Suicide in children and adolescents

Medical Progress SUICIDE IN CHILDREN AND ADOLESCENTS HARRY BAKWIN, M.D. NEW YORK, N. Y. E v e n in the 10- to 14-year-old children the death r a t e f r o m suicide is not inconsiderable. E a c h y e a r f r o m thirty-five to s i x t y children t a k e their own lives. Suicide accounted f o r 0.59 per cent of all deaths in this age r a n g e in 1954 in the United States. The n u m b e r of deaths (see Table I I ) is c o m p a r a b l e in m a g n i t u d e to the n u m b e r of children d y i n g f r o m appendicitis, tuberculosis, homicide, diabetes, or meningoeoecus disease. I t is i m p o r t a n t to k e e p in m i n d t h a t the n u m b e r of deaths f r o m suicide is p r o b a b l y considerably g r e a t e r t h a n is given in the m o r t a l i t y data. Ordinarily e v e r y effort is m a d e to conceal a suicide d e a t h a n d to a t t r i b u t e it to accident or o t h e r cause, t h e r e b y shielding the p a r e n t s f r o m the shame and guilt feelings associated w i t h a self-inflicted death. Some of the motor vehicle accidents in y o u n g people due to reckless d r i v i n g m a y have in t h e m a suicidal component. Neavles and W i n o k u r , 3 in a p s y c h i a t r i c s t u d y of more t h a n t h i r t y hot rodders, coneluded t h a t there is a g r e a t self-destructive element in t h e i r behavior. "These boys," t h e y wrote, " g a m b l e with their lives." I n vital statistics r e p o r t s deaths f r o m suicide and homicide are cust o m a r i l y included u n d e r "accidents,"

U I C I D E r a n k s fifth in f r e q u e n c y as a cause of d e a t h a m o n g y o u n g people 15 to 19 y e a r s of age (Table I ) . I t is s u r p a s s e d in this age group only b y accidents, m a l i g n a n t neoplasms, r h e u m a t i c h e a r t disease, and homicide, p r i n c i p a l l y in N e g r o children. I n 1954, the last y e a r in the United States for which figures are available, 261 adolescents lost their lives in this w a y - - m o r e t h a n the n u m b e r t h a t d i e d f r o m renal disease, pneumonia, tuberculosis, leukemia, or poliomyelitis. Suicide accounted for 2.5 p e r cent of all deaths in this age g r o u p in 1954 in the United States. I n a recent r e p o r t f r o m Yale for the y e a r s 1925-19551 suicide was the second most f r e q u e n t cause of d e a t h among" students. I t accounted for 12 per cent of all deaths. M o r e o v e r suicide was the only m a j o r cause for which more deaths o c c u r r e d t h a n was expected, the general d e a t h r a t e a m o n g Yale students being considera b l y lower t h a n in the general popula~ tion. I n an earlier s t u d y (1925-1935) made in various colleges, suicide was the t h i r d most f r e q u e n t cause of death. 2

S

F r o m t h e D e p a r t m e n t of P e d i a t r i c s , N e w Y o r k U n i v e r s i t y C o l l e g e of Medicine, a n d Children's Medical Service, Bellevue Hospital. 749

750

THE JOURNAL OF PEDIATRICS

along with m o t o r vehicle accidents, mishaps w i t h firearms, drownings, and so on. I n suicide and homicide, however, there is an element of conscious intention which is not p r e s e n t in other "accidents." F o r this reason it seems justifiable to consider t h e m s e p a r a t e l y f r o m other accidental deaths. The relative i m p o r t a n c e of the suicide p r o b l e m in children and adolescents has increased as other causes of death, n o t a b l y the infections, have diminished. Nevertheless the recent l i t e r a t u r e contains little on this subject. The only i m p o r t a n t contributions are the r e p o r t on suicide att e m p t s in children b y B e n d e r a n d Schilder 4 in ]937, which has been f u r t h e r amplified b y B e n d e P in 1953, a r e p o r t b y Stearns 6 of an i n t e r e s t i n g group o~ boys who h u n g themselves, a study by Schachter and Cotte/and an excellent account of childhood suiTABLE I. THE ~UMBER OF DE&THS FRO]~[ SELECTED CAUSES, UNITED STATES, ]9'54, 15 TO 19 YEARS All causes 10,302 Accidents, poisonings, and violence (including suicide and homicide) 5,450 Malignant neoplasms (including leukemia a n d ]ymphosarcoma) 830 Rheumatic heart disease1 464 Homicide 400 Suicide 261 Nephritis and nephrosis 244 Leukemia 235 P n e u m o n i a , all forms2 226 Congenital m a l f o r m a t i o n s 206 Tuberculosis, all forms3 166 Complications of pregnancy 159 Vascular lesions of central nervous system 155 Poliomyelltis4 123 Diabetes 92 Appendicitis 58 Source: Vital Statistics of the United States, 1954, vol. II, Table 50. 1Sixth :Revision of the International Lists, 2~os. 410-443. 2Sixth l=r of the International Lists, :Nos. 490-493. 8Sixth :Revision of the International Lists, Nos. 001-019. 4Sixth Revision of the International Lists, Nos. 080-081.

tide in E n g l a n d by Mulcock. s B y c o n t r a s t a large n u m b e r of extensive studies a p p e a r e d in the last c e n t u r y a n d d u r i n g the e a r l y y e a r s of this century. Notable a m o n g these were the contributions of M o r s e l l i / Dur a n d - F a r d e l , 1~ P ~ r i e r, 11 Siegert, TM Baer, la a n d Redlich and Lazar. ~4 W e have f o u n d n o t h i n g on this subject in the p e d i a t r i c l i t e r a t u r e except for the r e p o r t of a suicide a t t e m p t in an l l year-old boy in the Archly f~r Kinderheilkunde25 The principal contributions h a v e been made b y sociologists a n d psychiatrists. T h e r e was ample reason f o r concern a b o u t suicide in children and adolescents d u r i n g the l a t t e r half of the n i n e t e e n t h c e n t u r y and the e a r l y y e a r s of the present century. The r a t e s w e r e exceedingly high, especially in Prussia, France, and Russia. Moreover, t h e y w e r e rising. A b o u t as m a n y children and adolescents died f r o m suicide each y e a r in TABLE

II.

THE

NUMBER

OF DEATHS

FROM

SELECTED CAUSES~ UNITED STATES, 1954, 10 TO 14 YEAES

All causes 6,273 Accidents (including suicide and homicide) 2,732 M a l i g n a n t neoplasms (including leukemia and lymphosarcoma) 781 Leukemia 310 Congenital malformations 271 Pneumonia, all forms 219 Rheumatic fever 204 Acute poliomyelitis 161 Rheumatic heart disease1 150 Nephritis and nephrosis 150 Vascular lesions of central nervous system 113 Homicide 93 B e n i g n a n d unspecified neoplasms 87 Diabetes 75 Appendicitis 74 Nonmeningococcus meningitis 51 Anemias 45 Meningoeoeeal infections 40 Suicide 37 Tuberculosis, all forms 35 Source: Vital Statistics of the United States, 1954, vol. II, Table 50. 1Sixth :Revision of the International Lists, Nos. 410-443.

751

MEDICAL PROGRESS

Prussia d u r i n g the t h i r t y - y e a r period 1869-1898 as in the whole of the United States t o d a y (Table I I I ) . I n the five-year period 1903-1907, the suicide rates in S a x o n y for children 10 to 14 y e a r s of age were 5.3 p e r 100,000 in males a n d 2.6 in f e m a l e s ; in the 15- to 19-year-old g r o u p the figures were 34.1 for males a n d 19.2 for females2 ~ These rates are almost ten times as high as the c o m p a r a b l e

all suicides took place in children 10 to 14 y e a r s old. On the other hand, in W e s t p h a l i a a n d the Rhineland, both of which are m a i n l y Catholic, the rates, t h o u g h still m u c h higher t h a n are c u r r e n t today, were only a f r a c t i o n of those in the a b o v e - n a m e d provinces (Westphalia, 2.5 per cent; Rhineland, 4.8 per cent). The n u m b e r of suicides in children u n d e r 15 rose s t e a d i l y in Prussia,

TABLE I I ~ . 0OMPARISON OF TttE ~V[E&N ANNUAL NUMBER OF ])EATtIS FROM SUICIDE IN TtIE I)RUSSIAN t~INGDOM~ 1 8 6 9 - 1 8 9 8 (BAER)~ AND THE ~UMBER OF DEATHS FROM SUICIDE IN THE UNITED STATESt 1 9 5 4 AOE

PRUSSIA

(~R.)

