Merck Manual

Please confirm that you are a health care professional

honeypot link

Suicidal Behavior in Children and Adolescents

By

Josephine Elia

, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Last full review/revision Apr 2021| Content last modified Apr 2021
Click here for Patient Education
Topic Resources

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.)

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); increased parental opioid prescriptions (2); increased suicide rates among adults leading to increased awareness of suicide by youths (3) ; increasingly conflicted relationships with parents; and academic stressors (4, 5).

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 leading cause of death in 10- to 24-year-olds and the 9th cause of death among children 5 to 11 years old (6). 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

  • 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).

Table
icon

Risk Factors for Suicidal Behavior in Children and Adolescents

Type

Examples

Mental disorders and physical disorders that affect the brain

Mood disorders* (eg, schizophrenia, depressive disorders)

Aggressive, impulsive tendencies (conduct disorder)

Previous suicide attempts

Anxiety disorders

Family history

Family history of suicidal behavior

Increased rates of suicide in adults

Parental opioid use‡

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)

Sexual/gender minority status

Environmental factors

Easy access to lethal methods (eg, guns)

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

Medications

Isotretinoina

Montelukastb

Gabapentinc

Prednisoned

Benzodiazepinesd

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

Gobbi G, Atkin T, Zytynski, et al: Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: A systematic review and meta-analysis. JAMA Psychiatry 76(4):426-434, 2019. doi: 10.1001/jamapsychiatry.2018.4500.

Turecki G, Brent DA, Gunnell D, et al: Suicide and suicide risk. Nat Rev Dis Primers 5(1):74, 2019. doi: 10.1038/s41572-019-0121-0.

§ Almost half of completed suicides occur after recent disciplinary action.

aBrenner JD, Shearer K, McCaffery: Retinoic acid and affective disorders: The evidence for an association. J Clin Psychiatry 73(1):37-50, 2012.

bBenard B, Bastein V, Vinet B, et al: Neurosychiatric adverse drug reactions in children initiated on montelukast in real-life practice. Eur Respir J 50(2):1700148. doi: 10.1183/13993003.00148-2017.

cMolero Y, Larsson H, D'Onofrio B, et al: Associations between gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime: Population based cohort study in Sweden. BMJ Clin Res 365:12147, 2019. doi: 10.1136/bmj.l2147.

dGibbons RD, Brown CH, Hur K, et al: Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry 164(9);1356-1363, 2007. doi: 10.1176/appi.ajp.2007.07030454.

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

  • 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, bipolar disorder, 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.

Treatment reference

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). 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). Starting in July 2019, the Joint Commission has been requiring hospitals to assess for suicide as part of standard medical care (4, 5). 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

  • Access mental health services

  • Get support from the family and community

  • Learn ways to peacefully resolve conflict

  • Limit media access to suicide-related content (6)

Suicide-prevention programs can also help. The most effective programs are those that strive to ensure that the child has the following (7):

  • 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.

Drugs Mentioned In This Article

Drug Name Select Trade
SOTRET
SINGULAIR
RAYOS
NEURONTIN
Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read

Test your knowledge

Sleep Problems in Children
Which of the following best represents the percentage of children between the ages of 5 and 12 years who have at least one episode of sleepwalking?
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID

Also of Interest

Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
TOP