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Suicidal Behavior in Children and Adolescents

by Josephine Elia, MD

Suicidal behavior is an action intended to harm oneself and includes suicide ideation, suicide attempts, and completed suicide. Suicidal ideation is thoughts and plans about suicide. Suicide attempts are acts of self-harm that could result in death, such as hanging or drowning.

  • A stressful event may trigger suicide in children who have a mental health disorder such as depression.

  • Children at risk of suicide may be depressed or anxious, withdraw from activities, talk about subjects related to death, or suddenly change their behavior.

  • Family members and friends should take all suicide threats or attempts seriously.

  • Health care practitioners try to determine how serious the risk of suicide is.

  • Treatment may involve hospitalization if the risk is high, drugs to treat other mental health disorders, and individual and family counseling.

Suicide is rare in children before puberty and is mainly a problem of adolescence, particularly between the ages of 15 and 19, and of adulthood (see Suicidal Behavior). However, preadolescent children do commit suicide, and this potential problem must not be overlooked.

In the United States, suicide is the second or third leading cause of death in adolescents. It results in 2,000 deaths per year. It is also likely that a number of the deaths attributed to accidents, such as those due to motor vehicles and firearms, are actually suicides.

Many more young people attempt suicide than actually succeed. A survey done by the Centers for Disease Control and Prevention found that 28% of high school students had suicidal thoughts and 8.3% had attempted suicide. Frequently, suicide attempts involve at least some ambivalence about wishing to die and may be a cry for help.

Among adolescents in the United States, boys outnumber girls in completed suicide by more than 4 to 1. However, girls are 2 to 3 times more likely to attempt suicide.

Did You Know...

  • Suicide is the second or third leading cause of death among adolescents in the United States.

Risk Factors

Several factors typically interact before suicidal thoughts become suicidal behavior. Very often, there is an underlying mental health disorder and a stressful event that triggers the behavior. Stressful events include

  • Death of a loved one

  • A suicide in school or another group of peers

  • Loss of a boyfriend or girlfriend

  • A move from familiar surroundings (such as the school or neighborhood) or friends

  • Humiliation by family members or friends

  • Being bullied at school

  • Failure at school

  • Trouble with the law

However, such stressful events are fairly common among children and rarely lead to suicidal behavior if there are no other underlying problems.

The most common underlying problems are the following:

  • Depression: Children or adolescents with depression have feelings of hopelessness and helplessness that limit their ability to consider alternative solutions to immediate problems (see Depression in Children and Adolescents).

  • Alcohol or drug abuse: The use of alcohol or drugs lowers inhibitions against dangerous actions and interferes with anticipation of consequences (see Substance Use and Abuse in Adolescents).

  • Poor impulse control: Adolescents, particularly those who have a disruptive behavioral disorder such as conduct disorder, may act without thinking.

Other mental disorders and physical disorders can also increase the risk of suicide. They include schizophrenia, head injury, and posttraumatic stress disorder.

Children and adolescents attempting suicide are sometimes angry with family members or friends, are unable to tolerate the anger, and turn the anger against themselves. They may wish to manipulate or punish other people (“They will be sorry after I am dead”). Having difficulty communicating with their parents may contribute the risk of suicide.

Sometimes suicidal behavior results when a child imitates the actions of others. For example, a well-publicized suicide, such as that of a celebrity, is often followed by other suicides or suicide attempts. Similarly, copycat suicides sometimes occur in schools. Suicide is more likely in families in which mood disorders are common, especially if there is a family history of suicide or other violent behavior.

Diagnosis

  • Identification of risk by parents, doctors, teachers, and friends

Parents, doctors, teachers, and friends may be in a position to identify children who might attempt suicide, particularly those who have had any recent change in behavior. Children and adolescents often confide only in their peers, who must be strongly encouraged not to keep a secret that could result in the tragic death of the suicidal child. Children who express overt thoughts of suicide, such as “I wish I’d never been born” or “I’d like to go to sleep and never wake up,” are at risk, but so are children with more subtle signs, such as social withdrawal, falling grades, or parting with favorite possessions.

Health care practitioners have two key roles:

  • Evaluating a suicidal child’s safety and need for hospitalization

  • Treating underlying disorders, such as depression or substance abuse

Prevention

Directly asking at-risk children about suicidal thoughts can bring out important issues that are contributing to the child’s distress. Identifying these issues can, in turn, lead to meaningful interventions.

Crisis hot lines, offering 24-hour assistance (see Suicide Intervention: National Suicide Prevention Lifeline), are available in many communities and provide ready access to a sympathetic person who can give immediate counseling and assistance in obtaining further care. Although it is difficult to prove that these services actually reduce the number of deaths from suicide, they are helpful in directing children and families to appropriate resources.

The following may help reduce the risk of suicide:

  • Getting effective care for mental, physical, and substance use disorders

  • Being able to easily access mental health services

  • Getting support from family and the community

  • Learning ways to peacefully resolve conflict

  • Having cultural and religious beliefs that discourage suicide

Suicide prevention programs can help. The most effective programs are those that try to make sure that the child has a supportive nurturing environment, ready access to mental health services, and a school or other social setting that promotes respect for individual, racial, and cultural differences. In the United States, the Suicide Prevention Resource Center Suicide Prevention Resource Center lists some of the programs, and the National Suicide Prevention Lifeline (1-800-273-TALK) provides crisis intervention for people threatening suicide.

