Community Outreach
To foster more discussion about violence among teens, APA accesses its national network of psychologists that it began developing at the outset of the "Talk to Someone Who Can Help" campaign. Almost every state and some provinces and practice divisions have a "Talk to Someone Who Can Help" public education campaign coordinator, who in turn has a local network of psychologists who are interested in community outreach and other public education activities.
These psychologists conduct community outreach events by using a VHS copy of the APAâ€"MTV "Warning Signs" documentary as a springboard for discussion with youth and others about violence. Special involvement kits were sent to APA's local public education campaign coordinators to help them prepare for activities that can be implemented in every community. The "how to" kits contain information for APA members on how to conduct community youth forums on violence, a discussion guide, a VHS copy of the documentary, how to alert media to the event, and how to conduct other grassroots activities. Any APA member can receive a free kit by contacting APA's Public Education Campaign Services Bureau toll-free number (1-877-274-8787, ext. 135).
APA members can take three basic approaches to organizing grassroots educational activities centered around the "Warning Signs" MTV special and the "Warning Signs" guide that lend themselves to copromotion with local MTV cable affiliates. (These three basic activities also can be done without the involvement of cable affiliates.) These are single-class school forums, multiple-class or assembly school forums, and community youth forums.
Single-class school forums.
Practitioners are partnering with middle or high schools in their community and identifying a class, such as a health class or a physical education class, where they hold a forum to watch "Warning Signs." After the show, they conduct a facilitated discussion with students about warning signs and ways to cope with anger and frustration, and they distribute copies of the "Warning Signs" brochure.
Multiple-class or assembly school forums.
Instead of targeting one class period, individual psychologists or regional, state, or local psychological associations have teamed up with a school in their community to provide a series of forums during a single day or to convene an entire school assembly at one time. Because more students are involved in this activity, a team of several psychologists is needed to conduct these forums.
Community youth forums.
Psychologists have identified and teamed up with community groups and organizations that provide a built-in audience for a youth forum. Youth groups at religious institutions, boys' and girls' clubs, and scouts are some of the kinds of groups that psychologists have targeted to capture not only a young audience but also concerned adults. As with the format for school forums, psychologists present the videotape and then facilitate a discussion on teen violence and possible warning signs.
This larger activity extends the information beyond schools and into the community. A community forum affords an ideal opportunity to invite community leaders and public officials to take part. For example, psychologists have invited the local mayor or police chief to talk about how serious a problem youth violence is in the community and what is being done to address it. In one instance, a U.S. Senator attended a psychologist-led youth forum.
In 1999, the "Warning Signs" initiative sought to (a) air the "Warning Signs" documentary at least once, (b) distribute 50,000 "Warning Signs" guides, and (c) convene a minimum of 50 psychologist-led school and community youth forums. The initiative received such overwhelming support from APA members that it greatly exceeded these targets. Because of its enormous success, almost all of APA's 1999 "Talk to Someone Who Can Help" public education campaign activities were related to the "Warning Signs" project.
Results of the APAâ€"MTV "Warning Signs" Initiative
Film Documentary Results
MTV reported that the "Warning Signs" documentary is the highest rated prosocial special in its history. Originally scheduled to air once in April 1999, the show appeared on MTV 13 times after the Columbine shooting incident. Some 3.9 million youth viewed the film.
The "Warning Signs" project received tremendous media attention, particularly at the forum that launched the effort inLos Angeles in April 1999 and at a second special forum in July 1999 in Littleton , Colorado
At the local level, psychologists have been interviewed on television and radio and by newspapers across the country about "Warning Signs." Practitioners also have publicized their local efforts through relationships with cable affiliates, who earlier received public service announcements about the "Warning Signs" project from MTV.
Guide Distribution and Collaborative Partnerships
Requests for the "Warning Signs" guide far exceeded the original distribution goal of 50,000. More than 27,700 individual consumers requested "Warning Signs" brochures from the toll-free number or via E-mail. Some 375,000 "Warning Signs" brochures were distributed in 1999 alone through single-copy and bulk requests through the toll-free number, on-line orders, psychologists conducting forums, and special requests from school districts ( APA Practice Directorate, 2000 ).
The project also helped to establish connections and nurture new partnerships. In the early stages of the "Warning Signs" initiative, APA forged a connection with U.S. Secretary of Education Richard Riley, who sent a letter to school officials throughout the country recommending that they incorporate the "Warning Signs" youth forum project into their curricula. (The Secretary's letter is now included in the project's campaign planning kit.) The U.S. Department of Education mailed 39,000 copies of the letter to middle schools, high schools, and state school boards. Members of the National Association of Secondary School Principals and the National School Board Association also received copies. Special packets featuring copies of the "Warning Signs" guide and the videotape were created for members of Congress. In addition, U.S. Attorney General Janet Reno expressed support for the program at an MTV news conference about antiviolence efforts in the summer of 1999.
APA collaborated with the YWCA and its "Week Without Violence" activities in October 1999. More than 350 YWCA community organizers received information about the "Warning Signs" campaign and were encouraged by the national director to integrate "Warning Signs" into their local efforts. Twenty-two YWCA chapters received "Warning Signs" brochures. As a result of this effort, aNorth Carolina
Finally, a publication of the U.S. Conference of Mayors, the U.S. Mayor , featured an article on the "Warning Signs" initiative that urged mayors to contact APA to set up forums in their communities. APA created a special toll-free line to respond to mayoral requests.
Community Outreach Activities
Since the launch of "Warning Signs" in April 1999, 613 psychologist-led youth forums were conducted through December 1999, more than 10 times the goal that APA originally hoped to achieve. These forums across the country attracted 58,461 youth and 12,918 adults to the meetings. Forums continue in 2000.
More than 2,400 practitioners have requested planning kits, giving at least 1 practitioner in every state the necessary tools to conduct youth antiviolence forums in schools and community centers. A total of 5,776 planning kits have been distributed through state training sessions and other means.
Training and Presentations
APA brought public education campaign coordinators together for a workshop on the "Warning Signs" initiative at the State Leadership Conference held inWashington , DC
Two special sessions on the "Warning Signs" project also were held in August during the national convention inBoston Kentucky , Minnesota , Puerto Rico, and Oklahoma
APA Consumer HelpCenter Website
On-line ordering of "Warning Signs" brochures enhanced the popularity of the HelpCenter website among consumers. The HelpCenter has been a part of the "Talk to Someone Who Can Help" campaign since its launch in 1996. The website was redesigned in February 1999 and received a total of 3,094,062 hits that year, with 461,809 on the "Warning Signs" guide page alone. Links from an array of popular websites such as MTV, MSNBC, CNN, Families First, and Parenthood Web have helped drive traffic to the site.
USA Today recognized the APA Consumer HelpCenter twice in its daily selection of hot sites, once shortly after the redesign of the website and again after the posting of the "Warning Signs" guide. Both USA Today and the Los Angeles Times cited it as 1 of their top 10 sites for 1999. ThirdAge.com, a content and community site for adults over age 45, listed the site as a "recommended" site, and the editors of the ABCs of Parenting directory (www.abcparenting.com) gave the site a four-star rating. The ABCs of Parenting directory provides websurfers with reviews and ratings of the best websites of interest to families and parents-to-be.
In the first-ever World Wide Web Health Award, the APA Consumer HelpCenter received gold awards in 1999 in two categories: Patient Education Information and Health Promotion/Disease and Injury Prevention Information.
A New Thrust in 2000
On March 9, 2000, APA launched a new component of the "Warning Signs" initiative targeting parents. The parenting component addresses a primary concern that emerged from hundreds of youth forums conducted across the country in 1999: Many teens said that it is difficult to communicate with adults, including their parents, about their problems and concerns. In addition, many parents involved in the youth forums requested forums of their own. As a result, APA developed a new planning kit to assist psychologists in setting up and facilitating forums for parents. The parenting component was introduced inOklahoma
Among other materials, the new parent kit contains a discussion guide, a communication tips sheet for parents, and a list of reading resources for parents. The "Warning Signs for Parents" kits are being sent to all current "Warning Signs for Youth" kit holders and will be made available to all APA members. Psychologists will be encouraged to host "Warning Signs for Parents" forums to help advise parents on how to talk to their children about violence, how to keep the lines of communication open, and how to listen effectively when their children are ready to talk about any type of difficult issue. These issues have been central to the "family relations" theme in the "Talk to Someone Who Can Help" campaign since its inception.
How the "Warning Signs" Initiative Began
The success of the "Warning Signs" initiative cannot be attributed solely to APAâ€"MTV activities in 1999. Its success is the culmination of APA's many years of planning and hard work on its "Talk to Someone Who Can Help" public education campaign dating back to 1995.
In 1995, as it became clear that the changing health care delivery system was having a negative and irreversible impact on psychologists, APA members began contacting APA's Practice Directorate about the need for additional advocacy beyond typical legislative lobbying. APA members expressed a common theme that "the public does not understand what we do." Members of the APA Council of Representatives also were receiving communication from members expressing the same concerns and looking to APA for help. In response to these concerns, the APA Council of Representatives, at its February 1995 meeting, directed APA's Office of Public Communication and the Practice Directorate to work together to develop and implement a public education campaign. The Council, recognizing that successful public education requires a sustained effort over a long period of time, allocated an ongoing budget of $1 million each year for 5 years for a public education campaign ( APA Council of Representatives, 1995 ). The campaign, called "Talk to Someone Who Can Help," was to focus on educating and informing consumers about the various roles of psychologists in public, private, and institutional health care; the education and training of psychologists; and the value of psychological interventions.
Public Opinion Research
In April 1995, APA hired two national public relations firms, Porter Novelli and Pacific Visions Communications, to help APA in creating APA's public information and education campaign. The first step was to measure the public's present knowledge of and attitudes toward mental health, psychologists, and the services that psychologists offer. Do consumers understand what psychological services are? What positive and negative attitudes do they hold about psychological services? What are their feelings about psychologists? Do people understand the difference between psychologists and other mental health professionals?
Without thoroughly evaluating the public's current level of understanding of the profession and what level and types of messages they could presently "hear," APA would run the risk of communicating messages that the public did not care about or could not assimilate or comprehend.
The public opinion research began in June 1995 and was completed in August 1995. It consisted of eight consumer focus groups and a national telephone survey of a random sample of 1,200 households. In addition, the researchers also held focus-group meetings with psychologists and members of APA's governance. (For an extensive discussion of the "Talk to Someone Who Can Help" campaign research, see Farberman, 1996. )
The significant findings showed that an information gap existed in the public's knowledge of psychology and psychological services: The public did not make distinctions among the different mental health providers, most respondents believed that their emotional health affects their physical health but were typically unwilling to pay more for mental health insurance coverage, most respondents agreed that psychological health is important, and almost half expressed interest in acquiring more information about how and when to seek psychological services. An exception to the public's lack of perceived value for mental health services involved children. Respondents believed that psychological services are important when children need mental health care (e.g., for a child who is doing poorly in school or who seems depressed), and respondents were willing to pay additional insurance coverage for it. A further interesting result was that for respondents, the educational level attained by the provider (e.g., PhD) was less important than finding a provider "you could trust and feel personally comfortable with" ( Farberman, 1996 ).
Campaign Development
The public opinion research findings guided APA in developing the thrust, themes, and messages for the "Talk to Someone Who Can Help" campaign. APA examined some of the public's concerns gleaned from both the focus groups and the public opinion poll and developed the campaign around three themes: job stress; the mindâ€"body connection; and family relations, in particular, the troubled teen. APA developed vignettes and strategic messages about psychology around these themes and tested these vignettes with focus groups to make sure the vignettes were actually saying what APA wanted them to conveyâ€"that people were understanding what psychologists do from hearing them. The vignettes were also tested for "generalizability," that is, if a person heard this story, would it make him or her think of other situations when a psychologist could be helpful?
Next, APA decided to focus on two campaign strategies. First, the campaign should focus on educating the public about psychology rather than on marketing psychology. Second, because APA's greatest resource is its members and because members are best positioned to deliver campaign messages, APA's membership would be the cornerstone of a grassroots public education campaign. Given the relatively small budget for the endeavor, APA realized that the campaign could not rely solely on paid advertising (e.g., the popular "Got Milk" campaign depends on a $200 million advertising budget per year).
