1. Associate Medical Director DMH
Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior
Laine Young-Walker, M.D.
Associate Medical Director DMH
Associate Training Director of Child and Adolescent Psychiatry Fellowship Program at University of Missouri-Columbia

2. Historical Review
• Until late 1950’s literature on suicide was confined to case reviews
• In the late 1950’s there was the first systematic psychological autopsy study done at Washington University (St. Louis)
These studies gave evidence for the importance of psychiatric disorder as the proximal cause of most suicides

3. Historical Review
• The 1960’s started a period of increasing suicides in young males
• By early 1980’s the suicide rate in white, male teenagers had more than doubled
• A task force of clinical and research experts convened by the US Dept of Health and Human Services to develop policies to reduce the rates of youth suicide

4. Historical Review
• There is substantial information on the characteristics of suicide victims
• There is less information about child and adolescent attempters
• There is little systematic evidence-based knowledge about the optimal treatment of the suicidal child or adolescent
• The suggestions by the PP are based on experience and clinician observations due to the lack of substantial research

5. Suicide Epidemiology
• 1997 suicide mortality rate for y/o’s was 1.6 per 100,000
• 1997 suicide mortality rate for y/o’s was 9.5 per 100,000 (boys 15.2 per 100,000; girls 3.4 per 100,000)
• 1997 suicide mortality rate for y/o’s was 13.6 per 100,000

6. Suicide Epidemiology
1) What ranking does suicide have as a cause of death in teens?
2) Who attempts suicide more frequently (males or females)??
3) Who commits suicide more frequently (males or females)??

7. Suicide Epidemiology
• 2000 adolescents (13-19) commit suicide each year
• Suicide is the 3rd leading cause of death in teens
• The ratio of male to female suicide in: young children is 3:1
fifteen to nineteen year olds is 4.5:1
twenty to twenty-four year olds is 6:1

8. Suicide Epidemiology • Males are more likely to commit suicide
• Females are more likely to attempt suicide

9. Suicide Epidemiology
• Between early 1960’s and late 1980’s the suicide rate among year old males increased threefold
• What do you think are reasons for this increase?

10. Suicide Epidemiology
• Suggested reasons for increase in suicidal behavior among teenage boys are increased availability of firearms and increased substance use
• Loaded guns were risk factors for the small number of suicides without diagnosed psychopathology

11. Suicide Epidemiology
• Teen suicide rates among whites reached a peak in 1987 and has since declined
• The African-American male suicide rate increased dramatically after 1986, but since 1994 it has declined
• What are your thoughts about the reason for the decline in rates??

12. Suicide Epidemiology
• Potential reasons for decline in suicide rates include
lowered substance and alcohol use rates among the young (CDC, 1998)
greatly increased prescribing of antidepressants to depressed individuals (largest increase in children/adolescent/young adults)

13. Suicide Epidemiology
1) Where do you think the highest rates of suicide are found (geographically)?
2) What is the most common method used for suicide completion?

14. Suicide Epidemiology
• Suicide rates are highest in western states and Alaska
• Firearms are the most common method by which Americans of all ages, ethnicities, and genders commit suicide
• The methods used to commit suicide show great geographic variation (may reflect availability)
• Ingestions account for 16% of year old female suicides but only 2% of suicides in males of that age

15. Suicide Epidemiology (Clinical Characteristics)
• Completed suicide occurs most commonly in older adolescents
• 90% of adolescent suicides occur in people with pre-existing psychiatric disorder
• Most common forms of psychiatric disorder in completed suicides
Mood disorder (in boys often co morbid with conduct d/o or substance abuse)
Substance and/or alcohol abuse

16. Suicide Epidemiology (clinical characteristics)
• Many children and adolescents who committed suicide were irritable, impulsive, volatile, and prone to outbursts of aggression
• Most adolescent suicides appear to be impulsive
• Suicide is often preceded by a stressful event
Trouble at school or with law
Ruptured relationship with boy/girl friend
Fight with friends

17. Suicide Epidemiology (clinical characteristics)
• It appears that suicide can be precipitated (in a presumably already suicidal youth) by exposure to news of another’s suicide or by reading about/viewing suicide portrayed in a romantic light
• One third of people who complete suicide have made a prior attempt (prior attempts more common in girls and in suicide where there is a mood disorder at the time of death)
• Suicide pacts are very uncommon in young people

