Suicide and Suicide Attempts in Adolescents and Young Adults

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322 PEDIATRICS Vol. 81 No. 2 February 1988

AMERICAN

ACADEMY

OF PEDIATRICS

Committee

on Adolescence

Suicide

and Suicide

Attempts

in Adolescents

and Young

Adults

Suicide is the third leading cause of death dun-ing adolescence and the second leading cause in young adults. It is preceded in frequency only by accidental deaths and homicide. Recent statistics indicate that the number of adolescent suicides has increased dramatically in the past decade, re-sulting in more than 5,000 deaths annually for youths between 15 and 24 years of age. For

ado-lescents 15 to 19 years of age, suicide rates have

actually tripled in the years between 1960 to 1980.’ Among children and younger teenagers be-tween ages 5 and 14 years, suicides increased from 205 deaths in 1983 to 232 in 1984.2 As distressing as these data are, they may represent underne-porting. Furthermore, many experts believe that numerous “accidental” deaths are actually suicides.3

Suicide affects young people from all races and socioeconomic groups. For every suicide com-pleted, between 50 and 200 are attempted. Ado-lescent boys succeed in killing themselves more often than girls, although adolescent girls make more nonfatal attempts. This difference appears to be related, in pant, to the methods favored by each sex. Boys are more likely to complete suicide because they use more lethal methods, such as firearms or hanging. These methods leave little chance for rescue. In contrast, adolescent girls more commonly attempt suicide by ingesting pills. Recently, however, there has been a trend toward the use of more lethal methods among girls.

This statement has been approved by the Council on Child and Adolescent Health.

The recommendations in this statement do not indicate an ex-clusive course of treatment or procedure to be followed. Varia-tions, taking into account individual circumstances, may be appropriate.

American Academy of Pediatrics.

“Cluster suicide” has also emerged in recent years. This phenomenon refers to the occurrence ofmultiple suicides during a short perioed of time in the same geographic location.4 Although the cause of cluster suicide is unclear, some believe that media coverage of individual suicides plays a major role in precipitating suicide by other

youths.5 There is also evidence that imitative

be-havion may follow television movies dealing with suicide.6

ADOLESCENTS AT INCREASED RISK

Although there are no specific tests capable of identifying suicidal individuals, there appear to be populations at increased risk. At-risk

individ-uals commonly demonstrate certain behaviors,

including a previous suicide attempt, family

dis-ruption, a family history of psychiatric disorders

(especially depression and suicidal behavior), and a chronic on debilitating physical or psychi-atnic illness. Living out of the home (in a cor-rectional facility on group home) and a history of

physical andlon sexual abuse are additional

fac-tons more commonly found in youths who exhibit

suicidal behavior.7

Current situational problems and stresses such as conflicts with parents, breakup of a relation-ship, school difficulties or failure, substance abuse, social isolation, and physical ailments (in-cluding hypochondriacal preoccupation) are com-monly reported or observed in young people who attempt suicide. These factors are often cited by

youths as precipitating their suicidal acts.

Although teenagers suffering from depression may be at increased risk for suicidal behavior, nec-ognition of depression in young people is difficult because the signs and symptoms are often

atyp-ical. Manifestations of depression in children and

adolescents may include declining school

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AMERICAN ACADEMY OF PEDIATRICS 323 ance, truancy, multiple physical complaints,

fam-ily conflicts, alcohol and drug abuse, and problems with authorities. A sense ofhopelessness also con-relates with suicidal tendencies and may occur without other symptoms of depression.8 Episodic despondency leading to self-destructive acts can occur in any adolescent, including high achievers. These individuals may believe that they have failed or disappointed their parents and family and perceive suicide as their only option.

APPROACHING THE ADOLESCENT

The pediatrician should not hesitate to question an adolescent directly about suicidal thoughts. There are no data indicating that inquiry about suicide precipitates the behavior. In fact, the ad-olescent is often relieved that someone has heard his or hen cry for help. For most adolescents, this

cry for help represents an attempt to resolve a

difficult conflict, escape an intolerable living sit-uation, make someone understand how desperate the teenager feels, on make someone feel sorry on

guilty. Suicidal thoughts on comments should

never be dismissed as unimportant. The adoles-cent must be told that the plea for assistance has been heard and that the pediatrician wishes to help.

