Adolescent suicide in Australia: Rates,risk and resilience

Abstract

Adolescent suicide rates in Australia have fallen significantly during recent years. The incidence, however, clearly remains a serious concern for young people, parents, professionals and policy makers. Some groups of Australian youth appear to be at heightened risk. Adolescents within the welfare system, indigenous, rural and refugee youth, along with same sex attracted young people often need very careful monitoring and support. Young men continue to take their lives more frequently than young women. Prevention programmes in Australia aim to develop resilience in young people, families and communities that can serve as protection against self harm and suicide. The improvement of mental health literacy, a fostering of adolescent self-efficacy and better access to early intervention strategies are currently privileged in national and state policies related to young people in Australia. More work is needed, however, to achieve a well integrated mental health framework capable of effectively addressing adolescent suicide prevention into the twenty-first century.

Keywords

Adolescent suicide Australia rates risk resilience

Background

In the past twenty years, Australian federal and state governments have funded and encouraged several public health programmes to raise community awareness about mental health, and particularly depression, to promote well-being. The best known initiative, beyondblue (www.beyondblue.org.au), creates a national focus for community education, prevention and treatment of depression. This has had a positive influence on the popular media. The programme actively uses social media to engage the community and influence government policy (twitter.com/beyond_blue). The community’s embracing of beyondblue, along with other similar programmes, illustrates the contemporary challenge to hitherto embedded societal stigma around mental illness in Australia.

As part of the growing general acceptance of mental health as a priority for community response, there has been a particular focus on the emotional wellbeing of youth (youthbeyondblue, 2011). There has been special concern expressed about youth mental health in rural communities, especially that of adolescent and young adult males. The mental health of Australian Aboriginal and refugee young people in all parts of the country has also been high on the agenda of governments and mental health activists. Improved attitudes to mental health issues and a more sophisticated level of mental health literacy in the general community would appear to have emerged from more open acknowledgement of Australian levels of suicidality. In this context, adolescent suicide has emerged from the shadows. The perceived extent of the problem has, indeed, evoked general alarm in recent times. This has had a major impact on general community perceptions and on Federal and State Government policy and programmatic responses.

As is so often the case with increasing community awareness however, false impressions have somewhat derailed discourse at times. Perhaps the most misleading of impressions is that the rate of suicide among young people in Australia is of epidemic proportions. In reality, the rate of youth suicide has declined steadily over the past two decades (Australian Bureau of Statistics [ABS], 2009). There appears to be no reason to anticipate a reversal of this trend. The shift is, of course, a hopeful development and would appear to reflect the positive impact of recent community responses to the problem, especially the impact of programmes targeting depression, substance abuse and schizophrenia. Hopeful signs notwithstanding, there is no cause for complacency. Suicide is still a major cause of adolescent death in Australia, more statistically significant than road accidents. In 2008, 24% of all male deaths aged 15–24 years were due to suicide. Similarly for females, suicide deaths comprise a much higher proportion of total deaths in younger age groups compared with older age groups (ABS, 2010). There are clearly many issues to be addressed if Australia is to continue to reduce its youth suicide rate. The development of effective interventions aimed at addressing the complex psycho-social and structural situations of high risk groups, including Aboriginal and refugee youth, young people subject to community services involvement, same sex attracted youth (Western Australian Suicide Prevention Strategy, Government of Western Australian Department of Health, (2009) and those living in rural and remote areas must remain high priorities (Australian Institute of Health and Welfare [AIHW], 2009).

This paper adopts an operational model for understanding adolescent suicide in Australia which emphasises the intrinsic links between mental illness, depression, hopelessness, suicidal ideation and suicide (Nock et al., 2008). These are explored within a socio-developmental framework encompassing individual, family and community strengths and stressors. Australian adolescent suicide rates, the risk factors associated with suicidality in young people and adolescent resilience to suicidal thoughts and behaviours are explored within this frame of reference.

Rates

The word suicide comes from the Latin words, sui caedere, meaning to intentionally kill oneself. Suicide in Australia is defined as deliberate self-harm leading to a death which must be confirmed as suicide by a Coroner’s Inquest (ABS, 2009). For a death to be considered a suicide and counted as such in Australian statistics, three criteria need to be met:

1. The death must be due to unnatural causes, such as injury, poisoning or suffocation rather than an illness

2. The actions which result in death must be self-inflicted

3. The person who injures himself or herself must have had the intention to die

(ResponseAbility, 2012).

