IACAPAP Textbook of Child and Adolescent Mental Health

MOOD DISORDERS

Chapter

E.4

SUICIDE AND SELF-HARMING
BEHAVIOUR
2018 edition
Thomas Jans, Timo D. Vloet, Yesim Taneli & Andreas Warnke
Thomas Jans PhD
Clinical psychologist,
Department of Child andAdolescent Psychiatry,
Psychosomatics andPsychotherapy, Centre for
Mental Health, University
Hospital of Würzburg, Germany
Conflict of interest: nonereported

Timo D. Vloet MD
Child and adolescent
psychiatrist, Departmentof Child and Adolescent
Psychiatry, Psychosomatics
and Psychotherapy, Centre
for Mental Health, University
Hospital of Würzburg, Germany
Conflict of interest: nonereported

Yesim Taneli MD, PhD, MSc
Assistant Professor of Childand Adolescent Psychiatry,
Department of Child andAdolescent Psychiatry, Uludag
University School of Medicine,
Bursa, Turkey
Conflict of interest: nonereported

This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2018. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Jans T, Vloet TD, Taneli Y, Warnke A. Suicide and self-harming behaviour. In Rey JM (ed), IACAPAP e-Textbook
of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions
2018.

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IACAPAP Textbook of Child and Adolescent Mental HealthIn many countries suicide is one of the leading causes of death among children
and adolescents. Identifying young people at risk and offering effective
treatment is a major concern of mental health policies. This chapter includes
a review of suicidality in children and adolescents. Non suicidal self-injury (NSSI)
will also be addressed, but the major focus will be on attempted and completedsuicide. The review refers to epidemiology, risk factors and etiological features,
clinical presentation, assessment, treatment and prevention. Because clinical issues
are emphasized this review does not include an overview of the neuropsychobiologyof suicidality.

Andreas Warnke MD, MA
Professor of child andadolescent psychiatry & former
director of the Departmentof Child and Adolescent
Psychiatry, Psychosomatics
and Psychotherapy, Centre
for Mental Health, University
Hospital of Würzburg, Germany
Conflict of interest: nonereported

The term “non suicidal self-injury” does not include self-mutilation or otheractions causing bodily symptoms with the pure intent of eliciting medical care oradvice (Munchhausen syndrome) or malingering (to achieve some benefit). Because
Table E.4.1 Coding of non suicidal self-injury, suicide attempts andsuicide as an “external cause of morbidity and mortality” according to
ICD-10 (X60–X84)*
X6..

Intentional self-poisoning by and exposure to:

X60.

Non-opioid analgesics, antipyretics and antirheumatics

X61.

Antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs
not elsewhere classified

X62.

Narcotics and psychodysleptics [hallucinogens] not elsewhere classified

X63.

Other drugs acting on the autonomic nervous system

X64.

Other and unspecified drugs, medicaments and biological substances

X65.

Alcohol

X66.

Organic solvents and halogenated hydrocarbons and their vapours

X67.

Other gases and vapours

X68.

Pesticides

X69.

Other and unspecified chemicals and noxious substances

X7../X8..

Intentional self-harm by:

X70.

Hanging, strangulation and suffocation

X71.

Drowning and submersion

X72.

Handgun discharge

X73.

By rifle, shotgun and larger firearm discharge

X74.

Other and unspecified firearm discharge

X75.

Explosive material

X76.

Smoke, fire and flames

X77.

Steam, hot vapours and hot objects

X78.

Sharp object

X79.

Blunt object

X80.

Jumping from a high place

X81.

Jumping or lying before moving object

X82.

Crashing of motor vehicle

X83.

Other specified means

X84.

Unspecified means*World Health Organisation, 1996.

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Definitions
Suicidality refers to the
cognitions and activities of
persons seeking their own
death, including thoughts,
actions or omissions.
Suicide (from the Latinsui caedere, to kill oneself)means the act of a person
intentionally causing his or
her own death.
Suicide attempt
denotes non-fatal actsor preparations intended
to result in death. The
suicidal act may have beenabandoned, interrupted or
was unsuccessful.
Parasuicide refers toa non-habitual, potentiallylife-threatening selfharming behavior whichis performed without theintention to kill oneself.
Because the behavior isnon suicidal, most authors
today prefer the term “nonsuicidal self-injury” (NSSI)(in this chapter the term non
suicidal self-injury is used).
The terms “deliberate
self-injury” or “deliberate
self-harm” are typicallyused without distinguishing
between NSSI and non fatal
suicide attempt.

2IACAPAP Textbook of Child and Adolescent Mental Healthof the indirect nature of the consequences of self-harm, unprotected intercourse,
high-risk behaviors (e.g., extreme forms of downhill riding, illegal car racing) or
intoxication by psychoactive substances are not included, even if an intention toself-destruct may be present. For descriptive purposes, non lethal suicide attempts
and non suicidal self-injury are classified using the same codes.
The mere listing of codes in Table E.4.1 does not indicate how frequent
these different methods of self-harm are in children and adolescents. Methods
commonly used are presented in the side box. These methods comprise non lethal
self-harming behaviors – like pinching, scratching or biting – as well as highly
lethal methods, which are mostly associated with clear suicidal intent (e.g., use of
firearms, jumping from high places). However, from a clinical point of view, it is
crucial to differentiate between suicide attempts and non suicidal self-injury (seeTable E.4.2).

IntentThe key difference between deliberate self-injury and suicide attempt is in
the intent to end one’s life. For example, a 14-year-old girl takes a small overdoseof paracetamol intending to kill herself, although she does not succeed (suicide
attempt). Another 14-year-old girl takes a large overdose of paracetamol because
she is angry and upset. She did not want to kill herself but tried to reduce a stressful
situation (non suicidal self-injury). Further, some non suicidal self-harming acts
may actually result in death − by ignorance or miscalculation (the latter 14-yearold was not aware of the toxic effects of paracetamol and actually died as a result).
It has to be kept in mind that both forms of self-harm may overlap: individuals
with suicide attempts may also show non suicidal self-injuring behavior and viceversa.

Methods of self-harm(Non-lethal suicide attempts
and non suicidal self-injury)(Greydanus et al, 2009)• Drug overdose• Self-poisoning• Self-cutting• Other forms of selfmutilation- Self-hitting- Pinching- Scratching- Biting- Burning• Shooting oneself• Hanging• Jumping from highplaces• Jumping into wells

Regrettably, evaluating intent is often difficult in clinical practice. Thishas been a major barrier in researching this topic. The Columbia Classification
Algorithm for Suicide Assessment (C-CASA) − a standardized suicide rating systemdeveloped for the evaluation of suicidality in antidepressant trials − has been shown
to be reliable, transportable, and the FDA has mandated that it should be used in
psychotropic and other drug trials (Posner et al, 2007). Although this is a research
instrument, it may also be useful in clinical practice, at least by standardizing theterminology. C-CASA definitions and selected training examples are shown intable E.4.3. Currently there is a debate about the validity of the C-CASA (Sheehan
Table E.4.2

Differences between suicide attempt and non suicidal self-injury

Suicide attempt

Non suicidal self-injury (“parasuicide”)•

Intending to end one’s life•

No suicidal intent•

May be impulsive, but in most of the cases there is achronic feeling of hopelessness or loneliness•Emotional state is acute anger, despair or intolerable
distress•

More severe and life-threatening forms of selfdestructive behaviors are typical (e.g., self-poisoning,hanging, jumping, use of firearms)•

Less severe and mostly not life-threatening forms
of self-destructive behaviors are typical (e.g., skinlesions by biting, cutting, burning or freezing)•

Typically, the person is aware that the behavior may
cause serious injury, but is not life-threatening•

Recurrent self-injury is common•

There is a clear risk that suicide attempts arerepeated, but to a lesser frequency than non suicidal
self-injuries

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Suicide		E.4

Passive thoughts about wanting to be dead or active thoughts about killing oneself,
not accompanied by preparatory behavior.

A potentially self-injurious behavior, associated with at least some intent to die, asa result of the act. Evidence that the individual intended to kill him/herself, at least
to some degree, can be explicit or inferred from the behavior or circumstance. A
suicide attempt may or may not result in actual injury.
The individual takes steps to injure him- or herself, but is stopped by self or othersfrom starting the self-injurious act before the potential for harm has begun.

Suicidal events
A self-injurious behavior that resulted in fatality and was associated with at least
some intent to die as a result of the act.

After a long argument with his girlfriend, which resulted in the end of theirrelationship, the patient collected a rope and rode his bike to an isolatedarea where he fatally hanged himself. A suicide note was later found.
After a fight with her friends at school, in which they discontinued speaking
with her, the patient ingested approximately 16 aspirin and eight other pillsof different types on the school grounds. She said that she deserved todie, which was why she swallowed the pills.
The patient had run away from home overnight because his father hadgone to school and retrieved a recent “bad” report card. He was fearfulof his father’s reaction. Upon his return home, a 5- to 6-hour argumentwith his parents ensued, and he took a vegetable (broad, sharp) knife
and went to his room. He reported putting the knife to his wrist but neverpuncturing the skin.
Active thoughts: The patient reported to the doctor that he was thinking
about hanging himself in the closet. He was taken to the hospital andadmitted.

ExampleNon suicidal events
Self-injurious
Self-injurious behavior associated with no intent to die. The behavior is intended
The patient was feeling ignored. She went into the family kitchen where
behavior, nopurely for other reasons, either to relieve distress (often referred to as “selfher mother and sister were talking. She took a knife out of the drawer andsuicidal intent
mutilation,” e.g., superficial cuts or scratches, hitting/banging, or burns) or to effectmade a cut on her arm. She denied that she wanted to die at all (“not evenchange in others or the environment.
a little”), but she just wanted them to pay attention to her.
Other, noNo evidence of any suicidality or deliberate self-injurious behavior associated
The patient had a cut on the neck from shaving.
deliberate selfwith the event. The event is characterized as an accidental injury, psychiatric or
harm
behavioral symptoms only, or medical symptoms or procedure only.
Indeterminate or potentially suicidal events
Self-injurious
Self-injurious behavior where associated intent to die is unknown and cannot be
The patient cut her wrists after an argument with her boyfriend (no further
behavior, suicidal
inferred. The injury or potential for injury is clear, but why the individual engaged in
information).
intent unknown
that behavior is unclear.
Not enoughInsufficient information to determine whether the event involved deliberate suicidal
A child who “stabbed himself in [the] neck with a pencil.” The event
information
behaviour or ideation. There is reason to suspect the possibility of suicidality but not may have been deliberate as opposed to accidental, as suggested byenough to be confident that the event was not something other, such as an accident “stabbed,” but not enough information was provided to determine whether
or psychiatric symptom. An injury sustained on a place on the body consistent withthe event was deliberate.
deliberate self-harm or suicidal behavior (e.g., wrists), without any information as to
how the injury was received, would warrant placement in this category.
*Posner et al (2007); only one of several C-CASA examples is cited.