TOTAL

0-9 10-14 15 -19

3.1 53.8 328.1

I

MALES 2.4 42.5 221.8

5'

o" 0

FEMALES 0.7 11.3 106.3

SUICIDE

MALEE] 0 0 0

I

TOTAL 0 37 261

UNITED STATES 1 9 5 4 I MALES I FEMALES 0 0 30 7 191 70

RATE

FEMALEN

4"

i

3-

G:

~2i,i n"

]-

I0

II

12 AGE:

-

13 14 YEARS

15

16

17

18

19

F i g . 1 . - - A v e r a g e a n n u a l d e a t h r a t e s !oer 100,000 f r o m s u i c i d e in w h i t e p e r s o n s a g e d 10 to 19 Years, 1 9 5 3 - 1 9 5 5 . (Industrial Policyholders, Metropolitan Life Insurance Company. Data kindly supplied by Dr. George Vgheatly.)

United States figures f o r 1954. E v e n in children u n d e r 10 y e a r s of age the a v e r a g e n u m b e r of suicide deaths each y e a r d u r i n g the t h i r t y - y e a r period 1869-1898 in P r u s s i a was 3.1. W i t h i n Prussia itself the r a t e s v a r i e d widely. T h e y were especiaIly high in Saxony, Silesia, and B r a n d e n burg. I n S a x o n y over 12 p e r cent of

f r o m an annual a v e r a g e of 38.2 in 1869-1873 to 64.8 in 1894-1898. A t the same time the t o t a l n u m b e r of suicides at all ages rose f r o m 2,929 to 6,431 per year. G e r m a n y maintained high rates of childhood and teenage suicides u p to W o r l d W a r II. I n France, too, the n u m b e r of suitides in children and y o u n g people

752

THE

J O U R N A L OF P E D I A T R I C S

was 61 and 303, respectively, in 1881 and rose to 90 and 450 by 1895. la The rates among children in certain parts of Russia were also v e r y high d u r i n g the early years of this century. Serkoff 17 reports t h a t 4.5 per cent of all suicides in Moscow 60-

10 to 14 years, 0.23 per cent, and 15 19 years, 1.6 per cent. Recent figures for suicide in Russia are not available, vital statistics being a state secret there. The incidence of suicide b y age is shown in Figs. I and 2. Self-destruc-

to

SUICIDE RATE

51.:

F--

50-

42.4

F

40MALE

= D a2.3

o o o

30-

I

I

FEMALE =

c9

o

2.3.8

n" hJ f3.

bJ < n-

2015.0 12.2

3.9

~

7.3

I0-14 15-19 20-24 25-29 30-39 40-49 50-59 60-69 70&0VER AGE - YEARS Fig. 2.--The death rate per 100,000 from suicide by age and sex, United States, 1954. during the years 1908-1909 were in the age group 8 to 14 years, and 38.1 per cent were in the 15- to 20-yearold group. The corresponding figures for the United States in 1954 were:

tion is rare u n d e r 10 years and remains i n f r e q u e n t until about 15 years of age, when a sharp rise in both boys and girls takes place. The rate continues to increase in boys t h r o u g h o u t

MEDICAL PROGRESS

the 15- to 19-year age period; the rate for the girls shows an upward trend during these years. After the adolescent years, the suicide rate in males climbs steadily and is highest in the aged (Fig. 2). There is a rise in females also but it is more gradual and the rate is actually lower in the decades 70 and over than in the preceding three decades. 15 To 19 YEARSOF AGE The mortality rates from suicide in a selected group of countries for young people 15 to 19 years of age are shown in Table IV. The median male death rate is 6.1 per 100,000, the female, 2.5. The difference in the rates for the various countries is striking, from a high of 26.1 in Japan to 0.6 in Ireland. The rates for the United States (3.9 for males, 1.6 for females) are considerably below the median. The mortality from suicide in the 15- to 19-year-old group is highest in Japan (26.1 for males, 18.7 for females in 1952-1954). About 2,000 young persons in this age group took their lives in Japan each year during the period under consideration (19511953). An unusual feature of the Japanese data is the high suicide rate among females. Indeed the suicide rate in Japanese girls, 15 to 19 years old, is higher than the male rate in any other country. Up to the middle twenties the female suicide rate in this age group in J ap an exceeded the male. This was not true among adults. A higher female than male suicide rate among adolescents is also recorded for Ireland and Italy during the years shown in Table IV. The number of deaths from suicide in Ire-

753

land is so small that no conclusions can be drawn. In I t a l y the suicide deaths over the years are approximately equal in the sexes. Almost as high as the Japanese figures are those from prewar Germany. In 1938 the suicide rate in the 15- to 19-year-old group was 23.5 per 100,000 for boys and 11.0 for girls. During 1932-1934 the rate was even higher--30.8 for males and 16.2 for females. TABLE I V . MORTALITY PER 100,000 F R 0 ~ SUICIDE IN SELECTED COUNTRIES~ 15 TO 19 YEARS OF AGE~ BY SEX

Japan 1951-1953 26.1 ]8.7 Switzerland 1952-1954 16.9 6.4 Finland 1952-1954 12.3 2.6 G e r m a n F e d e r a l Republic 1952-1954 12.1 6.8 Austria 1952-1954 11.7 8,1 Union South Africa (European population only) 1951-1953 9.7 2.8 Denmark 1952-1954 8.3 5.9 Chile 1950-1951 7.6 4.3 Portugal 1947-1949 6.9 6.0 Australia 1951-1953 6.2 1.9 Sweden 1951-1953 6.0 3.3 New Z e a l a n d (without M a o r i s ) 1952-1954 5.2 0.5 France 1952-1954 4.4 2.4 United States 1951-1953 3.9 1.6 Spain 1951-1953 3.8 2.0 Canada 1952-1954 3.8 0.7 Italy 1951-1953 2.9 3.3 England and Wales 1952-1954 2.9 1.1 Netherlands 1952-1954 2.3 0.8 Norway 1952-1954 2.0 1.0 Scotland 1952-1954 1.9 0.4 Ireland 1952-1954 0.6 1.1 Source: Epidemiological and Vital Statistics Report, M o r t a l i t y F r o m Suicide, issued by t h e W o r l d H e a l t h O r g a n i z a t i o n 9: 243. 1956.

The suicide rates in Germany do n o t appear to have been influenced by the advent of Hitler. For persons 15 years and over they remained unchanged from 1911 to 1938. The rates in Germany in the 15- to 19year-old group have fallen markedly since World W a r II.

754

THE JOURNAL

High suicide rates in adolescents are also recorded in Switzerland (16.9 per 100,000 for males, 6.4 for females), Finland (12.3 for males, 2.6 for females), and Austria (11.7 for males, 8.1 for females). The lowest rates in this age group are in Ireland, Scotland, and Norway. The suicide rates in teenagers follow fairly closely the rates in adults. There are, however, notable exceptions. The suicide rate in the 15- to 19-year-old group in Japan is 10.9 per cent of the over-all suicide rate (15 years and over). In Sweden, on the other hand, the percentage is only 0.2. F o r the twenty-two countries shown in Table IV the correlation coefficient (r) for male suicides is .72. The suicide rate in the 15- to 19year age group in the United States TABLE V.

OF PEDIATRICS

upward trend in boys. In Australia the male rates rose and the female rates dropped sharply. New Zealand shows no trend in males but a marked fall in the rates in girls. In percentage of all suicides in the United States the rates in adolescents 15 to 19 years has dropped, more strikingly in girls than in boys (Table VI). TABLE V I . DEATHS FROM SUICIDE, 15 TO 19 YEAI~S~ AS I~ CENT 01v DEATHS FROM SUICIDE AT 2~LL .AGES, UNITED STATES

YEARS 1921 1929~1931 1936-1938 1947-1949 1951-1953 1954

I M~LES J FEmALeS 1.8 1.9 2.1 1.6 1.6 1.5

6.9 5.8 4.4 2.4 2.4 2.1

Suicide is less common in the United States in nonwhites than in

COMPARISON OF THE I~IORTALITY FROIVs SUICIDE IN AGE GROUPS 10 TO 14 YEARS AND 15 TO 19 YEARS t3Y SEX AND I:~ACE

1921 1929-1931 1936-1938 1947-1949 1951-1953

WHITES 1V~ALE S .. FED/~ALES 10-14 I 1 5 - ] 9 10-14 I 15-19 0.9 4.3 0.5 4.6 0.6 5.1 0.2 4.3 0.7 5.2 0.2 3.4 0.8 3.9 0.2 1.9 0.7 4.9. 0.1 1.6

has fallen during the last thirty-five years (Table V). In males a rise occurred during 1929-1931 and 19361938, but the rates were lower in 1947-1949, 1951-1953 and 1954. The decrease is especially marked in the females. The figures show a steady drop from 1921, when the rate was actually higher in girls than boys, to 1954 when the female rate was only 37 per cent of the male. Reductions have also taken place in Germany, France, Italy, England and Wales, and Scotland. Switzerland shows an

.

