Academic journal article Adolescence

Suicide Attempts among Adolescent Mexican American Students Enrolled in Special Education Classes

Academic journal article Adolescence

Suicide Attempts among Adolescent Mexican American Students Enrolled in Special Education Classes

Article excerpt

The number of suicides in the United States exceeds the number of homicides. In the year 2000, 16,765 homicides and 29,350 suicides were reported (as cited in Price, Thompson, & Drake, 2004). A successful suicide rate for adolescents between 15 and 24 years of age has increased nearly 300% in the last three decades (Rich, Kirkpatrick-Smith, Bonner, & Jans, 1992). It is estimated that 12 people each day between the ages of 15 and 24 successfully commit suicide (American Association of Suicidology, 2004). Bearman and Moody (2004) reported that 4% of American adolescents considered suicide at least once in the past year, and 20% of adolescents indicated they knew someone who had attempted suicide in the past year. Twenty to 100 suicides are attempted for every completion (Metha, Weber, & Webb, 1998). Although research can approximate the number of suicides and attempted suicides each year, it is impossible to know with certainty how many there are among school-aged youth. Research notes that adolescent suicides are underreported, with attempts significantly outnumbering reported attempts four to one (see, e.g., Davis, 1985; Poland, 1989). This may be due to families who feel stigmatized by their tragedies disguising the deaths as being caused by automobile accidents or drug overdoses. Given these findings, it can be reasonably concluded that reported estimates are probably conservative.

The investigation of suicide among Mexican American youth in special education for emotional and behavioral disorders is a relatively new field of study. In one of the few studies that did investigate youth suicide among Hispanics, Loya (1976) found that it increased at a higher rate for Hispanics than for non-Hispanics in Colorado during the period of 1960-1975. Garland and Zigler (1993) reported that suicides for nonwhites have more than doubled over the past 28 years. Most studies on suicide do not recognize Mexican Americans adolescents in special education as a separate risk group. Guetzloe (1991) contends that special education populations are often among the victims of suicide due to behavioral characteristics associated with their exceptionalities.

In view of the increasing frequency of suicide and other self-destructive behaviors among Mexican American youth and special education students, it is urgent for school personnel to uncover the factors related to suicide. Substance abuse, social conflict, and depression are significant predictors of suicidal ideation among adolescents (Shaughnessy, Dosi, Jones, & Everett, 2004). There is a strong association between depressive symptoms, drug use, and suicidal ideation among Mexican American teenagers living in U.S./Mexico border communities in Texas (Swanson, Linskey, Quintero-Salinas, Pumariega, & Holzer, 1992). Recognizing Mexican American youth who are in special education classes as a separate risk group, the present study (a) identifies the factors that contribute to suicide, (b) reviews the signs and characteristics associated with these factors, (c) interviews Mexican American students in special education programs for emotional and behavioral disorders who exhibited various characteristics of suicidal thoughts and/or have attempted suicide, (d) explores effective prevention programs, and (e) provides suggestions for school personnel.

METHOD

Eight adolescent students, ages 13 to 18 with emotional/behavioral disabilities and placed in special education programs, were asked to participate in the study. It was only determined through interviews that four of the eight adolescents had attempted suicide. Another adolescent had several interactions with friends who had committed suicide and had also contemplated suicide himself.

All interview data gathered utilized Seidman's (1991) phenomenological in-depth interviewing procedures which followed a three-question framework addressing factors often associated with suicidal youth. Each interview lasted 45 to 60 minutes, and was conducted approximately 10 days apart. Each interview was initiated with a general question which encouraged the students to relate their own experiences within the context of the topic.

Prior to the interviews, students, parents, and teachers were provided with (a) a copy of the teacher, parent or student consent forms which included the purpose of the study; (b) a list of names and telephone numbers that parents, teachers, or students could call should issues arise from their participation in the research; (c) information regarding how to terminate their involvement, and (d) the extent to which confidentiality would be maintained. These procedures ensured that the participants understood the purpose of the study and how confidentiality would be maintained.