Suicidal ideation

Preparatory acts
toward imminentsuicidal behavior

Suicide attempt

Completed suicide

Definition

Columbia Classification Algorithm for Suicide Assessment (C-CASA): definitions and training examples*

Classification/
Category

Table E.4.3

IACAPAP Textbook of Child and Adolescent Mental Health4IACAPAP Textbook of Child and Adolescent Mental Healthet al. 2014). This emphasizes the importance of the clinical examination beside theuse of questionnaires.

EPIDEMIOLOGY
According to World Health Organization (WHO) statistics about 800,000
people worldwide die from suicide every year (mean mortality rate in 2012: 11,4
per 100,000; 15 for males and 8 for females (WHO 2014), that is, one death every
40 seconds. In some countries suicide is the second leading cause of death in the
10 to 24 years age group. For example, in Germany only accidents − mainly fatal
traffic injuries − are a more frequent cause of death in adolescents aged between 15
to 19 years (Elsässer, 2010). The relative weight of suicide as a cause of death varies
between countries and regions according to the impact of a variety of factors (seeTable E.4.4). Nevertheless, suicide remains an important cause of death among
adolescents and young adults worldwide.
As an example of nation specific variations in suicide rates, European andworld data are presented in Figures E.4.1 and E.4.2. Suicide rates varied widelyfrom 0 (Lichtenstein) to 16.7 (Latvia). In Europe, the average suicide rate forboys declined significantly from 2.02 per 100 000 in the 1990s to 1.48 in thesubsequent decade (Kõlves & De Leo 2014). Out of 36 European countries in thisanalysis, 14 demonstrated significantly decreasing suicide rates for boys. However,France and Romania showed a significant increase, although the average rate
for girls did not change: 0.67 in the 1990s and 0.64 in the 2000s. No country
reported a significant decline for girls; instead, a significant rise was measured inTable E.4.4
frequency*

Main causes of death in adolescents and young adults in decreasing order ofAfrica:Southeast Asia:

South America/Caribbean:

1.
2.
3.
4.
5.

1.
2.
3.
4.
5.

1.
2.
3.
4.
5.

AIDS
Other infections
Homicide/War
Unintended Injuries
SuicideUnintended Injuries
Other Infections
AIDS
Suicide
Homicide/War

Homicide/War
Unintended Injuries
SuicideOther Infections
AIDS

Western Pacific:1

Europe:Eastern Mediterranean:2

1.
2.
3.
4.
5.

1.
2.
3.
4.
5.

1.
2.
3.
4.
5.

Unintended Injuries
SuicideOther Infections
Homicide/War
AIDS

Unintended Injuries
Suicide
Homicide/War
Other Infections
AIDS

Unintended Injuries
Other Infections
Homicide/War
AIDS
SuicideNorth America:
1.
2.
3.
4.
5.
6.

Unintended Injuries
Suicide
Homicide
CancerOther Infections
AIDS

Australia, New Zealand, China, Japan, Korea, Malaysia, Micronesia,
Philippines, Singapore, Vietnam, and others in this area
1

Afghanistan, Egypt, Iraq, Jordan, Saudi Arabia, Israel, and other Middle East
Countries2*Adapted from Greydanus et al (2009).

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure E.4.1 Suicide death rate inEurope in 2014: Adolescents aged
15 to 19 years (crude death rate per
100000 persons). Source: Eurostat

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure E.4.2

Age-standardized rates (per 100000 population, both genders, 2015. Source: WHO

Figure E.4.3

Suicide rates (per 100000) by gender and age

Data from 2000; Source: WHO

Figure E.4.4 Global suicides
by age and income level ofcountry, 2012. Source WHO.

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IACAPAP Textbook of Child and Adolescent Mental Health

Belgium, Russia, Slovakia and Romania. Analysis of the European regions showed
the highest rates occurred in eastern European countries with a non-significant
average decline for boys from 3.49 per 100 000 in the 1990s to 2.76 in the 2000s.
Because of unreliable allocation − e.g., inaccurate ascertainment, religious or
cultural attitudes about suicide − reported suicide rates are likely to underestimate
the problem. Moreover, these figures do not include suicide attempts, which occur
10 to 20 times more frequently than completed suicides. Serious suicide attempts
are estimated to occur in about 3% of adolescents in Western societies. Keeping
these variations in mind, general statements on the epidemiology of suicide may
be invalid for specific populations, regions and time periods.
Qualifications need to be made with respect to:• Age• Gender• Specific regions and countries• Ethnicity, and• Secular trends.

Click on the picture to access
WHO suicide statistics.

Age
Globally, during the last few decades suicide rates have been highest in theelderly (see Figure E.4.3). However, according to World Health Organization’s
Suicide Prevention Program (SUPRE) website, in some countries suicide rates
among young people have increased so much that adolescents and young adults
represent the group at highest risk for suicide. This refers to a third of all countries
and holds for more and less industrialized nations. Therefore, clearly elevatedsuicide rates in the elderly seem not to be present worldwide (see Figure E.4.4).
In pre-pubertal children, completed suicide is very rare. However, Kazakhstan had
the highest rate in the world for boys aged 10-14 years. Children become able tounderstand the concept of suicide from the age of 8 years and become capableof carrying it out, leading to increasing rates of completed suicide in pubertal
children and young adolescents. Relatively low suicide rates in children may be
accounted for by the age-dependent absence of, or lower exposure to major risk
factors (e.g., mental illness, substance-related disorders) or the protection offered
by a close relationship with the family.

GenderOverall, rates of completed suicide are higher in males than in females. This
holds true for all age groups, with a male to female ratio of about 4:1 in adolescentsand young adults. However, gender ratios vary between countries. There are regionsin which the gender distribution of completed suicides is similar (e.g., China).
Suicide among young girls is alarmingly high in the west coastal region of India(Kanchan et al, 2009). Reasons for the relatively high suicide rates among young
females, especially in rural areas of China, may partly be due to the easy access anduse of pesticides, very lethal, and the limited access to emergency medical services(by contrast, in Western European countries the use of the less lethal analgesics is
far more prevalent in suicidal females) (for a review see Turecki & Brent, 2016) .
Globally higher rates of completed suicide in males are associated with more
violent means (e.g., guns, hanging) and the pattern of risk factors in males (e.g.,
impulsive aggression, alcohol misuse). However, with respect to gender ratio the

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IACAPAP Textbook of Child and Adolescent Mental Healthopposite is true for suicide attempts, which are far more common in females thanin males (sometimes referred to as the “gender paradox”).

Specific Regions and Countries
Regional variations in suicide rates reflect varying environmental and social
risk factors. Reported suicide rates vary widely between countries; even withinquite homogenous states there are regional differences (e.g., relatively high rates in
Saxony, Germany). The highest rates worldwide are reported for Eastern European
countries, among them countries with a traditionally high suicide rate since theend of the 19th century (e.g., Estonia). Generally, in the last few years there has
been a shift in the prevalence of suicide from Eastern Europe to Asia. Relatively
low rates are still reported for the Gulf States, e.g. Kuwait (Värnik, 2012).
Besides differences in the recording of suicides, variations suggest countryspecific patterns of risk and protective factors (e.g., socioeconomic disadvantage,
rapid cultural change), geography and climate (e.g., light exposure and depression),
access to lethal means (e.g., poisons or firearms), use of alcohol and drugs, ethnicity,and religious beliefs.
Low suicide rates in the Gulf States may reflect religious norms and low
alcohol use. In general, a gradient has been described whereupon agnostics show
the highest suicide rates, Muslims have the lowest, while Christians, Buddhists andHindus are in the middle (Bertolote & Fleischman, 2009).
Suicide rates are high among minority groups, particularly those who haveundergone rapid social change, acculturation, or have become disenfranchised as aresult of colonization (e.g., American Indians, Indigenous Australians, Inuit). For
a comprehensive review the reader may refer to Turecki and Brent (2016).

Secular Trends
An increase in the rate and absolute number of suicides has been described in
the last decades (Curtin et al, 2016; review from Dilillo et al, 2015). However, thiseffect is not consistent. For example, across OECD countries (the Organization for
Economic Co-operation and Development, OECD, comprises 32 industrialized

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IACAPAP Textbook of Child and Adolescent Mental Healthnations) there has been a slight decline in suicide rates overall. Some countries withtraditionally high rates (e.g., Hungary) have shown a sharp decline while otherswith low rates (e.g., Korea, Japan) have shown a sharp increase (Jeon et al, 2016).
The reasons for these changes are not well understood but may include rapidsocial or economic changes (e.g., unemployment). However, major burdens fora population may also have the opposite effect. For example, in Germany suicide
rates decreased considerably in the years following the First and Second World
Wars. For a circumscribed period, the urge of a society to concentrate on the basic
needs of daily life may partly protect from suicide.
Time trends appear not to be stable. For example, in many Westerncountries a reduction in youth suicide rates was observed in the last two decades(e.g. Laido et al, 2017). This decline may be explained by the more prevalentand effective treatment of psychiatric disorders (e.g., pharmacological treatment
of depression). However, data from the National Vital Statistics System (2014)indicated a 24%-increase of age-adjusted suicide rate in the US (10.5 to 13.0
per 100 000 population). The percent increase in suicide rates for females was
greatest for those aged 10-14 (Curtin et al, 2016). Factors speculatively blamed
for this increase might be the influence of online social networks or higher rates of
untreated depression following FDA warnings on suicidality associated with theuse of antidepressants.

Recent US data on suicidal
behavior among 9th to 12th
grade students are available
from the Youth Risk Behavior
Survey (YRBS), Centers for
Disease Control.

Suicidal Thoughts and Suicide Attempts
Recent data from the Youth Risk Behavior Surveillance (2012) reported
students between the age of 14 and 18 years to have:•••

Seriously considered attempting suicide (15.8%)
Attempted suicide (7.8%,)
Attempted suicide resulting in injury, poisoning, or an overdose that
had to be treated by a doctor or nurse (2.4%).

The Youth Risk Behavior Survey data illustrate that suicidal ideation is very
common among adolescents and that a significant percentage is carrying out serious
suicide attempts. Fortunately, rates for completed suicide are comparatively low(US data for 2013: prevalence of death by suicide among adolescents: 0.006%).
However, data indicate a progression in the development of acute suicidality fromsuicidal ideation, to planning, and to a suicide attempt. Thus, suicidal thoughts
always have to be considered a significant warning sign requiring professional
advice. With respect to suicidal ideation and suicide attempts, there is a female
preponderance in most countries (more than twice as common among females).