NON W HITES MALES FEMALI~S 10-14 I 15-19 10-14 I 1 5 1 9 0.2 2.8 3.2 0.3 2.4 2.7 0.7 3.2 0.4 2.0 0.3 2.3 0.2 1.6 0.5 1.7 0.3 1.4

whites at all ages (Table V). In the 15- to 19-year-old group the difference is not as marked in girls as in boys. The most common means of committing suicide by adolescents in the United States (Table VII) is "firearms and explosives." This holds true in both boys and girls. These agents were used by 133 out of 261 teenagers (51 per cent). They were used somewhat more frequently by boys (108 out of 191 cases, 57 per cent) than by girls (25 out of 70 cases, 36 per cent).

755

MEDICAL PROGRESS

The next most frequent means is "hanging and strangulation" in boys, and "poisoning" in girls. In 1954 in the United States 43 out of 191 males (22 per cent) took their lives by hanging and only 3 out of 70 females (4 per cent). On the other hand, 33 out of 70 females (47 per cent) used poison and only 30 out of 191 boys (16 per cent). 10

TO

14

It follows in a general way the rate in adults (r = .53). It is more closely related to the suicide rate of the 15to 19-year-old group (r = .73). The most frequent means of selfdestruction by boys is "hanging and strangulation" (Table VII). This was used in 1954 in the United States by 17 out of 30 boys (57 per cent) and by 2 of the girls. "Firearms and explosives" is next, accounting for about one-third of the deaths in boys and 3 out of 7 girls. Four boys and 2 of the girls used poison.

YEARS OF AGE

The mortality rates for suicide in this age group in twenty-two selected TABLE V I I .

THE 1VIEANS OF COMMITTING SUICIDE BY SEX AND AGE, UNITED STATES, 1954 NUMBEK O~ DEAr21-IS I0-14

MEANS All means Poisoning H a n g i n g and s t r a n g u l a t i o n F i r e a r m s and explosives All other means Source:

~ital

Statistics

of the United

YEARS

..

TOTAL I MALE I FEMALE 37 30 7 6 4 2 19 17 2 12 9 3 States,

countries are shown in Table VIII. For these countries the median rate is 0.65 per 100,000 for boys and 0.2 for girls. The highest rates are recorded in Germany (boys 1.9, girls 0.5). Portugal (boys 1.7, girls 0.3), Denmark (boys, 1.3, girls 0.2), and New Zealand (boys 1.3, girls 0). The lowest rates arc those of Norway, Scotland, and Ireland. The rates for the United States (boys 0.7, girls 0.2) are slightly above the median. In this age group the male rate generally far exceeds the female. In the United States the male rate is three and one-half times the female. The rate in white boys is much higher than in nonwhites; it is about the same in white and nonwhite girls. The death rate from suicide in children 10 to 14 years old has not varied appreciably in the United States since 1921.

1954,

15-19

vol. II, Table

TABLE u SUICIDE

YEARS

TOTAL I 1Vs 261 191 63 30 46 43 133 108 19 10

I FEMALE 70 33 3 25 9

50.

IV~OI%TALIT~'/PER I00,000 IN SELECTED

COUNTRIES, ~irEAI%S, BY SEX

COUNTRY

Germany, Federal l~epublic Portugal Denmark New Zealand ( w i t h o u t Maoris) Finland Switzerland

YEARS

FRO~[ 10 TO 14

MALES

FEIV~ALES

1952-1954 1947-1949 1952-1954

1.9 1.7 1.3

0.5 0.3 0.2

1952-1954 1952,1954 195/1-1953

1.3 1.2 1.1

0.4 0.4

Japan

1952-1954

0.9

0.5

Chile Sweden U n i t e d States Austria France Australia Italy Netherlands Canada Spain Union South A f r i c a ( E u r o p e a n population only) E n g l a n d a n d Wales Ireland Scotland Norway

1950-1951 1951-1953 1951-1953 1952-1954 1952-195/i 1951-1953 1951-1953 1952-1954 1952-1954 1951-1953

0.8 0.7 0.7 0.7 0.6 0.5 0.5 0.5 0.5 0.5

0.5 0.1 0.2 0.3 0.2 0.2 0.2 0.2

1951-1953 1952-1954 1952-1954 1952-1954 1952-]954

0.2 0.2 0.2 -

0.1 0.2 0.3

Source: Epidemiological and Vital Statisties Report, Mortality F r o m Suicide, issued by the World Health Organization 9: 243, 1956.

756

THE

JOURNAL

U N D E R 1 0 Y E A R S OF AGE

Of special interest to the pediatrician is suicide in children u n d e r 10 years. I t is rare in this age group, only an occasional ease having been recorded in the United States mortality figures. Suicide in y o u n g children must be considered in the light of their incompletely developed concept of the meaning of death. According to Sehilder and Wechsler, TM w h o s e studies were carried out on the children's w a r d of the psychiatric service of Bellevue Hospital, y o u n g children deal with death and its p a r a p h e r n a l i a in a matter-of-fact and realistic way. They c o m p r e h e n d t h a t death means immobility and insensitivity and t h e y u n d e r s t a n d the meaning of coffins, burial, c~meteries, and the like. B y and large, children are not concerned with their own death even though, h a v i n g observed the death of others, t h e y are willing to concede its possibility. T h e y disbelieve s t r o n g l y t h a t t h e y will die. W h e n the child considers his own death at all he projects it far into a f u t u r e which has for him no reality. D e a t h is only for the aged. I t is remote; it is so distant an event t h a t it is no cause f o r concern. Nevertheless child r e n almost universally declare t h a t t h e y do not w a n t to die, even t h o u g h t h e y m a y just have declared how nice it is in heaven. Death from disease is aeeepted but it is generally associated with the idea of violence and even dismemberment. The idea of death by violence is deeply ingrained in the child's mind. His a t t i t u d e t o w a r d death, whether agreeable or disagreeable, is

OF P E D I A T R I C S

to a large extent determined by the a t t i t u d e of the parents. V e r y y o u n g children often r e g a r d death as reversible. E v e n later on it seldom has the character of something definite and final. I t is t h e r e f o r e easy for children to wish the death of o t h e r s - - o r t h e m s e l v e s - - a n d to speak of killing people without a n y eonscience-stricken feeling. The results of studies on Hungarian, Swiss, English, and other groups of A m e r i c a n children are in general agreement w i t h those of Schilder and Wechsler (summarized b y BenderS). Redlieh and L a z a r .4 in 1914 presented a n u m b e r of ease histories of suicide in y o u n g children gleaned principally from newspaper accounts. Their youngest patient, and t h e youngest recorded ease of a suicidal attempt, was a 3-year-old boy. He and his sister aged 1 8 9 years were f o u n d unconscious in a gas-filled room with the gas jet open. The children were revived with great difficulty. The boy said that he wanted to kill himself and his sister because his m o t h e r would not t a k e ' h i m for a walk. E a r l i e r in the day the child's f a t h e r had told, in the child's presenee, about a y o u n g man who att e m p t e d suicide with illuminating gas. An a t t e m p t by a 3-year-old boy to hang himself is r e p o r t e d by Baer ~a but here the child was playing and had no intention of killing himself. Several suicides or suicidal att e m p t s have been r e p o r t e d in 5-yearold children. *~ 11, ~ Redlieh and Lazar *~ relate the ease history of an a 1 e r t, well-brought-up 51~-year-old boy. He had been scolded by his mother. Shortly afterward he brought his f a t h e r his luneh. On the way home, he deposited the luncheon pail

MEDICAL PROGRESS

on a bridge a n d j u m p e d into the r i v e r Mur. H e d i s a p p e a r e d at once and his b o d y was f o u n d several h o u r s later. He had told his m o t h e r r e p e a t e d l y t h a t he was u n h a p p y a n d t h a t he would j u m p into the water. A u t o p s y showed s t r i k i n g changes in the brain. A n o t h e r 5-year-old r e p o r t e d b y Redlieh and L a z a r w a s a girl who att e m p t e d suicide b y j m n p i n g out of a window. The w i n d o w w a s not v e r y high and she sustained only m i n o r injuries. She came f r o m a home in which she was b a d l y treated. W e h a v e observed a 5-year-old boy who m a d e r e p e a t e d a t t e m p t s at suicide. 19 CASE HiSTORu 51/2 years old, j u m p e d or fell out of a sevenths t o r y window. He got up and t r i e d to w a l k b u t collapsed a n d was stuporous f o r five days. The small bones of one foot w e r e b r o k e n . R e c o v e r y was complete. He was a d m i t t e d to the Children's P s y c h i a t r i c Division at Bellevue H o s p i t a l f o r study, b u t he was r e m o v e d b y his p a r e n t s a f t e r f o r t y - e i g h t hours, before a n y conclusion was r e a c h e d a b o u t him. H e n r y was the oldest of three children. D u r i n g p r e g n a n c y the m o t h e r h a d h a d a " k i d n e y condition" a n d was "swollen." He was b o r n at t e r m w i t h o u t difficulty. H e h a d measles at 1 year. T h u m b s u e k i n g s t a r t e d at 11 nmnths a n d continued until ahnost 3 y e a r s of age. A t 5 months he b e g a n to b a n g his head. This became worse with time and he would strike his h e a d against a h a r d object like the floor or a stone wall w h e n e v e r he was frustrated. The habit lasted until he was 2 y e a r s old. A t this time he was described as v e r y aggressive, negativistic, bossy, quarrelsome, talkative, and overactive. His I.Q. score on the Goodenough " D r a w - a - M a n " test a t 4~/2 y e a r s w a s 127.

