The Correlates of Planning in Adolescent Suicide Attempts LARRY K. BROWN , M.D ., JAMES OVERHOLSER , PH.D., ANTHONY SPIRITO, PH.D., AND GREGORY K. FRITZ , M.D. Abstract. Adolescent suicide attempts are often impulsive. It has been suggested that individuals who make nonimpulsive (premeditated) attempts have greater suicidal intent and are more hopeless than the impulsive attempters. Eighty-six adolescent suicide attempters were catergorized according to the degree of premeditation of their attempt , as measured by two items of the Suicide Intent Scale. Sex, age, method of attempt, and the number of prior attempts were not useful discriminators between these groups. The nonimpulsive attempters were significantly more depressed and more hopeless than the impulsive attempters, as measured by several standardized scales. Measures of depression, hopelessness, and suicidal ideation were highly correlated in both groups. Anger turned inward and hopelessness were strongly correlated only in the premeditated group, suggesting that the nonimpulsive attempter 's distress may bear a strong relationship to self anger. J . Am . Acad. Child Adolesc. Psychiatry, 1991,30, 1:95-99. Key Words: Adolescent suicide attempters, depression, impulsivity.
Suicide and suicidal behavior in adolescents have become a problem of enormous concern to health experts and the public (U.S. Public Health Service, 1980). Suicide is now the second leading cause of death for those 15 to 24 years of age (Rosenberg et al. , 1987). Nonlethal suicidal behavior is even more prevalent, with approximately 9% of high school students reporting that they have made a suicide attempt (Smith and Crawford , 1986). A significant number of attempters go on to complete suicide (Goldacre and Hawton, 1985), and even those that do not are at risk for significant psychiatric comorbidit y (Otto, 1972). Unfortunately, the prediction of suicidal behavior is hampered by the diagnostic diversity of the attempters and the multitude of antecedent conditions (Eisenberg, 1980). A recent review (Spirito et al ., 1989) notes that adolescent suicide attempters can be characterized as having a significant degree of individual and family dysfunction, but that the types of dysfunction are largely nonspecific. Precipitants of the attempt and methods of attempt (i.e., medical lethality) have been studied but show a limited range in adolescents (Garfinkel et al., 1982) and thus are of little utility for prediction. Assessment of psychological factors, such as hopelessness and impulsivity, may be more useful, especially if those constructs are directly related to suicidal actions. Impulsivity , as a general style, has been identified as a risk factor for suicide (Arffa, 1983), and adolescent suicide attempts are often described as being impulsive (White, 1974). In this context, several studies report that approximately two-thirds of adolescent suicide attempts occur with Accepted March 28, 1990. Drs . Brown, Spirito, and Fritz are with Brown University, Rhode Island, and.Dr. Overholser is with Case Western Reserve University. Research was fund ed in part by NIMH Faculty/Scholar Award (1 TO 1 MHI9065-0IAl). Preliminary data were presented at the Annual Meeting ofthe American Academy of Child and Adolescent Psychiatry, October 1988. Reprint requests to Dr . Brown, Department of Child Psychiatry, Rhode Island Hospital , Providence, Rhode Island 02903. 0890-8567/91/3001-0095$02.00/0© 1991by the American Academy of Child and Adolescent Psychiatry. J .Am.Acad. Child Adolesc.Psychiatry , 30:1, January 1991
little premeditation (Hawton and Osborn, 1984; Brent, 1987). To emphasize the serious consequences of impulsivity, Shaffer and Bacon (1986) note that most completed adolescent suicides are preceded by only a short period of planning. Impulsive attempts may be related to cognitive or behavioral impulsivity, but data in this area are conflicting. The literature reports that adolescent suicide attempters lack impulse control , compared to acutely ill adolescents (Slap et al. , 1988), and do not differ from controls in cognitive impulsivity (Patsiokas et al. , 1979). Although impulsivity , as a personality trait , may not be characteristic of all attempters , it may help define groups of different risk levels. Impulsive adult attempters have been reported to be less depressed and more likely to consider that they would survive the attempt (Williams et al. , 1980). Brent (1987) found that unplanned adolescent suicide attempts were made by nonhopeless individuals group who made well-planned and highly lethal attempts. In general , it has been suggested that greater premeditation is associated with greater suicidal intent (Hawton and Osborn, 1984), and greater intent, in tum, may be associated with greater lethality (Brent, 1987). The purpose of this study is to examine the importance of planning, as defined by the amount of premeditation, in adolescent suicide attempters seen in a general hospital. Impulsive and nonimpulsive attempters are contrasted on the basis of demographic factors and relevant psychological variables (as measured by standardized scales). It was expected that the premeditators would be more depressed , hopeless, and suicidal than the impulsive group . Method SAMPLE
All adolescents admitted to the pediatric unit of a general hospital following a suicide attempt were evaluated by the Child Psychiatry Consultation Service . The study sample was composed of 112 attempters (78% female). Ages ranged from 12 to 17, with a mean age of 15.3 years . Patients came from a broad range of socioeconomic backgrounds . For all patients, an initial medical evaluation in the emer-
95
BROWN ET AL.
gency room indicated a need for hospitalization . Medical care ranged from observation to intensive care management.
