Suicide is among the leading causes of death in individuals 5 to 24 years old. The most important methods of preventing the tragic loss of young lives are early identification of those at risk and implementation of interventions to deter suicide attempts. Primary care providers are among the most influential professionals, serving as gatekeepers to recognize, treat, and refer at-risk youngsters. Lack of time, infrequent meetings with older children and adolescents, and, perhaps, a need for specialized clinical skills may mandate referral of at-risk patients to professionals who specialize in pediatric mental disorders. Prevention of suicide requires community-based interventions offered within a continuum of care. Practitioners often serve as links to such services for children and adolescents.

This chapter provides an overview to assist pediatric primary care providers in identifying, treating, and preventing suicide in children and adolescents. It highlights practical guidelines that address the significant risk factors for youth suicide.

Nonfatal suicidal behavior is a complex psychiatric symptom that manifests as an episodic phenomenon. Specific co-occurring acute or chronic risk factors increase the likelihood of suicide. The basic neurobiology of suicide is currently a subject of intensive study. Promising results suggest that aspects of dysregulation of the serotonergic neurotransmitter system are prominent features of serious suicide attempts in adults, children, and adolescents (Greenhill et al., 1995; Kruesi et al., 1992; Mann & Stoff, 1997; Pfeffer et al., 1998; Pine et al., 1995).

Generally, dysregulation of the serotonergic system involves findings of low concentrations of presynaptic serotonergic neuroreceptors and dense concentrations of post-synaptic receptors (Mann, 1998). These results, with a down-regulation at the presynaptic receptors and an up-regulation at the post-synaptic receptors, suggest a functional disequilibrium. Low levels of serotonin metabolites, such as 5-hydroxy-indol-acetic acid (5-HIAA) in the cerebrospinal fluid, have been identified in adults who committed suicide and among adolescents who reported recent serious suicide attempts. Low levels of serum tryptophan, a basic precursor of serotonin, have been identified in prepubertal children with histories of recent suicide attempts (Pfeffer et al., 1998).

Postmortem neuroradiographic studies and in vivo biologic challenges with PET neuroimaging techniques suggest that serotonin abnormalities may involve the ventrolateral prefrontal cortex and brainstem of those who attempt and successfully complete suicide (Arango, Underwood, & Mann, 1997). The ventrolateral prefrontal cortex is involved in behavioral inhibition; impulsivity and emotional instability may be associated with dysfunctions in the ventrolateral prefrontal cortex, possibly increasing an individual’s vulnerability for suicide. Research results also suggest the association of suicidal behavior with polymorphisms of the tryptophan hydroxylase gene (Mann, 1998). Validation of such results may enable the development of a blood test for suicidal behavior.

Most neurobiologic research has been with adults, and developmental differences in younger individuals may exist. Children and adolescents may not manifest these same neurobiologic dysfunctions. For example, lower levels of 5-HIAA concentrations have been found in the cerebrospinal fluid of adolescents who made serious suicide attempts, compared with levels in their adult counterparts. Conversely, low levels of cerebrospinal fluid homovanillic acid have been identified as being associated with adolescents who made serious suicide attempts (Greenhill et al., 1995; Kruesi et al., 1992).

Co-occurring psychopathologies significantly increase the risk for child and adolescent suicide. Only 10% of youth who commit suicide have no diagnosed psychopathology (Brent et al., 1993a; Marttunen, Hillevi, Henriksson, & Lonnqvist, 1991; Shaffer et al., 1996). This figure may overestimate the absence of clinically significant psychiatric symptoms or psychiatric disorders. The prevalent psychiatric disorders among suicidal youths include mood disorders and substance abuse (including alcoholism). Features of mood disorders include major depressive disorder, dysthymia, mania, hypomania, or mixed periods of rapid cycling. An important suicide risk for those who have a mood disorder is a mixed state of mania and depression. In males, mood disorders are frequently comorbid with conduct and substance abuse disorders. Particularly for males older than age 15 years, drug abuse, alcohol abuse, or both are significant risk factors. In general, psychiatric disorders are found to have been present for at least 2 years before the suicide.

Many suicidal youths manifest impulsivity, irritability, and outbursts of aggression. A small number of suicidal youths, however, are anxious and do not manifest signs of comorbid psychiatric disorders. They often are characterized as excellent students and well liked by peers. Their suicides are often surprises to those who know them well. Regardless, at least one third of adolescents who commit suicide have a history of suicide attempts.

According to controlled research, males and females share similar risk factors for suicide (Shaffer et al., 1996). Studies that compared completed and attempted suicides in children and adolescents failed to find significant differences in risk
factors (Brent et al., 1988; Shaffer et al., 1996). A marked difference exists, however, in the relative strength of risk factors with respect to gender (Shaffer, 1988; Shaffer et al., 1996). Specifically, a previous suicide attempt increases the risk over 30-fold in males. The next significant level of risk is depression, which elevates risk 11-fold in males. Substance abuse follows, which elevates suicide risk in males approximately five-fold; and disruptive disorder, which elevates risk three-fold. In females, the presence of major depressive disorder imparts the greatest suicide risk, increasing risk 20-fold. A history of a prior suicide attempt increases risk for females approximately three-fold.

