Suicidal Behavior
Suicidal behavior, an action intended to harm oneself, encompasses both suicide attempts and completed suicide.
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 (see Section 7, Chapter 102). However, child suicide does occur and must not be overlooked in preadolescents. After accidents, suicide is the leading cause of death in adolescents, resulting in 2,000 deaths per year in the United States. It is also likely that a number of the deaths attributed to accidents, such as from motor vehicles and firearms, are actually suicides.
Many more young people attempt suicide than actually succeed. A survey performed by the Centers for Disease Control and Prevention found that 28% of high school students had suicidal thoughts and 8.3% had attempted suicide.
Among adolescents in the United States, boys outnumber girls in completed suicide by more than four to one. Girls, however, are 2 to 3 times more likely to attempt suicide than boys.
Risk Factors
Multiple factors typically interact before suicidal thoughts become suicidal behavior. Very often, there is an underlying mental health problem and a triggering stressful event. Examples of stressful events include the death of a loved one, loss of a boyfriend or girlfriend, a move from familiar surroundings (school, neighborhood, friends), humiliation by family or friends, failure at school, and trouble with the law. Stressful events such as these are fairly common among children, however, and rarely lead to suicidal behavior if there are no other underlying problems. The two most common underlying problems are depression and alcohol or drug abuse. Adolescents with depression have feelings of hopelessness and helplessness that limit their ability to consider alternative solutions to immediate problems. The use of alcohol or drugs lowers inhibitions against dangerous actions and interferes with anticipation of consequences. Finally, poor impulse control is a common factor in suicidal behavior. Adolescents attempting suicide are commonly angry with family members or friends, are unable to tolerate the anger, and turn the anger against themselves.
Sometimes suicidal behavior results when a child imitates the actions of others. For instance, a well-publicized suicide, such as that of a celebrity, is often followed by other suicides or suicide attempts. Suicides may cluster in families with a genetic vulnerability to mood disorders.
Prevention, Diagnosis, and Treatment
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 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 professionals have two key roles: evaluating a suicidal child's safety and need for hospitalization, and treating underlying conditions, such as depression or substance abuse.
Directly asking an at-risk child about suicidal thoughts and plans reduces, rather than increases, the risk that the child will attempt suicide because identifying suicidal thinking can lead to interventions. Crisis hot lines, offering 24-hour assistance (see Section 7, Chapter 102), 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.
Children 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 completed suicide had a previous suicidal attempt--sometimes apparently trivial, such as making a few shallow scratches to the wrist or swallowing a few pills. When parents or caretakers belittle or minimize an unsuccessful suicide attempt, children may see this 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. The seriousness of a suicide attempt can be gauged by a number of factors, including whether the attempt was carefully planned rather than spontaneous, whether steps were taken to prevent discovery, the type of method used, and whether any injury was actually inflicted. It is critical to distinguish intent from actual consequences; for example, an adolescent who ingests harmless pills he or she believes 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 and sharp objects are removed or securely locked.
 See the sidebar Risk Factors for Child and Adolescent Suicide.
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