T AB LE
I. Demographic and Clinical Variables of the Attempters
Impulsive (N
MEASURES
Several standardiz ed scales were administered to measure suicidality, depression , hopelessness, and anger. Suicidality
1. The Suicide Intent Scale (SIS) (Beck et aI. , 1974) is a widely used measure of the wish to die that is reflected in a suicide attempt. This IS-item scale assesses both the objective circumstances of the act and the attempter's perception of the lethality and purpose of the act. Adequate interrater reliability has been demonstrated with adult populations. The SIS has been suggested for use with adolescents (Hawton, 1986) and used as a chart review measure in another adolescent suicide project (Brent, 1987). 2. The Suicide Ideation Questionnaire (SIQ) is a selfreport measure of suicidal thoughts designed for adolescents (Reynolds, 1987a). Norms are available based upon a sample of 2,400 adolescents. Scores above 70 (out of possible total of 175) are two standard deviations above the mean for the normat ive sample. Depression
1. The Reynolds Adolescent Depression Scale (RADS) (Reynolds, 1987b) has been found to be useful in quantifying the severity of depression experienced by the subject. It was specifically developed for adolescents and has demonstrated adequate internal consisten cy and reliability based on a normative data from 6,000 adolescents. Scores greater than 77 (out of 120) are two standard deviations beyond the mean in a normative sample. 2. The Children's Depression Inventory (COl) (Kovacs , 198011 981) is a self-report measure of depression that is a downward extension of the Beck Depression Inventory (Beck, 1978) for adults. The 27 multiple choice items assess the severity of depressive symptoms over the past 2 weeks. The scale is widely used , and it has demonstrated good concurrent validity (Saylor et al. , 1984) and reliabilit y (Smucker et al. , 1986). Scores greater than 19 (out of a possible 54) are in the upper 10% of the normative distribution (Kovacs, 198011981 ). 3. The Children ' s Depres sion Rating Scale-Revised (CDRS-R) is a clinician-rated scale designed to aid in differentiating depressed from nondepressed children (Poznanski et aI., 1984). It correlates well with other ratings of depression and has been found useful in a variety of settings. Scores above 40 (out of a total possible 113) are generally indicative of depression . Other Psychological Variables
1. The Hopelessnes s Scale for Children (HSC) (Kazdin et aI. , 1986) is a true/false scale that measures pessimism and correlates negatively with measures of self-esteem . It has adequate internal consistency and reliability with adolescents and has been found to strongly relate to suicidal potential in both adult and adolescent samples. Only one96
Race, white Sex, female SES, lower Attempt characteristics Drug overdose Used available drug Got help after No prior attempts Left note Psychiatric hospitalzation *p
= 57)
Nonimpulsive (N
= 29) 2
%
%
X
78.8 81.8 48.8
65.4 70.4 21.7
1.70 0.80 4.06*
83.6 83.0 78. 3 60.6 5.9 34.0
96.6 62.5 81.5 57.9 25.0 52.2
1.91 2.62 0.01 0.00 2.56 1.17
< 0.05.
third of children will obtain scores greater than seven out of a possible 17 (Kazdin et aI., 1986). 2. The Anger Expression Scale (AX) (Spielberger et aI., 1983) is a self-report measure of anger and its mode of expression. It correlates with other measures of anger and personality and has been validated in adults and adolescents. This 20-item scale measures: 1) how often angry feelings are experienced but not expressed (Anger-In); 2) the extent of the direct expression of angry feelings (Anger-Out); and 3) the extent of total anger expressed (Anger-Ex) . PROCEDURE
A semi-structured interview and the self-report scales were administered within 24 hours of medical clearance. The semi-structured interview (developed by A. S.) was performed by the primary psychiatric clinician. It was used to obtain the standard, relevant prior history (prior suicide attempts, precipitants of the attempt, etc.) and sociodemographic data . Social class was determined , using Rhode Island census tract data (Humphrey et aI. , 1987). On the basis of their home address, patients were placed into one of four socioeconom ic categories : high , medium , low, or poverty. Data about the degree of premeditation (based on the SIS, items 6 and 15) were available on 101 patients. SIS items have three possible ratings that describe characteristics from the most impulsive to the most premeditated attempt . Impulsive attempts (lack of premeditation) were defined by both a rating of " no preparat ion" on the degre e of planning for a suicide attempt (SIS, item 6) and a rating of "noneimpulsive" for the degree of premeditation (SIS , item 15). Premeditated attempts were defined by rating the degree of planning , " minimal/moderate" or " extensive," and by rating the degree of premeditation , "suicide contemplated," for any length of time before the attempt. In 15 cases (14.85%) , the data were inconsistent between the two items on the SIS; these cases were dropped from subsequent analyses. Of the remaining 86 cases, 57 were classified as impulsive and 29 as premeditated . Results for impulsive and premeditated attempters were compared using the chi-square statistic or Student's t-test, as appropriate. l .Am . Acad . Child Adolesc . Psychiatry ,30: 1,January 1991
PLANNING IN SUICIDE T ABL E
Impulsive SD
X RADS CD! CDRS HSC SIQ AX-In AX-Out AX-Ex
2. Psychological Measures of the Attempters
71.65 14.08 40.59 4.40 53.30 19.28 20.41 46.37
15.3 9.20 8.95 3.75 45.53 4.74 5.45 10.54
N
X
52 34 22 55 46 39 37 38
78.05 23.95 52.86 7.74 75.59 19.32 18.89 45.89
Nonimpulsive SD 15.77 8.32 14.13 4.52 44.78 4.67 7.23 7.62
N
21 20 14 27 22 19 19 19
1.60 3.94** 3.20* 3.23* 1.90 0.78 0.88 0. 17
Note: RADS = Reynolds Adolescent Depression Scale; CD! = Children's Depression Inventory; CDRS = Children's Depression Rating Scale; HSC = Hopelessness Scale for Children; SIQ = Suicide Ideation Questionnaire; AX = Anger Expression Scale.