Means of Suicide
In the last years there is a trend that hanging has replaced self-poisoning
as the most common method of suicide in 10-19-year-olds in the US, Englandand other countries (e.g., Redmore et al, 2016). In the US, the most frequentsuicide method in 2014 was firearms (55.4%) for males and poisoning for females(34.1%). In Western Europe, by contrast, firearms play a minor role; jumping
from high places or before a train is the main method. Poisoning by pesticides isprevalent in agricultural regions in low and middle-income countries such as India.
In Turkey, in 2015 the five most common methods of suicide were in decreasing
frequency: hanging, firearms, jumping from a high place, chemicals, and using
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IACAPAP Textbook of Child and Adolescent Mental Healtha sharp instrument (TurkStat; Suicide Statistics 2010, www.tuik.gov.tr, 2015).
Carbon monoxide poisoning is becoming widespread in some Western Pacificcountries (e.g., Taiwan). In Western Europe and North America, over-the-counter
pharmaceuticals (mainly analgesics) and psychotropic drugs are also common.

Risk Factors
Major risk factors for suicide in adolescence are summarized in Table E.4.5.
As stated, there is a lack of research on suicide in preadolescents. No specific patternof risk factors for this age group has been found yet (Turecki & Brent, 2016).
In preadolescents, family-related stressors may play a more significant role thanin adolescents, while age-dependent psychopathology (e.g., alcohol use, bipolar
disorder, psychosis) may have less influence.
The effects of age and gender have already been described. However, it
should be kept in mind that statistical risk refers to averages in a community andhas limited relevance for the assessment and treatment of individual patients. For
example, a female adolescent is statistically at lower risk for completed suicide after
a suicide attempt than a male counterpart. However, assessment and treatment are
not gender-specific!
Previous Suicide Attempts
A previous suicide attempt is one of the most important predictors of further
attempts and of completed suicide (Hoertel et al, 2015):•••

About 30% of completed suicides have a history of suicide attempts
After a suicide attempt the risk of a further attempt is 20 times higher
than in individuals without a history of attempted suicide
The risk of a serious suicide attempt is strongly associated with thenumber of previous suicide attempts.

Table E.4.5
•
•

•

•
•
•
•
•

Major risk factors for suicide among adolescents*

Previous suicide attempt
Psychopathology− Especially major depressive disorder, bipolar disorder, conduct disorder, and substance use disorders− Psychiatric co-morbidity, especially the combination of mood, disruptive, and substance use disorders− Dysfunctional personality traits (especially antisocial, borderline, histrionic, and narcissistic traits)− Feelings of hopelessness and worthlessness− Impulsive aggression: the tendency to react to frustration or provocation with hostility or aggression
Family factors− A family history of depression or suicide− Loss of a parent through death or divorce− Family discord
Physical and sexual abuse
Lack of a support network, poor relationships with peers and feelings of social isolation“Coming out” or dealing with homosexual feelings or gender identity in an unsupportive family, community or school
environment
Availability of lethal means
Having been exposed to suicide (e.g., suicide or suicide attempt in family members or friends; media reporting)*Adapted from Cash and Bridge (2009).

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Psychiatric Disorder
Psychopathology is another major risk factor for suicide in children andadolescents. Psychiatric disorders are present in 80% to 90% of suicides (Hoertel
et al, 2015, Nock et al, 2013). Mood, anxiety, conduct and substance use disorders are
the most important conditions. School dropout and co-occurring mental disorders
as a consequence of specific learning disorders also play a role (APA, 2013).
Besides co-morbidity the severity of impairment caused by psychiatric symptoms
as well as the total symptom load is of importance. The severity of symptom-related
impairment explained most of the risk for suicidality associated with current
psychiatric disorders in the Great Smoky Mountains Study (Foley et al, 2006).
Sleep problems also seem to be closely associated with suicidality (Wong et al,2016). Within this national survey, two of the three insomnia symptoms had asignificant association with suicide thoughts and plan even after controlling forpsychiatric disorders that were known to affect suicidality. Having trouble falling
sleeping or staying asleep had both direct and indirect relationships (via substanceuse, mood and anxiety disorders) on suicidal behavior.
Apart from the presence of manifest psychiatric disorders, health risk
behaviors (disruptive, sexual, and substance use behaviors) are associated with higher
suicidal risk in young adolescents (Seguin et al, 2014). Feelings of hopelessness andworthlessness as well as impulsive aggression are also linked with suicidality. Althoughthese states often occur within the context of depression or conduct disorder, they
may also be significant in individuals without a psychiatric disorder. This also refers
to the disinhibiting effects of acute intoxication, which may account for suicidal
acts in individuals without manifest substance dependence.
Suicidal behavior can also occur in youngsters without current psychiatricdisorder. In the Great Smoky Mountains Study, youth suicide in the absence ofa psychiatric disorder was related to prior suicidal behavior, legal and disciplinary
problems, and psychiatric disorders in the family.
Family Environment

Émile Durkheim (18581917), French sociologist,
sought to explain suicide asa social phenomenon.

Parental psychopathology and history of suicidal behavior in the family areassociated with higher suicide risk in the offspring. The liability to suicide infamilies may be independent of a family history of psychiatric illness. Children ofparents with mood disorders show more suicide attempts when there is a historyof parental suicidality, as compared to the offspring of parents without suicide
attempts. Family psychopathology – especially suicide attempts in mothers andsubstance misuse in both parents – and family discord predict higher suicidality inadolescence even when psychiatric morbidity is controlled for (Björkenstam et al,
2017, review from Turecki & Brent, 2016).
Adversity
In the Great Smoky Mountains Study, poverty was associated with suicidal
behavior irrespective of the psychiatric profile or the severity of psychopathology.
Stability of the psychosocial network is also relevant. In a Danish study, frequentchanges of residence were associated with an increased risk of attempted andcompleted suicide in children and adolescents (Qin et al, 2009). Younger subgroupsof suicides often present a high burden of adversity and a history of childhood
abuse/neglect (Seguin et al, 2014). The severity of sexual abuse correlated with the

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IACAPAP Textbook of Child and Adolescent Mental HealthModeling suicidal behavior – The “Werther effect”
There has been much discussion about the influence of media depictions of suicidal acts on the frequency of suicide. A
classic example is what happened in Germany after the publication of Goethe’s popular book “The Sorrows of Young Werther”
in 1774. Publication was followed by a number of suicides of young people. This was attributed to the vivid description of theyoung protagonist romantically killing himself after being rejected by the woman he loved. The book was subsequently bannedin most of Europe.
Suicide clustering following media reporting and fictional presentation of suicide on television does occur (“Werthereffect”). According to a German naturalistic study (Schmidtke & Hafner, 1988), broadcast of a soap opera showing the railway
suicide of a 19 year-old male resulted in an increase (175%) in railway
suicides among 15 to 19 year-old males. Factors associated with imitation
are: time (suicides peak in the first few days after publication), amount andprominence of media coverage, similarity between victim and teenager,celebrity status of the victim, specific description of the suicide (method,time, place), romanticized and sensationalized reporting, suggestions that
there is an epidemic, and simplifying the reasons for suicide (World HealthOrganization, 2008).
Suicide attempts and suicides among peers (Hazell & Lewin, 1993) also
increase the risk. Different pathways can lead to a clustering of suicides.
Apart from posttraumatic stress symptoms, bereavement and assortative
friendships with vulnerable peers, mere imitation is a significant factor.

risk of suicide attempts in a Canadian sample (Brezo et al, 2008). This is observed
even in preadolescents. In a study of maltreated 8-year-old children, 10% reported
suicidal ideation (Thompson et al, 2005).
Stressors
Bullying is associated with suicidal attempts and self-harming behavior. In a
two-year longitudinal study bullying and victimization was associated with suicidal
ideation. Interestingly, cyber bullying was not associated with suicidal ideation
after controlling for baseline suicidal ideation (Bannink et al, 2014). In a Finnish
study, frequent victimization among girls was associated with later suicide attempts
and completed suicide even after controlling for psychopathology (Klomek et al,2009).
Other relevant stressors include legal or disciplinary crises, incarceration andschool difficulties. Highly competitive placement examinations for high schools
may contribute to suicide. For example, in 2010 in Turkey, 13 young people aged
up to 19 years committed suicide, which was hypothesized to be associated withrecent academic failure (TurkStat; Suicide Statistics, 2010, 2011).
Sexuality
There is good evidence that gay, lesbian, and bisexual young people are atincreased risk of suicidal behavior (Haas et al, 2011). This may be more so when“coming out” or when families are not supportive (Ryan et al, 2009).
Internet and Social Networks
A broad spectrum of suicide websites is available on the Internet. There
are also helpful “anti-suicide” websites, mostly maintained by self-help groups,
governments, or international organizations. On the other hand, there are sites
clearly celebrating suicide, giving advice on lethal means, offering chat groups
in which users can announce their intention to suicide or fix a date for a joint

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IACAPAP Textbook of Child and Adolescent Mental Healthsuicide (for a review see Marchant et al, 2017). Some of these websites are linked to
specific subcultures (e.g., Emo). A German service aiming to protect youths fromharmful web sites reported about 450 critical sites, about 40% of them promoting
or trivializing suicide.

SUICIDAL BEHAVIOR
Stages of Suicidal Behavior
Suicidality can be conceptualized as a continuum with thoughts about deathat one end and serious suicidal acts at the other (Figure E.4.5; Bronisch & Hegerl,2011). Acute suicidality often develops in a stepwise fashion, with increasing andmore specific ideation and planning overcoming ambivalence and the individual
becoming more and more determined.
As suicidal ideation becomes more specific, a characteristic “pre-suicidal
syndrome” may develop (Ringel, 1959; Ringel, 1976). According to Warnke(2008) it is characterized by:
•
•
•
•
•
•
•

Feelings of hopelessness, self-blame, of being alone and misunderstood
Negative ruminations, self-pity
Inactivity and social withdrawal
Inhibited aggression turned toward the self (auto-aggression)
Suicidal fantasies and planning
Dysphoria
Somatic symptoms, sleep problems, fatigue, and loss of appetite.

Once the decision to commit suicide is made, the suicidal person may
be less agitated and may appear more stable, leading clinicians to underestimate

Number of affected individuals

Figure E.4.5

Stages of suicidality*

Moderatesuicide risk

Thinking about death
Passive wishes
to be deadSuicidal thoughts
Suicidal ideation

ConsiderationHighsuicide risk

Plans for suicide
Preparations

Ambivalence

Suicidalact

Decision*From Bronisch and Hegerl (2011)

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IACAPAP Textbook of Child and Adolescent Mental Healththe suicide risk. Presence of the pre-suicidal syndrome should be a warning sign.
However, this may be less so in children and adolescents in whom impulsive suicide
is more common than in adults. Therefore, it has to be kept in mind that suicide
attempts may occur during any of these stages.
Suicide usually occurs in a crisis and it rarely happens in the absence of otherimportant factors. For this crisis to take place it usually requires a predisposition, a
trigger, a facilitator, and availability of a method to carry it through. Being aware ofthis allows possible interventions to decrease the risk at various stages of the crisis.
• Predisposition. As already discussed, youth who attempt suicide havea predisposition to do so, in many cases because of a mental healthproblem, often depression.
• Trigger. Most suicides or suicide attempts take place after something
happened that made adolescents feel unhappy, afraid or angry. Conflicts
with other people (parents, friends, school, police) are frequent triggers.
Examples are disciplinary crises (when teenagers are found to havedone something wrong such as stealing and are awaiting punishment),a public humiliation, the threat of separation from a girlfriend or
boyfriend, and disclosure of sexual abuse. These are usually perceived as
more catastrophic by the teenager than by other people.
• Facilitator. The strong emotions produced by crises are more likely tolead to suicide if the young person’s judgment is impaired by alcoholor drugs. Other facilitators include identification with someone wellknown or admired who had committed suicide, suicides among family
members or friends, or if the teenager lacks firm religious beliefs thatforbid suicide.
• Opportunity. Finally, adolescents need to have access to the means ofcommitting suicide in an acceptable way for them. Although it may
appear strange, people often have a clear idea about the way they would
like to kill themselves.