Elements of the continuing "Talk to Someone Who Can Help" public education campaign include media relations, community outreach, and local advertising placement with the help of a national matching grant program. APA developed campaign materials and activities for each of these three areas. All materials were consistent with the themes and messages of the campaign. The materials developed for the "Talk to Someone Who Can Help" campaign were as follows:
"Talk to Someone Who Can Help" brochure: This brochure outlines the common life situations that can cause emotional stressâ€"job stress, family and relationship problems, and how one's mental and emotional state affects the prognosis of serious illness. It also illustrates instances when one needs professional psychological help as well as how therapy works;
an 800 number (1-800-964-2000) that anyone can call to receive a free copy of the brochure and/or be connected to the local state psychological association for a referral;
a Consumer HelpCenter website (www.helping.apa.org) that the public can access to learn more about psychology and psychological services. The site includes categories such as "how psychotherapy helps" and "how to find help for everyday problems" and an on-line version of the "Warning Signs" guide;
one television advertisement and three radio and newspaper advertisements covering the three major themes of the campaign. Pacific Visions Communications produced a series of radio commercials for APA including a "family relations" ad focused on a troubled teen;
"how to" kit for APA members for implementing campaign activities, from organizing, to media relations, to community outreach activities, to fund-raising for advertising placements; and
a bimonthly newsletter, Campaign Update, to apprise members of current activities.
Campaign Development Efforts at the Local Level
Concurrent with the development of materials at the national level, APA also began developing a nationwide campaign infrastructure through which activities could be routinely filtered down to the local level. APA began by getting the word out about the public education campaign to APA's membership through various internal communication channels and through numerous training sessions sponsored by state associations and practice divisions. Regional, state, and local affiliates were engaged to appoint a public education campaign coordinator to organize activities at the local level and to encourage member participation. Once several public education campaign coordinators were in place, APA distributed the Campaign Update newsletter to inform coordinators of current and upcoming activities and how to implement them at the local level.
Campaign Results
The "Talk to Someone Who Can Help" campaign activities began in 1996. By the end of 1998, 54 regional, state, and local associations and divisions had conducted campaign activities. Fifty associations had been involved in community outreach activities such as screening day activities and speaker bureau presentations. Thirty-four associations had engaged in media relations activities, and 11 had taken part in APA's matching advertising grant program and placed local advertising.
Overall, by the end of 1998, the "Talk to Someone Who Can Help" campaign generated 1,304,191 hits to its Consumer HelpCenter website; 5,029 APA members had requested "how to" kits; 11,070 consumers called the help line to receive the brochure or to request a local referral to a psychologist; and the campaign had generated 222,743,252 media impressions through advertising and local media.
In 1999, a spot in a series of radio advertisements developed by Pacific Visions Communications for "Talk to Someone Who Can Help" received a national Communicator Award. The honor is given by a national organization founded by communications professionals to recognize individuals and companies in the communications field whose talent and creativity achieve a high standard of excellence and serve as standards for the industry. The campaign's "family relations" radio commercial received the Crystal Award of Excellence in the associations/institutions category among the 1,300 entries submitted (13% of entries received awards).
Joint Ventures
From the outset of the campaign, APA considered it important to develop national joint ventures to extend the reach of the campaign and to fuel activities at the local level. Starting in 1996, 24 partnerships and joint ventures were established, such as joint ventures with Race for the Cure, Screening Days, and Breast Cancer Awareness Month. For example, the American Cancer Society encouraged its local chapters to collaborate with state and local psychological associations to bring greater awareness to consumers of the mindâ€"body connection and how it relates to overall health. APA's public education campaign was included in the resource guide of Perspectives , the American Association of Retired Persons' newsletter that targets 18,000 professionals who deliver services to older Americans. By the end of 1997, several state and local associations were routinely working with commercial establishments (e.g., Barnes & Noble and Borders bookstores) as venues for administering screening projects for depression, anxiety, eating disorders, and alcohol abuse.
Since its inception, the campaign has evolved from its launch and grassroots organizing phases in 1996 into a fully developed infrastructure made up of thousands of psychologists around the country. In 1998, APA believed that the campaign infrastructure at the national level was sufficiently developed to enable APA's Practice Directorate to cultivate a national joint venture that would have a significant impact nationwide. APA's criteria for such an initiative were as follows: (a) Its theme should address the public's health concerns as gleaned from the campaign's three main themesâ€"the mindâ€"body relationship in health care, work stress, and improvements in family relations, particularly help for troubled teens; (b) the theme should be one of national interest and concern because it would "catch on" only if the general public cared about the initiative's focus; and (c) the partner should give APA access to a large audience, one wider than what APA could reach on its own.
The APAâ€"MTV Joint Venture
APA's Practice Directorate came up with a number of ideas to pursue. One of these was developing a youth antiviolence campaign with MTV: MTV certainly had the attention of an audienceâ€"adolescentsâ€"that APA could not access on its own; youth antiviolence was relevant to one of APA's research-tested themes, specifically troubled teens; and it was an issue of national concern.
APA's initial contact with MTV proved to be fruitful. Within a week, meetings were convened with relevant MTV, APA, and Pacific Visions Communications personnel to further discuss APA's proposal. APA discussed its grassroots infrastructure of psychologists who could take the youth antiviolence material out into the community and talk with youth. It was this idea of community outreach, the active grassroots network, that set APA apart from the hundreds of other organizations that approach MTV each year proposing joint ventures.
With the "Warning Signs" initiative, the "Talk to Someone Who Can Help" public education campaign achieved new levels of success with unprecedented levels of practitioner activity around the country. The initiative has served as a catalyst for expanded practitioner involvement. For example, inMontana and North Dakota
"Warning Signs" has achieved multiple campaign goals by conveying the value of psychology to the next generation and by responding to a national need for information and tools that help to curb youth violence. Its success has also provided a springboard for future joint ventures with other media entities as the "Talk to Someone Who Can Help" campaign continues to expand.
To foster more discussion about violence among teens, APA accesses its national network of psychologists that it began developing at the outset of the "Talk to Someone Who Can Help" campaign. Almost every state and some provinces and practice divisions have a "Talk to Someone Who Can Help" public education campaign coordinator, who in turn has a local network of psychologists who are interested in community outreach and other public education activities.
These psychologists conduct community outreach events by using a VHS copy of the APAâ€"MTV "Warning Signs" documentary as a springboard for discussion with youth and others about violence. Special involvement kits were sent to APA's local public education campaign coordinators to help them prepare for activities that can be implemented in every community. The "how to" kits contain information for APA members on how to conduct community youth forums on violence, a discussion guide, a VHS copy of the documentary, how to alert media to the event, and how to conduct other grassroots activities. Any APA member can receive a free kit by contacting APA's Public Education Campaign Services Bureau toll-free number (1-877-274-8787, ext. 135).
APA members can take three basic approaches to organizing grassroots educational activities centered around the "Warning Signs" MTV special and the "Warning Signs" guide that lend themselves to copromotion with local MTV cable affiliates. (These three basic activities also can be done without the involvement of cable affiliates.) These are single-class school forums, multiple-class or assembly school forums, and community youth forums.
Single-class school forums.
Practitioners are partnering with middle or high schools in their community and identifying a class, such as a health class or a physical education class, where they hold a forum to watch "Warning Signs." After the show, they conduct a facilitated discussion with students about warning signs and ways to cope with anger and frustration, and they distribute copies of the "Warning Signs" brochure.
Multiple-class or assembly school forums.
Instead of targeting one class period, individual psychologists or regional, state, or local psychological associations have teamed up with a school in their community to provide a series of forums during a single day or to convene an entire school assembly at one time. Because more students are involved in this activity, a team of several psychologists is needed to conduct these forums.
Community youth forums.
Psychologists have identified and teamed up with community groups and organizations that provide a built-in audience for a youth forum. Youth groups at religious institutions, boys' and girls' clubs, and scouts are some of the kinds of groups that psychologists have targeted to capture not only a young audience but also concerned adults. As with the format for school forums, psychologists present the videotape and then facilitate a discussion on teen violence and possible warning signs.
This larger activity extends the information beyond schools and into the community. A community forum affords an ideal opportunity to invite community leaders and public officials to take part. For example, psychologists have invited the local mayor or police chief to talk about how serious a problem youth violence is in the community and what is being done to address it. In one instance, a U.S. Senator attended a psychologist-led youth forum.
In 1999, the "Warning Signs" initiative sought to (a) air the "Warning Signs" documentary at least once, (b) distribute 50,000 "Warning Signs" guides, and (c) convene a minimum of 50 psychologist-led school and community youth forums. The initiative received such overwhelming support from APA members that it greatly exceeded these targets. Because of its enormous success, almost all of APA's 1999 "Talk to Someone Who Can Help" public education campaign activities were related to the "Warning Signs" project.
Results of the APAâ€"MTV "Warning Signs" Initiative
Film Documentary Results
MTV reported that the "Warning Signs" documentary is the highest rated prosocial special in its history. Originally scheduled to air once in April 1999, the show appeared on MTV 13 times after the Columbine shooting incident. Some 3.9 million youth viewed the film.
The "Warning Signs" project received tremendous media attention, particularly at the forum that launched the effort in
At the local level, psychologists have been interviewed on television and radio and by newspapers across the country about "Warning Signs." Practitioners also have publicized their local efforts through relationships with cable affiliates, who earlier received public service announcements about the "Warning Signs" project from MTV.
Guide Distribution and Collaborative Partnerships
Requests for the "Warning Signs" guide far exceeded the original distribution goal of 50,000. More than 27,700 individual consumers requested "Warning Signs" brochures from the toll-free number or via E-mail. Some 375,000 "Warning Signs" brochures were distributed in 1999 alone through single-copy and bulk requests through the toll-free number, on-line orders, psychologists conducting forums, and special requests from school districts ( APA Practice Directorate, 2000 ).
The project also helped to establish connections and nurture new partnerships. In the early stages of the "Warning Signs" initiative, APA forged a connection with U.S. Secretary of Education Richard Riley, who sent a letter to school officials throughout the country recommending that they incorporate the "Warning Signs" youth forum project into their curricula. (The Secretary's letter is now included in the project's campaign planning kit.) The U.S. Department of Education mailed 39,000 copies of the letter to middle schools, high schools, and state school boards. Members of the National Association of Secondary School Principals and the National School Board Association also received copies. Special packets featuring copies of the "Warning Signs" guide and the videotape were created for members of Congress. In addition, U.S. Attorney General Janet Reno expressed support for the program at an MTV news conference about antiviolence efforts in the summer of 1999.
APA collaborated with the YWCA and its "Week Without Violence" activities in October 1999. More than 350 YWCA community organizers received information about the "Warning Signs" campaign and were encouraged by the national director to integrate "Warning Signs" into their local efforts. Twenty-two YWCA chapters received "Warning Signs" brochures. As a result of this effort, a
Finally, a publication of the U.S. Conference of Mayors, the U.S. Mayor , featured an article on the "Warning Signs" initiative that urged mayors to contact APA to set up forums in their communities. APA created a special toll-free line to respond to mayoral requests.
Community Outreach Activities
Since the launch of "Warning Signs" in April 1999, 613 psychologist-led youth forums were conducted through December 1999, more than 10 times the goal that APA originally hoped to achieve. These forums across the country attracted 58,461 youth and 12,918 adults to the meetings. Forums continue in 2000.
More than 2,400 practitioners have requested planning kits, giving at least 1 practitioner in every state the necessary tools to conduct youth antiviolence forums in schools and community centers. A total of 5,776 planning kits have been distributed through state training sessions and other means.
Training and Presentations
APA brought public education campaign coordinators together for a workshop on the "Warning Signs" initiative at the State Leadership Conference held in
Two special sessions on the "Warning Signs" project also were held in August during the national convention in
APA Consumer HelpCenter Website
On-line ordering of "Warning Signs" brochures enhanced the popularity of the HelpCenter website among consumers. The HelpCenter has been a part of the "Talk to Someone Who Can Help" campaign since its launch in 1996. The website was redesigned in February 1999 and received a total of 3,094,062 hits that year, with 461,809 on the "Warning Signs" guide page alone. Links from an array of popular websites such as MTV, MSNBC, CNN, Families First, and Parenthood Web have helped drive traffic to the site.
