SUICIDE RISK AMONG ADOLESCENTS: PRIMARY PREVENTION STRATEGIES FOR THE SCHOOL CONTEXT

ABSTRACT

This study aimed to discuss primary prevention strategies for the risk of suicide in adolescents in the school context, in addition to investigating associated factors, warning signs and possible intervention proposals, through a narrative review of the literature. The materials researched as reference for this study were collected from electronic databases (SciELO, PubMed and PePSIC), books and manuals. Identifying and understanding risk factors and warning signs for the risk of suicide in adolescents is necessary in order to intervene effectively. Among the preventive strategies found are the teachers’ training, guidance to families and students’ training in social skills. For these strategies to be effective, the importance of the psychologist in the school team is highlighted, in addition to the need for greater investments so that intervention programs aimed at preventing suicide in adolescents must be created.

Keywords: suicidal behavior; prevention; school psychology

RESUMO

O presente estudo objetivou abordar estratégias de prevenção primária para o risco de suicídio em adolescentes no contexto escolar, além de investigar fatores associados, sinais de alerta e possíveis propostas de intervenção, através de uma revisão narrativa da literatura. Os materiais que serviram de referência para este estudo foram coletados a partir de bases de dados eletrônicas (SciELO, PubMed e PePSIC), livros e manuais. Identificar e compreender os fatores de risco e os sinais de alerta para o risco de suicídio em adolescentes é necessário para que se possa intervir de modo eficaz. Dentre as estratégias preventivas encontradas, estão a capacitação de professores, orientação às famílias e treinamento de habilidades sociais com os estudantes. Para que essas estratégias sejam efetivas, destaca-se a importância do psicólogo na composição da equipe escolar, além da necessidade de maiores investimentos para que programas de intervenção voltados à prevenção do suicídio em adolescentes sejam criados.

Palavras-chave: suicídio; prevenção; psicologia escolar

RESUMEN

En el presente estudio se tuvo por objetivo abordar estrategias de prevención primaria para el riesgo de suicidio en adolescentes en el contexto escolar, además de investigar factores asociados, señales de alerta y posibles propuestas de intervención, por intermedio de una revisión narrativa da literatura. Los materiales que sirvan de referencia para este estudio fueron recopilados a partir de bases de datos electrónicas (SciELO, PubMed y PePSIC), libros y manuales. Identificar y comprender los factores de riesgo y las señales de alerta para el riesgo de suicidio en adolescentes es necesario para que se pueda intervenir de modo eficaz. Entre las estrategias preventivas encontradas, están la capacitación de profesores, orientación a las familias y entrenamiento de habilidades sociales con los estudiantes. Para que estas estrategias sean efectivas, se destaca la importancia del psicólogo en la composición del equipo escolar, además de la necesidad de más inversiones para que programas de intervenciones volcados a la prevención del suicidio em adolescentes sean creados.

Palabras clave: comportamiento suicida; prevención; psicología escolar

INTRODUCTION

The alarming scenario provoked by elevated suicide rates has turned the theme into a public health concern (OMS, 2000b). Every year, over 800 thousand people commit suicide, which represents a rate of 11.4 for every 100.000 deaths all over the world (WHO, 2014). Between 2011 and 2016, 1.173.418 cases of interpersonal, or self-inflicted violence were registered in the Sistema de Informação de Agravos de Notificação (SINAN), or Aggravation Notification Information System. 15% of the total sum were related to the practice of self-inflicted aggression (Ministry of Health, 2017). Besides that, the number of suicides among adolescents has grown so much among young people aged between 15 and 29 that it has become the second major cause of death around the world, which implies the need for preventive actions targeting this public (WHO, 2014).

In Brazil, the rate for suicide mortality is 5.8 for every 100.000 inhabitants (Botega, 2015) and, from 2002 to 2012, there was an increase of 33.6% in cases, a greater number than the growth of the country’s population for this period (Moreira & Bastos, 2015). In comparison to other countries, this suicide mortality coefficient is relatively low, while Brazil is a populous country. However, it is known that our country ranks number 8 among the nations that register high rates for suicide deaths in the world (Botega, 2015).