Every effort is made to determine the level of intent to complete the suicidal act so that accidental deaths as a result of self harm (such as that resulting from an overdose of drugs) are not confused with intentional suicide. However, it is clear that comparative and longitudinal suicide rates are inevitably subject to a degree of error due to difficulties in assessing intention. It has been noted that there may be some under-enumeration of suicide deaths; for example, suicide deaths from drowning or single vehicle car accidents are known to be difficult to differentiate from unintentional deaths occurring through the same means (AIHW, 2009).

Suicide rates in Australia are recorded within Government statistics across the States of the Commonwealth (New South Wales, Queensland, South Australia, Victoria and Western Australia) and the two Commonwealth territories (Australian Capital Territory and Northern Territory); these feed into Federal Australian Government statistics. ABS data reviewed by the Australian Institute of AIHW in Canberra in July, 2009, manifest an overall reduction of deaths by suicide from 2722 in 1997 to 1799 in 2006. In 1997 there were 510 suicides in the 15–24 age range; this figure had dropped to 244 in 2006. Whilst there has been a prevailing community belief that suicides among youth dominate the overall figures, the median age at death for suicide in 2008 was 42.4 years for males and 43.5 years for females; it was 42.7 years overall (ABS, 2010). Figure 1 records suicide by age and gender in Australia in 2009 (the most recent figures available); the highest suicide rate for that year lies within the 50–54 year age range for women and the 40–44 age range for men.

Figure 1.

Suicide rates in Australia.

Figure 2 presents suicides among Australian 15 to 19 year olds between 1989 and 2010. It is of interest to note the slight increase in the 2010 figure for young men over those recorded in the previous two years. It will be important to watch future figures for any identifiable trend. The female suicide rate for this age group seems relatively stable over recent years.

Figure 2.

Suicide rates amongst 15 to 19 year olds in Australia.

The suicide rate for young people aged 15–24 years appears to increase with geographical remoteness. The age-standardised rate in ‘Remote/Very Remote’ areas was more than three times that for ‘Major Cities’ in 2003−2005 (31 compared with 9 per 100,000 young people). The age-standardised suicide rate was also higher among young people aged 15–24 years in the most socioeconomically disadvantaged areas of Australia, compared with the least socioeconomically disadvantaged areas (13 per 100,000 young people compared with 9 in 2003–2005) (AIHW, 2008). It is also important to note an overall under-reporting and under-numeration of child/early adolescent suicide in Australia. This is seemingly due to reluctance on the part of the courts to identify death as suicide in children less than 15 years of age. The reluctance stems from the belief that children lack the capacity to understand the finality of death and to fully comprehend the irreversibility of their actions. The ABS does not record deaths by suicide of this age group (Queensland Commission for Children and Young People and Child Guardian – 2009). There is evidence, however, to suggest that child suicide is emerging as a serious concern in Australia. It is recognised that far more information is needed about this age group. Major research into suicide amongst Australian children aged below 15 years is currently in progress (Australian Institute for Suicide Research and Prevention, 2010).

There also appear to be significant gender differences evident in Australian youth suicide figures. During the mid to late 1980s, suicide rates for 15 to 19 year old males rose rapidly and peaked at 21 per 100,000 in 1988. The increase in suicide rates at this time has been attributed to social isolation and unemployment (Cantor, Neulinger, & De Leo, 1999; Donaldson, Bi, & Hiller, 1997; Dorsch and Roder, 1983). Community concern around this time resulted in a number of mental health reforms, especially de-institutionalisation. The Australian Health Ministers Advisory Council (AHMAC, 1990) committed to reduce suicide rates in the early 1990s. Over the following decade, rates fluctuated from around 17 to 19 per 100,000 for this group and stood at 18.4 per 100,000 in 1997. Since 1998, suicide rates among 15 to 19 year old males have decreased fairly consistently and in 2007, the rate was 9.3 per 100,000 – the third lowest rate seen in this age group for at least 20 years. In contrast, for 15 to 19 year old females, the suicide rate has been relatively stable during the past 20 years, at around 3 to 5 suicide deaths per 100,000. In 2008, 3.2 per 100,000 15 to 19 year old females had died by suicide (ABS, 2010). There does appear, however, to be some diversity within figures emergent from the various Australian states. The overall annual suicide count for the State of New South Wales declined greatly in this period, whilst for the state of Tasmania the count tended to increase (with fluctuations) ( Mindframe, 2012 ). Figures from Queensland suggest that the suicide rate of 15 to 17 year-olds more than doubled between the start of 2004 and the end of 2007. The figures for 10 to 14 year olds recorded in that State remained stable (Queensland Commission for Children and Young People and Child Guardian –2009).