* =p < 0.01 ** = P < 0.001.
Results To insure interrater reliability of the SIS , one of the authors , in addition to the clinician, completed the SIS items for 20% of the final sample (N = 17). Cohen ' s kapp a for the two items were : 0.870 (SIS, item 6) and 0 .807 (SIS, item 15), indicating excellent reliabilit y between raters. In fact, the only disagre ements betwe en raters occurred in specifying the amount of premeditation. Rater s were in complete agreement when they classified attempts as impuls ive or premeditated to some degree. Characteristics of the adolescents and their suicide attempt s are found in Table 1. The mean ages were similar between group s (Impulsive = 15.5 ; Non impulsi ve = 15.4 ; t [86] = 0.49). There were no gender or racial difference s between groups. Home addre sses were available on 63 patients and analysis indicated that impuls ive attempters, more than premeditated attempters, were likely to be classified in the " poverty" or " low " social class . There were no statistically significant differences between groups in the characteristics of the attempt. Drug overdoses were, by far, the most common method of self-injury in both groups. Impulsive attempts tended to be characterized by using any available drug , seeking assistance after the act , and not leaving a note ; howe ver , none of these tendenc ies were statistically significant. Although a slightly higher percentage of premeditated attempters were psychiatrically hospitalized following medical clearance, this difference was not statistically signifi cant. Table 2 reports differences between groups based upon the psychological measures. Signifi cant differences were apparent in the measures of depres sion and hopelessness. The premeditators, as compared to the impulsive suicide attempters , were found to display highe r levels of depre ssion as assessed by two of the three measures of depression. One of the two self-report measures (CDI) and the clinician-rat ed scale (CDRS) indicated statisticall y significant differences between the group s. Also , the non impulsi ve attempters reported significantly higher levels of hopelessness (HSC) and tended to report more suicidal ideation (SIQ) (t = 1.90 , p = 0 .06). Correlational analyses were performed to examine the relationship between variables in each group and the results J.Am . Acad . Child Adolesc ,Psychiatry , 30 :/ ,January 1991
T A BL E
3. Correlational Analysis across Attempter Groups
Impulsive attempters NS HSC and AX-In r( 38) = 0 .25 r(52) = 0 .41 p < 0.001 HSC and RADS HSC and CD! r( 34) = 0 .61 P < 0.001 SIQ and CD! r(2 7) = 0 .30 P < 0.05 Nonimpulsive attempters HSC and AX-In r(l9 ) = 0.50 p < 0.02 HSC and RADS r(21) = 0.55 p < 0.05 HSC and CD! r(19) = 0.71 p < 0.001 SIQ and CD! r(22 ) = 0.4 8 p < 0.05 Note: HSC = Hopelessness Scale for Children; RADS = Reynolds Adolescent Depression Scale; CD! = Children's Depression Inventory; SIQ = Suicide Ideation Questionnaire; AX = Anger Expression Scale.
are found in Table 3. Measures of depression and hope lessness were stron gly correlated for both groups . However, anger turned inwards was more highly correlated with hopelessnes s in the nonimpulsive subjects as compared to impulsive suicide attempters . The two self-report measures of depression (CDI and RADS ) were moderately correlated (r [44] = 0.64).
Discussion Little research is available to help clinicians ident ify adolescents who are at a part icularl y high risk for repeated suicide attempts or for psychiatric comorbidity. Factors that have been identified for prediction of high-risk adult attempters, such as marital and job status, are irrel evant for most adolescents (Rotheram , 1987). Psychological constructs , such as hopel essness, that are thought to be relevant require the admin istration of a complete self-report scale to be accurately assessed. Most adolescents make attempts by taking an overdose of drugs , so the medical lethality of the attempts show a limited range in this population. In contrast, the degree of premeditation in an adolescent' s suicide attempt is directl y tied to his/her recent behavior, can be easily assessed , and appears to have practical implications. This study suggests that a common clinic al impression may be correct: premeditated suicide attemp ts seem to be made by a different group of adolescents than those who make im-
97
BROWN ET AL.
pulsive attempts. Nonimpulsive attempters were characterized as more depressed and hopeless than impulsive attempters. Scores on these psychological measures for the nonimpulsive group were elevated as compared with normative groups and were generally one standard deviation above the impulsive group scores. In addition, premeditators tended to experience more suicidal ideation than the impulsive attempters, although the difference did not quite reach statistical significance. The impulsive attempters were more likely to come from impoverished circumstances than the premeditated group. Perhaps when few environmental resources are available, alternatives to an impulsive suicide attempt are not readily apparent. The diversity of economic circumstances found for the premeditated group highlights the fact that serious attempts associated with depression and hopelessness can be found in adolescents of all economic backgrounds. Given the greater depression and hopelessness of the premeditating attempters, it may appear surprising that the rate of psychiatric hospitalization was not statistically greater for this group than for the impulsive group. This fact underlines the multitude of factors that determine hospitalization, including available alternatives to hospitalization, family factors, insurance coverage, and the clinician's assessment of the extent of the patient's depression (Schreiber and Johnson, 1986). In view of the small sample size, the correlational analyses are more properly hypothesis-generating rather than hypothesis-testing. It is intriguing that repressed anger was so highly correlated with hopelessness in the premeditating group. This fact suggests that, while emotional distress is important in impulsive suicidal behavior, nonimpulsive suicidality may have a stronger basis in anger toward oneself. Gispert et al. (1987) found that repeating adolescent attempters, as compared to first-time attempters, were more dysphoric, more angry, and less academically successful, emphasizing the important consequences of long-term negative moods. While this study found differences between impulsive and nonimpulsive attempters on standard scales, it can only be suggested that these differences are of clinical importance. Whether differences noted here will actually predict differences in repeat attempts or in treatment response will need to be determined in longitudinal studies. The limitations of self-report measures are inherent in this study, although it is noted that the clinician-generated CDRS-R measure largely agreed with patients' self-reports. The standardized and validated scales remain imperfect. Two measures of the same construct (CDI and RADS) were not identical and gave slightly different results when the two groups were compared. This study assessed the importance of the degree of premeditation of one action but did not assess with a structured interview the adolescents' generally impulsivity or their psychiatric diagnosis. As previously discussed, reports conflict regarding the relation of impulsive attempts to cognitive or behavioral impulsivity. Additional research is needed to determine the relationship among premeditation, cognitive impulsivity, impulse control problems, and personality disorders.
