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Suicidal Behavior of Children and Youth
Symposium on Behavioral Pediatrics
Suicidal Behavior of Children and Youth
Elizabeth R. McAnarney, M.D.':'
There has always been a higher incidence of successful suicides of teenagers compared to younger children, and for adolescents, suicidal behavior is becoming an increasing problem. In 1968, 5.1 deaths by suicide per 100,000 adolescents were recorded, compared to 4.0 per 100,000 in 1965. Children less than 14 years of age commit suicide infrequently.L 2, 4,10 In 1965 in the United States, 103 youngsters 10 to 14 years old took their lives,12 Suicide is now the fourth most common cause of death during the teenage years, preceded in frequency only by accidents, malignancies and homicidesY However, death by suicide is probably under-reported. The pediatrician may be called first after a teenager attempts suicide and his response to the adolescent and his family will depend upon his knowledge and attitude about suicide. Few physicians have had formal training in this area, and their fund of information may be limited. In one survey of 56 practicing physicians, only 7 per cent reported having had any education in residency training about suicide and only 9 per cent thought their knowledge was sufficienU Some doctors may feel uncomfortable caring for suicidal adolescents, partly because of this lack of knowledge, but also because of their own ambivalence about life and death issues of youth. It is sometimes difficult for those in the health care professions to face the prospect of a teenager's death, particularly that resulting from self-destructive behavior. The doctor may not recognize his own feelings of anger at the youngster who is trying to hurt himself at a time when he should be growing and developing. The physician may also resent the professional time taken from "really sick patients" who line his waiting room or the emergency department. From the Adolescent Program, Departments of Pediatrics, Psychiatry, Medicine and Obstetrics-Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York ':'Assistant Professor of Pediatrics, Psychiatry and Medicine, The University of Rochester School of Medicine and Dentistry; Associate Pediatrician, Strong Memorial Hospital, Rochester, New York Supported by Patient Care Programs-Demonstration Teaching Project in Family Medical and Adolescent Care; Maternal Child Health Service, Project 148, Rochester-Monroe County Youth Board, Rochester, New York
Pediatric Clinics of North America- Vol. 22, No.3, August 1975
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Of more serious import, the pediatrician may not recognize the acute nature of his suicidal patient's distress and need for help. An additional practical issue, in addition to physician knowledge and attitude, is that follow-up of the suicidal teenager can be complex and time-consuming, and the doctor may think that he does not have the time to assume responsibility for his care. As a result of all these factors, the physician may be reluctant to manage suicidal adolescents in his practice. Nonetheless, pediatricians are in an ideal position to assume some responsibility in the care of these patients. Each physician should define his own role in the care of suicidal youth. He should have a basic understanding of adolescence, appreciate the meaning of suicidal behavior, know how to differentiate between a gesture and an attempt, be able to plan for the evaluation and management treatment program of these patients, and be aware of other health care facilities in his community. His degree of involvement beyond the initial evaluation will depend upon his own skills, his comfort in working with suicidal youth, and community resources. "Although there is no single explanation for adolescent suicidal behavior, clinical experience and a wealth of data indicate that the most common denominator in both suicide attempters and suicide com pIeters is a depressive constellation of feelings of deprivation, guilt, helplessness and impulsive rejection."12 The teenager's family or the physician involved may not easily recognize the youngster's symptoms of depression. The adult who feels depressed gives the typical history of somatic complaints: anorexia, constipation or sleep difficulties. The adolescent may not know he is depressed and may complain of other symptoms or depressive equivalents such as boredom, restlessness, fatigue, bodily preoccupation, concentration difficulties, acting-out behavior or flight to and from others.12 Older teenagers may experience symptoms of both early adolescent and adult depression and thus it may be easier to recognize depression in them. Teenagers who try suicide may have both chronic and acute problems. Frequently, there is a history of chronic family disorganization with loss of a parent by deathS or by divorce or separation. 9 Acute losses include termination of a relationship with a boyfriend or girlfriend, death of a family member, a move away from a familiar setting or pregnancy. Acute crises usually occur against a background of chronic problems, and the teenager may think that he cannot handle all of these concerns.1O At this point, the youngster may use non suicidal means of communicating his distress (acting-out, running away, getting pregnant). If his environment does not respond positively to him, he may then resort to suicidal means to gain attention or help. The ratio of gestures to successful suicides is between 50 and 120 to 1. 12 These figures may not be entirely accurate as suicidal gestures may go undiagnosed, as may suicides. Some gestures do not come to the attention of health professionals, and even if the teenager comes to a medical facility, suicidal behavior may not be recognized. A review of the diagnoses of 50 youngsters treated at two poison control centers showed that on initial evaluation, 42 per cent were "accidents" and 58 per cent
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suicidal attempts. On re-study, the "accidents" represented only 4 per cent of the diagnoses, suicidal gestures 70 per cent, suicidal attempts 2 per cent, intoxication 22 per cent, and homicide, 2 per cent. More teenage girls make suicidal gestures than boys; more boys than girls are successful in taking their lives. Gestures usually consist of drug or poison ingestion; successful suicides are most often by firearms. One study reported a high incidence of suicidal gestures by Puerto Rican youth and by youngsters in unsupervised settings at the time of the attempt. The lowest incidence of suicide was in the fall; the highest in the spring. 5 The pediatrician who recognizes depression and behavioral problems in his adolescent patient may intervene at that time in an effort to avert a suicidal gesture. In other cases, he will not see the teenagers until after the attempt has been made, and thus will also need to be prepared to care for these youngsters.