Click on the picture tohear a powerful antisuicide message (“If you’recontemplating suicide, thisis for you...”) by the gifted
rapper Angel Haze. Warning:coarse language. (04:12)

As an example, features of the development of suicidality which are relevant
for suicide prevention are shown in figure E.4.6 (American Academy of Child andAdolescent Psychiatry, AACAP, 2001).

CourseIn most studies about the natural history of self-harming behavior no
distinction is made between non suicidal self-injury and suicide attempts. This ispartly due to research relying on data gathered in non-psychiatric routine clinicalcare (without thorough examination with respect to suicidal intent). Moreover,in a significant proportion of patients non suicidal and suicidal self-harm cooccur. As stated above, the risk for completed suicide is considerably increased
in individuals with previous suicide attempts. A recent naturalistic, prospective
study of adolescents followed after psychiatric hospitalization into adulthood,with multiple assessments per participant, provided an opportunity to examine
different developmental trajectories of suicidal thoughts and behaviors, as well as
associated demographic variables, risk factors, protective factors and non suicidal
outcomes (Goldston et al. 2016). The authors analyzed data from 180 adolescents(ages 12–18 at recruitment) who were repeatedly assessed over an average of
13.6 years (2,273 assessments) since their psychiatric hospitalization. The results
indicated four classes that were associated with distinct patterns of correlates

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure E.4.6
Model of the development of suicidality with types oftargeted preventive interventions

Reproduced with permission from Practice parameter for the assessment and treatment of children and adolescents withsuicidal behavior. Journal of the American Academy of Child & Adolescent Psychiatry. 40 (sup):24S-51S. ©2001

American Academy of Child and Adolescent Psychiatry.

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IACAPAP Textbook of Child and Adolescent Mental Healthin risk and protective factors and non suicidal outcomes. The highest risk classcorresponded to chronically anxious and hopeless individuals, with fewer reasonsfor living over time, and increasing impulsivity during adulthood. This was the
only class with a higher likelihood of sexual trauma, and a higher proportion oftime experiencing episodes of major depression and general anxiety disorder. The
increasing risk class was marked by greater impulsivity and self-reported aggression,as well as impairment in role performance throughout adulthood and elevated trait
anxiety. The decreasing and lowest risk classes showed high levels of trait anxiety andfewer reasons for living, but were able to develop greater skills in emotional andbehavioral regulation as they matured, or benefited from changes in circumstances
as they transitioned into living more independently. These data highlight theheterogeneity of developmental patterns of suicidal thoughts and behaviors among
different groups of at-risk youths and young adults.
In a large British sample of children and adolescents aged less than 15 years
who presented to general hospitals because of deliberate self-harm, long-term
follow-up (11 years) pointed to death by suicide in 1% of the patients (Hawton &Harris, 2008). This reflects a relatively low individual risk of completed suicide in
self-harming patients even in the long term. On the other hand, the data suggestthat people who self-harm have a risk of suicide 100 times higher than in thegeneral population.

ASSESSMENT
There are questionnaires to screen for suicide risk in children and adolescents
but will not be discussed here in detail because most are only available in English
and data on their psychometric properties and specific translations are often
supported by too few studies to allow for evaluation of accuracy (Runeson et al,
2017; Horowitz et al, 2009; the interested reader may also refer to AACAP, 2001).

Click on the picture toaccess the Columbia-Suicide
Severity Rating Scale(C-SSRS) training program.

Because of its availability owing to its translation into more than 100
languages, the Columbia–Suicide Severity Rating Scale (C-SSRS; Posner et al,2011) is described. The C-SSRS was designed to distinguish between suicidal
ideation and suicidal behavior measuring four constructs:
1. Severity of ideation (wish to be dead, nonspecific active suicidal
thoughts, suicidal thoughts including methods, suicidal intent, andsuicidal intent with a plan)
2. Intensity of ideation (frequency, duration, controllability, deterrents,
and reason for ideation)
3. Behavior (actual, aborted, and interrupted attempts; preparatory
behavior; and non suicidal self-injurious behavior)
4. Lethality.
Different forms of this scale have been developed, including versions forchildren. Forms are available on the C-SSRS website. Psychometric properties
appear to be good (Posner et al, 2011), and administration time is only a few
minutes. A training program is available on the website, which is required forclinical trials and strongly recommended for clinical practice before administering
the C-SSRS.
Rating scales can be helpful for screening purposes – e.g., in prevention
projects to detect individuals at risk. However, a clinical assessment by a trained
professional is required to assess suicide risk. This assessment should comprise a

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IACAPAP Textbook of Child and Adolescent Mental Health

Table E.4.6
Examples of questions to screen for suicide risk
(DGPPN, 2009)
−
−
−
−
−
−
−
−
−
−

“Have you been thinking that you don’t want to live anymore or that life is not worth
living?”“Does this happen often?”“Do you think about it unintentionally? That is: Have you been bothered by unwanted
suicidal thoughts?”“Have you been able to push these thoughts aside?”“Do you have specific ideas about how you would do it?”“Did you make any plans or preparations?”“Is there anything that prevents you from doing it?”“Did you talk to anyone about your suicidal ideas?”“Did you ever try to kill yourself?”“Has anyone in your family or among your friends or acquaintances committed
suicide?”The co-occurence ofvarious risk factors should
be taken into account.
This is exemplified in thefollowing case vignettes:•

A 14 year-old girl was
unsure about her
sexual orientation;
she had romantic
feelings towards afemale classmate who
had harshly rejected
her recently. The girlperformed poorly
academically and had
become increasingly
depressed threemonths prior to
examination.
Psychiatricassessment was
prompted by her
posting a suicide notein a chat room. Herparents reported thather uncle had diedby suicide two years
earlier.

•

A 16 year-old wasreferred for psychiatricassessment by the
emergency unit whereself-inflicted skincuts on his wrists
had been treated; hewas also inebriated.
The young man had
been stigmatizedby a congenital
haemangioma on his
left cheek. He had
been brought up by
his single mother on
her own, she had
become pregnant
with him at the age of17; she had not hada stable relationship.
The boy had talked
about recent suicide
attempts with hisclassmates.

Table E.4.7
Indicators of acute suicide risk - current individual
factors (mental state examination)
Suicidal ideation:•
No disassociation from suicidality even after a long conversation•
Pressing suicidal thoughts, emerging spontaneously•
Precise suicide plan (method, place, time, or other specifications)•Preparation for suicide, especially in the case of a violent method; preparations to
say goodbye•
Altruistic (pseudo-altruistic) ideas of suicide; ideas of self-sacrifice
Symptoms and co-morbidities:•
Marked hopelessness (missing perspectives for the future; low academic
achievement; failing on the job; the conflict leading to suicidal ideation remains
unsolved)•
Recent social withdrawal•
High agitation, irritability, aggression, emotional instability or panic•
Intoxication (alcohol, drugs)•
Symptoms of acute psychosis•
Impaired impulse control and disinhibition (e.g., in the case of alcohol intoxication,acute delirium or mania)•
Symptoms of severe depression•
Prominent symptoms of personality disorder or conduct disorder, most notably in
combination with alcohol abuse•
Severe self-injuring behavior
Other important factors:•
A stable rapport cannot be established•
Patient making the effort to be admitted to inpatient-treatment•
Time of examination within a one-year period after the last suicide attempt

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IACAPAP Textbook of Child and Adolescent Mental Health

Table E.4.8
Indicators of acute suicide risk - individual factors in thepast (patient history) and in the family (family history)
Patient history•
Previous suicide attempts•
Suicides in the surroundings
Social stresses•
Loss of a loved one - most notably a parent - by suicide, natural or accidental
death, separation, divorce or long-standing absence•
End of a close relationship (romantic or friendship)•
Missing social contacts and poor integration in the peer group leading to feelings ofbeing lonely and rejected, most notably in the case of migration or relocation
Symptoms and co-morbidities•
Aggressive behaviour and delinquency•
Psychiatric disorders, most notably depression and substance misuse/dependency•
Children: poor discipline, school absenteeism
Other important factors•
No religious or similar attachments•
Seemingly unsolvable conflicts due to unwanted pregnancy•
Conflicts due to homosexuality or gender identity
Family history•
Suicides and suicide attempts in family members•
Paternal psychopathology•
A family history of violence, misuse and substance abuse•
Unstable family relations and unresolved conflicts in the family, missing social
support by family members

Access to lethal means increases suicide risk.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table E.4.9 Indicators of acute suicide risk - characteristics of priorsuicide attempt•

Suicide attempts or suicidal thoughts referring to a “hard method” (e.g., hanging,shooting, jumping from a high place, jumping or lying before moving vehicle)
The suicide attempt is well-thought-out with a clear planning
Low chance of help and intervention (specific arrangements were made to prevent
being found, e.g., suicide attempt in isolation, far from others, time of suicide
chosen to prevent being found, not alerting others after the suicidal act)
Others have been informed of the suicide intention, a suicide note was written
A clear wish to die is expressed without relief about being still alive

•
•
•
•

Table E.4.10 Specific issues in the assessment of pre-pubertal children– example of questions*Interviewing children whose grasp of the concepts of time, causality anddeath may be limited:−−−−“Do you think about killing yourself more than once or twice a day?”“Have you tried to kill yourself since last summer/since school began?”“What do you think would happen when you tried to jump out of the window?”“What would happen if you died; what would that be like?”

Interviewing parents about suicidal ideation and behavior in their children−−−−“What exactly happened (step by step) on the day your child spoke of wanting or
tried to hurt himself?”“How did you find out that your child was thinking about or trying to hurt himself?”“What were you doing when your child was thinking about or trying to hurt
himself?”“What happened after your child thought about or tried to hurt himself?”*Jacobsen et al (1994)

Click on the picture to view
the NICE guideline “Selfharm: The Short-Term
Physical and PsychologicalManagement and Secondary
Prevention of Self-Harmin Primary and Secondary
Care”

physical and psychiatric examination including a comprehensive history (withinformation from patient, parents, and significant others) to obtain information
about acute psychosocial stressors, psychiatric diagnoses, current mental status andcircumstances of prior suicide attempts.
Suicidality should be addressed directly and openly in a supportive
atmosphere. There is no risk to cause suicidality by talking about it; there is a riskof ignoring suicidality if the topic is avoided. Assessment should be stepwise, fromgeneral to specific questions. Examples of questions to be asked when screening
for suicidality are given in table E.4.6. Further assessment may be skipped if acutesuicide risk can be ruled out. On the other hand, exploration will be more detailed
if risk factors for suicide become apparent.

