Suicide in Children

Suicide

Epidemiology

Figures published in 2005 by the World Health Organization (WHO) estimated that approximately 877,000 suicides occur annually worldwide. Of these 200,000 of these occur among individuals 15 to 24 years of age. Rates vary from culture to culture and among ethnic groups. In the United States it is estimated that per 100,000 individuals, there are 10 to 15 deaths from suicide annually.
This equates to approximately 31,655 deaths from suicide in 2002 , with about 2000 deaths occurring in individuals 15 to 19 years of age, and another 2000 occurring in those 20 to 24 years of age. Among the adolescents and young adults committing suicide each year in the United States, approximately 90% have some sort of mental illness, with depression constituting the majority of diagnoses.

Sex Differences: Although females make more attempts at suicide, males are much more successful in completing suicide. This is partly because males typically choose more lethal methods such as firearms, hanging, and motor vehicles.
Females tend to choose medication or drug overdosing and cutting, overall less lethal methods. Data published in 2004 showed firearms were involved in 49% of completed suicides among individuals aged 10 to 19 years; hanging in 38%, and poisoning in 7%. Most research reviewing suicide attempts vs completions has demonstrated that there are between 40 and 60 attempts for every completion.

It is important to note that the childhood suicide rate -- the rate among those 5 to 14 years of age -- has also increased over the past 30 years. In fact, this rate doubled between 1979 and 1992. During the 1990s, there were approximately 300 suicides per year in this age group.

Perception variation in different age groups: It has been demonstrated that children and adolescents typically do not perceive suicide in the same way as adults. Mishara and colleagues found that preschool children viewed death as sleeping, raising the question of whether children this age are actually capable of committing suicide. The researchers surmised that children in this age group who kill themselves very likely do not understand the finality of death.

By 6 to 7 years of age, 67% of the children in the study understood that everyone will eventually die. However, during their prepubertal years, many of the children still did not really understand the concept of permanent death. By age 12, 80% of the children still did not think about death occurring in healthy people.

Various Causes of Suicide: Among prepubertal children, depression is not usually a contributor to suicide. Suicide in young children is more likely to be related to family dysfunction, physical abuse, substance abuse, or schizophrenia. The combination of suicidal ideation and disruptive behavior in this age group has also been associated with a marked increase in suicide risk. Additionally, suicidal behavior during childhood significantly increases the risk that suicide will be completed in adolescence.

Multiple data provide a strong evidence base for the link between depression in childhood and/or adolescence and suicide. A study by Olfson and colleagues estimated that
9% of all teenagers make a suicide attempt,
19% express suicidal ideation.
In a cohort of depressed adolescents,
35% to 50% made a suicide attempt
5% to 10%, diagnosed with a major depressive disorder, completed suicide within 15 years. Among those surviving a suicide attempt, 71% had major depression or dysthymia;
64.5% were female.

Characteristics Associated With Suicide Risk

Several factors were associated with increased risk of suicide, including
mood disorders,
familial history of psychiatric illness,
history of abuse,
past suicide attempts, and
presence of a lethal means of suicide.
Gay and lesbian youth, perhaps because they have higher rates of depression than heterosexual adolescents, have also been shown to be at higher risk for suicidal ideation and suicide.

Risk Factors for completed suicide among adolescent boys:
A previous suicide attempt, followed by
a major depressive disorder and
substance abuse.

For girls, major depressive disorder and substance abuse were the 2 leading factors. Family history of suicide also increased the risk 3 to 5 times that an individual would complete suicide. Additional risk factors identified include hopelessness, hostility, and negative self-concept.

Self-injurious Behavior/Deliberate Self Harm

Self-injurious behavior (SIB)/Deliberate Self Harm(DSH) can be defined as a purposeful intent to inflict harm on one's body without an obvious intention of committing suicide.
Prevalence: Estimates indicate that SIB occurs in 20% to 60% of inpatient psychiatric populations and that with increasing levels of psychopathology, increasingly severe behavior can be found.
Risk factors for DSH/SIB:B
Borderline personality disorder,
depression,
posttraumatic stress disorder,
eating disorders, and
abuse or trauma.

Diagnostic features of SIB include:

• An intentional desire to hurt oneself;
  
  
• An inability to resist the impulse to injure oneself; and
  
  
• Injury, not death, is the desired end result.

In a study of 6000 UK adolescents 15 to 16 years of age, 6.9% had experienced SIB within the past 12 months.
The rate was much higher in girls; 11.2% vs 3.2% in boys. Twelve percent of adolescents with SIB episodes had to seek medical care for the injury sustained.

Within this cohort, it was demonstrated that SIB could occur as a result of an irresistible urge. Completing the urge allowed release of whatever tension pushed the individual to self-injury, providing temporary respite. However, in many, tensions inevitably built again. If initial SIB provided relief for the person, he or she was at increased risk for repeating the behavior. Therefore, SIB is considered addictive in nature. Within this framework, some medication or drug overdoses could also be considered SIB.

The UK study also identified some risk factors and predictors for SIB. For both boys and girls, a family history of SIB, drug abuse, and low self-esteem were contributing factors. A history of sexual trauma or abuse also markedly increased SIB risk. For girls, recent SIB by friends, anxiety, and impulsivity were linked to SIB; an additional factor for boys was suicidal behavior in friends.