PREVENTION OF SUICIDE Teenagers who attempt suicide often have histories of trying first to communicate their distress by non suicidal means. The adolescent may give a prior history of falling school marks or acting-out behaviors. Faigel noted, "Danger signs which should alert the physician to the possibility of an attempt at self-destruction are attempts at suicide, accident proneness, recent anger, deflated self-image, sex anxieties and depression."3 The primary care physician should recognize these behaviors as potentially pre-suicidal. Intervention by the professional at the time that the teenager's marks start dropping or immediately after he has run away may prevent the youngster from feeling hopeless and resorting to suicide. Contacts with pre-suicidal youngsters, after initial psychological evaluation, consist of regular visits to the physician, nurse, social worker or school counselor. The adult and adolescent should work on possible solutions to the problems. The patient often benefits from being given a telephone number through which the professional can be reached, both day and night, so he will have an adult in whom he can confide. Teenagers often use the telephone very effectively in this context. In some cities, "hot lines" provide crisis intervention, but the ideal situation is one in which the teenager has access to a health care facility where there is a professional who knows the youngster and cares about helping him solve his problems.
THE SUICIDAL CHILD AND ADOLESCENT If a child is talking of suicide, then both he and his family should be evaluated psychologically. The first contact should be in the doctor's office. Psychiatric referral will depend upon the results of the initial eval-
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uation. Some children who talk of suicide are significantly disturbed, and for those who are not, there are frequently major family disruptions to which the child is attempting to draw attention. Any child who attempts suicide should be seen in psychiatric consultation.
The Teenager Who Talks of Suicide Some teenagers talk openly to the physician about suicide. Others are unable to discuss their thoughts, because it is too frightening. Only when the doctor asks his patient whether he has considered suicide may he then say he has been thinking about taking his life. When the depressed youngster does not initiate discussion about feeling suicidal, the physician may comment: "When people are depressed, they sometimes think of taking their own lives. I am concerned because you seem depressed, and I wonder if you have had such thoughts?" Discussion of the youngster's suicidal ideation will not suggest that he commit suicide, nor will it encourage his self-destructive tendencies. In fact, it may tell the teenager something about the physician. It says that the doctor understands that the depressed adolescent may feel suicidal and that this is an acceptable feeling. Second, the physician's communication with his patient is open. Third, the doctor is not afraid to talk about suicide, a thought which may be frightening to the youngster. The teenager may feel relieved that the physician initiated this discussion. After confirming that the teenager is suicidal, both the adolescent and his family should be evaluated separately and together. The focus should be on the youngster's suicidal intention, his psychologieal status and family function. After the initial evaluation of the teenager and his family, a decision about future care should be made. The professional training of the psychiatrist, nonpsychiatric physician, school counselor, social worker, nurse or minister is probably unimportant, except when the youngster is severely depressed or psychotic and in need of psychiatric care. The important factor in following a depressed, potentially suicidal youth is that the professional is an understanding, sensitive person who develops a relationship of mutual trust with the teenager at a time in his life when he is feeling rejected and hopeless. The Teenager Who Attempts Suicide Medical management of the patient who attempts suicide is the first priority of the physician. A detailed discussion of the medical care of suicidal youth will not be undertaken here. Instead, the focus will be on the behavioral evaluation and management of suicidal teenagers. The major issue is to decide whether the suicide attempt was a gesture or a serious attempt. The youngster should be evaluated psychologically initially, but, if there are any signs of drug-induced toxicity, further study should be made after he is in a nontoxic state. The first portion of the evaluation is a separate interview with the adolescent and with his parents. A decision about a family interview can be reached after the separate ones.
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TEENAGER. The Suicidal Act. 1. A description of the events leading up to the suicidal attempt, including any specific precipitating occurrences. 2. What method was used? What does the patient know of the lethality of this method? If he ingested a substance, what was it; what amount; how long before . being seen was it taken; did he vomit; if he injured himself, how did he do it? 3. Was his intention to take his life or to manipulate his environment? Was it spontaneous or well planned? 4. Was there a note or other communication? 5. Will he repeat again if he has a chance? School History. 1. In general, how are things going? 2. What school is he in? What grade is he in? 3. What is his acadeInic standing? Are there any recent changes in grades? 4. What is his attendance record over the last year? The last 6 months? 5. Have there been any recent behavioral problems (fighting, running away from school)? Peers. 1. Who are his friends by name, age, sex? What are their activities? 2. Does he have a girlfriend? Are there any problems with her recently? Family. 1. What are his parents' ages, marital status, and health? 2. What are the names of his siblings and their ages? How are they doing in school? Chronic Problems. The doctor should discuss any chronic faInily, school, or peer problems the teenager has had and how he has tried to solve them. Psychological Status (nontoxic state) Is he depressed, psychotic, angry? INTERVIEW WITH PARENTS. Family Status. 1. In general, are they concerned about the adolescent's suicidal attempt? 2. What is the parents' marital status and occupational level? Who are the other faInily members? Are there individuals other than the faInily living in the home? 3. How does the faInily spend its time? 4. What is their level of communication? 5. Are there any major current faInily problems (financial, marital)? Teenager. 1. Do they think he is having problems? What are they? 2. What have the parents tried to do about their teenager's problems? 3. What do they think should be done? 4. How is his peer interaction? 5. How is he doing in school? 6. How does he behave at home?