USA Today recognized the APA Consumer HelpCenter twice in its daily selection of hot sites, once shortly after the redesign of the website and again after the posting of the "Warning Signs" guide. Both USA Today and the Los Angeles Times cited it as 1 of their top 10 sites for 1999. ThirdAge.com, a content and community site for adults over age 45, listed the site as a "recommended" site, and the editors of the ABCs of Parenting directory (www.abcparenting.com) gave the site a four-star rating. The ABCs of Parenting directory provides websurfers with reviews and ratings of the best websites of interest to families and parents-to-be.
In the first-ever World Wide Web Health Award, the APA Consumer HelpCenter received gold awards in 1999 in two categories: Patient Education Information and Health Promotion/Disease and Injury Prevention Information.
A New Thrust in 2000
On March 9, 2000, APA launched a new component of the "Warning Signs" initiative targeting parents. The parenting component addresses a primary concern that emerged from hundreds of youth forums conducted across the country in 1999: Many teens said that it is difficult to communicate with adults, including their parents, about their problems and concerns. In addition, many parents involved in the youth forums requested forums of their own. As a result, APA developed a new planning kit to assist psychologists in setting up and facilitating forums for parents. The parenting component was introduced in
Among other materials, the new parent kit contains a discussion guide, a communication tips sheet for parents, and a list of reading resources for parents. The "Warning Signs for Parents" kits are being sent to all current "Warning Signs for Youth" kit holders and will be made available to all APA members. Psychologists will be encouraged to host "Warning Signs for Parents" forums to help advise parents on how to talk to their children about violence, how to keep the lines of communication open, and how to listen effectively when their children are ready to talk about any type of difficult issue. These issues have been central to the "family relations" theme in the "Talk to Someone Who Can Help" campaign since its inception.
How the "Warning Signs" Initiative Began
The success of the "Warning Signs" initiative cannot be attributed solely to APAâ€"MTV activities in 1999. Its success is the culmination of APA's many years of planning and hard work on its "Talk to Someone Who Can Help" public education campaign dating back to 1995.
In 1995, as it became clear that the changing health care delivery system was having a negative and irreversible impact on psychologists, APA members began contacting APA's Practice Directorate about the need for additional advocacy beyond typical legislative lobbying. APA members expressed a common theme that "the public does not understand what we do." Members of the APA Council of Representatives also were receiving communication from members expressing the same concerns and looking to APA for help. In response to these concerns, the APA Council of Representatives, at its February 1995 meeting, directed APA's Office of Public Communication and the Practice Directorate to work together to develop and implement a public education campaign. The Council, recognizing that successful public education requires a sustained effort over a long period of time, allocated an ongoing budget of $1 million each year for 5 years for a public education campaign ( APA Council of Representatives, 1995 ). The campaign, called "Talk to Someone Who Can Help," was to focus on educating and informing consumers about the various roles of psychologists in public, private, and institutional health care; the education and training of psychologists; and the value of psychological interventions.
Public Opinion Research
In April 1995, APA hired two national public relations firms, Porter Novelli and Pacific Visions Communications, to help APA in creating APA's public information and education campaign. The first step was to measure the public's present knowledge of and attitudes toward mental health, psychologists, and the services that psychologists offer. Do consumers understand what psychological services are? What positive and negative attitudes do they hold about psychological services? What are their feelings about psychologists? Do people understand the difference between psychologists and other mental health professionals?
Without thoroughly evaluating the public's current level of understanding of the profession and what level and types of messages they could presently "hear," APA would run the risk of communicating messages that the public did not care about or could not assimilate or comprehend.
The public opinion research began in June 1995 and was completed in August 1995. It consisted of eight consumer focus groups and a national telephone survey of a random sample of 1,200 households. In addition, the researchers also held focus-group meetings with psychologists and members of APA's governance. (For an extensive discussion of the "Talk to Someone Who Can Help" campaign research, see Farberman, 1996. )
The significant findings showed that an information gap existed in the public's knowledge of psychology and psychological services: The public did not make distinctions among the different mental health providers, most respondents believed that their emotional health affects their physical health but were typically unwilling to pay more for mental health insurance coverage, most respondents agreed that psychological health is important, and almost half expressed interest in acquiring more information about how and when to seek psychological services. An exception to the public's lack of perceived value for mental health services involved children. Respondents believed that psychological services are important when children need mental health care (e.g., for a child who is doing poorly in school or who seems depressed), and respondents were willing to pay additional insurance coverage for it. A further interesting result was that for respondents, the educational level attained by the provider (e.g., PhD) was less important than finding a provider "you could trust and feel personally comfortable with" ( Farberman, 1996 ).
Campaign Development
The public opinion research findings guided APA in developing the thrust, themes, and messages for the "Talk to Someone Who Can Help" campaign. APA examined some of the public's concerns gleaned from both the focus groups and the public opinion poll and developed the campaign around three themes: job stress; the mindâ€"body connection; and family relations, in particular, the troubled teen. APA developed vignettes and strategic messages about psychology around these themes and tested these vignettes with focus groups to make sure the vignettes were actually saying what APA wanted them to conveyâ€"that people were understanding what psychologists do from hearing them. The vignettes were also tested for "generalizability," that is, if a person heard this story, would it make him or her think of other situations when a psychologist could be helpful?
Next, APA decided to focus on two campaign strategies. First, the campaign should focus on educating the public about psychology rather than on marketing psychology. Second, because APA's greatest resource is its members and because members are best positioned to deliver campaign messages, APA's membership would be the cornerstone of a grassroots public education campaign. Given the relatively small budget for the endeavor, APA realized that the campaign could not rely solely on paid advertising (e.g., the popular "Got Milk" campaign depends on a $200 million advertising budget per year).
Elements of the continuing "Talk to Someone Who Can Help" public education campaign include media relations, community outreach, and local advertising placement with the help of a national matching grant program. APA developed campaign materials and activities for each of these three areas. All materials were consistent with the themes and messages of the campaign. The materials developed for the "Talk to Someone Who Can Help" campaign were as follows:
"Talk to Someone Who Can Help" brochure: This brochure outlines the common life situations that can cause emotional stressâ€"job stress, family and relationship problems, and how one's mental and emotional state affects the prognosis of serious illness. It also illustrates instances when one needs professional psychological help as well as how therapy works;
an 800 number (1-800-964-2000) that anyone can call to receive a free copy of the brochure and/or be connected to the local state psychological association for a referral;
a Consumer HelpCenter website (www.helping.apa.org) that the public can access to learn more about psychology and psychological services. The site includes categories such as "how psychotherapy helps" and "how to find help for everyday problems" and an on-line version of the "Warning Signs" guide;
one television advertisement and three radio and newspaper advertisements covering the three major themes of the campaign. Pacific Visions Communications produced a series of radio commercials for APA including a "family relations" ad focused on a troubled teen;
"how to" kit for APA members for implementing campaign activities, from organizing, to media relations, to community outreach activities, to fund-raising for advertising placements; and
a bimonthly newsletter, Campaign Update, to apprise members of current activities.
Campaign Development Efforts at the Local Level
Concurrent with the development of materials at the national level, APA also began developing a nationwide campaign infrastructure through which activities could be routinely filtered down to the local level. APA began by getting the word out about the public education campaign to APA's membership through various internal communication channels and through numerous training sessions sponsored by state associations and practice divisions. Regional, state, and local affiliates were engaged to appoint a public education campaign coordinator to organize activities at the local level and to encourage member participation. Once several public education campaign coordinators were in place, APA distributed the Campaign Update newsletter to inform coordinators of current and upcoming activities and how to implement them at the local level.
Campaign Results
The "Talk to Someone Who Can Help" campaign activities began in 1996. By the end of 1998, 54 regional, state, and local associations and divisions had conducted campaign activities. Fifty associations had been involved in community outreach activities such as screening day activities and speaker bureau presentations. Thirty-four associations had engaged in media relations activities, and 11 had taken part in APA's matching advertising grant program and placed local advertising.
Overall, by the end of 1998, the "Talk to Someone Who Can Help" campaign generated 1,304,191 hits to its Consumer HelpCenter website; 5,029 APA members had requested "how to" kits; 11,070 consumers called the help line to receive the brochure or to request a local referral to a psychologist; and the campaign had generated 222,743,252 media impressions through advertising and local media.
In 1999, a spot in a series of radio advertisements developed by Pacific Visions Communications for "Talk to Someone Who Can Help" received a national Communicator Award. The honor is given by a national organization founded by communications professionals to recognize individuals and companies in the communications field whose talent and creativity achieve a high standard of excellence and serve as standards for the industry. The campaign's "family relations" radio commercial received the Crystal Award of Excellence in the associations/institutions category among the 1,300 entries submitted (13% of entries received awards).
Joint Ventures
From the outset of the campaign, APA considered it important to develop national joint ventures to extend the reach of the campaign and to fuel activities at the local level. Starting in 1996, 24 partnerships and joint ventures were established, such as joint ventures with Race for the Cure, Screening Days, and Breast Cancer Awareness Month. For example, the American Cancer Society encouraged its local chapters to collaborate with state and local psychological associations to bring greater awareness to consumers of the mindâ€"body connection and how it relates to overall health. APA's public education campaign was included in the resource guide of Perspectives , the American Association of Retired Persons' newsletter that targets 18,000 professionals who deliver services to older Americans. By the end of 1997, several state and local associations were routinely working with commercial establishments (e.g., Barnes & Noble and Borders bookstores) as venues for administering screening projects for depression, anxiety, eating disorders, and alcohol abuse.
Since its inception, the campaign has evolved from its launch and grassroots organizing phases in 1996 into a fully developed infrastructure made up of thousands of psychologists around the country. In 1998, APA believed that the campaign infrastructure at the national level was sufficiently developed to enable APA's Practice Directorate to cultivate a national joint venture that would have a significant impact nationwide. APA's criteria for such an initiative were as follows: (a) Its theme should address the public's health concerns as gleaned from the campaign's three main themesâ€"the mindâ€"body relationship in health care, work stress, and improvements in family relations, particularly help for troubled teens; (b) the theme should be one of national interest and concern because it would "catch on" only if the general public cared about the initiative's focus; and (c) the partner should give APA access to a large audience, one wider than what APA could reach on its own.
The APAâ€"MTV Joint Venture
APA's Practice Directorate came up with a number of ideas to pursue. One of these was developing a youth antiviolence campaign with MTV: MTV certainly had the attention of an audienceâ€"adolescentsâ€"that APA could not access on its own; youth antiviolence was relevant to one of APA's research-tested themes, specifically troubled teens; and it was an issue of national concern.
APA's initial contact with MTV proved to be fruitful. Within a week, meetings were convened with relevant MTV, APA, and Pacific Visions Communications personnel to further discuss APA's proposal. APA discussed its grassroots infrastructure of psychologists who could take the youth antiviolence material out into the community and talk with youth. It was this idea of community outreach, the active grassroots network, that set APA apart from the hundreds of other organizations that approach MTV each year proposing joint ventures.
With the "Warning Signs" initiative, the "Talk to Someone Who Can Help" public education campaign achieved new levels of success with unprecedented levels of practitioner activity around the country. The initiative has served as a catalyst for expanded practitioner involvement. For example, in
"Warning Signs" has achieved multiple campaign goals by conveying the value of psychology to the next generation and by responding to a national need for information and tools that help to curb youth violence. Its success has also provided a springboard for future joint ventures with other media entities as the "Talk to Someone Who Can Help" campaign continues to expand.