Data from the latter part of last century suggests that Australian women of all ages tended to take their own lives through means of relatively ‘lesser violence’, such as drug overdose. There are indications, however, that in recent years, females might be choosing more active means of self harm, such as hanging. Over half (55%) of male suicide deaths in 2008 were by hanging, followed by 12% linked to poisoning by gases and vapors. Hanging was the most commonly recorded method of suicide by females in 2008 accounting for 42% of all female deaths by suicide. The second commonest cause of suicide death was poisoning by drugs (25% of female suicide deaths and less than 10% of male suicides) (ABS, 2010). The fact that hanging has emerged as the major method of suicide in Australia is considered unfortunate as it is more difficult to develop controls to restrict people’s access to this method (Response-Ability, 2010). In 1979, 13% of all suicides were by hanging; in 2008 this had increased to over 50% of all suicide deaths (AIHW, 2010). Deaths resultant from firearm misuse in Australia were far more common (especially among males) in the mid 1990s. This has reduced significantly, since enactment of 1996 firearms laws which ban possession of automatic and semi-automatic guns and strictly controlled ownership of other firearms in every State and territory (Chapman et al., 2006). Radical change to gun laws swiftly followed the Port Arthur (Tasmania) massacre in April 1996 perpetrated by a young man with dual mental health and intellectual disabilities. Young males in rural and remote communities who have ready access to firearms are, however, still considered to be a high risk group. It is felt that a culture of risk taking, recreational boredom, poor mental health literacy in families and communities and a reluctance to seek mental health or other social assistance exacerbates risk of suicide, especially amongst young males, in Australian rural communities (Campo, 2009).

Surveys conducted by the Centre for Adolescent Health ([CAH], 2011) in Melbourne indicate that approximately 5% of Australian young people engage in self harming behaviour. Females are more likely than males to engage in self-harming behaviours though the rate of female youth suicide is about one quarter that of males. Young people overall have higher rates of deliberate self-harm than adults. A review of Australian studies (CAH, 2011) found that between 23.5% and 49% of teenagers have thoughts of suicide at some time during adolescence. Often this is associated with stress relief rather than suicidal intent. That phenomenon should not, of course, be ‘over-normalised’. The risks associated with minimising suicidal thoughts or behaviours in adolescents have recently been highlighted (McGorry, 2010).

The Western Australian Aboriginal Child Health Survey collected data on approximately 5,000 Indigenous children over 2000-2001. It reported that one in four Aboriginal children were at high risk of developing serious emotional or behavioural difficulties (Silburn et al., 2006). This compares to about 1 in 6 or 7 of non-Aboriginal children. Suicide is believed to have been a rare event among Australian Aboriginal and Torres Strait Islander (ATSI) communities prior to colonial settlement. However, between the late 1970s and the late 1990s, the rising incidence of suicide and other self-inflicted injuries amongst Aboriginal people in general, and among males especially, reached catastrophic levels. At that time, many in Australia considered the rate of Aboriginal suicide to constitute a national disaster. The suicide rate then seemed to respond somewhat to state and federal intervention programmes. This is exemplified by the rate of suicide among Aboriginal males in Western Australia which increased from 4 per 100,000 in 1986 to 78.8 per 100,000 in 1999 and then declined a little to 68.4 per 100,000 in 2006. The AIHW reports that age-standardised suicide rate for 12–24 year olds in 2003–2005 was still more than four times higher among ATSI young people compared with non-Indigenous youth: 37 deaths compared with 8 deaths per 100,000 youth (AIHW, 2008). In 2007 and 2008, the Western Australian Coroner’s inquests indicate that there may once again be a rise in Aboriginal suicide in that state (Government of Western Australia, Department of Health, 2009). The emergence of suicide clusters (suicides which occur in close geographical time and/or space proximity to one another) in Aboriginal communities has also been identified in both Western Australia and Queensland (Government of Western Australia, Department of Health, 2009; Queensland Commission for Children and Young People and Child Guardian, 2009). Accurate national suicide statistics and population estimates are difficult to obtain for ATSI peoples. The ABS records data only in New South Wales, Queensland, South Australia and the Northern Territory. There is also under-identification of ATSI ethnic status. Thus data on suicide in ATSI communities are likely to be under-numerative and should be regarded with caution. It is clear that deaths in ATSI communities are over-represented, at 4.2% of the total number of Australians in 2008, versus non-ATSI Australians comprising 1.5% (ABS, 2010). It has been estimated that overall the suicide rate in Aboriginal communities may be 40% higher than the rate of non-Aboriginal suicide (Centre for Adolescent Health, 2010). The majority of Australian Aboriginal people who suicide are under the age of 29. The Queensland Commission for Children and Young People and Child Guardian’s (2009) Reducing youth suicide in Queensland discussion paper reports that the four-yearly rate (2004–2007) of ATSI children aged 10 to 14 years who suicided was more than 17 times higher compared to other Queensland children who suicided. ATSI young people aged 15 to 17 years were also over-represented, suiciding at a rate of more than 2.5 times that of other Queensland young people aged 15 to 17 years (Commission for Children and Young People and Child Guardian, 2009).

