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National Youth Violence Prevention Resource Center

A Federal resource for professionals, parents and youth working to prevent violence committed by and against young people.

Youth Suicide Fact Sheet
(Printable Version)

This document is also available in a portable document format (PDF 3.3 MB).

Overview  top

Youth suicide is a major public health problem in the United States. Although the overall suicide rate has declined over the past twenty years, from 12.1 per 100,000 in 1979 to 11.3 per 100,000 in 1998, the suicide rate for teens 15 to 19 years old has increased by 6 percent. For adolescents 10 to 14 years old, the suicide rate increased by more than 100 percent over that time period.1 While youth suicide rates did decrease significantly between 1993 and 1998, suicide was still the third leading cause of death for young people 10 to 19 years old in 1998.2 More teenagers died from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined.3 In 1998, among youth ages 10 to 19 in the United States, there were 2,054 suicides.4

1979-1998, Suicide Rates per 100,000 in United States5

A far greater number of youths attempt suicide each year. Suicide attempts are difficult to count, because many may not be treated in a hospital or may not be recorded as self-inflicted injury. Survey data from 1999 indicate that 19.3% of high school students had seriously considered attempting suicide, 14.5% had made plans to attempt suicide, and 8.3% had made a suicide attempt during the year preceding the survey.6 All suicide attempts should be taken seriously.

Firearms are the most common method of suicide by youth. This is true for both males and females, younger and older adolescents, and for all races. More than 60 percent of youth suicides (between the ages of 10-19 years) in 1998 were firearm-related suicides. The rate of youth suicides involving a firearm increased 38% between 1981 and 1994, and although firearm-involved suicides declined more than 20% from 1994 to 1998, these numbers are still much too high.7

1981-1998, United States, Youth 10-19, Firearm-Related and Overall Suicide Deaths

Population Differences  top

In the United States, more than four times as many male youth die by suicide8, but girls attempt suicide more often and report higher rates of depression.9 The gender difference in suicide completion is most likely due to the differences in suicide methods. Men are more likely to use firearms, which lead to a fatal outcome 78% to 90% of the time.10, 11 Girls and women in all countries are more likely than males to ingest poisons. In countries where poisons are highly lethal and/or where treatment resources are scarce, more females complete suicide than males.12

Age differences  top

Suicide is extremely rare in young children, and the suicide rate among 10-to-14 year olds, while increasing rapidly, is still much lower than the rate for older teens.13 Younger children may be less likely to complete suicide because they do not have the cognitive ability to plan and carry out a suicide attempt, but research also suggests that the increase in suicide rates with age may be due to the increased likelihood of exposure to critical risk factors, such as serious depression and drugs and alcohol, with age. Studies have found that for younger children exposed to such risk factors, the suicide rate is similar to that for older teens.14

Cultural variation  top

In 1998, white males accounted for 61% of all suicides among youth 10-19, and white males and white females together accounted for over 84% of all youth suicides. However, the suicide rate among Native American male youth is exceedingly high in comparison with the overall rate for males 10 to 19 (19.3 per 100,000 vs. 8.5 per 100,000). The suicide rate has been increasing most rapidly among African American males ages 10 to 19 - more than doubling from 2.9 per 100,000 to 6.1 per 100,000 from 1981 to 1998.15 Finally, a National survey of high school students in 1999 found that Hispanic students, both male and female, were significantly more likely than white students to have reported a suicide attempt (12.8% vs. 6.7%). Among Hispanic students, females (18.9%) were almost three times more likely than males (6.6%) to have reported a suicide attempt.16 The most likely explanation for ethnic rate differences are variations in cultural factors that promote or inhibit suicide.

