Diagnosis of childhood and adolescent suicidal behavior: unmet needs for suicide prevention

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

The association between anxiety and internet addiction among left-behind secondary school students: the moderating effect of social support and family types

BACKGROUND

The left-behind children (LBC), children and adolescents aged 0-18 whose parents have migrated for economic purposes for extended periods exceeding three months, present a unique social concern. These children remain in their place of household registration, often under the guardianship of relatives, while receiving compulsory education. LBC with growing Internet addiction (IA) have made it urgent to take a close look at the mechanisms and effective interventions for them. Anxiety has been proven to be correlated with IA in adolescents; however, the mechanisms of addiction in this population are less well-fully grasped. Based on the current theories and empirical results, the study examined whether and how social support (SS) and family types moderated the associations between anxiety and IA among left-behind secondary students.

METHODS

Stratified cluster sampling survey. A questionnaire was administered to 5290 secondary school children (2553 classified as left-behind) to explore the relationships between anxiety, IA, left-behind types, family types, and social support. This cross-sectional study employed a stratified cluster sampling survey of students in the ethnic areas of southeast Chongqing. The study sought to appraise the relationships between anxiety and IA in different types of left-behind children and to assess the potential moderating effect of SS on the relationship among the population and its family types differences.

RESULTS

The relationship between anxiety and IA was moderated significantly by social support and family types. Notably, the impact of social support on the moderating effect between IA and anxiety varied among students from both family types. For students from families where both parents had migrated, social support weakened the association between IA and anxiety. Conversely, for students from single-parent families where the parent had migrated, social support seemed to strengthen the relationships between these two issues.

CONCLUSIONS

The moderating effects of SS on the relationship between anxiety and IA differs based on family type among various groups of left-behind secondary students. Gaining insights into the IA mechanisms can guide the development of targeted intervention strategies aimed at minimizing IA among diverse groups of left-behind students.

Validation of the Spanish ASQ translation: Screening pediatric patients for suicide-risk in Argentina

BACKGROUND

The high frequency of suicide risk in adolescents necessitates the development and validation of specific tools for systematic screening. To date, there are translated, but not validated suicide risk screening tools in Spanish.

OBJECTIVE

To validate the Spanish version of the Ask Suicide-Screening Questions (ASQ) for suicide risk screening in pediatric patients in Argentina.

METHOD

Using a cross-sectional multicenter design, a convenience sample of pediatric patients aged 10 to 18 years old were recruited from outpatient/inpatient medical settings and private psychiatric clinics. The Spanish version of the Suicidal Ideation Questionnaire (SIQ) assessment tool was used as a standard criterion to validate the ASQ.

RESULTS

A total of 301/380 pediatric patients were screened for suicide risk. Twentyeight percent of the entire sample (83/301) of youth screened positive on the ASQ, and 21% (62/301) screened positive on the SIQ/SIQ-JR and were considered "at risk" for suicide. Compared with the SIQ, the Spanish ASQ yielded a sensitivity of 96.8% (95% Confidence Interval [CI]: 88.8-99.6%), specificity of 90.4% (95% CI: 85.9-93.8%), positive predictive value of 72.3% (95 CI: 61.4-81.6%), and negative predictive value of 99.1% (95% CI: 96.7-99.9%). The positive Likelihood Ratio (LR) was 10.1 (95% CI: 6.1-14.0), and the negative LR was 0.03 (95% CI: -0.01-0.09). Kappa was 0.77 (95% CI: 0.69-0.86), and the Area Under the Curve was 0.94 (95% CI: 0.91-0.97).

CONCLUSION

The Spanish language ASQ demonstrated strong psychometric properties, providing initial evidence that it is a valid tool for identifying Spanish-speaking youth at risk for suicide.

