Death by suicide in children has reached a 30-year high in the United States. During middle and high school, 10 to 15% of kids have thoughts of suicide, according to the Centers for Disease Control and Prevention.
How early in a child’s life do these thoughts begin? New research from Washington University in St. Louis is narrowing the gap in psychology’s understanding of suicidal thoughts in young people, the findings show that such thoughts begin as early as 9 and 10 years old.
Further, family conflict and parental monitoring are significant predictors of suicidal thoughts, and the majority of children surveyed had caregivers who either didn’t know, or didn’t report, the suicidal thoughts of the children in their charge.
“There’s already been press about suicidal ideation in teenagers,” said Deanna Barch, chair and professor of Psychological & Brain Sciences in Arts & Sciences and professor of radiology in the School of Medicine “But there’s almost no data about rates of suicidal ideation in this age range in a large population sample.”
The results were published in the JAMA Network Open.
The study, conducted by Barch and Diana Whalen, Ph.D., psychiatry instructor at the School of Medicine, as well as colleagues at the Laureate Institute for Brain Science, looked at 11,814 9- and 10-year-olds from the Adolescent Brain Cognitive Development (ABCD) study, a national, longitudinal study on adolescent brain health in which caretakers also participate.
Dividing suicidal thoughts and actions into several categories, researchers found that 2.4 to 6.2% of the children reported having thoughts about suicide, from wishing they were dead to devising—but not carrying out—a plan.
When it came to actions, they saw 0.9% of these 9- and -10-year-olds said they had tried to commit suicide; 9.1% reported non-suicidal self-injury.
Going into this study, Barch said she did not know what to expect, but she did expect to see nontrivial amounts of suicidal thoughts in this age group.
“There were two reasons I was sure,” she said. “When you look at the CDC rate of kids in middle and high school who have these thoughts, it’s pretty high. It’s clear that they weren’t arising out of the blue.”
The second reason she was prepared: In previous work, she had already seen suicidal thoughts in preschoolers.
Also of note are some discrepancies seen between males and females. Specifically, males showed more suicidal thoughts and more non-suicidal self-injury than the girls; these trends reverse as people age, studies show.
“We don’t really know why ,” Barch said. “By the time adolescence hits, the rates go up for everyone, but they go up disproportionately for girls. The discrepancy was completely unexpected.”
Another group that may have found the results unexpected: caregivers.
This is the age when kids and their caregivers generally tend to give different reports of internal experiences, Barch said, but still, the disconnect between self-reports of suicidal thoughts and caregivers’ reports of their kids’ thoughts diverged widely.
In more than 75% of cases where children self-reported suicidal thoughts or behaviors, the caregivers did not know about the child’s experience.
The nature of the ABCD study, following the children over time, will allow researchers to tease out this apparent contradiction. “One question is going to be whether one of those reports”—that of the child or the caregiver—”is more predictive than the other of how the kids do over time,” Barch said.
In fact, caregivers seem to play an important role when it comes to suicidal thoughts and behaviors in this young age group.
After adjusting for sex, family history, and other variables, family conflict was a predictor of suicidal thoughts and non-suicidal self-injury. Monitoring by a caretaker was also predictive of those measures, as well as suicide attempts.
Historically, the belief has been that people don’t need to ask kids about suicidal thoughts before adolescence, Barch said. “Our data suggests that’s absolutely not true. Kids are having these thoughts. They’re not at the same rates as adults, but they are nontrivial.”
She suggested parents, caregivers and people working with children should be aware of the possibility that a 9-year-old is thinking about suicide.
“If you have kids who are distressed in some way, you should be asking about this,” she said. “You can help identify kids that might be in trouble.”
Suicide is one of the most important actions that health professionals must address. Your assessment and intervention remain a critical moment in your patient’s life. Remember that suicide constitutes a permanent solution to a temporary problem.
