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Record: 1
Title: Adolescent suicide families: an ecological approach.
Authors: Henry, C, S. Dept. of Family Relations and Child Development, Oklahoma State Univ., Stillwater 74078
Stephenson, A, L.
Hanson, M, F.
Hargett, W.
Source: Adolescence. Vol. 28 (110) 1993. p292-308, 17p
SWAB Print Version: 29 (4) No. 1526 1993
Abstract: Suicide is an issue of increasing concern for professionals who work with adolescents and their families. Over the past three
decades, the rate of suicide has increased dramatically among 15- to 24-year-olds and is the third leading cause of death in this
age group. Previoustheoretical approaches to understanding adolescent suicide (i.e., Durkheim's sociological theory of suicide,
social learning theory, psychological theory, and family systems theory) are reviewed, and the utilization of human ecological
theory is proposed. Factors associated with adolescent suicideat the organism (individual), microsystem, mesosystem, exosystem,
and macrosystem levels are examined. Finally examples of prevention and intervention at each level are presented. (Journal
abstract.)
Classification: 3315 - Children and Families/Child and Family Welfare
Subjects: Adolescents
Families
Death
Ecological approach
Suicide
Prevention
Intervention
Document Type: Article
Accession Number: 29173
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ecological approach.</A>
Database: Social Work Abstracts

ADOLESCENT SUICIDE AND FAMILIES: AN ECOLOGICAL APPROACH

ABSTRACT
Suicide is an issue of increasing concern for professionals who work with adolescents and their families. Over the past three decades, the rate of suicide has increased
dramatically among 15-to 24-year-olds and is the third leading cause of death in this age group. Previous theoretical approaches to understanding adolescent suicide (i.e.,
Durkheim's sociological theory of suicide, social learning theory, psychological theory, and family systems theory) are reviewed, and the utilization of human ecological theory is
proposed. Factors associated with adolescent suicide at the organism (individual), microsystem mesosystem, exosystem, and macrosystem levels are examined. Finally,
examples of prevention and intervention at each level are presented.

Over the past three decades, professionals who work with adolescents and their families have become increasingly concerned with the issue of suicide. The most dramatic
increase in adolescent suicide has been among 15- to 24-year-olds, for whom suicide is the third leading cause of death in the United States, behind accidents and homicides
(U.S. Bureau of the Census, 1991). Over 5,000 suicides occur in this age group each year, averaging 14 each day. The suicide rate among adolescents 15 to 19 years of age
rose 142% between 1960 and 1981, with the greatest increase among white males. Suicide rates among 10-to 14-year-olds have increased slightly during the same time period,
resulting in about 560 deaths per year (Hawton, 1986). In addition, it is estimated that the number of attempts is five times greater than that for completed suicides, totaling
approximately 65 adolescent suicide attempts each day in the United States (Tishler, McKenry, & Morgan, 1981). The actual numbers of completed and attempted suicides
among youth are probably underestimated because many are reported as accidents due to the social stigma associated with suicide (Molin, 1986).

Researchers, clinicians, and educators have attempted to understand adolescent suicidal behaviors using biological, psychological, sociological, and social psychological models.
Yet, none of these approaches provides a framework for integrating the range of previous work on suicidal adolescents and their families within a single model. To address this
deficiency, this article provides an overview of traditional theoretical approaches to understanding adolescent suicide, introduces the human ecological model, integrates
information about adolescent suicide and families within this model, and recommends methods of prevention and intervention at multiple ecosystemic levels.

TRADITIONAL THEORIES OF ADOLESCENT SUICIDE

Biological Theories
It has been proposed that adolescent suicidal behaviors have biological foundations, such as psychiatric disorders (e.g., schizophrenia or manic depressive illness; Holinger &
Offer, 1981), the biological transmission of suicidal precursors (Cosand, Bourque, & Kraus, 1982; Garfinkel & Golombek, 1983; Hawton, 1986; Shaffer, 1974), biochemical
changes which make adolescents more vulnerable to affective disorders (e.g., depression; Holinger & Offer, 1981; Shaughnessy & Nystul, 1985), and whether they had a difficult
birth or if their mothers were ill during pregnancy (Salk, Lipsitt, Sturner, Reilly, & Levat, 1985). Further, the relationship between physical illness and adolescent suicide attempts
has been examined. Empirical evidence, however, indicates that physical illness is a better predictor of suicidal tendencies in adults than in adolescents (Hawton, 1986).

