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The Taxonomy of Suicide as Seen in Poison Control Centers
The Taxonomy of Suicide as Seen in Poison Control Centers MATILDA S. McINTIRE, M.D.* CAROL R. ANGLE, M.D. **
"Accidental poisoning" is a socially acceptable diagnosis, and this is presumably why more self-poisoning by adolescents is seen in poison control centers than in psychiatric clinics and suicide centers. Poison control centers, the only extensive network of reporting systems of self-poisoning, are a unique and often overlooked community resource in epidemiologic studies of suicide. Although 80,000 poisonings in children under 15 are reported annually to the National Clearinghouse for Poison Control Centers, almost all epidemiologic studies have been directed toward the child under 5 years of age. There are absolutely no data on the incidence of suicidal gestures and attempts in self-poisoning by children 5 to 15 years of age. Even more significant than the lack of mass epidemiologic and demographic data concerning poisoning events in older children and adolescents is the apparent disinterest in a meaningful classification of the phenomena leading to the event, just as there was long a resistance to the taxonomy of suicide. 16 A diagnosis of suicide attempt, as contrasted to a gesture or an affect reaction, implies both a lethality of intent and a mature concept of death as an irreversible cessation. Lethality is defined by Shneidman l7 as the probability of an individual's killing himself in the immediate future. In addition to classifying all deaths as intentioned, subintentioned, and unintentioned (as opposed to the traditional natural, accidental, suicidal, and homicidal), he has proposed the dimension of lethality to cut across the terms attempted, threatened, and completed suicide. Imputed lethality, ranging from high ':'Assistant Professor of Pediatrics. University of Nebraska College of Medicine; Director of Maternal and Child Health, Omaha-Douglas County Health Department, Omaha, Nebraska; Secretary, American Association of Poison Control Centers "":'Associate Professor of Pediatrics, University of Nebraska College of Medicine, Omaha, Nebraska This work was supported by a grant (MH-14532-01) from the Center for Studies of Suicide Prevention, National Institutes of Mental Health, U.S. Public Health Service. Pediatric Clinics of North America- Vol. 17, No.3, August, 1970
697
698
MATILDA
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MCINTIRE, CAROL
R.
ANGLE
to absent, or scaled from 4 to 0, may be ascribed to the specific acts and life style of any individual. The subject definitely wants to die and anticipates that his actions will result in death. Medium: The individual is ambivalent, playing some partial, covert, or unconscious role, as in drug abuse, foolhardiness, carelessness, or outright disregard of life-saving medical care. Low: The subject plays some small but not insignificant role, such as the adolescent "inhalers," who have no conscious wish to die and yet are willing to take unknown risks. Absent: No lethal intent. High:
Adolescence is a time of great change, crisis, and pressure with a tendency for impulsive overreaction. This crisis-pressure behavior can lead to manipulative and self-destructive behavior. Self-poisoning, as demonstrated by Kessel,8 is rarely of high lethality. His study in Edinburgh concluded that at least four fifths of self-poisonings are supported by the secure belief that death will not occur. Patients can go to the brink but not fall off. They are not attempting suicide but attempting to alter their life situation by playing the game of pharmacologic brinkmanship. Unfortunately, they do not know the toxicology of this pharmacologic game and so tragic results can ensue. It becomes even more relevant to consider what the child and adolescent means when he considers his own death. The concept of death in childhood matures from a sleep-like or reversible state to an irreversible state with cognizance of the world being left, and then to spiritual continuation or total cessation. 7 , 12, 14 The adolescent has a sense of personal immortality no matter what his stated concepts are; because his own death is so remote in time; he enjoys the invincibility of youth, Our own ongoing study of the maturation of the concept of death shows that the young child up to age 5 or 6 has an immature concept, the grade school child an awareness of the permanent state, and the older child and adolescent a mature concept,11 Psychodynamic investigation of poisoning in children and youth reveals a continuum of self-destructive behavior. Self-poisoning may be classified as (1) accidental, (2) "kick" or "trip," (3) suicidal or manipulative gesture, or (4) suicide-attempted or completed, The trip and the manipulative act are usually of low to medium lethality. The diagnosis of suicide attempt implies a high lethality, Unfortunately, a pharmacologic mishap may convert an act of low lethality to a completed suicide, Shneidman's classification of lethality avoids this particular dilemma and, more important, is an index of the degree of individual perturbation. This provides a basis for the psychodynamic diagnosis and the most expedient and effective therapy.
