Suicidal Behavior in Children and Adolescents: Causes and Management
Cynthia R. Pfeffer M.D.
Introduction
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.
Historical Note
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:
Recommendations made at the close of these conferences (7) included the need to:
Define the term suicide and other aspects of suicidal behavior and to report suicide in national databases more consistently.
Develop research to identify the multifaceted elements of youth suicidal behavior.
Evaluate the efficacy of treatments for suicidal youth and those at risk.
Support and plan appropriate suicide prevention strategies.
Educate those providing health care about identification, treatment, and prevention of youth suicidal behavior.
Collaborate in the public and private sectors to prevent youth suicide.
National attention to this major mental health problem was stimulated by the publication of the Surgeon General’s guidelines to prevent youth suicide (1).
Epidemiology
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).
Clinical Description
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.
Etiology and Pathogenesis
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.
sociocultural factors. In addition, the role of genetic factors in suicidal behavior has increasingly become a focus of attention.
TABLE 5.4.3.1 MULTI-AXIAL RISK FACTORS FOR YOUTH SUICIDE | ||||||
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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.
Primary Psychiatric Disorders among Youth Suicide Victims
Psychological autopsy studies have provided the most important information about psychosocial characteristics of youth suicide victims. The largest of these studies included 119 youth suicide victims who were younger than 20 years old (20). The methods of these studies involve systematic assessments via interviews of the suicide victim’s relatives to determine the psychosocial features of the deceased youth. Because the age of onset of certain psychiatric disorders occurs in late adolescence or young adulthood, risk of suicide associated with these psychiatric disorders, such as schizophrenia, were not evaluated in such studies.
A notable finding in all psychological autopsy studies is that approximately 90% of children and adolescents who committed suicide had a psychiatric disorder at the time of death (20,21,22,23). The relative risk for suicide imparted by having a psychiatric disorder varied with each study: approximately 5% (20), 14% (24) and 22% (23). An important implication of this finding is that clinicians should evaluate suicidal risk during all evaluations of children and adolescents.
Psychological autopsy studies also documented a high rate of comorbid psychiatric disorders, with rates above 70% (20,23). This implies that treatment planning may be complex because of the need to provide multiple interventions to address the outcomes related to each psychiatric disorder.
The strongest risk factor for youth suicide is a prior history of a suicide attempt. Prior suicide attempts increase risk for suicide from 51-fold to 89-fold (20,24). The clinical implication is that inquiry about prior suicide attempts is necessary in evaluating suicidal risk, and such youth should be monitored for new signs of suicidal thinking.
The majority (61%–76%) of youth suicide victims suffered from mood disorders (4,20,23). The likelihood of committing suicide is increased 8- to 13-fold in the presence of a current episode of a mood disorder (20,23,24). Rates of major depressive disorders among youth suicide victims ranged from 32% to 54% (4,20,23,25). The likelihood of committing suicide was increased 27-fold by the presence of a current episode of major depressive disorder (21). Approximately one-fifth of youth suicide victims were diagnosed as suffering from bipolar disorder, which increased risk for suicide nine-fold (4,21).
The second most common group of psychiatric disorders was any type of substance abuse disorder, which occurred in approximately 27% to 62% of youth suicide victims (4,20,21,22,23). The likelihood of committing suicide was increased 8.5-fold with a current substance abuse disorder (21). Approximately 43% of suicide victims suffered from comorbid mood and substance abuse disorders (23), a combination that increased risk for suicide 17-fold (21). Substance abuse among suicide victims appears to be a specific characteristic of youth suicide victims as noted in the San Diego Suicide Study, which compared suicide victims older than age 30 years to suicide victims who were younger (26,27). The youth suicide victims had a higher prevalence of drug abuse, and substance abuse was chronic and prevalent for approximately 9 years among these younger suicide victims. The most frequently abused substances were alcohol, marijuana, and cocaine. The younger suicide victims had a lower prevalence of mood disorders. Another psychological autopsy study highlighted that older adolescent suicide victims, particularly those who were older than 16 years, compared to younger adolescent suicide victims, had higher rates of substance abuse (24). A clinical implication of this report is that specific attention to identifying and treating substance abuse is an important youth suicide prevention strategy.
The New York Psychological Autopsy Study described gender-specific suicide risk factors among youth suicide victims (20). Among males, the likelihood of committing suicide was increased approximately 23-fold with a history of a prior suicide attempt, nine-fold with current major depressive disorder, and seven-fold with current substance abuse disorder. Among females, the likelihood of committing suicide was increased approximately 49-fold with current major depressive disorder and nine-fold with a history of a prior suicide attempt. Implications of these results are that clinicians should be aware to evaluate and plan treatments for gender-specific risk factors for youth suicide.