Psychological Theories

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Psychoanalytic theory. From a psychoanalytic perspective, suicidal adolescents present an external reason for their attempts. Internally, however, suicide is viewed as an attempt
to deal with rejection and deprivation that resulted in the loss of love and support. Thus, a core component of the "suicidal personality" in adolescents is the perception of a loss of
love (Holinger & Offer, 1981).

Using a psychoanalytic model, adolescents are considered to be at particular risk for suicidal behaviors because puberty is a crucial period of development with respect to self-
destructive drives. Deficient ego development during adolescence may lead to suicidal tendencies (Holinger & Offer, 1981). Therefore, the psychoanalytic perspective proposes
that self-destructive tendencies such as suicidal behavior emerge as the product of an unconscious death wish resulting from anger turned inward.

Other psychological views. Another common psychological approach presents suicidal behavior as the result of the inability of youth to develop the qualities necessary to adapt
to, and cope with, stress. Within this approach, researchers and therapists seek to identify common characteristics of adolescent suicide attempters and completers. For example,
a "psychological autopsy" of adolescent suicide victims might be conducted by interviewing family members, other relatives, friends, and significant others to determine these
characteristics (Shafii, Carrigan, Whittinghill, & Derrick, 1985). From this perspective, adolescent suicide is generally considered a result of the inability to adapt to stress, as
manifested in hopelessness and despair.

Sociological Theory
Durkheim's (1951) sociological theory of suicide has been applied to adolescents. According to Durkheim, the rates of four types of suicide are predicted by the degree of
integration into social institutions (e.g., family, church, political system) and the degree of regulation within the society. Adolescent egoistic suicide, for example, is prevalent when
there is a lack of common beliefs, values, traditions, and views among members of a society (i.e., a low level of integration). Adolescents feel distant from the social group and
responsible for managing their burdens alone. In contrast, when adolescents become highly absorbed into social institutions (i.e., a high level of social integration), altruistic
suicide results--youths end their lives under conditions determined by, or beneficial to, society.

Further, Durkheim found that in societies with low social regulation, change often places individuals in new circumstances where the old moral rules no longer apply. Adolescents
become subject to "anomie" when their desires are no longer subject to social restraint due to the society's relative lack of values or goals, and anomie suicide may then occur.
Although lacking empirical support, Durkheim proposed that fatalistic suicide rates will be higher if inflexible social constraints (i.e., strong social regulation) stifle individual goals.

Social Psychological Theories

Social psychological approaches emphasize the identification of situational factors (e.g., family factors, environmental changes, social factors, childhood maltreatment,
relationship problems) that relate to adolescent suicidal behavior. While several social psychological approaches have been used to examine adolescent suicide, social learning
theory and family systems theory are presented as examples of this type of approach.

Social learning theory. Suicidal adolescents are said to imitate the behaviors of other family members and friends. For example, when family members attempt suicide,
adolescents may conclude that suicide is an acceptable means of addressing life's problems or for gaining attention (Hawton, 1986). When parents respond to the suicidal
gestures of youth with increased attention, they are viewed as reinforcing this coping style. Thus, youth learn pathological rather than adaptive coping strategies (Frederick &
Resnick, 1971).

Family systems theory. Rather than viewing suicidal acts as the result of individual problems (e.g., hopelessness or depression), the family systems model presents adolescent
suicide as a symptom of family dysfunction (Frances & Clarkin, 1985; Heillig, 1983; Landau-Stanton & Stanton, 1985; Molin, 1986; Walker & Mehr, 1983). Adolescents who
attempt suicide may unknowingly be helping their families avoid painful issues, such as acceptance of a family member's leaving home, or diverting attention from other family
conflicts (Landau-Stanton & Stanton, 1985). Suicidal adolescents become the focal point of their families, leaving other family problems intact. If suicidal adolescents recover,
other family members may develop symptoms that become the focal point unless interaction patterns within the family are changed. Thus, using a family systems approach,
intervention with suicidal adolescents involves creating change in the overall family system, rather than focusing upon the symptoms of the adolescent.