Considering the significant increase in the suicide rates among senior citizens (Ministry of Health, 2017) and the reduction in the Brazilian populational growth rates in the last few years (IBGE, 2018; OPAS, 2008), it is possible to observe the population’s aging process, which implies more investment in public policies targeting the elderly. It is also known that the incidence of self-extermination have decreased among the elderly, and increased among the young (Calixto Filho & Zerbini, 2016). Therefore, planning actions for the sake of the adolescent population is extremely important, considering that the current focus of government interventions is on the ascending population - the elderly.

Furthermore, it is important to highlight the locations of the occurrences if suicide attempts and self-inflicted injuries. According to the most recent epidemiological newsletter published by the Sanitary Surveillance Bureau (Ministry of Health, 2017), the school emerges as the scenario for such actions, while there is greater incidence among the female contingent. Thus, it is believed that school plays a fundamental role in the identification and prevention of these factors, since it is the “environment where the actors reproduce relationships and behaviors that might endanger the health of young people” (Baggio, Palazzo, & Aerts, 2009, p. 143). Thus, what has become evident is the need for primary, secondary, and tertiary prevention strategies against the risk of suicide in the school context, since it is an essential theme to be approached when working with young people, as well as their families and with the education professionals that work directly with this public.

The relevance of this study consists of the urgent need to discuss this theme, which is still considered taboo (Calixto Filho & Zerbini, 2016), by means of a preventive perspective, while turning school into a powerful ally. Due to underreporting and underrated records, it is estimated that the real numbers for suicide deaths might be even greater the ones officially registered in the SINAN. In this sense, the actions by the public authorities are restricted because they depend on these underreported notifications in order to promote effective interventions. Besides that, it is known that the costs related to suicide postvention are greater when compared to costs of prevention (DGS, 2017).

In this sense, the present article aims at presenting primary prevention strategies against the risk of suicide among adolescents at school, and approaching aspects connected to the theme, such as associated factors, warning signs, and, finally, possible intervention proposals for the school environment by means of a narrative review of literature.

TERMINOLOGY: FROM SUICIDAL THOUGHTS TO SUICIDAL BEHAVIORS

In order to better understand the theme, it is necessary to provide an explanation on the different nomenclatures employed. Suicidal behavior is understood as actions in which individuals injure themselves, no matter the level of lethality and the real motivation behind such actions. Suicide is conceived as a continuum. It gets started with suicidal ideations, hints, gestures, attempts, and its eventual consummation. Consequently, these are the concepts underlying the investigations on suicidal intentionality and the level of risk individuals are exposed to (Botega, 2015).

Suicidal ideation refers to thoughts of self-destruction and the wish to end one’s own life. Having such thoughts sporadically during adolescence is considered normal because it is a phase of huge changes. On the other hand, depending on the intensity and frequency of these thoughts, they might become warning signs for the risk of suicide when adolescents convince themselves that suicide is the only solution to their problems (Moreira & Bastos, 2015). According to Calixto Filho and Zerbini (2016), suicidal ideation is prevalent throughout life and it happens to approximately 17% of the Brazilian population. Such ideation is followed by the formulation of a plan, which gets actually carried out by 4.8% of the population.

The planning usually involves a specific method to be employed in order to carry out the suicide (Claumann, Pinto, Silva, & Pelegrini, 2017). The existence of a plan characterizes the individual with an elevated level of risk, because in addition to the intention of death, there is probably a pre-established date and place, as well as the means to do it (firearm, hanging, medication or poison, for example), and previous action has already been taken regarding the death plan (Botega, 2015). Thus, after the plan, comes the attempt or the parasuicide.

The word parasuicide, according to Piñero, Blasco, Baca-Garcia and Diaz (2002, quoted by Araújo, Vieira, & Coutinho, 2010), refers to behaviors in which the intention is not to take away one’s own life, but to try and change the context where a deeply discontented individual is inserted. A suicide attempt is characterized by intentionality, which is the end of life, or by the degree of lethality of the method. The successful execution of these acts characterizes suicide. According to its etymology, the word “suicide” comes from Latin. It means the action of killing (caedes) oneself (sui) (Correa & Barreto, 2006, quoted by Moreira & Bastos, 2015). The will to die is present both in the attempt and in the execution of the plan. Suicide is a voluntary act that results in one’s own death (Vieira, 2008, citado por Araújo et al., 2010).

