Suicidal behaviour in children and adolescents

By Cristiano Antonino On Feb 7, 2022

Suicidal behaviour includes completed suicide, attempted suicide (with at least the intention of dying) and suicidal acts; suicidal ideation refers to the presence of thoughts and plans concerning suicide

Suicidal behaviour in children and adolescents:

In a recent report detailing increasing trends in suicide mortality in the United States (NCHS Brief No 398, February 2021), females (aged 10 to 14 years) showed an increase in suicide deaths from 0.5% in 1999 to 3.1% in 2019; in males (aged 10 to 14 years), rates increased from 1.9% to 3.1%.

A number of factors may be contributing to the rise in attempts, including increased teenage depression, especially in girls; increased opioid prescriptions from parents; increased suicide rates among adults leading to increased suicide awareness among young people; increasingly conflicting relationships with parents; and academic stressors.

Many experts believe that the variable rate at which antidepressants are prescribed may be a fact.

Some experts speculate that antidepressants have paradoxical effects, making children and adolescents more willing to talk about suicidal feelings but less likely to commit suicide.

Nevertheless, although rare in prepubescent children, suicide is the 2nd leading cause of death in 10-24 year olds and the 9th leading cause of death in 5-11 year olds.

This remains a major public health problem, especially in minority groups, as the suicide rate nearly doubled in black children in primary schools between 1993 and 2012.

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Suicidal behaviour, 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

Aetiology of suicidal behaviour

In children and adolescents, the risk of suicidal behaviour is influenced by the presence of other mental and other disorders affecting the brain, family history, psychosocial factors and environmental factors.

Other drugs have been reported to increase the risk, leading to black box warnings from the Food and Drug Administration.

However, in some cases, such as with the use of antiepileptic 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 risk factors include

A lack of structure and connections, leading to an overwhelming feeling of lack of direction
Intense pressure from parents to succeed, leading to a constant feeling that expectations are not being met

A frequent motivation for a suicide attempt is to manipulate or punish others with the fantasy “you’ll be sorry I’m dead”.

Protective factors include

Effective clinical treatment for mental, physical and substance use disorders
Easy access to clinical interventions
Family and community support (social relationships)
Conflict resolution skills
Cultural and religious beliefs that discourage suicide

Treatment of suicidal behaviour

Crisis intervention, possibly hospitalisation
Psychotherapy
Possibly administration of medication to treat underlying illnesses, usually combined with psychotherapy
Referral to the relevant psychiatrist

Every suicide attempt is a serious problem that requires thoughtful and appropriate intervention.

Once the immediate danger to the person’s safety is removed, a decision must be made for possible hospitalisation.

The decision made is weighted on the basis of an assessment of the degree of suicidal risk along with the family’s ability to provide help.

Hospitalization (including in a medical or pediatric ward under supervision by specialized nurses) is the safest form of short-term protection and is sometimes indicated if depression and/or psychosis is suspected.

How lethal suicidal intent can be can be assessed on the basis of the following indicators:

observed degree of premeditation (e.g. writing a suicide note)
Measures taken to prevent detection
Method used (e.g. firearms are more lethal than drugs)
Severity of injury
Immediate precipitating circumstances or factors underlying the attempt
Mental state at the time of the episode (acute agitation is of particular concern)
Recent discharge from hospital
Recent withdrawal of psychoactive medication

Drug therapies may be indicated for any underlying condition (e.g. depression, bipolar disorder, conduct disorder, psychosis) but cannot prevent suicide.

The use of antidepressants may increase the risk of suicide in some adolescents.

The use of drugs should be carefully monitored, and only sub-lethal doses should be given.

Referral to a psychiatric specialist is usually necessary to provide appropriate pharmacological and psychotherapeutic treatment.

Cognitive-behavioural therapy for suicide prevention and dialectical behavioural therapy may be preferred.

Treatment is more effective if the general practitioner continues to be involved.

It is essential to rebuild morals and restore emotional balance within the family.

A negative approach or lack of help from the family is a serious problem, and may suggest the need for a more effective intervention such as removal from the home.

A positive outcome is more likely if the family shows love and involvement.

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 have committed suicide have complicated reactions to suicide, including grief, guilt and depression.

Counselling can help them understand the psychiatric context of suicide and reflect on and acknowledge the child’s difficulties prior to 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 (e.g., guides for coping with a suicide loss) are available to help schools and communities after a suicide.

School and community officials can arrange for clinicians from mental health centres to be available to provide information and consultation.

Prevention of suicidal behaviour

Suicides are often preceded by changes in behaviour (e.g., depressed mood, low self-esteem, appetite and sleep disturbances, inability to maintain concentration, listlessness at school, somatic complaints, and suicidal thoughts) that often lead to medical consultation.

Statements such as ‘I wish I had never been born’ or ‘I’d like to go to sleep and never wake up again’ should be taken seriously as possible suicide announcements.

A suicide threat or attempt is an important signal of the intensity of the despair experienced.

Recognising the risk factors mentioned above at an early stage can prevent a suicide attempt. In the presence of these premonitory signs of suicide attempts or high-risk behaviour, a strong therapeutic intervention must be instituted.

Adolescents should be questioned directly about their unhappiness and self-destructive thoughts; such targeted questions reduce the risk of suicide.

A doctor must not provide unfounded reassurance, which can undermine the doctor’s own credibility and further reduce the adolescent’s self-esteem.

Physicians must screen for suicide in the medical setting.

Research published in 2017 indicated that 53% of paediatric patients presenting to the emergency department for medical reasons unrelated to suicide tested positive for suicidal tendency.

There is also evidence that the majority of adults and children who eventually die by suicide had received medical care in the year prior to death.

Beginning in July 2019, The Joint Commission required hospitals to assess suicide risk as part of standard medical care.

In addition to screening for suicide, physicians must help patients do the following to help reduce the risk of suicide:

Obtain effective treatment for mental, physical, and substance use disorders
Access mental health services
Get support from family and community
Finding out how to resolve conflicts peacefully
Limiting media access to suicide-related content

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

A supportive educational environment
Prompt access to mental health services
A social environment characterised by respect for individual, racial, and cultural differences.

In the United States, the SPRC Suicide Prevention Resource Center lists some of the programmes, 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.

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