Click here to access the NICE
guideline “Self-harm: LongerTerm Management”

A sophisticated exploration will comprehensively cover all known suicide
risk factors; these are summarized in tables E.4.7 to E.4.9 (Warnke, 2008),
comprising:• Current individual factors (mental state examination)• Individual factors in the past (patient’s history) and in the family(family history)• Specific characteristics of prior suicide attempts.

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Table E.4.11 Suicide risk assessment*

High risk

Medium risk

Low risk‘At risk’ mental state•
Depressed•
Psychotic•
Hopelessness, despair•
Guilt, shame, anger,agitation•
Impulsivity

Examples:•Severe depression•
Commandhallucinations ordelusions about dying•
Preoccupied withhopelessness,
despair, feelings ofworthlessness•
Severe anger, hostility.

Examples:•Moderate depression•
Some sadness•
Some symptoms of
psychosis•
Some feelings ofhopelessness•
Moderate anger,
hostility.

Examples:•Nil or mild depression,•sadness•
No psychotic
symptoms•
Feels hopeful about
the future•
None/mild anger,
hostility.

Suicide attempt or suicidal
thoughts•
Intentionality•
Lethality•
Access to means•
Previous suicide
attempts

Examples:•Continual/specificthoughts•
Evidence of clear
intention•
An attempt with highlethality (ever).

Examples:•Frequent thoughts•
Multiple attempts of low
lethality•
Repeated threats.

Examples:•Nil or vague thoughts•
No recent attempt or
one recent attempt oflow lethality and low
intentionality.

Substance disorder(current misuse of alcoholand other drugs)•

Current substanceintoxication, abuse ordependence.

•

Risk of substanceintoxication, abuse ordependence.

•

Nil or infrequent use of
substances.

Corroborative history•
Family, carers•
Medical records•
Other service providers
and sources•

Unable to accessinformation, unable toverify information, or
there is a conflicting
account of events tothat of those of theperson at risk.

•

Access to some
information
Doubts aboutplausibility of person’s
account of events.

•

Able to access orverify information andaccount of events ofperson at risk (logic,
plausibility).

Strengths and supports(coping & connectedness)•
Expressed
communication•
Availability of supports•
Willingness andcapacity of support
persons

Examples:•Patient is refusing help•
Lack of supportive
relationships or hostile
relationships•
Relatives or friends notavailable, unwilling or
unable to help•
Parental mental illness•
Violence or substancemisuse in the family.

Reflective practice•
Level & quality ofengagement•
Changeability of risk
level•
Assessment confidence
in risk level••

Low assessment
confidence or highchangeability or no
rapportPoor engagement•

Examples:•Patient is ambivalent•
Moderateconnectedness•
Few relationships,
may be available but
unwilling or unable tohelp consistently•
Moderate mental
symptoms in family
members•
Some instability or
dysfunctional parenting.

Examples:•Patient is accepting
help•
Therapeutic allianceforming•
Highly connected,
good relationships andsupports•
Relationships willing
and able to help
consistently•
Supporting family
environment.
••

High assessment
confidence and lowchangeability
Good rapport,
engagement.

No (foreseeable) risk: Following comprehensive suicide risk assessment, there is no evidence of current risk to theperson. No thoughts of suicide or history of attempts, has a good social support network.
*Modified from NSW Department of Health (2004, p20)

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IACAPAP Textbook of Child and Adolescent Mental Health

Table E.4.12

Acute management of suicidal behaviour*

High risk or high changeability or low assessment confidence: Re-assess within 24 hours••••

Ensure the patient is in an appropriately safe and secure environment
Organise re-assessment within 24 hours
Organise ongoing management and close monitoring
Make contingency plans for rapid re-assessment if distress or symptoms escalate.

Medium risk (significant but moderate risk): Re-assess within one week••

Organise re-assessment within one week
Make contingency plans for rapid re-assessment if distress or symptoms escalate

Low risk (definite but low suicide risk): Re-assess within one month•••

Organise re-assessment within one month (timeframe for review should be determined based on clinical judgment)
Reassess within one week after discharge from an in-patient unit
Provide written information on 24-hour access to suitable clinical care

*NSW Department of Health (2004a, p21).

Table E.4.10 gives examples of the type of issues that need to be exploredwhen evaluating suicide risk in prepubertal children. Apart from the topics
already mentioned, specific aspects refer to the difficulties interviewing children
whose understanding of time, causality, and death may be inadequate.

RISK ASSESSMENT
Acute Suicide Risk is Low if:
•
•
•
•
•
•
•

There is no major psychiatric disorder present requiring treatment
The patient is able to form an adequate therapeutic alliance with theclinicianThe suicide attempter did not intend to die
The patient clearly and believably states that a re-attempt will not takeplace
The patient is hopeful about the future and has concrete goals withrespect to his engagement in everyday activities
Stable social and family support is available
No significant life stressors are present.

Often suicide risk cannot be excluded definitively and an estimation of
the level of risk is needed. Table E.4.11 presents a summary of factors that need
to be considered for categorizing patients as being at high, medium, low, or noforeseeable risk of suicide (NSW Department of Health, 2004a).
Special attention has to be paid to the changeability of risk (e.g., suicide risk
is not static, it varies due to changes in mental state, relationships or stressors) andto the confidence on the assessment. Low assessment confidence can be attributedto (1) factors within the person (e.g., mental illness, the patient is intoxicated); (2)factors within the social environment (e.g., a divorce with a custody battle causing
one parent to remain silent about problems), or (3) factors within the assessment
procedure (e.g., incomplete assessment, the patient refuses to give information)(NSW Department of Health, 2004a).

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IACAPAP Textbook of Child and Adolescent Mental Health

MANAGEMENT OF SUICIDAL BEHAVIOR
Optimal treatment requires a continuum of services including emergency
intervention, outpatient, home-based, day, and inpatient treatment (Steele &Doey, 2007). In practice, however, this is often not possible due to lack of resources.

Contingency
planning (NSW
Department of Health,2004a, p23).

The first step in managing suicidality is to make sure that the child or
adolescent at risk is safe and receives support. The management strategy depends
on the level and changeability of risk and assessment confidence (see Table E.4.11).

Contingency planningrequires the clinician andthe person at risk and theirfamily to anticipate likely
escalations of risk such as:•
Deterioration of family
relationships•
Increase in symptoms(depression,
insomnia,
hallucinations, suicidal
feelings)•
Temporary
unavailability of theclinician or acute careteam.

At the emergency department, young persons who have made a suicide
attempt should be assessed by an experienced mental health professional, includinginterview with parents or relatives and a thorough risk assessment. Staff should betrained to provide care for suicidal youths, who are often disliked by emergency
room staff. Suicidal youth need to be treated with the same attention and respect
A 14 year old boy (Michael) was meandering on the railway tracks when he was removed
by railway workers. The police were called and initiated a referral to the child psychiatry
service. During assessment Michael admitted that he had repeatedly falsified school reportcards to hide his poor grades. A meeting between his parents and his teacher was to takeplace soon and the truth would inevitably be unearthed. Michael was afraid of his parents’reaction and had no idea about how to deal with this situation. He thought that getting
injured or killed on the tracks was the only way to avoid the confrontation with his parents.
Besides his poor achievement at school no other major risk factors for suicide could bedetermined. He was able to discuss his wrongdoings with his parents who accepted his
apologies. Since there were no symptoms of other mental disorders and he did not intend
harming himself any longer, he was discharged from the child psychiatric unit one day after
admission. An appointment with the child psychiatrist had been scheduled for three days after
discharge. Michael and his parents agreed that involving the school should also be part of the
management plan. Poor grades and the impending meeting with the schoolmaster were still asignificant worry for him.
The contingency plan worked out with Michael and his parents was as follows:
1.

For Michael: If I’m feeling desperate and have a strongurge to harm myself, I will openly talk to my parents.
We will contact <name of the mental health professional>.
<name of the mental health professional> will offer an
appointment on the same or the following day.

2.

For Michael: If my parents are not present at that time,
I will address a person I trust <names of persons>. If nosuch person is available, I will contact <name of the mental
health professional> myself.

3.

For Michael and his parents: If <name of the mental
health professional> cannot be contacted, we will phone<emergency number of the child psychiatric unit> andrequest an immediate appointment. The <child psychiatricunit> will offer this appointment within a few hours.

4.

For Michael’s parents: If Michael feels as described above,
one of us will stay with him until the appointment
takes place. If this cannot be ensured, we will call for an
immediate emergency appointment as specified above.

5.

If, for some reason, <name of the mental healthprofessional> cannot offer an appointment, an
appointment will be organised with a colleague instead.

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Contingency planning may
be framed, communicatedand documented in thefollowing manner:− If the patient <e.g.,
has a worsening ofsuicidal thoughts>,
then the patient
will <actions to be
performed, e.g.,phone doctor NN,
speak with parents
about it>
− The family will
<actions to be
performed by thefamily, e.g., ensure
the patient is not left
alone, phone doctor
NN, give prescribed
medication>− The service will
<actions to be
performed by theservice, e.g., organise
an urgent review, do ahome visit>

23

IACAPAP Textbook of Child and Adolescent Mental Healthas any other patient, avoiding either blaming them for endangering their life or
making well-meant attempts to cheer them up while dismissing the severity of
their predicament. Before discharge, it is essential to have prepared a plan to deal
with the crisis, making sure that supporting contact (e.g., telephone) is available
24 hours a day. “To-do-steps” of the contingency plan will depend on the intensityof the emotional crisis and should be worked out in cooperation with the patientand caregivers (NSW Department of Health, 2004a). Before discharging a suicidal
patient from an emergency unit or crisis center it is always necessary to (AACAP,
2001):• Counsel patient and family about the disinhibiting effects of drugs or
alcohol• Check that firearms and lethal medications and substances can beeffectively secured or removed• Check that there is a supportive person at home
• Check that a follow-up appointment has been scheduled (see Table
E.4.12).
In addition, a no-suicide contract may be helpful (formulated as acommitment by the patient and not as an insurance for the mental healthprofessional since there is no empirical evidence that no-suicide contracts are
actually effective). A no-suicide contract usually includes (1) confirmation thatthe patient is not to endanger his life during a defined short period (e.g., the nextday, until the next session with the therapist); (2) a commitment by the patientto adhere to the therapy; (3) a commitment by the patient to comply with thecontingency plan.
The management of suicidality in youth requires clear communication withthe young person and family. This also holds for contact with the school, whichshould always be attempted after obtaining permission from the young person andfamily.