THE HUMAN ECOLOGICAL APPROACH

In contrast to traditional conceptualizations, human ecological theory provides a multidisciplinary approach to understanding adolescent suicide that incorporates individual,
environmental (e.g., family), and social system factors that may be related to suicidal behaviors. Adolescent suicidal behaviors may be viewed as the result of difficulties that arise
in the "interplay of biological, psychological, social, and cultural forces at work in transforming a child into an adult" (Garbarino, 1985, p. 50).

Human ecological theory provides a comprehensive and integrated approach to understanding adolescent suicide and families within a broad environmental context, rather than
emphasizing specific risk factors. Further, within the family microsystem and total ecosystem, a variety of prevention and intervention possibilities can be identified.

Except for a few isolated works (e.g., DenHouter, 1981), the human ecological model has received minimal attention in the examination of adolescent suicidal behavior. Garbarino
(1985) provided an initial application of the human ecological approach by modifying Bronfenbrenner's (1979) model; suicidal behaviors are viewed as emerging from adolescents'
interactions and interdependencies within hierarchically organized, multiple level ecological contexts.

The first level in the ecological approach is that of the organism, or the individual adolescent (Garbarino, 1985). While the characteristics of suicidal youth are important, they do
not occur in a vacuum. Each adolescent is a member of several microsystems, or immediate settings such as the family, peer group, school, and work (Bronfenbrenner, 1979).
Previous research indicates that factors within microsystems serve as indicators of risk for suicidal behaviors. The lives of adolescents, however, vary in the combinations of
microsystems and the interrelationship of these microsystems. The links between the microsystems are described as mesosystems (Bronfenbrenner, 1979; Garbarino, 1985). For
example, in a rural area, parents are likely to know the families of the peers, teachers, and employers of their adolescents. In contrast, an adolescent living in a suburb of a major
metropolitan area may have friends, teachers, or employers whom their parents have not met.

Not only are there direct influences on the lives of adolescents at the organism, microsystem, and mesosystem levels that may increase their risk for suicidal behaviors, factors in
the broader environment may indirectly influence these behaviors. These exosystems include parents' employers, school boards, and the media. Exosystems occur within the
context of the broad institutional or ideological patterns of a culture or subculture, known as macrosystems. Components of macrosystems include the economic, social,
educational, medical, legal, and political systems, which indirectly set the stage for adolescent suicidal behaviors.

Although the human ecological model has been applied to other issues, such as alcoholism (Gacic, 1986), a systematic analysis has not been made regarding adolescent suicide.
This paper addresses this deficiency by integrating the literature on adolescent suicide into a human ecological model, focusing upon the family as a primary microsystem. In
addition, recommendations are made for additional research, prevention, and intervention relating to adolescent suicidal behavior.

Organism Level Predictors

At this level, the demographic and psychological characteristics of adolescents that indicate increased risk for suicidal behaviors are considered. Risk factors include feelings of
hopelessness (Allen, 1987; Emery,1983); difficulty in adapting to change (Cosand, Bourque, & Kraus, 1982); depression (Allen, 1987; Cole, 1989; Emery, 1983; McCants, 1985;
Stephens, 1985-1986); feelings of loneliness (Allen, 1987); a sense of personal inadequacy, failure, or low self-esteem (Allen, 1987; Dukes & Lorch, 1989; McKenry, Tishler, &
Kelly, 1982); social isolation (Emery, 1983; Holinger & Offer, 1981; Marks & Haller, 1977); substance use or other self-destructive tendencies (McKenry et al., 1982; Neiger &
Hopkins, 1988); cumulative stress (Hawton, 1986; McKenry, Tishler, & Christman, 1980; Tishler, McKenry, & Morgan, 1981); or previous suicide attempts or threats (Garfinkel,

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Froese, & Hood, 1982; Gispert, Wheeler, Marsh, & Davis, 1985).

