Suicide is the final common pathway for various situations in which the child experiences a pervasive sense of helplessness, with a perceived absence of alternative solutions To the distressed child, suicide appears to be the only solution to his or her problems and the family’s problems Most suicide attempts occur in depressed children; others occur with children experiencing major losses, such as serious illness or death in the family or in children with depression with associated impulsivity A small but significant percentage of suicide attempts occur in psychotic children and adolescents ( Table 126.9 ) Children have differing conceptions of death at various ages Up to age 5, death is seen as a reversible process in which the activities of life still occur From to years, the irreversibility of death is beginning to be understood, but death is personified rather than seen as an independent event It is not until about age that death is seen as irreversible in the adult sense of being both final and inevitable Even then, however, the child may imagine his or her own death as being reversible Under such circumstances, a suicide attempt may have a different meaning than for an adult, where suicide corresponds to a definite end of one’s life While it is common for psychiatric symptoms to be present for weeks to months before an attempt and the vast majority of patients who suicide meet criteria for a psychiatric or substance abuse diagnosis at the time of their death, the time between a patient deciding to kill themselves and carrying out the act is often quite short and often occurs in the midst of an acute crisis Studies of survivors of potentially lethal attempts suggest that close to 25% act on their decision within minutes, another nearly 25% act between and 19 minutes, while another nearly 25% act between 20 minutes and hour This means that effective prevention efforts include the strategies of identifying and treating psychiatric disorders prior to the development of suicidal ideation as well as efforts to restrict access to the most lethal and common means of suicide attempts Emergency physicians must provide clear guidance around means restriction including firearms and potentially dangerous medications Over 80% of pediatric patients who suicided by firearm