757

The first suicidal a t t e m p t was made at 31/2 years, w h e n H e n r y stepped out of a first-story window. Shortly t h e r e a f t e r he w a s f o u n d h a n g i n g b y his a r m s f r o m the fire escape. At about this time he fell down a flight of stairs and bruised his head. He was also i n j u r e d in a r e v o l v i n g door. A t 4 years, following a severe beating, he said he was going to j u m p out of the window. He r e p e a t e d this t h r e a t w h e n e v e r he got a n g r y . The p a r e n t s ' r e p l y was to "go a h e a d . " He m a d e n u m e r o u s other a t t e m p t s at self-destruction. A t 5 years, 4 months, while being t a k e n to a play group in a bus~ he w o u l d r e p e a t e d l y leave the bus w h e n it stopped, and rush out into the open r o a d a m o n g the m o v i n g ears. W h e n he saw an exceptionally large dog he would p u t his h a n d into the dog's mouth. He would ride his bicycle in :front of automobiles m o v i n g t o w a r d him. The k i n d e r g a r t e n t e a c h e r r e p o r t e d t h a t he t r i e d to s m o t h e r himself u n d e r a blanket. The c a m p director notified the mother that t I e n r y was "out to kill himself." W h e n cautioned t h a t he wouId h u r t himself he said, " I w a n t to get h u r t " and " I w a n t to b r e a k a leg." The m o t h e r was dull m e n t a l l y and r a t h e r passive. A sister of the m o t h e r characterized her as loving the child with '% love which is so intense it is a b n o r m a l . " The f a t h e r was foreign b o r n a n d was described as dictatorial in his a t t i t u d e t o w a r d the children. H e h a d been p r e v i o u s l y m a r r i e d and divorced. He s p a n k e d the boy repeatedly. W h e n t I e n r y was 2 or 3 years old, his p a r e n t s tied him in his crib because he t r i e d to get out and leave the house. H e n r y was v e r y antagonistic t o w a r d his f a t h e r and h a t e d him. He was intensely and o v e r t l y jealous of his f a t h e r ' s relationship with his mother. A t the same time he seemed to feel guilty about his feelings and w a n t e d to punish himself. H e n r y i n d u l g e d in all sorts of mischievous tricks, such as pulling off

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the tz,bleeloth and strewing china and silver on the floor, throwing his father's lamb chop into the garbage pail, and e m p t y i n g the saltcellar into his mother's coffee. W h e n spanked he would not cry, but would say "give me more." At 81/2 years, H e n r y had not voiced a n y more suicidal threats nor made any more suicidal attempts since he j u m p e d out of the window. His behavior was still troublesome. He was described as "high strung, uncooperative, v e r y disobedient." He had no interest in school, and his schoolwork was v e r y poor. His resentment t o w a r d his f a t h e r continued. He had completely recovered from his fall. W h e n asked what his three magic wishes would be, he answered (I) to be a famous man, (2) to have lots of money, and (3) to live forever. His dreams were, for the most part, bad ones. An oft-repeated dream was about J a c k and the Beanstalk. He was the 'giant and fell off the beanstalk. He woke up just in time to shve himself. He also had "love" dreams. He d r e a m t about a man named Tex. " T e x proposed to a girl. E v e r y t i m e she said no and slapped him in the face. Then Tex killed the girl. He killed 16,000 girls." At 13~/2 years, he was still a "terriffle problem." His schoolwork was v e r y poor. He created disturbances in the classroom and seemed to e n j o y flaunting authority. He was resentful against his father who now treated him gently and kindly. The f a t h e r was outwardly calm and easygoing. H e n r y f o u g h t with his mother continuously.

Suicide in a 7-year-old boy was described b y Redlieh and Lazar24 The youngster's parents left him at home to watch his grandmother. He was heard to call her and to cry out several times t h a t he would t h r o w himself out of the window if he could not find her. Soon a f t e r w a r d he actually j u m p e d out of the window and was

killed. The boy was born a f t e r a difficult delivery; he had convulsions and was r e g a r d e d as feeble-minded at school. An 8 89 boy, also described by Redlich and Lazar, had t a k e n m o n e y f r o m his mother. She discovered the theft shortly and caught the boy on the street after he had spent some of it. W h e n his f a t h e r came home in the evening the boy ran to the window of the third-story a p a r t m e n t and j u m p e d out. He sustained only minor injuries. He was a b a d l y behaved, disobedient, mischievous y o u n g s t e r given to stealing and setting minor fires. Baer ~8 gives brief case histories of three boys u n d e r 10 years who made serious suicide attempts, two of them fatal. A badly behaved 8-year-old child, who had been t r u a n t from school repeatedly, was locked in a closet b y his father. He escaped and j u m p e d from a f o u r t h - s t o r y window onto the asphalt pavement below, sustaining only a f r a c t u r e of the leg. A 9-year-old boy t h r e w himself into the river Spree and drowned. He had read r o b b e r stories and talked much about m u r d e r and suicide. He ran away several times and was brought back b y the police, tie disappeared f r o m home one day and was f o n n d in the water. Another 9-year old boy described by Beer had been scolded by his m o t h e r and punished b y his f a t h e r because of truancy. T h a t same evening the boy ~umped out of a f o u r t h - s t o r y window and died later of multiple injuries. FACTORS LEADING TO SUICIDE

General

Consideratlons.--Certain

generalizations r e g a r d i n g suicide hold d u r i n g the childhood years as well as

MEDICAL PROGRESS

l a t e r on. Suicide is m o r e c o m m o n in males t h a n in females a n d in whites t h a n in nonwhites. U r b a n dwellers o u t n u m b e r rural, a n d professional groups ( a n d students) o u t n u m b e r workers. The over-all suieide r a t e fluctuates according to the season of the year. F o r example, in the r e g i s t r a t i o n area of the United States, 1910-1923, the rate was highest in May. 2~ I t fell d u r i n g the s u m m e r and autumn, r e a e h i n g its lowest p o i n t in December. T h r o u g h o u t the w i n t e r m o n t h s the r a t e s rose g r a d u a l l y to the high point in May. T a k i n g the m e a n for the y e a r as 100, the seasonal v a r i a t i o n was considerable, the difference bet w e e n the high and low r a t e s being as m u c h as 35 points. Similar seasonal v a r i a t i o n s have been observed in other p a r t s of the world. The seasonal fluctuations are not related to t e m p e r a t u r e , m e a n relative humidity, precipitation, or wind velocity. I t is of some interest t h a t the seasonal swings are w i d e r f o r females t h a n males (Massachusetts, 191019232~ Mulcock 8 f o u n d a similar seasonal v a r i a t i o n in the incidence of suicide in children 8 to 17 y e a r s of age, the deaths being most f r e q u e n t f r o m M a r c h to July. I t m i g h t be supposed t h a t the high rates d u r i n g these months are related to the strain of school e x a m i n a t i o n s ; b u t this would h a r d l y account for the similar seasonal v a r i a t i o n in adults. Religious affiliation exerts a strong influence on the incidence of suicide2 ~ Aside f r o m the f a c t t h a t religious doctrine offers solutions to m a n y of the problems which h a r a s s man, membership in a church m e a n s belonging

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to a g r o u p with which the individual can i d e n t i f y and f r o m which he ean derive the means of s a t i s f y i n g his social needs. The firmer the church organization and the m o r e devoted the m e m b e r s to t h e i r beliefs, the more fully are personal p r o b l e m s resolved. I t is t h e r e f o r e to be e x p e c t e d t h a t suieide will be r e l a t i v e l y u n e o m m o n a m o n g Catholies a n d this is aetually the ease. I n general, suicide rates are lower in Catholic t h a n in P r o t e s t a n t countries, and in v a r i o u s countries with large m i x e d p o p u l a t i o n s a similar differenee obtains. P o t e n t f a e t o r s here, also, are the bitter opposition of the Chureh to self-destruction and the strong hold whieh it exerts on its members. Suicide rates were low a m o n g European J e w s d u r i n g the nineteenth cent u r y b u t t h e y rose s h a r p l y during the early decades of the p r e s e n t century. There h a v e been m a n y epidemics of suieide. 2~ Most of these t o o k place in ancient times. I n some instances large m n n b e r s of soldiers took their lives to avoid c a p t u r e b y an e n e m y ; at other times the motive was to achieve m a r t y r d o m , or religious ferVOF.