All interviews were audio-taped and transcribed in their entirety. Observational documentation prior to, during, and immediately after the interviews was also taken. The voices of students who had attempted suicide or who had contemplated suicide and knew other students who had attempted suicide are reflected below in relation to the primary characteristics of depression, substance abuse, social and interpersonal conflict, family distress, and school failure. Supporting literature following each characteristic identifies and clarifies the students' experiences.

STUDENT VOICES

Depression

Pablo:

When my grandpa died, [I was] very depressed and then when the kids teased me at school, that's when I got more depressed ... like, get mad. Yeah, [I had] a short fuse, and then I would pop like that (snaps finger). Tell me something that I don't really, really like and that's when I get depressed and that's when my fuse starts going faster ... When, they said, "Oh, your grandpa's going to die, or something like that;" I would get pissed. I would just get the short fuse and cut it off real big. And I would kick their butts. Believe me.

What stopped me from hurting myself was when my grandma talked to me. She said that it wasn't my fault that [my grandpa died] because my grandpa had something on his head like tumors.

Angela:

[I think] two other students in our class are depressed. One [student], he's always sad, and he'll always be. He doesn't know how to handle his depression so he gets into a lot of fights and he had a lot of anger towards others. He'll get in a lot of fights, and when he gets angry, he'll punch his face. He'll punch his face and he'll be crying and that's part of depression-anger. Another student he has sadness. He's lonely. I see that he's lonely. He's always real sad and he'll like smile to me once in a while. He's real sad ... That's why I tried suicide, I wanted to be one less problem and I wanted to stop being so sad. I think I will always be sad.

Researchers have confirmed that depression is a major indicator of suicidal ideation in children (Allan, Kashani, Dahlmeier, Beck, & Reid, 1998). It is estimated that 14% of adolescent students would meet the criteria for a diagnosis of depression (American Psychiatric Association, 1987). Depression is considered a pathological disorder that can be regarded as a disturbance in the adolescent's normal functioning, often demonstrated as diminished cognitive functioning, suppressed emotional and psychological responsiveness, inappropriate behavioral reactions, and general distress in functioning.

A review of the literature conducted by Abrams, Theberge, and Karan (2005) concluded that a variety of observable behaviors are directly tied to depressed mood: decreased ability to experience pleasure, acting-out behaviors, changes in appetite and weight, somatic complaints, feelings of worthlessness, difficulty concentrating or thinking clearly, and suicidal ideation. In a study conducted by Kubik, Lytle, Birnbaum, Murray, and Perry (2003) of the 3,621 adolescents who participated, 40% of girls and 30% of boys had depressive symptoms. It was also found that of the 97 Mexican American adolescents who participated in the study, 40% demonstrated depressive symptoms as compared to only 30% of Caucasian students. An earlier study by Smith and Crawford (1986) examined the relationship between depression and suicidal behaviors of 313 high school students, and the data revealed that 42% of the suicide attempters were markedly depressed (score of 21 or above on the BDI).

Hamrick, Goldman, Sapp, and Kohler (2004) suggested that up to 50% of adolescents referred for special education met the clinical criteria for a diagnosis of depression. Guetzloe (1991) reported that children are often at greater risk for suicide if they are enrolled in special education programs. This is largely due to the behavioral characteristics often associated with adolescents in special education programs (e.g., impulsivity, acting-out, and adaptational problems). This may be especially true for Mexican American youth enrolled in special education programs where differential treatment of them by peers and teachers coupled with linguistic and cultural differences create greater psychosocial stressors.

It is estimated that 50% of students referred for special education services have a depressive disorder (Guetzloe, 1991). While depressed students with conduct disorders are more likely to receive special education services, other depressed students with limited overt behaviors are less likely to be provided special educational support (Guetzloe, 1991). Since depression is strongly associated with other psychiatric disorders (e.g., anxiety, conduct disorder, bi-polar disorder, psychosis), students with emotional and behavioral disorders are at high risk for depression and suicidal ideation (Miller, 1993). Hamrick, Goldman, Sapp, and Kohler (2004) reported depression among adolescents with learning and behavioral disorders as being more prevalent than in the general population. Students with learning disabilities also have increased risk for depression and suicidal ideation because of cognitive deficits and limited problem-solving abilities (Guetzloe, 1991; Howard & Tyron, 2002). Despite the high prevalence of depression and suicidal thoughts among students in special education, warning signs may go unnoticed by parents and teachers who are preoccupied with the students' "primary" disabilities.

