Suicide

Suicide has become much more common in children and adolescents than it used to be. For children under age 15, about 1-2 out of every 100,000 children will commit suicide. For those 15-19, about 11 out of 100,000 will commit suicide. These are statistics from the USA. (2) Suicide is the fourth leading cause of death for children ages 10-14 and the third leading cause of death for teenagers 15-19. (3) Recent evidence suggests it is the lack of substance abuse, guns, and relationship problems in younger children which accounts for the lower suicide rates in those under age 15.(5)

The main way children kill themselves depends on what lethal means are available and their age. In countries where guns are readily available, such as the USA, that is the usual cause of suicide. Other causes are strangling and poisoning.(3)

Suicide attempts that do not result in death are more common. In any one year, 2-6% of children will try to kill themselves. About 1% of children who try to kill themselves actually die of suicide on the first attempt. On the other hand, of those who have tried to kill themselves repeatedly, 4% succeed. About 15-50% of children who are attempting suicide have tried it before.(4) That means that for every 300 suicide attempts, there is one completed suicide.(17)

But my son has never mentioned suicide.

Unfortunately, parents are aware of only a small proportion of suicidal attempts and suicidal thinking. In a study of 59 adolescents who had thought about suicide, the parents were aware in only 6 cases. Even more worrisome, out of 36 children who had made suicide attempts, the parents were only aware of this in two cases! (4) Parents do better at figuring this out if one of the parents has had depression, if the child has multiple psychiatric problems, or there had been lots of trouble in the home. The bottom line is that you should assume that all teens that are seriously depressed are thinking about suicide until proven otherwise. That means you should ask all seriously depressed teens about suicide on a regular basis.

How can you tell which child will commit suicide?

This is very hard to predict. Studying children and adolescents who have committed suicide can help us know what to look for. In children ages 10-14 in the USA, the most important factors for actually committing suicide are-

The most important of these was having a gun in the house. For older teenagers, the most important factors are having a mood disorder, having a substance abuse problem, family members having had psychiatric problems, having a gun in the house, and having made a suicide attempt in the past. In older teenagers, having psychiatric problems plus having a substance abuse problem are the most important predictors of suicide.(25)

Suicide Attempts

A suicide attempt means a child is trying to kill his or herself but survives.

What makes a child more likely to attempt suicide?

If a child has major depressive disorder, he or she is seven times more likely to try suicide. About 22% of depressed children will try suicide. Looking at it another way, children and teenagers who attempt suicide are 8 times more likely to have a mood disorder, three times more likely to have an anxiety disorder, and 6 times more likely to have a substance abuse problem.(7). A family history of suicidal behavior and guns that are available also increase the risk.

A very major factor is family members who have committed suicide. If a girl's biological parent has committed suicide, she is 4-5 times as likely to make a suicide attempt. If a girl's sibling has committed suicide, she is 11 times more likely to try to kill herself. (36) The vast majority (almost 90%) of children and adolescents who attempt suicide have psychiatric disorders. Over 75% have had some psychiatric contact in the last year. (6) If a number of these are present, suicide risk needs to be carefully assessed regularly. If children are constantly dwelling on death and think being dead would be kind of nice, they are more likely to make a serious attempt. (15).

Abuse is also a major predictor of children trying to kill themselves. Being abused as a child makes you 3 to 4 times more likely to become depressed or suicidal as a teenager or adult. Sexual abuse is the type of abuse that is most strongly associated with suicide attempts. It is thought that 15- 20% of all suicide attempts in teenagers and young adults can be linked to child sexual abuse. (26)

Many people have thought that the main reason that children and adolescents try to kill themselves is to manipulate others or get attention or as a "cry for help". However, when children and adolescents are actually asked right after their suicide attempts, their reasons for trying suicide are more like adults. For a third, their main reason for trying to kill themselves is they wanted to die. Another third wanted to escape from a hopeless situation or a horrible state of mind. Only about 10% were trying to get attention. Only 2% saw getting help as the chief reason for trying suicide. The children who truly wanted to die were more depressed, more angry, and were more perfectionistic.(16). Furthermore, most children and adolescents who try suicide believe that the method they have chosen will really kill them. (36)

Factors which make a Suicide attempt more likely -

 Depression

 Substance abuse

 Child Abuse victim

 Close Family members have committed suicide

 Close Family Members have tried Suicide

 Previous Suicide Attempts

 Access to Guns

 Bipolar Disorder

 Relationship problems

 Attention Deficit Hyperactivity Disorder

Predicting suicide and suicide attempts

Predicting suicide is very difficult. It is even more difficult in children and adolescents. When we discuss suicide, there are three different levels of concern.