Sexual orientation17  top

It has been widely reported in the media that gay and lesbian youth are at higher risk to complete suicide than other youth and that a significant percent of all attempted or completed youth suicides are related to issues of sexual identity. However, there are no national statistics for suicide completion rates among gay, lesbian or bisexual persons, and in the few studies examining risk factors for suicide completion where an attempt was made to assess sexual orientation, the risk for gay or lesbian persons did not appear any greater than among heterosexuals, once mental and substance abuse disorders were taken into account. With regard to suicide attempts, several state and national studies have reported that high school students who report to engaging in homosexual or bisexual activity have higher rates of suicide thoughts and attempts compared to youth with heterosexual experience. Experts have not been in complete agreement about the best way to measure reports of adolescent suicide attempts or sexual orientation, however, so the data are subject to question. Clearly, further research is needed in this area.

Risk and Protective Factors  top

Suicide is a complex behavior that is usually caused by a combination of factors in the absence of protective factors. Researchers have identified a number of risk factors associated with a higher risk for suicide and protective factors that may reduce the likelihood of suicidal behavior. It is important to note, however, that the importance of risk and protective factors can vary by age, gender, and ethnicity.

Risk Factors  top

Risk factors for suicide completion include:

Previous suicide attempts - If a youth has attempted suicide in the past, he or she is much more likely than other youths to attempt suicide again in the future. If a male teen has attempted suicide in the past, he is more than thirty times more likely to complete suicide, while a female with a past attempt has about three times the risk. Approximately a third of teenage suicide victims have made a previous suicide attempt.18
Mental disorders or co-occurring mental and alcohol or substance abuse disorders - Research shows that over 90% of young people who complete suicide have a diagnosable mental or substance abuse disorder or both, and that the majority have depressive illness.19 In a 10- to 15-year followup study of 73 adolescents diagnosed with major depression, 7 percent of the adolescents had completed suicide sometime later. The depressed adolescents were five times more likely to have attempted suicide as well, compared with a control group of age peers without depression.20 Almost half of teenagers who complete suicide have had a previous contact with a mental health professional. In addition, aggressive, disruptive, and impulsive behavior is common in youth of both sexes who complete suicide.21
Family history of suicide22 - A high proportion of suicides and attempters have had a close family member (sibling, parent, aunt, uncle, or grandparent) who attempted or completed suicide. Familial suicide can be a function of imitation or genetics. Many of the mental illnesses which contribute to suicide risk appear to have a genetic component.
Stressful life event or loss - Stressful life events often precede a suicide and/or suicide attempt. Such stressful life events include getting into trouble at school or with a law enforcement agency; fighting or breaking up with a boyfriend or a girlfriend; and fighting with friends. They are rarely a sufficient cause of suicide, but they often act as precipitating factors in young people.23, 24
Easy access to lethal methods, especially guns - As mentioned above, firearms are the most common method of suicide by youth. The most common location for the occurrence of firearm suicides by youth is in their homes, and there is a positive association between the accessibility and availability of firearms in the home and the risk for youth suicide. The risk conferred by guns in the home is proportional to the accessibility (e.g., loaded and unsecured firearms) and the number of guns in the home.25, 26
Exposure to the suicidal behavior of others, whether that of a peer or in the media 27 - Suicide can be facilitated in vulnerable teens by exposure to real or fictional accounts of suicide, including media coverage of suicide, such as intensive reporting of the suicide of a celebrity, or the fictional representation of a suicide in a popular movie or TV show. In addition, there is evidence of suicide clusters, that is, local epidemics of suicide that have a contagious influence. Suicide clusters nearly always involve previously disturbed young people who knew about each other's death but rarely knew the other victims personally.
Incarceration28 - Although there are insufficient national data regarding the incidence of youth suicide in custody, information suggests a high prevalence of suicidal behavior in juvenile correctional facilities. One study found that suicide in juvenile detention and correctional facilities was more than four times greater than youth suicide overall. According to another recent study, more than 11,000 juveniles engage in more than 17,000 incidents of suicidal behavior in juvenile facilities each year.