Having obtained a history from the patient and his family and having evaluated the family function, the next step is to organize these data into meaningful form. Table 1 distinguishes between a suicidal gesture and an attempt. Four case presentations illustrate the use of the chart. CASE 1. SUICIDAL GESTURE. P.T. was a 14 year old girl who ingested 20 five grain aspirin tablets 1 hour before arriving in the emergency department. She nad no previous history of drug ingestion and had recently broken up with her boyfriend. She left a note that read, "For starters, I find Tim is cheating on me with all those girls at his trailer... No one cares about me." Additionally, her mother said that she was bored and had failed her school grade the year before. On interview, P.T. was lucid and moderately depressed. She was sorry she had taken the aspirin, but wanted Tim and her faInily to know of her distress. The fact that mother and father had both responded immediately by bringing her to the emergency department indicated their true and open concern.
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Table 1.
R.
McANARNEY
Factors Distinguishing Suicidal Gestures from Suicidal Attempts':'
PATIENT HISTORY
GESTURE
Sex History of previous attempts
Girl> Boy Usually no
Method of suicide Communication or suicidal notes Communication with others
Ingestion Yes Close interpersonal relationship May have mild to moderate depression Usually no
Psychological profile
Planning Intention Environment Repeat if there is a chance
Attention-seeking manipulation Responsive No
ATTEMPT
Boy> Girl History of attempts, gestures and threats Firearms or ingestion Usually no Distant interpersonal relationships May have moderate to severe depression, occasional psychosis Details of how, where, and lethality of method Killing oneself U nresponsi ve Yes
*Modified after Weiner. 12
COMMENT. P.T.'s behavior most likely was a suicidal gesture. The following data from the history support the diagnosis of a gesture: girls gesture more frequently than boys. She had never tried a suicidal act before; she used an ingestant, rather than the more violent means of a firearm or hanging; she left a note that clearly directed her distress toward Tim and the note was left where it could be found. When her family realized what had happened after finding the note, they brought her to the emergency department and expressed their concern to her and to the physicians. P.T.'s history also combines a more chronic picture of boredom and school failure the year prior to the gesture, and subsequently she was feeling the acute loss of her boyfriend. These changes culminated in her suicidal gesture. P.T. was moderately depressed. CASE 2. SUICIDAL ATTEMPT. F.M. was an 18 year old boy who presented with a self-inflicted gunshot wound of his ear. He was found by his brother on the floor of the family garage. This was the second time within a year that F.M. had sustained such an injury. In the emergency department, F.M. was very depressed, but not psychotic, and said that his symptoms began a year before when his best friend died in a motorcycle accident. F.M. related that his depression had worsened to the point where he no longer wanted to. live. He tried to communicate his distress to his father, but was told to work harder and forget about his problems. F.M. stated that he wanted to kill himself.
COMMENT. F.M.'s suicidal act represented a serious attempt. He was a boy and boys are more apt to make serious attempts and to be successful at suicide than girls; he has a history of a previous attempt using a lethal weapon, a shotgun. On this, his second attempt, he again used a firearm, and violent methods are the most frequent causes of death by suicide. F.M. left no note, which means that he was probably not trying to manipulate his environment. F.M. was severely depressed and openly
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stated that he wanted to kill himself. His father did not respond to his verbalized concerns. His depression had worsened since the death of a peer by an accident. The management of these two patients by the pediatrician differs markedly. P.T. made a suicidal gesture. She was only moderately depressed, but she needed follow-up care. With a patient like P.T., the primary care doctor may want to confirm his impression of the diagnosis of suicidal gesture with his psychiatric colleague. Once it has been decided that the patient has made a suicidal gesture, outpatient care may be managed in the primary care physician's office. The decision to provide pediatric outpatient supportive care to this youngster will depend upon the physician's interest and comfort in working with such youth. Sessions should be scheduled regularly, for the teenager needs to know that someone has heard her. Routine in-hospital management of youngsters who have made obvious suicidal gestures is not necessary. F.M., however, has made a serious attempt at taking his life, and should have psychiatric hospitalization both for protective reasons and for the firm establishment of eventual psychiatric outpatient care. F.M. is at high risk to commit suicide because of his previous attempt and his stated intention to kill himself. CASE 3. MIXED GESTURE/ATTEMPT. M.N. was a 15 year old girl who had made ,suicidal gestures twice before and was admitted to the emergency department after having ingested 25 Librium tablets 30 minutes previously. She said that she wanted to take her life because she could no longer tolerate her home situation. She had planned the ingestion 2 months in advance. Immediately afterwards, she called a friend and told her that she had taken the pills. In the emergency department, she was lethargic and uncooperative. She was admitted tb the hospital for further evaluation. Psychological evaluation 24 hours later revealed an hysterical, moderately depressed girl. No family member was with her in the emergency department, and on being called, they said to telephone when she was ready to be discharged home.
COMMENT. M.No's behavior had several features of a suicidal gesture. She was a female, had ingested medication, was hysterical, and had called a friend after the ingestion. Contact with a peer is like a suicidal note, a direct communication of the suicide gesture. But her behavior also had some characteristics of an attempt. She had made two earlier attempts and had planned the event 2 months previously, and her family was unresponsive. M.No's care could be planned in one of several ways. She definitely needed further evaluation because the diagnosis was not clear in the emergency department. The pediatrician, following confirmation by a psychiatrist of M.No's moderate depression, could choose one of several plans: 1. Inpatient admission to a general medical ward in order to communicate professional concern to the youngster and her family and to further evaluate her history. Simultaneously, the family could be seen by a hospital social worker, thus decreasing the total length of time of the evaluation. Outpatient planning could be done while the patient was in the hospital. Post-hospitalization care could be the responsibility of the primary care physician, the psychiatrist or social worker, depending upon the results of the evaluation and the availability of community services.