Psychosocial Aspects of Deliberate Physical Suicide Attempts by Children and Adolescents

Suicide is the second most common cause of death among young people in Lithuania. This study aimed to evaluate circumstance, and conditions possibly related to suicide attempt in adolescents. Study was performed at the tertiary Children's Hospital. Medical documentation of the suicide attempts from January 2011 to April 2018 was analyzed. There were 102 cases included in the study: 83.8% female and 16.2% male patients (average age of 15.02 ± 1.9); 40.6% of patients lived in divorced families, 17.7% in orphanages, 4.2% in foster care; 36.4% suffered from parental alcoholism, and 17.2% experienced suicide in close surroundings; 54.1% experienced bullying or violence (26.0%), and 85.4% showed signs of other types of self-harm, girls more often (P < .001). In 52.8% of cases, the attempt was spontaneous, and 34% relapsed. In summary female gender, living in orphanages, and signs of other self-harm were significantly related to suicide attempt.

Characterization of Suicide and Deliberate Self-Harm Among Children in the United States

We analyzed data from the Nationwide Emergency Department Sample (NEDS) database for the years 2008 to 2013 to characterize deliberate self-harm among children and adolescents presenting to an emergency department (ED) in the United States. All ED visits for patients aged 19 years or younger involving any self-inflicted injuries were selected. We identified 594 658 ED visits involving self-harm. The majority of patients were female (65.8%), and between ages 16 and 19 years (62.6%). Most were treated and released from the ED (44.9%). The most common mechanisms involved injury by cutting/piercing instruments (26.4%) or poisoning by analgesics or antipyretics (21.5%). There was decrease in ED visits involving 16 to 19 year olds (-8%), and an increase in visits involving 13 to 15 year olds (+45%), 11 to 12 year olds (+94%), and 10 year olds or younger (16%). Our findings highlight a new vulnerable younger population at risk for self-inflicted injuries.

Association of aggression and suicide behaviors: A school-based sample of rural Chinese adolescents

BACKGROUND

To determine the prevalence of suicide behaviors and the associations between aggression and suicide behaviors among a nationwide school-based sample of adolescents in rural China.

METHODS

A total of 16,271 students from 24 junior and 23 senior high schools in five provinces of China participated in a self-administered anonymous survey to report suicide ideation, plans, attempts, aggression and other related information. Multivariable logistic regression models were used to investigate the associations between aggression and the risks of suicide behaviors while controlling for potential confounders.

RESULTS

The prevalence of suicide ideation, plans, and attempts during the past one year was 15.1%, 7.2%, and 3.5% respectively. In the fully adjusted model, participants with high level of total aggression had 4.31 times (95% CI, 3.69-5.05), 4.10 times (95% CI, 3.26-5.11), and 3.29 times (95% CI, 2.62-4.93), higher risk of suicide ideation, plans, and attempts, respectively, compared with subjects who had low level of total aggression. Moreover, high levels of all the five dimensions of total aggression also had positive associations with suicide behaviors.

LIMITATIONS

This study was cross-sectional. Hence, the causal link between aggression and suicide behaviors should be verified in the future studies.

CONCLUSIONS

This study suggests that aggression may be a risk factor for suicide behaviors among rural Chinese adolescents. Our findings highlight the importance of aggression treatment in suicide prevention programs. Further longitudinal studies are needed to confirm these associations.

Postdischarge Suicide and Death in South Korean Children and Adolescents Hospitalized for a Psychiatric Illness

OBJECTIVE

The postdischarge suicide rate in children and adolescents ever hospitalized for a psychiatric illness is much higher than that of children and adolescents in the general population. We aimed to investigate the postdischarge death and suicide among children and adolescents hospitalized for a psychiatric illness using the Korean National Health Insurance database and causes of death statistics from the National Statistics Office.

METHOD

We identified children and adolescents less than 18 years of age who experienced at least one psychiatric hospitalization from 2008 to 2013 with a principal diagnosis of a psychiatric disorder based on the International Classification of Diseases, 10th Revision, Code Fxx.x). Postdischarge deaths (all-cause death or suicide) after the first psychiatric hospitalization were investigated.

RESULTS

The total number of patients hospitalized for a psychiatric illness was 14,097, and the numbers of all-cause deaths and suicide deaths after discharge were 93 and 64, respectively. The rates of suicide according by diagnostic group were 440.1 (per 100,000 person-years) for psychosis, 248.8 for depression, 155.4 for conduct disorder, 153.6 for bipolar disorder, 103.4 for posttraumatic stress disorder, 93.0 for anxiety disorder, and 38.4 for attention-deficit/hyperactivity disorder.

