Adolescents face many developmental challenges academically, socially, and within their families. The large majority of youth handle this developmental period without major difficulty. However, this is also the time when rates of depression and suicide begin to increase. Youth suicidality has become a public health concern. Whether suicidal youth are encountered in the office with depressed mood and passive suicidal ideation or in the emergency department (ED) after an attempt, clinicians are faced with difficult decisions regarding their care. Not only must clinicians decipher when to recommend hospitalization, but they must also determine how best to facilitate outpatient treatment and, in some cases, figure out how to manage recurrent suicide attempts and begin to ameliorate the social chaos that often surrounds suicidal youth. These decisions are taxing under the best circumstances for even the most experienced clinicians. All too often, however, clinicians find themselves with limited time, limited training in mental health in general, and/or limited experience with youth.
This chapter reviews the salient features of child and adolescent suicidality that primary care physicians, general psychiatrists, and other primary clinicians must consider as they are the front-line clinicians encountering youth at risk. Emphasis is on delineating an approach to the assessment of suicidality and disposition of suicidal youth from the primary clinician’s office to other services. The literature on the management and treatment of suicidal youth is reviewed.
Classification of Suicidal Behaviors and Methods
Historically, there has been some debate as to how best to define and classify a range of behaviors on the suicide spectrum. Some authors draw parallels between suicide and selfinjury enacted without the intent to die, referring to these nonlethal behaviors as “parasuicide” or “suicidal gestures.” Understanding these phenomena is important, as a subset of youth use self-injury to manage negative affect and communicate their distress to significant others, and studies estimate that 50% to 75% of teens who engage in nonsuicidal self-injurious behavior have also made at least one prior suicide attempt. These issues are complex and the subject of much investigation. In the current chapter, suicidality includes preoccupations and overt behaviors enacted with the intent to cause one’s own death. Although the intent to die is an essential element of this definition, it is important to note that children and developmentally delayed youth may not have a mature concept of the finality of death or an accurate assessment of the lethality of their behavior. If youth expect that their behavior will bring about death, then that behavior should be considered a suicidal act, even if of low lethality. The main “differential” will be self-injurious and high-risk behaviors without the intent to die. Such nonlethal behaviors are a concern in that they cause suffering and have an association with suicidality, but require different interventions.
Youth with emerging personality disturbance, highly dysregulated affect, and dissociative features often engage in self-injurious behaviors, such as cutting or burning, in an effort to manage negative affect and communicate distress to others without an intent to die. They may report a sense of relief upon such injury or may acknowledge that they wanted to “get back at” a significant other for a perceived transgression. Self-injurious behaviors without suicidal intent are more likely to be repetitive, with multiple injuries over relatively short periods of time.
High-risk behaviors such as reckless driving, frequent accidents, and running in front of vehicles must be differentiated from suicide attempts. There is some suggestion that suicidal individuals engage in endangering behavior, even at a very young age. Youth with disruptive behavior disorders put themselves in harm’s way, either without consideration of the consequences or with the assumption that nothing bad will happen to them, such as driving fast, provoking police, or binging on drugs or alcohol. Open-ended questioning about such youth’s assumptions regarding their intent and the expected outcome of their behavior helps to differentiate suicide from reckless behavior.
Epidemiology of Youth Suicidality
Rates of Suicidality
Suicidal ideation and nonlethal attempts are a major concern for youth at all ages. In the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study of 9- to 17-year-olds, 5.2% of youth reported suicidal ideation and 3.3% reported having attempted suicide. Data from the 2007 Youth Risk Behavior Surveillance—United States report show that in the 12 months prior to the survey, 14.5% of youth had seriously considered suicide, 11.3% of youth had made a plan about how they would attempt suicide, and 6.9% had made one or more attempts—2% of which required treatment. Across studies, annual rates of suicide attempts range from 1.7% to 8.3%, and rates of suicide attempt over the lifetime range from 7% to 9.7%.
Overall, each year in the United States, 2 million adolescents attempt suicide, but only 25% ever come to medical attention, suggesting that many of these youths are missed by current systems of care. The risk of recurrent suicide attempts is high. Among youth hospitalized for suicidality, 18% attempt to kill themselves again within 6 months of discharge and 42% reattempt within 44 months. Similarly, in community samples of youth with prior suicide attempts, 25% will reattempt suicide within 3 months after an initial attempt. Finally, postmortem data suggest that 10% to 46% of youths who eventually complete suicide had prior suicidal behaviors.