98
In summary, this report suggests that an easily obtained marker, the degree of premeditation of the adolescent's suicide attempt, can identify high-risk attempters. Based on standardized scales, premeditators are more depressed and hopeless than impulsive attempters. Evidence of such premeditation can alert the clinician to the need for an increased awareness of potential psychiatric morbidity and the necessity for particular care in the psychiatric disposition of that group. Ultimately, longitudinal research of adolescent attempters will better define the variables that identify the attempters at greatest future risk. References Arffa, S. (1983), Cognition and suicide: a methodological review. Suicide Life Threat. Behav., 13:109-121. Beck, A. T. (1978), Depression Inventory. Philadelphia: Center for Cognitive Therapy. - - Schuyler, D. & Herman,!. (1974), Development of suicidal intent scales. In: The Prediction of Suicide, eds. A. T. Beck, H. L. P. Resknik & D. J. Lettiere. Philadelphia: Charles. Brent, D. A. (1987), Correlates of the medical lethality of suicide attempts in children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 26:87-89. Eisenberg, L. (1980), Adolescent suicide: on taking arms against a sea of troubles. Pediatrics, 66:315-320. Garfinkel, B., Froes, A. & Hood, J. (1982), Suicide attempts in children and adolescents. Am. J. Psychiatry, 139:1257-1261. Gispert, M., Davis, M. S., Marsh, L. & Wheeler, K. (1987), Predictive factors in repeated suicide attempts by adolescents. Hosp. Community Psychiatry, 38:390--393. Goldacre, M. & Hawton, K. (1985), Repetition of self-poisoning and subsequent death in adolescents who take overdoses. Br. J. Psychiatry, 14:286--291. Hawton, K. (1986), Attempted Suicide among Children and Adolescents. Beverly Hills, CA: Sage Publications, Inc., pp. 105-106. - - & Osborn, M. (1984), Suicide and attempted suicide in children and adolescents. In: Advances in Clinical Child Psychology, Vol. 7, eds. B. Lahey & A. Kazdin. New York: Plenum. Humphrey, A. B., Buechner, J. S. & Velicer, W. F. (1987), Differentiating geographic areas by socioeconomic characteristics. Northeast Journal of Business Economics, 13:47-64. Kazdin, A. E., Rodgas, A. & Colbus, D. (1986), The hopelessness scale for children: psychometric characteristics and concurrent validity. J. Consult. Clin. Psychol., 54:241-245. Kovacs, M. (1980/1981), Rating scales to assess depression in schoolaged children. Acta Paedopsychiatrica, 46:305-315. Otto, U. (1972), Suicidal acts in children and adolescents. Acta Psychiatr. Scand., 233(Suppl. 233):5-123. Patsiokas, A. T., Clum, G. A. & Luscomb, R. L. (1979), Cognitive characteristics of suicide attempters. J. Consult. Clin. Psychol., 47:478-484. Poznanski, E. 0., Grossman, 1. A., Buchsbaum, Y., Banegas, M., Freeman, L. & Gibbons, R. (1984), Preliminary studies of the reliability and validity of the children's depression rating scale. J. Am. Acad. Child Psychiatry, 23:191-197. Reynolds, W. M. (l987a), Suicide Ideation Questionnaire. Odessa, FL: Psychological Assessment Resources, Inc. - - (l987b), Reynolds Adolescent Depression Scale. Odessa, FL: Psychological Assessment Resources, Inc. Rosenberg, M. L., Smith, J. C., Davidson, L. E. & Conn, J. M. (1987), The emergence of youth suicide: an epidemiologic analysis and public health perspective. Annu. Rev. Public Health, 8:417427. Rotheram, M. J. (1987), Evaluation of imminent danger for suicide among youth. Am. J. Orthopsychiatry, 57:102-110. Saylor, C. F., Finch, A. J. & Spirito, A. (1984), The children's depression inventory: a systematic evaluation of psychometric properties. J. Consult. Clin. Psychol., 52:955-967. Schrieber, T. J. & Johnson, R. L. (1986), The evaluation and treatment
J.Am.Acad. Child Adolesc.Psychiatry, 30:1 ,January 1991
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of adolescent overdoses in an adolescent medical service. lAMA , 78:101-108 . Shaffer, D. & Bacon, K. (1986, June), A critical review ofprevention and intervention efforts in suicide with particular reference to youth suicide. Paper presented at the Prevention and Intervention Working Group of the HHS Task Force on Youth Suicide , Oakland, CA. Slap, G. , Vorters, D. , Chaudhur i, S. & Centor , R. (1988, March), Risk f actors f or adolescent suicide attempters. Poster presented at the Society of Adolescent Medicine, New York. Smith, K. & Crawford , S. (1986), Suicidal behavior among " normal" high school students. Suicide Life Threat . Behav. , 16:31 3-325. Smucker , M. R., Craighead, W. E., Craighead, L. W. & Green, B. J. (1986), Normative and reliability data for the Children' s Depression Inventory. J , Abnorm. Child Psychol. , 14:25-39 . Spielberger, C. D., Johnson, E. H., Russell , S. F., Crane, R. J.,
I .Am.Acad . Child Adolesc . Psychiatry , 30 :1, l anuary 1991
Jacobs, G. A. & Worden, T. J. (1983), The experien ce and expression of anger: construction and validation of an Anger Expression Scale. In: Advances in Personality Assessment, Vol. 2, eds. J. N. Butcher & C. D. Spielberger. Hillsdale, NJ: Erlbaum . Spirito , A. , Brown, L., Overholser, J. & Fritz , G. (1989), Attempted suicide in adolescence: a review and critique of the literature . Clinical Psychology Review. 9:335-363. United States Public Health Service (1980) , Promotin g Health/Preventing Disease: Objectives f or the Nation. Washington, DC: U. S. Government Printing Office. White, H. C. (1974), Self-poisoning in adolescents. Br. I. Psychiatry, 132:180-1 85. Williams, C. L. , Davidson , J. A. & Montgomery, 1. (1980), Impulsive suicidal behavior. J. Clin. Psychol ., 36:90-94 .