This article outlines critical statistics and risks factors so you can recognize the individuals requiring special intervention, identifies the major questions to ask a potentially suicidal individual, details the actual steps to ensure the patient’s safety, and concludes steps that should be addressed with the family and friends in the case of a completed suicide.[1][2][3][4][5]
Etiology
A number of factors correlate with serious suicide attempts and completed suicides, including, but not limited to, the following:
- Medications
- Mental illness
- Sex
- Genetics
- Availability of firearms
- Life experiences
- Physical illness
- Economic instability and status
- Media and the Internet
- Psychodynamic formulation
An understanding of the causes of suicidal behavior will not only clarify the roots of the patient’s self-destructive path but also help the clinician to determine the appropriate treatment for the patient. Once the patient is safe, then the underlying dynamics can be addressed.
Epidemiology
Suicide represents the tenth leading cause of death in the United States and the third leading cause of death for children, adolescents, and young adults. In 2014, there were 42,773 suicides in the United States.
Several suicide-related demographic factors often occur in the same person. For example, if a male police officer with major depression and a significant problem with alcohol commits suicide using his service revolver (which, unfortunately, happens not infrequently), 5 risk factors are involved: sex, occupation, depression, alcohol, and gun availability.
In the United States, certain states have higher suicide rates than others, as illustrated by the map below. The Western states have the highest suicide rates, with the exception of Vermont. In addition, living in rural areas carries a higher risk of suicide than living in urban areas.[6]
History and Physical
Patient History
A host of thoughts and behaviors are associated with self-destructive acts. Although many assume that people who talk about suicide will not follow through with it, the opposite is true; a threat of suicide can lead to the completed act, and suicidal ideation is highly correlated with suicidal behaviors.[7][8][9][10]
Numerous activities are associated with committing suicide, including the following:
- Making a will
- Getting the house and affairs together
- Unexpectedly visiting friends and family members
- Purchasing a gun, hose, or rope
- Writing a suicide note
- Visiting a primary care physician
With regard to the last item, a significant number of people see their primary care physician within 3 weeks before they commit suicide. They come for a variety of medical problems, but rarely will they state they are contemplating suicide. Therefore, the practitioner must pay attention to the entire person; the physician must look for factors in the patient’s life beyond the chief complaint.
Suicide-related characteristics
Individuals who are suicidal have a number of characteristics, including the following:
- A preoccupation with death
- A sense of isolation and withdrawal
- Few friends or family members
- An emotional distance from others
- Distraction and lack of humor – They often seem to be “in their own world” and lack a sense of humor (anhedonia)
- Focus on the past – They dwell in past losses and defeats and anticipate no future; they voice the notion that others and the world would be better off without them.
- Haunted and dominated by hopelessness and helplessness – They are without hope and therefore cannot foresee things ever improving; they also view themselves as helpless in 2 ways: (1) they cannot help themselves, and all their efforts to liberate themselves from the sea of depression in which they are drowning are to no avail; and (2) no one else can help them.
Evaluation
Assessing Suicide Risk
A clear and complete evaluation and clinical interview provide the information upon which to base a suicide intervention. Although risk factors offer major indications of the suicide danger, nothing can substitute for a focused patient inquiry. However, although all the answers a patient gives may be inclusive, a therapist often develops a visceral sense that his or her patient is going to commit suicide. The clinician’s reaction counts and should be considered in the intervention.[11][12][13][14]
Suicidal Ideation
Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide. Some inexperienced clinicians have difficulty asking this question. They fear the inquiry may be too intrusive or that they may provide the person with an idea of suicide. In reality, patients appreciate the question as evidence of the clinician’s concern. A positive response requires further inquiry.
Suicide Plans
If suicidal ideation is present, the next question must be about any plans for suicidal acts. The general formula is that more specific plans indicate greater danger. Although vague threats, such as a threat to commit suicide sometime in the future, are the reason for concern, responses indicating that the person has purchased a gun, has ammunition, has made out a will, and plans to use the gun are more dangerous. The plan demands further questions. If the person envisions a gun-related death, determine whether he or she has the weapon or access to it.
