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Clinical Considerations Suicidal behavior involves thoughts or actions that may lead to self-inflicted death or serious injury A distinction is made between suicidal ideation and suicidal attempts in which deliberate attempts to take one’s life occurred The increasing trend toward suicidal behavior by children and adolescents is alarming ( Table 126.10 ) Clinical Recognition Table 126.11 indicates the high-risk situations for suicidal behavior in which direct questioning about suicide should occur The first two situations immediately alert the physician to the danger of suicidal behavior The other situations involve a different chief complaint, masking possible suicidal ideation or behavior All ingestions that are not clearly accidental, intoxicated drivers, drivers involved in single vehicle crashes, and patients who present with trauma from engaging in high-risk behaviors should be screened for suicidal behavior Overtly depressed children, depressed children who present with somatic complaints, and children who have acted violently are also at risk Psychotic children present a special problem and may present with inadvertent suicide attempts as the result of impaired judgment, hallucinations, and delusions of persecution The isolated, withdrawn child may harbor suicidal thoughts that are uncovered only by direct questioning TABLE 126.10 CHILDHOOD AND ADOLESCENT SUICIDE: NATURE OF THE PROBLEM Adolescent suicide 44% rise in suicide rate, adolescents ages 15–19 yrs, since 1970 4,000 completed adolescent and young adult suicides, since 2000 Estimated 400,000 adolescent attempts, since 2000 (1:50–1:100 attempts succeed) Suicide is the third leading cause of death, ages 15–24 yrs (after accidents, homicides) Childhood suicide Serious problem Younger children attempt suicide as a result of depression and/or poor judgment Increase in attempted and completed suicides, children ages yrs and older Suicide attempts via ingestions (children ages 5–14 yrs) five times more common than all forms of meningitis Additional data Girls attempt at least three times more often than boys Boys succeed at least two times more often than girls 80% of attempts are pill ingestions More lethal means—gun, knife, jumping, running into car—more common with boys Many car “accidents” are not accidents TABLE 126.11 CHILDHOOD AND ADOLESCENT SUICIDE: HIGH-RISK SITUATIONS FOR SUICIDE ATTEMPTS Suicide attempt just made Suicidal threat made “Accidental” ingestion Child complains of depression Psychotic child Significant withdrawal by child History of aggressive or violent behavior History of substance abuse History of previous suicide attempt(s) Medical concerns, but child appears depressed Highly lethal method of suicide attempt Availability of or access to firearms In school-aged children, certain risk factors have been identified that distinguish children with suicidal behavior from other children with emotional problems ( Table 126.12 ) Suicidal children are likely to be depressed and hopeless Self-esteem is low, and they see themselves as worthless The want to die is present, as are preoccupations with death The family history may include past episodes of parental depression and suicidal behavior Suicidal children tend to view death as temporary and pleasant rather than irreversible Assessment All patients require a thorough medical assessment in order to identify and treat any potential physical sequelae Consider obtaining urine toxicology for drugs of abuse and serum screens for acetaminophen and salicylates on all suicidal teenage patients, as a concealed ingestion may be present or the patient may be self-medicating with drugs of abuse TABLE 126.12 CHARACTERISTICS ASSOCIATED WITH CHILDHOOD AND ADOLESCENT SUICIDE ATTEMPTS Positive family history Hopelessness Low self-esteem Active desire to die Depression Anger/desire for revenge TABLE 126.13 ASSESSING CHILDHOOD/ADOLESCENT SUICIDE ATTEMPTS: FOUR MAJOR DIMENSIONS Medical lethality Suicidal intent Impulsivity Strengths/supports The psychiatric evaluation should include an assessment of the actual and believed medical lethality of the act, the suicidal intent, the impulsivity of the act, and the strengths and supports within the family ( Table 126.13 ) The lethality of a suicide attempt by itself may be misleading because suicidal children may over- or underestimate the harm intended In general, more violent methods of attempted suicide (e.g., hanging, shooting, jumping) often reflect greater suicidal intent ( Table 126.14 ) However, the physician cannot conclude that attempts with low lethality are not serious attempts until they have specifically asked about and assessed the child’s suicidal intent, that is, determined how seriously the child wanted to end their life ( Table 126.15 ) These questions should be asked of the child without the parents in the room The physician should gather as much information as possible about the attempt itself to help infer the degree of suicidal intent on the part of the