Professional Psychology: Research and Practice © 2000 by the American Psychological AssociationÂ
October 2000 Vol. 31, No. 5, 509-514
For personal use only--not for distribution.Â
Helping to Curb Youth Violence
The APAâ€"MTV "Warning Signs" Initiative
Jan L. Peterson
American Psychological Association
Russ Newman
American Psychological Association
ABSTRACT
This article describes how the joint American Psychological Association (APA)â€"Music Television "Warning Signs" initiative evolved, its nationwide impact, and the history of APA's 4-year "Talk to Someone Who Can Help" effort that provided the basis for it. "Warning Signs," aimed at helping the nation's youth to identify the warning signs of violent behavior and to recognize the need to seek professional help, has brought new levels of visibility to APA's public education campaign. It has greatly energized and mobilized psychologists nationwide for expanded practitioner involvement at both the national and community levels. Not only has the project responded to the call for national prevention efforts to curb youth violence, but it also has served as an effective medium for educating youth, adults, and their communities about the value of psychology.
--------------------------------------------------------------------------------
Intentional interpersonal violence accounts for one third of all injury-related deaths in theUnited States
The APAâ€"MTV "Warning Signs" Initiative
The rash of school shootings in recent years has heightened fears about the increasing amount of violence in the lives of American youth and provided the impetus for a unique partnership aimed at dealing with this problem. As part of a public education campaign entitled "Talk to Someone Who Can Help," the American Psychological Association (APA) launched an initiative to help prevent youth violence ( Zabriskie, 1999 ). In 1998, APA's Practice Directorate forged a partnership with Music Television (MTV) to develop a youth antiviolence initiative called "Warning Signs." The goal of the initiative was to help the nation's youth in identifying the warning signs of violent behavior and recognizing the need to get help should they see any of the warning signs in themselves or in their peers. According to a 1999 APAâ€"Penn, Schoen and Berland Associates' poll, 71% of youth said they wanted to learn the violence warning signs, and 40% have been concerned about a potentially violent classmate.
The problem of youth violence is rooted in many levels throughout society, and to address its causes will require interventions at multiple levels. In the meantime, however, APA and MTV hope that by educating youth to recognize the warning signs of violence and to seek help when problems arise, the "Warning Signs" initiative will provide youth with an important stop-gap measure that can help them to intercede in a violent act before it occurs.
The APAâ€"MTV initiative is reaching out to youth audiences nationwide in three ways: (a) a 30-minute MTV documentary, "Warning Signs," on youth and violence; (b) a "Warning Signs" guide on violence prevention, which is available to youth and the general public free of charge through a toll-free number; and (c) nationwide presentations by psychologists to youth on the topic of violence.
The "Warning Signs" campaign officially kicked off with a youth forum held inLos Angeles , California Columbine High School Los Angeles County
"Warning Signs" Documentary
The 30-minute documentary, coproduced by MTV and APA, shows vignettes of violent episodes that actually happened in American schools and explores the feelings, thoughts, opinions, and fears of teenagers and young adults who were connected to the incidents. Expert psychologists appear on the show, calling attention to warning signs in youth behavior that may be precursors to violent acts. During commercial breaks and at the end of the documentary, MTV viewers are provided with APA's toll-free number (1-800-268-0078) and APA's HelpCenter website address (www.helping.apa.org) so they can request a free copy of the "Warning Signs" guide. Callers can also request local referral information for a psychologist. This toll-free number is also publicized in a youth action guide produced by the U.S. Department of Justice that began distribution in February 1999.
"Warning Signs" Guide
The "Warning Signs" guide, developed by APA and designed by MTV, is a handy brochure that complements the film documentary. The guide is intended to help young people recognize when a classmate or a friend might be a potential danger to himself or herself or others. It outlines
factors that contribute to violent behavior,
reasons for violence,
ways to recognize violence warning signs in others,
what one can do if someone shows violence warning signs,
how to deal with anger,
how to control one's own risk for violent behavior, and
warning signs of potential self-violence.
Examples of indicators for potential violence in the guide include
losing one's temper on a daily basis,
significant vandalism or property damage,
increase in use of drugs or alcohol,
increase in risk-taking behavior,
enjoyment in hurting animals,
frequent physical fighting, and
threatening to hurt others.
The guide also provides suggestions for identifying and controlling the thoughts and feelings that may lead to violence. For example, violence can be a way that people express pent-up feelings of anger or frustration, or it can be used as a tool to control others. Unfortunately, because there is no single cause of violent behavior, there is no single sign or single solution.
The brochure is available to the public by calling APA at 1-800-268-0078 or by going on-line to APA's HelpCenter website: www.helping.apa.org.
October 2000 Vol. 31, No. 5, 509-514
For personal use only--not for distribution.Â
Helping to Curb Youth Violence
The APAâ€"MTV "Warning Signs" Initiative
Jan L. Peterson
American Psychological Association
Russ Newman
American Psychological Association
ABSTRACT
This article describes how the joint American Psychological Association (APA)â€"Music Television "Warning Signs" initiative evolved, its nationwide impact, and the history of APA's 4-year "Talk to Someone Who Can Help" effort that provided the basis for it. "Warning Signs," aimed at helping the nation's youth to identify the warning signs of violent behavior and to recognize the need to seek professional help, has brought new levels of visibility to APA's public education campaign. It has greatly energized and mobilized psychologists nationwide for expanded practitioner involvement at both the national and community levels. Not only has the project responded to the call for national prevention efforts to curb youth violence, but it also has served as an effective medium for educating youth, adults, and their communities about the value of psychology.
--------------------------------------------------------------------------------
Intentional interpersonal violence accounts for one third of all injury-related deaths in the
The APAâ€"MTV "Warning Signs" Initiative
The rash of school shootings in recent years has heightened fears about the increasing amount of violence in the lives of American youth and provided the impetus for a unique partnership aimed at dealing with this problem. As part of a public education campaign entitled "Talk to Someone Who Can Help," the American Psychological Association (APA) launched an initiative to help prevent youth violence ( Zabriskie, 1999 ). In 1998, APA's Practice Directorate forged a partnership with Music Television (MTV) to develop a youth antiviolence initiative called "Warning Signs." The goal of the initiative was to help the nation's youth in identifying the warning signs of violent behavior and recognizing the need to get help should they see any of the warning signs in themselves or in their peers. According to a 1999 APAâ€"Penn, Schoen and Berland Associates' poll, 71% of youth said they wanted to learn the violence warning signs, and 40% have been concerned about a potentially violent classmate.
The problem of youth violence is rooted in many levels throughout society, and to address its causes will require interventions at multiple levels. In the meantime, however, APA and MTV hope that by educating youth to recognize the warning signs of violence and to seek help when problems arise, the "Warning Signs" initiative will provide youth with an important stop-gap measure that can help them to intercede in a violent act before it occurs.
The APAâ€"MTV initiative is reaching out to youth audiences nationwide in three ways: (a) a 30-minute MTV documentary, "Warning Signs," on youth and violence; (b) a "Warning Signs" guide on violence prevention, which is available to youth and the general public free of charge through a toll-free number; and (c) nationwide presentations by psychologists to youth on the topic of violence.
The "Warning Signs" campaign officially kicked off with a youth forum held in
"Warning Signs" Documentary
The 30-minute documentary, coproduced by MTV and APA, shows vignettes of violent episodes that actually happened in American schools and explores the feelings, thoughts, opinions, and fears of teenagers and young adults who were connected to the incidents. Expert psychologists appear on the show, calling attention to warning signs in youth behavior that may be precursors to violent acts. During commercial breaks and at the end of the documentary, MTV viewers are provided with APA's toll-free number (1-800-268-0078) and APA's HelpCenter website address (www.helping.apa.org) so they can request a free copy of the "Warning Signs" guide. Callers can also request local referral information for a psychologist. This toll-free number is also publicized in a youth action guide produced by the U.S. Department of Justice that began distribution in February 1999.
"Warning Signs" Guide
The "Warning Signs" guide, developed by APA and designed by MTV, is a handy brochure that complements the film documentary. The guide is intended to help young people recognize when a classmate or a friend might be a potential danger to himself or herself or others. It outlines
factors that contribute to violent behavior,
reasons for violence,
ways to recognize violence warning signs in others,
what one can do if someone shows violence warning signs,
how to deal with anger,
how to control one's own risk for violent behavior, and
warning signs of potential self-violence.
Examples of indicators for potential violence in the guide include
losing one's temper on a daily basis,
significant vandalism or property damage,
increase in use of drugs or alcohol,
increase in risk-taking behavior,
enjoyment in hurting animals,
frequent physical fighting, and
threatening to hurt others.
The guide also provides suggestions for identifying and controlling the thoughts and feelings that may lead to violence. For example, violence can be a way that people express pent-up feelings of anger or frustration, or it can be used as a tool to control others. Unfortunately, because there is no single cause of violent behavior, there is no single sign or single solution.
The brochure is available to the public by calling APA at 1-800-268-0078 or by going on-line to APA's HelpCenter website: www.helping.apa.org.
Ovid Technologies, Inc. Email Service
------------------------------
Full Text of: VERMEIREN: J Am Acad Child Adolesc Psychiatry, Volume 42(1).January
2003.41-48
Journal of the American Academy of Child & Adolescent Psychiatry
Copyright 2003 (C) American Academy of Child and Adolescent Psychiatry
----------------------------------------------
Volume 42(1) January 2003 pp 41-48
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Suicidal Behavior and Violence in Male Adolescents: A School-Based Study
[Articles]
VERMEIREN, ROBERT M.D., PH.D.; SCHWAB-STONE, MARY M.D.; RUCHKIN, VLADISLAV V.
M.D., PH.D.; KING, ROBERT A. M.D.; VAN HEERINGEN, CORNELIS M.D., PH.D.;
DEBOUTTE, DIRK M.D., PH.D.
From the University Department of Child and Adolescent Psychiatry, Middelheimhospital,
University of Antwerp, Belgium (Drs. Vermeiren and Deboutte); Yale Child Study
Center, New Haven, CT (Drs. Schwab-Stone, Ruchkin, and King); and Unit for
Suicide Research, University of Ghent, Belgium (Dr. Van Heeringen).
Accepted July 23, 2002.
This article was written when the first author was Belgian American Educational
Foundation Research Fellow in theYale Child Study Center
appreciate the support of the Hewlett Foundation for the Yale Child Study
Program on International Child Mental Health. The authors gratefully acknowledge
the support and helpful guidance of Donald J. Cohen, M.D., the late Director,
Yale Child Study Center
Reprint requests to Dr. Vermeiren, UCKJA, Middelheimhospital, Lindendreef 1,
2020Antwerp , Belgium
DOI: 10.1097/01.CHI.0000024905.60748.73
----------------------------------------------
Outline
ABSTRACT
METHOD
Sample
Procedure
Instruments
Socioeconomic Status.
Delinquency Questionnaire.
Suicidal Behavior.
Behavior Assessment System for Children.
Expectations About the Future.
Buss-Durkee Hostility Inventory-Dutch Version.
Alcohol and Marijuana Use.
Diminished Perception of Risk.
Statistical Analysis
RESULTS
Description of Comparison Groups
Sociodemographic Characteristics and Suicide Attempts
Internalizing Problems
Aggression
Risk-Taking Behavior and Sensation Seeking
Interaction Between Suicidal Behavior and Violent Behavior
Logistic Regression
DISCUSSION
Clinical Implications
Limitations
REFERENCES
Graphics
Table 1
Table 2
Table 3
----------------------------------------------
ABSTRACT
Objective: To investigate characteristics of suicidal and violent behavior in a
community school sample of adolescents.
: Self-report questionnaires were administered to 794 male students (aged 12-18
years) fromAntwerp , Belgium
suicidal-only (n = 40; suicidal ideation and/or self-harming behavior), a
violent-only (n = 142), a suicidal-violent (n = 21), and a control group (n =
591).
: Compared with controls, higher levels of internalizing problems, risk-taking
behavior (substance use, diminished perception of risk, sensation seeking), and
aggression were found in the comparison groups. The suicidal-violent group had
the highest levels of depression, somatization, overt and covert aggression, and
risk-taking behavior. Compared with the suicidal-only group, the violent-only
group had less depression, anxiety, and covert aggression, but higher levels of
overt aggression, sensation seeking, diminished perception of risk, and
marijuana use.
Conclusions: Although adolescent suicidal and violent behavior are both related
to internalizing problems, aggression, and risk-taking behavior, marked
differences in severity and nature exist in these relationships. Differentiation
of suicidal youths based on the presence or absence of violent behavior may add
to our understanding of suicidal phenomena and may thus have important clinical
consequences.
