Each year more than 300,000 children and adolescents intentionally poison themselves,1 and selfpoisoning (usually by overdose of commonly available medications) comprises about 90% of all suicide attempts in the young. Suicidal behavior in children and adolescents is associated with emotional, behavioral, and family problems and is one of the most common reasons for psychiatric admission following emergency room evaluation.2
DEFINITION OF SUICIDAL BEHAVIOR
A suicide attempt (suicidal behavior) is any act of nonfatal self-injury with intention to harm or call attention to oneself.3 Although the patient's stated intent is usually the best guideline, the clinician should not ignore the behavior itself (eg, repeated selfcutting) or others' reports (parents report that the child has been talking about suicide for a week but the child insists the overdose was an "accident"). We also treat as "attempters" those children who talk of suicide and initiate potentially self-destructive activity, such as climbing on a bridge or railing, toying with a gun, or putting a rope around the neck. Suicidal ideation includes talk of suicide or wanting to die without formulation or initiation of a plan to harm oneself.
In a review of a consecutive series of emergency room admissions of 5 to 19 year olds, we identified 171 suicide attempters and an additional 35 subjects with self-inflicted injuries, usually overdoses of alcohol and street drugs, who denied suicidal intent. These "unintentional" attempters were as likely to have made a prior suicide attempt as the intentional attempters, but much less likely to receive psychiatric care (P.D. Trautman, unpublished data, 1987). Pediatricians should be alert to the suicidal risk of nonsuicidal selfpoisoners, to inquire about past suicidal behavior, and to obtain psychiatric consultation.
METHODS OF SUICIDE AND ATTEMPTED SUICIDE
In a study of 1,225 girls and 321 boys, Otto4 reported that nearly 90% of adolescent attempts were by selfpoisoning with tablets, 4% by gas and other poisons, and the balance by "active" methods such as cutting, hanging, drowning, and shooting. Boys are more than twice as likely (18% vs 7%) to choose active methods. In contrast, the common causes of death by suicide in adolescents are firearms, hanging and suffocation, gas poisoning, and drug ingestion, followed by all other methods.5
There is an important association between attempted suicide and later suicide. Among completed adolescent suicides, one fifth of boys and one third of girls have a history of attempted suicide.6 Conversely, the risk of death in 10 to 15 years following self- injury (overdose and other methods) is 10% for boys and 2.9% for girls,4 but following overdose alone the risk is 0. 7% for boys and 0. 1% for girls in 2.8 years. 7 The risk of death is greatest in adolescents who make attempts by active methods, but the choice of method does not predict future attempts. Boys are five times more likely than girls to commit suicide, whereas girls are six to nine times more likely than boys to attempt suicide. Both attempts and deaths increase with age during adolescence and young adulthood (Table 1).
GUIDELINES AND GOALS
Who should evaluate? Every child making a suicide attempt, no matter how trivial, should receive a psychiatric evaluation prior to discharge from the emergency room. Ideally, this evaluation should be by a child psychiatrist or general psychiatrist. When one is unavailable, a pediatrician, social worker, nurse, or psychologist with experience in childhood psychiatric crisis evaluation, working in consultation with a psychiatrist, may reliably evaluate the child and develop an initial treatment plan.8
Signs of High Risk for Further Suicidal Behavior*
Who should be evaluated? A child should never be discharged from the emergency room until a parent has been interviewed; an older sibling, aunt, or babysitter will not do. Parental absence from the emergency room should warn the clinician about parental neglect of or anger toward the child, about a lack of family cohesion and the unlikelihood of compliance with future treatment recommendation. No effective treatment plan can be formulated without parental participation. Ideally, the child and parents should be interviewed separately to develop a comprehensive list of child and family problems, and then the family should be seen together to review these problems and formulate an initial treatment plan.
Does the child require hospital admission? The absolute indications for admission include medical management of the self-injury (eg, IV administration of acetylcysteine for acetaminophen poisoning), psychiatric management (persisting suicidal intent, severe depression, or psychosis with command hallucinations), or psychosocial management (the family cannot be relied upon to watch the child 24 hours a day, remove weapons and poisons from the home, and return with the child for follow-up outpatient care).
What are the immediate précipitants of the suicidal behavior - the day's events, the circumstances and plan' ning of the attempt? Both examiner and patient will have an easier time if the interview begins with the question, "What did you do?" rather than "Why did you do it?" In our experience, children are usually only partly conscious of "why, " have multiple goals in making a suicide attempt, and often have difficulty articulating contradictory motives. These will emerge during the course of interview.