Suicidal thinking

This means a person is thinking about suicide but has no plan. This is not uncommon. About 3-4% of adolescents will have considered suicide in the last two weeks. However, these thoughts are much more likely, and more likely to be serious, if the child has previously made a suicide attempt is depressed, or is pessimistic. Children who are still depressed and have made previous suicide attempts are extremely likely to be thinking seriously about suicide. (17)

Example:

Jenna is 13. She is quite depressed. She has most of the symptoms mentioned. She sleeps poorly, she has no energy, can't concentrate on her work and is super cranky. She thinks about running away or how nice it would be to out of this horrible life. She thinks sometimes about killing herself, but she doesn't think about how she might do it. At the moment, she says she is too scared to actually do something. This is suicidal thinking.

Suicidal plans

This means that you are thinking about suicide and have a way to do it in mind.

Example

Allan is 12. From what he can see, life gets worse every year. He can not imagine living like this for 50 more years. He is very irritable, is always getting in fights with his parents, and mostly says and thinks that "Life sucks!". He goes out for walks and thinks about two things. First, jumping in front of a truck. He doesn't do this because he is afraid it won't work. That is, he will end up hurt but not dead. Second, he thinks about going down to the wharf and jumping off. He is not exactly sure how to do this to make sure no one saves him.

Tina is 15. She is also very depressed. She is waiting until Friday night. Her parents are going out and leaving her home. She has been collecting Tylenol and her Grandmother's heart pills for the last two weeks. She has almost 100 pills. She has been working on a suicide note. She is scared that she will "blow it" and tell someone.

Ryan is 15. He is depressed, but has not been thinking about suicide. In fact, he told his mother this a few days ago. He told the doctor the week before that he wasn't thinking about suicide. But now, at 10:15 at night, he has had it. His mom will not let him go and see his girlfriend. That is, his ex-girlfriend. She told him on the phone this evening that she just wants to be friends. Ryan can't take it anymore. He has decided to break a light bulb and cut his wrists and just see what happens. If he dies, fine. That's okay with him.

These are all suicidal plans. Some suicide plans are well thought out, like Tina's. Others are very impulsive, like Ryan. Others are not that serious yet, like Allan's.

Suicide attempts

This means you have actually tried to hurt yourself. These can be medically serious or not serious. They can be psychologically serious or not. About 40% of teenagers will have thought about suicide for only a half hour or so before they try something. The most frequent reason for these impulsive suicide plans are relationship problems.

Medically non-serious, Psychologically non-serious

Janet is 13. She has dysthymia but has never been treated. She has a new boyfriend who is very nice to her. The only problem is that her parents will not let her go out with him by herself. He is 17, does not go to school, and is on probation for selling cigarettes to other children. That is how he met Janet. Janet's parents have told that she is not to have any contact with him. She has decided to show her parents how much this hurts her. She went and took a pop can lid and scratched her wrists and then walked by her parents so they could see this. She had no intention of hurting herself seriously. She wanted to drive her parents nuts. It was successful. They were more excited about this than anything she had ever done!

Janet was not trying to kill herself. What she was doing was not going to really hurt her. She needs help, but probably not this very minute.

Medically non-serious, Psychologically serious

Wayne is 16. He has been very depressed for the last year and has a full depressive syndrome. He is now failing in school, refusing to do work around the house, and all he does is sit in his room and listen to his stereo with the headphones on loud. He overheard his mother mention that the pills she was taking for her nerves were quite strong, so she was only taking a half. So he thought that sounded like a good way to go. He took the 7 remaining pills. They were .5 mg Ativan (Lorazepam) pills and this was a very small dose. He took them, fell asleep, and woke up a little tired the next morning. His mom asked if he had seen her pills and he told her the story.

Wayne was really trying to kill himself. He just did not know that what he was doing was not that serious. Wayne needs to be seen in the next day or so and watched carefully before then.

Medically serious, Psychologically non-serious

Diane is 13. She just found out that she will not be going to her best friend's house for a sleep over birthday party. She has gone to her house for abut three years. Now her best friend has invited some new friends and Diane is not going. The other girls who are going are all talking about it at school. It seems to Diane that they are just doing it to bug her. Diane has been pretty irritable lately, and that may or may not have something to do with why she was not invited. She has decided to take some pills on the night of the party so they will be really sorry. She has decided to take some tylenol, which she believes is very safe. She takes 30. Nothing happens. She goes to tell her mom, but her mom is on the phone. She goes up to her room and falls asleep. The next morning she tells her mom. Diane is very surprised when she ends up in the hospital with IV medications to counteract the tylenol.