99
Suicide and suicidal behavior in adolescents have become a problem of enormous concern to health experts and the public (U.S. Public Health Service, 1980). Suicide is now the second leading cause of death for those 15 to 24 years of age (Rosenberg et al. , 1987). Nonlethal suicidal behavior is even more prevalent, with approximately 9% of high school students reporting that they have made a suicide attempt (Smith and Crawford , 1986). A significant number of attempters go on to complete suicide (Goldacre and Hawton, 1985), and even those that do not are at risk for significant psychiatric comorbidit y (Otto, 1972). Unfortunately, the prediction of suicidal behavior is hampered by the diagnostic diversity of the attempters and the multitude of antecedent conditions (Eisenberg, 1980). A recent review (Spirito et al ., 1989) notes that adolescent suicide attempters can be characterized as having a significant degree of individual and family dysfunction, but that the types of dysfunction are largely nonspecific. Precipitants of the attempt and methods of attempt (i.e., medical lethality) have been studied but show a limited range in adolescents (Garfinkel et al., 1982) and thus are of little utility for prediction. Assessment of psychological factors, such as hopelessness and impulsivity, may be more useful, especially if those constructs are directly related to suicidal actions. Impulsivity , as a general style, has been identified as a risk factor for suicide (Arffa, 1983), and adolescent suicide attempts are often described as being impulsive (White, 1974). In this context, several studies report that approximately two-thirds of adolescent suicide attempts occur with Accepted March 28, 1990. Drs . Brown, Spirito, and Fritz are with Brown University, Rhode Island, and.Dr. Overholser is with Case Western Reserve University. Research was fund ed in part by NIMH Faculty/Scholar Award (1 TO 1 MHI9065-0IAl). Preliminary data were presented at the Annual Meeting ofthe American Academy of Child and Adolescent Psychiatry, October 1988. Reprint requests to Dr . Brown, Department of Child Psychiatry, Rhode Island Hospital , Providence, Rhode Island 02903. 0890-8567/91/3001-0095$02.00/0© 1991by the American Academy of Child and Adolescent Psychiatry. J .Am.Acad. Child Adolesc.Psychiatry , 30:1, January 1991
little premeditation (Hawton and Osborn, 1984; Brent, 1987). To emphasize the serious consequences of impulsivity, Shaffer and Bacon (1986) note that most completed adolescent suicides are preceded by only a short period of planning. Impulsive attempts may be related to cognitive or behavioral impulsivity, but data in this area are conflicting. The literature reports that adolescent suicide attempters lack impulse control , compared to acutely ill adolescents (Slap et al. , 1988), and do not differ from controls in cognitive impulsivity (Patsiokas et al. , 1979). Although impulsivity , as a personality trait , may not be characteristic of all attempters , it may help define groups of different risk levels. Impulsive adult attempters have been reported to be less depressed and more likely to consider that they would survive the attempt (Williams et al. , 1980). Brent (1987) found that unplanned adolescent suicide attempts were made by nonhopeless individuals group who made well-planned and highly lethal attempts. In general , it has been suggested that greater premeditation is associated with greater suicidal intent (Hawton and Osborn, 1984), and greater intent, in tum, may be associated with greater lethality (Brent, 1987). The purpose of this study is to examine the importance of planning, as defined by the amount of premeditation, in adolescent suicide attempters seen in a general hospital. Impulsive and nonimpulsive attempters are contrasted on the basis of demographic factors and relevant psychological variables (as measured by standardized scales). It was expected that the premeditators would be more depressed , hopeless, and suicidal than the impulsive group . Method SAMPLE
All adolescents admitted to the pediatric unit of a general hospital following a suicide attempt were evaluated by the Child Psychiatry Consultation Service . The study sample was composed of 112 attempters (78% female). Ages ranged from 12 to 17, with a mean age of 15.3 years . Patients came from a broad range of socioeconomic backgrounds . For all patients, an initial medical evaluation in the emer-
95
BROWN ET AL.
gency room indicated a need for hospitalization . Medical care ranged from observation to intensive care management.