All adolescents thought to be considering sui-cide should be questioned about suicidal ideation,

and an estimation of the degree of intent should

be made. This can be accomplished in an outpa-tient or hospital setting, depending upon the spe-cific situation and skills of the practitioner. If the pediatrician lacks expertise in this area, mental health professionals on an adolescent medicine specialist should be consulted. When serious psy-chopathology is suspected, a complete evaluation should include comprehensive psychologic

assess-ment. In all cases, determination of the sequence

of events that preceded the threat, identification of current problems and conflicts, and assessment ofthe degree ofsuicidal intent must be completed.

Prior to allowing the young person to return

home, the physician should assess individual cop-ing resources, accessible support systems, and at-titudes of the individual and family toward in-tervention and follow-up.9

MANAGEMENT OF ATTEMPTED SUICIDE

When dealing with adolescents who have

at-tempted suicide, the safest course of action is hos-pitalization. A brief inpatient stay will allow time

for a complete medical and psychologic evaluation

and initiation of therapy. The choice of hospital setting or unit depends upon available facilities.

Proper medical intervention and treatment are

essential for stabilization and management of

pa-tients. Adolescent medicine units may be staffed

to manage both the medical and psychiatric needs of suicidal ‘#{176}After the adolescent has

recovered medically, psychosocial assessment should be completed and intervention initiated.

Interviews with a youth who has attempted

su-icide should be carried out in privacy, and the

phy-sician should first try to establish rapport and

trust. Family members should also be interviewed to determine their perception of the adolescent’s general adjustment, recent stresses, and reasons the attempt occurred. Teachers and family friends may also provide useful information.

Inquiry should be made into the events that pre-ceded the attempt, the individual’s current prob-lems, and the presence of current on previous psy-chiatnic illness and self-destructive behavior. It is

also important to assess the adolescent’s degree

of intent to die. The degree of intent can be in-ferned from the actual, as well as the adolescent’s perception of, lethality of the means used. Use of

firearms in an isolated setting, for example, has

a high degree of lethality and low chance of nes-cue. In contrast, an adolescent who takes a few pills in the presence of others is using a means of low lethality with a good chance of rescue.”

Intervention should be tailored to the

individ-ual’s needs. Some will require only brief, crisis-oriented intervention that can be provided by an interested and supportive primary care provider

who has experience in caring for such 2

These adolescents are more likely to have

respon-sive intact families, good peer relations and social

support, hope for the future, and a desire to

re-solve conflicts. In contrast, adolescents who have

made prior attempts, exhibit a high degree of in-tent to commit suicide, show evidence of depres-sion on other psychiatric illness, and have families who are unwilling to commit to counseling will

require consultation from mental health

professionals.

All adolescents who attempt suicide need cane-fully planned follow-up prior to discharge. Specific plans are needed because compliance with out-patient therapy is poor. The majority of adoles-cents seen in emergency rooms and referred to

outpatient facilities fail to keep their

appoint-ments. This is especially true when the appoint-ment is made with someone other than the family pediatrician on the person who performed the in-itial assessment.’3 Continuity of care is, there-fore, of paramount importance. Pediatricians can enhance continuity and compliance by maintain-ing contact with such patients even when refer-nals are made.

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324 PEDIATRICS Vol. 81 No. 2 February 1988

RECOMMENDATIONS

Pediatricians can play a major role in the pre-vention of youth suicide.’4”5

1. Pediatricians must become aware of risk

fac-tons associated with adolescent suicide. They should be familiar with the signs and symptoms of depression in children and youth and should be able to identify those who are experiencing the feelings of helplessness and hopelessness which may lead to suicide.

2. Pediatricians should include questions about suicidal thoughts in the routine medical history throughout the adolescent years. Such thoughts should be openly discussed with the adolescent.

3. Pediatricians should become familiar with community, state, and national sources that are concerned with youth suicide. Working relation-ships should be developed with colleagues in child psychiatry and clinical psychology, local mental health agencies, family and children’s services, crisis hot lines, and crisis intervention centers.