Other identified risk factors include a family history of mental or substance abuse disorders, a history of physical and/or sexual abuse, low levels of communication with parents, the possession of certain cultural and religious beliefs about suicide (for instance, the belief that suicide is a noble resolution of a personal dilemma), and lack of access or an unwillingness to seek mental health treatment.29

The impact of some risk factors can be reduced by interventions (such as providing effective treatments for depressive illness). Those risk factors that cannot be changed (such as a previous suicide attempt) can alert others to the heightened risk of suicide during periods of the recurrence of a mental or substance abuse disorder, or following a significant stressful life event.30

Protective factors31  top

Protective factors can include an individual's genetic or neurobiological makeup, attitudinal and behavioral characteristics, and environmental attributes. Some identified protective factors are: learned skills in problem solving, impulse control, conflict resolution, and nonviolent handling of disputes; family and community support; access to effective and appropriate mental health care and support for help-seeking; restricted access to highly lethal methods of suicide; and cultural and religious beliefs that discourage suicide and support self-preservation instincts. Measures that enhance resilience or protective factors are as essential as risk reduction in preventing suicide. Positive resistance to suicide is not permanent, so programs that support and maintain protection against suicide should be ongoing.

Suicide Prevention  top

A scientific approach to preventing suicide involves describing and monitoring the problem, understanding risk factors and causes of suicidal behavior and protective factors, developing and implementing interventions and prevention strategies in the context of evaluation research, and disseminating information about effective strategies.32

The research on risk and protective factors suggests that one promising prevention strategy is to promote overall mental health among school-aged children by reducing early risk factors for depression, substance abuse and aggressive behaviors and building resiliency. In addition to the potential for saving lives, youths benefit from an overall enhancement of academic performance and a reduction in peer and family conflict. A second positive approach is to detect youth most likely to be suicidal by confidentially screening for depression, substance abuse, and suicidal ideation. If a youth reports any of these, further evaluation of the youth can take place by professionals, followed by referral for treatment as needed.33 Efforts should be made to develop and implement strategies to reduce the stigma associated with accessing mental health, substance abuse, and suicide prevention treatments. Adequate treatment of mental disorders among youth, whether they are suicidal or not, has important academic, peer and family relationship benefits.

Additionally, efforts to limit young people's access to lethal agents -- including firearms and medications -- may hold great suicide prevention value. Media education is also important, as the risk for suicide contagion as a result of media reporting can be minimized by limited, factual and concise media reports of suicide.34 Finally, following exposure to suicide or suicidal behaviors within one's family or peer group, suicide risk can be minimized by having family members, friends, peers, and colleagues of the victim evaluated by a mental health professional.35 Persons deemed at risk for suicide should then be referred for additional mental health services.

Caution should be used in the development of suicide prevention programs for youth, because researchers have found that some types of suicide prevention efforts may be counterproductive. For example, some school-based youth suicide awareness and prevention programs have had unintended negative effects.36 These programs typically try to increase high-school students' awareness of the problem, provide knowledge about the behavioral characteristics of teens at risk, and describe available treatment or counseling resources. Unfortunately, some appear to have had the unintended effect of suggesting that suicide is an option for many young people who have some of the risk factors and in that sense "normalize" it-just the opposite message intended. Similarly, caution should be used in the widespread distribution of lists of suicide warning signs.37 The warning signs listed are not necessarily risk factors for suicide and may include common behaviors among distressed persons, such as "loss of energy" or "making negative comments about oneself," behaviors that are not specific for suicide. Such lists can, again, promote suicide as a possible solution to ordinary distress or suggest that suicidal thoughts and behaviors are normal responses to stress. As these examples indicate, suicide prevention efforts must be carefully planned, implemented, and evaluated. Because of the tremendous effort and cost involved in starting and maintaining programs, we should be certain that they are safe and effective before they are further used or promoted.

Federal Responses and Resources  top

U.S Department of Agriculture

U.S. Department of Education

U.S. Department of Health and Human Services

U.S. Department of Justice


U.S. DEPARTMENT OF AGRICULTURE (USDA)
http://www.usda.gov

The mission of the USDA is to enhance the quality of life for the American people by supporting production of agriculture:

The Cooperative State Research, Education and Extension Service (CSREES)
The Cooperative Extension System response to pervasive conditions in America which place children and their families at risk for not meeting their basic physical and social needs and not building the basic competencies necessary for successful participation in childhood, adolescent, and adult life is the Children, Youth, and Families At Risk (CYFAR) National Initiative. With the CYFAR National initiative, the USDA makes a commitment to supporting programs for at risk youth and limited resource families as a part of the educational outreach mission of the Land-Grant University system. One of the goals of CYFAR is to reduce risk factors and increase protective measures that will prevent the use of violence or suicide as a way to solve problems or as a response to difficult situations and stressful life events.