SUICIDAL IDEATION IN ADOLESCENTS: ASSOCCIATED FACTORS

By means of the identification of factors associated to suicide, it is possible to organize preventive actions in the school environment. Such factors include the small number of friends and the aggressive relationship the individual establishes with these friends (Souza et al., 2010). In turn, the school serves a significant purpose in the lives of children and adolescents because it is known to promote their health and well-being (Haavet, Dalen, & Straand, 2005), especially because it is one of the first environments where children learn how to socialize. When there is no feeling of affiliation, or when individuals are excluded from their groups, depression symptoms are more likely to develop (Barros, Coutinho, Araújo, & Castanha, 2006; Forlim, Stelko-Pereira, & Williams, 2014). Also, being a victim of bullying also predicts a greater tendency for the development of psychological disorders (Kumpulainen et al., 1998). Concerning the aggressiveness underlying relations, it is known that the impulsive-aggressive behavior variable is present in many cases of consummated suicide (Turecki, 1999) and such variable might be associated to the very developmental phase of adolescence (Crestani, 2016).

Another factor that is closely connected to the suicidal ideation in adolescents is the existence of psychiatric disorders (Souza et al., 2010; Moreira & Bastos, 2015; Botega, Barros, De Oliveira, Dalgalarrondo, & Marín-Léon, 2004). The clinical condition of individuals with any type of mental disorder might affect their social, professional, and academic life. As a consequence, they might display greater difficulty to adapt to society, symptoms such as anxiety, anger, frustration, and a general deterioration in quality of life. These factors, in combination with unreliable diagnoses and inadequate treatments, can aggravate the risk of death for individuals who already harbor suicidal ideations. Among the mental disorders that are most commonly associated with suicide are Major Depressive Disorder, Bipolar Disorder, Drug and Alcohol Addiction, Schizophrenia, and other Personality Disorders that include characteristics such as impulsiveness, aggressiveness, or lability (Botega, 2015). Besides that, symptoms such as sadness, loneliness, and low self-esteem are related to suicidal planning, which does not depend on the existence of a disorder (Baggio et al., 2009; Souza et al., 2010).

Behavioral problems, drug abuse, records of abuse and violence, dysfunctional family relationships, as well as the scarcity of skills to solve problems, which are also factors associated to suicide among adolescents (Claumann et al., 2018; Baggio et al., 2009; Moreira & Bastos, 2015; Souza et al., 2010; Botega et al., 2004). In addition, having known someone who had committed suicide is another important factor, which can be explained by the Werther Effect, which suggests that the suicidal behavior can be learned by modeling (Almeida, 2000). Another associated factor that should be highlighted is the difficulty to deal with personal body image. It important to keep in mind that adolescence is considered a troubled period due to the numerous changes that take place during puberty. Thus, it is important to identify this factor as a peculiar characteristic of this period, as long as it does not imply risks to individuals, because this condition might influence the susceptibility to mental disorders - such as Major Depressive Disorder, or Eating Disorders (Claumann et al., 2017; Baggio et al., 2009).

WARNING SIGNS FOR THE RISK OF SUICIDE AMONG ADOLESCENTS

The ability to identify and understand the warning signs for the risk of suicide among adolescents is necessary for efficient interventions. Besides that, it is important to know the difference between reactions considered normal in adolescence and true warning signs. The difficulty lies on spotting the difference. Many of these signs are not specific and might come up by means of mental disorders that, in turn, normally get started during the period of adolescence (Botega, 2015).

Hawton, Saunders and O’Connor (2012, p. 2375) propose a list of fourteen major signs that an adolescent might be at risk of committing suicide. Such signs include “significant changes in personality or in habits” as well as the manifestation of “depressive, restless, or anxious behavior”. Whenever remarkable changes are noticed in an individual, we need to pay attention. Some behaviors, which might otherwise be considered atypical, might seem normal for an adolescent because adolescence is known to be a phase of fathomless contradiction, ambivalence, and conflict (Moreira & Bastos, 2015).

