The

Relationship Between Adolescent Suicidal Behavior and Life Events in Childhood and Adolescence Erik J. de Wilde, M.Sc., Ineke C.W.M. Ren#{233} F.W. Diekstra, Ph.D., and Willem

Objective: Although the relationship between adolescent suicidal behavior has frequently been ies

oflife

events

have

been

initiated

that

and depressed adolescents. Therefore, with both depressed and nondepressed to life years)

events that happened and adolescence (age

Kienhorst, Ph.D., H.G. Wolters, Ph.D.

experience recognized

of problematic during the past

discriminated

between

adolescent

the authors adolescents

compared who never

adolescent attempted

in two periods: 1 2 and older).

childhood Method:

life events and decade, few studsuicide

attempters

suicide attempters suicide with respect

(defined as the period Using a semistructured

up to age 12 interview, the

authors gathered life event data about childhood and adolescence from three groups of adolescents: 48 suicide attempters, 66 depressed adolescents who had never made a suicide attempt, and 43 nondepressed adolescents who had never made a suicide attempt. Results: The group of adolescents who attempted suicide differed from both of the other groups in that they

had

during

experienced

last year to repeat

before

During the attempt,

a class,

embedded their

more

adolescence.

occurred.

turmoil

rooted

families,

they

further

instability,

social

Conclusions:

not just in the problems

families,

in their

adolescence,

in childhood

traumatic events during adolescence (Am J Psychiatry 1992; 149:45-51)

For

every and

and

social

Received Jan. 10, 1991; revision received June 5, 1991; accepted July 16, 1991. From the Department of Pediatrics, University of Utrecht, and the Department of Clinical, Personality and Health Psychology, University of Leiden, The Netherlands. Address reprint requests to Dr. de Wilde, Wilhelmina Children’s Hospital, Psychosocial Department, P.O. Box 18009, 3501 CA Utrecht, The Netherlands. Supported by the Praeventiefonds, the Programmeringscollege Onderzoek Maatschappelijke Dienstverlening (Ministry of Welfare, Health and Cultural Affairs), the K.F. Heijnfonds, the Stichting voor Vergeten Groepen, the Stichting Elise Mathilde Fonds, the Stichting “Dc Balije,” the Prof. Dr. Weijers Stichting, the Evert Zoudenbalchhuis, Crediet & Effectenbank, and the Stichting Lam#{233}ris Foundation. Copyright © 1992 American Psychiatric Association.

January

1992

suicidal

in childhood

often

such

sexually

as changes

adolescents, during

instability

and

not

abused.

the

suicide

stabilizing

During

in residence

has to deal with

not stabilizing

n their impressive review of attempted suicide in adolescence, Spinito et al. ( 1 ) stated, “Presence of stressful life events . . . seems to have important implications for understanding suicide attempts in children and adolescents.” Nevertheless, although the relationship between experience of problematic life events and adolescent suicidal behavior has frequently been recognized during the past decade (2, 3), few studies of life events have been initiated that discriminated between adolescent suicide attempters and depressed adolescents. This comparison is essential because many life

149:1,

more

adolescent

I

Am J Psychiatry

starting

were

and attempt

but in greater

adolescence, in the year

the

having seems

turmoil

in combination preceding

in with

the attempt.

events that take place in the lives of suicide attempters are also found in the lives of adolescents who report depressed mood (4), which implies that not taking depression into account is problematic when identifying life events specific for adolescent suicide attempters. Several studies compared suicidal adolescents with heterogeneous psychiatric groups of nonsuicidal adolescents (5-7) or with other clinical groups (8, 9). However, it is not clear from these studies whether the compared groups were depressed or hot.