SUBSTANCE ABUSE

David:

I just started smoking cigarettes at about nine years [of age] and about ten [years of age] I started smoking marijuana. I'd have to say more or less friends [got me started], because I was hanging with a bunch of head bangers and it was like marijuana is a status thing, so I got involved with that. [The first time] it stung my throat.... It felt harsh going down. I was like, "ahhh." It was like smoking a cigarette for the first time. Also at the age often, I started taking hits of acid and I was tripped out about acid. I was like awkward. Saw lots of weird things ... [It was] taking acid and I was smoking pot in the eighth grade.... I was in eighth grade when I started speed crystal. I was about 14 years or 15 years [old] ... I tried speed crystal at Monty High School, because with speed crystal all you have to do is just put them in a cigarette, light up the cigarette, and you smoke the speed crystal away. That hits you a little bit worse than acid ... It was a trip. I tried hash once but I got sick from that, and I was like, "Nope, never again."... I've only tried coke once, and I didn't like it. It didn't do anything for me.

While I was there [at Monty High School] I met this chick there and we started going out and it got kind of serious and then when she broke up with me, I got suicidal and I told everybody I was going to kill myself and everybody was like, "Ah, nah, you wouldn't do it." And then one night over the weekend, it was on a Sunday night, I asked my morn if she could get me some sleeping pills because I told her I wasn't sleeping well. She was like, "Okay." She goes, "Well grandma's got some [pills]. I told her I've already tried those [pills] and I told her I needed sleeping pills. She got me sleeping pills and I took those ... I took a whole bottle of sleeping pills, which was 16, and eight tablets of ibuprofen. The next morning I just like woke up and threw up on the floor. My mom called the counselor that was working with me at that time.

Jaime:

[I know of] 10 students who tried to hurt themselves by getting pregnant, having kids, saying hello to the needle, doing drugs. Yeah. [Those] who have tried alcohol and prostitution ... Everything. Selling drugs, hanging out late, not going to school, just not caring. I knew someone who attempted suicide. Yeah.... My cousin, he was about 14, 15, or 16, and he ran away from the house. He was drinking and on drugs. He cut himself, all the way, all over. He didn't care, because my uncle was in prison.

A primary factor in adolescent suicides is substance abuse (see Andrews & Lewinsohn, 1992; Johnson & Maile, 1987; Rich, Sherman, & Fowler, 1990). As Johnson (1999) stated, the purposeful overdose of drugs, legal or illegal, as a method of suicide is seen more often in females than in males. But any habitual substance abuse can be a factor because such use reduces inhibitions that might otherwise keep the teen from completing a self-destructive act. (p. 10).

Johnson (1999) noted, "For a depressed young person, the temporary 'high' of drugs or alcohol is a dysfunctional coping strategy that provides a brief 'escape,' only to be followed by a decline into depression" (p. 9). The strongest association with suicide was legal and disciplinary problems, and these factors were closely associated with substance abuse and conduct disorders (Brent, Perper, Moritz, Baugh, Roth, Balach, & Schweers, 1993). In research conducted by Cavaiola and Lavender (1999), 20% of the 250 adolescents in a residential program for chemical dependency had attempted suicide within two years of admission. Chemical dependency is one of the most prevalent health-impairing conditions among adolescents and a major factor in adolescent suicide.

Suicidal youth who are substance abusers, acting out, and expressing self-destructive behavior are likely to be flushed out of the educational system through school failure, homebound status, expulsion, or referral to special education. In severe cases, delinquent behavior may move from the schoolyard to the juvenile legal system where students are tracked and further alienated from appropriate interventions.