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2. Outpatient management by the primary care physician and psychiatrist. There were several issues about M.N.'s behavior that needed clarification, since it was not clear whether this was a gesture or an attempt. Psychiatric consultation might help clarify these issues. The primary care doctor and the psychiatrist could then plan outpatient management, to be done separately or together. 3. Direct referral to a behavioral facility or to some one person for further evaluation and management. The primary care doctor might refer M.N. to a behavioral pediatrician, psychiatrist, social worker, psychologist or a mental health clinic or an adolescent clinic, and thus relinquish the behavioral management of his patient. The decision depends upon the availability of services in the community and in the physician's degree of comfort in working with suicidal teenagers. If the history is not dear or if there is some portion which is ambivalent and makes outpatient diagnosis impossible, hospitalization is indicated. CASE 4. AN ACCIDENT MASKING A SUICIDAL ATTEMPT. M.B. was a 16 year old boy, hospitalized following an automobile accident in which he sustained a broken femur. M.B. had multiple problems, all noted prior to his accident: borderline intelligence, poor communication with parents, low self-esteem and chronic drug use. Weekend activity included driving his car as fast as he could along the edge of a river, which was what he was doing when he had the accident. From the history, M.B. was often depressed and had thought of committing suicide prior to his hospitalization.
COMMENT. Any teenager who has had a serious accident or burn should be evaluated for behavioral problems and suicidal potential. A general history, evaluating school, home and peer relationships, often yields significant data about the adolescent prior to the incident. Youngsters who abuse drugs may overdose themselves intentionally. The primary care physician who cares for these youngsters should also be concerned about their suicidal potential.
OUTPATIENT MANAGEMENT OF SUICIDAL YOUTH Once initial evaluation is completed, behavioral management of suicidal patients is a challenge to the primary care doctor. Having committed himself to the care of such teenagers, he may find that it is very frustrating at times, and at others, rewarding. The physician must be tenacious in following these young people, and tolerant of their attempts at manipulation. The teenager may be convinced that no one really heard him at the time of his gesture, and may test the physician to see if he cares. Therefore, the adolescent may not keep appointments in order to find out if anyone misses him. He may think that if the doctor really cares about him, he will call and inquire where his patient is. Since adolescents are mobile and not inclined to sit by the telephone, it may take several calls to locate him. Once it is established that the doctor is sincere in his concern, the patient may then keep his appointments regularly.
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The suicidal youngster may decide to call the doctor in the midst of his busiest practice day to report that he is feeling depressed and suicidal and needs to see him. Similarly, he may be "testing" his physician by asking, "Do you care enough about me to see me when I want to come in?" It is difficult over the telephone to differentiate the level of concern, and the physician has little option but to respond with concern. A short visit to the office will clarify the extent of the teenager's depression and corroborate the physician's interest. Not to respond because the doctor thinks he is being manipulated may spell disaster for both the youngster and the physician. The frequency and length of sessions between the doctor and the adolescent in the outpatient setting will depend upon several factors. The depressed teenager may not be very verbal; short, frequent contacts may be ideal and may serve to communicate to the teenager that the physician cares and is available. When the adolescent is ready, then he and his physician can decide jointly to meet for a longer time. The goals of the meetings depend upon the problem. If the patient is depressed, resolution of his depression will be an important focus. If he is angry, verbal expression of his feelings may substitute for turning his anger into self-destructive behaviors. The ph)[sician's goal should be to help the adolescent resolve his problems by non suicidal means. It is difficult to estimate how long to continue to follow suicidal teenagers. Frequently, as the adolescent improves, he will let his doctor know openly or, if appointments are made for him, and he feels better, he may not keep them. When by mutual decision the teenager and his doctor decide he no longer needs to return for regular care, the physician can give him his telephone number and suggest the adolescent call him if he has problems.
CONCLUSION Each pediatrician must define his role in the care of the pre-suicidal and suicidal children and youth. His decision will be affected by his. knowledge and comfort in caring for suicidal teenagers, other demands upon his time, his interest, and by -the availability of local mental health facilities. Some physicians may choose only to evaluate each teenager who has attempted suicide. Others may wish to become involved before the adolescent attempts suicide and work toward more success in preventing suicide. The pediatrician is in an ideal position to do such preventive work both with youngsters whose behavior is pre-suicidal as well as with those who have made a suicidal gesture. Whichever role the physician decides to take, the most important issue is that the teenagers' "cry for help" does not go unheeded.
ACKNOWLEDGMENT
Gratitude is extended to Mrs. Ellen Kremer and Mrs. Marda Meth for their assistance in preparation of the manuscript. Dr. Christopher Hodgman's consultation is appreciated.