A key project of CYFAR is the Children, Youth and Families Education and Research Network (CYFERNet). CYFERNet is a national network of Land Grant university faculty and county Extension educators working to support community-based educational programs for children, youth, parents and families. Through CYFERNet, partnering institutions merge resources into a "national network of expertise" working collaboratively to assist communities. CYFERNet provides program, evaluation and technology assistance for children, youth and family community-based programs. It provides: access to the latest research, statistical, and demographic information; guidance in locating funding opportunities and grant writing information; resources and instruments for program evaluation; and information on 3000 community-based State Strengthening programs targeting at-risk audiences.

Finally, the Department of Agriculture coordinates the Partnerships Against Violence Network (PAVNET), a "virtual library" of information about violence and youth-at-risk, representing data from seven different Federal agencies. The PAVNET Research Database is an online, searchable source of information about current Federally-funded research on violence and includes research on youth suicide.

U.S. DEPARTMENT OF EDUCATION
http://www.ed.gov

The mission of the Department of Education is to ensure equal access to education and to promote educational excellence for all Americans.

Office of Elementary and Secondary Education
The mission of the Office of Elementary and Secondary Education is to promote academic excellence, enhance educational opportunities and equity for all of America's children and families, and to improve the quality of teaching and learning by providing leadership, technical assistance and financial support. The OESE's Safe and Drug-Free Schools Program is the Federal government's primary vehicle for reducing drug, alcohol and tobacco use, and violence, through education and prevention activities in our nation's schools. This program supports initiatives designed to prevent violence in and around schools, and to strengthen programs that prevent the illegal use of alcohol, tobacco, and drugs, involve parents, and are coordinated with related Federal, State and community efforts and resources.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
www.hhs.gov/

The Department of Health and Human Services is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.

The U.S. Department of Health and Human Services issued The Surgeon General's Call to Action to Prevent Suicide that details a three-pronged blueprint to address and prevent suicide in this country. Known as AIM-which stands for Awareness, Intervention, and Methodology-this three-pronged approach was developed by a broad government-sponsored collaboration of experts on suicide, and an equally broad coalition of organizations working in the field of suicide prevention. AIM serves as the foundation for a comprehensive National Strategy for Suicide Prevention.

The goal of this national strategy is to make significant, measurable, and sustained reductions in suicidal behaviors by mobilizing all sectors of society and:

Centers for Disease Control and Prevention (CDC)
www.cdc.gov

The mission of the CDC is to promote the health and quality of life of the citizenry of the U.S. by preventing and controlling disease, injury, and disability. In particular, the CDC is committed to reducing and preventing youth violence through a public health approach that focuses on understanding the prevalence of youth violence; identifying risk and protective factors that influence its occurrence; research and program evaluation; and dissemination of information and technical assistance to its constituents.

The Centers for Disease Control and Prevention's National Center for Injury Prevention and Control (NCIPC), is working to raise awareness of suicide as a serious public health problem, and NCIPC is applying science-based prevention strategies to reduce injuries and deaths due to suicide. To this end, current activities include conducting and supporting research on risk factors for suicide, evaluating the effectiveness of suicide prevention programs for young people, convening conferences to exchange information about research and prevention strategies, and developing a Suicide Prevention Research Center at the University of Nevada.

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

SAMHSA's mission is to improve the quality and availability of prevention, treatment, and rehabilitation services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illnesses.

SAMHSA is funding community organizations to lead/facilitate intensive, community-wide collaborations to address healthy youth development, enhance youth resilience, and prevent youth violence, suicide, substance abuse, and other problem behaviors. The program is designed to complement the much larger Safe Schools/Healthy Students Initiative.