Identifying Children and Adolescents at Risk of Suicide

Type

Specific Factors

Risk factors

Disorders that affect the brain

Mood disorders such as depression

Schizophrenia

Alcohol or drug abuse in adolescents

Conduct disorder

Head injury

Posttraumatic stress disorder

Family history

A family history of suicidal behavior

A mother with a mood disorder

A father with history of trouble with the police

Lack of communication with parents

Triggering events

Difficulties in school, including being disciplined or suspended

Loss of a loved one (such as a boyfriend or girlfriend), especially by suicide

Separation from parents

Lack of social contacts, sometimes due to having no job or not going to college

Victim of bullying

Reports of suicide in the media, which may lead to a copycat suicide

Circumstances

Access to firearms or prescription drugs

A previous attempt at suicide

Barriers encountered when trying to access mental health services and/or a feeling that a stigma is attached to seeking such help

Warning signs

Mental and physical symptoms

Preoccupation with morbid themes

Depression

A feeling of hopelessness

Low self-esteem

Dramatic changes in mood

Changes in appetite

Sleep disturbances

Tension, anxiety, or nervousness

Poor control of impulses

Changes in behavior

Poor hygiene and neglect of personal appearance (especially if it is an abrupt change)

Withdrawal from social interactions

Playing hooky from school

A decline in grades

An increase in violent behavior

Giving away favorite possessions

Conversation

Statements about feeling guilty

Statements suggesting a wish to be dead, such as “I wish I’d never been born” or “I’d like to go to sleep and never wake up”

Direct or indirect threats to commit suicide

Treatment

  • Sometimes hospitalization

  • Precautions to prevent future attempts

  • Treatment of any disorder contributing to risk of suicide

  • Referral to a psychiatrist and psychotherapy

Children who express thoughts of wanting to hurt themselves or who attempt suicide need urgent evaluation in a hospital emergency department. Any type of suicide attempt must be taken seriously because one third of those who complete suicide have previously attempted it—sometimes an apparently trivial attempt, such as making a few shallow scratches to the wrist or swallowing a few pills. When parents or caregivers belittle or minimize an unsuccessful suicide attempt, children may see this response as a challenge, and the risk of subsequent suicide increases.

Once the immediate threat to life has been removed, the doctor decides whether the child should be hospitalized. The decision depends on the degree of risk in remaining at home and the family’s capacity to provide support and physical safety for the child. Hospitalization is the surest way to protect the child and is usually indicated if doctors suspect the child has a serious mental health disorder such as depression.

The seriousness of a suicide attempt can be gauged by a number of factors, including the following:

  • Whether the attempt was carefully planned rather than spontaneous—for example, leaving a suicide note indicates a planned attempt

  • Whether steps were taken to prevent discovery

  • What type of method used—for example, using a gun is more likely to cause death than taking pills

  • Whether any injury was actually inflicted

  • What the child's mental state was when suicide was attempted

It is critical to distinguish serious intent from actual consequences. For example, adolescents who ingest harmless pills that they believe to be lethal should be considered at extreme risk.

If hospitalization is not needed, families of children going home must ensure that firearms are removed from the home altogether and that drugs (including over-the-counter drugs) and sharp objects are removed or securely locked away. Even with these precautions, preventing suicide can be very difficult, and there are no proven measures for successfully preventing it.

If the child has a disorder that may contribute to risk (such as depression or bipolar disorder), doctors treat it. But such treatment cannot eliminate the risk of suicide. Although there have been concerns that taking an antidepressant may increase the risk of suicide in some adolescents (see Antidepressant drugs and suicide), not treating the depression is probably just as dangerous or more so. Doctors carefully monitor children who take antidepressants and prescribe only small amounts that would not be lethal if taken all at once.

Doctors usually refer children to a psychiatrist, who can provide appropriate drug treatment, and to a therapist, who can provide psychotherapy, such as cognitive-behavioral therapy. Treatment is most successful if the primary care doctor continues to be involved.

If suicide occurs

Family members of children and adolescents who commit suicide have complicated reactions to the suicide, including grief, guilt, and depression. They may feel purposeless, detached from everyday activities, and bitter. They may have difficulty continuing with their life. Counseling can help them understand the psychiatric context of the suicide and reflect on and acknowledge the child’s difficulties before the suicide. They may then be able to understand that the suicide was not their fault.

After a suicide, the risk of suicide may increase in other people in the community, especially friends and classmates of the person who committed suicide. Resources (such as a toolkit for schools ) are available to help schools and communities after a suicide. School and community officials can arrange for mental health practitioners to be available to provide information and consultation.

Nonsuicidal Self-Injury

Nonsuicidal self-injury refers to intentional harm to self that is not intended to cause death. Examples are superficial scratching, cutting, or burning the skin (using cigarettes or curling irons), as well as stabbing, hitting, and repeated rubbing the skin with an eraser.

Adolescents who abuse drugs or other substances are more likely to injure themselves.

In some communities, self-injury suddenly becomes a fad in a high school, and many adolescents do it. In such cases, they gradually stop over time.

Self-injury suggests that an adolescent is in great distress. However, in many adolescents, self-injury does not indicate that suicide is a risk. Instead, it may be a self-punishing action that they feel they deserve. Self-injury can also be used to gain the attention of parents and/or significant others, express anger, or identify with a peer group. In other adolescents, the risk of suicide is increased, especially if they have used several methods to harm themselves.

All adolescents who deliberately injure themselves should be evaluated by a doctor experienced in working with troubled adolescents. The doctor tries to determine whether suicide is a risk and to identify the underlying distress that led to self-injury.

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