To the best of our knowledge, this study is the first to report on recent help-seeking behavior (in contrast to intentions) among suicidal high school students, and also the first to conceptualize help-seeking as a combination of self-disclosure and intention. This conceptualization is grounded in the contention that help-seeking disclosure of suicide ideation is critical for recruiting appropriate intervention and research demonstrating that approach-focused self-disclosure leads to more positive outcomes (Chaudoir and Fisher 2010
). Among 381 suicidal high school students, fewer than 15 % engaged in help-seeking using our definition, and students were twice as likely to disclose their SI to peers (54 %) than to adults (23 %). Given that adults are the primary gatekeepers to mental health services for adolescents (Logan and King 2001
; Costello et al. 1998
) and often do not, on their own, detect in adolescents signs of depression (Logan and King 2002
) or suicide risk (Kerr et al. 2008
; Klaus, Mobilio and King 2009
), the paucity of teens’ explicit help-seeking communication with adults helps to explain why so few suicidal youth receive services (McCarty et al. 2011
Youth with suicide ideation who disclosed SI and sought help resembled their non-suicidal peers across all attitudinal and social measures, and differed only in terms of having more depressive symptoms. Communicating with trusted adults about emotional distress may be one marker of healthy adaptation in adolescence, especially for youth with significant mental health symptoms and/or suicide risk for whom adult help and intervention are critical. Because patterns of health behavior begun in adolescence often carry to adulthood (Maggs et al. 1997
), learning to identify and communicate severe distress to capable and appropriate confidantes could influence the long-term trajectory for youth at risk for mental disorders and suicide. The ability to use internal signals of distress, including but not limited to suicide ideation, to motivate help-seeking and other approach-focused strategies (Seiffgr-Krenke and Klessinger 2000) may be a developmental competency that could be targeted in prevention programs (e.g. Muehlenkamp et al. 2009
; Wyman et al. 2010
) as well as positive youth development efforts (Lerner et al. 2010
Building from a Network Episode framework, our findings are congruent with theory and research based on help-seeking and service use for mental-health problems other than suicide, indicating that teenage help-seeking is a psychological process that is embedded within a social context (Pescosolido 1992
; Andersen 1995
; Costello et al. 1998
; Logan and King 2001
; Stiffman et al. 2004
). Youth with attitudes and perceived norms indicating help-seeking acceptance, and those with more positive perceptions of their connection to school and access to people and settings that support their coping, were more likely to seek help. Our findings also extend that prior work by linking help-seeking and two potentially modifiable attitudinal factors that are specific to suicide concerns: perception that adults are available to help suicidal youth and willingness to overcome secrecy requests. These suicide-specific norms and attitudes may help to explain the tendency that has been documented among youth with suicide ideation to avoid or reject help that appears to be readily available to them (Wilson et al. 2010
This study has several implications for research and prevention. First, adolescents’ disclosure of SI to an adult and attempting to get help were related but distinct. More examination is needed of the communication behaviors and intentions of suicidal youth who engage with adults to shed light on the apparent disconnect that exists in some youth between disclosure and trying to get help. Second, at present, very little is known about the characteristics of productive help-seeking disclosure among youth with SI or how it unfolds over time and in relation to adolescent development—critical knowledge for professionals who develop interventions to promote more frequent and effective help-seeking on the part of at-risk youth (and responsiveness from adults). Third, and equally important, studies are needed to uncover key junctures in the help-seeking process in which initial motivations to get help for SI either become derailed, leading the vast majority of suicidal youth to keep suicidal thoughts, plans, and behavior to themselves; or are deepened, and lead to constructive engagement that improves functioning and lowers risk.
Building from a Network-Episode framework, our present findings are an initial step in creating a more detailed, developmentally-informed model of the youth help-seeking process, leading up to and continuing through an initial help-seeking interaction, such as recognizing SI as a problem, selecting an adult confidant, interacting with an adult, and evaluating the interaction. This model places adolescents’ autonomy in making choices in the context of their continued dependence on adults. For example, knowing adults who are trustworthy and capable of helping with suicide concerns was the most robust predictor of youth help-seeking in this study. More research is needed to understand factors that influence these judgments among suicidal teens. The decisions to disclose SI and seek help also likely are influenced by other developmental tensions not assessed in this study, such as underdeveloped emotion-regulation abilities (Casey et al. 2010
), which previously have been linked with lower intentions to seek help for emotional problems and SI, and with less successful prior help-seeking experiences (Ciarrochi et al. 2002
). Specific emotion regulation deficits, such as restrictive emotionality (Jacobson et al. 2011
), have been linked with suicide ideation and depressive symptoms. The interplay between emotion regulation skills, norms/attitudes, and social support in shaping help-seeking behavior merits further exploration.