Two

studies

(10,

1 1), however,

made

comparisons

using depressed groups. Friedman et al. (10) compared suicidal depressed adolescents with nonsuicidal depressed adolescents but restricted their research to family history of illness. Chronic psychiatric illness of a parent (especially depression) was more frequently found among suicide attempters. Cohen-Sandlen et al. (11) compared suicidal children and young adolescents (514 years old) with depressed and other psychiatric control groups regarding life events during different developmental periods. They found that more life events

were

related

to suicidal

behavior

If the results of Cohen-Sandler cable to adolescents, they would

with

increasing

age.

et al. were also appliagree with those of

45

ADOLESCENT

SUICIDAL

BEHAVIOR

Jacobs (12), who compared SO adolescent suicide attempters with matched control subjects from schools. He hypothesized that 1) the first of four phases leading to a suicide attempt consists of a longstanding history of problems from childhood to the onset of adolescence and 2) the second phase is a period of “escalation of problems” at the onset of adolescence in excess of those “normally” associated with adolescence (p. 64). In our opinion, Jacobs failed to find adequate support for his valuable hypotheses because his data analysis was rather obscure and because, by comparing suicidal adolescents with normal adolescents, he did not account for depression. A comparison of suicide attemptens with both depressed and “normal” adolescents (as a baseline for “normal” adolescent turmoil) may give more solid information about his hypotheses. In addition, analysis of Jacobs’ hypotheses requires the specification of the period (childhood or adolescence) during which life events have taken place. Therefore, the present study compared adolescent suicide attempters with both depressed and nondepressed adolescents who never attempted suicide with respect to life events that happened in two periods: childhood (defined as the period up to age 12) and adolescence (age 12 and older). Moreover, because of the growing evidence about the importance of recent life events negarding suicide attempts and psychiatric disorder in young people (1 1, 13, 14), the last year before the attempt (for the suicide attempters) on before the interview (for the other groups) was studied separately.

METhOD Subjects Three groups of subjects were asked to cooperate with this study. The first group comprised 41 girls and seven boys 14-21 years old (mean±SD age=17.S±1.S years) who attempted suicide 1-52 weeks before the measurement date. The second group consisted of 52 girls and 14 boys 14-21 years old (mean=17.9±1.6) who suffered from a depressed mood at the time of assessment and had never attempted suicide. (For reasons of readability, the adolescents who suffered from a depressed mood will be referred to as “depressed adolescents”

in the

remainder

of the

text.)

The

third

group

comprised 31 girls and 12 boys 14-21 years old (mean=17.S±1.3), randomly selected from a “normal” school population. The three groups were not matched, but there were no significant differences among them in relevant sociodemographic features such as age (F= 1.45, df=2, 154, p=O.24), sex (X2=2.43, df=2, p=O.3O), and current type of school (x2=7.22. df=6, p=O.l2). Two methods were used to recruit subjects for this study.

First,

institutions

for

mental

health

care

were

asked for referrals, and, second, 9,393 secondary school students were screened (iS). Approximately half of the suicide attempters and half of the depressed adolescents were recruited through the institutions of men-

46

tal

health

cane.

The

rest

of the

suicide

attempters

and

depressed adolescents as well as the entire group of normal adolescents were recruited from among the 9,393 secondary school students. The suicide attempters and the depressed adolescents did not differ significantly in this

recruitment

procedure

(2=3.1,

df=2,

p=O.O8).

The study was performed in compliance with the U.S. Human Subject Research Guidelines. Informed consent was obtained from all subjects and their parents. Almost two-thirds of the suicide attempters had taken an overdose of medicine on toxic substances, onequarter had injured themselves, and the rest had thrown themselves in front of a moving vehicle, tried to hang themselves, on jumped from a height. The mean±SD

scone

of the

suicide

attempters

on the

Suicide

Intent Scale (16), 6.8±3.4, was comparable to that of SO British adolescents who attempted suicide (2). Three suicide attempters had scores of 1 3, indicative of a strong suicide intent. The mean risk scone of all 48 suicide

attempters

8.1±2.1,

on

the

indicative

rescue

score

of

on this

Risk-Rescue

Rating (1 7) was risk, and their 1 1 .6±2.3, indicative of a

a moderately

scale

was

low

moderately high rescue level. The 66 depressed adolescents sion

at two

separate

were

times.