T AB LE
I. Demographic and Clinical Variables of the Attempters
Impulsive (N
MEASURES
Several standardiz ed scales were administered to measure suicidality, depression , hopelessness, and anger. Suicidality
1. The Suicide Intent Scale (SIS) (Beck et aI. , 1974) is a widely used measure of the wish to die that is reflected in a suicide attempt. This IS-item scale assesses both the objective circumstances of the act and the attempter's perception of the lethality and purpose of the act. Adequate interrater reliability has been demonstrated with adult populations. The SIS has been suggested for use with adolescents (Hawton, 1986) and used as a chart review measure in another adolescent suicide project (Brent, 1987). 2. The Suicide Ideation Questionnaire (SIQ) is a selfreport measure of suicidal thoughts designed for adolescents (Reynolds, 1987a). Norms are available based upon a sample of 2,400 adolescents. Scores above 70 (out of possible total of 175) are two standard deviations above the mean for the normat ive sample. Depression
1. The Reynolds Adolescent Depression Scale (RADS) (Reynolds, 1987b) has been found to be useful in quantifying the severity of depression experienced by the subject. It was specifically developed for adolescents and has demonstrated adequate internal consisten cy and reliability based on a normative data from 6,000 adolescents. Scores greater than 77 (out of 120) are two standard deviations beyond the mean in a normative sample. 2. The Children's Depression Inventory (COl) (Kovacs , 198011 981) is a self-report measure of depression that is a downward extension of the Beck Depression Inventory (Beck, 1978) for adults. The 27 multiple choice items assess the severity of depressive symptoms over the past 2 weeks. The scale is widely used , and it has demonstrated good concurrent validity (Saylor et al. , 1984) and reliabilit y (Smucker et al. , 1986). Scores greater than 19 (out of a possible 54) are in the upper 10% of the normative distribution (Kovacs, 198011981 ). 3. The Children ' s Depres sion Rating Scale-Revised (CDRS-R) is a clinician-rated scale designed to aid in differentiating depressed from nondepressed children (Poznanski et aI., 1984). It correlates well with other ratings of depression and has been found useful in a variety of settings. Scores above 40 (out of a total possible 113) are generally indicative of depression . Other Psychological Variables
1. The Hopelessnes s Scale for Children (HSC) (Kazdin et aI. , 1986) is a true/false scale that measures pessimism and correlates negatively with measures of self-esteem . It has adequate internal consistency and reliability with adolescents and has been found to strongly relate to suicidal potential in both adult and adolescent samples. Only one96
Race, white Sex, female SES, lower Attempt characteristics Drug overdose Used available drug Got help after No prior attempts Left note Psychiatric hospitalzation *p
= 57)
Nonimpulsive (N
= 29) 2
%
%
X
78.8 81.8 48.8
65.4 70.4 21.7
1.70 0.80 4.06*
83.6 83.0 78. 3 60.6 5.9 34.0
96.6 62.5 81.5 57.9 25.0 52.2
1.91 2.62 0.01 0.00 2.56 1.17
< 0.05.
third of children will obtain scores greater than seven out of a possible 17 (Kazdin et aI., 1986). 2. The Anger Expression Scale (AX) (Spielberger et aI., 1983) is a self-report measure of anger and its mode of expression. It correlates with other measures of anger and personality and has been validated in adults and adolescents. This 20-item scale measures: 1) how often angry feelings are experienced but not expressed (Anger-In); 2) the extent of the direct expression of angry feelings (Anger-Out); and 3) the extent of total anger expressed (Anger-Ex) . PROCEDURE
A semi-structured interview and the self-report scales were administered within 24 hours of medical clearance. The semi-structured interview (developed by A. S.) was performed by the primary psychiatric clinician. It was used to obtain the standard, relevant prior history (prior suicide attempts, precipitants of the attempt, etc.) and sociodemographic data . Social class was determined , using Rhode Island census tract data (Humphrey et aI. , 1987). On the basis of their home address, patients were placed into one of four socioeconom ic categories : high , medium , low, or poverty. Data about the degree of premeditation (based on the SIS, items 6 and 15) were available on 101 patients. SIS items have three possible ratings that describe characteristics from the most impulsive to the most premeditated attempt . Impulsive attempts (lack of premeditation) were defined by both a rating of " no preparat ion" on the degre e of planning for a suicide attempt (SIS, item 6) and a rating of "noneimpulsive" for the degree of premeditation (SIS , item 15). Premeditated attempts were defined by rating the degree of planning , " minimal/moderate" or " extensive," and by rating the degree of premeditation , "suicide contemplated," for any length of time before the attempt. In 15 cases (14.85%) , the data were inconsistent between the two items on the SIS; these cases were dropped from subsequent analyses. Of the remaining 86 cases, 57 were classified as impulsive and 29 as premeditated . Results for impulsive and premeditated attempters were compared using the chi-square statistic or Student's t-test, as appropriate. l .Am . Acad . Child Adolesc . Psychiatry ,30: 1,January 1991
PLANNING IN SUICIDE T ABL E
Impulsive SD
X RADS CD! CDRS HSC SIQ AX-In AX-Out AX-Ex
2. Psychological Measures of the Attempters
71.65 14.08 40.59 4.40 53.30 19.28 20.41 46.37
15.3 9.20 8.95 3.75 45.53 4.74 5.45 10.54
N
X
52 34 22 55 46 39 37 38
78.05 23.95 52.86 7.74 75.59 19.32 18.89 45.89
Nonimpulsive SD 15.77 8.32 14.13 4.52 44.78 4.67 7.23 7.62
N
21 20 14 27 22 19 19 19
1.60 3.94** 3.20* 3.23* 1.90 0.78 0.88 0. 17
Note: RADS = Reynolds Adolescent Depression Scale; CD! = Children's Depression Inventory; CDRS = Children's Depression Rating Scale; HSC = Hopelessness Scale for Children; SIQ = Suicide Ideation Questionnaire; AX = Anger Expression Scale.