Center for Mental Health Services (CMHS)
http://mentalhealth.samhsa.gov/cmhs/

CMHS leads Federal efforts to treat mental illnesses by promoting mental health and by preventing the development or worsening of mental illness when possible. CMHS pursues its mission by helping States improve and increase the quality and range of their treatment, rehabilitation, and support services for people with mental illness, their families, and communities. Further, it encourages a range of programs—such as systems of care—to respond to the increasing number of mental, emotional, and behavioral problems among America's children. CMHS supports outreach and case management programs for the thousands of Americans with severe mental illness who are homeless and supports the development and adoption of "models" for improving services.

CMHS is taking the lead for SAMHSA in addressing suicide and suicide prevention as a public health issue. CMHS sponsored a 2-day workshop to consult with experts in suicide prevention and related fields on the development of a National Suicide Prevention Strategy (NSPS). The NSPS is the first-ever national strategy to reduce the burden of self-directed violence, injury, and death in the United States. When completed, it will suggest activities for Federal, State, tribal, and local governments, based on the best available science. The strategy will also provide guidance for organizations and individuals who seek to be involved in suicide prevention. The final version of the NSPS will establish a conceptual framework for understanding suicide and suicide prevention and will suggest how government agencies, private organizations, and individuals can effectively help to achieve the NSPS Goals and Objectives.

Additionally, eighty School Action Grants were funded by CMHS in communities across the country in order to implement and evaluate school-based programs designed to prevent violence and suicide and to promote mentally healthy development. CMHS will continue to work with its grantees to evaluate these school violence and suicide prevention programs and to implement strategies from effective programs.

CMHS is also supporting a 5-year series of coordinated annual national suicide prevention conferences and workshops being organized and conducted by the University of Rochester School of Medicine's Center for the Study and Prevention of Suicide. CMHS is also a sponsor of the National Academy of Sciences Institute of Medicine report on suicide prevention, to be titled "Pathophysiology and Prevention of Adolescent and Adult Suicide".

CMHS is supporting the operations and analysis of information gathered from a high school screening and suicide intervention program. The High School Outreach Program 2000 embraces the U.S. Surgeon General's Call to Action to Prevent Suicide and is a first-ever program of depression education, screening, and suicide intervention targeted at high schools. The High School Outreach Program 2000 is designed to expand awareness of depression through educational materials for the classroom and to provide the opportunity for self-administered depression screening under the supervision of a school health professional. Students will be encouraged to seek further evaluation, if necessary, through existing school and community resources.

Finally, CMHS has commissioned a review of the literature and recommendations on the role of mental health anti-stigma information campaigns in suicide prevention. Given that anti-stigma efforts are considered by many to be a valuable intervention in any overall national strategy to reduce suicide and suicidal behaviors, the scientific basis for advocating the expenditure of resources in this area merits exploration.

Health Resources Services Administration (HRSA)
http://www.hrsa.gov

The Health Resources and Services Administration (HRSA) directs national health programs that improve the Nation's health by assuring equitable access to comprehensive, quality health care for all. HRSA works to improve and extend life for people living with HIV/AIDS, provide primary health care to medically underserved people, serve women and children through State programs, and train a health workforce that is both diverse and motivated to work in underserved communities.

The Health Resources Services Administration's Maternal and Child Health Bureau (MCHB) administers grants to states for maternal and child health. MCHB has created performance indicators in a number of areas for their grantees. One of these performance indicators is youth suicide rates and this has encouraged many states to begin to develop and implement state youth suicide prevention efforts. Additionally, MCHB supports the Children's Safety Network which works with states to assist their efforts to prevent childhood injury, including injuries from suicidal behavior. Finally, MCHB has sponsored Bi-Regional Adolescent Suicide Prevention Conferences to strengthen and expand state and local efforts to develop partnerships and systems of care for preventing youth suicide. The proceedings include conference presentations and state by state data on youth suicide deaths.

