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Teen Suicide: Practical Interventions for Adolescents in Crisis
10 CEUs Teen Suicide: Practical Interventions for Adolescents in Crisis

Section 18
Family Conflict and "Suicidal Fits"

CEU Question 18 | CEU Test | Table of Contents | Crisis CEU Courses
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Mental health clinicians in inner-city mental health centers serving high concentrations of Hispanic residents have observed that many of the adolescent Hispanic females are referred after suicide attempts. Some confirmation of this phenomenon has come from a recent report from the Centers for Disease Control and Prevention (CDC, 1996) that shows that adolescent Hispanic females have a 21 percent prevalence of suicide attempts, whereas African American and non-Hispanic white females have rates of 10.8 percent and 10.4 percent, respectively. Furthermore, adolescent Hispanic females are also twice as likely as African American and non-Hispanic white adolescent females to have made suicide attempts requiring medical attention (CDC, 1996). Adolescent males overall have lower rates of suicide attempts (CDC, 1996). A small body of literature describing suicide attempts by adolescent Hispanic females has emerged gradually, but the careful empirical scrutiny that these attempts deserve has not occurred.

To provide conceptual direction to clinical and research efforts, this article presents a model for understanding the suicide attempts of adolescent Hispanic females in U.S. urban centers. The model integrates knowledge gleaned from theoretical formulations, clinical experience, and research reports on suicidal behavior by Hispanic and non-Hispanic adolescents and proposes that some factors cut across ethnic and racial groups, whereas other factors appear to have a distinct effect on adolescent Hispanic females. That we focus on suicide attempts by adolescent Hispanic females should not be read as implying that all Hispanic females (or males, for that matter) are prone to suicidal behavior, just as no small group with homogeneous medical or psychiatric problems represents the larger population. If we extrapolate from the CDC (1996) report, we see that the vast majority (80 percent) of adolescent Hispanic females do not attempt suicide.

The model presented here is intended to deepen understanding of the phenomenon of adolescent Hispanic female suicide attempts and to better inform clinical practice. In fact, conceptual models for understanding ethnic and racial minority groups frequently neglect the ecological circumstances underlying social and mental health problems and instead point to individual and family sources of problems. The difficulty in understanding disenfranchised racial and ethnic minority populations comes about when social workers rely on experiences of the dominant mainstream population and fail to highlight the unique experiences, strengths, and resilience, as well as the dynamic forces that underlie the specific problems of ethnic minority groups. The social work profession has a unique interest in understanding suicide attempts for at least two reasons. First, it has a firm commitment to serve oppressed groups through direct practice, program development, and policy initiatives. Second, the ecological approach of social work naturally encourages attention to both external and internal environments, as well as their dynamic interaction. Prevention and intervention efforts deriving from this understanding would include attention to resilience and protective factors, not just problematic ones (Norman, Turner, & Zunz, 1994).

Suicide Attempts by Adolescent Hispanic Females
During recent years, research has shown that more than 50 percent of 13-to 19-year-olds report intermittent suicidal thoughts and that 12 to 15 percent have come close to attempting suicide (Grosz, Zimmerman, & Asnis, 1995). Overall, more adolescent females than adolescent males attempt suicide (Andrews & Lewisohn, 1992; Friedman, Asnis, Boeck, & Difiore, 1987; Grossman, Milligan, & Deyo, 1991; Kovacs, Goldstein, & Gatsonis, 1993; Peterson, Zhang, Santa Lucia, & King, 1996; Shaffer, 1988; Wagner, Cole, & Schwarzman, 1995; Weissman, 1986). Those that report attempting suicide often report multiple attempts and are from six (Pfeifer, Klerman, Hurt, & Kakuma, 1993) to eight times (Lewisohn, Rohde, & Seeley, 1994) more likely to reattempt than adolescents who never have attempted. A suicide attempt often is followed by another, increasing the possibility of a completed suicide and making this a serious mental health issue.

During the late 1950s, Trautman (1961a, 1961b) identified the so-called "suicidal fit" among Puerto Rican people in the South Bronx, many of whom were young females. The suicidal fit was often an impulsive act of ingesting pills or a household cleanser during a stressful situation related to disturbances in family relations, typically with a spouse or mother. Most of the individuals had no thought of death, were often unaware of their thoughts, and did not manifest psychotic symptoms. Trautman hypothesized that relocation to a new geographic and cultural context was related to the suicide attempt.

Razin et al. (1991) reported that at a municipal hospital in New York City serving an ethnically and racially diverse low socioeconomic population, adolescent Hispanic females "represent[ed] more than 25 percent of all patients admitted to the hospital for suicidal behavior" (p. 46). Robles (1995) also reported that in Dade County, Florida, Hispanic females were 22 percent of public school students but 35 percent of the student suicide attempts. Although the term suicidal fit has been discarded, the phenomenon, which seemed at first to be a phenomenon among the Puerto Rican population, has been reported among adolescent females of diverse Hispanic backgrounds, such as Cuban, Dominican, Mexican, and Nicaraguan (Berne, 1983; Ng, 1996; Razin et al., 1991; Robles, 1995; Trautman, Rotheram-Borus, Dopkins, & Lewin, 1991). The changing demographics of the Hispanic population in the United States may help account for this diversity. Between 1990 and 1994 the number of Hispanic people in the United States grew from about 21 million to 27 million, a 28 percent growth rate compared with a 6 percent growth rate for the total U.S. population during the same period (U.S. Bureau of the Census, 1995). This growth has been accompanied by an increase in Hispanic national-origin diversity. In 1980 people of Puerto Rican ethnic origin in New York City made up more than 61 percent of the Hispanic population, and people of Dominican ethnic origin were only 9 percent (Hispanic Research Center, 1995). In 1990 people of Puerto Rican ethnic origin were 50 percent of the Hispanic population (although the number of people remained nearly the same), and the proportion of people of Dominican ethnic origin rose to nearly 20 percent. The remaining 30 percent of the Hispanic population was made up of people of Colombian, Ecuadoran, Mexican, and other Central and South American ethnic groups (Hispanic Research Center, 1995). Although substance abuse is correlated highly with suicide attempts among adolescents in general (Berman & Jobes, 1991), similar findings have not been reported for adolescent Hispanic females who attempted suicide (Berne, 1983; Ng, 1996; Razin et al., 1991; Trautman, 1961a, 1961b).