In addition to learning more about adolescents’ willingness to engage adults for help, research also is needed to determine what prepares adults to be effective in their interactions with suicidal teens, in terms of emotional responsiveness, instrumental support, and encouraging ongoing engagement. System-level factors, such as family preferences and access to care, also influence whether help-seeking results in receipt of appropriate care and improved outcomes; these factors must be considered in comprehensive models of help-seeking and suicide prevention. Along similar lines, the NEM predicts that cultural norms and values profoundly influence help-seeking and other health behavior (Pescosolido 1992
). Participants in this study were adolescents from primarily rural and low-income communities. More work is needed to understand the “cultural cartography” (Olafsdottir and Pescosolido 2009
) of suicide-related adolescent help-seeking, including how the influence of specific attitudes, norms, and perceptions of social support varies with geography and socioeconomic status. Finally, the link between social support and help-seeking disclosure in this study should be followed up with research investigating the contours of disclosure in different social settings, such as home, school, and community, each of which has a unique role in shaping help-seeking and service utilization, according to the family-based network episode model (Costello et al. 1998
Our findings also point to the need to determine how youth attitudes and perceived norms relating to help-seeking are communicated, maintained, and changed. Although depressive symptoms previously have been linked with low help-seeking intentions in a general sample of high school students (Wilson et al. 2007
), the lack of a univariate association between depressive symptoms and help-seeking behavior in this sample of students with SI suggests that targeting the alleviation of depressive symptoms alone may not promote help-seeking behavior among at-risk adolescents, unless norms, attitudes and social integration are directly affected. The adolescent risk-behavior literature has demonstrated that adolescents’ peer networks influence a broad range of norms, attitudes, and health behaviors (Valente 2010
). Since youth are particularly sensitive to modeling about suicidal behavior (Insel and Gould 2008
), one fruitful direction for investigation may be to discover whether adolescent norms and attitudes about seeking help, trusting adults, and drawing support for coping in the midst of suicidal crises could likewise be influenced by peers.
Several limitations of this study should be noted. First, suicide ideation was measured with a single dichotomous item. The measure does not define what is meant by “seriously considered attempting suicide,” which could be interpreted by students in different ways. However, this item has been found to have test–retest reliability, and the word “seriously” reduces the chances that individuals will respond positively if they have only had fleeting thoughts about suicide ideation. This measure of suicide ideation is well established for defining at-risk groups in population studies, in which a more detailed measure of suicide ideation is not feasible. However, a more precise measurement of suicide ideation and intention would be needed for clinical research seeking to screen a population for clinical risk. Second, due to reliance on retrospective reports of help-seeking behaviors, positive experiences resulting from seeking and receiving help could have increased some adolescents’ attitudes, such as the perception that adults are available to help suicidal students and perception of their social resources. Furthermore, adolescents could have been subject to a choice-supportive bias (i.e., reporting beliefs that are consistent with past behavior). Prospective studies are needed to assess the impact of norms and perceptions prior to the adolescents’ experiencing SI and potentially deciding to seek help. Third, students’ responses to questions about disclosure and seeking help could reflect a variety of interpretations of what it means to “tell an adult” or to “try to get help.” Psychometric work is needed to develop reliable and valid measures of the processes within the proposed help-seeking sequence. Nevertheless, this study provides the first measures of students’ help-seeking disclosure of SI to adults in a large sample of recently suicidal adolescents. Finally, this study was conducted in high schools serving primarily white students and the findings may not generalize to other populations, including those with greater racial diversity.
Seeking help from adults is a potentially life-saving response for adolescents who consider suicide. We have proposed that help-seeking for the suicidal adolescent involves, at minimum, telling an adult about SI together with the intention to get help. Our findings provide additional empirical rationale for suicide-prevention strategies that focus on changing norms, attitudes, and social environment in order to promote help-seeking (see, for example, Wyman et al. 2010
; Aseltine and DeMartino 2004
) and suggest targets to investigate through intervention studies. The low prevalence of student SI disclosure and help-seeking highlights an urgent need to understand more about at-risk adolescents who do and do not seek help, how to identify them, and what might encourage them to reach out for help when they are most in danger.