Important Messages to the Suicidal Youth, His Parents and Teachers
It is essential that clinicians inspire confidence and give the impressionthat they are familiar with this type of problem and in control, avoiding fuelingunnecessary drama but calming, reassuring and soothing everyone involved.
However, one needs to be careful about not deceiving patients or promising things
that one cannot deliver.
Messages to the Suicidal Youth:• My main concern is your safety and I will try to ensure that the best
way I can• Your treatment will be kept confidential unless you give permission to
discuss it with other professionals or unless there is immediate risk toyour or other people’s life
• Many young people think about death or suicide and some try to killthemselves at one time or another• Almost every decision you make can be changed. However, death is
final and irrevocable. It’s worth taking enough time to balance the pros
and cons• We would like to know more about you. Together we may get tounderstand the circumstances that placed you in this crisis

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IACAPAP Textbook of Child and Adolescent Mental Health•••Every suicidal youth I have met had reasons for their self-destructive
ideas but in most cases reasons changed over time
I am sure that together we can find a way out of your predicament –even if this seems out of reach for you right now
As a first step we will try to formulate a contingency plan with you
and your parents.

Messages to parents and caregivers:••

Suicidal thoughts and attempts are not uncommon in young people.
In most of cases, this is an acute crisis that is overcome within a shortperiod of time. We are familiar with managing suicidal crises and will
frankly discuss every step with you
Like with every medical treatment we are bound by confidentiality. In
the course of treatment, it may be useful to establish contact with otherprofessionals (e.g., teachers, psychologists). However, contact will only
be established with your child’s consent or if there is immediate risk toyour child’s life•

The first priority is to ensure your child’s safety. Close supervision isneeded until we can estimate the suicide risk. Depending on theestimated risk, we will decide after consultation with you and your childon further treatment options•

As a first step we will formulate a contingency plan for you, your childand us•

Dealing with suicidal behavior is only effective if there is a close
cooperation between you, your child and treatment team.

Parents should receive specific information on the setting and therapeutic
options for the treatment of their child. They should have the opportunity to
express their opinions and feelings. Unscheduled contact (by phone or face to face)should be offered to deal with suicidal behavior, or if they have worrying questions
or complaints about the management.

Click on the picture to view
eighth grader Jonah Mowryshare his story of years ofbullying and self-injury, andfears for the future (04:36)

Messages to Teachers and School Staff:
•

•

•

•
•

•

Suicide		

When the suicidal youth return to school, a thorough risk estimation
will have been made which will have concluded they are stable enoughto engage in daily school activities
A contingency plan to deal with potential issues will have been worked
out. This includes specific advice about what school staff can do andwho to contact in case of concern about the student
Because school is an important part of a young person’s life, teachersand other school staff can be of assistance in helping students settle
after a suicidal crisis. Specific strategies will be discussed with schoolstaff, the family and health professionals
Teachers should regularly talk to the student and parents to keep trackof his progress
Suicidality is a dynamic rather than a static phenomenon. Hence,
students may experience a crisis again. Teachers should feel free to talk
openly to the young persons if they have concerns that they may be
deteriorating. Avoid arguing or giving hasty advice but speak with thetreating clinician instead.
General strategies in case of a suicidal crisis may include:

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IACAPAP Textbook of Child and Adolescent Mental Health••

Do not leave the suicidal student alone, even for a short time;
escort the student away from other students to a safe place• Ask whether they are in possession of potentially dangerous
objects or medications. If students have dangerous items, try
to persuade them to give them to you but do not engage in aphysical struggle• If a student keeps dangerous items, clearly makes suicidal
statements or is agitated, call an ambulance, the police and thestudent’s parents• If students are cooperative, contact the parents and ask them topick up their child• Tell students and their parents that you would like to contact
the patient’s treating mental health service to inform them of thesituation
School staff should document all actions taken.

Hospital Admission or Not
Not all persons at risk of suicide can or should be admitted to hospital.
Hospitalization may have little benefit and even increase risk for some people.
Many issues are involved in the decision to hospitalize – availability of resources,
hospital beds, informal support networks, and cultural traditions may all play arole – and there are no hard and fast rules but such a decision should be madeon clinical grounds and involving the patient and family. If in doubt, one should
consult with a colleague. In general, hospitalization may be needed if:•••

Suicide risk is high, particularly if no alternative ways of ensuring thepatient’s safety are available
There has been a recent suicide attempt requiring intensive medicalcare
It is not possible to reliably estimate suicide risk.

If hospitalization is required, treatment should ideally take place in a securechild psychiatry ward. If this is not possible – e.g., surgical or medical care isneeded – close supervision of the patient has to be assured. When acute suicidality
occurs together with high agitation, short-term medication may be considered(e.g., benzodiazepines, neuroleptics). Inpatient treatment can be life-saving,
provides relief from acute stressors and overwhelming demands, and may enable
patients to gradually regain control of their lives as well as to start treatment ofconcurrent psychiatric illnesses.
Inpatient units treating suicidal patients should establish protocols tomaximize safety. This includes routine search on admission and further searches
when there are grounds for suspicion. Special attention has to be paid to thephysical surroundings (e.g., hanging points, blind spots, exits, design of windows,
storage of poisonous substances). An “Access to Means of Suicide and Deliberate
Self-Harm Facility Checklist” can be found in the NSW Mental Health Service(2004b).
General Principles for the Management of Suicidality
Management should be individually tailored to target the risk factors
for a specific patient. Interventions should not be restricted to specific

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IACAPAP Textbook of Child and Adolescent Mental Healthpsychopharmacological or psychotherapeutic interventions but involve acomprehensive treatment plan including other strategies to achieve relief fromacute stressors. This will largely depend on the services available. In low income
countries this comprehensive management may be unrealistic. However, in mostplaces, informal supports can be marshalled to ensure patients safety by enlisting
the support of the extended family, community elders and religious figures. These
principles may include:
•

•
•
•

•
•
•
•
•
•
•

Strategies to improve adherence to treatment (e.g., offering shortinterventions that are acceptable to the youth; sometimes focusing on
support is more effective than insight-oriented psychotherapy)
Active involvement of the patient and parents in the planning andimplementation of interventions
Protecting the patient if major adversities threatening the patient’s
mental and physical health are present
Offering support to the family (e.g., in case of marital conflict,problems arising from divorce, parental mental illness, poor parenting
practices, parental substance misuse)
Enlisting support from child welfare agencies if indicatedOrganizing for relief from excessive demands (e.g., school demands
exceeding patients’ current capacity)
Treating underlying psychiatric disorders
Regular monitoring for recurrence of suicidal behavior
An emergency plan for acute suicidal crises
Offering flexible treatment sessions, time and frequency adapted to thepatient’s needs
Establishing an effective communication between all the professionals
involved (social worker, psychotherapist, child psychiatrist,
pediatrician).

Psychosocial Interventions
Psychosocial interventions comprise:
•

•

•

•
•
•

Suicide		Interventions to foster help-seeking behavior and to improve follow-up areimportant because of the low treatment compliance that has repeatedly
been described for youths who attempted suicide: motivating youths
and parents by providing psychoeducation during the attendance to theemergency department. Moreover, compliance is fostered by actively
contacting the families immediately after discharge from the emergency
department (review from Luxton et al, 2013).
Organizing support for the suicidal youth — e.g., by social workers assisting
the youth’s aftercare. Other approaches involve identifying and coachingsupport persons in the patient’s environment (parents, extended family
members, individuals at school or the religious community).
Strategies to improve parent-child relationships. These include improving
problem solving within the family, parenting, and communication
skills.
Cognitive behavior therapy (CBT)Multisystemic therapy (MST)
Dialectic behavioral therapy (DBT) (see Chapter H.4). Originally

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IACAPAP Textbook of Child and Adolescent Mental Healthdeveloped for the treatment of borderline personality disorder,
DBT involves training in mindfulness, interpersonal skills, emotion
regulation, and stress tolerance and it has been adapted for adolescentswith suicidal behavior.
Most effective treatments for suicidal behavior share a number of common
elements: using exploratory interventions to understand the suicidal behavior
and change-oriented interventions to encourage positive and discourage negative
behaviors.
Empirical data on the effectiveness of interventions are sparse and, currently,
no intervention can be recommended over another (Robinson et al, 2011; Turecki& Brent 2016). In respect to engagement in therapy, specific psychologicaltreatments seem not to be superior to treatment as usual (Ougrin & Latif, 2011).
DBT is probably the most commonly investigated psychotherapy for recurrent
suicidal behavior. DBT has repeatedly been shown to reduce the recurrence ofsuicidal behavior relative to treatment as usual, with more modest differences
relative to expert community care (Cochrane review from Stoffers et al, 2013).
However, with respect to reducing recurrence of suicidal behavior, larger effects
are found in adults compared to adolescents, and in individual vs. group treatment
when suicidality is an explicit treatment focus (Turecki & Brent 2016). For
adolescents, a meta-analysis of studies addressing self-harm found an overall effectof treatment vs. therapy as usual, with some of the most promising interventions
being CBT, DBT, and family therapy. Successful interventions were more likely tohave a family component and be offered as multiple sessions (Ougrin et al, 2015).
Psychopharmacological Treatment
There are no specific medications for suicidality. However, medication may
be needed to treat underlying psychiatric disorders. Risk of suicidality with SSRI
use has been extensively discussed (see Chapters A.8 and E.1). The implicationis that depressed adolescents treated with medication, and their families, need toknow about this risk, and what to do if suicidal behavior emerges. They require
careful follow up. For further details on suicide treatment please see also Wasserman
et al, (2012).
Problems and Risks in Treatment
Pitfalls and lapses in the management of suicidal youth may occur if:
•
•
•
•
•
•
•
•
•
•

Suicide		

There is not enough cooperation or communication between theagencies and people involved
Collateral information is not obtained
Comorbid conditions are not detected and treatedDemands and stressors are overlooked
Suicidal behavior is labeled as manipulative or not serious
Minimization (“flight to health”) by the patient is uncritically accepted(e.g., “I am OK”, “There is nothing wrong with me”)
There is too much focus on therapy, overburdening the patient
Confrontation strategies are too hard
There is not enough validation of the patient’s predicament
There is too much use of clichés

E.4

The World HealthOrganization has useful
guides for suicide prevention
targeting:· Physicians· Teachers and schoolstaff· Media professionals

28

IACAPAP Textbook of Child and Adolescent Mental Health

•
•
•
•
•

Termination of treatment or non-adherence is accepted without
scrutiny
Signs of suicide risk are overlooked
Suicidality is not monitored during the course of treatment
Dependence on the therapist is overlooked at the end of treatment
Therapists neglect their own supervision.

