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PEDIATRICS Vol. 105 No. 4 April 2000, pp. 871-874
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ABSTRACT |
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Abstract
Recommendation
References
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Suicide is the third leading cause of death for adolescents 15 to 19 years old.1 Pediatricians can help prevent adolescent suicide by knowing the symptoms of depression and other presuicidal behavior. This statement updates the previous statement2 by the American Academy of Pediatrics and assists the pediatrician in the identification and management of the adolescent at risk for suicide. The extent to which pediatricians provide appropriate care for suicidal adolescents depends on their knowledge, skill, comfort with the topic, and ready access to appropriate community resources. All teenagers with suicidal symptoms should know that their pleas for assistance are heard and that pediatricians are willing to serve as advocates to help resolve the crisis.
The number of adolescent deaths from suicide in the
United States has increased dramatically during the past few decades. In 1997, there were 4186 suicides among people 15 to 24 years old, 1802 suicides among those 15 to 19 years old, and 2384 among those 20 to 24 years old.1 In 1997, 13% of all deaths in the 15- through
24-year-old age group were attributable to suicide.1 The
true number of deaths from suicide actually may be higher, because some
of these deaths are recorded as "accidental."3
From 1950 to 1990, the suicide rate for adolescents in the 15- to
19-year-old group increased by 300%.4 Adolescent males 15 to 19 years old had a rate 6 times greater than the rate for
females.1 The ratio of attempted suicides to completed suicides among adolescents is estimated to be 50:1 to 100:1, and the
incidence of unsuccessful suicide attempts is higher among females than
among males.5 Suicide affects young people from all races
and socioeconomic groups, although some groups seem to have higher
rates than others. Native American males have the highest suicide rate,
African American women the lowest. A statewide survey of students in
grades 7 through 12 found that 28.1% of bisexual and homosexual males
and 20.5% of bisexual and homosexual females had reported attempting
suicide.6 The National Youth Risk Behavior Survey of
students in grades 9 through 12 indicated that nearly one fourth
(24.1%) of students had seriously considered attempting suicide during
the 12 months preceding the survey, 17.7% had made a specific plan,
and 8.7% had made an attempt.7
Firearms, used in >67% of suicides, are the leading cause of death
for males and females who commit suicide.8 More than 90%
of suicide attempts involving a firearm are fatal because there is
little chance for rescue. Firearms in the home, regardless of whether
they are kept unloaded or stored locked up, are associated with a
higher risk for adolescent suicide.9,10 Parents must be
warned about the lethality of firearms in the home and be advised
strongly to remove them from the premises.11 Ingestion of
pills is the most common method among adolescents who attempt suicide.
Youth, who seem to be at much greater risk from media exposure than
adults, may imitate suicidal behavior seen on
television.12 Media coverage of a teenage suicide may lead
to cluster suicides, additional deaths from suicides in youths within a
1- to 2-week period afterward.12-14
Although no specific tests are capable of identifying suicidal
persons, specific risk factors exist. Adolescents at higher risk
commonly have a history of depression, a previous suicide attempt, a
family history of psychiatric disorders (especially depression and
suicidal behavior), family disruption, and certain chronic or
debilitating physical disorders or psychiatric illness.15 Alcohol use and alcoholism indicate high risk for
suicide.16 Alcohol use has been associated with 50% of
suicides.17 Living out of the home (in a correctional
facility or group home) and a history of physical or sexual abuse are
additional factors more commonly found in adolescents who exhibit
suicidal behavior.18 Psychosocial problems and stresses,
such as conflicts with parents, breakup of a relationship, school
difficulties or failure, legal difficulties, social isolation, and
physical ailments (including hypochondriacal preoccupation), commonly
are reported or observed in young people who attempt suicide. These
precipitating factors often are cited by youths as reasons for
attempting suicide. Gay and bisexual adolescents have been reported to
exhibit high rates of depression and have been reported to have rates
of suicidal ideation and attempts 3 times higher than other
adolescents. Studies of twins show that monozygotic twins show
significantly higher concordance for suicide than dizygotic
twins.16 Long-term high levels of community violence may
contribute to emotional and conduct problems and add to the risk of
suicide for exposed youth.19 Adolescent and parent
questionnaires that cover those risk factors listed above, may be
useful in the office setting to assist in obtaining a complete
history.20
All adolescents with symptoms of depression should be asked about
suicidal ideation, and an estimation of the degree of suicidal intent
should be made. No data indicate that inquiry about suicide precipitates the behavior. In fact, adolescents often are relieved that
someone has heard their cry for help. For most adolescents, this cry
for help represents an attempt to resolve a difficult conflict, escape
an intolerable living situation, make someone understand their
desperate feelings, or make someone feel sorry or guilty. Suicidal
thoughts or comments should never be dismissed as unimportant.