CONCLUSION

As suicide is the main cause of postdischarge death, there is an urgent need to develop and implement effective prevention strategies after psychiatric hospitalization.

Understanding Suicide Across the Lifespan: A United States Perspective of Suicide Risk Factors, Assessment & Management

Suicide is a troubling, preventable phenomenon. Prior to attempts, individuals often seek help, prompting practitioners to perform risk assessments that ideally use evidence-based risk management strategies. A literature review was performed using Harvard Countway Library of Medicine, Google Scholar, PubMed. Key words used were "Forensic Science," "Suicide Risk Management," "Pediatric Suicide Risk Factors," "Adult Suicide Risk Factors," "Geriatric Suicide Risk Factors," "Suicide Risk Assessment." Parameters limited articles to studies/reviews completed in the past twenty years in the United States. Results indicated predictors of suicide in juveniles were insomnia, burdensomeness, and recent conflicts with family or a romantic partner. Adults had greater risk if male, substance abusing, with marital/job loss. Elderly individuals with multiple medical comorbidities, hopelessness, and isolation were at higher risk. Everyone evaluated should be screened for access to firearms. Management of suicide risk involves providing the least restrictive form of treatment which maintains an individual's safety.

Clinical characteristics and precipitating factors of adolescent suicide attempters admitted for psychiatric inpatient care in South Korea

OBJECTIVE

We aimed to examine the rates, correlates, methods, and precipitating factors of suicide attempts among adolescent patients admitted for psychiatric inpatient care from 1999 to 2010 in a university hospital in Korea.

METHODS

The subjects consisted of 728 patients who were admitted for psychiatric inpatient care in a university hospital over a 12-year period and who were aged 10-19 years at the time of admission. We retrospectively investigated the information on suicidal behaviors and other clinical information by reviewing the subjects' electronic medical records. Whether these patients had completed their suicide on 31 December 2010 was determined by a link to the database of the National Statistical Office.

RESULTS

Among 728 subjects, 21.7% had suicidal ideation at admission, and 10.7% admitted for suicidal attempts. Female gender, divorced/widowed parents, and the presence of mood disorders were associated with a significantly increased likelihood of suicide attempts. Most common method of suicide attempts was cutting, and most common reason for suicide attempts was relationship problems within the primary support group. A diagnosis of schizophrenia was associated with increased risk of death by suicide after discharge.

CONCLUSION

These results highlight the role of specific psychosocial factor (e.g., relational problems) and psychiatric disorders (e.g., mood disorders) in the suicide attempts of Korean adolescents, and the need for effective prevention strategies for adolescents at risk for suicide.

A randomized controlled pilot trial of classroom-based mindfulness meditation compared to an active control condition in sixth-grade children

The current study is a pilot trial to examine the effects of a nonelective, classroom-based, teacher-implemented, mindfulness meditation intervention on standard clinical measures of mental health and affect in middle school children. A total of 101 healthy sixth-grade students (55 boys, 46 girls) were randomized to either an Asian history course with daily mindfulness meditation practice (intervention group) or an African history course with a matched experiential activity (active control group). Self-reported measures included the Youth Self Report (YSR), a modified Spielberger State-Trait Anxiety Inventory, and the Cognitive and Affective Mindfulness Measure -Revised. Both groups decreased significantly on clinical syndrome subscales and affect but did not differ in the extent of their improvements. Meditators were significantly less likely to develop suicidal ideation or thoughts of self-harm than controls. These results suggest that mindfulness training may yield both unique and non-specific benefits that are shared by other novel activities.

Suicidal ideations and sleep-related problems in early adolescence

AIMS

Suicidal ideation and sleep-related problems are associated with many common psychopathological entities in early adolescence. This study examined possible association between suicidal ideation and sleep-related problems.

METHODS

A cross-sectional study was performed in classroom settings at 840 early adolescents 11-13 years of age. Of those, 791 adolescents fully completed the data and thus represent an actual sample. Suicidal ideations were assessed with three dichotomous (yes/no) items: 'I often think about death'; 'I wish I was dead'; 'I often think about suicide.' A composite measure of perceived sleep-related problems was formed by combining items from the Junior Eysenck Personality Questionnaire (Do you find it hard to sleep at night because you are worrying about things?), Children Depression Inventory (It is hard for me to fall asleep at night), and two additional dichotomous questions (I often was not able to fall asleep because of worrying; At times I was not able to stay asleep because of worrying). This score mainly assessed difficulties in initiating or maintaining sleep.