Psychological autopsy studies of youth suicide victims reported relatively low rates of anxiety disorders (27%), eating disorders (4%), and schizophrenia (4%) (20). Nevertheless, youth suffering from these disorders should be evaluated for suicide risk factors, such as suicidal ideation.
Primary Psychiatric Disorders among Youth with Nonfatal Suicidal Behavior
Reports of youth at risk for nonfatal suicidal behavior are important to guide clinicians in evaluating and treating risk
factors for suicidal ideation and suicide attempts. However, there are few studies of community samples of children and adolescents who attempted suicide and were systematically compared to youth who died as a result of suicide.
factors for suicidal ideation and suicide attempts. However, there are few studies of community samples of children and adolescents who attempted suicide and were systematically compared to youth who died as a result of suicide.
Studies of nonfatal suicidal behavior suggest that rates and types of psychiatric disorders are similar for suicide victims and those youth with nonfatal suicidal acts. Approximately 80% of youth who attempted suicide had a psychiatric disorder (29,30,31,32). Rates of comorbid mood, substance abuse, and disruptive disorders approximate 80% among adolescents who attempt suicide (33,34). A high correlation was identified among serious suicide attempts and cannabis abuse or dependence among adolescents in the community (33).
Research with psychiatric patients and youths in the community provided validating information about the significant association of mood disorders and youth suicidal behavior (35). Among child and adolescent psychiatric outpatients with a diagnosis of major depressive disorder, more than 70% reported suicidal ideation or attempts (36). Future suicidal tendencies were best predicted by irritability or anger, past history of suicidal thinking or behavior, and older age.
Prevalence of moderate to severe suicidal ideation in a community sample of 1,542 adolescents was 4% in males and 8.7% in females (37). Prevalence of suicide attempts was 1.9% in males and 1.5% in females. Presence of major depressive disorder imparted a seven-fold increased risk for suicidal ideation and an almost 10-fold increased risk for suicide attempts. Although most studies of community samples included adolescents who attended school, 37% of runaway youths reported a history of a suicide attempt (38). Although females were more likely to have attempted suicide, depression was significantly associated with suicide attempts in males and females.
Complexities exist in relating risk factors for suicide to those youth who actually will attempt or commit suicide. For example, differences between suicidal depressed youth and nonsuicidal depressed youth are difficult to identify (39). A study of adolescent psychiatric inpatients that aimed to identify which aspects of major depressive disorder were associated with suicidal behavior reported that suicidal ideation or acts were significantly associated with severity of depressed mood, intensity of negative self-evaluation, increased level of hopelessness, poor concentration, and high levels of anhedonia (40). The seriousness of suicidal intent was associated with increased degree of depressed mood and elevated degrees of negative self-evaluation. The lethality of suicide attempts was found to be correlated with increased level of depressed mood, elevated negative self-evaluation, intense states of anhedonia, presence of psychomotor agitation, and presence of alcohol or substance abuse. Gender differences have been identified in suicide risk among adolescents with major depressive disorder, with hopelessness being more frequent among females (41).
Reports of population-based studies of adolescents indicated that for males, but not for females, sexual orientation was associated with suicidal intent and suicide attempts (42). Bisexual and homosexual adolescents had higher risk of suicide attempts. Data from 1,007 young adults followed for 21 years in the New Zealand Birth Cohort Study documented that 2.8% who were classified as being gay, lesbian, or bisexual exhibited more suicidal ideation and suicide attempts, as well as more severe symptoms of depression, generalized anxiety, and conduct disorder than the other young adults in this longitudinal study (43).
Follow-up investigations suggest risk factors for youth suicidal behavior. Prospective research indicates that child psychiatric inpatients who attempted suicide are at six-fold increased risk to attempt suicide in adolescence and those who report suicidal ideation are at four-fold increased risk for a suicide attempt in adolescence (44,45). Adolescent psychiatric inpatients who attempt suicide are at significant risk for a repeat suicide attempt within 6 months of followup (46), and for suicide in less than 10 years (3). Approximately 25% of adolescent psychiatric inpatients were reported to have attempted suicide during the 5 years after psychiatric hospital discharge, but no adolescent committed suicide during this followup period (47). The first year after psychiatric hospital discharge was the period of highest risk. The strongest predictor of a suicide attempt was the number of prior suicide attempts. Mood disorder alone was not a predictor of a posthospitalization suicide attempt, but in conjunction with a history of a suicide attempt, mood disorder predicted a future suicide attempt.
Prepubertal children who have a major depressive disorder are at risk for suicide attempts in adolescence (48) and suicide in young adulthood (49). A 10-year longitudinal followup of children and adolescents suggested that major depressive disorder was related to a seven-fold increased risk for a suicide attempt (50). Clinical implications of these findings are that comprehensive monitoring is warranted for adolescents who were psychiatrically hospitalized after a suicide attempt.
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