To date, few studies oi the treatment of suicidal behavior among children and adolescents have been conducted. There is an immediate need for such studies, especially as it is clear that the suicide rates among adolescents and young adults have significantly increased in the last two decades. In fact, despite recent efforts to enhance community awareness of the need for early identification of youth at most risk, suicide rates remain high. The scope of the problem is highlighted by trends in youth suicide rates, which are illustrated in the Table.1
In 1986. approximately 30 904 persons committed suicide, which accounts for an age-adjusted suicide rate of 12.8 per 100 000 populalion.1 The age-adjusted suicide rates for youth show a significantly higher suicide rate among I 5- to 24-yearolds than among 5- to 14-year-olds. In 198b. 5 120 adolescents and young adults, ages 1 5 to 24. committed suicide compared with 255 children ages 5 to 14. The Table illustrates increasing suicide rates in recent years. In fact, a 4% increase has occurred in age-adjusted suicide rates for all ages from 1985 to 198b.1 Data on suicide attempt rates among youth in community samples have suggested that between 9% and 18% of children and adolescents report having attempted suicide within a year of study.23 These data may represent minimal estimates, as most data were obtained using survey methods in which the youngsters were not interviewed directly. Nevertheless, suicidal behavior among youth appears to be not only highly lethal but also quite prevalent.
Evidence suggests the method most commonly used to commit suicide (ic, the use of firearms) has increased proportionately to the increase in youth suicide rates.' In addition, substance abuse, particularly alcohol abuse, has been linked to suicide among youth.10 Finally, psychopathology is an important risk factor for fatal and nonfatal suicidal behavior among youth.4,7-11 Symptoms of affective and conduct disorders are the most prevalent symptoms among suicidal youth.
Age-Adjusted Suicide Rates*
With advances in classification of youth psychopathology, improved methods of quantifying change in psychiatric symptoms, and enhanced knowledge in psychopharmacology, psychotherapy and psychosocial interventions, means of systematically studying the treatment of suicidal children and adolescents can be designed. This article suggests treatment approaches for suicidal youth and. when possible, draws on empirical dala that may lend insights into efficacy of or directions for treatment. Specifically, this article focuses on three main issues:
* when to hospitalize a suicidal child or adolescent.
* intervention planning, and
* specific treatments.
INDICATIONS FOR PSYCHIATRIC HOSPITALIZATION
A decision to hospitalize a child or adolescent is often difficult, both clinically and emotionally, lor the parents as well as the clinician. Parents and clinicians often try to avoid admitting a youngster to the hospital because of fears of the stigma of hospitalization, exposure to other disturbed youngsters, and separation from the home environment. Yet. with regard to suicidal behavior, psvchiatric hospitalization must be considered as a potential treatment setting from the outset of clinical assessment. Empirical data for preadolescents suggest that a high number of youngsters admitted for psychiatric inpatient treatment are suicidal.10 For example, approximately 88% of 106 preadolescent psychiatric inpatients, compared with 24% of 101 preadolescent psychiatric outpatients, exhibited suicidal ideation or acts. Furthermore, in a study of 200 consecutively admitted adolescent psychiatric inpatients. 58% had suicidal ideation or acts." Specifically, in this sample of adolescent psychiatric inpatients. 54% had attempted suicide within b months of hospitalization.
The main reason to consider admitting a preadolescent or adolescent to a psychiatric hospital unit is to protect the youngster from intentional self-inflicted injury. Hospitalization, however, is not a guarantee against suicide or suicide attempts. Suicidal behavior has occurred among psvchiatric inpatients. However, in most cases, psychiatric inpatient treatment can provide intensive observation and intervention for patients with seriously acute suicidal risk.
Two studies ot preadolescents with wide variation in social status and race/ethnicity suggest factors associated with whether a child with psychiatric symptoms should be hospitalized.12,15 Statistical multiple regression techniques were used to identify lhe interactions among those factors associated with admission to a psychiatric hospital. The factors that predicted psychiatric hospitalization most strongly were severity of suicidal behavior, severity of assaultive behavior, level of reality testing, and symptoms of depression or antisocial behaviors. Other factors included signs of projection and regression in thinking and behavior and loss of environmental support because of parental psychopathology and separation. Combinations of these factors occurring with suicidal behavior provides an adequale guide for suggesting psychiatric hospitalization of a child or adolescent. The following case study illustrates lhe dala obtained by these studies.