Risks

Individual

Individual young people at risk of suicidal ideation, intent or behaviors can present with a wide range of socio-emotional indicators (Apter et al., 2009). Some of the most well documented include stressful life events/trauma (CAH, 2010; Gould et al., 2003; Plener, 2011; Singer & Goldbeck, 2011) social withdrawal/isolation, school disengagement, obesity, physical illness or injury (Christiansen & Stenager, 2009; Riala et al., 2011) victimisation by adult predators (including both that initiated directly and online), victimisation through both face-to-face bullying and cyberbullying by peers (Bhat, 2008; Commission for Children and Young People and Child Guardian, 2009; Reynolds, 2011), abuse (sexual and other) (Wiech et al., 2009), drug and alcohol misuse/dependency (Windle, Miller-Tutzauer & Domenico, 1992) diagnosed mental illness including attention deficit hyperactivity disorder (Halasz et al., 2002), obsessive compulsive disorder (D’Alessandro, 2009), depression and perinatal mental illnesses, posttraumatic stress disorder, conduct disorder, opposition-defiant disorder, anxiety and eating disorders (Belfer, 2007; Costello, Foley & Angold, 2006; Esposito & Clum, 2002; Main, 2008; Phillips, 2010); serious learning difficulties (including dyslexia) leading to ailing academic performance (compared to above average) have been associated with a five-fold increased likelihood of a suicide attempt (Richardson et al., 2005). A history of self-harm (Owens, Horrocks & House, 2002), sleep and or appetite disturbance, changes in behaviour or performance such as truancy, negative conduct, a decline in academic or other areas of achievement (e.g. sports or interests), evidence of a concrete plan to carry out suicidal intent and intimacy with another young person who has taken their own life (especially close friends and siblings), or communication of intent (in direct conversation, suicide letters, art work, poetry, internet blogs or journal entries) (Cash, Bridge & McNamara, 2012; Lifeline Australia, 2010; Steele & Doey, 2007; Response-Ability, 2011). Adverse reaction to psychiatric medications including antidepressants and stimulants (such as those prescribed for Attention Deficit Hyperactivity Disorder) are also linked to suicidality (Cash, Bridge & McNamara, 2012; Halasz et al., 2002; Pliszka, 2007). Recent research with a US adolescent mental health cohort suggests that suicidal thoughts and behaviours link to internalising conditions (such as depression and anxiety), whilst externalising conditions (such as conduct, oppositional and defiant disorder) link to suicidal thoughts but not behaviours. Substance abuse (alcohol and cannabis) appears to be associated with suicidal threats and attempts but not suicidal thinking (Verona & Javdani, 2011).

Fascination with sad or violent fiction or web based material, preoccupation with knives, firearms and other weaponry, along with potential ligatures (ropes, cords etc) is sometimes associated with pre-suicidal profiles. Saying goodbye to people, giving away possessions and evidence of sudden quiescence or uplifted mood after a period of intense agitation or depression can be indications that suicidal behavior is imminent. Such behaviours feature in website warnings (Cash, Bridge & McNamara, 2012; Lifeline Australia, 2010; SANE Australia, 2010).

Young women tend to be more identified with hoarding and then overdosing on prescription or over the counter medications. Social issues such as unemployment, managing negative family and community responses to same sex attraction (Brown, 2002; Pitts et al., 2006; Quinn, 2003), relationship breakups, stress of school or university examinations, dropping out of school or other study programmes, domestic violence (Guggisberg, 2006), homelessness, torture or trauma survival (especially when associated with refugee status), reluctance to seek help and drug and alcohol abuse have been linked to heightened risk of suicidality among young people (Francis et al., 2001; Lustig et al., 2004). Clearly ATSI young people are at greater risk of suicide than other young people in Australian society. A recent study found 20% of young Indigenous women aged 12–17 years report that they have seriously considered ways to end their life and some have also attempted suicide (Australian Government Department of Health and Ageing, 2008).

