This article delves into the unpleasant subject of youth suicide. Issues related to childhood suicide are introduced, including elements of Piaget's developmental theory, myths surrounding childhood suicide, childhood depression and other pre-emptive characteristics of suicide, as well as a potential treatment option (i.e., play therapy). After segueing into the subject of adolescent suicide, Piaget's theory is once again broached by highlighting a concept known as adolescent egocentrism, and its corresponding manifestations (e.g., imaginary audience, the personal fable). Predisposing factors that contribute toward teen suicide and a brief commentary on treatment are included. Finally, gender-related matters are covered, including statistical information and a gender-identity theory, which correlates "event centered" stage of development with suicide.
Keywords Adolescent Egocentrism; Event-Centered Stage of Development; Imaginary Audience; Personal Fable; Piaget's Developmental Stages; Play Therapy; Childhood Suicide
Suicide is a disquieting reality that afflicts many young people—making it the third leading cause of death (according to the National Institute for Mental Health) for people between the ages of fifteen and twenty-four in 2007. The National Institute for Mental Health indicates that in 2007, per 100,000 people, suicide deaths account for .9 children between the ages of 10 and 14, 6.9 teenagers between the ages of 15 and 19, and 12.7 young adults between the ages of 20 and 24. Bereaved family members who survive these permanent, self-inflicted tragedies are left to scrutinize over the emotionally agonizing and mystifying details that contributed toward their child's untimely demise. Therefore, research and clinical professionals are often bewildered by child suicide cases. Perhaps one of the reasons why childhood suicide is underestimated relates to the romanticized notion people tend to extend toward childhood itself. Most people view childhood as a carefree, buoyant existence brimming with promise, possibility, endless play dates, and accompanied by the creation of naïve, imaginative fantasies with very few pragmatic responsibilities to shoulder.
Piaget's Stages of Development
Additionally, many people deem childhood suicide as cognitively unfeasible, given that the brain is still in the process of developing and cannot comprehend concepts that are categorically irrevocable, let alone contrive such destructive schemes. For example, according to renowned child psychologist Jean Piaget, children in the preoperational stage of development (i.e., ages 2-7) are still unable to grasp certain intellectual principles such as reversibility and decentration (Burger, 1991; Gainotti, 1997; Siegler & Ellis, 1996; Sigelman & Rider, 2006; Singer & Revenson, 1996; Favre & Bizzini, 1995), which mentally conceptualizes the multi-dimensional aspects of problems. By the time children reach the concrete operations stage, which roughly lasts between the ages of 7 and 12, they have made significant strides in their thought processes and can master sequential relationships and classify objects in accordance with their various physical properties (i.e., types of cars; types of dogs) (Mareschal & Shultz, 1999).
However, it is not until children reach adolescence, or the formal operations stage, when they are able to fully enter into the complex realm of abstract thinking. At this age, they can derive conclusions to hypothetical ideas, whereas beforehand they were limited to that which they could tangibly grasp through their five senses. These intellectual augmentations allow the adolescent to "think outside" of the conventional box that had been placed before them throughout their formative years, namely the rules and values that had been imposed upon them by parents, teachers, and society as a whole. It makes "neurological sense," therefore, that the adolescent era is inexorably linked with suicide, since teenagers are more apt to be rebellious and can examine their dilemmas from a variety of angles, thus believing that they had exhausted all options before settling on suicide as a final determination.
Myths of Youth Suicide
According to Greene, there are many myths that accompany childhood suicide, and that these myths ultimately serve as barriers toward conquering such a devastating phenomenon (1994). Many people mistakenly presume that children under the age of six do not commit suicide. They also think that children in their latent period of growth (i.e., 6-12 years of age) are not capable of such obliteration. In reality, Greene eludes to the existence of several documented cases of young children within these age ranges who have countered against the will to live. Although evidence on this is unclear, Dervic, Friedrich, and Oquendo indicate that children cannot quite grasp the permanence of suicide until age 10 (2006). Or, as Fritz indicates, children may be drawn to the prospect of their own mortality, but do not possess the intellectual skill set to interpret and verbalize their destructive motivations (2004). Instead, they habitually choreograph death-defying activities to increase their fatal odds. As Greene points out, when young children make resolute statements such as "I'm going to jump off the house!," they are often perceived as eliciting attention-seeking behavior; but when such misdeeds are actually implemented, they are often regarded as accidental.