National Institute of Mental Health (NIMH)
www.nimh.nih.gov

The mission of the National Institute of Mental Health (NIMH) is to diminish the burden of mental illness. Basic neuroscience, behavioral science, and genetics research are used to improve our understanding of the fundamental mechanisms underlying thought, emotion, and behavior - and what goes wrong in mental illness - and to translate scientifically-generated information into clinical applications.

The National Institute of Mental Health has been at the forefront of research on how to identify youth in crisis and how to prevent youth suicide. NIMH currently is developing more precise diagnostic criteria for pinpointing depressive disorders among young people. There is an increased risk for suicidal behavior among children who have depressive disorders, and such disorders have often gone unrecognized, or misdiagnosed and untreated. NIMH is also examining the role of substance abuse as a contributing factor to suicidal behavior. NIMH researchers also are devising and testing an array of pioneering interventions to prevent suicide in children and adolescents. Its research confirms that early diagnosis and treatment of depressive disorders are critical to a young person' mental health and, consequently, to preventing suicide.

NIMH is also rigorously evaluating existing school-based suicide awareness programs. A vital aspect of these evaluations is to determine how these programs can be improved to more effectively keep young people from completing suicide.

NIMH funds a range of suicide research projects with topics ranging from neurobiological and psychological correlates of suicidal behavior, to treatment studies of patients who are suicidal, as well as studies that investigate possible precursors and risk factors.

U.S. DEPARTMENT OF JUSTICE
www.usdoj.gov
The Department represents the citizens of the United States in enforcing the law in the public interest and plays a key role in protection against criminals; ensuring healthy competition of business; safeguarding the consumer; enforcing drug, immigration, and naturalization laws; and protecting citizens through effective law enforcement.

Office of Juvenile Justice and Delinquency Prevention (OJJDP)
http://ojjdp.ncjrs.org
The Department of Justice's Office of Juvenile Justice and Delinquency Prevention has developed a document, "Promising Strategies to Reduce Gun Violence" in order to provide law enforcement, State and local elected officials, prosecutors, judges, school administrators, community organizations, and other local stakeholders with the tools for fighting firearm violence in their communities. It includes a blueprint for communities to develop their own comprehensive, strategic violence reduction plan and a wealth of practical information on demonstrated and promising gun violence reduction strategies and programs. A number of the programs included have the goal of reducing suicide among adolescents by encouraging safe storage of guns in the home.

OJJDP also supports research and the dissemination of information about family strengthening programs. A number of these interventions have been found to decrease risk factors for suicide and to build resiliency. Descriptions of these programs are included in OJJDP's Family Strengthening Series.

Additionally, OJJDP, in response to concerns about youths in confinement has supported initiatives and programs that target youth with mental health problems in the juvenile justice system. They have recently funded a national survey on the prevalence of juvenile suicide in confinement.

Finally, OJJDP has developed a number of other mental health initiatives that target youth at risk of mental health, substance abuse, and delinquency problems.

Notes
i. For the purposes of this document, the term "youth" will refer to youth 10-19 years of age. Data will often be provided separately for youth ages 10-14 and 15-19.

