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Suicidal Behavior in Children and Adolescents

By Josephine Elia, MD, Professor of Psychiatry and Human Behavior, Professor of Pediatrics;Attending Physician, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

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Suicidal behavior includes completed suicide, attempted suicide (with at least some intent to die), and suicide gestures; suicidal ideation is thoughts and plans about suicide. Psychiatric referral is usually required.

(See also Suicidal Behavior in adults.)

Youth suicide rates have declined in recent years after more than a decade of steady increase, only to have started climbing again. The exact reasons for these fluctuations are unclear. Many experts believe that the changing rates with which antidepressants are prescribed may be a factor (see Depressive Disorders in Children and Adolescents : Suicide risk and antidepressants). Some experts hypothesize that antidepressants have paradoxical effects, making children and adolescents more vocal about suicidal feelings but less likely to commit suicide. Nonetheless, although rare in prepubertal children, suicide is the 2nd or 3rd leading cause of death in 15- to 19-yr-olds and remains a considerable public health concern.

Etiology

In children and adolescents, risk of suicidal behavior is influenced by the presence of other mental disorders and other disorders that affect the brain, family history, psychosocial factors, and environmental factors (see Table: Risk Factors for Suicidal Behavior in Children and Adolescents).

Risk Factors for Suicidal Behavior in Children and Adolescents

Type

Examples

Mental disorders and physical disorders that affect the brain

Mood disorders* (eg, bipolar disorder, depressive disorders)

Aggressive, impulsive tendencies (conduct disorder)

Previous suicide attempts

Family history

Family history of suicidal behavior

Mother with a mood disorder

Father with a history of trouble with the police

Poor communication with parents

Psychosocial factors

Recent disciplinary action (most commonly, school suspension)

Interpersonal loss (loss of a girlfriend or boyfriend, especially in boys); separation from parents)

Difficulties in school

Social isolation (particularly not working or going to college)

Minority in upwardly mobile home

Victim of bullying

Media reports of suicide (copycat suicide)

Environmental factors

Easy access to lethal methods (eg, guns)

Barriers to and/or stigma associated with accessing mental health services

*Mood disorders are present in more than one half of suicidal adolescents.

Almost half of completed suicides occur after recent disciplinary action.

Other contributing factors may include

  • A lack of structure and boundaries, leading to an overwhelming feeling of lack of direction

  • Intense parental pressure to succeed accompanied by the feeling of falling short of expectations

A frequent motive for a suicide attempt is an effort to manipulate or punish others with the fantasy “You will be sorry after I am dead.”

Protective factors include

  • Effective clinical care for mental, physical, and substance use disorders

  • Easy access to clinical interventions

  • Family and community support (connectedness)

  • Skills in conflict resolution

  • Cultural and religious beliefs that discourage suicide

Treatment

  • Crisis intervention, possibly including hospitalization

  • Psychotherapy

  • Possibly drugs to treat underlying disorders, usually combined with psychotherapy

  • Psychiatric referral

Every suicide attempt is a serious matter that requires thoughtful and appropriate intervention. Once the immediate threat to life is removed, a decision regarding the need for hospitalization must be made. The decision involves balancing the degree of risk with the family’s capacity to provide support. Hospitalization (even in an open medical or pediatric ward with special-duty nursing) is the surest form of short-term protection and is usually indicated if depression, psychosis, or both are suspected.

Lethality of suicidal intent can be assessed based on the following:

  • Degree of forethought evidenced (eg, by writing a suicide note)

  • Steps taken to prevent discovery

  • Method used (eg, firearms are more lethal than pills)

  • Degree of self-injury sustained

  • Circumstances or immediate precipitating factors surrounding the attempt

  • Mental state at the time of the episode (acute agitation is especially concerning)

  • Recent discharge from inpatient care

  • Recent discontinuation of psychoactive drugs

Drugs may be indicated for any underlying disorder (eg, depression, bipolar or conduct disorder, psychosis) but cannot prevent suicide. Antidepressant use may increase risk of suicide in some adolescents (see Depressive Disorders in Children and Adolescents : Suicide risk and antidepressants). Use of drugs should be carefully monitored, and only sublethal amounts should be supplied.

Psychiatric referral is usually needed to provide appropriate drug treatment and psychotherapy. Cognitive-behavioral therapy for suicide prevention and dialectical behavioral therapy may be preferred. Treatment is most successful if the primary care practitioner continues to be involved.

Rebuilding morale and restoring emotional equilibrium within the family are essential. A negative or unsupportive parental response is a serious concern and may suggest a need for a more intensive intervention such as out-of-home placement. A positive outcome is most likely if the family shows love and concern.

Response to suicide

Family members of children and adolescents who committed suicide have complicated reactions to the suicide, including grief, guilt, and depression. Counseling can help them understand the psychiatric context of the suicide and reflect on and acknowledge the child’s difficulties before the suicide.

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 (eg, a toolkit for schools) are available to help schools and communities after a suicide. School and community officials can arrange for mental health care practitioners to be available to provide information and consultation.

Prevention

Suicidal incidents are often preceded by behavioral changes (eg, despondent mood, low self-esteem, sleep and appetite disturbances, inability to concentrate, truancy from school, somatic complaints, and suicidal preoccupation), which often bring the child or adolescent to the physician’s office. Statements such as “I wish I had never been born” or “I would like to go to sleep and never wake up” should be taken seriously as possible indications of suicidal intent. A suicidal threat or attempt represents an important communication about the intensity of experienced despair.

Early recognition of the risk factors mentioned above may help prevent a suicide attempt. In response to these early cues, to threatened or attempted suicide, or to severe risk-taking behavior, vigorous intervention is appropriate. Adolescents should be directly questioned about their unhappy or self-destructive feelings; such direct questioning may diminish suicide risk. A physician should not provide unfounded reassurance, which can undermine the physician’s credibility and further lower the adolescent’s self-esteem.

Physicians should help patients do the following, which may help reduce the risk of suicide:

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

  • Access mental health services

  • Get support from the family and community

  • Learn ways to peacefully resolve conflict

Suicide prevention programs can help. The most effective programs are those that strive to ensure that the child has the following:

  • A supportive nurturing environment

  • Ready access to mental health services

  • A social setting that is characterized by respect for individual, racial, and cultural differences

In the US, the SPRC 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.

Key Points

  • Suicide is rare in prepubertal children but is the 2nd or 3rd leading cause of death in 15- to 19-yr-olds.

  • Consider drug treatment for any underlying disorder (eg, mood disorders, psychosis); however, antidepressants may increase risk of suicide in some adolescents, so carefully monitor use of drugs, and supply only sublethal amounts.

  • Look for early warning changes in behavior (eg, skipping school, sleeping or eating too much or too little, making statements suggesting suicidal intent, engaging in very risky behavior).

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