Nine-year-old Anna attempted suicide a year after her parents separated. Her mol her was scriouslv depressed and had difficult) concentrating al work: she tended to withdraw from involvements with Anna and Anna's 15-year-old brother. Anna. too. was depressed, cried almost daily, was frequently truant from school, and was intensely preoccupied with suicide, thinking that no one loved her and that her fa her had abandoned her. Three days before hospitalization. Anna took a whole bottle of acetaminophen tablets in an effort to kill herself. She told her mother about her actions 1 hour alter the overdose ingestion. Anna was hospitalized on a pediatric unit for medical treatment of the overdose and subsequently transferred to a child psychiatry inpatient unit for psychiatric treatment of the suicidal behavior.
Serious suicidal behavior, which necessitated medical care and could have caused serious injury or death, was the main determinant for psychiatric hospitalization in this case. Associated factors that raised the level ol risk were the child's severe depression, evidenced by depressed mood, withdrawal from activities (particularly school), and repeated preoccupation with suicide. Other factors included environmental losses, suggested by the unavailability of her fallier and the impairment of her mother due to depression. The combination ol intense psychopathology and loss of environmental support made the child a high risk for repeated suicidal behavior.
Suicidal behavior is a multidetermined symptom for which factors that enhance risk can be clustered into categories involving the current siale of ego functioning, current status of affect and behavioral expression, current interpersonal relations, and past developmental history.14 These risk categories require extensive assessment, so that iI certain aspects are present, they can be targeted for intervention. Thus, interventions with a suicidal child or adolescent usually require a multifocal approach pragmatically planned to decrease specific risk factors.
The treatment modalities. whether applied during psychiatric inpatient or outpatient therapy, must involve individual work with the child and selected adjunctive treatments.14 The adjunctive treatments should focus primarily on the child's environmental support system and also on the child's physiological system. A network of professionals who are involved with the youngster must be defined and maximum communication between these individuals developed. This will ensure that changes in the child or adolescent's slate can be identified and appropriate interventions or changes in the treatment schema made. The treating clinician should be considered the coordinator of the therapeutic network.
When creating this therapeutic network for a suicidal youth, it is imperative that a professional within the network be available immediately if a youngster feels distraught and is in need of rapid intervention. Suicidal behavior is a state phenomenon that waxes and wanes within relatively brief periods of time. When the suicidal slate is maximal, the most acute need for intervention is evident and requires immediate attention. Thus, the treatment of a suicidal child or adolescent requires that a therapist have certain qualities thai enhance any means of decreasing a suicidal siale. A number of qualities have been outlined as essential14; among them are:
* ease of availability to the patient and family.
* skill and training in managing a suicidal youngster.
* honesty and consistency in relating to a suicidal youngster.
* objectivity in understanding the suicidal youngster's attitudes and life problems, and
* optimism and energy in stimulating open communication.
Anna's case illustrates a common situation in which a therapist must develop, at least initially, a multilevel treatment plan. In her case, direct work with Anna was immediately necessary to evaluate her psyehopalhology. In addition, meetings with her parents were warranted to learn about the family interactions and the parents' degree of involvement with Anna. Contact with school personnel was helpful in planning for Anna's return to school to facilitate her interactions with peers and teachers and to monitor her academic progress. As hospitalization necessitated her absence from school, someone in the school needed lo be available lo meet with Anna regularly. Such a plan for network building is usually needed during the phases of treatment when a youngster may be most at risk for suicidal behavior. Changes in this treatment plan can be made and are dependent upon the evolving clinical state of the youngster.
Unfortunately, empirical information from studies of specific treatments for suicidal behavior compared with oilier defined treatments of placebo effects are lacking in both the child and adolescent and adult literature. Treatment formats have been derived from clinical observations of intervention effects and from theoretical notions of the psyehopalhologv of the suicidal individual.
At least three specific types of intervention formats are relevant to a successful outcome ol decreasing suicidal intent and action:
* a psychotherapeutic-eogniiive approach.
* an environmental-stabilizing approach, and
'These formats, when used together. appear to provide the most powerful effects on limiting suicidal behavior. Yet. as noted above, systematic investigation ol the efficacy of these treatments has not been done.
