Suicidal behavior is an action intended to harm oneself and includes suicidal gestures, suicide attempts, and completed suicide. Suicidal ideation is thoughts and plans about suicide. Suicide attempts are acts of self-harm that could result in death, such as hanging or drowning.
A stressful event may trigger suicide in children who have a mental health disorder such as depression.
Children at risk of suicide may be depressed or anxious, withdraw from activities, talk about subjects related to death, or suddenly change their behavior.
Family members and friends should take all suicide threats or attempts seriously.
Health care professionals try to determine how serious the risk of suicide is.
Treatment may involve hospitalization if the risk is high, drugs to treat other mental health disorders, and individual and family counseling.
(See also Suicidal Behavior in adults.)
Suicide is rare in children before puberty and becomes more common in adolescence, particularly between the ages of 15 and 19, and of adulthood. However, preadolescent children do commit suicide, and this potential problem must not be overlooked.
In the United States, suicide is the second leading cause of death in 10- to 24-year-olds and the 9th leading cause of death among 5- to 11-year-olds. It results in 2,000 deaths per year. Suicide has had a particularly large impact on the Black community, as the rate nearly doubled in Black children in elementary school between 1993 and 2012. It is also likely that a number of the deaths attributed to accidents, such as those due to motor vehicles and firearms, are actually suicides.
Many more young people attempt suicide than actually succeed. The Centers for Disease Control and Prevention recently provided information about increasing trends in suicide across a number of groups and time periods:
For females (ages 10 through 14), the overall suicide rate increased from 0.5% in 1999 to 2% in 2019.
For males (ages 10 through 14), the overall suicide rate increased from 1.9% in 1999 to 3.1% in 2019.
Additional findings highlight suicide-related statistics about high school students in the United States in 2015:
Between 2001 and 2015, visits to the emergency department for self-inflicted injuries, suicidal thoughts, or attempted suicide increased across all age groups.
The sharp increase in suicide attempts was first noted in 2011, even while the actual number of suicides remained stable.
From 2006 to 2015, there were over 40,000 suicides in 10- to 19-year-olds. During that same period, 118,000 children and adolescents in that same age group required medical treatment for nonfatal suicide attempts.
Many factors may contribute to the increase in suicide attempts among children and adolescents, among them the increases in adolescent depression (especially in girls), increased parental opioid prescriptions, exposure to increasing suicide rates among adults in their circle, conflict-filled relationships with parents, and academic stress.
Frequently, suicide attempts involve at least some ambivalence about wishing to die and may be a cry for help.
Among adolescents in the United States, boys outnumber girls in completed suicide by more than 4 to 1. However, girls are 2 to 3 times more likely to attempt suicide.
The COVID-19 pandemic contributed to increases in suicides in children and adolescents. Emergency department visits for suspected suicide attempts were 22% higher for all adolescents during the summer of 2020 than they had been just one year earlier, and 39% higher during the winter of 2021. Higher rates were reported in girls (26% higher during the summer and 51% during the winter).
Did You Know...
|
Risk Factors
Suicidal thoughts do not always lead to suicidal behavior, but they are a risk factor for suicidal behavior. Several factors typically interact before suicidal thoughts become suicidal behavior. Very often there is an underlying mental health disorder and a stressful event that triggers the behavior. Stressful events include
Death of a loved one
A suicide in school or another group of peers
Loss of a boyfriend or girlfriend
A move from familiar surroundings (such as the school or neighborhood) or friends
Humiliation by family members or friends
Being bullied at school, especially for lesbian, gay, bisexual, and transgender (LGBT) students
Failure at school
Trouble with the law
However, such stressful events are fairly common among children and rarely lead to suicidal behavior if there are no other underlying problems.
The most common underlying problems are the following:
Depression: Children or adolescents with depression have feelings of hopelessness and helplessness that limit their ability to consider alternative solutions to immediate problems.
Alcohol or substance use disorders: The use of alcohol or illicit drugs lowers inhibitions against dangerous actions and interferes with anticipation of consequences.
Poor impulse control: Adolescents, particularly those who have a disruptive behavioral disorder such as conduct disorder, may act without thinking.
Other mental disorders and physical disorders can also increase the risk of suicide. They include anxiety, schizophrenia, head injury, and posttraumatic stress disorder.
Children and adolescents attempting suicide are sometimes angry with family members or friends, are unable to tolerate the anger, and turn the anger against themselves. They may wish to manipulate or punish other people (“They will be sorry after I am dead”). Having difficulty communicating with their parents may contribute to the risk of suicide.
Sometimes suicidal behavior results when a child imitates the actions of others. For example, a well-publicized suicide, such as that of a celebrity, is often followed by other suicides or suicide attempts. Similarly, copycat suicides sometimes occur in schools.
Suicide is more likely in families in which mood disorders are common, especially if there is a family history of suicide or other violent behavior.
Diagnosis
Identification of risk by parents, doctors, teachers, and friends
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 strongly 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
Treating underlying disorders, such as depression or substance abuse
Treatment
Sometimes hospitalization
Precautions to prevent future attempts
Treatment of any disorder contributing to risk of suicide
Referral to a psychiatrist and psychotherapy
Children who express thoughts of wanting to hurt themselves or 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 complete suicide have previously attempted it—sometimes an apparently trivial attempt, such as making a few shallow scratches to the wrist or swallowing a few pills. When parents or caregivers belittle or minimize an unsuccessful suicide attempt, children may see this response 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. Hospitalization is the surest way to protect the child and is usually indicated if doctors suspect the child has a serious mental health disorder such as depression.
