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

This article highlights strategies for diagnosing risk for childhood and adolescent suicidal behavior. Empirical studies identifying risk factors for childhood and adolescent suicidal behavior guided recommendations for suicide risk assessment. Diagnostic assessment involves identification of multiple factors including demographic characteristics, suicidal behavior, psychopathology, interpersonal problems, family discord, family psychopathology, accessibility of lethal suicide methods, exposure to suicide, and protective factors. Interview methods and self-report questionnaires are reliable and valid in identifying suicidal risk but are limited by low base rates of suicide. Identification of risk factors as foci for intervention is important for suicide prevention.

Suicidal behavior and hypothalamic-pituitary-adrenocortical axis indices in child psychiatric inpatients.

Studies of adults have reported associations between suicidal behavior and hypothalamic-pituitary-adrenocortical (HPA) axis functioning, but these associations were inconsistent. Very few studies of prepubertal children evaluating these relations exist. This study of 49 prepubertal psychiatric inpatients evaluates associations between suicidal behavior and predexamethasone and postdexamethasone plasma cortisol levels shortly after hospital admission and 7 weeks later. Results suggest that associations between suicidal behavior and plasma cortisol levels are independent of diagnosis. Covariation of predexamethasone and postdexamethasone plasma cortisol levels with major depression was associated with severity of suicidal behavior. Implications of these results for childhood suicidal risk are discussed.

Peripheral serotonin measures in prepubertal psychiatric inpatients and normal children: associations with suicidal behavior and its risk factors.

BACKGROUND: This study reports relationships between suicidal behavior and its risk factors in prepubertal children and whole blood and platelet serotonin-related measures. METHODS: Seventy-five prepubertal psychiatric inpatients including 23 (30.7%) nonsuicidal, 32 (42.7%) with suicidal ideation, and 20 (26.6%) with a suicide attempt were compared to 35 normal prepubertal controls with regard to platelet serotonin content, serotonin-amplified platelet aggregation, and whole blood tryptophan. RESULTS: Mean whole blood tryptophan content was significantly lower among inpatient children with a recent suicide attempt than among normal controls or inpatients with suicidal ideation (F = 3.94, df = 3.54, p < or = .01). Inpatient children with a mood disorder had significantly higher platelet serotonin content than inpatients without a mood disorder (F = 3.86, df = 2.80, p < or = .03). Racial/ethnic differences were also observed for inpatients and normal controls, with whites having significantly lower levels of platelet serotonin (expressed as ng/mL blood or ng/10(9) platelets) than blacks or Latinos. Blacks had significantly higher levels of whole blood tryptophan than other racial/ethnic groups. CONCLUSIONS: The results suggest that whole blood tryptophan and platelet serotonin content should be studied for their predictive validity as risk factors for suicidal behavior in youth while controlling for racial/ethnic differences.

Psychopathology and plasma cortisol responses to dexamethasone in prepubertal psychiatric inpatients.

This study of 51 prepubertal psychiatric inpatients evaluates plasma cortisol measurements at 8 AM, 4 PM, and 11 PM before and after dexamethasone was administered in counterbalanced order at doses of 0.5 mg and 1.0 mg. Approximately 76.5% of the children had an affective disorder. Major depressive disorder was associated with higher plasma cortisol levels than other disorders. Pre- and postdexamethasone plasma cortisol levels using 0.5 mg dexamethasone exhibited a circadian variation. The optimal criterion for cortisol nonsuppression was 5 micrograms/dl measured at 8 AM after administration of 0.5 mg dexamethasone.

Suicidal behavior of children: a review with implications for research and practice.

The author reviews the environmental and psychological factors associated with suicidal behavior of children aged 6-12 years; the incidence of such behavior seems to be increasing. Assessment of a child's suicide potential should focus on such issues as depression, family communication patterns, the child's concepts about death, and the state of ego functioning. The author emphasizes the need for more systematic investigations of suicidal behavior among children, more precise methods of interviewing and recognizing potentially suicidal children, and widespread education of the public about this life threatening

Sequelae of bereavement resulting from suicide.

Although clinical experience suggests that individuals who have been bereaved as a result of suicide may be especially vulnerable to adverse sequelae, such as unusually severe grief or increased risk of committing suicide themselves, the idea that this type of bereavement is special has received only limited systematic investigation. The authors review the literature on the subject, with special attention to the clinical and research evidence about whether bereavement resulting from suicide is different from bereavement due to other types of death, and make suggestions for further clinical and epidemiological research on this question.