PREVENTION
The World Health Organization suicide prevention program (SUPRE)
emphasizes reducing mortality, morbidity and other consequences of suicidal
behaviors by:• Minimizing access to means of suicide (e.g., toxic substances, firearms)• Early detection and treatment of mental disorders, and• Responsible media reporting of suicide.
Risk factors are universal but their nature and relative importance differ
from region to region. The WHO is running suicide prevention programs taking
Table E.4.13
p16)

Preventing suicide: recommendations for teachers and school staff (WHO, 2000;

Suicide is not an incomprehensible bolt from the blue: suicidal students give people around them enough warnings and scope
to intervene. In suicide prevention work, teachers and other school staff face a challenge of great strategic importance, inwhich it is fundamental to:
•
•
•
•
•
•
•
•

Identify students with personality disturbances and offer them psychological support
Forge closer bonds with young people by talking to them and trying to understand and help
Alleviate mental distress
Be observant of and trained in the early recognition of suicidal communication whether through verbal statements
and/or behavioral changes
Help less skillful students with their school work, to be observant of truancy
De-stigmatize mental illness and help to eliminate misuse of alcohol and drugs, to refer students for treatment of
psychiatric disorders and alcohol and drug abuse
Restrict students’ access to means of suicide - toxic and lethal drugs, pesticides, firearms and other weapons, etc.
Give teachers and other school personnel on-the-spot access to means of alleviating their stress at work.

Table E.4.14
•
•
•
•
•
•
•
•
•
•
•

Suicide		Preventing suicide: recommendations for media professionals (WHO, 2008; p3)

Take the opportunity to educate the public about suicide
Avoid language which sensationalizes or normalizes suicide, or presents it as a solution to problems
Avoid prominent placement and undue repetition of stories about suicide
Avoid explicit description of the method used in a completed or attempted suicide
Avoid providing detailed information about the site of a completed or attempted suicide
Word headlines carefully
Exercise caution in using photographs or video footage
Take particular care in reporting celebrity suicides
Recognize that media professionals themselves may be affected by stories about suicide
Show due consideration for people bereaved by suicide
Provide information about where to seek help

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29

IACAPAP Textbook of Child and Adolescent Mental Healthculture-specific issues into account. For example, enhancing early recognition
and treatment of mental disorders may be more important in low- than highincome countries; controlling access to firearms is more important in the US thanin Western Europe where building physical barriers (e.g., in bridges, railways)
to make jumping difficult is more relevant. Restricting access to pesticides andeducation about their effects are especially important in the countryside in lowand middle-income countries. Reducing harmful alcohol consumption is a major
concern in Western and Eastern Europe, but of minor importance in the Middle
East. Programs addressing the disadvantage of minority indigenous peoples arealso necessary (e.g., Indigenous Australians, Maori in New Zealand, American
Indians, and Inuit in Canada and Greenland).
Recommendations for schools and media professionals are summarized inTables E.4.13 and E.4.14. For an overview of preventive strategies please see figure
E.4.6.
Empirical evidence for the effectiveness of suicide-preventive interventions
in reducing suicidal behavior is still rather poor but has strengthened during thepast decade (Katz et al, 2013; Zalsman et al, 2016; AACAP, 2001). The following
strategies have been investigated in interventional studies:• Restricting access to lethal means, e.g., firearms, analgesics, or hot-spots
for suicide by jumping (effective and recommended)• Pharmacological and psychological treatments of depression (effective
and recommended; anti-suicidal effects of clozapine and lithium havebeen demonstrated in adults)• Direct case-finding among students or among the patients of primarycare practitioners by screening for conditions that place teenagers at risk
for suicide (inconsistent data on effectiveness but recommended)• Media counseling to minimize imitative suicide (inconsistent data on
effectiveness but recommended)• School-based awareness programs (were shown to reduce suicide
attempts; however, there are also data showing that indirect casefinding by educating the public, e.g., teachers, parents, peers, to identify
warning signs may also increase suicides)• Gatekeeper training, education of physicians, and internet and crisis
helpline support (inconsistent data on effectiveness but recommended).

NON SUICIDAL SELF-INJURY
This section deals with non suicidal self-injury (NSSI) in emotionally unstablepatients acting out their inner distress. However, self-harming behavior may also
occur in other psychiatric conditions such as in psychosis, mental retardation,
pervasive development disorders, and severe deprivation. For management of selfharm in these disorders please refer to the respective chapter in this textbook. In
addition to being dangerous in its own right, NSSI may be a risk factor for futuresuicidal behavior.

IS SUICIDEPREDICTABLE?
Two meta-analyses mayhelp to clarify this. Largeet al (2016) reviewed
longitudinal cohort studies
on psychiatric patientsor people with suicide
attempts stratified into
high-risk and lower-risk
groups for suicide. Aftera mean follow-up of six
years, 5.5% of the subjects
in the high-risk group vs.
1% of those in the lowerrisk group committed
suicide. However, theaccuracy of prediction was
low and the combinationof multiple risk factors for
suicide did not substantiallyexceed the predictive
power of individual risk
factors. Chan et al (2016)
examined prospective
studies on risk factors andrating scales to predict
suicide following self-harm.
Again, the accuracy of
prediction was low andthe statistically significant
risk factors (repeatedself-harm, suicidal intend,
male gender, physicalhealth problems) are
quite common in clinicalpopulations and not specificfor suicidality. It can beconcluded that there
are no reliable statisticalstrategies available to allow
an accurate prediction ofsuicide. In clinical practice,a categorization into highor low suicide risk basedon rating scales may be
misleading and cannot berecommended. A thoroughclinical assessment of thepatient covering individual
risks and needs is
indispensable.

Non suicidal self-injury mainly involve skin lesions (e.g., cutting or carving
the skin; picking at a wound; scraping, erasing or picking the skin until it bleeds;
self-biting; inserting objects under the skin; self-tattooing; burning or freezing theskin; pulling hair out; self-hitting). Swallowing sharp or non-edible objects andnon suicidal self-poisoning also occur. Refusal to take prescribed medication in

Suicide		

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IACAPAP Textbook of Child and Adolescent Mental Healththe case of severe illness or risky behaviors as a symptom of a specific psychiatricdisorder are usually not subsumed under the concept of NSSI (e.g., refusing to eat
in the case of anorexia nervosa, self-mutilation in the context of psychosis, autoaggressive behavior in mental retardation). The relationship between culturally
sanctioned self-mutilation (e.g., in the Goth scene in some Western societies,
initiation rituals) and NSSI is not well understood.
Epidemiology
Non suicidal, deliberate self-injury is very frequent in high-income countries.
Lifetime prevalence of these behaviors range from 5.5–17% in community samples(among teens and adults respectively) and 50% in clinical samples (meta-analysis
from Fox et al, 2015). Although there is little knowledge about the prevalenceof NSSI before the early 2000s, prevalence rates have been rather stable acrosspublications from different countries within the past 15 years when controllingfor methodological differences (review from Brown & Plener, 2017). Prevalence
is higher in late adolescence than early adolescence or childhood. The peak age of
onset is early adolescence, between 12 and 14 years of age.
Risk Factors
NSSI in adolescents is associated with high psychiatric morbidity, especiallymood disorders, substance use disorders, and externalizing disorders (Nitkowski& Petermann, 2011). However, data on psychiatric morbidity in self-injuring
individuals are limited because they mainly refer to clinical samples. According
to a recent meta-analysis among specific NSSI risk factors, prior history of NSSI,
cluster B personality disorder, and perceived hopelessness yielded the strongest
predictive values (odds ratio > 3) (Fox et al, 2015). However, these results have to
be interpreted with care since standardized NSSI measurement is still not available.
Besides psychopathology, other risk factors associated with NSSI areadolescent age, female gender, being bullied, negative life events, and symptoms
often linked with psychiatric morbidity (e.g. depression, dissociation, anxiety poor
self-esteem, deficits in emotion regulation) (for a review see Bresin & Schoenleber,
2015; Brunstein Klomek et al, 2016; Rasmussen et al, 2016; Jacobson & Gould,2007). Stressful life events often involve interpersonal conflict, losses, family
discord, difficulties with friends, problems in romantic relationships, and school
Table E.4.15 Hypothesized functions of non suicidal self-injury and support by empiricalevidence.*
Function

Description

Evidence

Affect-regulation

To diminish acute negative affect or aversive affective arousal

StrongAnti-dissociation

To end feelings of depersonalization or other dissociative states

ModestAnti-suicide

To replace, compromise with, or avoid suicide attempts

ModestInterpersonal boundaries

To assert one's autonomy or a distinction between self and others

ModestInterpersonal-influence

To seek help from or manipulate others

ModestSelf-punishment

To punish oneself or express anger towards oneself

StrongSensation-seeking

To generate excitement

Modest*Klonsky (2007)

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IACAPAP Textbook of Child and Adolescent Mental Health

Table E.4.16 Functional analysis of the consequences of non suicidal self-injury*
IntrapersonalInterpersonal

Positive
reinforcement··

To punish oneself
To feel relaxed·

Negative
reinforcement·

To distract from negative thoughts andfeelings (affect-regulation)
To feel something, even if it is pain (antidissociation)
Injuries may prevent from engaging inserious self-harm (anti-suicide)

·

·
·

·

To get attention or help from significant
othersTo make others angry, punish them or toexert control
To avoid doing something unpleasant(this should be differentiated frommalingering)*Nock and Prinstein (2004)

problems (de Kloet et al, 2011).
Jacobson et al (2008) in a chart review compared four groups of adolescentoutpatients: (1) no NSSI, (2) NSSI alone, (3) suicide attempt, and (4) suicide
attempt plus NSSI. They found that NSSI patients had similar rates of suicidal
ideation as those without deliberate self-harm, supporting the validity of the
distinction between suicide attempts and NSSI. Other results point to thefollowing additional conclusions (Jacobson & Gould, 2007):• Depression seems not to be a specific risk factor for NSSI (as comparedto suicide attempt)• The co-occurrence of NSSI and suicide attempts points to a more severe
psychopathology• All risk factors empirically found for NSSI are not specific and are alsorisk factors for suicidal behavior• Suicidal behavior and NSSI are related: engaging in one behavior
increases the likelihood of engaging in the other (Lofthouse & YagerSchweller, 2009).
Table E.4.15 summarizes the different psychological functions that may be
fulfilled by NSSI. According to a review by Klonsky (2007) all these models are atleast moderately supported by empirical evidence. A framework to analyze NSSI
behavior is provided by operant learning theory and summarized in Table E.4.16(Nock & Prinstein, 2004, see also Brown & Plener, 2017). Self-injuring behavior
has positive and negative reinforcement aspects and meets both intrapersonal andinterpersonal (social) functions.
Clinical Course
Most NSSI in adolescents resolves spontaneously by the time they become
young adults. A series of surveys that followed 1800 adolescents from the age of
14-15 years found that about one in ten had self-harmed (Moran et al, 2011).
Self-harm was more frequent in girls and the most common method was cutting
or burning. However, self-harm declined significantly by the age of 17, with nineout of ten of those who initially reported self-harm reporting not self-harmingin young adulthood. Self-harm was more likely to persist in females and it was

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IACAPAP Textbook of Child and Adolescent Mental Healthassociated with depression and anxiety, antisocial behavior, high risk alcohol use,
cannabis use, and cigarette smoking.