Specific Foci for Treatment
Start with a review of the entire day's events - where did the child go, who did the child see, were there any arguments or disappointments? Did the child get into any trouble? When did the idea of self-injury first come and did the child tell anyone about these thoughts? How much planning was involved (this is usually minimal)? Who was nearby and how was the attempt discovered? Very often adolescents get scared when they start to feel sick and will tell a family member about the attempt. What does the child know about the dangerousness of the method (rare)? Some children sincerely believe that 5 aspirin are lethal or that 50 methadone are not, so that the actual method is of less interest than the child's belief about it. Did the child write a note or will, or give belongings away? These steps are unusual and indicate planning.
Most often, a suicide attempt is a response to a crisis - an argument with parents, breakup with a boyor girlfriend, teasing or humiliation by peers, or a disciplinary action at school. The event may seem trivial to the parents but overwhelming to a child who is impulsive and copes poorly with interpersonal problems. Often the child will say, "I did it for attention." While the attention-getting method may be wrong, such children often are being neglected by parents who are themselves ill, working excessively, or preoccupied with a more symptomatic sibling or otherfamily member. And it is not uncommon to see children who are receiving overt or covert messages that the family would be better off if the child were gone (the "expendable child").9
What are the child's physical, psychiatric, and social problems? Adolescent suicide attempters, particularly older adolescents, have higher rates of current medical illness than age-matched peers.8,10 Appropriate medical management and education can be expected to promote physical and psychiatric functioning and to improve self-esteem.
Broadly speaking, younger adolescents make suicide attempts because of interpersonal (usually family) problems; oldeT adolescents are more likely to have a major mental illness, especially depression, conduct disorder, and substance abuse, and a history of school and work failure.11 Anger, not sadness, is the most common affect at the time of a suicide attempt - nearly three quarters of adolescents report feeling angry. About half also complain of recent sad mood, and about 25% meet full criteria for major depressive disorder. Because depression is a treatable disorder, both with psychotherapy and medication, it should not be overlooked. Bipolar (manic -depressi ve) disorder frequently has an onset in late adolescence. Mania may appear as irritability, aggressiveness, impulsivity, elation, and rapid mood shifts (Table 2).
Aggressive and antisocial behavior, and drug and alcohol abuse are nearly as common as depression in adolescent suicide attempters, perhaps more so in males. These problems may precede or follow the onset of depressive symptoms. It has been suggested that increased alcohol abuse and firearm availability have substantially contributed to the dramatic increase in suicide in young men in the past 25 years. 12
A small group of attempters and completers show overanxious and perfectionistic traits. These children have difficulty at exam time, or when major life changes, such as moving from one house to another, occur. They may also suffer from depression, but rarely from behavior problems; in fact, they may seem "too perfect."
The families of adolescent suicide attempters are often highly disturbed, and family problems contribute not only to the adolescent's anger and hopelessness but also interfere with treatment. Up to 50% of parents have a major psychiatric illness and 30% to 40% may have alcohol and drug problems. A family history of suicide or attempted suicide is found in nearly 40% of adolescent suicides. Marital conflict and parent-child conflict are extremely common. Attempters often complain that their parents are hostile, indifferent, and inconsistent in their expectations and rules. Such parents have difficulty responding to adolescent crisis. And finally, other children in the family may be having problems. Sometimes the attempter is the least of the parents' worries.
Formulation of a treatment plan. Once the child and parents have been interviewed, it is essential to bring the family together to review the identified problems and suggest a treatment plan. It is helpful to write a problem list for the family to take away, and to be as specific and thorough as possible - include problems, big and small, as identified by parent, child, or physician, starting with the suicidal behavior. Try to say how particular problems will be treated, who will need to participate, and how long treatment will take. Avoid statements such as, "We'd like you to come back for further evaluation." Rather, offer a specific plan, such as, "John is depressed, and his drinking is making his depression worse. He needs individual therapy and possibly medication. You've told me how much you've been arguing with one another. A few family sessions will help reduce the tension and improve communication."
