Progress has been made in many areas related to youth suicide prevention, an important mental health problem in the United States and worldwide. This chapter will discuss features of youth suicidal behavior to assist clinicians in recognizing those children and adolescents who are most at risk for suicide and to intervene to prevent fatalities and morbidities arising from suicidal acts. The information reported in this chapter is based on empirical investigations to identify risk factors for youth suicidal behavior. Treatment is discussed with regard to empirical research on efficacy to reduce risk factors for youth suicidal behavior.

Guidelines for a national initiative to prevent youth suicide, published by the Surgeon General of the United States, stimulated renewed intensive efforts for suicide prevention (1). Issues highlighted in this initiative included awareness, intervention, and methodology. Awareness that suicide is a public health problem focused on the reduction of stigma and the enrichment of community resources for suicide prevention. Recommendations included development of a National Strategy for Suicide Prevention involving public and private resources aimed to improve the recognition and treatment of suicide risk by primary care providers, to eliminate barriers in insurance coverage for treatment, to educate families about suicide risk, to implement effective crisis and peer support programs in schools, to use schools and workplaces as referral and access points, and to provide support to those who lose a loved one to suicide. Scientific advances in suicide prevention were considered possible through research on the identification of risk factors, evaluation of suicide prevention interventions, promotion of interagency collaborations to improve identification and treatment of suicidal youth, and reduction of access to lethal suicide methods.

The Surgeon General’s report built on the aggressive efforts to eradicate youth suicidal behavior that began in the 1980s with the initiation of innovative research methodologies involving epidemiologic, cross-sectional, psychological autopsy, and longitudinal approaches. Numerous scientific papers published in the 1990s have educated health care professionals and the community about the characteristics of this profound mental health problem.

The definitions of the spectrum suicidal behavior are important to clarify so that a common approach of communicating about youth suicidal risk is possible. The concept of suicidal behavior in children and adolescents includes thoughts about causing intentional self-injury or death (suicidal ideas) and acts that cause intentional self-injury (suicide attempt) or death (suicide) (2,3). Based on research suggesting that the severity of depression, death preoccupations, and general psychopathology are directly proportional to the severity of suicidal behavior, researchers concluded that suicidal behavior among children and adolescents involves a continuum from nonsuicidal behavior to suicidal ideas, suicide attempts, and suicide (3,4). These concepts are complicated by cognitive and emotional developmental variations among children and adolescents.

In the early nineteenth century, when Goethe’s classic The Sorrows of Young Werther was published, an epidemic of youth suicide occurred. This epidemic was attributed to imitation of the book’s hero, who shot himself after the breakup of a love relationship. Subsequently, the book was banned in Europe. Issues of imitative suicidal behavior have been empirically studied in the 1980s (5). In 1910, the Vienna Psychoanalytic Society convened a special meeting to evaluate risk factors for youth suicidal behavior (3). Similar to our modern-day concerns, this historic meeting was organized to discuss and understand the causes of the significant rise in youth suicide and to propose means of preventing this tragic problem. Among the participants at this meeting were Federn, Freud, Rank, Steckel, and Tausk. Sigmund Freud, for example, suggested that the most significant influence on youth suicide was conflict with loved persons. He proposed that intensive study of specific suicidal individuals would elucidate dynamic aspects of childhood suicidal behavior. Others offered suggestions about how to decrease stresses, such as school pressure, that may enhance risk of youth suicidal behavior. Many advocated the need to develop systematic techniques to study youth suicidal behavior. These propositions continue to be main foci for prevention of youth suicide in modern times.

A rapid rise in suicide among male 15- to 24-year-olds in the United States began in the late 1960s, peaked in 1977, and has decreased in recent years. Clusters of youth suicide were recognized in the 1980s. This phenomenon stimulated extensive public demands to develop effective suicide prevention strategies. Among methods implemented were programs in schools to increase student awareness about the characteristics of youth suicide and to promote treatment seeking among youth at risk for suicide. Research of such school suicide prevention programs redirected the thinking about the most effective and safe strategies for such suicide prevention efforts (6) and refocused school-based suicide prevention efforts toward identification of youth at risk.

The importance of developing well conceptualized approaches to decrease youth suicide was highlighted in the 1986 Health and Human Services–National Institute of Mental Health Task Force Conferences on Youth Suicidal Behavior. Participants at these conferences included international research experts on youth suicidal behavior.
Recommendations made at the close of these conferences (7) included the need to:

The most recent year for complete death records of the United States Vital Statistics is 2003 (8). The age-adjusted rate of suicide for 15- to 24-year-olds was 9.5 per 100,000, a rate lower than that of 10.5 per 100,000 for all ages. In recent years, the rates of youth suicide have decreased. For example, the rate of suicide for 15- to 24-year-olds in 2003 was less than that of 11.1 per 100,000 in 1998 (9) and 12.4 per 100,000 in 1979. The age-adjusted suicide rate for 15- to 24-year-olds in 2003 is significantly higher than the age-adjusted suicide rate of 0.6 per 100,000 for 5- to 14-year-olds in 2003 (8). Suicide among 15- to 24-year-olds was the third leading cause of death, and in 5- to 14-year-olds the fifth leading cause in 2003. In 2003, there were 3,921 suicides among 15- to 24-year olds and 255 suicides among 5- to 14-year-olds. The recent decrease in youth suicide rates may be related to better identification of youth at risk and more effective treatments.