In E n g l a n d in 665, the m o r t a l i t y f r o m pestilence was so high that m a n y persons c r o w d e d the seaside and t h r e w themselves f r o m the cliffs, p r e f e r r i n g a s p e e d y d e a t h to the lingering t o r m e n t s of illness. In Russia in 1666 whole communities killed themselves d u r i n g a r e v i v a l of religious fanaticism. I n 1897 t w e n t y eight persons b u r i e d themselves alive in Tiraspol to escape the census enumeration which t h e y a p p a r e n t l y reg a r d e d as sinful. A t various times epidemics of suicide occurred a m o n g

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Jews to avoid persecution and torture. In York, in 1190, over 500 died b y t h e i r own hands. As recent as 1928 an epidemic of suicide in Budapest resulted in 150 deliberate drownings* d u r i n g the months of April and May. The epidemic was t e r m i n a t e d b y setting up a squadron of boats or "suicide flotilla" which patroled the Danube and managed to save nine out of ten would-be suicides. Popow 21 described an epidemic of suicides among school children in Moscow. W i t h i n one school district seventy children took their lives between May, 1908, and October, 1910. ( U n f o r t u n a t e l y the age range is not given in the German abstract of Popow's paper.) The motives were school difficulties--conflict with the school ~administrator, poor grades, bad examination results; adverse home situations; love affairs; and physical illness. Popow considered imitation an i m p o r t a n t factor. Suicide is r e g a r d e d b y m a n y as a trait largely determined by heredity. This idea is not borne out b y the studies on twins by Kallmann and assoeiatesY 2 T h e y f o u n d t h a t one-egg twin p a r t n e r s are not concordant for suicide. In their series of 10 pairs of one-egg twins and 17 pairs of two-egg twins where one twin committed suicide, aI1 of the cotwins remained alive beyond the crucial age period in which the suicides of their twin partners occurred. The authors consider various possible explanations for their findings. F o r one thing the surviving twin m a y be psychologically immunized against suicide. Possibly the d e t e r r e n t s to a *Ne~v Yorlr T i m e s , J u l y 27, 1928.

cotwin suicide are painful memories of the circumstances and events incidental to the suicide, or the survivor's t e n d e n c y to i d e n t i f y himself with his suicidal twin so completely t h a t a second suicide would be like t a k i n g one's life a second time. A n o t h e r possible explanation proposed b y the authors is that suicide of a twin leads to dramatic relief of a chronic state of tension produced b y a r i v a l r y much more intense t h a n among siblings. B y the suicide of a twin, the eotwin is deprived not only of a suitable object for f u r t h e r competition but also of a sufficiently strong" motive for his own suicide at a later date. The authors reject both these mechanisms to explain the discordance among twins and conclude t h a t their data r e f u t e the possibility of a special genetic f a c t o r predisposing a person to the commitment of self-destruction. As a rule, they hold, successful suicides " c a n n o t be simply explained b y a certain type of personality and genetic constitution, or by a p a r t i c u l a r combination of social f r u s t r a t i o n and personal distress, or by the effect of a sp e cial psychotic syndrome." T h o u g h each of these m a y play a part, t h e y cannot be expected in themselves to lead to suicide even if all these factors are present together. The successful suicidal act seems to be "a compulsive and certainly abnormal t y p e of short-circuit reaction of a person in distress." I t has been described as a "twilight state of selfdestructive ecstasy" in response to the inability to adjust to adverse life pressures. The eireumstauees u n d e r which t h e self-destructive action takes place must be the outcome of

NtEDICAL P R O G R E S S

such a peculiar combination of motiv a t i o n a l f a c t o r s as to r e n d e r a duplication of this high-tension s t a t e unlikely, even in one-egg twins. A n o t h e r c u r r e n t idea, t h a t suicide is more common in only children t h a n in children who have b r o t h e r s and sisters, was also i n v e s t i g a t e d b y Kallm a n n and associates. T h e i r results indicate t h a t the p e r c e n t a g e of only children who die of suicide is no g r e a t e r t h a n the p e r c e n t a g e of only children who die f r o m other causes. T h e y conclude t h a t the n u m b e r of only children with self-destructive tendencies does not differ significantly f r o m the expected n u m b e r as d e d u c t e d f r o m data available w i t h respect to the general population. SOCIAL FACTORS

The "social" causes of suicide h a v e been emphasized by D u r k h e i m Y ~ He pointed out t h a t the suicide r a t e of a n y p a r t i c u l a r nation r e m a i n s f a i r l y constant over a period of y e a r s a n d differs consistently f r o m t h a t of other nations. I t follows f r o m this observation t h a t there are causes f o r suicide which are outside the individual and which h a v e to do w i t h the social milieu. The i m p o r t a n c e of the social f a c t o r s can be i n f e r r e d f r o m the magnitude of the v a r i a t i o n s in the suicide r a t e in different countries. The male suicide r a t e s in adolescents 15 to 19 y e a r s of age v a r y f r o m 0.6 p e r 100,000 in I r e l a n d to 26.1 in J a p a n (Table I V ) ; the rates in boys 10 to 14 years f r o m 0 in N o r w a y a n d Scotland to 1.9 in G e r m a n y (Table V I I I ) . D u r k h e i m groups the social f a c t o r s in t h r e e categories : 1. D u r k h e i m p r o p o s e d t h a t the suicide r a t e of a c o m m u n i t y varies with

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the extent to which each individual feels t h a t he is a p a r t of the controlling social group. I f t h e g r o u p loses cohesion it can no longer exercise its function and the i n d i v i d u a l ' s s t r i v i n g will lack p u r p o s e a n d meaning. As a result the suicide r a t e rises in times of social and economic disturbance. So, also, the r a t e is r e l a t i v e l y high in classes and occupations which arc least subject to the c o m m o n mores. D u r k h e i m ' s studies have been elaborated and e x t e n d e d b y a n u m b e r of A m e r i c a n w o r k e r s ~4 and, most recently, b y Sainsbury. 2~ H e observed consistent differences in the suicide rates of L o n d o n b o r o u g h s over a period of three decades in spite of considerable changes in the composition of their populations. The suicide r a t e s were significantly correlated w i t h such characteristics as social isolation (e.g., people living alone or in b o a r d i n g h o u s e s ) , social mobility (e.g., daily t u r n o v e r of population and n u m b e r of i m m i g r a n t s ) , divorce and illegitimacy. The r a t e s were higher in middle-class groups t h a n among' the poor. U n e m p l o y m e n t and o v e r c r o w d i n g w e r e not significant factors. The r a t e was increased b y social conditions which led to a sudden fall in the s t a n d a r d of living. 2. To explain the f r e q u e n c y of suicide in societies where there is seemingly g r e a t i n t e g r a t i o n of the individual into the g r o u p a n d where the individual is r i g i d l y g o v e r n e d b y custom and habit, e.g., J a p a n , D u r k h e i m p r o p o s e d t h a t here the basis for the act is altruistic, the inividual t a k i n g his life because of noble ideals, religious sacrifice, or blind allegiance. 3. A t h i r d basis f o r suicide proposed b y D u r k h e i m is characteristic of

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times of economic crises. The selfd e s t r u c t i v e act results fronl a failure of the individual to adjust w h e n social r e s t r a i n t s are w e a k e n e d d u r i n g periods of stress. The v a r i a b i l i t y in the d e a t h rate f r o m suicide is wider in children and adolescents t h a n in adults. This is shown in Table I X where the coTABLE I X . T H E VARIABILITY OF I)EATH IC~ATES ~kOM SUICIDE IN TWENTY~TWO COUNTRIES BY AGE AGE (YR.)