RESULTS

A total of 7.1% adolescents reported suicidal ideation and 86.7% of them had sleep problems. Sleep-related problems were associated with any suicidal ideation and each type of ideation separately.

CONCLUSION

This study suggests association of sleep problems and suicidal ideations in early adolescence. Therefore, clinicians should evaluate this population for sleep disturbances, as they might be a marker of increased risk for suicidality.

Association of positive responses to suicide screening questions with hospital admission and repeated emergency department visits in children and adolescents

OBJECTIVES

Although validated suicide screening tools exist for use among children and adolescents presenting to emergency departments (EDs), the associations between screening positive for suicide risk and immediate psychiatric hospital admission or subsequent ED use, stratified by age, have not been examined.

METHODS

This is a retrospective cohort study of a consecutive case series of patients aged 8 to 18 years presenting with psychiatric chief complaints during a 9-month period to a single urban tertiary care pediatric ED. Eligible patients were administered a subset of questions from the Risk of Suicide Questionnaire. Outcomes included the odds of psychiatric hospitalization at the index visit and repeated ED visits for psychiatric complaints within the following year, stratified by age.

RESULTS

Of the 568 patients presenting during the study period, responses to suicide screening questions were available for 442 patients (78%). A total of 159 (36%) of 442 were hospitalized and 130 (29%) of 442 had 1 or more ED visits within the following year. The proportion of patients providing positive responses to 1 or more suicide screening questions did not differ between patients aged 8 to 12 years and those aged 13 to 18 years (77/154 [50%] vs 137/288 [48%], P = 0.63). A positive response to 1 or more of the questions was significantly associated with increased odds of psychiatric hospitalization in the older age group [adjusted odds ratio, 3.82; 95% confidence interval, 2.24-6.54) and with repeated visits to the ED in the younger age group (adjusted odds ratio, 3.55 95% confidence interval, 1.68-7.50).

CONCLUSIONS

Positive responses to suicide screening questions were associated with acute psychiatric hospitalization and repeated ED visits. Suicide screening in a pediatric ED may identify children and adolescents with increased need of psychiatric resources.

Parental involvement in the war in Croatia 1991-1995 and suicidality in Croatian male adolescents

Aim

To investigate the association between parental war involvement and different indicators of psychosocial distress in a community sample of early adolescents ten years after the war in Croatia 1991-1995.

Methods

A total of 695 adolescents were screened with a self-report questionnaire assessing parental war involvement, sociodemographic characteristics, and alcohol and drug consumption. Personality traits were assessed with the Junior Eysenck Personality Questionnaire; depressive symptoms with the Children’s Depression Inventory (CDI); and unintentional injuries, physical fighting, and bullying with the World Health Organization survey Health Behavior in School-aged Children. Suicidal ideation was assessed with three dichotomous items. Suicidal attempts were assessed with one dichotomous item.

Results

Out of 348 boys and 347 girls who were included in the analysis, 57.7% had at least one veteran parent. Male children of war veterans had higher rates of unintentional injuries (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.56 to 2.63) and more frequent affirmative responses across the full suicidal spectrum (thoughts about death – OR, 2.1; 95% CI, 1.02 to 4.3; thoughts about suicide – OR, 5; 95% CI, 1.72 to 14.66; suicide attempts – OR, 3.6; 95% CI, 1.03 to 12.67). In boys, thoughts about suicide and unintentional injuries were associated with parental war involvement even after logistic regression. However, girls were less likely to be affected by parental war involvement, and only exhibited signs of psychopathology on the CDI total score.

Conclusion

Parental war involvement was associated with negative psychosocial sequels for male children. This relationship is possibly mediated by some kind of identification or secondary traumatization. Suicidality and unintentional injuries are nonspecific markers for a broad range of psychosocial distresses, which is why the suggested target group for preventive interventions should be veteran parents as vectors of this distress.