Assessment
Every child or adolescent who has self-harmed should be assessed for risk ofrepetition and suicide risk. According to the NICE guideline (2011), assessment
should take into account:
•
•
•
•
•

•

•

•

•

Methods and frequency of current and past self-harmCurrent and past suicidal intent
Depressive symptoms and their relationship to self-harm
Psychiatric illness and its relationship to self-harm
The personal and social context and any other specific factors
preceding self-harm such as specific unpleasant affective states or
emotions and changes in relationships
Specific risk factors and protective factors (social, psychological,
pharmacological, and motivational) that may increase or decrease therisks associated with self-harm
Coping strategies that the person has used to either successfully limit
or avert self-harm or to contain the impact of personal, social or otherfactors preceding episodes of self-harm
Significant relationships that may either be supportive or represent a
threat (such as abuse or neglect) and may lead to changes in the levelof risk
Immediate and longer-term risks.

Parents and other important caregivers should be included in the assessment.
Individual assessment is essential and should take into account the psychologicalneeds met by the self-harm described in Table E.4.15; in each individual patient
one or more of them may predominate (please see also Bresin & Gordon, 2013).
The use of risk assessment tools and scales to predict future suicide or repetition ofself-harm is not recommended by the NICE guideline.

A 16 year-old girl wascalled by her boyfriend
who cancelled theirdate scheduled for thatevening because his
soccer (football) mates
were having a meeting
he preferred to go to(antecedent). She agreed
during the phone call but
afterwards she felt hurt
and negative thoughts
proliferated (“he doesn’t
love me”, “I will lose him”,“I am not attractive tohim or to anybody else”).
The girl felt increasingly
desperate, angry withherself; urges to harm
herself began to emerge.
Finally, she began cutting
her arms superficially witha razor, watching the blood
seeping from the wounds(cognitive, emotional andbehavioral reactions).
While watching her arms
bleed she felt relieved(reinforcing consequence).
When her boyfriend foundout what had happened,
he apologized andcomforted her (reinforcing
consequence) andpromised never to do
anything similar again(reinforcing consequence).
Together with her therapist,
she explored alternative
ways of coping with thissituation: planning dates
more carefully; voicing her
disappointment and her
wishes instead of silently
accepting; examining
alternative interpretationsof her boyfriend’s behavior
instead of devaluating
herself; finding alternative
activities for the evening;
considering the long-term
consequences of self-harm(e.g., scarring); rewarding
herself for alternative
behaviors.

Treatment
For detailed information please refer to the NICE clinical guideline (NICE,
2013). This quality standard covers the initial management of self-harm and the

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IACAPAP Textbook of Child and Adolescent Mental Healthprovision of longer-term support for children and young people (aged 8 to 18)
who self-harm. It describes high-quality care in priority areas for improvement.
Hospitalization is needed if:• NSSI co-occurs with high suicide risk
• NSSI coexists with severe comorbid disorders requiring inpatient
treatment• NSSI severely endangers the physical health or social functioning of
the patient (e.g., repeated surgery is needed, self-harming behavior at
school)• Outpatient treatment has not been successful,• A reliable assessment is not possible in an outpatient setting.
Patients severely harming themselves may need the same close supervision as
patients with high or moderate suicide risk. Following the NICE (2011) guideline,
long-term treatment of self-harm involves psychoeducation of patients and theirfamilies. Treatment goals may include:
•
•
•
•
•
•
•

Preventing escalation of self-harm
Reducing harm arising from self-harm
Reducing or stopping self-harm
Reducing or stopping other risk-related behavior
Improving social or occupational functioning
Improving quality of life
Improving any associated mental health condition.

A risk management plan should be developed covering strategies to deal
with the risks identified (psychological, pharmacological, social, and relational).
This plan should include self-management strategies and ways of accessing services
and receiving support during a crisis when self-management strategies fail.
The NICE guideline also recommends considering short-term psychologicalinterventions that specifically target the self-harm. Interventions could include
cognitive-behavioral, psychodynamic, or problem-solving elements – therapists
should be specifically trained in the treatment they use in the management ofself-harm. Strategies may involve interventions already described earlier in thesection on management of suicidal behavior. Individual treatment should be basedon a functional analysis of the self-harming behavior that takes into account (1)antecedents, (2) type of self-harming behavior and associated cognitions, emotions,and sensations, and (3) the consequences of self-harm, mainly in terms of thepsychological needs met by NSSI, described in Table E.4.15.
Alternative behaviors that can be helpful instead of self-injuring comprise:••

Suicide		Low urge to self-harm: distracting activities such as playing with a pet,listening to music and singing, reading, writing, painting, calling afriend, counting breaths, taking a warm bath, taking a walk to be nearother people, using meditation or relaxation techniques, listening to
a comedy tape or video, repeating 5 things one sees, smells, touches,
tastes in the present surroundings
Medium urge to self-harm: highly activating behavior, high sensory or low
painful non-harming stimulation, such as eating a lemon, snapping a

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34

IACAPAP Textbook of Child and Adolescent Mental Health•rubber band on the wrist, running, biking, sit-ups, hitting pillows,dancing, using a red felt tip pen to mark regions on the skin wherecutting usually occurs, squeezing a stress ball, making some noise,screaming into a pillow, tearing up paper (old phone books, newspapers)
High urge to self-harm: moderate painful non-harming stimulation, e.g.
chewing a jalapeño pepper, taking a very cold shower, placing hands infreezing cold water, walking with dried peas in the shoes, rubbing ice
across the skin where cutting usually occurs

In severe cases, advice on damage limitation techniques should be given(using a clean and sharp blade, avoiding cutting areas near major veins and arteries,
not sharing instruments used for self-harm, ensuring tetanus protection, having
access to first aid and a basic knowledge of medical care, avoiding alcohol/drug use
in association with self-harm)
Despite encouraging results from pilot studies, empirical evidence for theefficacy of psychosocial interventions, including dialectic behavior therapy, in thetreatment of self-injuring behavior in adolescents still is limited (Wilkinson &Goodyer, 2011; Plener et al, 2016). There is also no evidence supporting the useof medication to reduce self-harm, although medication may be indicated to treat
comorbid disorders.

Ophelia (detail), Sir John Everett Millais, 1851-52 (Tate Britain, London)

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IACAPAP Textbook of Child and Adolescent Mental Health

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Bannink R, Broeren S, van de Looij-Jansen PM (2014). Cyberand traditional bullying victimization as a risk factor
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Bertolote JM, Fleischman A (2009). A global perspective on themagnitude of suicide mortality. In D Wasserman &C Wasserman (eds) Oxford Textbook of Suicidology andSuicide Prevention. A Global Perspective, New York:
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Björkenstam C, Kosidou K, Björkenstam E (2017). Childhood
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548 721 adolescents and young adults in Sweden.
British Medical Journal, 357:j1334 http://dx.doi.
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Bresin K, Schoenleber M (2015). Gender differences in theprevalence of nonsuicidal self-injury: a meta-analysis.
Clinical Psychology Review, 38:55–64.
Bresin K, Gordon KH (2013). Changes in negative affectfollowing pain (vs. nonpainful) stimulation in
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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix A.4.1
SELF-ASSESSMENT EXERCISES
A.4.1 These factors are indicators ofsuicide risk in the family history
except:A) Suicides and suicide attempts in family
membersB) Paternal psychopathologyC) A family history of violenceD) Unstable family relations and unresolved
conflicts in the familyE) A large number of siblings

A.4.2 The effect of media depictions ofsuicidal acts
A)
B)
C)
D)
E)

Is called “Papageno” effect.
Is called “Werther” effect.
Does not occur in adolescence.
Is not influenced by adapted reporting.
Only occurs in adulthood.

A.4.5 These are all symptoms and comorbidities that may indicate acutesuicide risk except:
A)
B)
C)
D)
E)

Tourette’s disorderMarked hopelessness
Recent social withdrawal
Intoxication (alcohol, drugs)
Symptoms of severe depression

A.4.6 Acute suicide risk is high if:
A) There is no major psychiatric disorderpresentB) The patient is able to form an adequate
therapeutic alliance with the clinician.
C) The patient is hopeful about the futureD) Stable social and family support isavailable.
E) The patient has a history of previous
suicide attempts.

A.4.3 These are all characteristic of the“pre-suicidal syndrome” except:

A.4.7 All these are helpful messages to asuicidal youth except:A) Feelings of hopelessness, self-blame, of
being alone and misunderstoodB) Negative ruminations, self-pityC) Inactivity and social withdrawal
D) ObsessionsE) Suicidal fantasies and planningA) “My main concern is your safety and I will
try to ensure that the best way I can”B) “Many young people think about death or
suicide and some try to kill themselves at
one time or another”
C) “I cannot help you”
D) “Almost every decision you make canbe changed. However, death is final andirrevocable. It’s worth taking enough time
to balance the pros and cons”
E) “I would like to know more about you”.
Together we may get to understand thecircumstances that placed you in thissituation”

A.4.4 These are all major
psychopathological risk factors for
suicide among adolescents except:A) Severe major depressive disorderB) The combination of mood, disruptive, andsubstance use disordersC) Attention-deficit hyperactivity disorderD) Feelings of hopelessness andworthlessnessE) Impulsive aggression

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IACAPAP Textbook of Child and Adolescent Mental Health

A.4.8 These are helpful messages toparents or caregivers of a suicidal
youth except:A) “Suicidal thoughts and attempts are notuncommon in young people. In mostof cases, this is an acute crisis that is
overcome in a short period of time”
B) “We are familiar with managing suicidal
crises and will frankly discuss every stepwith you”
C) “As a first step we will formulate acontingency plan for you, your child andus”
D) “It is not important to supervise your childclosely”
E) “Dealing with suicidal behavior is only
effective if there is a close cooperation
between you, your child and the treatment
team”

Suicide		E.4

A.4.9 What is the specificpsychopharmacological treatment
for suicidal youth?
A)
B)
C)
D)
E)

Neuroleptics
SSRIs
Stimulants
There are no specific medications for
suicidality.
Benzodiazepines

A.4.10 Non-suicidal self-injury differs froma suicide attempt in that it:A) Occurs predominantly in pre-pubertal
youthB) Does not have suicidal intent
C) Is carried out impulsively
D) Usually happens in a group contextE) Is more common in males.

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IACAPAP Textbook of Child and Adolescent Mental HealthANSWERS

A.4.1: E. See page 18, Table E.4.8
A.4.2: B. Page 12
A.4.3: D. Page 13
A.4.4: C. Page 10, Table E.4.5
A4.5:

A. Page 17, Table E.4.7

A.4.6: E. Pages 18, 21
A.4.7: C. Page 23
A.4.8: D. Page 24
A.4.9: D. Page 27
A.4.10: B. Pages 31, 32

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