----------------------------------------------
A strong body of literature has demonstrated an association between violent
and/or antisocial and suicidal behavior (Plutchik and van Praag, 1997). Evidence
for the association between both conditions in adolescents derives from
different sources. First, psychological autopsy studies have found that the
proportion of young suicides in which a disruptive behavior disorder could be
diagnosed ranged from 20% to 50% (Brent et al., 1993;Marttunen et al.,
1991;Shaffer et al., 1996). Second, epidemiological studies have shown that
disruptive disorders are more prevalent in youthful suicide ideators and/or
attempters than controls and that child and adolescent suicidal ideation and/or
attempts are associated with violent and risk-taking behavior (e.g., substance
use) (King et al., 2001;Orpinas et al., 1995;Sosin et al., 1995;Woods et al.,
1997). Similarly, clinical studies have shown that youthful suicidal patients
fairly often reveal histories of violent behavior (Cohen-Sandler et al., 1982),
while others found aggression to be associated with repetition of attempted
suicide in adolescents (Stein et al., 1998). Also, studies of incarcerated
delinquent male youths have shown high prevalence rates of current suicidal
ideation (13%-19%) (Morris et al., 1995;Rohde et al., 1997).
Further evidence for an association between suicidality and aggression comes
from family aggregation studies (Botsis et al., 1995;Pfeffer et al., 1994), in
which an increased level of antisocial and aggressive behavior in first-degree
relatives of suicidal adolescents has been demonstrated. In addition, higher
rates of aggression in young suicide victims have been related to higher
loadings of suicide attempts in the family (Brent et al., 1996). Biological
psychiatric research has demonstrated a pathogenetic role of serotonergic
dysregulation in the development of both violent and suicidal behavior
(Traskman-Bendz and Mann, 2000). However, the mechanisms that may determine the
direction of aggression, i.e., inward or outward or both, still remain unclear.
An important line of research focuses specifically on the association between
aggression and suicidal behavior. Although, as Plutchik and van Praag (1990)
point out, the psychoanalytic idea that suicide reflects violence turned inward
has some validity, it does not help us to understand why some aggressive people
are suicidal while others are not. Consequently, Plutchik and van Praag (1997)
developed a model that focuses specifically on the interconnection between
violent and suicidal behavior. The model is based on evidence that aggression,
described as an adaptive inner state, is influenced by a number of amplifiers
and attenuators that may produce overt violence toward others or oneself.
Plutchik and van Praag (1997) described almost 40 psychiatric, biological,
personality-related, social, and familial variables as risk factors for violent
behavior, of which more than half were also associated with an increased risk of
suicidal behavior.
Apter et al. (1995) hypothesized that at least two types of suicidal behaviors
can be discerned during adolescence. The first behavior reflects a wish to die
and characterizes suicidal behavior in depressive disorders, while the second is
characterized by impulse control problems and is commonly associated with
externalizing disorders, such as conduct disorder. In a clinical sample of
adolescents, Pfeffer et al. (1989) differentiated four groups based on the
presence or absence of suicidal or assaultive behavior and found that, compared
with controls, the group showing suicidal behavior was characterized by
depression, drug use, and environmental stress, whereas the assaultive-only
behavior group showed aggression and violence. The combined assaultive-suicidal
behavior group showed both accidents and violence. Horesh et al. (1999)
investigated the role of impulsivity and demonstrated a relationship between
suicidal behavior and impulsivity, even after controlling for aggression.
Although of great importance for understanding the underlying mechanisms of
suicide and violent behavior, the limitation of these studies was the almost
exclusive reliance on clinical samples. Therefore, the current study aimed at
examining suicidal and violent behavior in a community sample of adolescent
students. This study was designed to examine and compare characteristics of
youths with suicidal ideation/behavior only (suicidal-only), those with violent
behavior only (violent-only), and those with histories of both suicidal
ideation/behavior and violent behavior (suicidal-violent) with respect to
internalizing problems, aggression, and risk-taking behavior. Suicidal
adolescents were predicted to show primarily internalizing problems, risk-taking
behavior, and some increase in aggression, while violent and combined violent-suicidal
subjects were predicted to show increased aggression and risk-taking behavior.
METHOD
Sample
Subjects were adolescents participating in an ongoing cross-cultural project
assessing risk and protective factors for adolescent adjustment. For this study,
self-report surveys administered to a school sample of adolescents (aged 12-18
years) in Antwerp, Belgium, were used. Fifteen percent of the students were
absent on the day of administration. Of the surveyed group (N = 1,634), 125
subjects provided incomplete or inconsistent surveys and some classes (77
students) did not complete the questionnaires used for this study, so that the
total study group consisted of 1,432 students (male 794, female 638). Because of
the very low prevalence of severe violent behavior in girls, analysis was
confined to males.
The mean age of the participants was 14.9 (SD = 1.9). Ethnic distribution was as
follows: 73.7%, native Belgian; 11.6%, Moroccan; 5.4%, Turkish; and 9.3%, others
(mainly Southeast European and Central African). The study sample was representative
of the general adolescent population of the Flemish part of Belgium with respect
to unemployment (5.5% versus 5.0%) and parental education. Forty-four percent of
the ethnic Flemish population had a high school diploma or higher (versus 45.1%
for the population age category 35-64) (VRIND, 1999). Because most parents from
other ethnic groups arrived in Belgium during adulthood, no comparison is
available for this group.
Procedure
Data were collected in eight schools (middle and high school levels) in the city
of Antwerp, Belgium, during the spring of 2000. Schools were chosen to represent
different administrative school systems and different levels of education
(Belgium has three main levels of education: professional, technical, and
general). Intraclass correlation coefficients of the variables of interest were
fair to good (bivariate correlation between schools: 0.54-0.87). Therefore, it
was decided not to use school in the analyses. The survey was approved by the
relevant boards of the school system, as well as those of the individual
schools. Students and their parents were informed of the planned date of the
survey administration. All students who were present on the day of administration
were surveyed, unless they declined to participate or their parents had
objections (eight individuals). Before starting the assessment, students signed
assent forms, which included a statement of confidentiality. Concerning
confidentiality, it was noted that nobody (teachers, police, parents, or others)
would ever know about the individual results of the respondent. The surveys were
administered in the classrooms on a regular school day by trained personnel
(psychologists, doctors, or medical students), who read all the questions aloud
while students followed along, circling answers on their questionnaires.
Questionnaires were in Dutch for all participants. Ten students reported
language difficulties and were included in the noncompliant group.
Instruments
Socioeconomic Status.
Parental education and current employment, as reported by the students, were
used to assess socioeconomic status (SES). The parental education variable was
transformed into three categories: did not complete high school, completed high
school, and higher education. The current employment variable consisted of the
categories no employment (0), industrial worker (1), employee (2), self-employed
(3), and manager or professional (e.g., doctor, lawyer) (4). The final scores
were added for adolescents reporting on both parents and doubled for those
adolescents who reported that information regarding one of the parents was
unavailable (e.g., because of death, being unknown). Doubling was done because
the SES of one-parent families would otherwise be underestimated. Based on the
final scores, five socioeconomic categories were created.
Delinquency Questionnaire.
Violence items were derived from the self-report delinquency questionnaire of
Junger-Tas (1994). Two interpersonal violence items were used to assess violent
behavior during the past year: having threatened someone or having beaten
someone up (Cronbach [alpha] = .82). Severity was assessed by asking the
respondents about the frequency of each of these violent acts, using a 5-point
scale (once, 2-4 times, more than 5 times, more than 10 times, or more than 20
times).
Suicidal Behavior.
Questions derived from an unpublished questionnaire on child and adolescent
self-harm (Child & Adolescent Selfharm in Europe, 2000) assessed the presence of
suicidal ideation and deliberate self-harm during the past year. Suicidal
ideation was assessed by asking whether a respondent had seriously thought about
taking an overdose or harming himself, but did not do so. Deliberate self-harm
was assessed by asking whether a respondent deliberately took an overdose of
medication or tried to harm himself in some other way (e.g., cut himself). In
addition, it was asked whether the participant had ever had the wish to die when
deliberately harming himself (suicide attempt).
Behavior Assessment System for Children.
Four scales from the Behavior Assessment System for Children were used to assess
depressive symptoms, anxiety, somatization, and sensation seeking, using a
true/false format (Reynolds and Kamphaus, 1992). The validity and reliability of
this instrument have been widely documented, providing age-appropriate norms for
each scale, and the instrument is being increasingly used internationally for
assessment of psychopathology in children and adolescents. Four items on
delinquent behavior (e.g., having a fight, stealing from a store) were excluded
from the sensation seeking scale to ensure differentiation of sensation seeking
from antisocial behavior constructs. Cronbach [alpha] values for the subscales
in this population ranged from .60 for sensation seeking to .73 for depression.
Expectations About the Future.
Five of the 10 items of Jessor's Expectations of Goal Attainment Scale (Jessor
et al., 1989) were used to assess students' beliefs about their chances of
achieving commonly accepted goals (i.e., chances that you will graduate from
high school, will go to college, will have a job that pays well, will have a
happy family life, will stay in good health most of the time). Cronbach [alpha]
for this scale was .60.
Buss-Durkee Hostility Inventory-Dutch Version.
The Buss-Durkee Hostility Inventory is a self-report questionnaire that has been
translated and validated in the Dutch version by Lange et al. (1995). This
instrument comprises three subscales assessing overt aggression, covert
aggression, and social desirability. Whereas overt aggression consists of verbal
and physical aggression toward others (i.e., "I never get so angry that I throw
things"; "When I am angry, I slam doors"; "When I have to use violence to defend
my rights, I will"), covert aggression can be characterized as a combination of
hostility and suppressed anger (i.e., "I like to gossip"; "I am more often
irritated than people know"; "I do not allow that little things bother me").
Cronbach [alpha] values for the scales were .74, .74, and .43, respectively.
Alcohol and Marijuana Use.
Alcohol use was assessed by seven items derived from the Monitoring the Future
Scale (Johnston et al., 1990). The instrument uses a 4-point frequency scale and
includes six items that assess the use of three different alcoholic beverages
(beer, wine, hard liquor; ever and during the past 30 days) and one item that
assesses the frequency of binge drinking. All seven items were summed to obtain
a total alcohol consumption score. Cronbach [alpha] for this scale was .91.
Marijuana use was assessed by two questions, using a 4-point scale about the use
of marijuana ever and during the past 30 days. Cronbach [alpha] for this scale
was .89.
Diminished Perception of Risk.
Ten items were used to assess the respondents' perception of risk of harming
themselves if they were to engage in such activities as substance use, gun
carrying, fighting, dropping out of school, and sexual intercourse without a
condom. Four items were derived from the Monitoring the Future Scale (Johnston
et al., 1990) and were further complemented by six additional items, drawn from
the Social and Health Assessment, a school-based epidemiological instrument
(Schwab-Stone et al., 1999). Choices on a 4-point scale ranged from no risk to
great risk. Higher scores reflected diminished perception of the risk. The
Cronbach [alpha] for this scale was .76.
Statistical Analysis
For statistical analysis, SPSS 10.0 was used. For all calculations, [alpha] was
set at .05. First, groups were compared on demographic variables and the
variables of interest by means of [chi]2 and analysis of variance (ANOVA) tests.
For ANOVA, post hoc pairwise comparisons were adjusted for multiple calculations
with the Bonferroni procedure. Second, interaction between suicidal behavior and
violence was tested with a series of univariate ANOVA (UNIANOVA) tests. Finally,
logistic regression analyses were performed to analyze which variables predict
group membership (suicidal-only versus violent-only, suicidal-only versus
combined, violent-only versus combined). In the first step, SES, age, and race
were entered simultaneously as adjusting variables. In the second step, all
psychobehavioral variables were entered, and the best fit model was derived by
using forward conditional selection.