An Integrative Model for Understanding the Suicide Attempts
As researchers and clinicians, we integrated the salient factors that in our experience appear to cluster into sociocultural, familial, developmental, and psychological domains of suicide attempts. We have provided an integrative model of these factors (Figure 1). For exposition, each domain is discussed separately, although they act together. To address the issues associated with the effect of family structure, especially the absence of fathers, on the relations between parents and daughters, we have emphasized the mother-daughter relationship as a subdomain contiguous with the familial domain.

The model assumes that the factors do not exclude the possible influence of other factors (for example, biological factors) but that they represent the most salient ones and that the intensity of the interaction of the factors depends on the specific adolescent or family context for the suicide attempt. The suicide attempt typically occurs within the context of a progressive intensification in conflicts between the adolescent and her parents. An acute situation, usually an intense argument with parents regarding issues associated with autonomy or sexuality, embodied in the adolescent's involvement with a boyfriend, often triggers the suicide attempt.

Sociocultural Domain
Acculturation, generational status, and Hispanic cultural factors are crucial elements in understanding Hispanic adolescent females' suicide attempts (Sorenson & Golding, 1988; Swanson, Linskey, Quintero-Salinas, Pumariega, & Holzer, 1992; Vega, Gil, Warheit, Apospori, & Zimmerman, 1993). Empirical support for the influence of acculturation and generational factors on suicide attempts by people of Hispanic ethnic origin comes from reports showing that suicide rates are higher among Hispanic people in the United States than in their countries of origin (Group for the Advancement of Psychiatry, 1989; Swanson et al., 1992) and that in multiethnic U.S. samples Hispanic people report higher levels of suicidal thoughts and attempts than other groups (for example, Lester & Anderson, 1992; Vega et al., 1993). Disparities between adolescents' acculturation and parents' acculturation often are evident in suicidal Hispanic females. Zayas (1987,1989) proposed that the interaction of socioeconomic disadvantage, traditional gender-role socialization, acculturation, cultural identity, generational status, and intergenerational (adolescents-parents) conflict converge interactively and additively to influence the suicidal behavior of adolescent Hispanic females, especially ethnic Puerto Rican females. Both Razin et al. (1991) and Ng (1996) reported that the modal subject in their studies was a 15-or 16-year-old acculturated daughter of foreign-born ethnic Hispanic immigrants. Hispanic cultural and family traditions may influence how the adolescent female and her parents respond to the psychosocial stresses (Zayas, 1987). The model considers that acculturation and generational status act as background variables in the suicide attempt but recognizes that these factors alone do not sufficiently explain why some Hispanic females attempt suicide, whereas others do not.

Socioeconomic conditions (for example, parental education and occupation) also are major influences. Fewer incidents of suicide attempts are reported among middle-class adolescent Hispanic females than among girls of lower socioeconomic status (SES) (Ng, 1996; Razin et al., 1991; Zimmerman, 1991). This difference may be explained by the effects of parental education and acculturation on child-rearing beliefs and practices. As both education and acculturation rise, parents' interaction with their adolescent children becomes characterized by more democratic and less authoritarian parenting behaviors. As less disparity exists among parents and daughters, they may be more in tune with each others' values and agree on some values (for example, hold similar views about child-rearing and differ on career and courtship choices; Canino, 1982). Also, more education and acculturation may lead parents to avail themselves of both formal (for example, teachers and counselors) and informal (for example, coworkers and ministers) supports and information to help them and their daughters cope with the tasks of adolescence. Although low self-esteem may be associated with the phenomenon of suicide attempts, its effect should not be viewed in isolation from other factors, such as those associated with family organization and functioning and developmental coping strategies. Many low SES families demonstrate developmentally sensitive and responsive parenting and strong parent-daughter relations.

- Zayas, Luis H., Kaplan, Carol, Turner, Sandra, Romano, Kathleen, Gonzalez-Ramos, Gladys, Social Work, Jan2000, Vol. 45, Issue 1

Personal Reflection Exercise #4
The preceding section contained information about understanding suicide attempts by adolescent Hispanic females.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Cheng, Q., Shum, A. K. Y., Ip, F. W. L., Wong, H. K., Yip, W. K. K., Kam, A. H. L., & Yip, P. S. F. (2020). Co-creation and impacts of a suicide prevention video: A case study of a YouTube short film on youth suicide prevention. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 41(1), 7–14.

Christensen, K., Hom, M. A., Stanley, I. H., & Joiner, T. E. (2021). Reasons for living and suicide attempts among young adults with lifetime suicide ideation. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 42(3), 179–185.

Levi-Belz, Y., & Feigelman, W. (2021). Pulling together—The protective role of belongingness for depression, suicidal ideation and behavior among suicide-bereaved individuals. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication.

Online Continuing Education QUESTION 18
What did Zayas propose about influencing factors in the suicidal behavior of adolescent Hispanic females, especially ethnic Puerto Rican females? Record the letter of the correct answer the CEU Test.

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