(See also Suicidal Behavior Suicidal Behavior Suicide is death caused by an intentional act of self-harm that is designed to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors... read more in adults.)
In a recent report detailing increasing trends in suicide mortality in the US (NCHS Brief No 398, February 2021), females (ages 10 to 14) showed an increase in deaths by suicide from 0.5% in 1999 to 3.1% in 2019; in males (ages 10 to 14) rates increased from 1.9% to 3.1%.
A number of factors may be contributing to the increase in attempts, including the increase in adolescent depression, especially in girls (1 References 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... read more ); increased parental opioid prescriptions (2 References 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... read more ); increased suicide rates among adults leading to increased awareness of suicide by youths (3 References 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... read more ) ; increasingly conflicted relationships with parents; and academic stressors (4, 5 References 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... read more ).
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 Suicide risk and antidepressants Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by history and... read more ). 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 leading cause of death in 10- to 24-year-olds and the 9th cause of death among children 5 to 11 years old (6 References 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... read more ). This remains a considerable public health concern, especially in minority groups, as the rate of suicide nearly doubled in black elementary school children between 1993 and 2012 (7 References 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... read more ).
References
1. Mojtabai R, Olfson M, Han B: National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics 138(6):e20161878, 2016. doi: 10.1542/peds.2016-1878
2. Brent DA, Hur K, Gibbons RD: Association between parental medical claims for opioid prescriptions and risk of suicide attempt by their children. JAMA Psychiatry 76(9):941-947, 2019. doi: 10.1001/jamapsychiatry.2019.0940
3. Wang J, Sumner SA, Simon TR, et al: Trends in the incidence and lethality of suicidal acts in the United States, 2006 to 2015. JAMA Psychiatry 77(7):684-693, 2020. doi: 10.1001/jamapsychiatry.2020.0596
4. Shain B, Committee on Adolescence: Suicide and suicide attempts in adolescents. Pediatrics 138(1):e20161420, 2016. doi: https://doi.org/10.1542/peds.2016-1420
5. Bilsen J: Suicide and youth: Risk factors. Front Psychiatry 9:540, 2018. doi: https://doi.org/10.3389/fpsyt.2018.00540
6. Centers for Disease Control and Prevention: WISQARSTM: Web-based Injury Statistics Query and Reporting Systems. 2020. Accessed 3/12/21.
7. Bridge JA, Asti L, Horowitz LM, et al: Suicide trends among elementary school-aged children in the United States from 1993 to 2012. JAMA Pediatr169(7):673-677, 2015. doi: 10.1001/jamapediatrics.2015.0465
Etiology of Suicidal Behavior
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 
).
Other drugs have also been reported to increase risk, leading to black box warnings by the Food and Drug Administration. However, in some cases, such as with use of antiseizure drugs, it is difficult to determine because epilepsy itself is associated with a 5-fold increased risk of suicide in the absence of antiepileptic drugs.
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 Overview of Substance Use Substance-related disorders involve substances that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific characteristics... read more
Easy access to clinical interventions
Family and community support (connectedness)
Skills in conflict resolution
Cultural and religious beliefs that discourage suicide
Treatment of Suicidal Behavior
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 Depressive Disorders in Children and Adolescents Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by history and... read more , bipolar disorder Bipolar Disorder in Children and Adolescents Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more , conduct disorder Conduct Disorder Conduct disorder is a recurrent or persistent pattern of behavior that violates the rights of others or violates major age-appropriate societal norms or rules. Diagnosis is by history. Treatment... read more , psychosis Schizophrenia in Children and Adolescents Schizophrenia is the presence of hallucinations and delusions causing considerable psychosocial dysfunction and lasting ≥ 6 months. (See also Schizophrenia in adults.) Onset of schizophrenia... read more ) 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 Suicide risk and antidepressants Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by history and... read more ). 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.
Treatment reference
1. Hesdorffer DC, Ishihara L, Webb DJ, et al: Occurrence and recurrence of attempted suicide among people with epilepsy. JAMA Psychiatry 73(1):80-86. 2016. doi: 10.1001/jamapsychiatry.2015.2516
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, guides for coping with a suicide loss) 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 of Suicidal Behavior
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 screen for suicide in the medical setting. Research published in 2017 indicated that 53% of pediatric patients presenting to the emergency department for medical reasons not related to suicide screened positive for suicidality (1 Prevention references 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... read more ). There is also evidence that most adults and children who eventually die by suicide had received medical care in the year prior to death (2, 3 Prevention references 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... read more ). Starting in July 2019, the Joint Commission has been requiring hospitals to assess for suicide as part of standard medical care (4, 5 Prevention references 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... read more ). In addition to screening for suicide, 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 Overview of Substance Use Substance-related disorders involve substances that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific characteristics... read more
Access mental health services
Get support from the family and community
Learn ways to peacefully resolve conflict
Suicide-prevention programs can also help. The most effective programs are those that strive to ensure that the child has the following (7 Prevention references 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... read more ):
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 .
Prevention references
1. Ballard ED, Cwik M, Van Eck K, et al: Identification of at-risk youth by suicide screening in a pediatric emergency department. Prev Sci 18(2);174-182, 2017. doi: 10.1007/s11121-016-0717-5
2. Ahmedani BI, Simon GE, Stewart C, et al: Health care contacts in the year before suicide death. J Gen Intern Med 29(6):870-877, 2014.
3. Oein-Odegaard C, Reneflot A, Haugue LI: Use of primary healthcare services prior to suicide in Norway: A descriptive comparison of immigrants and the majority population. BMC Health Serv Res19(1):508, 2019.
4. The Joint Commission: Detecting and treating suicide ideation in all settings. Sentinel Alert Event, 56:1-7, 2016.
5. Brahmbhatt K, Kurtz BP, Afzal KI, et al: Suicide risk screening in pediatric hospitals: Clinical pathways to address a global health crisis. Psychosomatics 60(1):1-9, 2019. doi: 10.1016/j.psym.2018.09.003
6. Bridge JA, Greenhouse JB, Ruch D, et al: Association between the release of Netflix's 13 Reasons Why and suicide rates in the US: An interrupted time series analysis. J Am Acad Child Adolesc Psychiatry 59(2):236-243. doi:https://doi.org/10.1016/j.jaac.2019.04.020
7. Brent DA: Master clinician review: Saving Holden Caulfield: Suicide prevention in children and adolescents. J Am Acad Child Adolesc Psychiatry58(1):25-35, 2019. https://doi.org/10.1016/j.jaac.2018.05.030
Key Points
Suicide is rare in prepubertal children but is the 2nd or 3rd leading cause of death in 15- to 19-year-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).
More Information
The following are some English-language screening tools for suicide in the medical setting that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Ask Suicide-Screening Questions (ASQ) Toolkit: This five-question screening tool is designed to be used by doctors to screen children and adolescents for suicide risk for immediate, appropriate treatment.
Columbia Suicide Severity Rating Scale (C-SSRS): Comprehensive information on a unique suicide risk assessment tool that is endorsed by the World Health Organization, the Food and Drug Administration, and the Centers for Disease Control and Prevention, among other prestigious agencies.
Patient Health Questionnaire (PHQ-9) Tool: Along with this tool, there is in-depth information on when and why to use it as well as the pearls and pitfalls associated with its use.
