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Suicidal Behavior in Children and Adolescents

By

Josephine Elia

, MD, Nemours/A.I. duPont Hospital for Children

Last full review/revision Apr 2021
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Suicidal behavior is an action intended to harm oneself and includes suicidal gestures, suicide attempts, and completed suicide. Suicidal ideation is thoughts and plans about suicide. Suicide attempts are acts of self-harm that could result in death, such as hanging or drowning.

  • A stressful event may trigger suicide in children who have a mental health disorder such as depression.

  • Children at risk of suicide may be depressed or anxious, withdraw from activities, talk about subjects related to death, or suddenly change their behavior.

  • Family members and friends should take all suicide threats or attempts seriously.

  • Health care practitioners try to determine how serious the risk of suicide is.

  • Treatment may involve hospitalization if the risk is high, drugs to treat other mental health disorders, and individual and family counseling.

Suicide is rare in children before puberty and is mainly a problem of adolescence, particularly between the ages of 15 and 19, and of adulthood. However, preadolescent children do commit suicide, and this potential problem must not be overlooked.

In the United States, suicide is the second leading cause of death in 10- to 24-year-olds and the 9th leading cause of death among 5- to 11-year-olds. It results in 2,000 deaths per year. Suicide has had a particularly large impact on the black community, as the rate nearly doubled in black elementary school children between 1993 and 2012. It is also likely that a number of the deaths attributed to accidents, such as those due to motor vehicles and firearms, are actually suicides.

Many more young people attempt suicide than actually succeed. The Centers for Disease Control and Prevention recently provided information about increasing trends in suicide across a number of groups and time periods:

  • For females (ages 10 through 14), the overall suicide rate increased from 0.5% in 1999 to 2% in 2019.

  • For males (ages 10 through 14), the overall suicide rate increased from 1.9% in 1999 to 3.1% in 2019.

Additional findings highlight suicide-related statistics about high school students in the United States in 2015:

  • Between 2001 and 2015, visits to the emergency department for self-inflicted injuries, suicidal thoughts, or attempted suicide increased across all age groups.

  • The sharp increase in suicide attempts was first noted in 2011, even while the actual number of suicides remained stable.

  • From 2006 to 2015, there were over 40,000 suicides in 10- to 19-year-olds. During that same period, 118,000 children and adolescents in that same age group required medical treatment for nonfatal suicide attempts.

Many factors may contribute to the increase in suicide attempts among children and adolescents, among them the increases in adolescent depression (especially in girls), increased parental opioid prescriptions, exposure to increasing suicide rates among adults in their circle, conflict-filled relationships with parents, and academic stress.

Frequently, suicide attempts involve at least some ambivalence about wishing to die and may be a cry for help.

Among adolescents in the United States, boys outnumber girls in completed suicide by more than 4 to 1. However, girls are 2 to 3 times more likely to attempt suicide.

Did You Know...

  • Suicide is the second or third leading cause of death among adolescents in the United States.

Risk Factors

Suicidal thoughts do not always lead to suicidal behavior, but they are a risk factor for suicidal behavior. Several factors typically interact before suicidal thoughts become suicidal behavior. Very often there is an underlying mental health disorder and a stressful event that triggers the behavior. Stressful events include

  • Death of a loved one

  • A suicide in school or another group of peers

  • Loss of a boyfriend or girlfriend

  • A move from familiar surroundings (such as the school or neighborhood) or friends

  • Humiliation by family members or friends

  • Being bullied at school, especially for lesbian, gay, bisexual, and transgender (LGBT) students

  • Failure at school

  • Trouble with the law

However, such stressful events are fairly common among children and rarely lead to suicidal behavior if there are no other underlying problems.

The most common underlying problems are the following:

Children and adolescents attempting suicide are sometimes angry with family members or friends, are unable to tolerate the anger, and turn the anger against themselves. They may wish to manipulate or punish other people (“They will be sorry after I am dead”). Having difficulty communicating with their parents may contribute to the risk of suicide.

Sometimes suicidal behavior results when a child imitates the actions of others. For example, a well-publicized suicide, such as that of a celebrity, is often followed by other suicides or suicide attempts. Similarly, copycat suicides sometimes occur in schools.

Suicide is more likely in families in which mood disorders are common, especially if there is a family history of suicide or other violent behavior.

Diagnosis

  • Identification of risk by parents, doctors, teachers, and friends

Parents, doctors, teachers, and friends may be in a position to identify children who might attempt suicide, particularly those who have had any recent change in behavior. Children and adolescents often confide only in their peers, who must be strongly encouraged not to keep a secret that could result in the tragic death of the suicidal child. Children who express overt thoughts of suicide, such as “I wish I’d never been born” or “I’d like to go to sleep and never wake up,” are at risk, but so are children with more subtle signs, such as social withdrawal, falling grades, or parting with favorite possessions.