Self versus maternal reports of emotional and behavioral difficulties in suicidal and non-suicidal adolescents: an Israeli nationwide survey

There is relatively little research addressing parent-adolescent agreement as regards to reporting on adolescent suicidal behavior in general and their behavioral and emotional difficulties in particular. The objective of this study was to compare maternal and adolescents' reports on behavioral and emotional difficulties among adolescents with and without suicidal behavior. This nationally-representative sample included 906 adolescents and their mothers. The mothers and adolescents were interviewed and evaluated separately using the Development and Well-Being Assessment Inventory (DAWBA) and the Strengths and Difficulties Questionnaire (SDQ). Self-rated SDQ scores of the suicidal adolescents were significantly higher in all SDQ problem scales compared to the non-suicidal participants. In contrast, maternal-rated SDQ assessments failed to discriminate between these groups, except the Hyperactivity scale. We demonstrated that mothers of suicidal adolescents in the community hardly recognize the emotional and behavioral difficulties of their offsprings.

CONCLUSION

The mental examination of the adolescent patient should be maintained as the central and most reliable source of information regarding the suicidal adolescent. Mental health services planning of national suicide prevention programs should take into account these poor mother-adolescent agreement findings.

Early adolescence and suicidal ideations in Croatia: sociodemographic, behavioral, and psychometric correlates

BACKGROUND/AIMS

Suicidal ideations (SI) indicate and predict psychological distress. We examined the prevalence of SI among early adolescents and its association with parental war participation, personal, behavioral, and sociodemographic characteristics.

METHODS

We performed a cross-sectional questionnaire study on 803 12-year-old adolescents. Data were collected using a sociodemographic questionnaire, the Junior Eysenck Personality Questionnaire and Children Depression Inventory. Unintentional injuries, physical fighting, and involvement in bullying behavior were assessed using questions from the World Health Organization (WHO) survey Health Behavior in School-aged Children. Suicidal ideations were assessed with three dichotomous items.

RESULTS

There were no gender differences in SI prevalence. SI in males were associated with lower maternal education, crowded families, birth order, parental war participation, physical fighting, being bullied, and substance use. In females, we found associations with lower parental educational level, number of brothers, lower perception of the relationship with parents, parental relationship, family cohesion and parental control, negative attitude toward school, rare church attendance, fighting, and being bully or bullied. Depressive symptoms and SI were associated in both genders.

CONCLUSIONS

SI showed gender-specific associations that may partially be explained with parental war involvement. These findings may have potentially important clinical and preventive implications.

Reasons for living and their moderating effects on Korean adolescents' suicidal ideation

The present study validated the use of the Korean version of the Reasons for Living Inventory for Adolescents (KRFL-A) in a group of 406 South Korean high school students. Confirmatory factor analysis confirmed the original 5-factor and other psychometric properties demonstrated the usefulness of the KRFL-A as a measure of cognitive protective factors. Hierarchical regression analyses revealed that the KRFL-A total significantly moderated the impact of depressive symptoms on suicidal ideation. More specifically, the Family Alliance subscale among boys and the Peer Acceptance and Support subscale among girls moderated the relationships between depressive symptoms and suicidal ideation. This suggests that for Korean adolescents, gender-specific strategies are needed for more effective suicide interventions.

Short- and long-term functional consequences of fluoxetine exposure during adolescence in male rats

BACKGROUND

Fluoxetine (FLX), a selective serotonin reuptake inhibitor, is prescribed for the treatment of major depressive disorder in young populations. Here, we explore the short- and long-term consequences of adolescent exposure to FLX on behavioral reactivity to emotion-eliciting stimuli.

METHODS

Adolescent male rats received FLX (10 mg/kg) twice daily for 15 consecutive days (postnatal days 35-49). The influence of FLX on behavioral reactivity to rewarding and aversive stimuli was assessed 24 hours (short-term) or 3 weeks after FLX treatment (long-term). A separate group of adult rats was also treated with FLX (postnatal days 65-79) and responsiveness to forced swimming was assessed at identical time intervals as with the adolescents.