Suicidal and assaultive behavior in children: classification, measurement, and interrelations.

In 102 children aged 6 to 12 years who were in a municipal psychiatric inpatient or outpatient clinic, the authors identified four groups of suicidal and/or assaultive behaviors. Logistic regression analyses showed that neurosis, intellectualization, and low levels of aggression predicted membership in the nonassaultive-nonsuicidal group; intense aggression, parental suicidal behavior, parental assaultive behavior, and compensation predicted it in the assaultive-suicidal group; depression, a minimum of aggression, and adjustment disorder predicted it in the suicidal-only group; and intense aggression and absence of depression predicted it in the assaultive-only group. Two clearly distinct types of suicidal children were delineated.

Predictors of assaultiveness in latency age children.

The authors evaluated the presence of assaultive behavior in 103 children, aged 6-12 years, seen in the psychiatric inpatient and outpatient services of a municipal hospital. No racial or ethnic differences were found. Boys were significantly more assaultive than girls and used fire setting and hitting with objects more often. Inpatients were significantly more assaultive than outpatients. Children with conduct disorders, specific developmental disorders, and mental retardation were more assaultive than those with neurotic disorders. Multiple regression analysis showed that the child's past aggressive behavior, absence of anxiety and depression, and parental assaultive behavior were the best predictors of assaultive behavior.

Suicidal behavior in child psychiatric inpatients and outpatients and in nonpatients.

One hundred one child psychiatric outpatients were assessed using a standard battery of measures to identify factors associated with suicidal behavior. Data on these outpatients were compared to those for psychiatric inpatients and nonpatients previously studied. The frequency of suicidal behavior among the outpatients (24.8%) was less than for a comparable group of inpatients (78.5%) but more than for a comparable group of nonpatients (12%). Four variables--recent general psychopathology, preoccupation with death, and recent and past depression--were significantly associated with suicidal behavior in the three groups of children.

Suicidal children grow up: suicidal behavior and psychiatric disorders among relatives.

OBJECTIVE: This paper reports comprehensive data on psychiatric symptoms and disorders and medical problems of first- and second-degree biological relatives of prepubertal children who have contemplated or attempted suicide. METHOD: Standard family study and family history interview techniques were used to obtain information about psychopathology and medical illness in 488 first- and 1,062 second-degree relatives of 25 child psychiatric inpatients who reported suicide attempts, 28 child psychiatric inpatients who contemplated suicide, 16 nonsuicidal child inpatients, and 54 normal children. RESULTS: Suicidal behavior in children was associated with suicidal behavior in their families, although no first-degree relatives committed suicide. More first-degree relatives of child suicide attempters, compared to first-degree relatives of normal children, had antisocial personality disorder, assaultive behavior, and substance abuse. Mood disorders in first-degree relatives were not associated with child suicidal behavior. No significant associations were identified for psychopathology of second-degree relatives and child suicidal behavior. CONCLUSIONS: The results suggest the importance of evaluating familial psychopathology during assessments of suicidal children. Self-directed and externally directed violence, antisocial personality disorder, and substance abuse of relatives of suicidal children should be studied to elucidate the etiology of youth suicidal behavior.

Suicidal children grow up: psychiatric treatment during follow-up period.

This study compares the treatment course during a 6- to 8-year follow-up period of 53 suicidal preadolescent and young adolescent psychiatric inpatients with those of 16 nonsuicidal psychiatric inpatients and 64 nonpatients selected from a community. The three groups of subjects were matched on demographic characteristics. All 69 patients and 10 (15.6%) nonpatients received treatment during follow-up. Treatment course during follow-up for suicidal patients was significantly longer, earlier, and more intensive than for the nonpatient controls. Fifty-five percent of 20 subjects who attempted suicide during follow-up were in treatment at the time of the suicide attempt.

Suicidal adolescents and ego defense mechanisms.