Gender differences in suicidal behavior among youth are evident, with more males completing suicide (Allen, 1987; Kalafat, 1990; Neiger & Hopkins, 1988; Smith, 1981; U.S.
Bureau of the Census, 1991) and more females attempting suicide (Allen, 1987; Cole, 1989; Cosand et al., 1982; Kalafat, 1990; Neiger & Hopkins, 1988). Although a few studies
focused upon completed adolescent suicides, the majority of studies of individual factors focused on suicide attempters. Additional empirical work is needed to distinguish
between the characteristics of adolescents who attempt suicide and those who succeed at killing themselves.

Microsystem Level Predictors

In addition to the individual risk factors, several factors in the family microsystem appear to be associated with increased risk for adolescent suicide (Dukes & Lorch, 1989;
Hawton, 1986; Strother, 1986; Rotheram-Borus, Trautman, Dopkins, & Shrout, 1990; Tishler et al., 1981). In previous studies, the role of families has been viewed in ways that
range from "passive victims" of disturbed youth to "causing" the suicidal behaviors through inappropriate interaction patterns. Smith (1981), however, suggested that trouble within
families is a predominant issue.

Loss of a family member. Several researchers have noted that one of the most commonly reported precipitating events leading to adolescent suicidal behaviors is the loss of a
family member or close friend through death, divorce, or chronic mental illness (Allen, 1987; Miller, 1975; Rosenkrantz, 1978; Smith, 1981; Stephens, 1985-1986; Stivers, 1987).
Rosenkrantz (1978) proposed that suicidal gestures and threats more often followed a loss that was not permanent, such as parental separation. Parental death, however,
appeared to be more closely linked to completed suicides. Some studies also indicate that the death of a pet can serve as a precipitating event for suicidal behaviors among
adolescents (McKenry et al., 1980; Smith, 1981). Strother (1986) concluded that adolescent suicide attempts are often impulsive reactions to loss.

Feeling ignored by parents. Another factor related to adolescent suicide attempts is feeling ignored or rejected by one or both parents (Allen, 1987; Hawton, 1986; Marks & Haller,
1977; McKenry, Tishler, & Kelly, 1982). In a study of fifty female suicide attempters, the majority reported a lack of nurturance by their parents (Stephens, 19851986). Additional
studies are necessary to indicate the extent to which aspects of adolescent developmental processes (an organism level factor), parent-adolescent relations, divorce, or factors in
the exosystem (e.g., parental work pressures) are associated with adolescents' feeling ignored by their parents.

Economic insecurity. Adolescents in families with a high level of economic insecurity or pressure are at higher risk for suicidal behaviors (McKenry et al., 1980; Smith, 1981;
Stephens, 1985-1986). Cosand et al. (1982) found family economic pressures to be common among adolescent suicide completers. Economic pressures may emerge from family
microsystem issues or from economic conditions in the exosystem (e.g., parental employer) or macrosystem (e.g., a recession).

Parental alcohol use. Parents of suicidal adolescents have been found to use alcohol more than those of nonsuicidal adolescents (Garfinkel et al., 1982; Hawton, 1986; Smith,
1981). Further investigation is necessary to determine whether this factor alone is significantly related to adolescent suicidal behaviors or if other factors (e.g., feeling ignored)
mediate the effect of alcohol use. Further, additional studies are necessary to determine the extent to which other types of parental substance abuse relate to adolescent suicide.

Depression or suicide attempts in other family members. In a study of parents of adolescent suicide attempters, higher levels of depression were found, especially among fathers
(Tishler & McKenry, 1982). Further, lower self-esteem was found in the fathers of adolescent suicide attempters (Tishler & McKenry, 1982). Since the data were gathered soon
after the adolescents attempted suicide, further research is needed to determine the extent to which lower self-esteem resulted from the suicide attempts or if the same results
would be found at other times.

Several researchers have noted that a history of family suicide attempts is common among suicidal adolescents (Allen, 1987; Garfinkel et al., 1982; Landau-Stanton & Stanton,
1985; McKenry et al., 1982; Tiecher & Jacobs, 1966). Hawton (1986) suggested that adolescents may perceive attempts by other family members as an indication that suicidal
behavior is a readily available method of dealing with stress.