The Relationship Between Suicidal Ideation, Plans, and Attempts
In 2014, 9.4 million adults aged 18 years or older who responded to the National Survey on Drug Use and Health (NSDUH) reported they had thought seriously about trying to kill themselves at any time during the past 12 months.
Those who had serious thoughts of suicide were then asked whether they made a plan to kill themselves or tried to kill themselves in the past 12 months. Of the 9.4 million adults with serious thoughts of suicide, 2.7 million reported they had made suicide plans, and 1.1 million made a nonfatal suicide attempt.
Among the 1.1 million adults who attempted suicide in the past year, 0.9 million reported making suicide plans, and 0.2 million did not make suicide plans.
Nearly one-third of adults who had serious thoughts of suicide made suicide plans, and about 1 in 9 adults who had serious thoughts of suicide made a suicide attempt.
In other words, more than two-thirds of adults in 2014 who had serious thoughts of suicide did not make suicide plans, and 8 out of 9 adults who had serious thoughts of suicide did not attempt suicide. This data show that suicidal thoughts can serve as an indicator of suicidal plans and attempts.
Purpose of Suicide
Determine what the patient believes his or her suicide would achieve. This suggests how seriously the person has been considering suicide and the reason for death. For example, some believe that their suicide would provide a way for family or friends to realize their emotional distress. Others see their death as a relief from their own psychic pain. Still others believe that their death would provide a heavenly reunion with a departed loved one. In any scenario, the clinician has another gauge of the seriousness of the planning.
Potential for Homicide
Any question of suicide also must be coupled with an inquiry into the person’s potential for homicide. Suicide is often thought to represent aggression turned inward, whereas homicide represents aggression turned outward. Because suicide constitutes an aggressive act, the question regarding homicidal tendencies must be asked.
A mixed-methods study in the UK analyzed 60 homicide-suicides and found that most victims were spouse/partners and/or children. Most perpetrators were male (88%), and most victims were female (77%). Few perpetrators had been in recent contact with mental health services before the incident (12%).
Additional Questions
Collateral questions should be asked based on the reviewed risk factors. These questions deal with any family members or friends who have killed themselves and include questions about symptoms of depression, psychosis, delirium and dementia, losses (especially recent ones), and substance abuse.
Treatment / Management
Intervention
The treatment of a suicidal patient involves a 2-phase process. First and foremost, the patient’s safety must be assured; this is the intervention. Intervention is based on the application of risk factors coupled with a clinical inquiry. The second step is treatment aimed at diagnosing and treating the underlying mental disorder.[15][16][17][18][19]
First phase of intervention
In many cases, swift, decisive intervention can prevent a person from committing suicide. Because of this preventable aspect of suicide, recognizing and taking action if the potential arises is critical. Based on the clinical assessment and all of the information available, if the person is indeed suicidal, the intervention should consist of multiple steps.
The individual must not be left alone. In the ED, such a recommendation is handled easily by hospital security personnel. In other settings, summon assistance quickly. In an isolated place, call 911. Involve family or friends; they can remain with the patient while treatment arrangements are made.
Remove anything that the patient may use to hurt or kill him or herself. Remove sharp or potentially dangerous objects. Ask the patient for any weapon, such as knives or pills, and secure them away from the patient.
The suicidal patient should be treated initially in a secure, safe, and highly supervised place. Inpatient care at a hospital offers one of the best settings. Most managed care companies recognize the medical necessity of hospitalization in situations in which the suicide danger is acute.
A study of the association between the provision of mental health services and suicide rates found that removing ligature points (places where things like ropes could be attached to) was associated with significant reductions in the overall psychiatric inpatient suicide rate and in the rate of inpatient suicide by hanging. Similarly, assessing other available sources of self-destructive implements such as pills and guns is critical.