The seriousness of a suicide attempt can be gauged by a number of factors, including the following:
Whether the attempt was carefully planned rather than spontaneous—for example, leaving a suicide note indicates a planned attempt
Whether steps were taken to prevent discovery
What type of method was used—for example, using a gun is more likely to cause death than taking pills
Whether any injury was actually inflicted
What the child's mental state was when suicide was attempted
It is critical to distinguish serious intent from actual consequences. For example, adolescents who ingest harmless pills that they believe 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 medications (including over-the-counter medications) and sharp objects are removed or securely locked away. Even with these precautions, preventing suicide can be very difficult, and there are no proven measures for successfully preventing it.
If the child has a disorder that may contribute to risk (such as depression or bipolar disorder), doctors treat it. But such treatment cannot eliminate the risk of suicide. Although there have been concerns that taking an antidepressant may increase the risk of suicide in some adolescents (see Antidepressant drugs and suicide), not treating the depression is probably just as dangerous or more so. Doctors carefully monitor children who take antidepressants and prescribe only small amounts that would not be lethal if taken all at once.
Doctors usually refer children to a psychiatrist, who can provide appropriate drug treatment, and to a therapist, who can provide psychotherapy, such as cognitive-behavioral therapy. Treatment is most successful if the primary care doctor continues to be involved.
If suicide occurs
Family members of children and adolescents who committed suicide have complicated reactions to the suicide, including grief, guilt, and depression. They may feel purposeless, detached from everyday activities, and bitter. They may have difficulty continuing with their life. Counseling can help them understand the psychiatric context of the suicide and reflect on and acknowledge the child’s difficulties before the suicide. They may then be able to understand that the suicide was not their fault.
After a suicide, the risk of suicide may increase in other people in the community, especially friends and classmates of the person who committed suicide. Resources (such as a toolkit for schools) are available to help schools and communities after a suicide. School and community officials can arrange for mental health professionals to be available to provide information and consultation.
Prevention
Directly asking at-risk children about suicidal thoughts can bring out important issues that are contributing to the child’s distress. Identifying these issues can, in turn, lead to meaningful interventions. Research indicates that over 50% of children who showed up in an emergency department for any reason screened positive for suicidal thoughts and behaviors. As a result, hospitals have been required since 2019 to assess for suicide as part of standard medical care.
Physicians should also inquire about firearms, the leading cause of death for youth in the US (60% homicides, 35% suicides, 4% unintentional). Physician counseling combined with provision of a cable gun lock has been reported to increase safe storage of firearms.
Crisis hotlines, offering 24-hour assistance (see sidebar Suicide Intervention: Crisis Hot Lines), 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.
The following may help reduce the risk of suicide:
Getting effective care for mental, physical, and substance use disorders
Being able to easily access mental health services
Getting support from family and the community
Learning ways to peacefully resolve conflict
Limiting media access to suicide-related content
Having cultural and religious beliefs that discourage suicide
Suicide prevention programs can help. The most effective programs are those that try to make sure that the child has the following:
A supportive nurturing environment
Ready access to mental health services
A school or other social setting that promotes respect for individual, racial, and cultural differences
In 2022 a new 3-digit dialing code (988), referred to as the 988 Suicide and Crisis Lifeline, was activated in the United States. A call, text, or chat to 988 will route callers to the National Suicide Prevention Lifeline (whose previous Lifeline phone number, 1-800-273-8255, will continue to remain available). Trained counselors, in English and Spanish, available 24/7, will provide support and connect callers to resources if necessary. The service is confidential and free of charge.
Identifying Children and Adolescents at Risk of Suicide
Type | Specific Factors |
|---|---|
Risk factors for suicide | |
Disorders that affect the brain | |
Family history | A family history of suicidal behavior A mother with a mood disorder A father with a history of trouble with the police Lack of communication with parents Increased rates of suicide in adults Parents' use of opioids |
Triggering events | Difficulties in school, including being disciplined or suspended Loss of a loved one (such as a boyfriend or girlfriend), especially by suicide Separation from parents Lack of social contacts, sometimes due to having no job or not going to college Victim of bullying Reports of suicide in the media, which may lead to a copycat suicide |
Circumstances | Access to firearms or prescription medications A previous attempt at suicide Barriers encountered when trying to access mental health services and/or a feeling that a stigma is attached to seeking such help |
Sexual/gender minority status | — |
Medications | Benzodiazepines |
Warning signs of suicide | |
Mental and physical symptoms | Preoccupation with morbid themes Depression A feeling of hopelessness Low self-esteem Dramatic changes in mood Changes in appetite Sleep disturbances Tension, anxiety, or nervousness Poor control of impulses |
Changes in behavior | Poor hygiene and neglect of personal appearance (especially if it is an abrupt change) Withdrawal from social interactions Playing hooky from school A decline in grades An increase in violent behavior Giving away favorite possessions |
Conversation | Statements about feeling guilty Statements suggesting a wish to be dead, such as “I wish I’d never been born” or “I’d like to go to sleep and never wake up” Direct or indirect threats to commit suicide |
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Metanoia: This site directly and compassionately addresses the person considering suicide with valuable information about the imbalance between the pain they are experiencing and their coping resources and then provides direct access to suicide hotlines and other mental health services.
Patient Health Questionnaire (PHQ-9): Issued by the U.S. Preventive Services Task Force, this nine-item questionnaire is used by doctors to screen for depression.
