Suicidal Behavior in Children and Adolescents

Age at first suicide attempt

Mazza and colleagues¹ examined the age at onset of suicide attempts in youths. This longitudinal study included 883 youths who were assessed annually starting at approximately ages 6 to 18 years. Data were collected retrospectively regarding suicide attempts. When the youths were 18 to 19 years old, they were asked whether they had ever attempted suicide, the number of suicide attempts, the age of first suicide attempt, and whether they received medical treatment for their suicide attempt. Seventy-eight youths reported making a suicide attempt: 36% made their first suicide attempt during elementary or middle school. The youngest age of a suicide attempt was at 9 years.

Youths with multiple suicide attempts were more likely to have made their first attempt during elementary school or middle school compared with single attempters who had a later onset of suicide attempts. For those youths who attempted suicide, depressive symptoms were higher during the year that they made their first suicide attempt. The researchers stress the importance of including suicide prevention programs in elementary and middle schools, in addition to high school.

Suicide methods

Are the methods of suicide used by children and adolescents different from those of adults? Hepp and colleagues² examined Swiss suicides from 1998-2007. During this 10-year period, there were 12,226 suicides: 333 of the suicides were in the child and adolescent age-group. Of these, 226 (68%) were in boys and 107 (32%) were in girls. For boys, the most common methods of suicide were use of firearms (26.1%), hanging (25.2%), railway suicide (20.8%), and jumping from heights (19.5%). Compared with suicides by adults, railway suicides and jump-ing from heights were significantly higher in the child and adolescent age-group.

Suicide by intoxication was significantly higher in the male adult group than the male child and adolescent group. Suicides by gas, by drowning, and by firearms were also more common in the adult male group than in the child and adolescent male group.

For girls, the most common methods of suicide were railway suicide (31.8%), jumping from heights (23.4%), hanging (18.7%), and intoxication (16.8%). Railway suicides were significantly more common in the female child and adolescent group than in the female adult group, whereas drowning was significantly higher in the female adult group than the female child and adolescent group.

The researchers concluded that availability is an important factor in the methods chosen by children and adolescents who commit suicide. In Switzerland, railways are readily accessible, as are bridges. Such “hot­spots” should be adequately monitored to prevent youth suicides.

Suicide risk factors

Risk factors for suicide in children and adolescents have been a strong research focus. Mood disorders are a significant risk factor for suicidal behavior in youths. Three multicenter treatment studies of adolescents with depression, the Treatment for Adolescents with Depression Study (TADS), the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study, and the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT), provide clinically useful information about predictors of suicidal events in youths.

In the TADS study, predictors of suicidal events included higher levels of self-reported suicidal ideation and depression at baseline, persistent depression, minimal improvement in depression, and acute interpersonal conflict (eg, conflict with parents or peers).³ In the TORDIA study, predictors of suicidal events were high baseline suicidal ideation, family conflict, and drug or alcohol use.⁴ In the ADAPT trial, nonsuicidal self-injury, high suicidality, and family dysfunction were factors predictive of future suicide attempts. A history of nonsuicidal self-injury was a stronger predictor of suicide attempts than a prior history of a suicide attempt.⁵

Sguin and colleagues⁶ examined the effects of adversity on youths and young adults who committed suicide. The sample group included 67 persons who committed suicide; 36% were younger than 19 years. The control group consisted of 56 living individuals matched for age and sex.

Serious adversity was found to occur at a young age in the suicidal group compared with the nonsuicidal group. Half of the children in the suicidal group were exposed to abuse, physical violence, and/or sexual violence between birth and age 4 years. In the 5- to 9-year-old group, 60% were exposed to abuse or violence. By age 10 to 14 years, 77% of the group were exposed to these adversities. In contrast, the rates of abuse and violence in the nonsuicidal group were 14%, 18%, and 34%, respectively. The researchers note that the cumulative burden of adversity is greater for individuals with an earlier exposure to abuse and violence.

In a compelling editorial, Brent⁷ comments that identification of risk factors has been insufficient in preventing youth suicides. He argues that protective factors should be a research focus and that interventions should be directed toward family and personal resiliency. He suggests that consideration be given to an intervention that both treats the current disorder and fosters long-term resilience. He also recommends that health risk behaviors, such as substance use and risky sexual behavior, be included in interventions with suicidal youth.

References:

References

1. Mazza JJ, Catalano RF, Abbott RD, Haggerty KP. An examination of validity of retrospective measures of suicide attempts in youth. J Adolesc Health. 2011;49:532-537.
2. Hepp U, Stulz N, Unger-Köppel J, Ajdacic-Gross V. Methods of suicide used by children and adolescents. Eur Child Adolesc Psychiatry. 2011 Dec 1; [Epub ahead of print].
3. Vitiello B, Silva SG, Rohde P, et al. Suicidal events in the Treatment for Adolescents With Depression Study (TADS). J Clin Psychiatry. 2009;70:741-747.
4. Brent DA, Emslie GJ, Clarke GN, et al. Predictors of spontaneous and systematically assessed suicidal adverse events in the treatment of SSRI-resistant depression in adolescents (TORDIA) study. Am J Psychiatry. 2009;166:418-426.
5. Wilkinson P, Kelvin R, Roberts C, et al. Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). Am J Psychiatry. 2011;168:495-501.
6. Séguin M, Renaud J, Lesage A, et al. Youth and young adult suicide: a story of life trajectory. J Psychiatr Res. 2011;45:863-870.
7. Brent DA. Preventing youth suicide: time to ask how. J Am Acad Child Adolesc Psychiatry. 2011;50:738-740.