86 Suicidal behaviour in children and adolescents in different clinical settings

This chapter reviews the various clinical settings in which suicidal behaviours occur among children and adolescents. The chapter focuses on primary care settings (family or paediatric practices), emergency rooms, intensive care units, mental health outpatient departments and inpatient units. The authors discuss the need for early screening of suicidality and its risk factors, management of these high-risk children and adolescents and the different clinical interventions that are available. These interventions include psychosocial and medication treatments that have varying rates of success and still need more studies. In all clinical settings a multidisciplinary approach to treatment is recommended. The importance of risk assessment and continuity of care are highlighted.

Suicidal behaviours among children and adolescents occur in different clinical settings and contexts. These include primary care settings (family or paediatric practices), emergency rooms (ER), and intensive care units (ICU), both in general and psychiatric hospitals, mental health outpatient departments (OPD) and inpatient units.

Although there are several treatment methods targeting suicidal behaviour in adolescents, no treatment has been proven effective enough to permit its definition as the treatment of choice for suicidal teens. The different approaches to reducing suicidal behaviour include psychotherapy, psychosocial and medication treatments that have varying rates of success. Those treatments are described in this part of the book by Spirito in Chapter 92, Brent in Chapter 91 and Malone in Chapter 93.

Paediatricians are important gatekeepers in suicide prevention. Frequently, suicidal youth seek general medical care in the month preceding suicidal acts (Pfaff et al. 1999). These routine examinations are crucial for the early screening, management and referral of high-risk youth. Gatekeeper training is designed for the early identification of individuals at risk for suicide, facilitating timely referrals to mental health services (Pfaff et al. 2001). Mental health screening should be an essential part of the routine medical examination in primary practice. The screening should include questions regarding the signs and symptoms of childhood internalizing and externalizing disorders. Paediatric providers should be proactive and systematic in assessing suicide. Assessments must include direct inquiries about suicidal ideation and behaviour (Pfaff et al. 2001). Although depression is relatively common in paediatric settings, it often goes unnoticed. Therefore, improving physicians' recognition of depression and suicide risk will facilitate timely referrals for early treatment before complications arise.

Untreated internalizing disorders among children and adolescents tend to become chronic conditions with considerable morbidity. There are currently evidenced-based treatments for uncomplicated depression and anxiety for children and adolescents. These include cognitive behavioural therapy (CBT) (Brent et al. 1997; Compton et al. 2004) and interpersonal psychotherapy (IPT-A) (Mufson et al. 1999, 2004). In addition, pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) can be very useful for both disorders (The Research Unit on Pediatric Psychopharmacology Anxiety Study Group 2001; March et al. 2004). When untreated, many of these children and adolescents will become highly predisposed to suicidal behaviour and completed suicide.

Externalizing disorders are also a risk factor for suicidality (Brent et al. 1993; Renaud et al. 1999). These include a myriad of problems related to conduct disorders, attention deficit disorders and psychosexual disorders. Paediatricians and specialists in adolescent medicine should be trained in diagnosing sexual and physical abuse, as well as the early stages of drug and alcohol abuse. Moreover, they should learn to detect the physical signs of self-injury (e.g., cutting) and disordered eating. For youth, these disorders are often the harbingers of a spectrum of high-risk behaviours that include suicide.

Young people are commonly seen in the ER following suicidal behaviour. ER and other crisis staff should be trained in communicating with suicidal teens to optimize diagnosis and treatment. Staff members should be able to establish rapport with the suicidal individual and their family, and should be educated about the importance of treatment. There are no randomized controlled trials to determine whether hospitalizing high-risk suicide attempters saves lives. Clinicians, however, should be prepared to admit suicide attempters who express a persistent wish to die or who have a clearly abnormal mental state. Regardless of the apparent mildness of the patient's suicidal behaviour, the clinician must obtain information from a third party. Discharge can be considered only when the patient's mental state and suicidality have been stabilized and a reasonable degree of safety is assured. The clinician should assure that adequate supervision and support will be available for the patient (Brent 1997; American Academy of Child and Adolescent Psychiatry 2001).

The use of firearms is the most common method for adolescents who complete suicide (Gould et al. 2003). Ingestion of medication is the most common method for adolescents who attempt suicide (CDC 1995). Availability and presence of firearms and lethal medication at home must be determined during assessment, and parents must be explicitly told to remove firearms and lethal medication (Brent et al. 1991). It is also valuable for the clinician to warn adolescents and their parents about the dangerous disinhibiting effects of alcohol and other drugs.

Increased risk of suicide potential in a child or adolescent includes a previous attempt, an intent to attempt, a lethal plan, precautions against being rescued, accessibility of lethal means (especially guns) and probability of alcohol use (Shaffer et al. 1996; Gould et al. 1998). Additional features of high-risk clinical scenarios in a child or adolescent include suicide pacts with peers, desire to join a deceased friend or relative, inadequate parental supervision and support, and inability of the child or adolescent to agree to an explicit verbal or written no-suicide contract with the clinician. The value of ‘no-suicide contracts’, in which the child or adolescent agrees not to engage in self-harming behaviour and to tell an adult if they are having suicidal urges, is unknown (Reid 1998). The child or adolescent might not be in a mental state to accept or understand the contract. Even after a contract has been signed by the teen, the family and clinician should maintain their vigilance (Apter 2001).