COEFFICIENT OF VARIATIONS ~

15 a n d o v e r 15-19 10-14

50 63 63

* T h e coefficient of v a r i a t i o n is t h e s t a n d a r d d e v i a t i o n m u t i p l i e d b y 100, d i v i d e d b y t h e mean.

effieients of v a r i a t i o n for the d e a t h rates in t w e n t y - t w o countries are c o m p ~ ' e d . The coefficients are considerably higher for the age groups 10 to 14 and 15 to 19 t h a n for adults 15 y e a r s and over. This means t h a t e x t e r n a l f a c t o r s are even more import a n t in children and adolescents t h a n in adults. The suicide rates in children and adolescents correlate f a i r l y closely with the r a t e in adults. I t follows that, to a considerable extent, similar e x t e r n a l f a c t o r s affect the incidence of suieide at various age levels. D u r k h e i m ' s analysis of the social f a c t o r s leading to suicide fails to explain the m a r k e d differences in the rates in W e s t e r n countries. I t is h a r d to believe t h a t the n m e h higher figures f o r D e n m a r k t h a n for n e a r b y N o r w a y are due to g r e a t e r social isolation in D e n m a r k . I t seems likely t h a t the strictness of a social system, as exemplified b y the " P r u s s i a n " way of life, is a m a j o r f a c t o r leading to suicide. The rigid

c o n f o r m i t y expected of its m e m b e r s allows too few alternatives. F r o m the v e r y beginning the child is r e a r e d in an a t m o s p h e r e which d e m a n d s strict c o n f o r m i t y and which brooks f e w transgressions. P u n i s h m e n t is prompt, frequent, and severe. This a t t i t u d e is d o m i n a n t not only in the home, but also in the school and, later on, in the eom m u n i t y . A n o t h e r social f a c t o r of m a j o r imp o r t a n c e is the p o p u l a r a t t i t u d e tow a r d the suicide act. I n the United States, England, and elsewhere suicide is looked down upon as a c o w a r d l y act or as the act of a sick person. I n other countries, n o t a b l y G e r m a n y a n d Austria, it is generally r e g a r d e d as an honorable and noble w a y to die. Germ a n y has been r e f e r r e d to as the land of " r o m a n t i c suicide." Within a short space of time in recent years, t h r e e of Vienna's most distinguished p e d i a t r i c i a n s ~ P i r q u e t , Knoepfelmacher, and L e i n e r - - t o o k their lives. I n this p r e s e n t a t i o n a discussion of suicide in Asian countries has been o m i t t e d since the conditions are unique and do not a p p l y here or in Europe. F o r example, it was once the rule in I n d i a for the wife to kill herself w h e n her h u s b a n d died, a cust o m k n o w n as "suttee." A t times it has also been expected t h a t the servants will commit suicide w h e n their m a s t e r died. I t is of interest t h a t f o r m e r l y , in J a p a n , the ehildren of the n o b i l i t y and m i l i t a r y classes were f a m i l i a r i z e d with the idea of self-des t r u c t i o n f r o m their earliest years. T h e y were t a u g h t t h a t existence m u s t be s u r r e n d e r e d w h e n d u t y or honor demands.

I~iEDICAL P R O G R E S S INDIVIDUAL FACTORS

The n u m b e r of r e p o r t e d suicides a n d serious suicidal a t t e m p t s in child r e n u n d e r 10 y e a r s is so small t h a t generalizations r e g a r d i n g m o t i v a t i o n can only be made t e n t a t i v e l y . F o r the most p a r t the children are b a d l y t r e a t e d at home and r e a c t with rebellious behavior. The suieidaI act is usually p r e c i p i t a t e d b y f e a r of punishment. The 5-year-old boy described above who j u m p e d out of a s e v e n t h - s t o r y window does not fit into this category. He was welI t r e a t e d at home a n d had the affection of his parents. He was i n o r d i n a t e l y jealous of his f a t h e r ' s attentions to his m o t h e r and strong feelings of guilt seemed to be his principal motive for self-destruction. Hall 2~ r e g a r d s the w i d e s p r e a d desire to punish others who will be grieved b y t h e i r d e a t h as one of the m o s t f r e q u e n t motives to suicide in y o u n g children. An a n g r y child, unable to punish d i r e c t l y those who have i n j u r e d or insulted him, seeks in self-destruction to t a k e his revenge on those who love him. This motivation is more common in the girl and is likely to persist longer. Among" the reasons f o r suicides below the age of 15 y e a r s in Prussia, according to Baer, ~3 remorse, shame, and p a n g s of conscience r a n k high, being m a j o r considerations in about one-third of the eases. Mental illness accounted for less t h a n 1'0 p e r cent of cases. Other reasons were a n g e r and quarreling, passion, being fed up with life, physical suffering, w o r r y , and depravity. I n about one-third of the cases no cause could be found.

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I t seems reasonable to assume t h a t the high suicide rate a m o n g Prussian children was related to the overly strict " P r u s s i a n " a t t i t u d e t o w a r d children and the "children's f e a r of p u n i s h m e n t in the home and, p e r h a p s even to a g r e a t e r extent, in the schools. Bender and Sehilder 4 in 1937 rep o r t e d six children below the. age of 10 y e a r s who fantasied, threatened, or a t t e m p t e d suicide, none successfully. These children, a g e d 6, 7, 7, 7, 8, and 9 y e a r s old, respectively, came f r o m unstable homes. T h e y h a d all t h r e a t e n e d suicide on r e p e a t e d occasions and h a d m a d e serious suicidal attempts. Several were followed into adolescence b y Bender. None died by their own hands. Bender and Sehilder r e g a r d the suicidal a t t e m p t in y o u n g children as a reaction to a situation which the child finds unbearable. Most commonly the child is unloved, or he considers himself unloved, the need for affection in such eases being especially g r e a t because of a physical defeet or illness or because of social deprivation. The adverse home situation p r o v o k e s feeling's of aggression which are directed p r i m a r i l y against those who denied affection. Guilt feelings, e n g e n d e r e d b y the aggressive tendencies t o w a r d the p a r e n t s or p a r e n t substitutes, lead to the aggressive feelings being t u r n e d against the child himself. F a c t o r s which t e n d to increase aggressive feelings, such as the example of an aggressive parent, f a v o r the drive f o r self-destruction. The suicidal a t t e m p t , further, represents a w a y of p u n i s h i n g the environment and a m e t h o d of getting a g r e a t e r a m o u n t of love.

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The motives for suicide in children 10 to 15 y e a r s h a v e been listed b y B a e r ~ (Table X ) . His analysis is based on 936 eases in Prussia for the y e a r s 1884-1898. Of first i m p o r t a n c e are remorse, shame, and p a n g s of conscience, these being m a j o r considerations in a b o u t one-third of the eases. A n g e r a n d q u a r r e l i n g were of prim a r y i m p o r t a n c e in about 10 p e r cent of the suicides. I t is of interest t h a t only 7.5 p e r cent were a t t r i b u t e d to mentM illness. TABLE X. MOTIVES FOR S~JmWE I x 936 CgILDREN UNDER 1,5, YEARS~ PRUSSIA,

1884-18981a { BoYs

I GIR~S

Remors% sham% p a n g s of conscience 32.7

37.3

Anger and quarreling MeutM illness Passion Fed up with life Physical suffering Worry Depravity Unknown causes

11.4 10.4 1.5 1.5 2.0 1.0 1.5 31.8

9.8 7.5 2.6 1.8 1.9 1.5 0.8 37.4

B a e r ' s analysis corresponds closely with t h a t of Morselli ~ made in P r u s s i a for the y e a r s 1869-1872. P r e c i p i t a t ing f a c t o r s were an u n h a p p y home, f e a r of punishment, difficulty at school, a n d i n j u r e d pride. S e h a c h t e r and Cotte 7 studied 36 subjects, 25 girls and 11 boys, aged 7 to 19 years, who a t t e m p t e d , simuIated, or were obsessed with suicide. The children often came f r o m homes b r o k e n b y divorce, separation, abandonment, or death of a parent. The motives were rebellion against the parents, lack of p a r e n t a l affection, p r o t e s t a g a i n s t restriction of liberty, f e a r of i m p r i s o n m e n t a f t e r antisocial acts, u n h a p p i n e s s in love, jealousy, wounded pride, reproofs. A s t u d y of suicide in young' persons in Massachusetts was r e p o r t e d b y

Stearns 6 in the ten-year period 19411950 in which 81 y o u n g s t e r s (60 males, 21 females) u n d e r 20 y e a r s t o o k their lives. Of these, 18 were between 11 a n d 14 y e a r s a n d 63 were in the 15- to 19-year group. Onet h i r d t o o k their lives b y hanging, a n o t h e r 33 p e r cent b y firearms, 15.5 p e r cent used g a s , and 11.3 per cent poison. S t e a r n s 6 calls a t t e n t i o n to a unique g r o u p of teen-age boys who committed suicide b y hanging. N e a r l y all of t h e m were between the ages of 11 and 16 y e a r s (22 out of 24 cases). The age distribution was as follows: Age (:Yr.)