OBJECTIVES: To identify defense mechanisms that characterize adolescents with a range of suicidal behaviors and to differentiate them from nonsuicidal adolescents. METHODS: Fifty-five suicidal adolescent inpatients admitted for a definite suicide attempt were compared with 87 adolescent inpatients who had no history of suicide attempt or ideation and 81 nonpatients. Defense mechanisms were assessed by the Ego Defense Scale (EDS) which is part of a larger semistructured interview, the Child Suicide Potential Scale (CSPS), and by a self-report questionnaire, the Life Style Index (LSI). The CSPS was also used to quantity violent and suicidal behaviors. RESULTS: On the LSI suicidal adolescent patients scored higher on denial, displacement, repression, and total defenses than the nonpatients. On the EDS they scored higher on regression, denial, projection, introjection, repression, and total defenses and lower on sublimation. LSI scores on displacement (higher) and on compensation (lower) distinguished suicidal from nonsuicidal inpatients. Denial and regression correlated positively and sublimation correlated negatively with both suicidal and violent behaviors. Introjection and repression correlated with suicidal behavior only. CONCLUSIONS: Overuse of displacement is connected with increased risk for suicidal and aggressive behaviors, while sublimation is probably a protective factor. In addition, several immature ego defenses possibly amplify aggression, which then is directed against the self by the maladaptive overuse of introjection, displacement, and repression.

Death concepts in suicidal adolescents.

OBJECTIVE: To investigate the relationship between components of death concept (preoccupation with death, death as a pleasant state, and death as final) and suicidal behavior in adolescents. METHOD: The death concepts of 51 suicidal inpatients, 102 nonsuicidal inpatients, 36 emergency room suicidal subjects, and 81 normal controls were compared using Pfeffer's Child Suicide Potential Scale. In addition, the IQ level as well as emotions that potentially influence the death concept were measured. RESULTS: Both groups of suicidal adolescents evaluated death as more pleasant than the nonsuicidal groups. All the study groups equally perceived death as a final state. Suicidal inpatients were more preoccupied with death than nonsuicidal inpatients, but surprisingly among all study groups, including normal controls, the emergency room suicidal subjects were the least preoccupied with death. Partialing out depression, anxiety, and aggression specifically augmented the association between preoccupation with death and suicidality. Thus the relationship between death concept and suicidality appears to be a direct one. No correlation was found between suicidality and intelligence level. CONCLUSIONS: Elements of death concept distinguish suicidal from nonsuicidal as well as between hospitalized versus nonhospitalized suicidal adolescents. Thus the death concept evaluation is potentially valuable in the assessment of adolescents with a high risk for suicide.

Suicidal children grow up: suicidal episodes and effects of treatment during follow-up.

OBJECTIVES: This paper describes risk for first recurrent suicidal episodes in follow-up of suicidal child psychiatric inpatients. It identifies relations between suicide attempts in follow-up and psychosocial and psychopharmacological treatments. METHODS: First suicidal episodes involving either suicidal ideation or a suicide attempt in a 6 to 8 year follow-up period were rated for 69 child psychiatric inpatients and 64 children selected from the community. Psychiatric treatments were determined from reports from multiple sources. RESULTS: Forty-five percent of 133 subjects reported a suicidal episode during follow-up. Children who reported suicidal ideation or a suicide attempt were greater than twice as likely to report a suicidal episode in follow-up than were children from the community. Children treated with antidepressants in follow-up were more likely to attempt suicide than were those not treated with antidepressants. CONCLUSIONS: Close follow-up of suicidal children is warranted to identity risk and to intervene to prevent suicidal episodes. Lack of efficacy of naturalistic treatments implies that controlled treatment studies are needed to determine effective intervention for suicidal children.

Suicidal children grow up: ego functions associated with suicide attempts.

OBJECTIVE: To evaluate the relations between suicidal behavior in children and ego functions including impulse control, reality testing, and ego mechanisms of defense. METHOD: One hundred thirty-three children were assessed initially and at a 6- to 8-year follow-up for levels of reality testing and impulse control and frequency of use of several ego mechanisms of defense. Associations between suicidal ideation and suicide attempts at the initial assessment and at follow-up were analyzed with regard to ego functions. RESULTS: Specific ego functions, such as impulsivity, poor reality testing, and ego mechanisms of defense such as projection, regression, compensation, and reaction formation were positively associated with suicide attempts. Repression was a protective factor to prevent suicide attempts in the follow-up period. CONCLUSIONS: The results suggest that ego functions are related to behavior of consequence and are useful in the identification of children at risk for suicidal behavior.

An abused psychotic preadolescent at risk for Huntington's disease.

An abused 10-year-old girl with a family history of Huntington's disease developed incapacitating abdominal pain with concomitant behavioral symptomatology suggestive of dementia. The pseudoneurologic nature of her symptoms was clarified through exhaustive evaluation and did not appear to be that of early-onset Huntington's disease. Assessment included pediatric, psychiatric, neurologic, and gynecologic examination; extensive radiologic and laboratory tests; and chronobiology studies. Successful treatment necessitated the integration of numerous therapeutic modalities including dynamically oriented psychotherapy, psychopharmacologic intervention, physical therapy, behavior modification, and electroconvulsive therapy.