In planning outpatient care, the clinician should remember that 40% to 60% of patients will not keep outpatient treatment recommendations. Among the least likely to return are prior attempters, those with conduct disorder and drug and alcohol problems, those with ill parents, families that tend to share few activities or friends, and low income and minority families. Adolescents are not more likely than adults to be noncompliant, however. Compliance can be improved by taking a crisis-oriented approach13:
1. Before discharge, give the family a specific followup appointment and the name of the person who will see them; they are unlikely to make a call to arrange their own aftercare.
2. This appointment should be soon after the emergency visit (not more than a few days); the motivation for treatment rapidly diffuses.
3. Be clear about why follow-up is needed and what problems will be worked on. Do not blame the parents nor allow the parents to blame the child for the family's problems.
4. Try to estimate the length of treatment, erring on the low side; the vast majority of people expect brief treatment (six sessions or fewer) and fast results.
Emergency evaluation of the adolescent suicide attempter presents the pediatrician with a complex challenge. The attempter is acutely ill, in a psychosocial crisis, and may have one or more major mental disorders and a highly disturbed family. The adolescent rarely has planned the attempt for more than a few minutes, and usually does not know the dangerousness of the chosen method. Suicide attempts are quite common among adolescents14,15 and suicide quite rare, yet the risk of later death among attempters is substantial. Suicide is associated with a variety of problems and diagnoses, and in most ways attempters do not differ from other emotionally troubled adolescents. Suicide attempters and their families are often quite resistant to treatment, and this resistance seems to increase with the number of problems identified. How should the clinician proceed?
We have stressed the importance of rapid evaluation of parent and adolescent to identify individual and family risk factors (Table 1). As the number of risk factors increases, greater caution should be exercised. A short hospitalization can allow a more thorough evaluation of complicated cases. Brief, problem-oriented therapy (Table 2) is most likely to be accepted by the family and can result in rapid improvement. A smaller number of adolescents will require long term care.
1. McIntyre MS, Angle CR: The taxonomy of suicide and self-poisoning - A pediatric perspective, in Stewart IR, Wells CF (eds): Self-Destnictive Behavior in Children and Adolescents. New York. Van Nostrana Reinhold Co, 1981. pp 224-249.
2. Hillard JR, SlomowicJ, DeddensJ: Determinants of emergency psychiatric admissions for adolescents and adults. Am; Psychiatry 1988; 154:1416-1419.
3. Paykel E, Hallowell C, Dressier D. et al: Treatment of suicide attempters - A descriptive study. Arch Gen Psychiatry 1974; 31:487-491.
4. Otto VJ: Suicidal acts by children and adolescents: A follow-up study. Acia Psychiatr Scand 1972; 233(suppl):1-123.
5. National Center for Health Statistics (1988): Vital Statistics of the United States 1986-1988 Inclusive. Vol II. Parts A & B. US Department of Health and Human Services, Mortality Statistics Branch (published and unpublished data).
6. Shaffer D, Garland A, Gould M, et al: Preventing teenage suicide: A critical review. J Am Acad ChM Adoksc Psychiatry 1988; 27:675-687.
8. Hawton K, O'Grady J, Osbom M, et al: Adolescents who take overdoses: Their characteristics, problems and contacts with helping agencies. Br J Psychiatry 1982; 140:118-123.
9. Sabbath JC: The suicidal adolescent - The expendable child. ) Am Acad Child Adoksc Psychiatry 1969; 8:272-289.
10. Garfinkel BD, Froese A, Hood J: Suicide attempts in children and adolescents. Am / Psychiatry 1982; 139:1257-1261.
11. Trautman PD, Shaffer D: Treatment of child and adolescent suicide attempters, in Sudak HS. Ford AB. Rushforth NB (eds): Suicide in the Young. Littleton. Mass. John Wright PSG. Inc.. 1984.
12. Brent DA, Perper JA, Goldstein CE, et al: Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988; 45:581-588.
13. Trautman PD, Rothcxam MJ: Cognitive therapy with children and adolescents, in Frances AJ, Hales RE (eds): Review of Psychiatry, Vol. 7. Washington DC, American Psychiatric Press, 1988. pp 584-607.
14. Harkavy Friedman JM, Asnis GM, Boeck M. et al: Prevalence of specific suicidal behaviors in a high school sample. Am J Psychiatry 1987; 144:1203-1206.
15. Harkavy Friedman JM, Asnis GM: Letter to the editor. Am J Psychiatry 1988; 145:537-538.
Signs of High Risk for Further Suicidal Behavior*
Specific Foci for Treatment