RESULTS
Description of Comparison Groups
Based on the information on suicidal behavior and violence, four groups were
distinguished. One hundred forty-two participants who committed more than one
violent act during the past year but did not report suicidal ideation and/or
deliberate self-harm formed the violent-only group (17.9%). The criterion of
committing more than one violent act was used to include only the most severely
and persistently violent adolescents. Forty participants reported suicidal
ideation and/or deliberate self-harm during the past year but no severe violent
behavior and formed the suicidal-only group (5.0%). Twenty-one participants
reported suicidal ideation and/or deliberate self-harm and more than one violent
act during the past year and were considered as the combined or the suicidal-violent
group (2.6%). Finally, students who did not report suicidal ideation and/or
deliberate self-harm and who did not commit more than one violent act during the
past year were considered as the control group (n = 591; 74.4%).
Sociodemographic Characteristics and Suicide Attempts
Sociodemographic variables for all four groups are presented in Table 1. Age did
not differ significantly across groups. Both the violent-only and the suicidal-violent
group came from significantly lower socioeconomic classes. Also, subjects from
these two groups tended to live more frequently in single-parent households,
while significantly more violent-only subjects had changed schools since they
started high school. Minority youths were overrepresented in the violent-only
group.
----------------------------------------------
TABLE 1 Sociodemographic Characteristics and Suicide Attempts by GroupNote: NS =
not significant; SES = socioeconomic status.a Significant difference between
control and suicidal-only.b Significant difference between control and
violent-only.c Significant difference between control and suicidal-violent.*** p
----------------------------------------------
Suicide attempts ever (the wish to die when harming himself) was more than twice
as prevalent in the combined group when compared with the suicidal-only group, a
finding that was significant.
Internalizing Problems
Compared with controls, all other groups revealed significantly higher rates of
depression and somatization, while the suicidal-only group showed the highest
ratings of anxiety and the lowest scores with regard to expectations for the
future. Compared with the violent-only subjects, suicidal-only subjects showed
more depression, anxiety, and a trend toward lower expectations about the
future. The combined group was similar to the suicidal-only group, although a
trend toward lower anxiety was present, and the combined group differed from the
violent-only group on depression and somatization.
Aggression
All groups had higher levels of overt and covert aggression than controls,
although the difference between the suicidal-only group and controls did not
reach significance for overt aggression. Compared with the violent-only group,
the suicidal-only group was significantly higher in covert aggression and lower
in overt aggression. The combined group was high on both overt and covert
aggression and differed from the suicidal-only group in overt aggression and
from the violent-only group in covert aggression.
Risk-Taking Behavior and Sensation Seeking
When compared with controls, the suicidal-only and the combined groups more
commonly reported alcohol use, whereas the violent-only and the combined groups
reported higher levels of sensation seeking, diminished perception of risk, and
marijuana use. The violent-only and the combined groups differed from the
suicidal-only group in having a diminished perception of risk and more sensation
seeking and marijuana use.
Interaction Between Suicidal Behavior and Violent Behavior
By means of a series of UNIANOVAs, the interaction between suicidal behavior and
violent behavior in predicting the outcome variables was analyzed. Inadequate
power (F1,779 = 9.2;p F1,788 = 6.2;p
----------------------------------------------
TABLE 2 Means (SD) of Internalizing Problems, Aggression, and Risk-Taking
Behavior by GroupNote: Post hoc comparisons between subgroups corrected with
Bonferroni adjustment for multiple calculations.a Significant difference between
control and suicidal-only.b Significant difference between control and
violent-only.c Significant difference between control and suicidal-violent.d
Significant difference between suicidal-only and violent-only.e Significant
difference between suicidal-only and suicidal-violent.f Significant difference
between violent-only and suicidal-violent.* p p
----------------------------------------------
Logistic Regression
When compared with violent-only group status, suicidal-only group status was
best predicted by higher levels of covert aggression and lower levels of overt
aggression, marijuana use, and diminished perception of risk (Table 3). Combined
group status, when compared with suicidal-only group status, was best predicted
by higher levels of sensation seeking and diminished perception of risk. When
compared with violent-only, combined group status was best predicted by higher
levels of somatization, sensation seeking, and diminished perception of risk.
----------------------------------------------
TABLE 3 Logistic Regression, Variables Predicting Group Member Status (Adjusted
for Age, Socioeconomic Status, and Race)Note: OR = odds ratio; CI = confidence
interval.
----------------------------------------------
DISCUSSION
This community study of adolescents supports previous findings (Plutchik and van
Praag, 1997) that suicidal and violent subjects share characteristics related to
aggressive tendencies and risk-taking behavior. However, the nature of these
characteristics differs across groups; the suicidal-only subjects show more
covert aggression and alcohol use, while the violent-only subjects show more
overt aggression, sensation seeking, and marijuana use. Contrary to the expected
results, when compared with controls, all three comparison groups showed more
depression and somatization, although these problems were most apparent in the
suicidal-only group. Finally, the combined group differed substantially from the
suicidal-only group on overt aggression, sensation seeking, perception of risk,
and substance use, supporting the idea that distinct subgroups of suicidal
youths can be distinguished on the basis of the level of violence.
Summarizing the specific characteristics of each group, one may describe the
suicidal-only group as mainly anxious/depressed, and high in covert aggression
and in alcohol use; the violent-only group as high in somatization, overt
aggression, and severe substance use; and the combined group as high in
depression/somatization, both covert and overt aggression, and all forms of
risk-taking behavior. With regard to aggression, future research should
investigate whether differences in overt versus covert aggression arise from
differential influences of attenuators and amplifiers, as described earlier by
Plutchik and van Praag (1997).
The current study found few differences between the suicidal-only and the
control group on risk-taking behavior. Taken alone, the suicidal-only group does
not appear to manifest what Holinger (1979) suggested as a "continuum of self
destructiveness," ranging from the covert (e.g., substance use, unprotected and
precocious sexual activity) to the overt (e.g., self-mutilation and suicide
attempts). This finding, however, may be due to the differentiation of the
suicidal-only group from the suicidal-violent group, in which risk-taking
behavior was much higher. Considering suicidal individuals as just one group
(including violent subjects) would substantially increase the apparent
association between risk-taking behavior and suicidality. The profound
differences between the suicidal-only and the combined group in the current
study underline the importance of keeping in mind these differences in future
research and in clinical and preventive interventions. Differences in sensation
seeking may as well explain the higher number of past suicide attempts in the
combined group when compared with the suicidal-only group. Sensation seeking is
related to impulsivity, a known risk factor for actual suicidal behavior (Horesh
et al., 1999).
The high level of risk-taking behavior in both the combined and the violent-only
groups is not surprising, as violent youths often are involved in a delinquent
subculture as part of their behavior. Conversely, suicidal adolescents show
higher levels of anxiety, which might decrease their tendency toward hazardous
or delinquent behavior, while perhaps predisposing toward alcohol use.
The findings with regard to depression and somatization, which gradually
increase in severity from the control group through the violent-only group, the
suicidal-only group, and finally the combined group, correspond to increases in
covert aggression. This is expected, as an association between covert aggression
and internalizing problems has been demonstrated (Lange et al., 1995). As the
underlying mechanism for this association remains unresolved, it will be
important to investigate whether internalizing problems have any influence on
the qualitative development of aggression or the reverse, as this may be
critically important for an individual's behavioral outcome and may potentially
represent a critical intervention focus.
The present findings suggesting impoverished minority background and frequent
change of school as risk factors for violence are in keeping with previous
studies on the factors predisposing to violence (Patterson et al., 1998).
Minority youths were disproportionately represented in the violent groups. This
striking finding may well result from the association between minority status,
SES, and violence, with four fifths of minorities belonging to the lowest
socioeconomic group. In the Belgian context, where the parents of minority
youths commonly are recent immigrants, minority status serves as a marker for
differences in socioeconomic, language, acculturation, immigration, and exposure
to violence.
Clinical Implications
Differentiation of suicidal youths based on the presence or absence of violent
behavior may add to our understanding of the suicidal phenomena in adolescents
and may have important clinical consequences. Apart from screening for
depression as an efficient strategy in the prevention of suicide in children and
adolescents at risk (Shaffer and Craft, 1999), an adequate assessment of violent
behavior and risk-taking behavior may also be helpful.
Taking together the characteristics of the suicidal-only, the violent-only, and
the combined groups, it is evident that all groups are in need of multifaceted
intervention. The combined group in particular requires intense clinical
attention, especially because a higher number of actual suicide attempts may
occur in this group. Also, because the suicidal-only and the combined suicidal-violent
groups appeared substantially different, it is likely that specific therapeutic
interventions will be needed for each of these suicidal subgroups.
Limitations
Some limitations of the study need to be noted. First, the cross-sectional
nature of the study does not allow conclusions about etiological pathways.
Second, all information was derived from self-report surveys, and even though it
has been demonstrated that self-reports can be used reliably for the assessment
of behavioral problems (Junger-Tas, 1994;Rutter et al., 1998), the impact of
factors such as inconsistency of answering and social desirability cannot be
fully excluded. As most severe violent behavior is uncommon in community samples
(Plutchik and van Praag, 1990), epidemiological research by means of self-report
instruments is needed. Third, no information was available on the nonparticipants,
making it impossible to compare them with participants. Also, because this was a
school-based survey, assessments could only be done with adolescents attending
school. Future research should attempt to include out-of-school students and to
investigate in what way they differ from participants, as these absent youths
may present with more problems (and experience greater levels of violence) than
participating youths. Fourth, the combined suicidal-violent group in particular
was low in number, which may have reduced the power to detect interaction
effects. Fifth, the suicidal-only and the combined groups include both suicidal
ideation and/or self-harming behavior during the past year. Due to the
relatively low frequency of suicidal behavior, further differentiation of
suicidal groups was not feasible and should be a focus of future research.
Because the assessment of suicide attempts (self-harming behavior and the wish
to die) was not specified in time, the number of participants who attempted
suicide during the past year cannot be determined. Suicide attempts occurred
more often in the combined group when compared with the suicidal-only group,
which may have influenced the results. Finally, the study was conducted in just
one Western city, and one should be cautious when generalizing the findings to
other cultures.
REFERENCES
1. Apter A, Gothelf D, Orbach I et al. (1995), Correlation of suicidal and
violent behavior in different diagnostic categories in hospitalized adolescent
patients. J Am Acad Child Adolesc Psychiatry 34:912-918 [Fulltext Link]
[Medline Link] [PsycINFO Link] [BIOSIS Previews Link]
2. Botsis AJ, Plutchik R, Kotler M, van Praag HM (1995), Parental loss and
family violence as correlates of suicide and violence risk. Suicide Life Threat
Behav 25:253-260
------------------------------
Full Text of: VERMEIREN: J Am Acad Child Adolesc Psychiatry, Volume 42(1).January
2003.41-48
Journal of the American Academy of Child & Adolescent Psychiatry
Copyright 2003 (C) American Academy of Child and Adolescent Psychiatry
----------------------------------------------
Volume 42(1) January 2003 pp 41-48
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Suicidal Behavior and Violence in Male Adolescents: A School-Based Study
[Articles]
VERMEIREN, ROBERT M.D., PH.D.; SCHWAB-STONE, MARY M.D.; RUCHKIN, VLADISLAV V.
M.D., PH.D.; KING, ROBERT A. M.D.; VAN HEERINGEN, CORNELIS M.D., PH.D.;
DEBOUTTE, DIRK M.D., PH.D.
From the University Department of Child and Adolescent Psychiatry, Middelheimhospital,
University of Antwerp, Belgium (Drs. Vermeiren and Deboutte); Yale Child Study
Center, New Haven, CT (Drs. Schwab-Stone, Ruchkin, and King); and Unit for
Suicide Research, University of Ghent, Belgium (Dr. Van Heeringen).
Accepted July 23, 2002.
This article was written when the first author was Belgian American Educational
Foundation Research Fellow in the
appreciate the support of the Hewlett Foundation for the Yale Child Study
Program on International Child Mental Health. The authors gratefully acknowledge
the support and helpful guidance of Donald J. Cohen, M.D., the late Director,
Reprint requests to Dr. Vermeiren, UCKJA, Middelheimhospital, Lindendreef 1,
2020
DOI: 10.1097/01.CHI.0000024905.60748.73
----------------------------------------------
Outline
ABSTRACT
METHOD
Sample
Procedure
Instruments
Socioeconomic Status.