Regarding the school context, a third factor that emerges as a warning sign is poor academic performance and lack of interest in activities that an individual used to enjoy. Signs such as behavior problems at school, general decline in grades, and excess of absences are indicators that something wrong might be going on. Thus, we must pay careful attention to any abrupt change in behavior that affects a student’s academic performance (OMS, 2000a).

Another important factor mentioned by the authors is the “distance from family and friends”. When such disconnection from family members happens, we can understand this movement as an expected phase of an adolescent’s psychological development, when there is more investment in other object other than parents (Macedo, Azevedo, & Castan, 2012). On the other hand, when there is a distance not only from family, but from friends as well, there is an indicator of social isolation, which might be connected to some psychological disorder, and deserves closer attention as a consequence. In addition, there is loss of interest for activities that were formerly a source of pleasure, loss of hope, negative comments regarding the future, and changes in sleep patterns that might also be signs of mental disorders, and might indicate an increase in the risk of suicide (Hawton, Saunders & O’Connor, 2012).

Besides that, factors such as “disregard for appearance”, significant changes in weight, and “persistent self-deprecating remarks” (Botega, 2015, p. 157) might configure signs do risk. Considering that it is a period in which adolescents strive to be accepted by their peers, lack of interest in appearance goes against the flow of behaviors deemed as typical of this phase. Furthermore, weight loss or gain might also denote preoccupations concerning body image, while also indicating the possibility of a disorder at the same time.

The wish to die, plain or concealed, as well as comments that denote such interest - talk about deceased people, giving away valuable belongings, and other signs - can be signs of the risk of suicide. Thus, it is important to expose some myths concerning the theme that are sometimes present in the general population.

The first myth, according to the World Health Organization is: “People who talk about committing suicide do not have the intention to do it” (WHO, 2014, p. 15). It is important to pay attention to comments such as “I wish to disappear” or “I want to die”, no matter what context in which they were uttered. In this sense, it is necessary to keep in mind that, when an individual exposes such delicate personal matter, it is a sign that this individual might be in need of ventilating his/her suffering with someone in order to get help. Another bug mistake regarding the theme is the discourse according to which most of the cases of suicide take place without prior notice and threats are only a cry for attention. As we have mentioned before, there are diverse warning signs, which are not often not so clear, that a person is considering the possibility of taking away their own life. Therefore, it is vital that we do not underappreciate such signs and always inquire into their veracity, since they might be evidence that someone is going through serious problems (WHO, 2014).

Another very common myth on the theme is: “A suicidal person is determined to die” (WHO, 2014, p. 43). One of the most important characteristics of a person who has suicidal ideations is ambivalence, which is characterized by the presence of contradictory feelings. A person might have a plan, might have made a decision to commit suicide and, at the same time, act in ways as to as people for help (Leenaars, 2010). As a result, in view of situations like this, it is necessary to provide individuals with emotional support.

Finally, it is important to denounce one of the greatest myths on the theme: “Talking about suicide is a bad idea because it might be interpreted as encouragement” (WHO, 2014, p. 65). It is known that there is a stigma that prevents of hinders discussions on the theme in certain contexts. However, asking someone who is presenting signs of risk on their intentions is not a synonym for encouragement. It is rather a sign of sensibility or empathy. A person’s attitude that shows they care about another might become a much needed cue to talk about what is going on. Thus, it is important that the professionals who get to hear of suicidal ideations be prepared to know how to handle the situation. To so that, we will approach prevention strategies for the management of suicide risk in the school environment.

PREVENTION STRATEGIES AT SCHOOL

Suicide prevention might be classified as universal, selective, or specific. The universal or primary prevention is the one that aims at reducing the occurrence of new cases by means of educational actions. Selective or secondary preventions targets groups in risk situation. Specific or tertiary prevention focuses on individuals that present suicidal ideations and/or plans (Conte et al., 2012). Several programs of intervention have been proposed with intention to prevent suicide in the last few years (Conte et al., 2017). However, when it comes to the school environment, it is known that some risk groups are not being reached by these interventions because the mandatory presence of psychologists at school is something recent in Brazil.