18. Suicide Epidemiology
What are some risk factors?

19. Suicide Epidemiology • Risk factors include Psychiatric disorders
Psychosocial stressors
Cultural factors
Facilitating factors

20. Suicide Epidemiology (risk factors)
• Psychiatric Disorders
Controlled studies of completed suicide suggest similar risk factors for boys and girls but marked difference in their relative importance
Girls the most significant risk factor is the presence of major depression and the next is prior suicide attempt
For boys the most potent predictor is previous suicide attempt (increases risk over 30 fold) and the next is depression, substance abuse and disruptive behavior

21. Suicide Epidemiology (risk factors)
• Psychiatric Disorders (cont)
Disruptive disorders common in male teens who commit suicide
Disruptive disorder is commonly co morbid with mood, anxiety, substance abuse diagnosis
There is a greater risk for suicide in patients with schizophrenia

22. Suicide Epidemiology (risk factors)
• Psychosocial Stressors
Stressful life events often precede suicide and or an attempt
The stressor is rarely sufficient to cause suicide
The importance is that it can be a precipitating factor in youth already at risk due to their psychiatric condition
Controlled studies indicate low levels of communication between parent and children may be a significant risk factor

23. Suicide Epidemiology (risk factors)
• Cultural Factors
Since 1987 the difference in rates between young African Americans and whites have narrowed
Rate in AA and other minority males has increased rapidly, while rate in whites has been steady or declined
What do you think could be causes of the increase in AA and minority males??

24. Suicide Epidemiology (risk factors)
• Cultural Factors
Theories for the increase in AA suicide rates
Increased access to firearms
Weakened social support systems and weaker sense of group adherence
Increased secularism in AA youth

25. Suicide Epidemiology (risk factors)
• Facilitating Factors
Maladaptive attributes and coping styles
Parental psychopathology
Social-psychological factors
HIV-positive diagnosis and AIDS

26. Suicide Epidemiology (risk factors)
• Facilitating Factors (cont)
Maladaptive attributional and coping styles
Hopelessness is repeatedly found to be associated with suicidality
Biological factors is common in adult suicides (dysregulation of serotonergic system)
For Adolescents a preliminary small sample study found ¾ adolescent suicide attempters had CSF 5-HIAA concentrations that would indicate severe suicide risk in adults

27. Suicide Epidemiology (risk factors)
• Facilitating Factors (cont)
Parental psychopathology
Family history of suicidal behavior
Parental depression
Parental substance abuse

28. Suicide Epidemiology (risk factors)
• Facilitating Factors (cont)
Social-psychological factors
Suicide can be facilitated in vulnerable teens by exposure to real or fictional accounts of suicide (including media coverage)
Suicide clusters are 3 or more suicides that cluster in a particular locale in a three-month period (presumed to be related to imitation and usually involve adolescents or young adults)
Suicide clusters account for 1-5% of US teen suicides (small percentage)

29. Suicide Epidemiology (risk factors)
• Facilitating Factors (cont)
HIV-positive diagnosis and AIDS
It has been suggested that HIV infection increases the risk of suicide and suicidal behavior in adolescents and young-adult youth

30. Non-Lethal Suicidal Behavior Epidemiology
• Suicidal attempts—any behavior intended to end the child’s or adolescent’s life
• Parasuicide—nonfatal suicidal acts by ingestion, with non-lethal intent
• Each year 2 million US adolescents attempt suicide
• Each year almost 700,000 seek medical attention for their attempt

31. Non-Lethal Suicidal Behavior Epidemiology
• Suicide attempts in adolescence are twice as common in females as males
• Suicide ideation is very common among high school students
¼ females and 1/6 males have seriously considered suicide in a twelve-month period
Hispanic students of both sexes were more likely than whites or African Americans to have seriously considered suicide, made a plan, attempted suicide or made an attempt requiring medical attention
Reason for higher rate in Hispanic youth is unknown

32. Non-Lethal Suicidal Behavior Clinical Presentation
• Spectrum of severity ranges from suicidal ideation, suicide threats and attempts, to completed suicide