Delinquency Questionnaire.
Suicidal Behavior.
Behavior Assessment System for Children.
Expectations About the Future.
Buss-Durkee Hostility Inventory-Dutch Version.
Alcohol and Marijuana Use.
Diminished Perception of Risk.
Statistical Analysis
RESULTS
Description of Comparison Groups
Sociodemographic Characteristics and Suicide Attempts
Internalizing Problems
Aggression
Risk-Taking Behavior and Sensation Seeking
Interaction Between Suicidal Behavior and Violent Behavior
Logistic Regression
DISCUSSION
Clinical Implications
Limitations
REFERENCES
Graphics
Table 1
Table 2
Table 3
----------------------------------------------
ABSTRACT
Objective: To investigate characteristics of suicidal and violent behavior in a
community school sample of adolescents.
: Self-report questionnaires were administered to 794 male students (aged 12-18
years) from
suicidal-only (n = 40; suicidal ideation and/or self-harming behavior), a
violent-only (n = 142), a suicidal-violent (n = 21), and a control group (n =
591).
: Compared with controls, higher levels of internalizing problems, risk-taking
behavior (substance use, diminished perception of risk, sensation seeking), and
aggression were found in the comparison groups. The suicidal-violent group had
the highest levels of depression, somatization, overt and covert aggression, and
risk-taking behavior. Compared with the suicidal-only group, the violent-only
group had less depression, anxiety, and covert aggression, but higher levels of
overt aggression, sensation seeking, diminished perception of risk, and
marijuana use.
Conclusions: Although adolescent suicidal and violent behavior are both related
to internalizing problems, aggression, and risk-taking behavior, marked
differences in severity and nature exist in these relationships. Differentiation
of suicidal youths based on the presence or absence of violent behavior may add
to our understanding of suicidal phenomena and may thus have important clinical
consequences.
----------------------------------------------
A strong body of literature has demonstrated an association between violent
and/or antisocial and suicidal behavior (Plutchik and van Praag, 1997). Evidence
for the association between both conditions in adolescents derives from
different sources. First, psychological autopsy studies have found that the
proportion of young suicides in which a disruptive behavior disorder could be
diagnosed ranged from 20% to 50% (Brent et al., 1993;Marttunen et al.,
1991;Shaffer et al., 1996). Second, epidemiological studies have shown that
disruptive disorders are more prevalent in youthful suicide ideators and/or
attempters than controls and that child and adolescent suicidal ideation and/or
attempts are associated with violent and risk-taking behavior (e.g., substance
use) (King et al., 2001;Orpinas et al., 1995;Sosin et al., 1995;Woods et al.,
1997). Similarly, clinical studies have shown that youthful suicidal patients
fairly often reveal histories of violent behavior (Cohen-Sandler et al., 1982),
while others found aggression to be associated with repetition of attempted
suicide in adolescents (Stein et al., 1998). Also, studies of incarcerated
delinquent male youths have shown high prevalence rates of current suicidal
ideation (13%-19%) (Morris et al., 1995;Rohde et al., 1997).
Further evidence for an association between suicidality and aggression comes
from family aggregation studies (Botsis et al., 1995;Pfeffer et al., 1994), in
which an increased level of antisocial and aggressive behavior in first-degree
relatives of suicidal adolescents has been demonstrated. In addition, higher
rates of aggression in young suicide victims have been related to higher
loadings of suicide attempts in the family (Brent et al., 1996). Biological
psychiatric research has demonstrated a pathogenetic role of serotonergic
dysregulation in the development of both violent and suicidal behavior
(Traskman-Bendz and Mann, 2000). However, the mechanisms that may determine the
direction of aggression, i.e., inward or outward or both, still remain unclear.
An important line of research focuses specifically on the association between
aggression and suicidal behavior. Although, as Plutchik and van Praag (1990)
point out, the psychoanalytic idea that suicide reflects violence turned inward
has some validity, it does not help us to understand why some aggressive people
are suicidal while others are not. Consequently, Plutchik and van Praag (1997)
developed a model that focuses specifically on the interconnection between
violent and suicidal behavior. The model is based on evidence that aggression,
described as an adaptive inner state, is influenced by a number of amplifiers
and attenuators that may produce overt violence toward others or oneself.
Plutchik and van Praag (1997) described almost 40 psychiatric, biological,
personality-related, social, and familial variables as risk factors for violent
behavior, of which more than half were also associated with an increased risk of
suicidal behavior.
Apter et al. (1995) hypothesized that at least two types of suicidal behaviors
can be discerned during adolescence. The first behavior reflects a wish to die
and characterizes suicidal behavior in depressive disorders, while the second is
characterized by impulse control problems and is commonly associated with
externalizing disorders, such as conduct disorder. In a clinical sample of
adolescents, Pfeffer et al. (1989) differentiated four groups based on the
presence or absence of suicidal or assaultive behavior and found that, compared
with controls, the group showing suicidal behavior was characterized by
depression, drug use, and environmental stress, whereas the assaultive-only
behavior group showed aggression and violence. The combined assaultive-suicidal
behavior group showed both accidents and violence. Horesh et al. (1999)
investigated the role of impulsivity and demonstrated a relationship between
suicidal behavior and impulsivity, even after controlling for aggression.
Although of great importance for understanding the underlying mechanisms of
suicide and violent behavior, the limitation of these studies was the almost
exclusive reliance on clinical samples. Therefore, the current study aimed at
examining suicidal and violent behavior in a community sample of adolescent
students. This study was designed to examine and compare characteristics of
youths with suicidal ideation/behavior only (suicidal-only), those with violent
behavior only (violent-only), and those with histories of both suicidal
ideation/behavior and violent behavior (suicidal-violent) with respect to
internalizing problems, aggression, and risk-taking behavior. Suicidal
adolescents were predicted to show primarily internalizing problems, risk-taking
behavior, and some increase in aggression, while violent and combined violent-suicidal
subjects were predicted to show increased aggression and risk-taking behavior.
METHOD
Sample
Subjects were adolescents participating in an ongoing cross-cultural project
assessing risk and protective factors for adolescent adjustment. For this study,
self-report surveys administered to a school sample of adolescents (aged 12-18
years) in Antwerp, Belgium, were used. Fifteen percent of the students were
absent on the day of administration. Of the surveyed group (N = 1,634), 125
subjects provided incomplete or inconsistent surveys and some classes (77
students) did not complete the questionnaires used for this study, so that the
total study group consisted of 1,432 students (male 794, female 638). Because of
the very low prevalence of severe violent behavior in girls, analysis was
confined to males.
The mean age of the participants was 14.9 (SD = 1.9). Ethnic distribution was as
follows: 73.7%, native Belgian; 11.6%, Moroccan; 5.4%, Turkish; and 9.3%, others
(mainly Southeast European and Central African). The study sample was representative
of the general adolescent population of the Flemish part of Belgium with respect
to unemployment (5.5% versus 5.0%) and parental education. Forty-four percent of
the ethnic Flemish population had a high school diploma or higher (versus 45.1%
for the population age category 35-64) (VRIND, 1999). Because most parents from
other ethnic groups arrived in Belgium during adulthood, no comparison is
available for this group.
Procedure
Data were collected in eight schools (middle and high school levels) in the city
of Antwerp, Belgium, during the spring of 2000. Schools were chosen to represent
different administrative school systems and different levels of education
(Belgium has three main levels of education: professional, technical, and
general). Intraclass correlation coefficients of the variables of interest were
fair to good (bivariate correlation between schools: 0.54-0.87). Therefore, it
was decided not to use school in the analyses. The survey was approved by the
relevant boards of the school system, as well as those of the individual
schools. Students and their parents were informed of the planned date of the
survey administration. All students who were present on the day of administration
were surveyed, unless they declined to participate or their parents had
objections (eight individuals). Before starting the assessment, students signed
assent forms, which included a statement of confidentiality. Concerning
confidentiality, it was noted that nobody (teachers, police, parents, or others)
would ever know about the individual results of the respondent. The surveys were
administered in the classrooms on a regular school day by trained personnel
(psychologists, doctors, or medical students), who read all the questions aloud
while students followed along, circling answers on their questionnaires.
Questionnaires were in Dutch for all participants. Ten students reported
language difficulties and were included in the noncompliant group.
Instruments
Socioeconomic Status.
Parental education and current employment, as reported by the students, were
used to assess socioeconomic status (SES). The parental education variable was
transformed into three categories: did not complete high school, completed high
school, and higher education. The current employment variable consisted of the
categories no employment (0), industrial worker (1), employee (2), self-employed
(3), and manager or professional (e.g., doctor, lawyer) (4). The final scores
were added for adolescents reporting on both parents and doubled for those
adolescents who reported that information regarding one of the parents was
unavailable (e.g., because of death, being unknown). Doubling was done because
the SES of one-parent families would otherwise be underestimated. Based on the
final scores, five socioeconomic categories were created.
Delinquency Questionnaire.
Violence items were derived from the self-report delinquency questionnaire of
Junger-Tas (1994). Two interpersonal violence items were used to assess violent
behavior during the past year: having threatened someone or having beaten
someone up (Cronbach [alpha] = .82). Severity was assessed by asking the
respondents about the frequency of each of these violent acts, using a 5-point
scale (once, 2-4 times, more than 5 times, more than 10 times, or more than 20
times).
Suicidal Behavior.
Questions derived from an unpublished questionnaire on child and adolescent
self-harm (Child & Adolescent Selfharm in Europe, 2000) assessed the presence of
suicidal ideation and deliberate self-harm during the past year. Suicidal
ideation was assessed by asking whether a respondent had seriously thought about
taking an overdose or harming himself, but did not do so. Deliberate self-harm
was assessed by asking whether a respondent deliberately took an overdose of
medication or tried to harm himself in some other way (e.g., cut himself). In
addition, it was asked whether the participant had ever had the wish to die when
deliberately harming himself (suicide attempt).
Behavior Assessment System for Children.
Four scales from the Behavior Assessment System for Children were used to assess
depressive symptoms, anxiety, somatization, and sensation seeking, using a
true/false format (Reynolds and Kamphaus, 1992). The validity and reliability of
this instrument have been widely documented, providing age-appropriate norms for
each scale, and the instrument is being increasingly used internationally for
assessment of psychopathology in children and adolescents. Four items on
delinquent behavior (e.g., having a fight, stealing from a store) were excluded
from the sensation seeking scale to ensure differentiation of sensation seeking
from antisocial behavior constructs. Cronbach [alpha] values for the subscales
in this population ranged from .60 for sensation seeking to .73 for depression.
Expectations About the Future.
Five of the 10 items of Jessor's Expectations of Goal Attainment Scale (Jessor
et al., 1989) were used to assess students' beliefs about their chances of
achieving commonly accepted goals (i.e., chances that you will graduate from
high school, will go to college, will have a job that pays well, will have a
happy family life, will stay in good health most of the time). Cronbach [alpha]
for this scale was .60.
Buss-Durkee Hostility Inventory-Dutch Version.
The Buss-Durkee Hostility Inventory is a self-report questionnaire that has been
translated and validated in the Dutch version by Lange et al. (1995). This
instrument comprises three subscales assessing overt aggression, covert
aggression, and social desirability. Whereas overt aggression consists of verbal
and physical aggression toward others (i.e., "I never get so angry that I throw
things"; "When I am angry, I slam doors"; "When I have to use violence to defend
my rights, I will"), covert aggression can be characterized as a combination of
hostility and suppressed anger (i.e., "I like to gossip"; "I am more often
irritated than people know"; "I do not allow that little things bother me").
Cronbach [alpha] values for the scales were .74, .74, and .43, respectively.
Alcohol and Marijuana Use.
Alcohol use was assessed by seven items derived from the Monitoring the Future
Scale (Johnston et al., 1990). The instrument uses a 4-point frequency scale and
includes six items that assess the use of three different alcoholic beverages
(beer, wine, hard liquor; ever and during the past 30 days) and one item that
assesses the frequency of binge drinking. All seven items were summed to obtain
a total alcohol consumption score. Cronbach [alpha] for this scale was .91.