When proposing primary intervention strategies at school it is necessary to understand which factors are associated to the risk of suicide so that we can efficiently intervene. According to what has been mentioned in previous sessions, aggressive relationships with friends, dysfunctional communication with family, the presence of behavioral problems, and difficulty in solving problems emerge as some of the factors. The promotion of health at school takes place, for example, by means of actions targeting the development of social skills. It is known that a poor social repertoire might lead to psychological problems in one’s childhood and adolescence. As a result, social competence appears as a precise indicator of psychosocial adjustment and a necessary tool for development because it increases the capacity of an individual to handle adverse, stressful situations in everyday life (Del Prette & Del Prette, 2013).

Thus, it is important to emphasize that working on social competences at school since childhood might help the children develop skills for communication and problem-solving so that their developmental trajectory becomes satisfactory. Besides that, childhood aggressiveness might be related to a socio-cognitive pattern that expresses itself by means failure in the identification or interpretation of relevant signs in the environment of tendencies to attribute hostile intentions to the person who is speaking, and difficulty in coming up with effective solutions for social demands, or even deficits when it comes to social performance, or a egocentric assessment of other people, which might produce reflections in adolescence (Del Prette & Del Prette, 2013).

In addition, there is the factor referring the number of friends that adolescents at risk have. A study realized in the United States demonstrated that 12% of the children had only one friend, 6% had none, and 15% presented serious interpersonal relation problems (Matson, Sevin, & Box, 1995, citado por Del Prette & Del Prette, 2013). The ability to make and keep friends depends on countless conditions, including competence in specific social skills. On the other hand, the lack of assertiveness, cooperation, and empathy, little visual contact of few smiles, difficulty in demonstrating interest for others, as well as aggressive attitudes, hyperactivity, negativity, harassment, and excess of criticism regarding other people might do further harm in this field (Del Prette & Del Prette, 2013).

One of the ways to practice social skills in the school context is based on group experiences realized in order to promote group union. When an atmosphere of mutual appreciation is created, it is possible to verify the acquisition or the improvement of important skills for social interaction and friendship (Del Prette & Del Prette, 2013). Thus, it is important to emphasize that these activities must not provoke unnecessary exposition of those who are participating, because it might bring out emotions in some people that the group will e unable to handle. Consequently, we must come up with the best strategies for reaching certain objectives without turning the activity into an emotional trigger.

Other factors that come up as determiners for the risk of suicide in adolescents are records of sexual abuse, exposition to violence, and difficulty in dealing with one’s body image. The school is the ideal scenario for the discussion of different topics that approach the themes connected to sexual education. The themes range from violence up to typical developments of adolescence. One example of this is the rate for domestic and sexual violence notifications that, for children and adolescents from 10 to 19 years of age, is 25.4% (Assis, Avanci, Pesce, Pires, & Gomes, 2012). These data denote the necessity to provide guidance so that students and their families will be able to identify situations of abuse/violence. Furthermore, when it comes to body image, we must consider the relevance of informing adolescents on matters related to the vital cycle they are passing through. The difficulty to accept one’s own body and the way to handle such matters is related to this stage, but it is necessary that school provide information related to puberty so that students will be able to recognize the changes in their own bodies without any misinterpretations. It is also important to highlight the fact that, according to national curricular parameters, school must be a source of information, and the stage for discussions on different issues considered taboo in order to fill up the empty spaces in the students’ minds on themes of their interest concerning scientific knowledge (Moreira, 2011).

In addition, there are problems related to the abuse of alcohol and other substances, which is a factor present in one of every four suicidal patients (OMS, 2000a). Adolescence is one of the most suitable phases for initiation in the use of legal and illegal drugs, including alcohol, since it is a time at which teenagers feel increased curiosity for new experiences. Thus, as a prevention strategy, we recommend orientation on the health consequences and loss caused by the abuse of substances. Lectures, research works on the theme, pedagogical readings, and reflections inserted in the planning of different disciplines might help adolescents visualize the theme from a different perspective and adopt a more cautious attitude in their phase of their lives (Façanha, Erse, Simões, Amélia, & Santos, 2010).

Speaking of suicide prevention means thinking of different artifices that comprehend a sum of factors that are associated to the consummation of the act and the consideration that this is not a one-way road. Thus, promoting and appreciating life in a context such as the school one proves the best alternative. In order to do that, it is necessary not only to direct strategies towards the students, but also to the educators and make them agents of change, while focusing on the multi-disciplinary teamwork (OMS, 2000a).