Family

Family risk factors that have been linked to adolescent suicide include violence, emotional, sexual and physical abuse, early attachment disruption, emotional deprivation, parental conflict, parental relationship breakdown, exaggerated performance expectations, critical, rigid or overly-controlling parenting styles, poor mental health literacy, parental mental illness, suicide of a parent, financial difficulties, withdrawal or neglect, laissez faire or neglectful parenting and chaotic family relationships (Brent et al., 1998, Brent et al., 1999; Christiansen and Stenager, 2008; Francis et al., 2003; Kolves, 2010; LaRosa (2010); Ratnarajah & Schofield, 2008; Yoder & Hoyt, 2005). Where a sibling or parent has taken her or his life, the surviving siblings are known to be at greater risk of suicidal thoughts and behaviors (Cerel et al., 2000). Fantasies about joining a departed sibling are common (Suicide Prevention Australia [SPA], 2011).

A survey of suicides among young people in the State of Queensland released in 2009 would seem to manifest the important role of family issues in adolescent suicide as illustrated in Table 1. The strong interaction between family problems and individual and community risk factors is also apparent.

Table 1.

Number and proportion of common factors among children and young people (aged 10–17 years) who have suicided in Queensland, 2004–2007, merging risk factors and circumstances.

Risk factor	Number of completed suicides	Percentage of total suicides in this age range
Arguments and relationship breakdowns	51	78%
Argument with a significant other	26
Relationship breakdown with a significant other	24
Behaviour and disciplinary problems	41	63%
Suspended or expelled from school	31
Contact with police or youth justice	25
Communicating suicidal intent	39	60%
Suicidal behaviour	38	58%
Previous suicide attempts	14
Mental health issues	28	43%
Presented to medical practitioner with mental health issues	21
Mood disorders	19
Schizophrenia and psychosis	7
Attention-deficit and disruptive disorders	7
Contagion suicide	27	42%
Imitative (friend, acquaintance, community member)	14
Childhood abuse, chronic familial conflict and violence	26	40%
Familial (family member)	13
Known to the Department of Communities (Child Safety Services)	14
Case file current with the Department of Communities (Child Safety Services) at death	7

Data source: RYSQ (Reducing Youth Suicide in Queensland) Preliminary Findings Database (2004–2007).

Note: Sub-categories may not sum to risk factor totals due to repeated inclusion of cases where more than one sub-category risk factor was noted.

Findings from the 2005 Western Australian Aboriginal Child Health Survey: Strengthening the Capacity of Aboriginal Children, Families and Communities reveal that families of Aboriginal children report extraordinarily high levels of stress. In the 12 months prior to this research, one in five (22%) Aboriginal children aged 0–17 years were living in families where 7 to 14 major life stress events – including incarceration, violence, severe hardship and death – had occurred (Silburn et al., 2006). It is acknowledged that the ongoing trauma experienced by ATSI people as a result of past government policy of removing children from their parents impacts on indigenous youth suicide rates. In its Position Statement released in April 2008, SPA (2008, p. 6), a national non-government mental health policy organisation, argued that:

The detrimental effects of intergenerational transmissions of grief and trauma have been exacerbated for Aboriginal youth, in particular, by the conflicting sense of commonly feeling ‘caught between two cultures’ (Donaghy, 1997) and by the scientific and institutional racism inherent in past and present policies affecting Indigenous communities (Eckermann et al., 1992).

Community

Within the Australian community a number of groups have been identified as high priorities for monitoring and intervention based on recent recording of heightened suicide rates. Males constitute the most generic of these priority groups of young people. Others identified include indigenous youth, young people living in rural and remote communities, youth who have had community services involvement related to child protection issues, unemployed youth, refugees (especially those held in detention), same sex attracted young people and those incarcerated within or recently released from youth justice facilities (Reynolds, 2011; Government of Western Australia, 2009; Gilchrist, Horwath & Sullivan, 2007).

A number of socio-economic phenomena impacting upon communities have been linked to depression, anxiety and suicidality in both parents and young people. These include income deficit (often leading to financial crises), unemployment (Scutella & Wooden, 2008; Yoder &Hoyt, 2005; ABS 2004) housing uncertainty or homelessness, social isolation, lack of community support services (Cattell, 2001). Low levels of mental health literacy and a culture of reluctance to engage in help seeking within communities has also been linked to suicidality. Low levels of social capital – manifest in disconnectedness, exclusion and marginalisation from community based expression through the arts, recreation and sport - can undermine hope and aspiration for young people. Rural and remote communities appear to be at heightened risk in relation to most of these factors (ABS, 2009).