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REFERENCES 1. Bakwin, H.: Suicide in children and adolescents, J. Pediat., 50:749,1957. 2. Bender, L., and Schilder, P.: Suicidal preoccupations and attempts in children. Am. J. Orthopsychiat., 7:225,1937. 3. Faigel, H.: Suicide among young persons-a review of its incidence and causes, and methods for its prevention. Clin. Pediat., 5: 187, 1966. 4. Glaser, K.: Suicidal children-management. Amer. J. Psychotherapy, 25:27,1971. 5. Jacobziner, H.: Attempted suicides in children. J. Pediat., 56:519,1960. 6. McIntire, M. S., and Angle, C. R.: Psychological 'biopsy' in self-poisoning of children and adolescents. Amer. J. Dis. Child., 126:42,1973. 7. Rockwell, D. A., and O'Brien, W.: Physicians' knowledge and attitudes about suicide. J.A.M.A., 225:1347,1973. 8. Sabbath, J. C.: The role of the parents in adolescent suicidal behavior. Acta Paedopsychiatrica, 38:211,1971. 9. Schrut, A.: Suicidal adolescents and children. J.A.M.A., 188:1103, 1964. 10. Teicher, J. D.: Children and adolescents who attempt suicide. PED. CLIN. N. AMER., 17:687,1970. 11. Vital Statistics of the United States, 1968. 12. Weiner, I. B.: Psychological Disturbance in Adolescence. New York, Wiley-Interscience, 1970, pp. 164-165. 601 Elmwood Avenue Rochester, New York 14642
Suicidal Behavior of Children and Youth
Elizabeth R. McAnarney, M.D.':'
There has always been a higher incidence of successful suicides of teenagers compared to younger children, and for adolescents, suicidal behavior is becoming an increasing problem. In 1968, 5.1 deaths by suicide per 100,000 adolescents were recorded, compared to 4.0 per 100,000 in 1965. Children less than 14 years of age commit suicide infrequently.L 2, 4,10 In 1965 in the United States, 103 youngsters 10 to 14 years old took their lives,12 Suicide is now the fourth most common cause of death during the teenage years, preceded in frequency only by accidents, malignancies and homicidesY However, death by suicide is probably under-reported. The pediatrician may be called first after a teenager attempts suicide and his response to the adolescent and his family will depend upon his knowledge and attitude about suicide. Few physicians have had formal training in this area, and their fund of information may be limited. In one survey of 56 practicing physicians, only 7 per cent reported having had any education in residency training about suicide and only 9 per cent thought their knowledge was sufficienU Some doctors may feel uncomfortable caring for suicidal adolescents, partly because of this lack of knowledge, but also because of their own ambivalence about life and death issues of youth. It is sometimes difficult for those in the health care professions to face the prospect of a teenager's death, particularly that resulting from self-destructive behavior. The doctor may not recognize his own feelings of anger at the youngster who is trying to hurt himself at a time when he should be growing and developing. The physician may also resent the professional time taken from "really sick patients" who line his waiting room or the emergency department. From the Adolescent Program, Departments of Pediatrics, Psychiatry, Medicine and Obstetrics-Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York ':'Assistant Professor of Pediatrics, Psychiatry and Medicine, The University of Rochester School of Medicine and Dentistry; Associate Pediatrician, Strong Memorial Hospital, Rochester, New York Supported by Patient Care Programs-Demonstration Teaching Project in Family Medical and Adolescent Care; Maternal Child Health Service, Project 148, Rochester-Monroe County Youth Board, Rochester, New York
Pediatric Clinics of North America- Vol. 22, No.3, August 1975
595
596
ELIZABETH
R.
McANARNEY
Of more serious import, the pediatrician may not recognize the acute nature of his suicidal patient's distress and need for help. An additional practical issue, in addition to physician knowledge and attitude, is that follow-up of the suicidal teenager can be complex and time-consuming, and the doctor may think that he does not have the time to assume responsibility for his care. As a result of all these factors, the physician may be reluctant to manage suicidal adolescents in his practice. Nonetheless, pediatricians are in an ideal position to assume some responsibility in the care of these patients. Each physician should define his own role in the care of suicidal youth. He should have a basic understanding of adolescence, appreciate the meaning of suicidal behavior, know how to differentiate between a gesture and an attempt, be able to plan for the evaluation and management treatment program of these patients, and be aware of other health care facilities in his community. His degree of involvement beyond the initial evaluation will depend upon his own skills, his comfort in working with suicidal youth, and community resources. "Although there is no single explanation for adolescent suicidal behavior, clinical experience and a wealth of data indicate that the most common denominator in both suicide attempters and suicide com pIeters is a depressive constellation of feelings of deprivation, guilt, helplessness and impulsive rejection."12 The teenager's family or the physician involved may not easily recognize the youngster's symptoms of depression. The adult who feels depressed gives the typical history of somatic complaints: anorexia, constipation or sleep difficulties. The adolescent may not know he is depressed and may complain of other symptoms or depressive equivalents such as boredom, restlessness, fatigue, bodily preoccupation, concentration difficulties, acting-out behavior or flight to and from others.12 Older teenagers may experience symptoms of both early adolescent and adult depression and thus it may be easier to recognize depression in them. Teenagers who try suicide may have both chronic and acute problems. Frequently, there is a history of chronic family disorganization with loss of a parent by deathS or by divorce or separation. 9 Acute losses include termination of a relationship with a boyfriend or girlfriend, death of a family member, a move away from a familiar setting or pregnancy. Acute crises usually occur against a background of chronic problems, and the teenager may think that he cannot handle all of these concerns.1O At this point, the youngster may use non suicidal means of communicating his distress (acting-out, running away, getting pregnant). If his environment does not respond positively to him, he may then resort to suicidal means to gain attention or help. The ratio of gestures to successful suicides is between 50 and 120 to 1. 12 These figures may not be entirely accurate as suicidal gestures may go undiagnosed, as may suicides. Some gestures do not come to the attention of health professionals, and even if the teenager comes to a medical facility, suicidal behavior may not be recognized. A review of the diagnoses of 50 youngsters treated at two poison control centers showed that on initial evaluation, 42 per cent were "accidents" and 58 per cent
597
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suicidal attempts. On re-study, the "accidents" represented only 4 per cent of the diagnoses, suicidal gestures 70 per cent, suicidal attempts 2 per cent, intoxication 22 per cent, and homicide, 2 per cent. More teenage girls make suicidal gestures than boys; more boys than girls are successful in taking their lives. Gestures usually consist of drug or poison ingestion; successful suicides are most often by firearms. One study reported a high incidence of suicidal gestures by Puerto Rican youth and by youngsters in unsupervised settings at the time of the attempt. The lowest incidence of suicide was in the fall; the highest in the spring. 5 The pediatrician who recognizes depression and behavioral problems in his adolescent patient may intervene at that time in an effort to avert a suicidal gesture. In other cases, he will not see the teenagers until after the attempt has been made, and thus will also need to be prepared to care for these youngsters.