Marijuana use was assessed by two questions, using a 4-point scale about the use
of marijuana ever and during the past 30 days. Cronbach [alpha] for this scale
was .89.
Diminished Perception of Risk.
Ten items were used to assess the respondents' perception of risk of harming
themselves if they were to engage in such activities as substance use, gun
carrying, fighting, dropping out of school, and sexual intercourse without a
condom. Four items were derived from the Monitoring the Future Scale (Johnston
et al., 1990) and were further complemented by six additional items, drawn from
the Social and Health Assessment, a school-based epidemiological instrument
(Schwab-Stone et al., 1999). Choices on a 4-point scale ranged from no risk to
great risk. Higher scores reflected diminished perception of the risk. The
Cronbach [alpha] for this scale was .76.
Statistical Analysis
For statistical analysis, SPSS 10.0 was used. For all calculations, [alpha] was
set at .05. First, groups were compared on demographic variables and the
variables of interest by means of [chi]2 and analysis of variance (ANOVA) tests.
For ANOVA, post hoc pairwise comparisons were adjusted for multiple calculations
with the Bonferroni procedure. Second, interaction between suicidal behavior and
violence was tested with a series of univariate ANOVA (UNIANOVA) tests. Finally,
logistic regression analyses were performed to analyze which variables predict
group membership (suicidal-only versus violent-only, suicidal-only versus
combined, violent-only versus combined). In the first step, SES, age, and race
were entered simultaneously as adjusting variables. In the second step, all
psychobehavioral variables were entered, and the best fit model was derived by
using forward conditional selection.
RESULTS
Description of Comparison Groups
Based on the information on suicidal behavior and violence, four groups were
distinguished. One hundred forty-two participants who committed more than one
violent act during the past year but did not report suicidal ideation and/or
deliberate self-harm formed the violent-only group (17.9%). The criterion of
committing more than one violent act was used to include only the most severely
and persistently violent adolescents. Forty participants reported suicidal
ideation and/or deliberate self-harm during the past year but no severe violent
behavior and formed the suicidal-only group (5.0%). Twenty-one participants
reported suicidal ideation and/or deliberate self-harm and more than one violent
act during the past year and were considered as the combined or the suicidal-violent
group (2.6%). Finally, students who did not report suicidal ideation and/or
deliberate self-harm and who did not commit more than one violent act during the
past year were considered as the control group (n = 591; 74.4%).
Sociodemographic Characteristics and Suicide Attempts
Sociodemographic variables for all four groups are presented in Table 1. Age did
not differ significantly across groups. Both the violent-only and the suicidal-violent
group came from significantly lower socioeconomic classes. Also, subjects from
these two groups tended to live more frequently in single-parent households,
while significantly more violent-only subjects had changed schools since they
started high school. Minority youths were overrepresented in the violent-only
group.
----------------------------------------------
TABLE 1 Sociodemographic Characteristics and Suicide Attempts by GroupNote: NS =
not significant; SES = socioeconomic status.a Significant difference between
control and suicidal-only.b Significant difference between control and
violent-only.c Significant difference between control and suicidal-violent.*** p
----------------------------------------------
Suicide attempts ever (the wish to die when harming himself) was more than twice
as prevalent in the combined group when compared with the suicidal-only group, a
finding that was significant.
Internalizing Problems
Compared with controls, all other groups revealed significantly higher rates of
depression and somatization, while the suicidal-only group showed the highest
ratings of anxiety and the lowest scores with regard to expectations for the
future. Compared with the violent-only subjects, suicidal-only subjects showed
more depression, anxiety, and a trend toward lower expectations about the
future. The combined group was similar to the suicidal-only group, although a
trend toward lower anxiety was present, and the combined group differed from the
violent-only group on depression and somatization.
Aggression
All groups had higher levels of overt and covert aggression than controls,
although the difference between the suicidal-only group and controls did not
reach significance for overt aggression. Compared with the violent-only group,
the suicidal-only group was significantly higher in covert aggression and lower
in overt aggression. The combined group was high on both overt and covert
aggression and differed from the suicidal-only group in overt aggression and
from the violent-only group in covert aggression.
Risk-Taking Behavior and Sensation Seeking
When compared with controls, the suicidal-only and the combined groups more
commonly reported alcohol use, whereas the violent-only and the combined groups
reported higher levels of sensation seeking, diminished perception of risk, and
marijuana use. The violent-only and the combined groups differed from the
suicidal-only group in having a diminished perception of risk and more sensation
seeking and marijuana use.
Interaction Between Suicidal Behavior and Violent Behavior
By means of a series of UNIANOVAs, the interaction between suicidal behavior and
violent behavior in predicting the outcome variables was analyzed. Inadequate
power (F1,779 = 9.2;p F1,788 = 6.2;p
----------------------------------------------
TABLE 2 Means (SD) of Internalizing Problems, Aggression, and Risk-Taking
Behavior by GroupNote: Post hoc comparisons between subgroups corrected with
Bonferroni adjustment for multiple calculations.a Significant difference between
control and suicidal-only.b Significant difference between control and
violent-only.c Significant difference between control and suicidal-violent.d
Significant difference between suicidal-only and violent-only.e Significant
difference between suicidal-only and suicidal-violent.f Significant difference
between violent-only and suicidal-violent.* p p
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Logistic Regression
When compared with violent-only group status, suicidal-only group status was
best predicted by higher levels of covert aggression and lower levels of overt
aggression, marijuana use, and diminished perception of risk (Table 3). Combined
group status, when compared with suicidal-only group status, was best predicted
by higher levels of sensation seeking and diminished perception of risk. When
compared with violent-only, combined group status was best predicted by higher
levels of somatization, sensation seeking, and diminished perception of risk.
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TABLE 3 Logistic Regression, Variables Predicting Group Member Status (Adjusted
for Age, Socioeconomic Status, and Race)Note: OR = odds ratio; CI = confidence
interval.
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DISCUSSION
This community study of adolescents supports previous findings (Plutchik and van
Praag, 1997) that suicidal and violent subjects share characteristics related to
aggressive tendencies and risk-taking behavior. However, the nature of these
characteristics differs across groups; the suicidal-only subjects show more
covert aggression and alcohol use, while the violent-only subjects show more
overt aggression, sensation seeking, and marijuana use. Contrary to the expected
results, when compared with controls, all three comparison groups showed more
depression and somatization, although these problems were most apparent in the
suicidal-only group. Finally, the combined group differed substantially from the
suicidal-only group on overt aggression, sensation seeking, perception of risk,
and substance use, supporting the idea that distinct subgroups of suicidal
youths can be distinguished on the basis of the level of violence.
Summarizing the specific characteristics of each group, one may describe the
suicidal-only group as mainly anxious/depressed, and high in covert aggression
and in alcohol use; the violent-only group as high in somatization, overt
aggression, and severe substance use; and the combined group as high in
depression/somatization, both covert and overt aggression, and all forms of
risk-taking behavior. With regard to aggression, future research should
investigate whether differences in overt versus covert aggression arise from
differential influences of attenuators and amplifiers, as described earlier by
Plutchik and van Praag (1997).
The current study found few differences between the suicidal-only and the
control group on risk-taking behavior. Taken alone, the suicidal-only group does
not appear to manifest what Holinger (1979) suggested as a "continuum of self
destructiveness," ranging from the covert (e.g., substance use, unprotected and
precocious sexual activity) to the overt (e.g., self-mutilation and suicide
attempts). This finding, however, may be due to the differentiation of the
suicidal-only group from the suicidal-violent group, in which risk-taking
behavior was much higher. Considering suicidal individuals as just one group
(including violent subjects) would substantially increase the apparent
association between risk-taking behavior and suicidality. The profound
differences between the suicidal-only and the combined group in the current
study underline the importance of keeping in mind these differences in future
research and in clinical and preventive interventions. Differences in sensation
seeking may as well explain the higher number of past suicide attempts in the
combined group when compared with the suicidal-only group. Sensation seeking is
related to impulsivity, a known risk factor for actual suicidal behavior (Horesh
et al., 1999).
The high level of risk-taking behavior in both the combined and the violent-only
groups is not surprising, as violent youths often are involved in a delinquent
subculture as part of their behavior. Conversely, suicidal adolescents show
higher levels of anxiety, which might decrease their tendency toward hazardous
or delinquent behavior, while perhaps predisposing toward alcohol use.
The findings with regard to depression and somatization, which gradually
increase in severity from the control group through the violent-only group, the
suicidal-only group, and finally the combined group, correspond to increases in
covert aggression. This is expected, as an association between covert aggression
and internalizing problems has been demonstrated (Lange et al., 1995). As the
underlying mechanism for this association remains unresolved, it will be
important to investigate whether internalizing problems have any influence on
the qualitative development of aggression or the reverse, as this may be
critically important for an individual's behavioral outcome and may potentially
represent a critical intervention focus.
The present findings suggesting impoverished minority background and frequent
change of school as risk factors for violence are in keeping with previous
studies on the factors predisposing to violence (Patterson et al., 1998).
Minority youths were disproportionately represented in the violent groups. This
striking finding may well result from the association between minority status,
SES, and violence, with four fifths of minorities belonging to the lowest
socioeconomic group. In the Belgian context, where the parents of minority
youths commonly are recent immigrants, minority status serves as a marker for
differences in socioeconomic, language, acculturation, immigration, and exposure
to violence.
Clinical Implications
Differentiation of suicidal youths based on the presence or absence of violent
behavior may add to our understanding of the suicidal phenomena in adolescents
and may have important clinical consequences. Apart from screening for
depression as an efficient strategy in the prevention of suicide in children and
adolescents at risk (Shaffer and Craft, 1999), an adequate assessment of violent
behavior and risk-taking behavior may also be helpful.
Taking together the characteristics of the suicidal-only, the violent-only, and
the combined groups, it is evident that all groups are in need of multifaceted
intervention. The combined group in particular requires intense clinical
attention, especially because a higher number of actual suicide attempts may
occur in this group. Also, because the suicidal-only and the combined suicidal-violent
groups appeared substantially different, it is likely that specific therapeutic
interventions will be needed for each of these suicidal subgroups.
Limitations
Some limitations of the study need to be noted. First, the cross-sectional
nature of the study does not allow conclusions about etiological pathways.
Second, all information was derived from self-report surveys, and even though it
has been demonstrated that self-reports can be used reliably for the assessment
of behavioral problems (Junger-Tas, 1994;Rutter et al., 1998), the impact of
factors such as inconsistency of answering and social desirability cannot be
fully excluded. As most severe violent behavior is uncommon in community samples
(Plutchik and van Praag, 1990), epidemiological research by means of self-report
instruments is needed. Third, no information was available on the nonparticipants,
making it impossible to compare them with participants. Also, because this was a
school-based survey, assessments could only be done with adolescents attending
school. Future research should attempt to include out-of-school students and to
investigate in what way they differ from participants, as these absent youths
may present with more problems (and experience greater levels of violence) than
participating youths. Fourth, the combined suicidal-violent group in particular
was low in number, which may have reduced the power to detect interaction
effects. Fifth, the suicidal-only and the combined groups include both suicidal
ideation and/or self-harming behavior during the past year. Due to the
relatively low frequency of suicidal behavior, further differentiation of
suicidal groups was not feasible and should be a focus of future research.
Because the assessment of suicide attempts (self-harming behavior and the wish
to die) was not specified in time, the number of participants who attempted
suicide during the past year cannot be determined. Suicide attempts occurred
more often in the combined group when compared with the suicidal-only group,
which may have influenced the results. Finally, the study was conducted in just
one Western city, and one should be cautious when generalizing the findings to
other cultures.
REFERENCES
1. Apter A, Gothelf D, Orbach I et al. (1995), Correlation of suicidal and
violent behavior in different diagnostic categories in hospitalized adolescent
patients. J Am Acad Child Adolesc Psychiatry 34:912-918 [Fulltext Link]
[Medline Link] [PsycINFO Link] [BIOSIS Previews Link]
2. Botsis AJ, Plutchik R, Kotler M, van Praag HM (1995), Parental loss and
family violence as correlates of suicide and violence risk. Suicide Life Threat
Behav 25:253-260
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