Patients who attempt to commit suicide with prescribed medications represent one of the greatest clinical challenges. The dilemma involves balancing the fact that psychotropic drugs alleviate mental illness symptoms with the reality that some patients will use the very same medications to commit suicide.
Gjelsvik et al. highlight this conundrum in their study in which patients who engage in deliberate self-poisoning had a greater prescribed medication load compared with the general population, and that this medical load is more important in determining self-poisoning episodes than the timing of collection of prescribed medication prior to an episode.This study points out the need to pay attention to the amount of stockpiled medications available to the potentially self-destructive patient.
Second phase of intervention
After the initial intervention, which usually includes hospitalization, it is critical that there be in place an ongoing management treatment plan. The heart of the second phase of the intervention is addressing the underlying cause of the self-destructive behavior.
If the patient has selected suicide to escape physical pain, then a comprehensive pain management program must be initiated. If the patient is depressed, then the depression must be treated with medication and psychotherapy.
If the suicide attempt has been in response to the patient with schizophrenia struggling with destructive hallucinations and delusions, then these must be aggressively treated. The key remains an accurate assessment and diagnosis followed by a comprehensive treatment plan.
One would expect that intense intervention efforts following a suicide attempt would be effective in lowering morbidity and mortality. To test this theory, Morthorst et al. assessed the efficacy of the outpatient intervention in patients older than 12 years admitted to regional hospitals in Copenhagen with a suicide attempt within the past 14 days.
The intervention consisted of assertive outreach that provided crisis intervention and flexible problem-solving. This approach, assertive intervention for deliberate self-harm, incorporated motivational support and actively assisted patients to scheduled appointments.
The study followed 243 patients for 12 months. Rates of subsequent suicide attempts did not differ significantly between the intervention and control groups. Although this study did not show the advantage of an intensive follow-up care, it does point out the need for a clear, definite, and defined a postsuicide attempt treatment plan.
A study of brief CBT in a cohort of active-duty military personnel in Colorado who either attempted suicide or experienced suicidal ideation found the treatment effective in preventing follow-up suicide attempts. Over the course of two years, 8 out of 76 participants (13.8%) in treatment as usual combined with brief CBT and 18 participants out of 76 (40.2%) who did not receive CBT made at least one attempt at suicide. Data show that soldiers treated with brief CBT were a
Pearls and Other Issues
This section details steps a clinician should take in cases of completed suicide. Practitioners must work with the patient’s family and friends, as well as with the other patients who knew the deceased.
Upon learning of the death of a patient, focus on the immediate situation. Reschedule other patients and, whenever possible, meet with the family. Family members appreciate the clinician’s interest and the opportunity to voice their feelings and reactions. In some situations, the family may have expected the outcome.
In others, they may be hurt and angry. The clinician’s job is to be responsible and responsive to them. This intervention may require more than 1 session. Be available to family members, listen to them, and share their loss.
Often, other patients knew the deceased person. Without violating confidentiality, provide extra attention to these patients. This could include sessions to allow them to express their reactions to the death and loss. If the patient who committed suicide was an inpatient, convening a group meeting and discussing the other patients’ reactions is important. The staff should also have an opportunity to discuss their feelings.
Finally, the practitioner must take the time to review and discuss the event. Often, seeking a senior clinician is effective. The therapist needs an opportunity to recover and heal. Later, a psychological autopsy can be performed, but in the acute phase, the clinician requires sympathy and support.
Enhancing Healthcare Team Outcomes
The only way to prevent suicides is to work in an interprofessional team that includes a mental health nurse, psychiatrist, the primary care provider, social worker, and nurse practitioner. Practitioners must work with the patient’s family and friends, as well as with the other patients who knew the deceased.
The first step is to prevent harm to the patient and secondly, treating the cause of the behavior that is causing suicidal ideations. All patients with suicidal ideations should be closely monitored. The family should be educated about the potential signs of danger. Unfortunately, in many cases, the healthcare system does fail as many patients do go on to end their lives.[20] (Level V)
Provided by Washington University in St. Louis