33. Non-Lethal Suicidal Behavior Clinical Presentation
• Suicidal ideation
Thoughts about wishing to kill one’s self; making plans; thoughts about the impact of one’s suicide on others
Not all children appreciate suicide may result in irreversible death (this should not influence the clinician in judging seriousness of the ideation)

34. Non-Lethal Suicidal Behavior Clinical Presentation
• Suicide threats
Utterances made to others that indicate an intent to commit suicide
May be accompanied by actions
In young child the most commonly this is a threat to jump out of a window, run into traffic, or to stab himself/herself

35. Non-Lethal Suicidal Behavior Clinical Presentation
• Methods of attempt
What is the most common method of attempt??

36. Non-Lethal Suicidal Behavior Clinical Presentation
• Methods of attempt
Majority are by ingestions
Most commonly OTC analgesics
Prevalence of superficial cutting and hanging is not known
Less common methods include
Hanging
Jumping from height
Stabbing
Drowning

37. Non-Lethal Suicidal Behavior Clinical Presentation
• Methods of attempt (cont)
The choice of attempt and completion method largely determined by opportunity
The following are predictive of further suicide-attempt behavior and ultimate death by suicide
Repeated attempts
Attempts by unusual methods (other than ingestion or superficial laceration)
Medically serious attempts

38. Non-Lethal Suicidal Behavior Risk Factors
• Risk factors for attempts in both genders are mood or anxiety disorders or substance abuse
• Diagnoses with increased risk for suicidal ideation or attempt
Panic attacks in girls
Disruptive behavior in boys
• It is likely that serious family disturbances increase the risk for attempted suicide
This is inferred from high incidence of suicide in abused children
The clinician should assess past/present suicidal ideation or behavior in cases where abuse is suspected

39. Non-Lethal Suicidal Behavior Risk Factors
• There is no evidence that minority sexual orientation (homosexuality)is more common in completed teen suicides than in controls
• There is strong evidence that gay, lesbian, and bisexual youth of both sexes are more likely to experience suicidal ideation and attempt
suicide
There are a higher number of risk factors
High rates of drug/alcohol abuse
More likely to be bullied or victimized at school

40. Non-Lethal Suicidal Behavior Risk Factors
• There are differences between how persons who complete and attempt suicide present
• For attempted suicide
Most evidence from emergency rooms
Most commonly y/o female who has taken small or medium sized overdose of a readily available medication (OTC or family members meds)
Usually impulsive
Occurs in context of dispute with family or boyfriend/girlfriend

41. Non-Lethal Suicidal Behavior Risk Factors
• Attempted suicide (continued)
Recently information has been collected from community based studies
Indicate suicide attempt rate in boys is higher in community than in patients presenting to the ER
• There have been few risk factor comparisons between completed and attempted suicides

42. Non-Lethal Suicidal Behavior Natural History
• Early onset suicidal behavior in prepuberty predicts suicidal behavior in adolescents
• Early onset MDD is associated with suicidal behavior in adolescents

43. Non-Lethal Suicidal Behavior Developmental Features
• The younger the child the less complex and more easily available are methods used to enact suicidal impulses
• Social adjustment problems of young suicide attempters is mainly due to disturbed relationships within the family

44. Non-Lethal Suicidal Behavior Developmental Features
• Social adjustment problems of adolescents is mainly peer related conflicts
• The ages of onset of psychiatric symptoms and disorders that increase risk for suicidal behavior in adolescents are more common in older adolescents
MDD, substance abuse, BAD, schizophrenia, personality d/o

45. Assessment
What is included in the assessment of suicide??

46. Assessment
• Requires evaluation of the suicidal behavior and determination of risk for death or repetition
• Also requires evaluation of underlying diagnosis or promoting factors

47. Assessment • In assessing the attempt, determine
Type of method employed (more unusual=worse prognosis)
Potential medical lethality (not always reliable predictor)
Degree of planning involved
Degree to which chance of intervention or discovery was minimized
Availability of firearms or lethal meds should be ascertained and recommended for removal