Adolescents must be told by pediatricians that their plea for
assistance has been heard and that they will be helped.
Serious depression in adolescents may manifest in several ways. For
some adolescents, symptoms may be similar to those in adults, with
signs, such as depressed mood almost every day, crying spells or
inability to cry, discouragement, irritability, a sense of emptiness
and meaninglessness, negative expectations of self and the environment,
low self-esteem, isolation, a feeling of helplessness, markedly
diminished interest or pleasure in most activities, significant weight
loss or weight gain, insomnia or hypersomnia, fatigue or loss of
energy, feelings of worthlessness, and diminished ability to think or
concentrate.21 However, it is more common for an
adolescent with serious depression to exhibit psychosomatic symptoms or
behavioral problems. Such a teenager may seek care for recurrent or
persistent complaints, such as abdominal pain, chest pain, headache,
lethargy, weight loss, dizziness and syncope, or other nonspecific
symptoms.22 Behavioral problems that may be manifestations
of masked depression include truancy, deterioration in academic
performance, running away from home, defiance of authorities,
self-destructive behavior, vandalism, alcohol and other drug abuse,
sexual acting out, and delinquency.23 Episodic despondency
leading to self-destructive acts can occur in any adolescent, including
high achievers. These adolescents may believe that they have failed or
disappointed their parents and family and perceive suicide as their
only option. Other adolescents may believe that suicide is a better
option than life as they experience it.
One approach to initiate an inquiry into suicidal thoughts or concerns
is to ask a general question, such as "Have you ever felt so unhappy
or depressed that you thought about killing yourself or wished you were
dead?" If the response is positive, the pediatrician should inquire
about thoughts of death, thoughts of suicide, suicide plans (eg,
method, time, and place), securing the available means (eg, guns and
ropes), previous attempts (and whether the attempts were
discovered), and the response of the family. These basic questions can
help pediatricians construct an assessment of suicidal risk. In
addition, they should assess individual coping resources, accessible
support systems, and attitudes of the adolescent and family toward
intervention and follow-up.24
Although confidentiality is important in adolescent health care, for
adolescents at risk to themselves or others, confidentiality must be
breached. Pediatricians need to inform the appropriate persons when
they believe an adolescent is at risk of suicide. In all cases,
determination of the sequence of events that preceded the threat,
identification of current problems and conflicts, and assessment of the
degree of suicidal intent must be completed.
Adolescents with a well-thought-out plan that includes method,
place, time, and clear intent are at high risk. The degree of intent
can be inferred from the actual and perceived lethality of the intended
means. Use of firearms, for example, has a high degree of lethality and
poor chance of rescue. An adolescent who takes pills in the presence of
others, however, has a good chance of rescue (Table
1).25 Even adolescents who initially may seem at low risk, joke about suicide, or seek treatment for repeated somatic complaints may be asking for help the only way
they can. Their concerns should be assessed thoroughly and follow-up
arranged for additional evaluation and treatment. For adolescents who
seem to be at moderate or high risk for suicide or have attempted
suicide, a mental health professional should be consulted immediately
during the office visit. Options for immediate evaluation include
hospitalization, transfer to an emergency department, or an appointment
the same day with a mental health professional.