First,

tested

for depres-

at the

time

of the

screening procedure preceding the interview, they were selected randomly if they appeared to have a score of 46 on higher on the Zung Self-Rating Depression Scale ( 1 8) and had a score of at least 1 6 on the Depression Adjective Checklist (19). The depressed adolescents refenred from the institutions of mental health care met Research Diagnostic Criteria (20) for major depressive disorder. The second assessment took place at the time of the interview. Subjects who had a scone of 46 on higher on the Zung scale at that time were included in this study. Their mean scone on the Zung scale was 51.9±5.2, compared with 49.4±1 1 .7 for the suicide attempters and 33.5±5.6 for the normal subjects.

For the normal initially

comparison

selected

the secondary selection

school

were

these

made

a suicide

scone

higher

than

time

of the

interview,

and

43 adolescents Measures

and

Checklist.

were among

The criteria that

scale met

from

they on 16

had

did

not

on

the

at the

the criteria

the study,

comparison

for

they

Nevertheless,

students

in the normal Data

Zung

removed

from

reported

and

the

two

were

screened. students

on

45 students

interview

attempt

46

Adjective

depression

for

students

that

never

Depression

group,

at random

for

leaving

group.

Analysis

A semistructured interview including several self-neport questionnaires was conducted with each subject by a graduate psychology student or a psychologist who was especially trained for this purpose. Before the actual data collection, a pilot study was carried out with eight adolescents; the interview was modified on the basis of the

findings

of this

pilot

study.

The Life Event Time Schedule, a part of the Life History Interview (4), was developed for this study. The

Am J Psychiatry

149:1,

January

1992

DE WILDE,

TABLE 1. Number of Major Life Events Experienced Depressed Adolescents, and Normal Adolescents

During

Childhood

12

(up to

Suicide Attempters (N=48)

Years

of Age)

KIENHORST,

by Adolescents

Depressed Adolescents (N=66)

DIEKSTRA,

ET AL.

Who Attem pted Suicide,

Normal Adolescents (N=43)

Event

Mean

SD

Mean

SD

Mean

SD

KruskalWallis H

Serious illness Accident Change in living situation Change in caretaker Separation of parents Reunion of parents Change of residence Death of family member Physical health event of family member Mental health event of family member Unemployment of family member Imprisonment of family member Sibling leaving home Change of school or type of school Repeating a class Ending a relationship Physical abuse Sexual abuse Criminal events Totalnumberofevents

0.60 0.69 0.38 0.48 0.23 0.13 0.83 0.08 1.19 0.56 0.25 0.06 0.13 0.71 0.10 0.00 0.19 0.17 0.04 6.81

0.82 0.78 0.84 0.85 0.42 0.33 1.02 0.40 1.39 1.01 0.48 0.24 0.44 0.92 0.31

0.44 0.55 0.30 0.21 0.06 0.05 0.74 0.02 0.89 0.38 0.11 0.01 0.11 0.77 0.09

0.68 0.77 0.80 0.54 0.24 0.21 0.85 0.12 0.99 0.76 0.31 0.12 0.47 0.84 0.29

0.56 0.56 0.12 0.16 0.09 0.07 0.84 0.02 1.23 0.28 0.07 0.00 0.09 0.65 0.05

0.73 0.80 0.45 0.43 0.29 0.26 0.92 0.15 1.66 0.67 0.26

1.23 1.73 4.19 5.62 7.81a 2.51 0.23 0.84 0.46 2.61 5.83

-

4.03

0.37 0.72 0.21

0.21 0.63 1.08

-

0.00

-

0.00

0.14 0.05 0.12 5.03

0.43 0.21 0.41 3.68

0.00 0.05 0.19 5.02

-

0.00

0.49 0.48 0.29 3.91

significant significant significant

ape#{216}5;

bp