Suicidal Behaviors in Children and Adolescents

Assessing the lethality of an suicidal attempt (or gesture):

means (firearm v. overdose v. superficial cut);
privacy of attempt and probability of being discovered
prior attempt history
probability of being discovered; children may die even if they don't intend to kill themselves (e.g., if a child overdoses, then calls her friend to say she took the overdose, then hangs up, the friend may or may not take it seriously, may or may not call, and the child may die, so take all gestures seriously).

Most serious risk after suicide attempt is not for suicide but for major depression.

Serious suicidal intents are:

Carried out inisolation
Time so intervention unlikely
Precautions to avoid discovery
Preparation made for death, e.g., giving away things, writing a letter.

You must also assess the family. Risk is increased if the family response is:

Indifferent - family in a rush to get out of the hospital, not taking seriously.
punitive - "How could you do this to me? How could you embarrass me like that?"
minimizing - "Oh, he didn't really want to die."

Family stability

Family history

Hospitalization:

Necessary if:

child or adolescent actively wishes to die.
Family system is unresponsive;
Lethality assesment is high
Child's concept of dangerousness
Efforts (or lack of) toward discovery;
Impaired judgement (psychosis)
Accessibility of help

When in doubt, hospitalize: remember it's the clinician's responsibility for the safety of the patient, not the managed care or insurance company's (denial of payment should not override your clinical judgement).

Clustering = a contagion phenomenon leading to increase in suicidal behavior among adolescents, either because of suicide in the media or in one's family or community.

Suicide is rare among children under 10, but it does happen, so you should take the risk seriously. Even small children can hang themselves. Even a child who says, "I wish I never had been born," take this seriously.

Always consider issues of sexual orientation or "gender dysphoria" when exploring possible causes of suicidal attempts or ideation.

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