TABLE 1
ADOLESCENTS AT INCREASED RISK
APPROACHING THE ADOLESCENT
MANAGEMENT OF THE SUICIDAL ADOLESCENT
Examples of Adolescents at Low, Moderate, and High Risk for Suicide
The safest course of action is hospitalization, placing the adolescent in a safe and protected environment. An inpatient stay will allow time for a complete medical and psychiatric or psychologic evaluation and initiation of therapy in a controlled setting. The choice of hospital unit depends on available facilities in the area, health and mental health insurance, and managed care policies. Adolescent medicine units must be staffed to manage the medical and psychiatric needs of suicidal adolescents.26 Proper medical intervention and treatment are essential for stabilization and management of patients' conditions. After the adolescent's condition has been stabilized medically, a comprehensive emotional and psychosocial assessment must be initiated before discharge. Inquiry should be made into the events that preceded the attempt, the adolescent's current problems, and the presence of current or previous psychiatric illness and self-destructive behavior. In addition to an in-depth psychological evaluation of the adolescent, family members should be interviewed to obtain additional information to help explain the adolescent's suicidal thoughts or attempt. This information includes detailed questions about the adolescent's medical, emotional, social, and family history with special attention to signs and symptoms of depression, stress, and substance abuse. With parental permission and adolescent assent, teachers and family friends also may provide useful information if confidentiality is not breached.
Intervention should be tailored to the adolescent's needs. Adolescents with a responsive intact family, good peer relations and social support, hope for the future, and a desire to resolve conflicts may require only brief crisis-oriented intervention.27 In contrast, adolescents who have made previous attempts, exhibit a high degree of intent to commit suicide, show evidence of serious depression or other psychiatric illness, are abusing alcohol and other drugs, and have families who are unwilling to commit to counseling are at high risk and may require psychiatric hospitalization.
All adolescents who attempt suicide need a comprehensive outpatient treatment plan before discharge. Specific plans are needed because compliance with outpatient therapy often is poor. Most adolescents examined in emergency rooms and referred to outpatient facilities fail to keep their appointments. This is especially true when the appointment is made with someone other than the family pediatrician or the person who performed the initial assessment.28 Continuity of care is, therefore, of paramount importance. Pediatricians can enhance continuity and compliance by maintaining contact with suicidal adolescents even after referrals are made. All firearms should be removed from the home because adolescents may still find access to locked guns stored in the home.
Adolescents judged not to be at high risk for suicide should be followed up closely, referred for mental health evaluation in a timely manner, or both.
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RECOMMENDATIONS |
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Top
Abstract
Recommendation
References
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1. Pediatricians need to know the risk factors (eg, signs and
symptoms of depression) associated with adolescent suicide and serve as
a resource for parents, teachers, school personnel, clergy, and
community groups that work with youth about the issue of adolescent
suicide.
2. Pediatricians should ask questions about
depression, suicidal thoughts, and other risk factors associated with
suicide in routine history-taking throughout
adolescence.
3. During routine evaluations, pediatricians
need to ask whether firearms are kept in the home and discuss with
parents the risks of firearms as specifically related to adolescent
suicide. Specifically for adolescents at risk of suicide, parents
should be advised to remove guns and ammunition from the
house.
4. Pediatricians should recognize the medical and
psychiatric needs of the suicidal adolescent and work closely with
families and health care professionals involved in the management and
follow-up of youth who are at risk or have attempted
suicide.
5. Pediatricians should become familiar with
community, state, and national resources that are concerned with youth
suicide, including mental health agencies, family and children's
services, crisis hotlines, and crisis intervention centers. Working
relationships should be developed with colleagues in child and
adolescent psychiatry, clinical psychology, and other mental health
professions to manage the care of adolescents at risk for suicide
optimally. Because mental and physical health services are often
provided through different systems of care, extra effort is necessary
to assure good communication, continuity, and
follow-up.