RESULTS

Fluoxetine exposure during adolescence resulted in long-lasting decreases in behavioral reactivity to forced swimming stress and enhanced sensitivity to sucrose and to anxiety-eliciting situations in adulthood. The FLX-induced anxiety-like behavior was alleviated by re-exposure to FLX in adulthood. Fluoxetine treatment during adolescence also impaired sexual copulatory behaviors in adulthood. Fluoxetine-treated adult rats did not show changes in behavioral reactivity to forced swim stress as observed in those treated during adolescence and tested in adulthood.

CONCLUSIONS

Treating adolescent rats with FLX results in long-lived complex outputs regulated by the emotional valence of the stimulus, the environment in which it is experienced, and the brain circuitry likely being engaged by it. Our findings highlight the need for further research to improve our understanding of the alterations that psychotropic exposure may induce on the developing nervous system and the potential enduring effects resulting from such treatments.

Patterns of injury and childhood psychiatric disorder in a low-income population

This study examined cross-sectional patterns of association between childhood psychiatric disorders and non-fatal injuries. The study population consisted of 763,251 youth between the ages of five and 18 years. Having any psychiatric diagnosis increased the odds of injury by a factor of two (OR = 2.12, CI 2.08-2.16). Strong associations were found between poisoning and unipolar depression (OR = 5.45, 95% CI 5.02-5.93), bipolar mood disorders (OR = 7.00, 95% CI 6.15-7.95) and major depression (OR = 9.63; 95% CI 8.51-10.89). Medicaid data provide an important resource to examine the intersection of psychiatric diagnosis and injury on a population basis.

Parent-adolescent agreement concerning adolescents' suicidal thoughts and behaviors

Information on history of suicidal thoughts and behaviors is critical in risk assessment, and multi-informant assessment has been recommended. Despite this, relatively little is known about parent-adolescent agreement regarding adolescent suicidality. To examine the extent and predictors of such agreement, 448 psychiatrically hospitalized adolescents and their parents were administered structured interviews assessing suicidal thoughts, plans, and attempts and completed measures of youth internalizing and externalizing behaviors, perceived family social support, and parental distress and psychopathology. Adolescents reported significantly more suicidal ideation, plans, and attempts than parents. Parental history of depression and adolescent perceived family support were associated with significantly greater agreement about suicidality. History of multiple suicide attempts was associated with greater disagreement about suicidality.

Predicting adolescent suicidality: comparing multiple informants and assessment techniques

Adolescent suicidality is a serious problem among American youth. Common risk factors for adolescent suicidality include depression and conduct problems but there is little agreement on the best means to assess these factors. We compared multiple informants (mothers, fathers, the adolescent and a sibling) and multiple assessment techniques using a sample of more than 460 families. Assessment techniques included paper-pencil instruments, observer ratings, and diagnostic interviews. Suicidality was assessed concurrently and two years after the risk assessment. Adolescent-reported paper-pencil instruments and diagnostic interviews were strongly associated with concurrent and future suicidality. Parents' report of adolescent feelings and behaviors were also useful. Observed behaviors were not useful in assessing suicidality risk factors. Clinical recommendations include utilizing paper-pencil and diagnostic adolescent risk factor assessment and focusing on emotions.

Suicide and suicidal behavior

Suicidal behavior is a leading cause of injury and death worldwide. Information about the epidemiology of such behavior is important for policy-making and prevention. The authors reviewed government data on suicide and suicidal behavior and conducted a systematic review of studies on the epidemiology of suicide published from 1997 to 2007. The authors' aims were to examine the prevalence of, trends in, and risk and protective factors for suicidal behavior in the United States and cross-nationally. The data revealed significant cross-national variability in the prevalence of suicidal behavior but consistency in age of onset, transition probabilities, and key risk factors. Suicide is more prevalent among men, whereas nonfatal suicidal behaviors are more prevalent among women and persons who are young, are unmarried, or have a psychiatric disorder. Despite an increase in the treatment of suicidal persons over the past decade, incidence rates of suicidal behavior have remained largely unchanged. Most epidemiologic research on suicidal behavior has focused on patterns and correlates of prevalence. The next generation of studies must examine synergistic effects among modifiable risk and protective factors. New studies must incorporate recent advances in survey methods and clinical assessment. Results should be used in ongoing efforts to decrease the significant loss of life caused by suicidal behavior.