* =p < 0.01 ** = P < 0.001.
Results To insure interrater reliability of the SIS , one of the authors , in addition to the clinician, completed the SIS items for 20% of the final sample (N = 17). Cohen ' s kapp a for the two items were : 0.870 (SIS, item 6) and 0 .807 (SIS, item 15), indicating excellent reliabilit y between raters. In fact, the only disagre ements betwe en raters occurred in specifying the amount of premeditation. Rater s were in complete agreement when they classified attempts as impuls ive or premeditated to some degree. Characteristics of the adolescents and their suicide attempt s are found in Table 1. The mean ages were similar between group s (Impulsive = 15.5 ; Non impulsi ve = 15.4 ; t [86] = 0.49). There were no gender or racial difference s between groups. Home addre sses were available on 63 patients and analysis indicated that impuls ive attempters, more than premeditated attempters, were likely to be classified in the " poverty" or " low " social class . There were no statistically significant differences between groups in the characteristics of the attempt. Drug overdoses were, by far, the most common method of self-injury in both groups. Impulsive attempts tended to be characterized by using any available drug , seeking assistance after the act , and not leaving a note ; howe ver , none of these tendenc ies were statistically significant. Although a slightly higher percentage of premeditated attempters were psychiatrically hospitalized following medical clearance, this difference was not statistically signifi cant. Table 2 reports differences between groups based upon the psychological measures. Signifi cant differences were apparent in the measures of depres sion and hopelessness. The premeditators, as compared to the impulsive suicide attempters , were found to display highe r levels of depre ssion as assessed by two of the three measures of depression. One of the two self-report measures (CDI) and the clinician-rat ed scale (CDRS) indicated statisticall y significant differences between the group s. Also , the non impulsi ve attempters reported significantly higher levels of hopelessness (HSC) and tended to report more suicidal ideation (SIQ) (t = 1.90 , p = 0 .06). Correlational analyses were performed to examine the relationship between variables in each group and the results J.Am . Acad . Child Adolesc ,Psychiatry , 30 :/ ,January 1991
T A BL E
3. Correlational Analysis across Attempter Groups
Impulsive attempters NS HSC and AX-In r( 38) = 0 .25 r(52) = 0 .41 p < 0.001 HSC and RADS HSC and CD! r( 34) = 0 .61 P < 0.001 SIQ and CD! r(2 7) = 0 .30 P < 0.05 Nonimpulsive attempters HSC and AX-In r(l9 ) = 0.50 p < 0.02 HSC and RADS r(21) = 0.55 p < 0.05 HSC and CD! r(19) = 0.71 p < 0.001 SIQ and CD! r(22 ) = 0.4 8 p < 0.05 Note: HSC = Hopelessness Scale for Children; RADS = Reynolds Adolescent Depression Scale; CD! = Children's Depression Inventory; SIQ = Suicide Ideation Questionnaire; AX = Anger Expression Scale.
are found in Table 3. Measures of depression and hope lessness were stron gly correlated for both groups . However, anger turned inwards was more highly correlated with hopelessnes s in the nonimpulsive subjects as compared to impulsive suicide attempters . The two self-report measures of depression (CDI and RADS ) were moderately correlated (r [44] = 0.64).
Discussion Little research is available to help clinicians ident ify adolescents who are at a part icularl y high risk for repeated suicide attempts or for psychiatric comorbidity. Factors that have been identified for prediction of high-risk adult attempters, such as marital and job status, are irrel evant for most adolescents (Rotheram , 1987). Psychological constructs , such as hopel essness, that are thought to be relevant require the admin istration of a complete self-report scale to be accurately assessed. Most adolescents make attempts by taking an overdose of drugs , so the medical lethality of the attempts show a limited range in this population. In contrast, the degree of premeditation in an adolescent' s suicide attempt is directl y tied to his/her recent behavior, can be easily assessed , and appears to have practical implications. This study suggests that a common clinic al impression may be correct: premeditated suicide attemp ts seem to be made by a different group of adolescents than those who make im-
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BROWN ET AL.