SOCIAL AND INTERPERSONAL CONFLICT

David:

I was placed [in special education]. I know it wasn't because of academics. It was because of a behavioral disorders ... At first I came in and I was like, "Ahh, I don't want to do any work or anything." Leonard [the special education teacher] got me into doing my work, by [giving me] a lot of referrals. I was pretty bad when I first came in. When I first entered special education, I had it [hair] down to my buttocks. Nobody saw the likes of me when I came to this school. Everybody was tripped out because my pants had holes all the way down, and my hair was long, and everybody was just kind of like surprised to see someone like me. They [students] even gave me nicknames like warlock. They just gave me a whole bunch of them--let me see warlock, psycho, Freddie, Jason. You know like the horror movie people? It was like that. When someone would dare me to do something, I'd do it.

Jaime:

([Other teachers], they never got close with me. There was one in the RTC [Residential Treatment Center]... She was similar to Ms. Johnson. I liked her a lot. [Other teachers] could have told me, at least what was wrong with me. If I needed help, extend their hand or something when I needed help. I would [have] come to them. All I asked for from them was friendship. [They could have said], "I'll take you as you look, because I've always been like this [TM]all, muscular, and looking like a stereotypical gangster]." People all the time judge me by my looks. They think I'm a fucking criminal or something, get all scared and shit, I tell them, "Man, don't be scared of me, a 14-year-old kid. Fuck with me, then I'll kick your ass, but other than that, don't be scared of me.

[Teachers], they would all be looking at me and shit. No-one said, "Oh, how are you doing?" They wouldn't tell me all kinds of shit when I did something wrong to anybody else or screamed out loud. They wouldn't tell me shit. They didn't say nothing. They'd tell the other [students]. Yeah, and I would talk back to them and they wouldn't say shit. The other kids [who talked back], they [teachers] would send them to the office. Some of them [teachers] just stay clear of the students. They wouldn't say shit to me. That made me feel like shit I ain't nothing. Don't be scared of me, I am a 14-year-old boy.

Social desirability may be important in the prediction of suicidal ideation and interest (Madison & Vas, 2003). Interpersonal deficits, difficult personality features, and familial risk factors (e.g., physical abuse, family alcohol abuse) may be significant indicators of suicidal behaviors. Maladaptive coping strategies and personal isolation have been cited as predisposing factors in suicidal behavior (Ruchkin, Schwab-Stone, Koposov, Vermeiren, & King, 2003; Spirito, Francis, Overholser, & Frank, 1996).

A study by Rich, Sherman, and Fowler (1990) substantiated that poor social skills may be a precursor to suicidal behaviors in adolescents, with social withdrawal as the most prevalent symptom in adolescents who completed suicide. Moreover, a significant number of the adolescents in their study had marked interpersonal loss or personal rejection compounded with social relationship problems prior to their suicide.

Students with emotional and/or behavior disabilities are at particular risk of social alienation due to high anxiety and irritability, poor communication skills, and impaired peer relationships (Guetzloe, 1991).

FAMILY DISTRESS

Jaime:

[In fifth grade], my parents were splitting up. It was just my mother. My mother was drinking too much. My father was working and they got into a lot of fights. I was all depressed and the family was splitting up and my older brother, Andy, was getting into fights. He was in detention centers and my [brothers] were out stealing cars. And then pregnancies came in. Everything was changing. My brother's wife getting pregnant, the kids coming in, new nephews. I was going to be an uncle and stuff. It was just changing too fast for me. I wanted it to stay like it was, you know, all of us together. It all started separating. My dad started staying at my grandma's house. [My parents] started splitting up. My mom was drinking and she would leave the house. She wouldn't come back for quite a while. She would leave at 8:00 a.m. and she would come back like at one, two, or three in the morning, while we were asleep. She wouldn't even iron for us. Nothing. She didn't care. But then she stopped [drinking]. She stopped then my dad got to drinking. Then my dad started going off and they [mother and father] started getting in fights again. He had all these affairs with other women and that's what hurt me. He wouldn't pay attention that much to us anymore. Once in a while he would buy Us clothes and shirts and stuff. I didn't even have clothes. I was just wearing my older brother's clothes. He had clothes, but not me. I was borrowing his clothes.