High parental expectations. Adolescents who demonstrate suicidal behaviors often report that their parents expect more from them than they feel they can achieve (Allen, 1987;
Dukes & Lorch, 1989; McKenry et al., 1982; Stephens, 1985-1986; Teicher & Jacobs, 1966). For example, gifted adolescents who tend to perform well often exhibit suicidal
tendencies in response to their perception of unrealistically high expectations (McCants, 1985). In general, however, high parental expectations appear to be a more important risk
factor for suicidal behaviors in younger adolescents (Triolo, McKenry, Tishler, & Blyth, 1984).

Residential mobility. There is some evidence that recent changes in residence are associated with greater risk for adolescent suicidal behaviors (McKenry et al., 1980). Allen
(1987) suggested that after repeated residential relocations, adolescents may acquire a sense of rootlessness, fostered by the lack of long-term peer relationships and insecurity
related to the fear or expectation that everything is subject to change. An alternative interpretation is that the decision to move is often based on changes in parental careers (an
exosystem change) or parental remarriage (a microsystem change).

Ineffective family communication and interaction patterns. Williams and Lyon (1976) found that families of suicidal adolescents tended to have rigid interaction patterns that
discouraged adolescents from trying new roles in the family. These families demonstrated higher levels of conflict and lower levels of effective communication in decision making.
In a related study, both suicidal adolescents and their parents reported low levels of satisfaction with family relationships (McKenry et al., 1982). The adolescents not only rated
their relationships with parents as poor, they also saw their parents' marriages as not well adjusted. Tishler et al. (1981) found that 52% of adolescent suicide attempters in their
study reported problems with their parents, and 15% reported problems with siblings. Rotheram-Borus et al. (1990) found that 78% of the suicide attempts in their study followed a
fight with a family member. In a study using adolescent suicide attempters and two control groups, the attempters reported problems with their parents more often than did the
control groups (Spirito, Overholser, & Stark, 1989). Further, Hepworth, Farley, and Griffiths (1988) noted that the families of suicidal adolescents tend to lack cohesiveness. Rigid
families with lower emotional bonding, poor conflict manage meet, and ineffective communication patterns may provide less opportunity for healthy adolescent identity
development and increase the risk of suicidal behaviors.

Suicidal adolescents often have difficulty, in the form of recurring conflicts or jealousy, with siblings (Hawton, 1986). Williams and Lyon (1976) noted that poor relationships with
siblings can contribute to overall ineffective family communication. A related finding is that firstborn females are overrepresented in terms of suicide attempters (Cantor, 1972).

Abuse or neglect. Concern has been expressed about the possible link between earlier child abuse and neglect and later adolescent suicide attempts (Deykin, Alpert, &
McNamarra, 1985). In addition, physical violence during adolescence has been identified as a possible precipitating event for suicide attempts (Hawton, 1986). Using clinical
observations, Anderson (1981) found the incidence of sexual abuse within families to be a predictor of suicidal behaviors in adolescent females. To date, the association between
abuse and suicidal behaviors has relied upon pilot studies and clinical observations, and merits further empirical investigation.

Hawton (1986) noted an association between observing physical violence in the home and adolescent suicide attempts. When youth observe spousal abuse, parental suicide
attempts, and other violence, such behaviors can become part of a cycle of aggression, both internal and external. Adolescents may learn that violence toward oneself, including
suicide attempts, is an acceptable way of coping with problems (Hawton, 1986).

Adolescents beginning their own families. While suicide rates tend to be higher among single adults as compared with married adults, the opposite appears to be true for
adolescents. Married adolescents have higher suicide rates than do single adolescents. In the United States, the suicide rate for married adolescent males is about 1.6 times
greater than for unmarried males For married adolescent females, the rate is approximately 1.7 times greater than for unmarried adolescent females (Hawton, 1986). In order to

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interpret these findings, further research is necessary on the factors leading to the decision of adolescents to marry. Troubled adolescents may use marriage as a means of
entering a new family microsystem and avoiding conflicts within the family of origin.

Higher rates of suicidal behavior occur in adolescent females who are pregnant. New mothers and those who recently had an abortion are also at higher risk (McKenry et al.,
1980).