PREVENTION OF SUICIDE Teenagers who attempt suicide often have histories of trying first to communicate their distress by non suicidal means. The adolescent may give a prior history of falling school marks or acting-out behaviors. Faigel noted, "Danger signs which should alert the physician to the possibility of an attempt at self-destruction are attempts at suicide, accident proneness, recent anger, deflated self-image, sex anxieties and depression."3 The primary care physician should recognize these behaviors as potentially pre-suicidal. Intervention by the professional at the time that the teenager's marks start dropping or immediately after he has run away may prevent the youngster from feeling hopeless and resorting to suicide. Contacts with pre-suicidal youngsters, after initial psychological evaluation, consist of regular visits to the physician, nurse, social worker or school counselor. The adult and adolescent should work on possible solutions to the problems. The patient often benefits from being given a telephone number through which the professional can be reached, both day and night, so he will have an adult in whom he can confide. Teenagers often use the telephone very effectively in this context. In some cities, "hot lines" provide crisis intervention, but the ideal situation is one in which the teenager has access to a health care facility where there is a professional who knows the youngster and cares about helping him solve his problems.
THE SUICIDAL CHILD AND ADOLESCENT If a child is talking of suicide, then both he and his family should be evaluated psychologically. The first contact should be in the doctor's office. Psychiatric referral will depend upon the results of the initial eval-
598
ELIZABETH
R.
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uation. Some children who talk of suicide are significantly disturbed, and for those who are not, there are frequently major family disruptions to which the child is attempting to draw attention. Any child who attempts suicide should be seen in psychiatric consultation.
The Teenager Who Talks of Suicide Some teenagers talk openly to the physician about suicide. Others are unable to discuss their thoughts, because it is too frightening. Only when the doctor asks his patient whether he has considered suicide may he then say he has been thinking about taking his life. When the depressed youngster does not initiate discussion about feeling suicidal, the physician may comment: "When people are depressed, they sometimes think of taking their own lives. I am concerned because you seem depressed, and I wonder if you have had such thoughts?" Discussion of the youngster's suicidal ideation will not suggest that he commit suicide, nor will it encourage his self-destructive tendencies. In fact, it may tell the teenager something about the physician. It says that the doctor understands that the depressed adolescent may feel suicidal and that this is an acceptable feeling. Second, the physician's communication with his patient is open. Third, the doctor is not afraid to talk about suicide, a thought which may be frightening to the youngster. The teenager may feel relieved that the physician initiated this discussion. After confirming that the teenager is suicidal, both the adolescent and his family should be evaluated separately and together. The focus should be on the youngster's suicidal intention, his psychologieal status and family function. After the initial evaluation of the teenager and his family, a decision about future care should be made. The professional training of the psychiatrist, nonpsychiatric physician, school counselor, social worker, nurse or minister is probably unimportant, except when the youngster is severely depressed or psychotic and in need of psychiatric care. The important factor in following a depressed, potentially suicidal youth is that the professional is an understanding, sensitive person who develops a relationship of mutual trust with the teenager at a time in his life when he is feeling rejected and hopeless. The Teenager Who Attempts Suicide Medical management of the patient who attempts suicide is the first priority of the physician. A detailed discussion of the medical care of suicidal youth will not be undertaken here. Instead, the focus will be on the behavioral evaluation and management of suicidal teenagers. The major issue is to decide whether the suicide attempt was a gesture or a serious attempt. The youngster should be evaluated psychologically initially, but, if there are any signs of drug-induced toxicity, further study should be made after he is in a nontoxic state. The first portion of the evaluation is a separate interview with the adolescent and with his parents. A decision about a family interview can be reached after the separate ones.
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TEENAGER. The Suicidal Act. 1. A description of the events leading up to the suicidal attempt, including any specific precipitating occurrences. 2. What method was used? What does the patient know of the lethality of this method? If he ingested a substance, what was it; what amount; how long before . being seen was it taken; did he vomit; if he injured himself, how did he do it? 3. Was his intention to take his life or to manipulate his environment? Was it spontaneous or well planned? 4. Was there a note or other communication? 5. Will he repeat again if he has a chance? School History. 1. In general, how are things going? 2. What school is he in? What grade is he in? 3. What is his acadeInic standing? Are there any recent changes in grades? 4. What is his attendance record over the last year? The last 6 months? 5. Have there been any recent behavioral problems (fighting, running away from school)? Peers. 1. Who are his friends by name, age, sex? What are their activities? 2. Does he have a girlfriend? Are there any problems with her recently? Family. 1. What are his parents' ages, marital status, and health? 2. What are the names of his siblings and their ages? How are they doing in school? Chronic Problems. The doctor should discuss any chronic faInily, school, or peer problems the teenager has had and how he has tried to solve them. Psychological Status (nontoxic state) Is he depressed, psychotic, angry? INTERVIEW WITH PARENTS. Family Status. 1. In general, are they concerned about the adolescent's suicidal attempt? 2. What is the parents' marital status and occupational level? Who are the other faInily members? Are there individuals other than the faInily living in the home? 3. How does the faInily spend its time? 4. What is their level of communication? 5. Are there any major current faInily problems (financial, marital)? Teenager. 1. Do they think he is having problems? What are they? 2. What have the parents tried to do about their teenager's problems? 3. What do they think should be done? 4. How is his peer interaction? 5. How is he doing in school? 6. How does he behave at home?