For ATSI families (both urban and rural) fragmentation and trauma continues; this is in part related to the intervention that produced what have become known as the ‘Stolen Generations’. The Stolen Generations of children were forcibly removed from their families on the basis of Australian government policy between 1910 and 1970. The numbers removed have been estimated at 100,000 - between one third and one tenth of all Indigenous Australian children born during that time. These young people were almost always taken from their homes without parental consent and placed in orphanages, foster homes or were trained as domestic servants or farm hands in the employ of non-indigenous Australians; they frequently experienced serious abuse in these settings (Act Now, 2010; Fredericks, 2010).

Excessive alcohol useage and petrol sniffing in Aboriginal communities are major causes of self-harm for people of both genders and all ages, but particularly for males and for youth (FacSHIA, 2008). Those in remote communities are at increased risk. In 2005–2006, Indigenous Australians were three times more likely to be hospitalised for intentional self-harm than other Australians (ABS, 2008). Hospitalisations for ‘mental and behavioural disorders due to psychoactive substance use’ are almost five times higher than the general Australian population for Indigenous males and around three times higher for Indigenous females. Hospitalisation rates for intentional self-harm may also be indicative of mental illness and distress (FacSHIA, 2008).

People in any kind of custody are at higher risk of suicidality (Cash, Bridge & McNamara, 2012); in Australia, the rate seems to be three times that of the general population (ABS, 2009). This would appear to be true of youth justice and mental health facilities as well as adult settings where youth are housed, such as immigration detention centres. The mental health and suicidality of young male detainees especially, has led to the Australian Federal Government’s recent decision to release refugee minors from institutional detention. These young people are now placed in community settings pending resolution of their immigration status.

Incarceration has often been associated with increased risk of suicide among Aboriginal males, including adolescents and young adults. It would appear, however, that the high rate of suicide in custody might be associated with far higher levels of Aboriginal incarceration than is the case for the rest of the Australian community. This was the finding of the Royal Commission into Aboriginal Deaths in Custody (Commonwealth Government of Australia, 1991a).

An emergent area of suicide risk in Australia derives from the virtual communities inhabited by almost all young people. Online bullying, stalking and predatory behaviours toward young people have been linked to suicidality (Bhat, 2008). Australian laws have recently been extended in an attempt to outlaw ‘pro-suicide’ websites (Pirkis, et al., 2009). The Australian press has recently highlighted concern that some high schools and their local communities manifest youth suicide ‘clustering’ and an element of ‘contagion’ (Geelong Advertiser, 2010). Contagion has also been identified in suicide clusters within indigenous communities in Australia’s north (Hanssens, 2010). Television news stories focusing on suicide have also been long associated with ‘contagion’ of self- harming activity and completed suicides (Phillips, Lundie, & Carstensen, 1986). There is also evidence that ‘romanticising’ or ‘normalising’ suicide in the media can increase rates of self-harm and completed suicides (McGorry, 2010). Media outlets have, however, for some years, followed strict codes of practice regarding the reporting of suicide within Australia; the Australian Press Council code has recently been updated (Australian Press Council, 2011).

Resilience

Individual and family

Promising early findings of current Australian research into factors promoting resilience to depression and suicidality in children and adolescents suggest an important role for self-efficacy. Self-efficacy in the context of mental health research has been defined as a ‘perceived ability to cope with depressive symptomatology’ (Tonge et al., 2005). Young people whose self-efficacy is strong appear to be somewhat protected against depression and suicidality. Implicit within self-efficacy would appear to be the concept of ‘agency’ which links thought and action; choices for the individual are developed through the individual’s processing of a range of knowledge that is ‘actionable’ (Macmurray, 1957). Adolescents with high levels of self-efficacy are usually experiencing success in learning and/or recreational activities (the arts, sport etc), are positively connected socially and are adept at negotiating the transition to adult levels of socio-emotional responsibility (in relation to activities of daily living, paid work etc.). Effective attachment to a consistent caregiver and an early childhood relatively free of serious trauma clearly play vital roles in the development of self-efficacy. Neuro-physiological research internationally over the past decade has produced irrefutable international evidence on differential brain development in traumatised and non-traumatised populations of children and young people (Perry & Pollard, 1998; Van der Kolk, 2006). Australian findings in relation to children and adolescents both within the child protection system (Berry Street-Take Two, 2010) and in the mainstream population (Veltmeyer et al., 2005) are consistent with that data. Resilience in adolescence can manifest as the agency to reach out for personal support within the immediate social circle of family and friends, or from professionals such as teachers or counsellors (Reavley et al., 2010). Responsive mentoring clearly increases the likelihood of young people make pro-social choices in terms of behaviours and relationships.