Child survivors of suicide: psychosocial characteristics.

OBJECTIVE: To describe psychosocial characteristics of children and young adolescents who experienced the recent suicidal death of a parent or sibling. METHOD: Sixteen families with children aged 5 years to 14 years and who experienced the suicidal death of a relative on average within the year of research assessment were recruited from the community and evaluated with standard research instruments for levels of children's psychiatric symptoms and social adjustment. RESULTS: Child survivors of suicide had a higher rate of internalizing symptoms and poorer school adjustments than a standard community sample. Twenty-five percent of the families had children who reported clinically significant symptoms of depression. Approximately 40% of the families included children who reported at least moderate symptoms of posttraumatic stress. Approximately 31% of families had at least one child who reported suicidal ideation, but no child reported a suicide attempt. Significant associations were identified between psychosocial features of the children and parental psychiatric symptoms and stressful life events. CONCLUSION: Child survivors of suicide are at risk for psychiatric symptoms and social maladjustment which require early identification and preventive intervention to minimize risk for more extensive psychosocial morbidity.

Suicidal children grow up: demographic and clinical risk factors for adolescent suicide attempts.

This longitudinal study reports rates and demographic and clinical risk factors for adolescent suicide attempts during a 6- to 8-year follow-up period of an initial sample of 106 preadolescent and young adolescent psychiatric inpatients and 101 preadolescent and young adolescent nonpatients. Survival analysis was used to evaluate risk for a first suicide attempt in the follow-up period for 133 subjects who were interviewed. No deaths occurred. Suicidal inpatients, compared with nonpatients, had earlier first suicide attempts in the follow-up period. Adolescents who attempted suicide in the follow-up period were seven times more likely to have a mood disorder during the follow-up period than those who did not attempt suicide. Implications for clinical practice and research are discussed.

Interviewing prepubertal children about suicidal ideation and behavior.

OBJECTIVE: Much of the literature on assessment of suicidal children has focused on identifying risk factors associated with suicidal ideation and behavior in this population. Unique problems encountered in interviewing prepubertal children about suicidal ideation and behavior are examined in this paper. METHOD: Observations of problems encountered in interviewing prepubertal children about suicidal ideation and behavior were gleaned in the context of interviews of children admitted to a child psychiatry inpatient unit and interviews of the parents of these children. RESULTS: Unique problems include difficulties in assessment of suicidal intent, impact of cognitive development, particularly of the concept of death, interaction between current emotional state and memory of previous suicidal episodes, characteristics of play associated with suicidal states, effects of parents' attitudes toward assessment on information gathering, and the impact of certain risk factors on cognition and behavior during the interview. CONCLUSION: Interviewing children about suicidal ideation and behavior necessitates that the clinician attend to multiple elements of the interview simultaneously. These interviews are further complicated by the stressful thoughts and feelings that can be raised in both clinician and child in reaction to exploring the child's suicidal ideation and behavior. Additional research is needed to refine the process of reliable interviewing of children about suicidal ideation and behavior and to develop instruments both to quantitate the different elements of these interviews and to guide the clinicians conducting them.

Human figure drawings in the evaluation of severe adolescent suicidal behavior.

OBJECTIVE: To evaluate the reliability of using certain indicators derived from human figure drawings to distinguish between suicidal and nonsuicidal adolescents. METHOD: Ninety consecutive admissions to an adolescent inpatient unit were assessed. Thirty-nine patients were admitted because of suicidal behavior and 51 for other reasons. All subjects were given the Human Figure Drawing (HFD) test. HFD was evaluated according to the method of Pfeffer and Richman, and the degree of suicidal behavior was rated by the Child Suicide Potential Scale. RESULTS: The internal reliability was satisfactory. HFD indicators correlated significantly with quantitative measures of suicidal behavior; of these indicators specifically, overall impression of the evaluator enabled the prediction of suicidal behavior and the distinction between suicidal and nonsuicidal inpatients (p < .001). A group of graphic indicators derived from a discriminant analysis formed a function, which was able to identify 84.6% of the suicidal and 76.6% of the nonsuicidal adolescents correctly. Many of the items had a regressive quality. CONCLUSIONS: The HFD is an example of a simple projective test that may have empirical reliability. It may be useful for the assessment of severe suicidal behavior in adolescents.