Having obtained a history from the patient and his family and having evaluated the family function, the next step is to organize these data into meaningful form. Table 1 distinguishes between a suicidal gesture and an attempt. Four case presentations illustrate the use of the chart. CASE 1. SUICIDAL GESTURE. P.T. was a 14 year old girl who ingested 20 five grain aspirin tablets 1 hour before arriving in the emergency department. She nad no previous history of drug ingestion and had recently broken up with her boyfriend. She left a note that read, "For starters, I find Tim is cheating on me with all those girls at his trailer... No one cares about me." Additionally, her mother said that she was bored and had failed her school grade the year before. On interview, P.T. was lucid and moderately depressed. She was sorry she had taken the aspirin, but wanted Tim and her faInily to know of her distress. The fact that mother and father had both responded immediately by bringing her to the emergency department indicated their true and open concern.
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Table 1.
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Factors Distinguishing Suicidal Gestures from Suicidal Attempts':'
PATIENT HISTORY
GESTURE
Sex History of previous attempts
Girl> Boy Usually no
Method of suicide Communication or suicidal notes Communication with others
Ingestion Yes Close interpersonal relationship May have mild to moderate depression Usually no
Psychological profile
Planning Intention Environment Repeat if there is a chance
Attention-seeking manipulation Responsive No
ATTEMPT
Boy> Girl History of attempts, gestures and threats Firearms or ingestion Usually no Distant interpersonal relationships May have moderate to severe depression, occasional psychosis Details of how, where, and lethality of method Killing oneself U nresponsi ve Yes
*Modified after Weiner. 12
COMMENT. P.T.'s behavior most likely was a suicidal gesture. The following data from the history support the diagnosis of a gesture: girls gesture more frequently than boys. She had never tried a suicidal act before; she used an ingestant, rather than the more violent means of a firearm or hanging; she left a note that clearly directed her distress toward Tim and the note was left where it could be found. When her family realized what had happened after finding the note, they brought her to the emergency department and expressed their concern to her and to the physicians. P.T.'s history also combines a more chronic picture of boredom and school failure the year prior to the gesture, and subsequently she was feeling the acute loss of her boyfriend. These changes culminated in her suicidal gesture. P.T. was moderately depressed. CASE 2. SUICIDAL ATTEMPT. F.M. was an 18 year old boy who presented with a self-inflicted gunshot wound of his ear. He was found by his brother on the floor of the family garage. This was the second time within a year that F.M. had sustained such an injury. In the emergency department, F.M. was very depressed, but not psychotic, and said that his symptoms began a year before when his best friend died in a motorcycle accident. F.M. related that his depression had worsened to the point where he no longer wanted to. live. He tried to communicate his distress to his father, but was told to work harder and forget about his problems. F.M. stated that he wanted to kill himself.
COMMENT. F.M.'s suicidal act represented a serious attempt. He was a boy and boys are more apt to make serious attempts and to be successful at suicide than girls; he has a history of a previous attempt using a lethal weapon, a shotgun. On this, his second attempt, he again used a firearm, and violent methods are the most frequent causes of death by suicide. F.M. left no note, which means that he was probably not trying to manipulate his environment. F.M. was severely depressed and openly
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stated that he wanted to kill himself. His father did not respond to his verbalized concerns. His depression had worsened since the death of a peer by an accident. The management of these two patients by the pediatrician differs markedly. P.T. made a suicidal gesture. She was only moderately depressed, but she needed follow-up care. With a patient like P.T., the primary care doctor may want to confirm his impression of the diagnosis of suicidal gesture with his psychiatric colleague. Once it has been decided that the patient has made a suicidal gesture, outpatient care may be managed in the primary care physician's office. The decision to provide pediatric outpatient supportive care to this youngster will depend upon the physician's interest and comfort in working with such youth. Sessions should be scheduled regularly, for the teenager needs to know that someone has heard her. Routine in-hospital management of youngsters who have made obvious suicidal gestures is not necessary. F.M., however, has made a serious attempt at taking his life, and should have psychiatric hospitalization both for protective reasons and for the firm establishment of eventual psychiatric outpatient care. F.M. is at high risk to commit suicide because of his previous attempt and his stated intention to kill himself. CASE 3. MIXED GESTURE/ATTEMPT. M.N. was a 15 year old girl who had made ,suicidal gestures twice before and was admitted to the emergency department after having ingested 25 Librium tablets 30 minutes previously. She said that she wanted to take her life because she could no longer tolerate her home situation. She had planned the ingestion 2 months in advance. Immediately afterwards, she called a friend and told her that she had taken the pills. In the emergency department, she was lethargic and uncooperative. She was admitted tb the hospital for further evaluation. Psychological evaluation 24 hours later revealed an hysterical, moderately depressed girl. No family member was with her in the emergency department, and on being called, they said to telephone when she was ready to be discharged home.