Suicide rates in the United States in 2003 were highest among white males of all ages.

The age-adjusted suicide rates for white males were followed by those for nonwhite males, white females, and nonwhite females. From 1986 to 1991, suicide among black youths increased more rapidly than among white youths (10). This trend may be attributed to assimilation and loss of traditional cultural support among black youths, as well as higher risk that is associated with increases in social class (11). Rates of suicide are highest among Native Americans (12) and especially among those with high rates of loss of traditional cultural values, unemployment, and alcohol abuse (13).

Compliance of relatives in removing firearms from the home is problematic and a challenge to strategies for suicide prevention (14). Rates of suicide caused by firearms for all ages in 2003 were 5.9 per 100,000 (8). This is the leading cause of completed suicide among youth. Other leading causes of suicide among youth are hanging and poisoning (15).

Reliable national data for suicide attempts do not exist because there is no national registry for suicide attempts. Information about youth nonsuicidal behavior has been derived from the Youth Risk Behavior Surveillance System (16). A nationally representative sample of 1,270 high school students in ninth through twelfth grades in the United States completed this survey (16). Approximately 20% of the students had serious suicidal ideation, with rates of approximately 25% for females and approximately 14% for males in 1999 (16). In the year prior to completing this survey, approximately 8% of the students attempted suicide at least once, with females (10.8%) attempting more than males (5.7%). Approximately 3% of the students sustained serious injury when they attempted suicide. Other reports indicated that approximately 1% of preadolescents living in the community carried out a recent suicide attempt (17) and approximately 34% of adolescent psychiatric inpatients were psychiatrically hospitalized due to a recent suicide attempt (18). Suicide among children and adolescents who had a history of psychiatric hospitalization occurs approximately nine times more often than among children and adolescents in the community (19).

Suicidal ideation and acts are episodic events that have discrete onsets and durations (3). Intent to harm oneself is an essential defining characteristic of suicidal behavior. Suicidal intent may be explicit and strong or it may be ambiguous. Evaluating intentionality often is a difficult clinical task, especially among preadolescents. For example, a 9-year-old boy who was seriously despondent after his dog died threatened to stab himself with a knife during an argument with his mother. He denied that he had thoughts of wanting to kill himself, but stated that he wanted to upset his mother. In this case, the intent was not clear, but the overt behavior was potentially life threatening. In contrast, a 15-year-old girl ingested 127 aspirin tablets after she broke up with her boyfriend. She wanted to kill herself because she felt she “had nothing to live for.” In this case, suicidal intent was clearly stated.

Because intentionality often is difficult to identify in children and adolescents, it is helpful for clinicians to consider that self-injurious acts in children and adolescents are potentially suicidal and make efforts to protect such youths from self-harm. In this way, clinicians can be more focused on administering life-sparing interventions rather than to limit their intervention strategies.

It is essential to appreciate that young children will not know that death is final and that it is not until adolescence that comprehension of the finality of death is fully realized. Therefore, in evaluating suicidal behavior in children and adolescents the understanding that death is final is not an essential ingredient in determining whether children or adolescents are suicidal. Concepts about death develop in parallel with children’s advancing development (3). Although appreciation of the finality of death may not occur until adolescence, some suicidal adolescents do not have mature concepts of death. Additionally, children’s concepts of death may vary. For example, a 7-year-old may understand that because his pet bird has died, it will no longer be alive. However, this child may not understand that if he dies he will never be alive again. Children’s understanding of death also may fluctuate. Children may realize that death is final at one time but when severely stressed— for example, by the divorce and arguments of their parents— children may believe that death is reversible. Therefore, it is quite evident that young children, such as preschoolers who do not appreciate the finality of death, can be considered to be suicidal if they wish to carry out a self-destructive act with the goal of causing death.

Children and adolescents, like adults, can plan and carry out suicidal acts using a variety of potentially lethal methods that include shooting, hanging, ingestion, and other suicidal methods involving suffocation, stabbing, running into traffic, burning, and drowning. Females attempt suicide more frequently and use less violent methods than males. Gender differences for suicide methods may account for why suicide rates are higher among males.

Suicidal ideation and suicide attempts are psychiatric symptoms whose pathogenesis involves psychiatric disorders, stressful life events, problems in social adjustment, and
sociocultural factors. In addition, the role of genetic factors in suicidal behavior has increasingly become a focus of attention.

A multi-axial approach, similar to that of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), can be utilized to conceptualize the multiple pathogenic and etiological features of youth suicidal behavior. Factors involved in the incidence and prevalence of youth suicidal behavior may be outlined according to five axes: 1) primary psychiatric disorders, 2) developmental and personality disorders, 3) biological factors, 4) environmental stress factors, and 5) social functioning or coping mechanisms. Table 5.4.3.1 shows risk factors for youth suicide conceptualized within such a multi-axial framework.