What are the risks for suicide in children and adolescents?

Suicide is a very real risk for depressed youth. Suicide is the third leading cause of death in teenagers. A study by the Centers for Disease Control and Prevention of high school students yielded information that nearly 20% of teens had seriously considered suicide and that more than 1 in 12 had made a suicide attempt in the previous year. Male teens are more likely to kill themselves, whereas more females attempt suicide. The majority of teen suicides are with guns. Children also can have suicidal ideation but are less apt to make attempts the younger they are.

Risk factors for suicide include

• Previous suicide attempts

• Depression

• Alcohol or substance abuse

• A family history of psychiatric illness

• Stressful circumstances

• Access to guns

• Exposure to other teens who have committed suicide

Stressful life events tend to be higher in children and adolescents who attempt suicide and may include loss of family members because of death or separation, physical or sexual abuse, frequent arguing in the home, or witnessing violence. Youth who are grappling with their sexual identity are at particularly high risk for suicide. Suicidal youth tend to have poor social adjustment and lack adequate social supports.

Some depressed adolescents engage in self-injurious behavior of cutting or burning themselves without the specific intention of killing themselves. This is more typical in persons who experience a chronic emptiness and "emotional numbness." The pain from cutting may be described as a relief because the physical pain detracts from the emotional pain. Such behaviors are a sign that help is needed and are typically seen in depression when occurring in adolescence, but they are also a feature in some personality disorders in adults. Although those who engage in self-injurious behaviors do not necessarily intend to kill themselves, accidental death is a risk as well as the development of permanent scarring. Often, the cutting behavior is transient, occurring during particularly stressful periods (e.g., loss of relationship), and dissipates with the development of better coping skills and improved impulse control.

What is the treatment approach for children and adolescents?

Anne's comment:

One of the most important aspects in treating our child's depression was participating in weekly therapy with him until his condition became more stable. This facilitated the therapist in assessing our son's progress and helped us to communicate better and be more supportive as he struggled through the worst stages of the illness. It was an invaluable tool for all of us during a time of crisis.

The treatment of children and adolescents must first begin with a comprehensive evaluation by a qualified practitioner. It is important that the treatment provider has experience with this population or, better yet, has specialty training with this population. The evaluation tends to encompass more areas of inquiry than do adult evaluations, with full developmental history and family history obtained and school functioning assessed and contrasted with home functioning. As in adults, other conditions must be considered and excluded before diagnosing depression. Once diagnosed with depression, a treatment plan might address the following areas:

• Individual

• Medical

• Family

• School

• Legal

Individual needs can be addressed with psychotherapy. Cognitive-behavioral therapy and interpersonal therapy approaches have been studied and found to be effective in adolescent depression. Children and adolescents can benefit from other psychotherapeutic approaches as well. Group therapy should be considered if concerns exist about social development. In addition to individual psychotherapy, work with children and adolescents often requires some level of family work, either with the parents or with siblings. As members of a family system, dynamics between the child and others cannot always be effectively addressed in individual work alone. Problems with behavior may require enhancement of parenting skills.

Psychoeducation of family members too may be needed to help them understand the patient's illness.

Medically, the use of somatic^[1] treatments, such as an antidepressant medication, may be recommended for depression in a child or adolescent. All children and adolescents should have medical clearance through their pediatrician to exclude any underlying medical conditions. Depending on the severity of the depression, an antidepressant may or may not be recommended. It is more commonplace to attempt a trial at therapy alone in children and adolescents first in contrast to adults. However, if progress is slow or if symptoms worsen, a consultation for medication should then be sought.

Educational needs are also assessed in children and adolescents. Depression can cause academic delays and may be associated with comorbid learning disabilities. If significant academic problems exist, a board of education assessment may be needed to determine the most appropriate educational setting. Most states mandate that appropriate educational services be made available to minors with emotional and/or behavioral problems, which may consist of smaller classroom settings, nonpublic school placement, day treatment programs, or even residential treatment settings.

The legal needs of a child also have to be considered in the evaluation process. As a minor, the parent or guardian will make the final decision regarding the treatment intervention. Older adolescents, however, do have some say regarding their treatment. It is best if they are in agreement to a medication because they cannot be forced to take a medication against their will. Other legal issues to consider are custody issues and the need for family court involvement or state involvement.

Although various antidepressant medications are effective in treating adults with depression, these medications may not be as effective in treating children and adolescents.

• [1] referring to the body. Somatic therapy refers to all treatments that have direct physiologic effects, such as medication and ECT. Somatic complaints refer to all physical complaints that refer to the body, such as aches and pains.