COMMENT. M.No's behavior had several features of a suicidal gesture. She was a female, had ingested medication, was hysterical, and had called a friend after the ingestion. Contact with a peer is like a suicidal note, a direct communication of the suicide gesture. But her behavior also had some characteristics of an attempt. She had made two earlier attempts and had planned the event 2 months previously, and her family was unresponsive. M.No's care could be planned in one of several ways. She definitely needed further evaluation because the diagnosis was not clear in the emergency department. The pediatrician, following confirmation by a psychiatrist of M.No's moderate depression, could choose one of several plans: 1. Inpatient admission to a general medical ward in order to communicate professional concern to the youngster and her family and to further evaluate her history. Simultaneously, the family could be seen by a hospital social worker, thus decreasing the total length of time of the evaluation. Outpatient planning could be done while the patient was in the hospital. Post-hospitalization care could be the responsibility of the primary care physician, the psychiatrist or social worker, depending upon the results of the evaluation and the availability of community services.
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2. Outpatient management by the primary care physician and psychiatrist. There were several issues about M.N.'s behavior that needed clarification, since it was not clear whether this was a gesture or an attempt. Psychiatric consultation might help clarify these issues. The primary care doctor and the psychiatrist could then plan outpatient management, to be done separately or together. 3. Direct referral to a behavioral facility or to some one person for further evaluation and management. The primary care doctor might refer M.N. to a behavioral pediatrician, psychiatrist, social worker, psychologist or a mental health clinic or an adolescent clinic, and thus relinquish the behavioral management of his patient. The decision depends upon the availability of services in the community and in the physician's degree of comfort in working with suicidal teenagers. If the history is not dear or if there is some portion which is ambivalent and makes outpatient diagnosis impossible, hospitalization is indicated. CASE 4. AN ACCIDENT MASKING A SUICIDAL ATTEMPT. M.B. was a 16 year old boy, hospitalized following an automobile accident in which he sustained a broken femur. M.B. had multiple problems, all noted prior to his accident: borderline intelligence, poor communication with parents, low self-esteem and chronic drug use. Weekend activity included driving his car as fast as he could along the edge of a river, which was what he was doing when he had the accident. From the history, M.B. was often depressed and had thought of committing suicide prior to his hospitalization.
COMMENT. Any teenager who has had a serious accident or burn should be evaluated for behavioral problems and suicidal potential. A general history, evaluating school, home and peer relationships, often yields significant data about the adolescent prior to the incident. Youngsters who abuse drugs may overdose themselves intentionally. The primary care physician who cares for these youngsters should also be concerned about their suicidal potential.
OUTPATIENT MANAGEMENT OF SUICIDAL YOUTH Once initial evaluation is completed, behavioral management of suicidal patients is a challenge to the primary care doctor. Having committed himself to the care of such teenagers, he may find that it is very frustrating at times, and at others, rewarding. The physician must be tenacious in following these young people, and tolerant of their attempts at manipulation. The teenager may be convinced that no one really heard him at the time of his gesture, and may test the physician to see if he cares. Therefore, the adolescent may not keep appointments in order to find out if anyone misses him. He may think that if the doctor really cares about him, he will call and inquire where his patient is. Since adolescents are mobile and not inclined to sit by the telephone, it may take several calls to locate him. Once it is established that the doctor is sincere in his concern, the patient may then keep his appointments regularly.
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The suicidal youngster may decide to call the doctor in the midst of his busiest practice day to report that he is feeling depressed and suicidal and needs to see him. Similarly, he may be "testing" his physician by asking, "Do you care enough about me to see me when I want to come in?" It is difficult over the telephone to differentiate the level of concern, and the physician has little option but to respond with concern. A short visit to the office will clarify the extent of the teenager's depression and corroborate the physician's interest. Not to respond because the doctor thinks he is being manipulated may spell disaster for both the youngster and the physician. The frequency and length of sessions between the doctor and the adolescent in the outpatient setting will depend upon several factors. The depressed teenager may not be very verbal; short, frequent contacts may be ideal and may serve to communicate to the teenager that the physician cares and is available. When the adolescent is ready, then he and his physician can decide jointly to meet for a longer time. The goals of the meetings depend upon the problem. If the patient is depressed, resolution of his depression will be an important focus. If he is angry, verbal expression of his feelings may substitute for turning his anger into self-destructive behaviors. The ph)[sician's goal should be to help the adolescent resolve his problems by non suicidal means. It is difficult to estimate how long to continue to follow suicidal teenagers. Frequently, as the adolescent improves, he will let his doctor know openly or, if appointments are made for him, and he feels better, he may not keep them. When by mutual decision the teenager and his doctor decide he no longer needs to return for regular care, the physician can give him his telephone number and suggest the adolescent call him if he has problems.
CONCLUSION Each pediatrician must define his role in the care of the pre-suicidal and suicidal children and youth. His decision will be affected by his. knowledge and comfort in caring for suicidal teenagers, other demands upon his time, his interest, and by -the availability of local mental health facilities. Some physicians may choose only to evaluate each teenager who has attempted suicide. Others may wish to become involved before the adolescent attempts suicide and work toward more success in preventing suicide. The pediatrician is in an ideal position to do such preventive work both with youngsters whose behavior is pre-suicidal as well as with those who have made a suicidal gesture. Whichever role the physician decides to take, the most important issue is that the teenagers' "cry for help" does not go unheeded.
ACKNOWLEDGMENT
Gratitude is extended to Mrs. Ellen Kremer and Mrs. Marda Meth for their assistance in preparation of the manuscript. Dr. Christopher Hodgman's consultation is appreciated.
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