Studies have indicated that poor social skills within the family appear to be another significant factor in suicide. Coder, Nelson, and Aylward (1991) reported that counselors felt that family problems were the number one reason leading to attempted or completed suicides. Davis, Sandoval, and Wilson (1988) identified seven major family characteristics that increase the risk of adolescent suicide: (1) Necessary changes are not accepted. (2) Interpersonal failures result in role confusion and conflict. (3) Family structure is dysfunctional or disturbed. (4) Family relationships are confused, symbiotic, or double-binding. (5) The family has a pattern of emotional difficulty. (6) Communication problems exist. (7) Crises are not tolerated.

Jones (1997) reported that youths from lower socioeconomic families may be at higher risk for suicide. Family distress is particularly prevalent within the special education population. Family problems for students with special needs may be intensified due to lack of warmth, high irritability, poor communication, and parent-child hostility (Guetzloe, 1991).

SCHOOL STRESS

Celia:

Lunch? Oh, yeah, lunch is real exciting. Usually I stare at the food that makes me feel nauseous or if it looks okay I start to eat it, and it makes me feel nausseous anyway, so I usually stay in the classroom because I don't know anyone here and I have nowhere to go. Oh, there are people I talk to, but not real [friends]. Other schools I went to, it was real easy adapting to other people. I mean, I made friends right away. But this school it's like, it's like I'm the one that's really weird in this school. Everybody else is the same. They all like Selena and they all dress like gangsters. People [here] are weird. They're all the same. It's like they're sitting there talking about Tex Mex music. I'm like, "What are you [students] talking about? I don't know what the hell you're talking about. Why are you talking to me about this? It's like I don't know what you're talking about. Leave me alone. You're annoying me. I mean for god's sakes." I have this girl in my class. She talks about her [Selena] every day. She talks about her [Selena's] death everyday. She talks about her life everyday. I mean I'm sick of it. I never want to hear about Selena again, or I'll go to her grave and shoot her 50 times myself. It's like the most frustrating environment I've ever been in my entire life. I mean I thought [my other school was bad] when I first got there. I mean, I was like there for a week, I thought I was going to lose my mind.... Right now the only thing I want is passing grades. Just to get credits. That's basically it. I just need to graduate in about 2 years from now.... They should have left me in the scummy hospital. They said I tried to commit suicide by running into traffic. What do they know? I wasn't trying to kill myself.

Research suggests that school may place an already at-risk student in a more vulnerable position (Herring, 1990; Nelson & Crawford, 1990). Thompson, Eggert, Randell, and Pike (2001) noted that the stress associated with school attendance, academic achievement, social rejection, and humiliation may have serious consequences for many suicidal children. Curan (1987) noted that schools require adolescents to compartmentalize their lives and expend considerable energy in self-monitoring, organizing, and adapting in order to be independent within the school environment. Rohn, Sarles, Kenney, Reynolds, and Hearld (1977) concluded that over 1/3rd of adolescents who are suicidal are also school dropouts. Students with learning and behavior disabilities are likely to experience school stress and have a heightened risk of experiencing suicidal ideation (Guetzloe, 1991). Hazler and Carney (2002) noted that adolescents without adult and peer support have an increased tendency toward suicide. Many of these adolescents feel marginalized and unaccepted. This may be especially true for ethnic minority adolescents with cultural and language differences as well as emotional and behavioral difficulties.

SCHOOL PREVENTION PROGRAMS

Crucial to understanding suicide are the variety of associated factors that have been heard in the voices of the students in this study. Effective school suicide programs have to be systematic and comprehensive (Malley, Kush, & Bogo, 1994). Components include written policy statements, formal procedures to address risky behavior, in-service training of school personnel to identify and manage suicidal students, and screening processes to identify at-risk students (Malley, Kush, & Bogo, 1994).