Although issues regarding sexual orientation have not been identified as significant in studies of youth suicide victims, research suggests that bisexual, gay, and lesbian youths are at increased risk for suicide (Mueher, 1995; Remafedi, French, Story, Resnick, & Blum, 1998; Shaffer, Fisher, Hicks, Parides, & Gould, 1995). They are at significantly higher risk for suicidal intent, suicidal ideation, and more frequent suicide attempts than heterosexual teens. Recent instances of school violence underscore the often hidden suffering of youth who are bullied and labeled “different” by schoolmates and peers.

Repeated suicide attempts have been associated with hypomanic personality traits and cluster-B personality disorders (Brent et al., 1993a; 1994). Borderline personality disorder has been associated most closely with repeated suicidal behavior (Johnson et al., 1995). Controversy exists about whether borderline personality disorder is a form of bipolar disorder. Its main symptoms include repeated suicide attempts; other nonfatal self-injurious behaviors; impulsivity; unstable mood; chronic problematic interpersonal relationships; a self-concept involving grandiosity, worthlessness, or both; and irritability.

Rates of suicide, especially among those 15 to 24 years old, have increased since the late 1960s and remain high. Suicide in adolescents and young adults in particular is considered a national public health problem (Peters, Kochanek, & Murphy, 1998).

Suicide is the third-leading cause of death in non-Caucasian youth ages 15 to 24 years among all races and both sexes, following unintentional injuries and homicide. Suicide is the second leading cause of death for Caucasians ages 15 to 24 years. In general, Caucasian males have the highest suicide rates across all ages, although rates of suicide are increasing among African American males. This increase may be related to a decrease in previously available social supports. Regional distinctions in suicide rates are evident. Higher suicide rates are found in western states and Alaska, and lower suicide rates are found in northeastern, north central, and southern states. Urban centers have lower suicide rates than do rural regions, possibly related to the different availability of firearms used for hunting in rural communities (National Institute of Mental Health, 1999).

The most recent statistics (1997) compiled by the National Institute of Mental Health (1999) and also reported by Peters and colleagues (1998) are sobering:

Evaluation of suicidal behavior requires direct interview of the child or adolescent and interview of a parent or caregiver. Recommendations are for providers to obtain additional information from others who know the youngster, such as school professionals. Clinicians should obtain information about the suicidal behavior and risk for death or repetition of the behavior, as well as underlying problems or diagnosis. Providers also should identify the presence of any promoting factors, such as history of depression, perceived friendless state, substance use, school problems or failure, recent diagnosis of illness (eg, HIV), or recent change, such as loss of friend(s), divorce, death, or move from one area to another.

Practitioners should obtain information about the method that the patient has contemplated or used for a suicide attempt, the level of medical lethality, the degree of suicidal intent, the degree of planning, and the potential for discovery or intervention if the patient carries out the act. Clinicians can elicit suicidal intent even in children as young as 6 years (Jacobsen et al., 1994). Suicide intent involves the balance between the wish to live and the wish to die (Beck, Schuyler, & Herman, 1974; Beck, Kovacs, & Weissman, 1979a). Pervasive suicidal ideation increases the likelihood of planning suicide and usually is associated with a psychiatric disorder. An essential part of an evaluation of suicidal behavior is the determination of the availability of lethal means of carrying out suicidal impulses, such as the presence in the home of guns or firearms or knowledge of the availability of such weapons (Brent et al., 1991; 1993b).

During an evaluation, providers should strive to use a calm, reassuring, and caring tone of voice. Awareness of nonverbal cues, such as facial expression, arm placement, and sitting position in relation to the patient, can strengthen the quality of interview. Providers must ask interview questions in a manner that does not inadvertently convey a confrontational or accusing stance (Jacobsen et al., 1994). Display 29-1 provides examples of questions that clinicians may find useful when conducting this interview.

Any evaluation of suicidal risk factors must include a detailed interview about psychiatric symptoms and disorders. High-risk factors include history of mood disorders; symptoms of mania, hypomania, or mixed states of rapid cycling; anxiety disorders; substance use; conduct disorder;
and prior suicide attempt (Brent et al., 1987; Pfeffer, 1986; 1997).

Providers need to evaluate for several features of cognitive distortions, including hopelessness; psychotic distortions involving hallucinations, delusions, or paranoid ideation; poor self-esteem; perceptions of isolation; and problematic coping mechanisms associated with impulsivity. Several conditions that influence suicidal risk involve environmental stresses, including family discord, family history of suicide, and history of physical or sexual abuse. Family psychopathology also is important, particularly disturbances of mood, substance use, violence, and suicidal behavior (Brent, Bridge, Johnson, & Connolly, 1996; Brent, Moritz, Bridge, Perper, & Canobbio, 1996; de Wilde, Kienhorst, Diekstra, & Wolters, 1992; Gould, Fisher, Parides, Flory, & Shaffer, 1996; Pfeffer, 1997; Pfeffer et al., 1997; Pfeffer, Normandin, & Kakuma, 1994). Children and adolescents with conditions that may enhance depression and, perhaps, induce hopelessness, include such problems as diabetes, HIV, and epilepsy. Clinicians should evaluate regularly youth who have a diagnosis of chronic disease for signs of suicidal intent or behavior. They must identify precipitating factors in vulnerable youth, such as homosexual orientation, lack of a supportive peer group, loss of a boyfriend or girlfriend, failure in school, or isolation from social activities.