11 12 13 14 15 16 17 18 19

No. of Cases

3 2 1 8 3 5 1 0

1

T h e y were, f o r the most part, fine y o u n g s t e r s w i t h a record of good health, good personality, good standing in the community, showing leadership qualities, who for no obvious reasons h u n g themselves. The act t o o k plaee a b r u p t l y in the m i d s t of w h a t seemed a well-adjusted life. Usually there was some change of clothing, in some instances alI clothes were removed, in others t h e y used bits of female clothing like a brassigre or girl's stockings. Freq u e n t l y the boys tied up t h e i r hands and feet. T h e y m i g h t be chained, padlocked, bound with strings or adhesive tape. Sometimes pin-up t y p e s of alluring female nudes were set out within view. Similar eases are seen not infreq u e n t l y b y medical e x a m i n e r s in

~EDICAL PROGRESS

large centers. It is Simpson's 27 view t h a t these hangings are accidental r a t h e r than suicidal and t h a t t h e y are for the purpose of masochistic enjoyment of simple restraint or pain. Evidence in f a v o r of Simpson's thesis is found in a recent ease r e p o r t by Shankel and Cart. 2a T h e y studied a 17year-old boy who, since early adoleseenee, had f r e q u e n t l y dressed in female clothing and masturbated. On several occasions he had hanged himself. He did this, he said, because it p r o d u c e d erections a f t e r which he masturbated. In New Y o r k City it is the custom, w h e n e v e r doubt exists, to r e c o r d these eases as accidental. A typical ease related b y Dr. Milton Helpern, Chief Medical Examiner, was t h a t of a 14year-old boy, seemingly normal in e v e r y respect, who f r e q u e n t l y indulged in pranks. The parents, on ret u r n i n g home one evening, f o u n d the boy, dressed in some of his sister's clothes, suspended f r o m the doorway leading to the living room. Presumably he had chosen this p r o m i n e n t place so t h a t he could be seen b y his parents as t h e y entered the house from outdoors and t u r n e d on the lights. Since doubt existed as to this b o y ' s intentions in hanging himself the death was r e c o r d e d as circumstances undetermined. The predilection of boys for hanging is emphasized b y Mu]eock s who lists 112 deaths by hanging or strangulation in boys and only two in girls aged 10 to 15 years d u r i n g the years 1935-1949 in E n g l a n d and Wales. Mulcoek s points out the multiple factors which lead to a situation where the child sees no w a y of handling a problem except suicide. The circumstances are no different from

765

what others are up against, but the children who actually commit suieide or make a serious a t t e m p t at it seem ill-equipped to cope with such problems owing to inadequate homes, parental indifference or rejection, and tack of cooperation between school and home. Among the personal factors which predispose to suicide Mulcock mentions physical defects producing feelings of inferiority, hormonal changes accompanying adolescence, anxiety associated with pubertal changes, realization of some sexual abnormality, sex contacts and experiences, difficulty in social adjustment, a heredit a r y or familial weakness, personality disorders, psychosis, and low intelligence. Predisposing features in the environment are a home broken by divorce, separation, death, and so on, unaffeetionate parents, neglect, mental instability of members in the home, friction with siblings, feelings of exclusion, a feeling of b e i n g unwanted, school difficulty, and friction with teacher or schoohnates. At the University of Michigan suicide accounted for over half the deaths among students in 1932-1933. 2' In a five-year s t u d y at the same institution suicide or the possibility of suicide was an i m p o r t a n t consideration in 0.54 per cent of the students (313 out of 58,070). The ineidenee of suicidal attempts was highest among freshmen and nonprofessional u n d e r g r a d u a t e s . On the basis of a brief inspection given at the time of entrance examination 47 per cent of this group were regarded, from the standpoint of personality make-up and integration, to

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be candidates for problems of adaptation to u n i v e r s i t y life. This is considerably higher t h a n the figure of 27 per cent for students in general. Of the 313 students, a diagnosis of psychosis was made in 44. The largest group was made up of psychoneurosis or psychoneurotic reactions (153 eases). In 95 eases there was simple r e a c t i o n a r y depression and in 21, psychopathic personality. The most f r e q u e n t precipitating f a c t o r in the suicide a t t e m p t seemed to be a n x i e t y over schoolwork (96 cases). Other common precipitating factors were "aspect of a psychotic situation" (44 cases), concern over a love affair (33 cases), anxiety over the sex problem (22 eases), and difficulty in social adaptation (18 cases). In no instance was a single f a c t o r involved~ A c t u a l l y the median for the total factors was 22.18 per person. Raphael and co-authors 29 describe the suicide-prone individual as oversensitive, shy, self-conscious, and inclined to overact, to worry, and to be emotionally delicately balanced. He seems i m m a t u r e and infantile in his understanding, attitudes, and judgments; timid, fearful, and unsure of himself in the presence of e v e r y d a y life experiences; and concerned about his ability to cope with the academic situation and its responsibilities, tic responds readily with fatigue and even exhaustion. F u r t h e r he is a poor mixer. He has i n a d e q u a t e recreational outlets, m a r k e d feelings of inferiority, and a t e n d e n c y to self-pity. He shows little initiative and his living habits are poorly organized. He tends to react emotionally r a t h e r t h a n intellectually. He worries about the f u t u r e and is indecisive about choice of a career.

O~" P E D I A T R I C S

Effective sex adaptation is likely to be poor. In the study b y Raphael and associates, though made d u r i n g the depression years, financial considerations were relatively unimportant. The authors r e g a r d the suicidal situation as largely determined and mot i v a t e d subjectively. The outstanding element seems to be a vulnerable personality which is unable to meet e v e r y d a y life experiences and everyd a y problems in an integrated, understanding, and effective manner. T h e y r e g a r d the extrinsic component as playing a minor part. SUICIDAL ATTEMPTS Suicidal attempts, preoccupations, and t h r e a t s are f r e q u e n t in children. An almost universal fantasy, especially among the y o u n g e r ones, is " I f I die then my parents will feel sorry." Childish suicidal attempts are, in the overwhelming m a j o r i t y of cases, not serious. Many are, for the most part, merely self-mutilating acts, without real suicidal end in mind, carried out as self-punishment for actual or imagined misdeeds. W h e r e a s suicide is more common in boys, attempts are more f r e q u e n t in girls. They are, presumably, more likely to take out their aggressive impulses against themselves r a t h e r t h a n others. B y and large these children grow up into normal adults. 5, 29 A s t u d y of suicidal attempts from the Veterans Administration Hospital in Los Angeles County, California, was r e p o r t e d by Shneidman and FarberowY ~ They conclude that suicidal behavior, whether t h r e a t e n e d or attempted, should be t a k e n seriously.

2r

T h r e e - f o u r t h s of the subjects (veterans) who actually c o m m i t t e d suicide had p r e v i o u s l y m a d e t h r e a t s or attempts. The authors u r g e t h a t special caution be t a k e n f o r n i n e t y d a y s a f t e r an emotional crisis has been passed, Almost half the persons who t o o k their lives did so w i t h i n this period, even t h o u g h t h e y seemed to be recovering f r o m their troubles. A hint as to the real intentions of the suicide-minded p e r s o n m a y be gained f r o m the t y p e of suicide note. A person who m a k e s a serious att e m p t to t a k e his own life is likely to include in his note orders and admonitions, as if he h a d r e a c h e d a final decision to leave this w o r l d and h a d resigned himself to his d e p a r t u r e . An i n t e r e s t i n g finding in Shneidm a n and F a r b e r o w ' s s t u d y was t h a t persons who t h r e a t e n e d suicide were more disturbed, on the whole, t h a n those who a t t e m p t e d it. I t seemed almost as t h o u g h the a t t e m p t h a d acted in a t h e r a p e u t i c w a y and had lightened the g r a v i t y of the personality disturbance. Such a t h e r a p e u t i c effect, however, was not a l w a y s perm a n e n t and the self-destructive tendency m i g h t return. DISCUSSION

As the over-all death rate in adolescents has fallen, owing p r i n c i p a l l y to control of the infectious diseases, suicide has e m e r g e d as one of the leading causes Of death in teen-agers. D e a t h is always distressing to relatives and friends who r e m a i n behind, b u t it is especially so in the ease of suicide, f o r here grief is a c c o m p a n i e d b y shame and b y feelings of guilt and inadequacy. Most p a r e n t s feel t h a t t h e y are in some w a y responsible for

PROGRESS

767

the u n h a p p i n e s s which expressed itself in this e x t r e m e fashion. F o r t u n a t e l y the t r e n d in the suicide r a t e of teen-agers in the U n i t e d States is d o w n w a r d , especially a m o n g girls. The rate here, as in E n g l a n d and Wales, is well below the median. The wide fluctuation in the suicide rate f r o m c o u n t r y to c o u n t r y means t h a t f a c t o r s outside the individual exert a potent influence on the frequency of suicide. W h a t these factors are can only be conjectured. I t is likely t h a t the r i g i d i t y of the " P r u s s i a n " t y p e of society which is not limited to G e r m a n y is an imp o r t a n t consideration. I n such a society, w h e r e strict rutes g o v e r n minute details of behavior, t r a n s g r e s sions will necessarily be frequent. Compliance is b a s e d on f e a r of censure a n d punishment. There are too few excuses or e x t e n u a t i n g circumstances for one who e r r s ; there is too little consideration for h u m a n imperfection. F a i l u r e to live up to parental expectations at home or at school is r e g a r d e d as willful misbehavior. U n d e r these circumstances a reaction with s t r o n g guilt feelings is n a t u r a l and this, in turn, expresses itself in a desire for self-punishment. I m p o r t a n t , too, is the social attitude t o w a r d the self-destructive act. W h e r e suicide is r e g a r d e d , to some extent at least, as an honorable and noble w a y to die as, f o r example in G e r m a n y and Austria, the act will be more f r e q u e n t t h a n in countries like E n g l a n d and the U n i t e d States, where suicide is look down u p o n as cowa r d l y b e h a v i o r or as a sign of m e n t a l aberration. Social acceptibility is a p r o m i n e n t f a c t o r in the suicide r a t e in certain p a r t s of Asia.