pulsive attempts. Nonimpulsive attempters were characterized as more depressed and hopeless than impulsive attempters. Scores on these psychological measures for the nonimpulsive group were elevated as compared with normative groups and were generally one standard deviation above the impulsive group scores. In addition, premeditators tended to experience more suicidal ideation than the impulsive attempters, although the difference did not quite reach statistical significance. The impulsive attempters were more likely to come from impoverished circumstances than the premeditated group. Perhaps when few environmental resources are available, alternatives to an impulsive suicide attempt are not readily apparent. The diversity of economic circumstances found for the premeditated group highlights the fact that serious attempts associated with depression and hopelessness can be found in adolescents of all economic backgrounds. Given the greater depression and hopelessness of the premeditating attempters, it may appear surprising that the rate of psychiatric hospitalization was not statistically greater for this group than for the impulsive group. This fact underlines the multitude of factors that determine hospitalization, including available alternatives to hospitalization, family factors, insurance coverage, and the clinician's assessment of the extent of the patient's depression (Schreiber and Johnson, 1986). In view of the small sample size, the correlational analyses are more properly hypothesis-generating rather than hypothesis-testing. It is intriguing that repressed anger was so highly correlated with hopelessness in the premeditating group. This fact suggests that, while emotional distress is important in impulsive suicidal behavior, nonimpulsive suicidality may have a stronger basis in anger toward oneself. Gispert et al. (1987) found that repeating adolescent attempters, as compared to first-time attempters, were more dysphoric, more angry, and less academically successful, emphasizing the important consequences of long-term negative moods. While this study found differences between impulsive and nonimpulsive attempters on standard scales, it can only be suggested that these differences are of clinical importance. Whether differences noted here will actually predict differences in repeat attempts or in treatment response will need to be determined in longitudinal studies. The limitations of self-report measures are inherent in this study, although it is noted that the clinician-generated CDRS-R measure largely agreed with patients' self-reports. The standardized and validated scales remain imperfect. Two measures of the same construct (CDI and RADS) were not identical and gave slightly different results when the two groups were compared. This study assessed the importance of the degree of premeditation of one action but did not assess with a structured interview the adolescents' generally impulsivity or their psychiatric diagnosis. As previously discussed, reports conflict regarding the relation of impulsive attempts to cognitive or behavioral impulsivity. Additional research is needed to determine the relationship among premeditation, cognitive impulsivity, impulse control problems, and personality disorders.
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In summary, this report suggests that an easily obtained marker, the degree of premeditation of the adolescent's suicide attempt, can identify high-risk attempters. Based on standardized scales, premeditators are more depressed and hopeless than impulsive attempters. Evidence of such premeditation can alert the clinician to the need for an increased awareness of potential psychiatric morbidity and the necessity for particular care in the psychiatric disposition of that group. Ultimately, longitudinal research of adolescent attempters will better define the variables that identify the attempters at greatest future risk. References Arffa, S. (1983), Cognition and suicide: a methodological review. Suicide Life Threat. Behav., 13:109-121. Beck, A. T. (1978), Depression Inventory. Philadelphia: Center for Cognitive Therapy. - - Schuyler, D. & Herman,!. (1974), Development of suicidal intent scales. In: The Prediction of Suicide, eds. A. T. Beck, H. L. P. Resknik & D. J. Lettiere. Philadelphia: Charles. Brent, D. A. (1987), Correlates of the medical lethality of suicide attempts in children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 26:87-89. Eisenberg, L. (1980), Adolescent suicide: on taking arms against a sea of troubles. Pediatrics, 66:315-320. Garfinkel, B., Froes, A. & Hood, J. (1982), Suicide attempts in children and adolescents. Am. J. Psychiatry, 139:1257-1261. Gispert, M., Davis, M. S., Marsh, L. & Wheeler, K. (1987), Predictive factors in repeated suicide attempts by adolescents. Hosp. Community Psychiatry, 38:390--393. Goldacre, M. & Hawton, K. (1985), Repetition of self-poisoning and subsequent death in adolescents who take overdoses. Br. J. Psychiatry, 14:286--291. Hawton, K. (1986), Attempted Suicide among Children and Adolescents. Beverly Hills, CA: Sage Publications, Inc., pp. 105-106. - - & Osborn, M. (1984), Suicide and attempted suicide in children and adolescents. In: Advances in Clinical Child Psychology, Vol. 7, eds. B. Lahey & A. Kazdin. New York: Plenum. Humphrey, A. B., Buechner, J. S. & Velicer, W. F. (1987), Differentiating geographic areas by socioeconomic characteristics. Northeast Journal of Business Economics, 13:47-64. Kazdin, A. E., Rodgas, A. & Colbus, D. (1986), The hopelessness scale for children: psychometric characteristics and concurrent validity. J. Consult. Clin. Psychol., 54:241-245. Kovacs, M. (1980/1981), Rating scales to assess depression in schoolaged children. Acta Paedopsychiatrica, 46:305-315. Otto, U. (1972), Suicidal acts in children and adolescents. Acta Psychiatr. Scand., 233(Suppl. 233):5-123. Patsiokas, A. T., Clum, G. A. & Luscomb, R. L. (1979), Cognitive characteristics of suicide attempters. J. Consult. Clin. Psychol., 47:478-484. Poznanski, E. 0., Grossman, 1. A., Buchsbaum, Y., Banegas, M., Freeman, L. & Gibbons, R. (1984), Preliminary studies of the reliability and validity of the children's depression rating scale. J. Am. Acad. Child Psychiatry, 23:191-197. Reynolds, W. M. (l987a), Suicide Ideation Questionnaire. Odessa, FL: Psychological Assessment Resources, Inc. - - (l987b), Reynolds Adolescent Depression Scale. Odessa, FL: Psychological Assessment Resources, Inc. Rosenberg, M. L., Smith, J. C., Davidson, L. E. & Conn, J. M. (1987), The emergence of youth suicide: an epidemiologic analysis and public health perspective. Annu. Rev. Public Health, 8:417427. Rotheram, M. J. (1987), Evaluation of imminent danger for suicide among youth. Am. J. Orthopsychiatry, 57:102-110. Saylor, C. F., Finch, A. J. & Spirito, A. (1984), The children's depression inventory: a systematic evaluation of psychometric properties. J. Consult. Clin. Psychol., 52:955-967. Schrieber, T. J. & Johnson, R. L. (1986), The evaluation and treatment
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