Other microsystems. Although the focus has been on family microsystems, adolescents are usually part of several other microsystems. Three examples, discussed here, are
peers, school, and delinquencyrelated settings.

Several researchers note that the most common predictor of adolescent suicidal behavior, as related to peers, is problems with a girlfriend or boyfriend (Allen, 1987; Hawton,
1986; Tishler et al., 1981). Findings are ambiguous as to whether these difficulties relate to sexual interaction, feelings of rejection, or other issues.

In regard to school, the most serious suicide attempts tend to occur among youth who have experienced considerable success; less serious suicide attempts have been found to
be more common among those who are failing at school (Garfinkel & Golombek, 1983). In particular, gifted girls represent the largest category of school-related suicide
attempters (Shaughnessy & Nystul, 1985). Although being intellectually gifted alone does not predict higher rates of suicide, this group is subject to particular stresses. Delise
(1986) identified characteristics common to gifted youth: perfectionism or expectations of superior achievement, high expectations of parents and teachers, differential
development between intellectual and social skills, and the ability to see the possibility of solving world problems combined with an inability to bring about change. Immature social
development among the gifted may result in a lack of identification with peers, increasing the risk for adolescent suicide in the peer microsystem (Delise, 1982; Greuling &
DeBlassie, 1980).

In a study of 13- to 15-year-old youths in a correctional facility, conflict with parents was a significant predictor of suicide attempts (Miller, Chiles, & Barnes, 1982). Female
delinquents attempted suicide two and one-half times as often as did males. Additional predictors of suicide attempts among delinquent youth include depression and childhood
hyperactivity (Miller et al., 1982). In another study, depression predicted suicidal behavior in a sample of 48 delinquent females (Gibbs, 1981).

In a national survey of youth in adult jails and juvenile detention centers, suicide rates were higher in both settings than in the general population of youth. The suicide rate among
youth in adult jails was found to be higher than in juvenile detention centers (Flaherty, 1983).

Mesosystem Level Predictors

For each adolescent, the mesosystem is composed of the total set of microsystems. However, since there are a large number of variations in adolescent mesosystems, only one
example of predictors of adolescent suicide within the mesosystem is presented here.

The suicide rate among Native American youth is estimated to be ten times higher than that of white youth (Strother, 1986). Although there is considerable variation among tribal
cultures, hopelessness (an organism level factor) and overall economic and social conditions on reservations (exosystem and macrosystem factors) are commonly noted reasons
for suicidal behaviors among Native American youth. Another possible explanation can be found by examining the mesosystem of these youth. For Native American adolescents,
stress can result from the transitions between life on reservations, in boarding schools, and on the outside, and from the divergent expectations in these different environments
(Thurman, Martin, & Martin, 1985). Thus, the high suicide rate among Native American youth needs to be further examined to determine how the mesosystem, including different
living arrangements (e.g., home vs. boarding school), may provide insight into prevention.

Exosystem Level Predictors

As discussed in relation to the family microsystem, increased residential mobility increases the risk of adolescent suicidal behaviors (McKenry et al., 1980). However, the decision
to move is often made at the exosystem level, based on parental careers. Other exosystem issues that indirectly influence adolescents are those made by local school boards,
local or state politicians, and the mass media.

One of the clearest illustrations of the indirect influence of exosystems on youth in the United States involves the media. For example, press coverage of completed adolescent
suicides has been found to correlate with an increase in adolescent suicides and attempts (Bollen & Phillips, 1982; Phillips & Carstensen, 1986). The increase was more
significant when the reports appeared over several days, in different papers, and on different television stations. Further, the increase in suicide was greater in locations where the
suicides were the most publicized (Phillips & Carstensen, 1986). Additional studies are necessary to more fully understand the role of the media in adolescent suicide risk,
prevention, and intervention.