Most clinicians who treat suicidal individuals recognize that a flexible treatment style is needed. Such flexibility enables the therapist to modify the therapeutic process in order to meet the emergent needs of the patient who may suddenly experience thoughts and strong impulses toward suicidal action. Therefore, although a consistent schedule of therapeutic sessions should be established, telephone availability and interim meetings may be arranged. Although flexibility is important, limits must also be set on the degree oi urgency toward actions, repetition of problems, and demands the patient may exhibit. 'Thus, an empathie stance on the part of the therapist is needed and disorganization must be avoided. If, for example, a patient feels unable to cope unless he or she repeatedly speaks to the therapist on the telephone or must see the therapist at unlikely hours, an outpatient format may be insufficient and inpatient treatment. which can provide 24-hour intervention and therapist availability, may be essential.
Specific issues usually need to be considered in working psychotherapcutically with a suicidal child or adolescent. The psychotherapy must be aimed at diminishing morbid fantasies of death, rejection, alienation, loss, and punishment. Exploration and interpretation are key ingredients in the psychotherapy. For example, suicidal youngsters often feel isolated, depressed, and long to be with a supportive person whom the youngster believes will help relieve the pain of life's problems and provide the coping skills fell to be lacking.
Others feel alienated and display hostility, mistrust, and oppositionalmanipuiative behaviors. These youngsters believe they do not belong in society and often show disrespect for rules, ethics, and social values. Such youngsters require the establishment of firm limits during treatment, exploration of their own desires and social standards, and creation of an atmosphere to explore through discussion their discontents, disappointments, and ability to rectify their circumstances. Suicidal behavior often is manifest when such youngsters feel enraged and want to influence others to provide them with what they feel is lacking.
Another issue apparent among suicidal children and adolescents is a mourning reaction directed toward someone who has died or abandoned them. The concrete loss results in depression, fantasies of reuniting with the lost person, and often thoughts of dying if the loss is not restituted. Thoughts of dying arc probably the most common fantasies of suicidal youngsters. In adolescents, such a fantasy may involve a loss of a relationship - a boyfriend or girlfriend. Such circumstances should be viewed as serious, and extensive and empathie exploration musi be undertaken.
A cognitive orientation in psychotherapy is essential. This approach focuses attention on the coping mechanisms of the child and adolescent, specifically on impulse control, reality testing, and perceptions of life circumstances. A therapist must be aware of the degree of frustration tolerance and capacity to delay action apparent for suicidal youngsters. Impulsive acts are common among suicidal youngsters. Many do not appreciate that there arc alternate ways of responding to a situation. It may be necessary to define, in concrete terms, other ways of responding in a given circumstance. For example, a 17-year-old boy has been denied the use of the family car because his father needed it. He felt frustrated and angry and thought of taking the car and hurting himself because he feared he would be ridiculed by his friends. A therapist may help such an adolescent identify why he would feel ridiculed, how hecould make other arrangements with his friends, how he could reach another solution with his father, and realize that thinking about suicide docs not solve the problem.
A cognitive approach is often needed with respect to a youngster's perceptions of his or her circumstances. Suicidal youngsters, as well as suicidal adults, often feel intensely pessimistic and. at times. hopeless.15, 16 The therapist must identify the roots of these perceptions for the youngster and. by means of an intensely hopeful, supportive approach, begin to alter the youngster's views. Very often such children or adolescents believe they are worthless, unwanted, and failures. Praise, concern, and attention by the therapist can be helpful in altering these pessimistic perceptions. Concrete discussion, with occasional suggestions about how to manage these perceptions successfully, is indicated. Praise for success is essential. The self-esteem of suicidal children and adolescents is often so low that infusion ol optimistic concern by the therapist often provokes a positive response in the youngster.
In summary, the psychotherapeulic-cognitive intervention approach involves clarifying circumstances and behaviors; interpreting and identifying fantasies related to loss, abandonment, alienation, and failure; and providing concrete suggestions about modes of managing circumstances to avoid impulsive behavior, a sense of hopelessness, and intense frustration. "The therapist must exhibit an active approach that includes specific statements of praise, suggestions for alternative behaviors, and teaching ol effective coping skills.