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Without any explanation are the seasonal fluctuations in the suicide rate. It is true that the high rates during the spring months coincide with "examination time" in teen-agers, but this fails to explain the similar peak in adult rates. The individual factors within a society which lead to suicide var y according to age. In young children, fear of punishment, remorse, shame, guilt feelings, and anger arc prominent factors. Most of the reported cases have come from unsatisfactory homes. In the teen-ager similar factors operate and, in addition, feelings of inadequacy, feelings of exclusion, and problems of sex adjustment. School problems are taken more seriously by the teen-ager than by younger children. Interesting are the cases described by Stearns and others of lmnging in seemingly well-adjusted boys. I t is worth noting that mental illness is regarded as a minor cause of suicide, accounting for only about 10 per cent of the cases. The sole approach to the suicide problem lies in recognizing beforehand the susceptible individuals and in their proper management. Too often suicidal threats and even minor attempts are looked upon as bids for attention and sympathy, which they usually are, and the unhappy adolescent is subjected to teasing" and ridicule. Unfortunately tragedy follows in a certain number of eases. There are a few warning signs that should make the physician suspect impending suicide, a~ Most prominent is depression, often associated with insomnia, instability, and violent temper outbursts. In some instances suicide follows a recent surgical opera-

tion or a painful long drawn-out illness. And, last, the type of suicide note may give helpful information. Sifneos and associates 32 emphasize the value of hospital care as a preventive measure. The hospital helps by removing the person from the acute situation which is troubling" him. It provides a dramatic demonstration that his concerns, practical and psychological, are being" seriously considered and that something is being done for him. Physical aihnents are attended to. And, finally, psychiatric treatment is provided. An interesting approach to the suicide problem suggested by Wat ney 3a is the creation of a society on similar lines to Alcoholics Anonymous. This would be a permanent service which would be prepared to accept calls from any person seeking help. It might be possible to prevent suicide in some instances if a sympathetic listener eould be found who would give assistance and eneouragement. The persons ehosen for this work would, preferably, be ones who had themselves overcome a similar problem in the past. REFERENCES 1. Parrish, II. M.Causes of Death Among College Students, Pub. Health Rep. 71: 1081, 1956. 2. DieM, H. S., and Shepard, C . E . : The Health of College Students, Washington, D. C., Am. Council on Education, 1939, p. 100. 3. Neavles, J. C., and Winkour, G.: The Hot-Rod Driver, Bull. Menninger Clin. 21: 28, 1957. 4. Bender, L., and Schilder, P.. Suicidal Preoccupations and Attempts in Children, Am. J. Orthopsychiat. 7" 225, 1937. 5. Bender, L.: Aggression, Hostility and Anxiety in Children, Springfield, Ill., 1953, Charles C Thomas, p. 66. 6. Stearns, A . W . : Cases of Probable Suicide in Young Persons Without Obvious Motivation, J. Maine M. A. 44: 16, 1953.

~EDICAL PROGRESS 7. Schachter, 3&, and Cotte, S.: Tentatives, c h a n t a g e s et velleites de suicide chez les jeunes, Crlanca P o r t u g u e s a 171: 195'0-1951. 8. 3s D.: J u v e n i l e Suicide, Med. Officer 94: 155, ]955. 9. l~forselli, H.: Suicide, New York, 1882, D. Appleton and Co. 10. Durand-Fardel, M.: E t u d e sur le suicide chez les enfants, Ann. med.-psycho]. p. 61, 1885. 11. P6rier, E.: Le suicide ehez l ' e n f a n t et l'adoleseent, Ann. reed. et ehir. infant., Paris, Nov. 15, 1899, p. 821. 12. Siegert, G.: ]:)as P r o b l e m der Kinderselbstmorde, Leipzig, 1893. 13. Baer, A.: Der SeIbstmord im kindtichen Lebensalter, Leipzig, 1901. 14. Redllch, E., and Lazar, E.: K i n d l i c h e SelbstmJrder, Berlin, 1914, Julius Springer. 15. H a b e r m a n n , P.: Ueber elnem Selbstmordvcrsuch eines elf-j~hrigen K n a b e n , Arch. Kinderh. 139: 130, 1950. 16. Miner, J. R.: Suicide and I t s Relation to Climatic and O t h e r Factors, Am. J. Hyg. (monograph series), Nov. 2, 1922. 17. Serkoff, J.: Die SelbstmordfElle in lV[oskau in den J a h r e n 1908 und 1909, Ztschr. ges. Nenrologie 2: 1091, 1911 (Referate). 18. Schilder, P., and Wechs]er, D.: The A t t i t u d e of Children T o w a r d Death, J. Genet. PsychoL 45: 406, 1934. 19. Bakwin, H., a n d Bakwin, R . M . : Clinical /r of B e h a v i o r Disorders in Children, Philadelphia~ 1953, W. B. Saunders Co. 20. Dublin, L. I., and :Bunzel, B. C. : "To Be or Not to Be," A Study of Suieide~ New York, 1933, S m i t h and Haas. 21. Popow, N. M.: The P r e s e n t Epidemic of School Suicides in Russia, Nevrol Vestnik, K a z a n 18: 312, 592, 1911. 22. KaUmann, F. J., DePorte, J., DePorte, E., and Feingold~ L.: Suicide in Twins

23. 24. 25. 26. 27. 28.

29.

30. 31. 32.

33.

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and Only Children, Am. J. H u m a n Genet. 1: 113, 1949. Durkheim, E.: Suicide, Gleneoe, Ill., 1951, t r a n s l a t e d b y J. A. Spaulding and G. Simpson. Cavan, R. S.: Suicide, Chicago, 1928. Sainsbury, P.: Suicide in London, Maudsley Monographs, no. 1, London. Hall, G. S.: Adolescence, New York, 1904, D. Appleton & Co. Simpson, K.: Forensic Medicine, London, 1951, E d w a r d Arnold & Co., p. 22. Shankel, L. W., and Carr~ A. C.: Transvestlsm and H a n g i n g Episodes in a 1Kale Adolescent, P s y c h i a t r i c Quart. 30: 478, 1956. Raphael, T., Power, S. H., a.nd Berridge, W.L.: The Question of Suicide as a Problem in College M e n t a l Hygiene, Am. J. Orthopsychiat. 7: 1, 1937. Shneidman, E. S., and Farberow, N. L.: Clues to Suicide, Pub. H e a l t h Rep. 71: 109, 1956. Parnell, R. W., and Skottowe, I.: Towards P r e v e n t i n g Suicide, L a n c e t 1: 206, 1957. Sifneos, P. E., Gore, C., and Sifneos, A . C . : A P r e l i m i n a r y P s y c h i a t r i c Study of Attemptecl Suicide as Seen in a General Hospital, Am. J. Psychiat. 12: 883, 1956. Watney, A.: Toward P r e v e n t i n g Suicide, L e t t e r to the Editor~ L a n c e t 1: 531, 1957.

Additional I~efe~enees of Interest Eulenburg, A.: Ir und Jugendsselbstmorde, Ha/le, 1914, Carl Marhold. Le Moa], P. G. M.: Suicide, c h a n t a g e au suicide chez / ' e n f a n t et L'ado/escent, Paris, 1944. 1V[oreau, g.: Dt~ suicide ehez les enfants, These pour ]e doctorat en Medeeine, 1906. Oettinger, M.: Die M o r a ] s t a t l s t l k und ihre B e d e u t u n g f(ir eine Sociologie, Erlangen, 1882~ p. 774.