Over the past several years, data collected by the Centers for Disease Control and Prevention (CDC) show that suicide has accounted for the death of nearly 2000 youth (ages 5 to 19) each year. While these data show that the rates of suicide climbed steadily through 1988, peaking at a rate of 4.36 per 100,000, this number decreased by 35% and reached a low of 2.83 per 100,000 in 2003. Since then, however, youth suicide rates in 2004 and 2005 were higher by 12.4% and 7.8%, respectively, and there has been concern that the rate may again be on the rise in the United States. While it is difficult to know the reasons, one hypothesis has been that the decreased use of antidepressants following the black box warning from the Federal Drug Administration (FDA) in 2004 left depressed youth untreated. This issue of how antidepressants both treat depression and precipitate de novo suicidality continues to be debated and investigated.
Overall, these findings indicate that suicidality is a recurrent phenomenon and increases in severity over time and with age. These findings further suggest the importance of talking with all youth about previous suicidality. This is of utmost importance as such a history may not be known to caregivers who generally tend to be unaware of their children’s subjective distress.
Data from the CDC show that the use of firearms, suffocation (mostly hanging), and poisoning have been the three most common methods by which youth commit suicide. Since the early 1990s, however, there have been some changing trends in youth suicide methods. More specifically, between 1992 and 2001, rates of youth suicide by firearm and poisoning decreased, while that by suffocation increased. Although firearms continue to be the most predominant method of suicide for older adolescents (15 to 19 years), suffocation has eclipsed firearms as the predominant method of suicide among younger adolescents (10 to 14 years).
Firearms are the most lethal method of suicide attempt, being 200 times more likely to result in death than other methods, and currently account for approximately 46% of completed youth suicides. Youth in rural areas, where guns are readily available, are particularly vulnerable. The proportion of suicide victims who have detectable blood alcohol levels has also risen dramatically. Youth who use firearms to kill themselves are more likely to have been drinking than those who choose other methods. Thus, alcohol combined with access to firearms comprises a highly dangerous situation that differentiates completed suicides from serious suicide attempts.
Suffocation, mostly hanging, accounts for 39% of the suicides by youth 10 to 24 years old. Children, in particular, are much more likely to use suffocation. Poisoning is the third most common method of youth suicide, accounting for about 8% of completed suicides. Many families are not aware of the dangers of many medications, particularly common analgesics, such as acetaminophen and aspirin, which are often purchased in bulk through warehouse stores. Youth, then, may have easy access to large quantities of lethal medicines that are innocently stored in the family medicine cabinet and that often prove lethal when used in a suicide attempt. Likewise, youth who are allowed to take their medications without supervision have easy access to means by which to attempt suicide. Generally, the method chosen varies by sex, age, and opportunity. Girls favor poisonings, while boys and older attempters choose more lethal means, such as firearms and suffocation. Also, a suicide attempt by unusual methods and medically serious attempts are predictive of further suicide attempts, as well as of eventual completed suicide.
Etiology and Risk Factors
The etiology of youth suicide is unknown. It appears that there are several pathways to this outcome and that a multitude of risks may play a role leading to this tragedy. Risk factors appear to be cumulative; that is, the number of risk factors, as well as the severity and acuity of individual risks, is important in predicting suicide. Common risk factors are outlined in Table 21-1
Youth suicide rates increase with age. According to the CDC, suicide is rare among children (0.01 per 100,000 between the ages 5 and 9), but increases dramatically during the preadolescent and adolescent years (1.3 per 100,000 in youth between the ages of 10 and 14, and 7.67 per 100,000 in teens between 15 and 19 years). There are two predominant theories for this rise with age. First, it has been suggested that the lower rate of suicide among preadolescents is due to their cognitive immaturity and inability to successfully plan and execute a lethal suicide attempt, despite a desire to do so. A second explanation centers on increasing risk factors in adolescence, such as psychiatric and substance-use disorders, which
independently increase the risk of suicide. It is likely that both of these issues contribute to the rise of suicide with age.
