Behavioral Emergencies Update
In this issue...

The President's Column:
Behavioural Emergencies: Some Current Issues for Clinical Psychologists

Highlights from the 110th Annual APA Convention

Psychology and Terrorism

Adolescent Growth Spurt

Challenges in the Field of Adolescent Suicide Research

Taskforce on Education and Training in Behavioral Emergencies

An Editorial Comment: Assessment of Self-harm, Suicide and Violence Potential

Minutes from the Section VII Business Meeting

Special Offer for Section VII Members



Section VII Home

Challenges in the Field of Adolescent Suicide Research

Gabriella Johr
Jennifer Hartstein
Alec L. Miller
Albert Einstein College of Medicine,
Montefiore Medical Center, Bronx, NY

Suicide is the third leading cause of death among 15 to 24 year olds, preceded only by accidents and homicide (NCHS, 1996). While adolescent males are four times more likely than females to complete suicide, females are two to four times more likely to attempt suicide (Lewinsohn, Rohde & Seeley, 1996). Comparing different ethnic groups, Hispanic youth attempt suicide at the highest rate, whereas Caucasian males are at the greatest risk for suicide completion. The rate of suicide among African-American male adolescents has steadily risen over the past 20 years (Satcher, 2000).

The number of adolescents who receive medical attention and psychological services following a suicide attempt is alarmingly low. Approximately 50% of adolescents who attempt suicide fail to receive follow-up mental health treatment (Spirito, A, Brown, L, Overholser, J, & Fritz, G, 1989). Of those who do receive mental health care, 77% are non-compliant with outpatient treatment (Trautman, Stewart, & Moishima, 1993). These disturbing statistics suggest the need for greater research to help determine what types of treatment and treatment settings effectively engage and treat suicidal youth.

To date, only three randomized controlled studies evaluating psychological treatments for “suicidal” adolescents have been published (Cot grove, Zirinsky, Black & Weston, 1995; Harrington, Derfoor, Dyer, McNiver, Gill, Harrington, Woodhan & Bedford, 1998; Wood, Trainor, Rotherwill, Moore & Harrington, 2001). Only one of these studies achieved a significant reduction in deliberate self-harm. In this study, Wood et al. (2001) compared care as usual plus a group intervention (containing components of CBT and DBT) to care as usual alone and employed Hawton and Catalan’s definition of deliberate self-harm: "any intentional self-inflicted injury, irrespective of the apparent purpose of the act". The adolescents in the study engaged in at least two incidents of deliberate self-harm over the course of a year; however, the intent of self-harm was not assessed and acutely suicidal adolescents were excluded from the study. Self-report measures of depressive symptoms, suicidal ideation and self-harm behaviors were used to evaluate primary outcome variables.

In a quasi-experimental design, Rathus and Miller (2002) compared care as usual to dialectical behavioral therapy (DBT) for a group of suicidal ethnic minority adolescents receiving outpatient treatment. In contrast to the Wood et al. (2001) study, this investigation chose to evaluate suicidal behaviors as the primary outcome variable and failed to use deliberate self-harm as an outcome variable. Not surprisingly, given the low frequency of suicide attempts (i.e., with intent to die), there were no significant differences found between groups during the 12-week study. Rathus and Miller (2002) also employed self-report measures to assess depression, suicidal ideation and suicidal behaviors, although the instruments were different than those used in the aforementioned study.

Although the small field of adolescent suicide research is growing, there are several obstacles that warrant consideration in an effort to advance the field. The problems of 1) definitional obfuscation, 2) reliance on self-report measures, 3) a lack of culturally sensitive assessments, and 4) challenges in obtaining IRB approval for researching suicidal adolescents are presented below. One common problem found among studies with suicidal patients is "definitional obfuscation” (Linehan, 1997). That is, no universal and precise definition of suicidal behavior exists and some studies fail to assess the intent of self-injurious behavior to determine whether in fact they are suicidal. It is important to make a distinction regarding the intent of such behavior given that at least one-fourth of adolescents who engage in self-injurious behaviors report no intent to die (Lewinsohn, Rohde & Seeley, 1996). The varied terminology used to define suicidal behaviors coupled with inadequate assessment of suicidal intent makes it difficult to compare research findings and determine prevalence rates and treatment efficacy among suicidal youth.

Second, results from studies that rely on adolescents’ self-report measures have to be interpreted with caution due to several factors including response and social desirability biases and the impact of a mood disorder. A thorough assessment of suicidality, psychopathology, and functional impairment, would include additional reports from teachers, family members and therapists, using the same validated and standardized measures across studies. Third, all measures need to be normed on ethnically diverse populations. Without the development of a sophisticated, standardized, and culturally sensitive assessment battery, it is difficult to effectively compare research findings and identify the effective treatments for suicidal youth. On a final note, Institutional Review Boards (IRBs) are often reluctant to endorse research studies of suicidal adolescents due to the ethical and safety concerns. We propose that experts in the field of suicidology develop a generic IRB protocol for suicidal patients that can eventually be tailored to individual studies. Those protocols would address common risks, benefits and safety precautions. This may potentially reduce the IRBs' reluctance to endorse treatment studies with suicidal youth. In sum, now is the time for clinical researchers in adolescent suicidology to meet these challenges. Progress requires greater collaboration from researchers, clinicians and funding agencies to create a universal language and assessment battery that will hopefully translate into the development of effective treatments for suicidal youth (Spirito, Stanton, Donaldson, & Boergers, 2002).


American Academy of Child and Adolescent Psychiatry (1998). Teen Suicide—AACAP Facts for Families #10. Available from the American Academy of Child and Adolescent Psychiatry—

Cotgrove, AJ, Zirinsky, L, Black, D, & Weston, D (1995). Secondary prevention of attempted suicide in adolescents. Journal of Adolescence, 18, 569-577.

Harrington, R, Derfoor, M, Dyer, E, McNiven, F, Gill, J, Harrington, V, Woodhan, A, & Bedford, S (1998). Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 512-518.

Hawton, K & Catalan, J (1982). Attempted Suicide. Oxford, England: Oxford Medical Pulications.

Lewisohn, PM, Rohde, P, & Seeley, JR (1996). Adolescent suicidal ideation and attempts: Prevalence, risk factors, and clinical implications. Clinical Psychology Science and Practice, 3, 25-46.

Linehan, MM (1997). Behavioral treatments of suicidal behaviors: Definitional obfuscation and treatment outcomes. In D. Stoff & J. J. Mann (Eds.), Neurobiology Suicide. New York: Annals of the New Academy of Sciences, 302-328.

National Center for Health Statistics (1996). Advance report of final mortality statistics, 1994. National Monthly Vital Statistics Report, 45, 63.

Rathus, JH & Miller, AL (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life-Threatening Behavior, 32, 146-157.

Satcher, D (2000). Depression and suicide in children and adolescents. In Mental Health: A Report of the Surgeon General. Available at: _ HYPERLINK

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.

Spirito, A, Stanton, C, Donaldson, D, & Boergers, J (2002). Treatment-as-usual for adolescent suicide attempters: Implications for the choice of comparison groups in psychotherapy research. Journal of Clinical Child and Adolescent Psychology, 31, 41- 47.

Trautman, P, Stewart, N, & Morishima, A (1993). Are adolescent suicide attempters non-compliant with outpatient care? Journal of the American Academy of Child and Adolescent Psychiatry, 32, 89-94.

Wood, A, Trainor, G, Rothwell, J, Moore, A, & Harrington, R (2002). Randomized trial of group therapy for repeated deliberate self-harm in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1246-1253.

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