Completed suicide in childhood

Suicide in children and young adolescents up to 14 years of age has increased in many countries, warranting research and clinical awareness. International reported suicide rates per 100,000 in this young population vary between 3.1 and 0 (mean rate worldwide, approximately 0.6/100.000; male-female ratio, 2:1). Suicide occurs only in vulnerable children; this vulnerability begins with parental mood disorder and impulsive aggression, and family history of suicide. Childhood affective and disruptive disorders and abuse are the most often reported psychiatric risk factors. Suicide becomes increasingly common after puberty, most probably because of pubertal onset of depression and substance abuse, which substantially aggravate suicide risk. Biologic findings are scarce; however, serotonergic dysfunction is assumed. The most common precipitants are school and family problems and may include actual/anticipated transitions in these environments. Suicides in children and young adolescents up to 14 years of age often follow a brief period of stress. Cognitive immaturity/misjudgment, age-related impulsivity, and availability of suicide methods play an important role. Psychologic autopsy studies that focus on suicides in this age group are needed.

Suicide in early childhood: a brief review

The rate of suicide in the United States among prepubertal children and young adolescents had increased by 120% from 1980 to 1992. From 1992 to the present the rate has decreased slightly by 33%. We address a brief review of the most relevant findings in literature that are related to the risk of suicide. Although the most reported findings were child mood disorder, any type of family distress and family history of suicide attempts, the severity of those does not seem to increase the risk of suicide. However, there were other environmental factors that may influence the risk of suicide, such as the access to firearms. It is critical to detect risk factors and triggers in prepubertal populations in order to reduce the incidence of suicide in this age group and older age groups.

Suicidality and correlates among rural adolescents of China

PURPOSE

Despite high rates of suicide in rural youths of China, little is known about the epidemiological characteristics of suicidal behaviors among this group of population. This study examined the prevalence and correlates of suicidality among Chinese adolescents.

METHODS

An epidemiological survey was conducted in a sample of 1,362 adolescents from 5 high schools in a prefecture of Shandong, China. We obtained data using a structured questionnaire asking about suicidal behaviors, life stress, locus of control, depression, aggression, and individual and family characteristics. Data were analyzed using logistic regression models.

RESULTS

Overall, 19% of the sample reported having suicidal ideation, and 7% reported having made a suicide attempt during the past 6 months. The prevalence rates of suicidal behaviors significantly increased over age. Female adolescents were more likely to report suicidal ideation than males, and older females (ages 16-18) were more likely to report suicide attempts than older males. Multivariate logistic regression models showed that female gender, older age, boarding in school, life stress, depression, and external locus of control were significantly associated with increased risk for suicidal ideation, while older age, life stress, external locus of control, poor academic performance, depression, and aggression were related to suicide attempts.

CONCLUSIONS

Suicidal behaviors are common problems in rural adolescents of China. Female adolescents are particularly prone to report suicidal ideation and suicide attempts as they age. Multiple psychosocial factors are associated with suicidal behaviors, and psychopathology and life stress may play major roles in suicidal behaviors among rural adolescents of China.

Psychopathology associated with suicide attempts among rural adolescents of China

This case control study examined the relationship between psychopathological profiles and self-reported suicide attempts among rural adolescents of China. Cases consisted of 142 adolescents who reported a suicide attempt in the past 6 months in a questionnaire survey (n=1365). An equal number of adolescents without reporting a suicide attempt, matched on age, gender, and school class, were selected from the same survey sample as controls. The Youth Self Report (YSR) was used to assess psychopathological profiles for suicide attempters and matched controls. Results indicated that 73% of suicide attempters had at least one behavioral/emotional syndrome, significantly higher than in controls (30%). Logistic regression analyses showed that anxiety/depression (OR = 3.68) and aggression (OR = 5.02) were each significantly associated with increased risk of suicide attempts after controlling for other behavioral problems. These findings demonstrated the independent contribution of anxiety/depression and aggression to suicide attempts in Chinese adolescents.