Diane did not really want to kill herself. She wanted to make a point. Unfortunately, she did not realize how dangerous tylenol overdoses can be.

Medically Serious, Psychologically serious

Yvon is 16. His girlfriend has left him after he lost his temper with her. He was suspended from school for swearing at the teacher last week. His parents are constantly yelling at him for nothing. He has a headache all the time and feels like the world would be a much better place without him. While his dad is out fishing, he goes to the shed and gets some rope and sets it up to hang himself. He kicks away the chair just as the door opens. His dad forgot the bait bags. His father always told the story afterwards how his forgetfulness saved his son's life.

Managing Suicidal thoughts and behavior

When a person has thoughts about killing themselves or actually makes an attempt, There are a number of things that need to be done.

Take it seriously

If a child is saying he or she wants to die, it is worthy of attention. Maybe it is really nothing. At the very least, it requires a heart to heart talk. Many adults believe that children and teenagers do not really mean it when they talk about suicide. Data collected in the last two decades clearly suggests that sometimes children do mean it.

Take away the taboo from talking about suicide

If you have a depressed child, they certainly may be thinking about suicide. Not talking about it will not make this possibility go away. At the very least, openly ask the child if they are thinking about suicide. If some stressor has occurred (for example, girl friend and boyfriend troubles) ask again.

Get some help

Suicidal thinking or attempts almost always means that some sort of professional help is indicated. Most children and adolescents who have suicidal thoughts or have made suicidal attempts have at least one, and sometimes more than one, psychiatric disorder. These disorders obviously need to be identified and treated. For medically serious attempts, it usually means going directly to a hospital, and then seeing a psychiatrist once the medical emergency has passed. Sometimes it means psychiatric hospitalization. For less serious attempts, it means getting seen in the next week or so.

Supervision

If your child makes a suicide attempt or has a plan, you need to make sure they are not alone. They need to be watched until they can be carefully assessed. This may just be a matter of a day or so, or it could be longer. No one likes being watched all the time, and it is exhausting to all concerned. If a child has 5-6 risk factors for suicide and says they are thinking about it, I would assume they are trying to kill themselves unless they are being watched.

What if the child promises they will not hurt themselves?

I would not trust a promise a child makes not to hurt themselves. These attempts are usually too impulsive for that to work. It also gives people false confidence that no attempt will be made. I do not make much of such promises.

Avoiding manipulation

Some people will use suicidal thoughts or attempts to get what they want or to get out of things they do not want to do. People try suicide to hurt others, to try to get back at boy or girl friends, and to get out of work or school. By keeping this possibility in mind, most parents (with a little help) can prevent it suicidal behavior from becoming a habit.  

Preventing suicide by restricting access to guns, pills, etc.

Sometimes people forget that the most important thing to do about suicidal children is to make sure they donít have access to the common methods people use. That means putting away all medications in a locked cabinet. It means guns should not be in the home, even if they are locked up. It means that razors for shaving are kept in the same place medications are. These simple suggestions can make a great deal of difference (20)

Preventing suicide with medication

One medication has been found to be very helpful in preventing suicide, and that is Lithium. Since the early 1990s, there have been many studies that have shown this.

 If adults take lithium, they are less likely to attempt suicide.

 If adults take lithium they are less likely to commit suicide.

 Even if it does not help their depression, adults who take lithium are less likely to commit suicide.

 Adults with bipolar disorder who take lithium have suicide rates the same as the general population.

 One third of adults with bipolar disorder, who have tried suicide, and have taken lithium for at least a year and then stop their lithium, commit suicide. (1,2)

 

So why doesn't everyone take lithium?

 Because it is not the safest thing in the world

 You have to have blood tests regularly

Who should take Lithium?

Assuming the adult data apply to teenagers (always a big IF) it is reasonable to consider Lithium in youths who are not responding to other treatment and have persistent and severe suicidal thoughts and/or have made serious suicide attempts. (Click here to go to the section in the bipolar handout on lithium)

Other medications for Suicide prevention

Of course, if an antidepressant results in a child no longer having depression, it will certainly make suicide less likely. Proving this in a large study has been more difficult. There is some data that suggests that other antidepressants help prevent suicide. Compared to the data on lithium, it is more like a hint. (3)