4. Pediatricians can serve as resource persons for parents, teachers, schools, clergy, and other

community groups who work with youth.

Pedia-tnicians should take an active role in the devel-opment of school curricula designed to assist youths in developing problem-solving and coping skills.

5. Pediatricians must be able to manage the acute medical emergencies associated with sui-cide and suicide attempts. They should recognize the need for more in-depth psychiatric assessment and management and work closely with other

professionals involved in the management and

follow-up of youths who attempt suicide.

6. Pediatricians should serve as sources of sup-port for suicidal youth and should be prepared to

assist families in which a suicide on suicide

at-tempt has occurred.

7. Pediatricians and academy chapters should

urge state and federal funding for service pro-grams and research efforts that address youth suicide.

Individual pediatrician involvement with sui-cidal adolescents will depend on knowledge and comfort coupled with appropriate community re-sources. Some pediatricians can best help by being attuned to presuicidal youth and working to pne-vent adolescent suicide. Others may wish to evaluate, as well as treat, these youths. Still

oth-ens may choose to refer all suicidal adolescents to

a psychiatrist. Whatever role the pediatrician

adopts, the most important issue is that each

su-icidal teenager knows his or her plea for assist-ance is heard and that the pediatrician is willing to serve as an advocate in helping to resolve the crisis.

COMMIrFEE ON ADOLESCENCE, 1986-1987 Joe M. Sanders, Jn, MD, Chairman

Roberta K. Beach, MD

Richard R. Bnookman, MD Richard R. Brown, MD John W. Greene, MD

Elizabeth McAnarney, MD

Liaison Representative

Phillip Goldstein, MD, American College of Obstetricians and Gynecologists

Section Liaison

Mary-Ann B. Schafer, MD, Section on Adolescent Health

REFERENCES

1. Suicide-United States, 1970-1980. MMWR 1985;

34:353-357

2. Advance report offinal mortality statistics, 1984. Monthly Vital Statistics Report 1986;35(No. 6, suppl 2):1-44 3. Eisenberg L: The epidemiology of suicide in adolescents.

Pediatr Ann 1984;13:47-54

4. Robbins D, Conroy RC: A cluster of adolescent suicide at-tempts: Is suicide contagious? J Adolesc Health Care 1983;3:253-255

5. Phillips DP, Carstensen LL: Clustering ofteenage suicides after television news stories about suicide. N Engl J Med

1986;315:685-689

6. Gould MS, Shaffer D: The impact of suicide in television

movies: Evidence of imitation. N Engi J Med 1986;

315:690-694

7. Hodgman CH: Recent findings in adolescent depression and suicide. J Dev Behav Pediatr 1985;6:162-170

8. Mclntire MS, Angle CR, Wikoff RL, et al: Recurrent ad-olescent suicidal behavior. Pediatrics 1977;60:605-608

9. Gispert M, Wheeler K, Marsh L, et al: Suicidal adolescents: Factors in evaluation. Adolescence 1985;20:753-762

10. Marks A: Management of the suicidal adolescent on a nonpsychiatric adolescent unit. J Pediatr 1979;95:305-308

11. Eisenberg L: Adolescent suicide: On taking arms against a sea of troubles. Pediatrics 1980;66:315-320

12. Hodgman CH, Roberts FN: Adolescent suicide and the pe-diatrician. J Pediatr 1982;101:118-123

13. Hawton KE: Suicide and Attempted Suicide Among Chil-dren and Adolescents. Beverly Hills, CA, Sage Publica-tions, 1986, Developmental Clinical Psychology and Psy-chiatry series, vol. 5

14. Fine P, Mclntire MS, Fain PR: Early indicators of self-destruction in childhood and adolescence: A survey of pe-diatricians and psychiatrists. Pediatrics 1986;77:557-568 15. Irwin CE, Shafer MA: Adolescent suicide, in Rudolph A:

Pediatrics, ed 17. Norwalk, CT, Appleton-Century-Crofts, 1982, pp 773-776

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1988;81;322

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