Health care practitioners have two key roles:

Prevention

Directly asking at-risk children about suicidal thoughts can bring out important issues that are contributing to the child’s distress. Identifying these issues can, in turn, lead to meaningful interventions. Research indicates that over 50% of children who showed up in an emergency department for any reason screened positive for suicidal thoughts and behaviors. As a result, hospitals have been required since 2019 to assess for suicide as part of standard medical care.

Crisis hotlines, offering 24-hour assistance (see sidebar Suicide Intervention: Crisis Hot Lines Suicide Intervention: National Suicide Prevention Lifeline Suicide is death caused by an intentional act of self-harm that is designed to be lethal. Suicidal behavior includes completed suicide, attempted suicide, and suicidal ideation. Suicide usually... read more ), are available in many communities and provide ready access to a sympathetic person who can give immediate counseling and assistance in obtaining further care. Although it is difficult to prove that these services actually reduce the number of deaths from suicide, they are helpful in directing children and families to appropriate resources.

The following may help reduce the risk of suicide:

Suicide prevention programs can help. The most effective programs are those that try to make sure that the child has the following:

  • A supportive nurturing environment

  • Ready access to mental health services

  • A school or other social setting that promotes respect for individual, racial, and cultural differences

In the United States, the Suicide Prevention Resource Center lists some of these programs, and the National Suicide Prevention Lifeline (1-800-273-TALK) provides crisis intervention for people threatening suicide.

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Treatment

  • Sometimes hospitalization

  • Precautions to prevent future attempts

  • Treatment of any disorder contributing to risk of suicide

  • Referral to a psychiatrist and psychotherapy

Children who express thoughts of wanting to hurt themselves or who attempt suicide need urgent evaluation in a hospital emergency department. Any type of suicide attempt must be taken seriously because one third of those who complete suicide have previously attempted it—sometimes an apparently trivial attempt, such as making a few shallow scratches to the wrist or swallowing a few pills. When parents or caregivers belittle or minimize an unsuccessful suicide attempt, children may see this response as a challenge, and the risk of subsequent suicide increases.

Once the immediate threat to life has been removed, the doctor decides whether the child should be hospitalized. The decision depends on the degree of risk in remaining at home and the family’s capacity to provide support and physical safety for the child. Hospitalization is the surest way to protect the child and is usually indicated if doctors suspect the child has a serious mental health disorder such as depression.

The seriousness of a suicide attempt can be gauged by a number of factors, including the following:

  • Whether the attempt was carefully planned rather than spontaneous—for example, leaving a suicide note indicates a planned attempt

  • Whether steps were taken to prevent discovery

  • What type of method was used—for example, using a gun is more likely to cause death than taking pills

  • Whether any injury was actually inflicted

  • What the child's mental state was when suicide was attempted

It is critical to distinguish serious intent from actual consequences. For example, adolescents who ingest harmless pills that they believe to be lethal should be considered at extreme risk.

If hospitalization is not needed, families of children going home must ensure that firearms are removed from the home altogether and that drugs (including over-the-counter drugs) and sharp objects are removed or securely locked away. Even with these precautions, preventing suicide can be very difficult, and there are no proven measures for successfully preventing it.

Doctors usually refer children to a psychiatrist, who can provide appropriate drug treatment, and to a therapist, who can provide psychotherapy, Psychotherapy Extraordinary advances have been made in the treatment of mental illness. As a result, many mental health disorders can now be treated nearly as successfully as physical disorders. Most treatment... read more such as cognitive-behavioral therapy. Treatment is most successful if the primary care doctor continues to be involved.

If suicide occurs

Family members of children and adolescents who committed suicide have complicated reactions to the suicide, including grief, guilt, and depression. They may feel purposeless, detached from everyday activities, and bitter. They may have difficulty continuing with their life. Counseling can help them understand the psychiatric context of the suicide and reflect on and acknowledge the child’s difficulties before the suicide. They may then be able to understand that the suicide was not their fault.

After a suicide, the risk of suicide may increase in other people in the community, especially friends and classmates of the person who committed suicide. Resources (such as a toolkit for schools) are available to help schools and communities after a suicide. School and community officials can arrange for mental health practitioners to be available to provide information and consultation.

More Information

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

  • Metanoia: This site directly and compassionately addresses the person considering suicide with valuable information about the imbalance between the pain they are experiencing and their coping resources and then provides direct access to suicide hotlines and other mental health services.

  • Patient Health Questionnaire (PHQ-9): Issued by the U.S. Preventive Services Task Force, this nine-item questionnaire is used by doctors to screen for depression.

  • Suicide and Depression Awareness for Students: This repository of information for students includes guides to managing a variety of mental health and mental illness issues in the college setting. Topics covered include addiction, creating healthy intimacy, bullying awareness, depression, and suicide.

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