TABLE 21-1 Essential Risk Factors for Suicidality
History of suicidality (past attempts predict future suicidality)
Lethality of suicide attempt/medical compromise (intent)
Access to means (decreased time to consider options)
Psychopathology (fuels suicidality)
Bipolar disorder, depressed or manic phase
Substance abuse, especially alcohol
Conduct disorder, especially impulsive/aggressive
Personality traits and individual risks (act on suicidal thoughts)
Cognitive inflexibility (black and white thinking)
Note: Risk factors are cumulative in predicting suicide. Severity of risk factors is important in predicting suicide, especially severe acute stressors.
It is estimated that in the average US high school classroom, approximately 1 male and 2 females have attempted suicide within the past year. It has long been established that while females are more likely to attempt suicide, males are more likely to succeed. More specifically, between 1.5% and 10.1% of females make a suicide attempt in their lifetime, compared to 1.3% to 3.8% of males. However, boys are about four times more likely to die by suicide. In fact, the increased rate of adolescent suicides from the 1950s to the 1990s predominantly reflected boys’ choice of more lethal methods and girls’ choice of nonlethal methods. For both males and females, a prior suicide attempt is predictive of later completed suicide. While a previous
suicide attempt is the most potent predictor of eventual suicide for boys, the most potent risk factor for girls is depression followed by a previous suicide attempt.
Race and Ethnicity
Data from the CDC Web-based Injury Statistics Query and Reporting System (WISQARS) database show that while completed suicide in children between the ages of 5 and 9 is rare across all racial groups, differences begin to emerge among youth aged 10 to 14 and 15 to 19 years. Between 1999 and 2005, suicide in 10- to 14-years-olds was most prevalent among American Indian/Alaska natives, followed by White youth, Black youth, and Asian/Pacific Islander youth. In 15- to 19-year-olds, racial differences in suicide rates are much more pronounced. Among males 15 to 19 years old, American Indians have the highest rate (26.64 per 100,000), followed by Whites (13.48 per 100,000), Blacks (7.80 per 100,000), and Asian/Pacific Islanders (6.75 per 100,000). In females, the racial trends are similar, but less dramatic, for both American Indians (9.40 per 100,000) and Whites (3.00 per 100,000). Suicide among Asian/Pacific Islander females between the ages of 15 and 19 (2.76 per 100,000) is somewhat more common than in Black females (1.38 per 100,000). These data are not well understood. Although there is great variability among Native American and Alaska Native tribes, rates appear highest within tribes that have experienced erosion of traditional culture and that have high rates of delinquency, alcoholism, and family disorganization. As African American suicide victims tend to be from families of upper socioeconomic status (SES), it has been hypothesized that greater educational and employment achievement has led to identification with the majority White culture, along with the erosion of some traditional protective values. Although the overall rates of suicide are lower among Hispanic youth, suicide is, nevertheless, the third leading cause of death, and appears to be growing, with firearms, suffocation, and poisoning being the most common methods. More specifically, Hispanics in grades 9 to 12, particularly females, report more hopelessness, sadness, and suicidal ideation and attempts than non-Hispanic White and non-Hispanic Black youth. Hypothesized risk factors for this group include mental illness, substance use, acculturative stress, family issues, and low SES.
The rate of completed suicide for gay, lesbian, and bisexual youth is comparable to heterosexual youth. It should be noted, however, that these youth are thought to be more than twice as likely to attempt suicide than their heterosexual peers. Their heightened risk for depression and suicide is hypothesized to result from the additional stress of managing the stigma of “coming out” and developing an identity as a gay man or lesbian woman.
Religion seems to have a protective effect and reduces the risk for suicidality. This may be due to religious proscriptions against suicide, community involvement, and other beneficial effects of spirituality. However, the precise mechanism is difficult to establish, as religion is often confounded with reductions in other risks, such as substance abuse and parental divorce, precluding firm conclusions.
As noted earlier in the text, most suicidal youth have a major psychiatric disorder regardless of the severity of suicidality. Risk for suicide is estimated to increase 35-fold in the face of psychiatric disorder and, with each psychiatric comorbidity, the likelihood of a suicide attempt increases by nearly 250%. It has been suggested that most psychiatric disorders are associated with an increased risk of suicide attempts, although the nature of this association changes during the course of development. For example, an association between suicide and some disorders (e.g., major depression, substance-use disorders, and attention-deficit hyperactivity
disorder [ADHD]) becomes more robust as youth move into young adulthood, while the association with other disorders (e.g., conduct disorder and panic disorder) is attenuated.