Researchers have also examined the relationship between televised movies about suicide and adolescent suicide. Gould and Shaffer (1986) reported an increase in the
adolescent suicide rate in New York City after three movies about suicide were televised. However, when the study was replicated in California and Pennsylvania, no significant
difference was found between adolescent suicide rates before and after the broadcasts (Phillips & Paight, 1987). Preliminary evidence indicates that increased adolescent suicide
rates are correlated with broadcasts of true incidents, but not necessarily with fictionalized broadcasts. These studies were limited to suicide rates and did not consider the
relationship between suicide attempts and media presentations. Additional empirical work is necessary to assess the role of television and other forms of media in relation to
adolescent suicide attempts.

Macrosystem Level Predictors

Early examination of macrosystem level factors related to suicide was provided by Durkheim's study of social integration and regulation. Although he addressed overall suicide
rates rather than adolescent suicide, the results supported the view that societal conditions are related to suicidal behavior. An example of how broad societal factors can
indirectly be associated with adolescent suicide is described by Hawton (1986). During the 1960s and 1970s, adolescent suicide rates in Japan decreased at the same time
increases were noted in the United States and Canada. Hawton posited that a possible explanation for the decrease in completed suicides in Japan during this time was the
improvement in Japanese medical services, which may have led to the resuscitation of a greater portion of suicide attempters.

Another example of macrosystem factors in adolescent suicide is Holinger and Offer's (1981) finding that increases in adolescent suicide may be rooted in changes in the size of
the adolescent population. When dramatic increases in adolescent suicide were found in the United States during the 1960s and 1970s, in some cases no adjustment was made
for the increasing adolescent population. Thus, Holinger and Offer (1981) cautioned that changes in adolescent suicide within specific geographic regions be considered in light of
population changes.

A third example is the conflicting evidence concerning the time of year that is most common for adolescent suicidal behaviors. Garfinkel et al. (1982) found the spring to be most
common, while Tishler et al. (1981) reported autumn and winter to be more common. Further research is needed to assess whether the season is a significant factor, in addition
to the role of geographical and cultural factors during each time period.

PREVENTION AND INTERVENTION WITHIN ECOLOGICAL SYSTEMS

The human ecological approach to examining adolescent suicide holds potential for intervention and prevention at each level. Current approaches that relate to suicidal
adolescents and their families follow.

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Organism Level Interventions

Behavioral cues can help family members and professionals recognize the potential for adolescent suicide. Thus, interventions can be started before an actual attempt occurs.
Many of the signs are similar to those of depression. The American Academy of Child Psychiatry has suggested that when one or more of the following occur, professional help is
recommended: changes in eating and sleeping habits; withdrawal from friends, family, and regular activities; violent or rebellious behavior; running away; drug or alcohol abuse;
unusual neglect of personal appearance; radical change in personality; persistent boredom, difficulty in concentrating, or a decline in the quality of schoolwork; frequent
complaints about physical symptoms related to emotions, such as stomachaches, headaches, or fatigue; loss of interest in previously pleasurable activities; and an inability to
tolerate praise or rewards (Strother, 1986).

Family members, teachers, and others who comprise the microsystems of adolescents can make referrals for therapy when youth indicate that they have suicidal intentions, either
through general statements or specific plans about how to kill themselves, by expressing the feeling that others would be better off without them, or by giving away prized
possessions. Intervention after a suicide attempt can be designed by counselors and therapists to focus upon improving the coping and personal resources of adolescents
(Garbarino, 1985). Family therapy can help suicidal adolescents and their parents and siblings develop improved interactional patterns for dealing with stress (Hepworth et al.,
1988; Landau-Stanton & Stanton, 1985). Youth who are socially isolated may need help in integrating into peer and other interpersonal microsystems (Rook, 1984).

Microsystem Level Interventions

Prevention and intervention measures can be taken through several microsystems. Many professionals recommend treatment for family systems in cases of attempted or
completed suicide (Hepworth et al., 1988; Landau-Stanton & Stanton, 1985; Richman, 1979; Walker & Mehr, 1983). When a family loses an adolescent to suicide, therapy can
help the members work through their grief and reorganize family interaction patterns (Bolton, 1984).