Suicidal behavior arises, in part, as a result of environmental stresses. One study17 of suicidal child psychiatric inpatients suggested that the suicidal children endured more lifetime and recent life stresses compared with nonsuicidal psychiatric inpatients. These stresses involved loss of parents, death of relatives. family moves, birth of siblings, and family illness. Similar trends have been noted for older adolescents and adults.18
Interventions must be geared to diminishing current factors increasing stress. For example, it is helpful to meet with each youngster's parents and to determine their degree of impairment, their capacity to be interested in the youngster's treatment and life circumstances, and their own understanding of their child's problems. Frequently, individual, couple, or family treatment is indicated, especially if one or both parents' problems preclude an objective, supportive involvement with the child.
In all cases of treatment with a suicidal child or adolescent, family discussions arc needed. Usually, the parents and the suicidal youngster meet with the therapist to identify mutual concerns, determine methods they use to solve problems, and evaluate methods that are more effective in overcoming problems. Such meetings with the therapist provide a structured forum for discussion of often highly conflicted and disturbing issues and allow for the expression of intense affects and the alleviation of tensions. Often, issues that were denied and not discussed become apparent in these sessions, and their expression may begin verbal interchange about problems rather than suicidal actions.
As noted previously, a network of professionals is helpful. This approach maximizes communication among those who are involved with the child or adolescent and also provides a forum for discussion of problems. Such an approach may make it more likely that a suicidal act can be averted and other forms of intervention immediately provided. The therapist is responsible for coordinating the network of professionals. Time for communication must be allotted. Suggestions on how to respond to a crisis need to be offered. Al times, meetings to plan treatment strategies may be necessary. In this way, a systems approach io the treatment oí a suicidal child is developed that includes the child or adolescent, the parents, and other professionals.
At present, no medication unique for suicidal behavior is available. Therefore, medication should be used to treat specific target symptoms or disorders, such as serious depression, impulsivity. or psychotic symptoms. Medications should be used only after strici guidelines as to who will administer the medication have been determined, so as to avoid self-inflicted harm. Medication is probably most effective when used in conjunction with lhe treatment schema outlined above. The types of medicines most useful for the suicidal youngster are antidepressants, lithium, and major tranquilizers. Whenever possible, polypharmacy should be avoided. Trials of medications should involve careful assessment of premedication physical status, using electrocardiograms, electroencephalograms, and blood tests when indicated. Repeated assessments during the medication I rial are necessary. If the predetermined guidelines for medication administration cannot be adhered to. psychiatric inpatient treatment is indicated. This ensures adequate administration ol medication and enhances lhe therapist's ability to monitor beneficial effects as well as side effects. The use of medications that enhance serotonin functioning may hold promise for the treatment of suicidal children and adolescents. Although no studies have been conducted of serotonin functioning as it is relevant to suicidal behavior in children and adolescents, research with adults suggests that aberrations in serotonin systems are prominent in suicidal individuals.14,20 Certain serotoninergic medications may prove beneficial in the treatment of suicidal individuals. This issue awaits further research.
This article focused on three major issues in the treatment of suicidal children and adolescents: deciding on psychiatric hospitalization, strategies of treatment planning, and specific treatments that involve a psychotherapeutic-cognitive orientation, a network of professionals, and psychopharmacology.
Presently, few controlled systematic studies have been conducted on the treatment of suicidal children and adolescents. Nevertheless, the main clinical means of preventing suicidal acis among youth are early identification oï risk factors and the suicidal state and immediate interventions aimed al maximizing protection from harm. Each suicidal youngster musi be treated with methods thai suit his or her unique circumstances. Such treatment requires that the therapist not only work individually with the youngster but also organize other professionals who are involved with the youngster, work with the family, and evaluate and treat physiological underpinnings of suicidal tendencies.
Treating suicidal youngsters involves a broad treatment plan that allows for immediate changes ?? a suicidal crisis arises. The therapist must be readily available, offer active support and optimism, and be able to establish objectivity in determining responses to behaviors and in setting limits on demands and action.
Finally, the treatment of a suicidal child or adolescent requires skills and techniques that must be continually updated and evaluated. The scientific field is rapidly advancing, and lhe clinician should be aware of the most recent empirical data on the phenomenology, identification, and treatment of youth suicidal behavior.
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Age-Adjusted Suicide Rates*