The child suicide risk assessment: a screening measure of suicide risk in pre-adolescents

This study documents the initial reliability and validity of the Child Suicide Risk Assessment (CSRA) for children under the age of 13. The revised CSRA retained 18 of 20 original items based on item-specific psychometric data from 140 pre-adolescents in out-of-home treatment programs. The CSRA demonstrated adequate internal consistency (alpha=.69) for a multi-dimensional scale (3 factors: Worsening Depression, Lack of Support, and Death as Escape). CSRA scores correlated significantly with criterion measures of prior suicide attempts and ideations. A receiver operating characteristic (ROC) curve discriminated significantly between prior attempters and non-attempters and was used to select preliminary CSRA cut-off scores for identifying substantial suicide risk. The CSRA is the first screening measure of suicide risk in pre-adolescents validated by associations with suicide attempts as well as ideations.

Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents

OBJECTIVE

To focus attention on the critical unmet needs of children and adolescents with mood disorders and to make recommendations for future research and allocation of healthcare resources.

METHOD

The 36-member Consensus Development Panel consisted of experts in child/adolescent or adult psychiatry and psychology, pediatrics, and mental health advocacy. Reviews of the literature concerning youth mood disorders were performed on the subjects of risk factors, prevention, diagnosis, treatment, and services delivery, and opinions and experiences of mental health advocates were obtained.

RESULTS

The Consensus Development Panel listened to presentations and participated in discussions. Independent workgroups of clinicians, scientists, and mental health advocates considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed by the entire group and edited to incorporate input from all participants.

CONCLUSIONS

Evidence suggests high rates of unmet needs for children and adolescents with depression or bipolar disorder. Training is largely limited to child mental health specialists; general psychiatrists, pediatricians, and other primary care physicians receive little or no training. As a result, treatment patterns may reflect adult treatment plans that are not validated for youths. Effective treatments have been identified and some preliminary prevention models have been developed, but they are not yet widely applied. Patients experience limited exposure to clinicians adequately trained to address their problems and little information to guide care decisions, particularly concerning bipolar disorder. National efforts are required to restructure healthcare delivery and provider training and to immediately develop more advanced research on pathophysiology, prevention, and services delivery effectiveness.

Suicidal ideations and attempts in juvenile delinquents

BACKGROUND

Suicidality among adolescents is a common focus of clinical attention. In spite of links to disruptive behaviors and other types of psychopathology, it is not clear whether other factors commonly associated with suicide, such as personality and parenting, predict suicidality over and above psychopathology. The purpose of the present study was to assess suicidal ideations and attempts and their relationship to psychopathology, violence exposure, personality traits and parental rearing in Russian male juvenile delinquents with conduct disorder (CD).

METHOD

Suicidality and psychopathology were assessed using a semi-structured psychiatric interview in 271 incarcerated male juvenile delinquents diagnosed with CD. Violence exposure, personality characteristics and perceived parental rearing were assessed via self-reports.

RESULTS

Thirty-four percent of those diagnosed with CD (92 subjects) reported a lifetime history of either suicidal thoughts or attempts. Suicidal ideators and attempters did not differ significantly on any variable of interest, but both reported significantly higher rates of psychopathology and violence exposure than the non-suicidal group, as well as higher levels of harm avoidance, lower self-directedness, and higher rates of perceived negative parental rearing. Finally, even when controlling for the relationship with psychopathology, personality and perceived parental rearing factors showed significant associations with suicidality.

CONCLUSIONS

Juvenile delinquents with CD have high rates of suicidal ideations and attempts, related to a wide spectrum of psychopathology and specific personality traits. These findings suggest that a combination of intrinsic and extrinsic factors create vulnerability to stressors, which under the influence of situational factors (e.g., repeated traumatization) may lead to suicidal thoughts and acts. Factors potentially contributing to vulnerability for suicidality should be identified when planning prevention and rehabilitation efforts for troubled youth.

Suicidality in children and adolescents: a review

Suicide and suicide attempts by children and adolescents continue to be a major public health problem in the United States. Major risk factors include a previous suicide attempt, a mood disorder, a family history of suicide, a parental psychiatric disorder, and a history of sexual abuse. Genetic vulnerability appears to be a factor as well. Efforts to prevent subsequent attempts at suicide have not generally been successful, and many children and adolescents are not receiving treatment for the mood disorders and other psychiatric conditions that are risk factors. Evaluation of suicide risk should be carried out through multiple informants, not simply the adolescent or the parents, although a thorough clinical interview of the adolescent is essential.