three subjects. Three continued to have incapacitating thought disturbances. The dominant response in the other 1 1 was one of depression and entrap-ment related to poverty, alcoholic parents,

.chronic illness (two subjects), unwanted

preg-nancy (two subjects), homosexual guilt (one subject), and a sense of lifelong inability to cope with a multitude of problems.

OUTCOME AT 6 TO 24 MONTHS

No. (%)

of Subjects

Low-Risk High-Risk Total (No. = 6) (No. = 20) (No. = 26)

Suicidal behavior 0 8 (40) 8 (31) Other problems 4 (66) 15 (75) 19 (73) Institution 1 (15) 5 (25) 6 (23) Improved 3 (50) 3 (15) 6 (23)

As outlined in Table III, recidivism was primarily related to the subjects’ failure to change their circumstances or the inability to respond to environmental change. In the six subjects moving to an improved environment, two at home and four to foster homes, there were no repeated gestures. The move itself appeared fortuituous since only four of six foster homes were successful. In two cases, unsuccessful foster home placement led to sequential foster homes and institutions; one of these subjects made a repeated gesture while at an interval youth center.

Institutionalization for nine subjects was even less successful. Three institutionalizations were at reform school or prison, and only one of the three subjects made a subsequently good adjustment at home. Five of the six with prolonged psychiatric institutionalization made repeated gestures al-though there was no increasing lethality of intent.

Any predictive correlation of the duration of

TABLE III

THERAPY AND RE#{176}

Total

No.

No. (%)

of Subjects

Risk

Ratio

Making Gestures

Total 26 8 (31) 1.0

Environment

Worse 9 5 (56) 1.8

Better 6 0 0.0

Foster home 6 1 (15) 0.5

Recurrent 6 5 (88) 2.8

institutionalization

Therapy > 2 mo 9 5 (56) 1.8 Thought disturbance 4 1 (25) 0.8

#{176}Theoverall recurrence rate of 31% is given a risk ratio of 1.0. The percent recurrence for the subsequent groups divided by 31% gives the risk ratio.

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608 RECURRENT SUICIDAL BEHAVIOR

therapy with repetition is obscured by the fact that subjects with extreme perturbation in multiple spheres required recurrent therapy. All 26 subjects were initially dismissed at two to six

weeks. Therapy for more than eight weeks was received by nine subjects, all with severe func-tional disability, including three with thought disturbances. None of the nine with prolonged therapy were considered improved.

Subjects with a thought disturbance had a poor overall prognosis. Three of the four subjects with a thought disturbance went from one institution to another and one of these made a repeated suicide gesture; one deteriorated after being sent home but then made a surprisingly good adjust-ment with foster parents.

DISCUSSION

This study of adolescent suicidal behavior showed a 31% recurrence within two years; all recurrences were in adolescents predicted at the initial interview as being at high risk for recur-rence..

The development of suicide and crisis centers has demonstrated that a paraprofessional with special training in suicidology can reliably eval-uate the lethality of intent, the probability of rescue, the past history, and current stress. Employing a structured interview with a pedi-atric perspective, the paraprofessional in this study arrived at estimates of lethality, of risk of recidivism, and of current social incapacitation that correlated, at the 95th percentile, with the ratings by the psychiatrist.

Prediction of risk was 100% reliable in the low-risk subjects of this study. Low-risk subjects were identified by the low lethality of intent, past history of acting-out and delinquent behavior, and relatively high ratings for both hostility and self-esteem.

There was a 40% recurrence within two years in adolescents considered at high risk as predicted by moderate lethality of intent or the combina-lion of hostility and depression coupled with low self-esteem. The risk was significantly increased for those with severe perturbation requiring continuous therapy or prolonged hospitalization and for those who moved to a less compatible environment.

Only six of 26 adolescents improved and this was uniformly associated with an improved envi-ronment. In four of six cases this was a foster home; only two adolescents, both low risk, reported a more improved home environment as a result of counseling and improved parental understanding.

Psychiatric hospitalization with a return to an unchanged environment was uniformly unsuc-cessful. In many of these cases the degree of incapacitation became more manifest and seems to have been reinforced by repeated institutional-ization and failure to improve.

The present methods of management, psycho-therapy, and parental counseling are appallingly unsuccessful. Foster home acceptance is unlikely for the older and more intractable adolescent. These children are all known to multiple health and social agencies long before the first suicide gesture.

In the changing milieu of pediatrics due to the shift in problems confronting children and youth, the pediatrician must take the initiative for earlier intervention in the unremitting cycle of self-destructive behavior. We see, for example, training for parenthood courses both at the level of the high school student and the young parent, referral of problem families to such programs at the earliest possible moment, and earlier consid-eration of foster home placement. Just as pediatri-cians provided the leadership for early detection and development of needed programs for the retarded during the 1960s, they should, in a like manner, respond to the new challenge of child-hood decompensation in a disturbed familial environment.

REFERENCES

1. Vital Statistics of the United States, 1971, publication

HRA 75-1102. Rockville, Md, US Dept of Health,

Education, and Welfare, Public Health Service, National Center for Health Statistics, 1974, vol 2. 2. Mclntire MS, Angle CR: Suicide as seen in poison

control centers. Pediatrics 48:914, 1971.

3. Jacobziner H: Attempted suicides in adolescents. JAMA 191:7, 1965.

4. Schneer JI, Kay P, Boresky M: Events and conscious behavior leading to suicidal behavior in adolescents. Psychiatr Q 35:507, 1961.

5. Schrut A: Suicidal adolescents and children. JAMA 188:1103, 1964.

6. Lawler RH, Nakielny W, Wright N: Suicidal attempts in children. Can Med Assoc J 89:751, 1963.

7. Ravenhorst JM; Follow-up of young women who attempt suicide. Dis Nerv Syst 33:792, 1972. 8. Shneidman ES: Orientation toward cessation: A

reexam-ination of current modes of death. J Forensic Sci 13:33, 1968.

9. Mclntire MS, Angle CR: Evaluation of suicidal risk in adolescents. J Fam Pract 2:339, 1975.

10. Mclntire MS, Angle CR, Haffke EA: Adolescent suicide

. gestures: Reliability of evaluation by

paraprofes-sionals in a structured interview. Read before the Ambulatory Pediatric Society, San Francisco, May 16-17, 1973.

11. Mclntire MS. Angle CR, Schlicht ML: Suicide and self poisoning in pediatrics. Adv Pediatr, to be published.

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1977;60;605

Pediatrics

Matilda S. McIntire, Carol R. Angle, Richard L. Wikoff and Marilyn L. Schlicht