48. Assessment • Assess the person with suicide ideas
Question whether the child/adolescent is contemplating or has attempted suicide without anyone knowing
Evaluating presence and degree of intent is complicated
One approach is to evaluate motivating feelings
Ex: wish to gain attention, to effect change in interpersonal relationships, to rejoin a dead relative, to avoid an intolerable situation, to get revenge

49. Assessment
What are the risk factors for repeat suicide attempt or completed suicide??

50. Assessment
• Risk factors for repeat suicide attempt or completed suicide
Male gender
Increasing age
Living alone (homeless, runaway, isolated)
Previous attempts with method other than ingestion or superficial cutting and took steps to avoid detection

51. Assessment • Assessment of underlying conditions
Conditions that lead to suicidal behavior
Psychiatric diagnosis (depression, mania, hypomania, mixed states, rapid cycling, substances)
Social or environmental factors (isolation, anger, stress)
Cognitive distortions (hopelessness)
Inappropriate coping styles (impulsivity, catastrophizing)
History of family psychopathology
Family discord or other life-event stresses involving interpersonal relationship problems

52. Assessment
• Gather information from multiple sources and by varied developmentally sensitive techniques
Interviews, play and behavior observation, rating scales
• Children/adolescents are more likely to tell of suicidal ideation and actions than their parents

53. Treatment
1) So what do you do when you have a patient who is expressing suicidal ideations??
2) How do you proceed?

54. Treatment • Safety considerations is of over-riding importance
• Treatment should be provided within a ‘wrap around’ service delivery system (includes impatient, short and long term outpatient, and emergency intervention)

55. Treatment • Acute management
Hospitalize if condition makes behavior unpredictable
Examples of mental status features predictive of short term difficulty
Inability to form alliance with clinician
Lack of truthfulness or inability to discuss/regulate emotion and behavior
Psychosis
Intoxication from drugs or alcohol
Multiple prior serious suicide attempts

56. Treatment • Acute management
Diagnostic features indicating need for hospitalization
MDD with psychotic features
Rapid cycling with irritability and impulsive behavior
Psychosis with command hallucinations
Alcohol or substance abuse
Social factors affecting decision to hospitalize
Lack of sufficient environmental support to help stabilize the individual

57. Treatment •Emergency or Crisis Service Intervention
Never discharge from ER without caretaker verifying the patient’s account
Discuss making firearms and/or lethal meds inaccessible
Limiting access to alcohol or other potentially dis-inhibiting substances should be discussed
Arrange follow-up appointment

58. Treatment • Partial hospitalization and outpatient
Partial hospitalization is a good alternative if the child/adolescent is disturbed but containable in a supportive home or other residential setting
Outpatient is used when the child/adolescent is not likely to act on suicidal impulses, there is sufficient support at home, and someone can take action if the patients mood deteriorates

59. Treatment • Psychotherapy Aims to
decrease intolerable feelings and thoughts
Re-orient the cognitive and emotional perspectives of the suicidal patient

60. Treatment • Types of Psychotherapy
CBT—shown to be effective in adults; efficacy in adolescents not yet examined
Interpersonal—suicidal behavior in children/adolescents is frequently associated with interpersonal conflict; treatment of this may reduce suicidal risk
This therapy addresses interpersonal problems (loss, role disputes, role transitions, and interpersonal deficits)

61. Treatment • Types of Psychotherapy (continued)
DBT (dialectical-behavior therapy)--reduces suicidality in adults with BPD. Recently a modified and manualized form of this has been used with suicidal adolescents. Research suggests it is acceptable for teens and reduces hospitalization
Psychodynamic—no studies address efficacy
Family therapy—may decrease problems of family discord

62. Treatment • Psychopharmacological intervention
Lithium reduces suicide recurrence in adults
SSRI’s reduce suicidal ideation in adults
Studies not conducted in children/adolescents
In fact in last decade case reports of patients developing suicidal preoccupations has arisen
Monitor youth for increased agitation or suicidality

63. Prevention
Is prevention possible??

64. Prevention • Community based suicide prevention Crisis Hotlines
Research limited; failed to show impact on suicide
Method restriction (ex: reduce firearm access)
No evidence for significant impact
Indirect case finding through education
Ineffective mode of case finding
Direct case finding
An excellent and cost-effective way to identify possibly at risk children and adolescents
Media counseling