In addition to targeting family microsystems for intervention, schools are commonly used for establishing prevention programs (McBrien, 1983; Shulman & Margalit, 1985). Some
programs are designed to teach adolescents about suicide in a forthright manner, encouraging them to explore their feelings on the subject (Dryden & Jones, 1986; Hals, 1985).
There is some controversy regarding the extent to which teaching about suicide may increase the risk of suicidal behaviors, but empirical evidence is lacking. Other programs use
indirect prevention approaches, such as increasing communication skills, assertiveness, and coping techniques (Strother, 1986). Many school systems have programs designed
to help other students and the community deal with the crisis of a completed suicide in order to reduce the possibility of subsequent suicides.

Medical personnel are frequently the first microsystem to work with adolescents whose suicide attempt requires emergency-room attention. These professionals often make
determinations as to whether the adolescent should remain hospitalized for further psychological evaluation or can return directly to the family. Hawton (1986) proposed that after
the necessary medical care is provided, the following issues should be addressed: the events that preceded the attempt, the extent of suicidal intent and reasons for the act,
current stresses, current or previous psychiatric disorders or suicidal tendencies, family and personal history, coping resources and supports, the risk of further attempts, and
attitudes of the individual and family members toward intervention. Using a human ecological approach, an additional assessment issue would be to identify the suicidal
adolescent's microsystems and to investigate the relationships among them (i.e., the mesosystem).

Mesosystem Level Interventions

When an adolescent enters a medical setting for treatment after a suicide attempt, reentry into other parts of the mesosystem can be challenging. Members of other microsystems
may feel uncomfortable and unsure as to how they should respond to the suicidal adolescent. In addition, families and medical microsystems may have to relate to each other
more closely. Further, Praeger and Bernhardt (1985) suggest that after a completed suicide, the entire community is in need of intervention. Peer and religious groups,
schoolmates, and others who serve as microsystems for youth (i.e., the total mesosystem) may need support and education at the mesosystem level.

Exosystem Level Interventions

While direct intervention most commonly occurs at the organism, microsystem, and mesosystem levels, prevention and indirect intervention opportunities are available at the
exosystem and macrosystem levels. Funding for adolescent suicide prevention or intervention programs generally emanates from the exosystem (Garbarino, 1985). For example,
a state department of education or local school board may mandate the development of educational programs on suicide prevention (Strother, 1986). Further, policies in the
workplace which permit personal leave can allow parents to provide timely support for suicidal youth.

Although numerous articles are published each year on the subject of adolescent suicide, many studies are descriptive, use limited samples, and fail to account for the processes
which lead to suicidal behavior and the long-term repercussions. In addition, research variables need to be more specifically defined. For example, instead of merely determining
that family conflict resolution is often poor in families with suicidal adolescents, researchers need to investigate how these families differ from others on specific dimensions of the
variable. Understanding adolescent suicide requires more sophisticated research that allows for investigation of multiple contributors to suicidal behavior at all levels of the
ecological system (Bronfenbrenner, 1979).

Macrosystem Level Interventions

The primary macrosystem level interventions involve public policies that indirectly relate to the potential for suicidal behaviors among adolescents. For example, policies which
provide support for adolescent parents or gifted youth may reduce the suicide rate, since both of these groups have been identified as being at risk. Ladame and Jeanneret (1982)
observed that prevention approaches emerging from public policy need to emphasize family strengths and social support systems. Further research is needed to determine
specific areas of public policy that have implications for suicide risk in adolescents.

SUMMARY
The human ecological approach to suicidal adolescents and their families integrates previous research and theory into the model. It focuses on the different ecosystemic levels
(i.e., organism, microsystem, mesosystem, exosystem, and macrosystem), and identifies predictors of suicide, as well as intervention and prevention, at each level. In conclusion,
the human ecological model seems to hold considerable potential for conducting research and public policy analysis relating to suicidal adolescents and their families.

A version of this paper was presented at the annual meeting of the National Council on Family Relations, Atlanta, Georgia, 1987.

Andy L. Stephenson, Oklahoma State University.

Michelle Fryer Hanson, South Dakota State University.

William Hargett, Oklahoma State University.

Reprint requests to Carolyn S. Henry, Ph.D., Assistant Professor, Department of Family Relations and Child Development, Oklahoma State University, Stillwater, Oklahoma
74078.

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Carolyn S. Henry, Andy L. Stephenson, Michelle Fryer Hanson and William Hargett

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