Another myth involves the lack of weapons a child has within reach that may facilitate his suicidal pact. To some degree, this assumption has been squashed with the circulation of several media reports regarding the deadly recourse to which many youngsters resort (Children with Guns, 2000). Additionally, children often carry out their deadly, self-imposed intentions through accessible means such as consuming toxic concoctions or bolting into oncoming traffic. Additional myths that circulate around childhood suicide include the belief that children cannot fully understand the finality of death, and that depression, which is a likely antecedent to suicide, does not occur until adolescence (Brådvik, Mattisson, & Bogren, et al, 2008; Herskowitz, 1990). To rebut the first belief while operating in concurrence with Piaget's aforementioned premise, children do, in fact, cultivate an ability to distinguish between that which is reversible and irreversible by age 7. And with regard to depression, it is true that Freud elaborated on the roots of adolescent depression, saying that it stemmed from a "diseased superego." Freud also posed that depression was a result of the grievances related to parental attachments that had not been properly resolved (Polmear, 2004). Thus, Freud's inference suggests that the onset of depression coincides with puberty.
However, a substantial amount of current research proves that throughout the last 50 years, childhood depression and correlating suicide rates have significantly increased along with our understanding of the depressed person's symptomology (Murphy, 2004). For example, because young children tend to discern life's pertinent lessons through the process of play, an absence of such recreational indulgence (i.e., anhedonia) carries tremendous ramifications and is a primary indicator of depression. Indeed, the literature surrounding childhood depression is quite expansive and covers the following categories:
- Utilization of the Berkley Puppet Interview as a diagnostic tool for childhood depression and anxiety (Luby, Belden, & Sullivan, et al, 2007);
- The adverse reaction that some children yield when alleviating depression through psychotropic medication (Bylund & Reed, 2007);
- Family factors that influence childhood depression (Wang & Crane, 2001);
- The concomitance between childhood depression and other ailments such as cancer (Koocher, O'Malley, Gogan, & Foster, 1980) and ADHD (Redy & Devi, 2007).
In addition to depression, specific motivations surrounding childhood suicide puzzle experts and the layperson alike. Many decades ago, Gunther reported on possible incentives for childhood suicide by accounts made on behalf of children who had previously plotted their own demise (1967; Cytryn & McKnew, 1998; Pelkonen & Marttunen, 2003; Stefanowski-Harding, 1990). A history of prior attempts and sudden personality changes (e.g., shy to talkative; submissive to aggressive) are strong indications that a suicide attempt will subsequently repeat itself, along with feelings of invisibility, social isolation, hopelessness, and academic failure. These facts tend to couple with a specific trigger, usually revolving around the child's perception that he was recipient to undue punishment over a particular event. Family factors that contribute toward suicide consist of parental substance abuse, divorce or separation, abuse, rejection, parental psychopathology (e.g., depression, parental suicide or suicide attempts), as well as good parental intentions that have gone awry, including parents that are either overprotective or those who demand perfection. A suicidal child tends to be hypersensitive, depressed, anxious, and angry. Such angst may manifest through health maladies, oppositional behavior, sleep disturbances, or an overriding aversion toward school. Additionally, young children often conjure up enigmatic portrayals to help comprehend the inexplicable nature of death, particularly if they had recently lost a love one (Shaw & Schelkun, 1965). Oftentimes, death is explained to children in ethereal terms such as "Mommy is in heaven now," or "Grandpa is smiling at you from the clouds," and children select suicide as a means to reunite with their beloved in such a mysterious fantasyland.
Treating the Suicidal Child
Children who have demonstrated some form of suicidal ideation, such as those with a history of previous attempts, would highly benefit from therapy. Since children are ill equipped to both conceptualize and articulate their inner demons, non-verbal therapeutic alternatives such as play therapy (Landreth, 2002; Schaefer & O'Connor, 1983) should be considered. Play therapies have tremendously assisted children who have encountered a variety of psychosocial distress, including survivors of abuse, those in the throes of grief, and children who are terminally ill. The ways in which therapists elicit pertinent information from children via play therapy includes art (e.g., drawings, clay), as well as puppets, sand and water trays, and through storytelling techniques. The premise behind this therapeutic modality is that although children cannot directly understand or articulate their feelings (e.g., "I'm lonely"), such sentiments will manifest throughout the process of play. For example, the lonely child might portray a solitary puppet who is consistently estranged from the other puppets. The suicidal child might draw graphic depictions of a person getting hit by cars, or being held at gunpoint. From that point, the therapist encourages the child and his family to infuse change into the play characters that he has created, which eventually seek to transcend into the child's life. The following passage describes the resolution of a young girl's school phobia through this process:
Ann and her parents negotiate new solutions via the puppet play. The gorilla agrees to be more patient with the puppy and the cat. When the puppy runs away, the gorilla does not yell at the cat, but they express their worries about the puppy and together go look for the puppy. When they find her, the puppy is excited and hugs the cat and the gorilla. They go home together, the gorilla carrying the puppy on his back. When the therapist processes the play with the family, the dad reports that he used to carry Ann on his back when she was younger and got tired during long walks. The family transfers the "new solution" from the puppet play to their "real" life by changing their morning routine. Dad gets up a little...
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