Suicidal behavior is an action intended to harm oneself and includes suicide gestures, suicide attempts, and completed suicide.

• 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.

Suicide gestures are acts of self-harm that are unlikely to result in death, such as taking an overdose of vitamins.

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: Adolescents with depression have feelings of hopelessness and helplessness that limit their ability to consider alternative solutions to immediate problems.
• Alcohol or drug abuse: The use of alcohol or drugs lowers inhibitions against dangerous actions and interferes with anticipation of consequences.
• Poor impulse control: Adolescents, particularly those who have a disruptive behavioral disorder such as conduct disorder, may act without thinking.

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”).

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

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 and 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 Suicidal Behavior: 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.

Risk Factors and Warning Signs of Suicide in Children and Adolescents
Mental and physical symptoms: Preoccupation with morbid themes Depression 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 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 Circumstances: Access to firearms or prescription drugs Family history of suicide A previous attempt at suicide Death of a loved one, especially by suicide Alcohol or drug abuse

Treatment

Children 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. 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

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 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 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.

Last full review/revision February 2009 by Hugh F. Johnston, MD