Resilient adolescents gradually begin to acknowledge the transitory nature of intense psychological pain (often resultant from relationship breakdown, sexual identity challenges, family problems, unwanted pregnancy, exam failure and so on) rather than perceiving that distress/despair, sadness, or even low mood are almost certainly going to be lifelong companions. Misconceptions of this nature are common at the adolescent stage of cognitive development where the present is a more concrete reality than the future and complex phenomena tend to be understood in ‘black and white’ terms rather than being addressed at higher levels of abstraction. ‘Faulty thinking’ of this nature (e. g. ‘I will always feel as bad as I do right now’) can be extremely problematic as it often leads to escapist thoughts, with suicidality not an uncommon consequence (McNamara, 2000).

Another area recently identified with resilience in adolescence is that of spirituality. It is important to differentiate grounding within a spiritual belief system from religiosity. For some adolescents, values and beliefs associated with organised religion (especially those offering a proscriptive set of rules and principles such as fundamentalist faiths) can prove a reassuring basis for the complex decision-making and choices associated with transition to greater independence and social responsibility (Holder et al., 2000). For many young people however, a major part of the adolescent experience is the search for meaning and self-knowledge; this often involves experimentation with different ways of making sense of one’s self and one’s place in the world. Often this means a break (of varying degrees) with the belief and value system that predominates within the family of origin (McNamara, 2000). A value and belief system that is gradually developing some clarity for the young person, along with an appropriate level of self-knowledge, would seem to be associated with resilience in adolescence (McNamara, 2006).

Closely associated with spirituality is the formation of cultural identity during the adolescent stage of development. Knowing and accepting who one is culturally can be a challenging aspect of the adolescent journey. It is sometimes associated with a period of rejection of family ethnicity, culture and subculture followed later by partial or total acceptance.

Community

It is widely recognised that both urban and rural communities need to build cultures that privilege acceptance and inclusivity; they also need to promote mental health literacy, create opportunities for social experimentation within safe limits and provide resources for recreational expression Australian Research Alliance for Children and Youth ([ARACY], 2009). Various government and community sector initiatives are attempting to address these ends. One important Federal Government programme targeting young people (aged 12–25 years) in schools, tertiary institutions and wider communities is headspace (www.headspace.org.au). Services such as mental health, vocational, and alcohol and other drug services are offered nationwide through headspace centres. The headspace centres have become well known in the Australian community. In April 2008, headspace launched a help-seeking website. Designed to be ‘youth-friendly and easy to navigate’, the headspace website was designed to be a key port of call for people seeking information about youth mental health and wellbeing issues and services within Australia. Its effectiveness as a national vehicle for adolescent support has, however, been open to some conjecture; a formal evaluation is in progress.

Schools and tertiary institutions have a special role to play in developing resilience in young people. Australia’s bounceback programme which focuses on resilience building has been especially well received by teachers, students and families. The aims of bounceback (www.bounceback.com.au/) are to:

Maximise student engagement in learning and their connectedness to school

Contribute to a positive pro-social school culture in which all students feel safe

Promote positive relationships and develop the social skills that contribute to them

Develop resilience skills that contribute to coping in the face of adversity

Develop pro-social values such as respect, compassion, acceptance of differences and friendliness.

Identify student and staff strengths as a starting point for educational and future success

Help both students and teachers to develop a sense of meaning and purpose

Mindmatters (www.mindmatters.org.au) is another nation-wide school based mental health initiative. This programme began in 2002 and ‘aims to enhance the development of school environments where young people feel safe, valued, engaged and purposeful’. More recent revisions of the programme actively embrace schools as communities and linking schools with the broader communities in which they operate (Mindmatters, 2010). The current focus of the programme centres on developing ‘a healthy school–community partnership’.

Research into the outcomes of the Gatehouse Project, conducted by CAH in Melbourne, also suggests that school-based child and adolescent mental health services can be highly effective in preventing mental health problems and the sometimes attendant suicidality (Bond et al., 2007; Butler et al., 2010). Strategies such as anti-bullying and cannabis use education and teacher wellbeing programmes have been initiated and become embedded in the Victorian service system as a result of the Gatehouse Project (2003–2008). Whilst such initiatives have raised the profile of these issues there is clearly some distance to be travelled in overcoming the challenges they create.

As well as hosting these psycho-educational, school change and systemic interventions there is clearly a role for schools to play in hosting delivery of direct clinical services such as individual therapy/counselling, family therapy and group work (Child and Adolescent Mental Health Service [CAMHS] in Schools Project, 2004). Over the past decade, delivery of CAMHS services within schools has become more generalised in Australia, but is constrained by an acute lack of funds and resources. The CAMHS resource deficit is especially problematic in rural and remote communities, but is also acutely experienced in the state capitals and in regional cities. An example of where such resources might be targeted is the transition to tertiary education (especially when this involves relocation from a rural to an urban community). This transition creates important opportunities for developing support systems (financial as well as socio-emotional) and the promotion of community inclusiveness.

