Suicidal behavior in children and adolescents: risk factors and signs

In recent years, after more than a decade of steady increases, suicide rates among young people have declined. The reasons for the earlier increases and the current decline remain unclear. Some of the recent decline is thought to be due to a more liberal approach to the use of antidepressants, although there is growing concern that some antidepressants increase the risk of suicidal behavior. Nevertheless, suicide is the second or third leading cause of death in the 15- to 19-year-old age group and remains an important public health problem.

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Risk factors for suicidal behavior in children and adolescents

Risk factors vary with age. More than half of suicidal behavior in adolescents develops from depressive disorders. Other predisposing factors include suicide in a family member or close relative, death of a family member, substance abuse, and conduct disorder. More immediate triggers may include loss of self-esteem (e.g., as a result of arguments from family members, a humiliating parenting episode, pregnancy, failure at school); separation from a girlfriend or boyfriend; loss of familiar surroundings (school, neighbors, friends) due to moving. Other factors may include intense pressure from parents to achieve and succeed, accompanied by a feeling that one is not living up to expectations. Often the reason for suicide is an attempt to manipulate or punish someone, with the thought: "You will blame yourself after I die." Increases in suicides have been observed following high-profile suicides (e.g., rock stars) and in specific community settings (e.g., schools, student housing), indicating the power of suggestion. Early intervention to support young people in these circumstances may be effective.

Signs of suicidal behavior in children and adolescents

Almost one in four teenagers thinks about committing suicide. Among young children, suicidal thoughts may arise if they have been victims of violence.

It is very important that you take all signs of suicidal behavior seriously and seek help from a doctor immediately if they occur. If you are a child or teenager and you feel suicidal, talk to your parents, friends, or a doctor about it immediately.

Some problems in a child or teenager's life may only trigger thoughts of suicide, but some events may cause it.

Problems that can cause suicidal thoughts include:

• Depression or another mental illness, such as bipolar disorder or schizophrenia.
• Parents who suffer from depression or alcohol or drug addiction.
• History of suicide attempts.
• A friend, peer, family member or idol who has recently committed suicide.
• Domestic violence.
• Experienced sexual violence.

Problems that may trigger a suicide attempt include:

• Having weapons, pills or other means of suicide in the home and having access to them.
• Alcohol or drug abuse.
• Become an unwitting witness to a family member committing suicide.
• Problems at school, such as poor grades, bad behavior, or frequent skipping of classes.
• Loss of a parent or close relative due to death or divorce.
• Stress caused by puberty, chronic illnesses and sexually transmitted diseases.
• Withdrawal and unwillingness to talk about one's feelings with other people.
• Uncertainty associated with non-traditional sexual orientation (bisexuality or homosexuality).

The most common signs of suicidal behavior include:

• Expression of suicidal thoughts.
• Obsession with death in conversations, drawings or writings.
• Giving away your own things.
• Alienation from friends and relatives.
• Aggressive and rude behavior.

Other signs include:

• Leaving home.
• Life-threatening behavior, such as reckless driving or sexual promiscuity.
• Indifference to one's own appearance.
• Change in personality (for example, an active child becomes too quiet).

Symptoms of depression that may lead to suicide include:

• Indifference to once beloved activities.
• Changes in normal sleep and appetite patterns.
• Difficulty concentrating and thinking.
• Complaints of a constant feeling of boredom.
• Complaints of headaches, stomach pain or fatigue for no apparent reason.
• Expressing one's own guilt; avoiding praise.

Correction of suicidal behavior in children and adolescents

Every suicide attempt is a serious matter requiring careful and appropriate intervention. Once the immediate threat to life has passed, a decision is made about whether hospitalization is necessary. This decision depends on the balance between the degree of risk and the family's ability to provide support. Hospitalization (even in an open ward in a medical or pediatric unit with a separate observation post) is the most reliable form of short-term protection and is usually indicated when depression, psychosis, or both are suspected.

The seriousness of the intent to commit suicide can be assessed by the degree of thought involved (e.g. writing a suicide note), the method used (a firearm is more effective than pills), the degree of self-harm, and the circumstances or immediate precipitating factors associated with the suicide attempt.

Medication may be indicated for any disorder underlying suicidal behavior (e.g., depression, bipolar or impulsive disorder, psychosis), but it cannot prevent suicide. In fact, antidepressant use may increase the risk of suicide in some adolescents. Medication should be carefully monitored and given in amounts that are not lethal if all pills are taken at once. Referral to a psychiatrist is especially effective if there is continuity with the primary care physician. Emotional balance in the family must be restored. Negative or unsupportive parental reactions are serious problems and may indicate the need for more intensive intervention, such as hospitalization. A loving and caring family is more likely to have a favorable outcome.

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Prevention of suicide in children and adolescents

Suicide cases are often preceded by behavioral changes (e.g., depression, low self-esteem, sleep and appetite disturbances, inability to concentrate, truancy, somatic complaints, suicidal ideation), which often bring the child or adolescent to the clinician. Statements such as "I wish I had never been born" or "I wish I could go to sleep and never wake up" should be taken seriously as possible signs of suicidal intent. Suicidal threats or attempts send an important message about the degree of despair. Early recognition of the risk factors listed above can help prevent suicide attempts. Active intervention is indicated in response to these early signs, as well as when confronted with a suicide threat or attempt, or worrisome behavior. Patients should be asked directly about their feelings, failures, and self-destructive experiences; such direct questions may reduce the risk of suicide. The doctor should not allow unfounded reassurance, which can destroy trust in him and further reduce the patient's self-esteem.