Schools are viewed as the primary location for implementing prevention programs that identify and intervene with potentially at-risk students (Malley, Kush, & Bogo, 1994). Coder, Nelson, and Aylward (1991) discovered that only 20% of the 484 counselors surveyed reported that policies were in place at the high school level if a student were to demonstrate suicidal behaviors. They indicated that public schools fail to establish successful guidelines for students at risk for suicide. Other findings indicated that only 20% of 1,200 educators had suicide prevention policies in place (see, Speaker & Petersen, 2000). Hamrick, Goldman, Sapp, and Kohler (2004) found that both general and special education teachers had difficulty identifying both overt and covert indicators of adolescent suicide.

These findings indicate the overwhelming need for productive suicide prevention programs. The factors such programs share are: (1) provide at least a preliminary understanding of the risks encountered by target groups; (2) plan for long-term change; (3) provide social support and social skills; and (4) strengthen the support from family, community or school (Metha, Weber, & Webb, 1998, p. 154). Productive programs focus on physical, mental, social, and emotional health rather than just on the suicidal behavior, and must take grade level, developmental level, and culture into account. Further, coordination of school, parents, peers, and community is extremely important (Metha, Weber, & Webb, 1998). Research has demonstrated that suicide prevention programs that are well supported and funded, and offer well-trained counselors are most effective (Metha, Weber, & Webb, 1998). Nineteen states have legislated youth suicide prevention programs. These include "primary, secondary, and tertiary prevention efforts" (Metha, Weber, & Webb, 1998, p. 155). Most states have made an effort to "establish suicide prevention and awareness curricula in the public schools ... or the provision for suicide prevention for school personnel [and others]" (Metha, Weber, & Webb, 1998, p. 155).

WHAT SCHOOL PERSONNEL SHOULD KNOW AND DO

The lack of preventive programs for students at risk may reflect a lack of training on the part of school personnel. While 51% of schools surveyed had a written policy, only 42% provided staff training, and most schools did not have psychological screening to identify at-risk students or mental health counseling for at-risk students, regardless of written policy statements (Malley, Kush, & Bogo, 1994). Only 47% of written policies included faculty training in the identification of youth in crisis (Malley, Kush, & Bogo, 1994).

A copy of a school district's policy for dealing with children in crisis should be given to every teacher (Andergregg & Vergason, 1992), and teachers should be able to implement it if a student exhibits signs of suicide-risk behavior (Andergregg & Vergason, 1992). Teachers must be aware that suicidal ideation is also frequently expressed through conversations, artwork, and writing (Andergregg & Vergason, 1992). Even if threats of suicide and hysteria may turn out to be only attention-getting behaviors, they must be taken seriously (Andergregg & Vergason, 1992). Teachers must provide consistent supervision of an at-risk student until the parents or mental health authorities can provide assistance. Teachers should document and report changes in a student's behavior and/or threats of suicide (Andergregg & Vergason, 1992).

The parameters of teachers' responsibilities in responding to suicide risk were incorporated into law (see, Wicina v. Strecker, 1987). To a certain extent, teachers can be held liable after a student attempts suicide if they had knowledge of a potential attempt and failed to take action. Teacher responsibilities include: (a) application of the prudent person rule, (b) foreseeablity of harm, and (c) controlling the behaviors of others (Andergregg & Vergason, 1992). While the liability of teachers is limited to actions of a reasonably prudent person, special education teachers, especially those working with students with behavioral disorders, are more likely to observe pre-suicidal behaviors and will need to demonstrate more preventative action since this is an at-risk population (Andergregg & Vergason, 1992). Courts have determined that repeated warnings might be necessary to prevent suicide and physical restraint might also be required (Andergregg & Vergason, 1992).

School personnel need to be aware that self-destructive behaviors often look very similar and the primary characteristics that may lead to suicide such as depression, substance abuse, social and interpersonal conflict, family distress, and school failure may cause erratic behavior. More importantly, since all self-destructive behaviors may ultimately have the same end goal--death, school personnel must be on the alert to identify students who are at risk for these behaviors.

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Wicina v. Stretcker, 747 P.2d 167 (Kan. 1987).

Send reprint requests to Catherine Medina, Ph.D., Northern Arizona University, College of Education, P.O. Box 5774, Flagstaff, Arizona, 86011-5774. E-mail: Catherine.Medina@nau.edu

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