As major depression and other depressive disorders are most commonly associated with suicidality in youth, there has been some suggestion that suicidality may represent a severe variant of depression rather than a separate construct. In general, any form of psychopathology that is associated with high levels of emotional reactivity and low levels of inhibition, and interferes with self-regulation, judgment, and perception, confers risk for suicide in youth. In addition to depressive disorders, examples would include behavioral disorders, substance-use disorders, psychosis, and borderline personality disorder. Conduct disorder, in particular, places youth at risk due to impulsivity, low threshold for violent behavior, and poor judgment that accompanies this disorder. Additionally, youth with conduct disorder face recurrent stressors in the form of disciplinary crises, legal difficulties, peer problems, and social alienation. It can also be speculated that youth with conduct disorders may be more likely to use drugs and alcohol and may more readily have access to lethal weapons by virtue of the company they tend to keep.
While psychopathology places youth at increased risk for suicide, it should be noted that there are instances of suicide in which the behavior appeared to come “out of the blue” and a psychological autopsy does not reveal any significant psychopathology.
Personal Skills/Resources Deficits
To varying degrees, personal skills and resources, such as problem-solving ability and social effectiveness, can mitigate risk, whereas skills deficits and lack of personal resources, such as impulsivity, anger, aggressiveness, cognitive inflexibility, attributional style, hopelessness, and poor interpersonal problem-solving, have been found to be related to suicidality. In general, these factors are less well understood in youth than in adults, but data exist. Impulsive youth are at increased risk as they do not think through the repercussions of their behavior. They may hastily engage in high-risk behaviors, failing to recognize the consequences of their actions.
The association of suicidal behaviors with elevated levels of anger, hostility, and aggression supports the role of abnormal serotonergic function. Attributional style refers to individual’s approach to explaining life events. A negative attributional style is characterized by a tendency to attribute negative events as due to factors that are internal, stable, and global. This pattern has been associated with depression, as well as suicidality. Hopelessness is related to attributional style, and refers to pessimism about the future. Although hopelessness has been associated with suicide, in youth it is unclear whether hopelessness provides a unique role in predicting suicide. Youth who are hopeless, however, also often struggle with cognitive inflexibility and struggle with “black and white” thinking. The inability to see the shades of gray in a situation can lead suicidal youth to believe that their current situation and psychological pain will never improve, and as such, can lend itself to hasty decision-making in the face of high levels of stress and agitation. Poor interpersonal problem-solving is also commonly observed among suicidal youth who appear to generate fewer approaches to problems. These deficits discriminate suicidal youth from their peers even after controlling for depression. Such deficits likely prevent these youth from accessing social supports from peers during times of stress. These deficits in personal skills or resources can be considered liabilities that are expressed during times of stress when a youth’s coping resources are tested, rather than considered the primary force driving suicidality.
Debate continues over the relative importance of psychosocial stressors in explaining suicidal behavior. Overall, there appears to be a unique role for selective life stressors, such as child maltreatment, family dysfunction, and poor parent-child communication, interpersonal problems and losses, school problems, and legal or disciplinary crises, in accounting for suicidal behavior. The relative contribution of these stressors may even be comparable to that of primary
psychopathology. In particular, legal and disciplinary crises provide additional predictive value in the assessment of suicide risk after controlling for the presence of psychiatric disorders.
Maltreatment, both sexual and physical, is associated with the development of depression and suicidality. Sexual abuse appears to be especially prevalent among suicide attempters, and increases the risk of repeated suicide attempts up to eightfold, independently of associated factors such as depression or the contextual factors under which the abuse occurred. Physical abuse also contributes to repeated attempts. A 17-year longitudinal study found that maladaptive parenting and maltreatment lead to profound interpersonal difficulties in middle adolescence. In turn, these difficulties mediate the association between maladaptive parenting and suicidality in later adolescence. Youth experiencing such adverse experiences may have difficulties in developing skills that are essential for maintaining healthy relationships with both adults and peers when under stress. Perhaps such adverse experiences also account for the tendency of suicidal youths to engage in other risky behaviors.
Even in the absence of overt maltreatment, family dysfunction, and poor parent-child communication have consistently been identified as salient factors for young suicide attempters and completers. Specific risks include lack of an intact family, depressed mothers, fathers with legal difficulties, and a family history of suicidal behavior. In addition, families of suicidal youth have been described as less supportive, with more conflict and poor communication. Children in such families may also lack supervision. Likewise, suicidal adolescents have described their families as experiencing difficulties in adapting to change, problem-solving, and being prone to crises, with ineffective communication and more power struggles. Although some suicidal teens perceive their families as emotionally disengaged, others perceive them as enmeshed.