In a study of pediatric psychiatric inpatients, 63% of children with SIB also reported frequently experiencing suicidal ideation; 73% had made a suicide attempt in the previous 6 months. However, 74% with SIB stated that they inflicted self-harm to release unbearable tension, not to commit suicide.

Another potential explanation is that the pain caused by SIB could decrease or help to overcome feelings of dissociation, thus bringing a person back to reality and serving as a connection to the present. It is also possible that the attention an individual may receive due to SIB may be a way to influence others and gain control over one's environment.

Biologic theories suggest that SIB may be caused by a low level of serotonin -- providing an overlap with depression. Another interesting biological theory is that individuals with SIB may have an attenuated endogenous opioid system. It is postulated that perhaps it takes extreme situations, such as SIB, to trigger the opioid system of such individuals.

Intervention Strategies for SIB

The low level of disclosure of SIB to healthcare professionals, parents, and other adults represents a challenge to effectively identifying SIB, with identification being the first step in any intervention. It was suggested that clinicians be particularly aware of patients who wear clothing that hides much of their body, and that a thorough skin examination be included as part of the adolescent health maintenance visit. The practitioner should always inquire about any scars noted.

Behavioral therapies seem to show the most promise. In particular, dialectical behavior therapy is a promising option. This approach focuses on ineffective problem-solving skills and provides adaptive skills that are less injurious.
Steps to preventing SIB include promoting emotional health, preventing childhood trauma or treating trauma if this has already occurred, and helping to improve coping strategies through cognitive therapy.

Identification and Approach to Suicidal Ideation and Behavior

It has been shown that among youth, 1 suicide attempt raises the risk of suicide completion by 15-fold. Therefore, the initial evaluation following a suicide attempt should be focused on clearly determining intent. On the basis of an extensive review of literature concerning the management of adolescents with suicidal ideation or attempt, Kennedy and colleagues recommended that the following information be obtained:

• The frequency of suicidal thoughts and how long these have been present;
  
  
• The plan for the suicide, with particular emphasis on the details of the plan and the lethality of method selected;
  
  
• Past history of suicide attempts;
  
  
• The patient's access to lethal means of suicide;
  
  
• The history or presence of psychiatric illness, with particular attention to diagnosis and medications;
  
  
• Whether drug or alcohol use is present;
  
  
• Family history of psychiatric illness, substance abuse, and suicide;
  
  
• The relationships between the patient and parents or guardians;
  
  
• Whether physical or sexual abuse occurred in the past; and
  
  
• The sexual orientation of the patient.

It is also crucial to evaluate stressors and to assess whether the patient can state a reason or reasons for living.

Outpatient Management of Suicide Attempt

Kennedy and colleagues also formulated criteria for outpatient management of a patient who has made a suicide attempt. It is strongly suggested that if any of the criteria are not met, the patient should be hospitalized. The criteria include:

• No inpatient medical treatment needed for conditions such as delirium;
  
  
• No previous history of suicide attempt or a psychiatric disorder;
  
  
• The patient should not be actively suicidal;
  
  
• There should be an adult in the home where the adolescent will be cared for who has a good relationship with the adolescent, and this adult agrees to monitor the patient;
  
  
• The monitoring adult agrees to remove all lethal suicide methods from the home;
  
  
• Both the patient and the monitoring adult have a clear understanding of emergency contact procedures and when to return for additional care;
  
  
• Further outpatient care has been arranged; and
  
  
• Both the patient and monitoring adult agree with the plan and state they will comply with all recommendations.

It was stressed that even though a suicide contract (getting the patient to promise not to commit suicide until the clinician sees him or her again) has limited value, a treatment contract can serve to decrease the short-term risk of suicide. A treatment contract should include frequent and quantifiable goals for follow-up and should incorporate steps aimed at improving the patient's mental and emotional state.

Treatment of Suicidal Behavior

The mental status of the patient should be assessed, and stressors identified. If depression is present, a combination of cognitive and medication therapy is recommended.

There have been recent concerns about increased suicide risk in association with use of selective serotonin reuptake inhibitors (SSRIs) for treatment of depression. In 2005, the United States Food and Drug Administration (FDA) placed a black box warning on SSRI medications, citing an increased risk of suicide among children and adolescents taking this type of antidepressant. However, some experts are not sure the concern is justified. They point out that patients being treated for depression are the individuals most often prescribed SSRIs. Therefore, the multitude of data supporting the strong link between depression and increased risk of suicide cannot be easily discounted.

Additionally, other data show the overall suicide rate has not increased over the past decade, though use of SSRIs has increased significantly during the same time period.

Although there is continued debate about risk associated with SSRI use in treatment of depressed children and adolescents, the acknowledged benefits of treatment are substantial.However untreated depression is clearly associated with a very high risk of suicide which is much higher than among patients being treated with antidepressants.

The use of SSRIs in children and adolescents remains a difficult decision point for many clinicians. If use is being considered, frank discussions need to occur between clinician and parents/patient. It is incumbent upon the provider to fully inform those involved in treatment decisions about the potential risks and benefits. Currently, fluoxetine is the only antidepressant medication FDA approved for treatment of major depressive disorder in children.