The instrumentalization of those who are in daily proximity to the students is an efficient solution because it facilitates the identification of warning signs for the risk of suicide. So, we recommend the capacitation of teachers with the help of mental health professionals so that, after identification of the signs, we can resort to competent professionals (Baggio et al., 2009). Knowledge on mental disorders and its symptoms, in addition to all previously discussed signs, might help teachers to better understand the situation a student is going through - lack of interest in habitual activities, general decline in grades, bad behavior in the classroom, and too many absences, for example (OMS, 2000a).

In this sense, it is also necessary to provide a brief instruction concerning management when risk is already consolidated. At a first moment, an appropriate place must be found for a conversation. Conversations that are likely to activate emotional triggers must never take place in the hallways or in classrooms. Then, it is necessary to listen very carefully to what the person at risk has to say. It is not advisable to interrupt too often, or to get too shocked or emotional. Actually, it is important to demonstrate non-verbal signs of acceptance and respect for the person’s feelings, while conducting the conversation and a careful, affectionate way (OMS, 2000b). These steps are recommended to mental health professionals who work in educational spaces because, depending on the way the conversation goes, they will know the best measures to be taken. However, it is necessary to understand that this type of approach does not present itself as clinical, considering that this is not the role of the school psychologist or the educational advisor. It is just a protocol that must be followed in cases of risk to the physical integrity of individuals in any context.

However, taking care of the mental health of the whole school staff is essential. Experiencing situations involving the management of such cases can be very emotional for some professionals, and, consequently, support must be provided to these professionals whenever necessary. Besides, when it comes to management, it is important to make information available on services provided by the public mental health system (OMS, 2000a).

Regarding the families, the role played by psychologist must be one of orientation. Based on the detected risk, it is necessary to contact the student’s family and do the procedures. However, it is known that in some cases the families do not follow the instructions recommended by the professionals. Therefore, it is important that all meetings with family members or legal guardians be recorded and the participants have the opportunity to sign a term stating the fact that they are aware of any risk situation detected and notified by the school. Thus, the school and the professionals working there will be confident that their mission has been accomplished, despite the limitations for action for each case. Also, thinking of primary prevention, it is important to produce more strategies for the orientation of families on themes referring to mental health, which includes the distribution of reading material all the way to actions and lectures, or even, if possible, permanent study and discussion groups in order to go deeper into this debate on such crucial themes.

FINAL CONSIDERATIONS

According to what has been referenced in other studies, there is a necessity for greater investment so that specific intervention programs focusing on suicide prevention among adolescents can be created (Moreira & Bastos, 2015; Feijó & Oliveira, 2001; Baggio et al., 2009). It is possible to observe, then, the importance of the presence of the psychologist in the composition of the educational staff. Such presence is now guaranteed by Law no. 13.935, 2019). The promotion of health in this context depends on the practice by professionals who have theoretical and practical knowledge on mental health so that school reality can be changed.

In addition to the work done at the school environment, the effects of these strategies must produce a social impact, which overflows the walls of the educational institutions. The school community as a whole - the students, the teachers, families and others members of society - must enjoy the short and long-term benefits of actions that aim at suicide prevention, and that also reverberate in diverse realms when it comes to health and quality of life, as we have discussed along this article.

It is important, therefore, to highlight the role society itself plays in the life of every person and, in this case, death. We live in a context that is sick and that makes us sick at the same time. Diverse characteristics present in society nowadays - such as individualism, immediatism, low tolerance to frustration - reinforce the necessity for this kind of work, as well elucidated in a study by Nilson Berenchtein Netto (Berenchtein Netto, 2007), in which the researcher understands that, when we understand suicide from a psychosocial point of view, we become, therefore, more prepared to intervene with efficacy. Finally, understanding suicide as a matter of public health, we need to guarantee its prevention in the school environment as well as public policies that comprehend this theme as part of its actions towards prevention and promotion of health for the population in general, considering the full current concept of health.

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• This paper was translated from Portuguese by Régis Lima

Publication Dates

• Publication in this collection
  06 Dec 2021
• Date of issue
  2021

History

• Received
  30 July 2019
• Accepted
  20 Mar 2021