Another family issue relates to the risk conferred by a family history of suicidality. However, it is difficult to disentangle the relative contributions of genetic mechanisms from social factors associated with having a psychiatrically ill parent. Overall, studies suggest that suicidality is heritable and runs in families. Postmortem studies with adults have suggested a role for decreased functioning of central serotonin.
Interpersonal problems with peers have long been identified as precipitants to suicidal behaviors. In particular, conflicts with and separations from a romantic relationship play an important role as precipitants to both attempted and completed suicide. More generalized social alienation also appears to pose substantial risk. Such youngsters may give the impression of “drifting,” without affiliation with a school, community, or work institution. Comment is needed regarding ecological precipitants to suicidality. Studies of suicide “contagion” among high school students suggest that students with current major depression or past depression and suicidality may be the most likely to become suicidal subsequent to a peer’s suicide, regardless of the closeness of the relationship to the suicide victim. Furthermore, students who are close friends of a suicide victim may become suicidal at a lower threshold of psychopathology.
Finally, the directionality of risks and suicidality is not always clear. Stressors leading to suicidality may be normative outcomes of uncontrollable events, such as a death in the family. Alternatively, such stressors may ensue from the underlying mental disorder, for example, legal crises for conduct-disordered youth. The important issue is that the youth with a mental disorder may face greater numbers of stressful events, or may perceive such events as more stressful.
The importance of the front-line clinician in assessing and preventing suicide is suggested by three factors. First, only a minority of suicidal youth will access mental health treatment and, of those who are referred for such care, many may not receive effective treatments or may drop out of treatment prematurely only to resurface during crises. Second, many suicidal youth seek medical attention for factors unrelated to suicidality in the months prior to an attempt. Third, front-line clinicians usually have contact with a child and family members over a prolonged
period and can, therefore, monitor behavioral and environmental changes that may suggest a youth is at risk. The essential aspects of assessment of suicidal youth lie with the interview.
Interviewing about Suicidality
A critical part of any assessment of suicidality includes an interview with the youth and a caregiver. Caregivers usually are able to report a history of depression or disruptive behaviors, but may not be aware of their child’s suicidality or even of prior attempts. Caregivers may not be aware that a child has been depressed. In addition, youth can reveal sources of stress that their parents are unaware of or are reluctant to report themselves, such as abuse, domestic violence, or parental psychopathology. Thus, it is critical to conduct an interview with the youth alone.
Interviewing the Youth
Clinicians may be hesitant to initiate a candid interview about suicidality due to fears that they will encourage or increase suicidal ideation or behavior. To the contrary, it can be helpful to provide a safe environment to discuss these feelings with an adult who can assist in accessing resources for help. It is important to conduct the interview matter-of-factly while communicating confidence that help can be obtained. Promises of confidentiality should be avoided. Youth can be reassured that some details may be kept confidential; however, they should be aware that some information may need to be shared with their parents/caregivers and other providers in order to provide for their safety. In general, information directly related to risk for suicidal behavior and appropriate supervision and treatment will need to be shared.
When interviewing youth, questions should be posed in a developmentally appropriate manner that assesses the severity of ideation, intent, and plan. It is most effective to begin with broad, open-ended questions (e.g., “It sounds like you have been feeling really sad lately, how bad has it gotten?”) and then follow-up with probes to assess specific risk factors for suicidal behavior, such as thoughts about death and dying, frequency and intensity of suicidal ideation, level of intent to harm one’s self, and whether or not the child has developed a plan for how to commit suicide or has made any prior attempts. Attention should be given to the specificity, lethality, and anticipated outcomes that the child associates with a suicide attempt. It is also important to ask about associated risks such as current stressors, level of agitation, perceptions of social support, and reasons for living and dying. Inquiry about a child’s reasons for not committing suicide can reveal potential protective factors. For some, these reasons may include religious proscriptions, fear of pain, knowledge of the emotional pain inflicted on loved ones, or awareness of missing an event in life. These steps may provide a brief therapeutic intervention by making suicide seem a less viable “solution” to life’s problems, and by instilling hope.
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