6. Pediatricians should advocate for
benefit packages in health insurance plans to assure that adolescents have access to preventive and therapeutic mental health services that
adequately cover the treatment of clinically significant mental health
disorders.
COMMITTEE ON ADOLESCENCE, 1999-2000
David W. Kaplan, MD, MPH, Chairperson
Ronald A. Feinstein, MD
Martin M. Fisher, MD
Jonathan D. Klein, MD, MPH
Luis F. Olmedo, MD
Ellen S. Rome, MD, MPH
W. Samuel Yancy, MD
LIAISON REPRESENTATIVES
Paula J. Adams Hillard, MD
American College of Obstetricians and
Gynecologists
Diane Sacks, MD
Canadian Paediatric Society
Glen Pearson, MD
American Academy of Child and Adolescent Psychiatry
SECTION LIAISON
Barbara L. Frankowski, MD, MPH
Section on School Health
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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REFERENCES |
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Top
Abstract
Recommendation
References
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The following policy statement is a revision:
This article has been cited by other articles:
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  A. H. Cheung, R. A. Zuckerbrot, P. S. Jensen, K. Ghalib, D. Laraque, R. E.K. Stein, and and the GLAD-PC Steering Group Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing Management Pediatrics, November 1, 2007; 120(5): e1313 - e1326. [Abstract] [Full Text] [PDF]
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 R. M. Page, J. Yanagishita, J. Suwanteerangkul, E. P. Zarco, C. Mei-Lee, and N.-F. Miao Hopelessness and Loneliness Among Suicide Attempters in School-Based Samples of Taiwanese, Philippine and Thai Adolescents School Psychology International, December 1, 2006; 27(5): 583 - 598. [Abstract] [PDF]
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K. A. Hacker, E. Myagmarjav, V. Harris, S. F. Suglia, D. Weidner, and D. Link Mental Health Screening in Pediatric Practice: Factors Related to Positive Screens and the Contribution of Parental/Personal Concern Pediatrics, November 1, 2006; 118(5): 1896 - 1906. [Abstract] [Full Text] [PDF]
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 A. R. Joffe and A. Lalani Injury Admissions to Pediatric Intensive Care Are Predictable and Preventable: A Call to Action. J Intensive Care Med, July 1, 2006; 21(4): 227 - 234. [Abstract] [PDF]
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 from the Adolescent Health Update Editorial Board Assessing the risk of suicide in adolescents with mental illness AAP News, October 1, 2005; 26(10): 11 - 11. [Full Text]
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 L. J. Levine, D. F. Schwarz, J. Argon, D. S. Mandell, and C. Feudtner Discharge Disposition of Adolescents Admitted to Medical Hospitals After Attempting Suicide Arch Pediatr Adolesc Med, September 1, 2005; 159(9): 860 - 866. [Abstract] [Full Text] [PDF]
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 U.S. Preventive Services Task Force* Screening for Suicide Risk: Recommendation and Rationale Ann Intern Med, May 18, 2004; 140(10): 820 - 821. [Abstract] [Full Text] [PDF]
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U.S. Preventive Services Task Force* Screening for Depression: Recommendations and Rationale Ann Intern Med, May 21, 2002; 136(10): 760 - 764. [Abstract] [Full Text] [PDF]
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 S. R. Dube, R. F. Anda, V. J. Felitti, D. P. Chapman, D. F. Williamson, and W. H. Giles Childhood Abuse, Household Dysfunction, and the Risk of Attempted Suicide Throughout the Life Span: Findings From the Adverse Childhood Experiences Study JAMA, December 26, 2001; 286(24): 3089 - 3096. [Abstract] [Full Text] [PDF]
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H. L. Falik To prevent teen suicide, know risks, new therapies AAP News, June 1, 2000; 16(6): 1 - 30. [Full Text] [PDF]
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