Over the past decade, Australian Federal Government policy has shifted toward a model of capacity building in communities that are inclusive of young people as active participants (DHA, 2012). This includes specific targets in relation to suicide prevention (Commonwealth Department of Health and Aged Care, 2007). The Australian Government’s National Suicide Prevention Strategy, which commenced in 1999, aims to promote suicide prevention activities across the Australian population, as well as for specific at-risk groups, including young people (Headey et al., 2006). Its overall stated goal is to:

The goal of the National Suicide Prevention Strategy is to reduce deaths by suicide across the population and among at risk groups, and reduce suicidal behaviour. To inform and support this goal, the Australian Government is working together with communities across Australia to build resilience, resourcefulness and social connectedness in people, families and communities to protect against the risk factors for suicide. National Suicide Prevention Strategy, 2012

A variety of informal and formal mechanisms have been developed in the quest for greater community capacity and inclusiveness in Australia. Training and other opportunities for young people have been created in an attempt to ensure that youth are represented in community decision-making. There has also been an attempt to create culturally appropriate structures and mechanisms such as workshops and forums that represent and support young people. It is often observed, however, that whilst progress has been made, Australia still has not achieved the clarity of social policy needed to create community frameworks that can prevent youth suicides. This is especially the case in semi-rural, rural and remote areas of the country where specialist mental health services are especially under-resourced (Suicide Prevention Australia, 2011).

No common understanding of a defined population health model (Raphael, 2000) for Australian mental health care impacts negatively on clear definition of roles and responsibilities across sectors and between the federal government and the various states and territories. Under-funding of mental health care in all states for children, adolescents and youth has been recognised in all the reviews of National Mental Health Plans. Despite this, the funding deficit has not been adequately addressed, with existing funding even being reduced in some instances. Withdrawal of allied mental health practitioner rebates is a recent example of this (Australian Association of Social Workers, www.aasw.org.au).

Conclusions

It is encouraging for practitioners, researchers and the Australian community generally to learn that adolescent suicides rates appear to be reducing. The shift is consistent with international trends such as those recorded in the United States (Cash, Bridge & McNamara, 2012). No doubt improved access to treatment programmes for depression, substance misuse and schizophrenia is contributing to this. However, there are clearly many issues to be addressed for this trend to not only be maintained but accelerated. Some adolescents – welfare recipients, indigenous, refugee and same sex attracted youth, along with those in more isolated geographical locations - are clearly at significantly elevated risk. Young men continue to take their lives more frequently than young women. The latter disparity would appear to be associated with an avoidance of help-seeking within male sub-cultures and a tendency for young men to internalise negative emotion. Such features clearly need to be actively addressed in prevention programmes.

Greater self-efficacy can build resilience in ‘at risk’ youth, and indeed all young people; it is essential to celebrate strengths and broaden life choices. The creation of protective community systems through social capital enhancement and greater community connectedness must be a high priority. Early detection of risk through effective screening is clearly critical (Nock & Banaji, 2007). Developing more sophisticated mental health literacy in families and communities, especially those socially or geographically isolated, can also help protect young people from self-harm and suicide. Parents, teachers, community nurses, youth workers and other helping professionals who can offer containment and support as ‘mental health first aid’ have clearly not been fully mobilised at the preventive end of the intervention continuum. It would seem especially important that parenting programmes targeting ‘mental health safety’ within the family should be extended as an immediate priority. Significant adults can, with training and support, be highly effective in managing ‘frontline’ risk in the immediate term till mental health services can be accessed. Specialist adolescent psychiatric services are, without exception, an over-stretched resource and are most often called upon when a crisis erupts or the young person’s mental health has deteriorated to the point where she/he is deemed to be at serious risk. These services frequently enter the situation too late to contain a seemingly inevitable progress toward a tragic outcome.

Australian adolescent mental health policies and programme development have made significant strides over the past two decades. Community awareness and acceptance of the problem is far greater and we have had both a National Mental Health Framework (Australian Government - Department of Health and Ageing, Fourth National Mental Health Plan, 2009) and a National suicide prevention strategy (most recently Living is for everyone – LIFE ) for some time now; both are regularly reviewed. There are clear signs that these initiatives have been effective. There is, however, still considerable work needed to refine policies to make them far more responsive and internally consistent (Richardson, 2009). Adolescent mental health policies must be rendered capable of effectively guiding Australian youth suicide prevention initiatives and intervention services into the twenty-first century.

Footnotes

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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