References  top

  1. Calculated from data provided in: National Center for Health Statistics, GMWK291 Death Rates for 72 Selected Causes by 5-Year Age Groups, Race, and Sex: United States, 1979-98, p.485. Centers for Disease Control and Prevention.
  2. Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System)
  3. U.S. Public Health Service (1999). The Surgeon General's Call to Action to Prevent Suicide, p. 3. Washington, D.C.
  4. Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System)
  5. Data from: National Center for Health Statistics, GMWK291 Death Rates for 72 Selected Causes by 5-Year Age Groups, Race, and Sex: United States, 1979-98, p.485. Centers for Disease Control and Prevention
  6. Centers for Disease Control and Prevention. (2000). Youth risk behavior surveillance -- United States, 1999. In: CDC Surveillance Summaries, June 9, 2000. MMWR 2000;49(No. SS-5), p. 10.
  7. Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System)
  8. Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System)
  9. Centers for Disease Control and Prevention. (2000). Youth risk behavior surveillance -- United States, 1999. In: CDC Surveillance Summaries, June 9, 2000. MMWR 2000;49(No. SS-5), p. 10.
  10. Annest, J.L., Mercy, J.A., Gibson, D.R., Ryan, G.W. (1995): National estimates of nonfatal firearm-related injury. Beyond the tip of the iceberg. Journal of the American Medical Association, 273 (22), 1749-54.
  11. Card, J.J. (1974). Lethality of suicidal methods and suicide risk: Two distinct concepts. Omega, 5, 37-45.
  12. MoScicki, E.K. (1994). Gender differences in completed and attempted suicides. Annals of Epidemiology. 4(2):152-8.
  13. Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System)
  14. Groholt, B., Edebert, O., Wichstrom, L., & Haldorsen, T. (1998). Suicide among children and younger and older adolescents in Norway: A comparative study. Journal of the American Academy of Child and Adolescent Psychiatry, 37(5):473-481.
  15. Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System)
  16. Centers for Disease Control and Prevention. (2000). Youth risk behavior surveillance -- United States, 1999. In: CDC Surveillance Summaries, June 9, 2000. MMWR 2000;49(No. SS-5), p. 49.
  17. National Institute of Mental Health (1999). Frequently Asked Questions About Suicide.
  18. Shaffer, D., Gould, M. S., Fisher, P., Trautment, P., Moreau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348.
  19. Shaffer, D., Craft, L. (1999). Methods of adolescent suicide prevention. Journal of Clinical Psychiatry, 60,(Suppl. 2), 70-74.
  20. Weissman, M.M., Wolk, S., Goldstein, R.B., et al. (1999). Depressed adolescents grown up. Journal of the American Medical Association, 281, 1701-13.
  21. Shaffer, D., Gould, M. S., Fisher, P., Trautment, P., Moreau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348.
  22. Sorenson, S.B., Rutter, C.M. (1991). Transgenerational patterns of suicide attempt. Journal of Consulting and Clinical Psychology, 59, 861-866.
  23. de Wilde, E. J., Kienhorst, I. C., Diekstra, R. F., & Wolters, W. H. (1992). The relationship between adolescent suicidal behavior and life events in childhood and adolescence. American Journal of Psychiatry, 149, 45-51.
  24. Gould, M. S., Fisher, P., Parides, M., Flory, M., & Shaffer, D. (1996). Psychosocial risk factors of child and adolescent completed suicide. Archives of General Psychiatry, 53, 1155-1162.
  25. Brent, D.A., Perper, J.A., Moritz, G., Baugher, M., Schweers, J., & Roth, C. (1993). Firearms and adolescent suicide: A community case-control study. American Journal of Diseases of Children, 147, 1066-1071.
  26. Kellerman, A.L., Rivara, F.P., Rushford, N.B., et al. (1992). Suicide in the home in relationship to gun ownership. New England Journal of Medicine, 327, 467-472.
  27. Velting, D. M., & Gould, M. S. (1997). Suicide contagion. In R. W. Maris & M. M. Silverman (Eds.), Review of Suicidology (pp. 96-137). New York: Guilford Press.
  28. Hayes, L. M. (2000). Suicide prevention in juvenile facilities. Juvenile Justice, 7(1).
  29. U.S. Public Health Service (1999). The Surgeon General's Call To Action To Prevent Suicide, p. 9.
  30. U.S. Public Health Service (1999). The Surgeon General's Call To Action To Prevent Suicide, p. 9.
  31. U.S. Public Health Service (1999). The Surgeon General's Call To Action To Prevent Suicide, p. 9.
  32. U.S. Public Health Service (1999). The Surgeon General's Call To Action To Prevent Suicide, p. 11.
  33. National Institute of Mental Health (1999). Frequently Asked Questions About Suicide.
  34. National Institute of Mental Health (1999). Frequently Asked Questions About Suicide.
  35. National Institute of Mental Health (1999). Frequently Asked Questions About Suicide.
  36. National Institute of Mental Health (1999). Frequently Asked Questions About Suicide.
  37. U.S. Public Health Service (1999). The Surgeon General's Call To Action To Prevent Suicide, p. 10.