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.

Child-Adolescent Suicidal Potential Index (CASPI): a screen for risk for early onset suicidal behavior.

This study's purpose was to develop a reliable and valid self-report questionnaire, the Child-Adolescent Suicidal Potential Index (CASPI), to screen for risk for suicidal behavior in children and adolescents. Four hundred twenty-five child and adolescent psychiatric patients and nonpatients completed the CASPI and other research instruments to rate suicidal and assaultive behavior and symptoms of depression, anxiety, and hopelessness. The 30-item CASPI involves 3 factors (anxious-impulsive depression, suicidal ideation or acts, family distress) that contributed to a unidimensional 2nd-order factor accounting for 59% of the total variance. Internal consistency (alpha) for the total score was .90, and test-retest reliability (ICC) for the total score was .76. Total score distinguished between children and adolescents with different severity of psychopathology and different levels of suicidal and assaultive behavior. Each of the 3 factors had different contributions to discriminating between levels of suicidal status. CASPI total score of 11 distinguished suicidal ideation or acts from nonsuicidal behavior, with sensitivity 70% and specificity 65%. CASPI total score positively correlated with symptom severity of depression, anxiety, and hopelessness.

Adults mourning suicide: self-reported concerns about bereavement, needs for assistance, and help-seeking behavior.

This study empirically characterized the experiences of 227 adult next-of-kin as they mourned suicides that had occurred in New York City during 1997. Next-of-kin reported psychosocial problems including family difficulties, comorbid stressors, psychiatric symptomatology, and unresolved bereavement. Professional intervention was the most frequently reported need and the most frequently reported type of desired help. In terms of actual receipt of assistance, participants reported having received help from families, friends, and communities as well as from professionals. Although some next-of-kin had not sought help because they felt able to cope without assistance, others encounted barriers to receiving desired help. These findings warrant increased and sustained community outreach to this population. Recommendations include public education regarding de-stigmatization of suicide and the needs of the suicidally bereaved, enhancement of internal and external coping supports, facilitation of access to both professional and community help, and better coordinated and more culturally appropriate services.

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.

Child survivors of parental death from cancer or suicide: depressive and behavioral outcomes.

Depressive symptoms, social competence, and behavior problems of prepubescent children bereaved within 18 months of parental death from cancer (57 families, 64 children) or suicide (11 families, 16 children) were compared. Most children reported normative levels of depressive symptoms. Children whose parents died from suicide, compared with those whose parents died from cancer, reported significantly more depressive symptoms, involving negative mood, interpersonal problems, ineffectiveness, and anhedonia. Parental reports of children's competence and behavior were similar to a normative sample of children and did not differ between the children bereaved by parental cancer or suicide. Additional research should focus on other factors, such as family psychopathology, stresses, and impact of stigma, which may influence the course of bereaved children.

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.

Attachment disorganization in prepubertal children with severe emotional disturbance.

Four prepubertal psychiatric inpatients were selected to illustrate four proposed subtypes of attachment disorganization. These children were administered the Attachment Story-Completion Task, an instrument that assesses the quality of attachment security to the primary caregiver. Clinical vignettes of their respective inpatient treatments are presented, and the essential characteristics of the four corresponding proposed subtypes are discussed. It is argued that children assessed with attachment disorganization are a heterogeneous group who nevertheless suggest more subtle patterns of organization.

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.

Suicidal children grow up: relations between family psychopathology and adolescents' lifetime suicidal behavior.

Standard family history and family study methods were used with 650 first- and 1174 second-degree biological relatives of 133 adolescents who were studied initially 6 to 8 years ago. They included 69 prepubertal children considered at risk for suicidal behavior and 64 prepubertal children selected from the community. This study aimed to identify relationships between family psychopathology and adolescents' lifetime history of suicidal states. Family discord, suicide attempts of mother, and substance abuse of mothers and fathers were significantly more prevalent among adolescents with lifetime history of a suicide attempt. Mothers' and fathers' substance abuse was associated with adolescents' lifetime history of suicidal ideation. Results highlight importance of evaluating and treating family psychopathology to reduce risk for youth suicidal states.

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.

Childhood suicidal behavior. A developmental perspective.

This article provides an overview of the sociocultural and psychosocial features and implications for treatment of prepubertal suicidal children. It provides cross-sectional and longitudinal information about specific risk factors of prepubertal suicidal behavior with a focus on how these factors also predict future suicidal behavior. A developmental focus addresses issues of cognitive and emotional immaturity as related to early onset suicidal behavior.

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.

Buspirone treatment of psychiatrically hospitalized prepubertal children with symptoms of anxiety and moderately severe aggression.

Open-label buspirone was studied in 25 prepubertal psychiatric inpatients (age 8.0 +/- 1.8 years, 76% boys) presenting with anxiety symptoms and moderately aggressive behavior. Patients with severe aggression, requiring rapid treatment with mood stabilizers or neuroleptics, were excluded. A 3-week titration (maximum 50 mg daily) preceded a 6-week maintenance phase at optimal dose. Buspirone was discontinued in 6 children (25%): 4 developed increased aggression and agitation, and 2 developed euphoric mania. For the 19 patients who completed the study, mean optimal dose was 28 mg daily. Among completers, depressive symptoms were reduced 52% by Week 6 on Children's Depression Inventory (p < or = 0.001). Decreased aggressivity was reflected in a 29% reduction on Measure of Aggression, Violence, and Rage in Children [MAVRIC] ratings (p < or = 0.02) and in 86% less time in seclusion or physical restraints (p < or = 0.02). Clinical Global Assessment scores improved (CGAS 41 vs. 54, p < or = 0.01). Only 3 children improved sufficiently to continue buspirone after the study. Residual aggressivity and global functioning remained problematic. Buspirone may pose behavioral risks in treating moderate aggressivity in 24% of children with anxiety; in the others, the therapeutic effects on aggression, anxiety, and depression were limited but significant.

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.

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.

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.