Before discharge from the ER, an appointment should be scheduled for the child or adolescent to be seen for a thorough evaluation and a follow-up plan. If this is not possible, a telephone contact with a parent or other caretaker should be scheduled. If the clinical staff has not been contacted by the parent/caretaker within a reasonable period of time, they should initiate contact. The clinician treating the suicidal child or adolescent during the days following an attempt should have experience managing suicidal crises, be available to the patient and family (e.g., initiate and receive phone calls beyond therapeutic hours), and have support available for him or herself. A referral to a specific therapist and continued contact with the child and family until a therapeutic alliance is established increases the likelihood that the patient will continue treatment.

Few studies have examined serious suicide attempts in adolescents. The most well-known study is the Canterbury (New Zealand) Suicide Project (Beautrais et al. 1996), which is a case–control study of 200 suicide cases, 302 medically serious suicide attempts and 1028 randomly selected control subjects. Participants were aged 13–24 with a mean age of 19.4. The gender ratio was consistent among all groups. Nearly equal numbers of males and females made serious suicide attempts. Twice as many females used overdose than males, who used CO poisoning and hanging. Low income and residential mobility were highly associated with a serious attempt. Serious attempt was also associated with childhood sexual abuse, low parental care and poor parental relationship. There was also an elevated risk for mood disorder, substance abuse and conduct disorder. In addition, legal problems and difficulties with interpersonal relationships, work and finances made a significant contribution to risk of a serious suicide attempt (Beautrais, 1998). Although no gender differences were revealed regarding the seriousness of the suicide attempt, differences were depicted between suicide attempters who were admitted to ICU compared with those who were not.

Subjects with more severe suicide attempts were characterized with lower levels of self-disclosure. Self-disclosure is comparatively more limited in males. Impaired ability of self-disclosure was found to be associated with loneliness, psychiatric illness, anxiety and aggression, which are associated with suicidal behaviours (Apter and Ofek 2001). Thus limited ability of self-disclosure may indicate the necessity of psychological intervention that focuses on intimate interpersonal relationships and the ability to share feelings with others.

Mental health OPDs usually encounter youth with past suicide attempts and/or current suicidal ideation. Thus the OPD is responsible for the management of suicidality. Despite the magnitude of the problem and the volume of youth suicide research, there is no specific treatment that has been proven effective for suicidal behaviour among adolescents in outpatient settings.

Research indicates that the two most prominent risk factors for both completed suicide and suicidal behaviour in adolescents are past suicide attempt and a diagnosis of a depressive disorder, each independently contributing at least a 10–30-fold increased risk for completed suicide (Gould et al. 1996; Shaffer et al. 1996).

Although the evidenced-based literature is scarce, most OPDs provide a multidimensional treatment approach involving clinical (psychological and pharmacological) interventions, common sense and supportive therapy. This approach has proven sufficient in most cases and is recommended.

Suicidal behaviours are among the major reasons for admission to an adolescent inpatient unit in different parts of the world (Cohen et al. 1997). The prevalence of suicidal behaviour among inpatients is high (Robbins and Alessi 1985). Adolescent inpatients usually have a history of repeated suicide attempts and subsequent psychiatric hospitalization (Pfeffer et al. 1988; Cohen et al. 1997).

Studies have indicated that mortality rates among males are excessively higher than among females (e.g. Gould et al. 1998). As mentioned above, affective disorders (especially depression), schizophrenia, eating disorders (anorexia nervosa and bulimia nervosa) and borderline personality disorder are all associated with significant increased risk for suicidal behaviour (e.g. Shaffer et al. 1996; Gould et al. 1998). Serious psychiatric disorders in adolescence that require hospitalization compound suicidal risk, especially if accompanied by other risk factors for suicide and another diagnosed psychiatric disorder. In our own clinical practice we have identified four comorbid constellations that may be highly related to suicide in adolescent populations, requiring vigorous psychiatric intervention:

A multidisciplinary approach to treatment is recommended for suicidal patients. This includes formalized suicide assessment (done conjointly by medical and nursing staff), accurate psychiatric and medical diagnosis, psychotherapeutic and/or pharmacotherapy treatment, flexible and skilled observation policy, inpatient groups focusing on risk factors and triggers of suicidal behaviour, and a referral to continuing treatment once the patient is discharged. Prevention of suicidal behaviours in adolescent inpatients mostly involves treatment of the underlying psychiatric illness and the provision of sufficient after care following discharge. Lack of continuity of care places patients at an elevated risk for additional suicide attempts (Hulten and Wasserman 1998). When referring a suicidal patient, it is critical to highlight the strategies and skills acquired by the patient and identify those that are lacking.

Two prominent risk factors for both completed suicide and suicidal behaviour in adolescents are previous suicide attempts and a diagnosis of a depressive episode. Adolescents with different degrees of suicidal risk and severity are referred and/or admitted to various clinical settings. Research has yet to clearly identify the treatment of choice for suicidal patients. Regardless, clinical interventions should be based on a thorough suicide-risk assessment. Treatment strategies should be multidimensional, targeting suicidal behaviour as well as the underlying psychiatric illness and/or other personality and environmental risk factors. Given that adolescents are referred from one clinical setting to another, continuity of care (e.g. recommendation for after care, a concrete referral and a telephone follow-up) must be one of mental health practitioners' major concerns. Lack of continuity of care places patients at an elevated risk for additional suicide attempts.