INCIDENCE OF POISONING BETWEEN AGES 6 AND 18 The incidence of poisoning in children under age 5 years is estimated to be 400,000 cases per year," and there are 600,000 annual self-poisonings in adults. The National Clearinghouse of Poison Control Centers ':'It could well be 10 times that.-Em'wRs.
THE TAXONOMY OF SUICIDE AS SEEN IN PorSON CONTROL CENTERS
699
focuses on reports of children under 5, but in 1968 it received 6152 reports of self-poisoning in children aged 5 to 14; 71,563 under age 5; and 19,332 over age 15. 13 Extrapolating from the 71,563 reports as a sample of the estimated 400,000 total poisonings under age 5, then the sampling of cases in children aged 5 to 14 would represent a minimum of 34,000 cases. In our own survey of annual admissions for poisoning, the ratio of adults to children under 5 at 25 centers was very close to the 3:2 ratio of 600,000 adults to 400,000 children. Further extrapolation of the ratio of children under 5 (2712) to those aged 6 to 18 (784) at these 25 centers would suggest an annual incidence of 116,000 poisonings in children between 6 and 18. In addition, there are multiple indicators that suggest a current and continuing increase in drug abuse in progressively younger children. 2
CHARACTERISTICS OF CASES OF SELF-POISONING The demographic characteristics of 1103 cases of self-poisoning in children aged 6 to 18 fit into four age groups of biologic maturation. The sex distribution of patients between 6 and 10 (Fig. 1) shows a predominance of males even greater than that found for poisoning under age 5. At age 12 there is a sudden spurt of self-poisoning by adolescent girls that decreases after age 16. The increase in males aged 17 and 18 presages the known increase with age of male involvement. Racial distribution (Table 1) for girls shows an increase in Negroes aged 6 to 13 and in Puerto Ricans, Mexicans, and American Indians aged 14 to 16, while the distribution of whites approached the national average by ages 17 and 18. In boys aged 6 to 10,40 per cent were Negro, with a progressive decrease in Negroes with age. Conversely, selfpoisoning by white males increases with age. Socioeconomic status based on the occupation of the head of the family correlates with the racial distribution. Unlike poisoning under age 5, there is a definite decrease in the upper socioeconomic group aged 6 to 10, suggesting the benefits of education and supervision. A broken home was reported by 35 per cent of subjects. This is at the low range of 38 to 84 per cent reported by Dm.·pat5 in a review of psychiatric literature of attempted and completed suicide in adolescents. At all ages death of the father was almost twice as frequent as death of the mother; any psychiatric inferences from this must consider the fact that mortality of white men aged 30 to 50 is twice the rate for women. 18 Disruption of the home was more frequent in the history of mid adolescent girls than any other group. As expected, a broken home was more common in Protestant families (40 per cent) as compared to Jewish (21 per cent) or Catholic (31 per cent), but there were no other significant religious differences. The importance of sibling placement, cited by Toolan 20 and Lester,9 who reported increased rates for the oldest and only, was not confirmed by this study.
700
MATILDA
150 140
S.
McINTIRE, CAROL
R.
ANGLE
"SUICIDE" AS SEEN IN POISON CONTROL CENTERS 1103 SELF-POISONINGS AGES 6-18
130 120 110 100 II)
UJ
90
II)
'"
80
'"
70
u
...J
I-
0
I-
60 50 40 30 20 10
AGE -YEARS
AGE -YEARS
MALE
FEMALE
Figure 1. Age and sex distribution of 11 03 patients seen in poison control centers for self-poisoning.
701
THE TAXONOMY OF SUICIDE AS SEEN IN POISON CONTROL CENTERS Table
WHITE
1.
Race, Age, and Sex PUERTO RICAN, MEXICAN, INDIAN
NEGRO
OTHER OR NOT REPORTED
TOTAL
Female 6-10 11-13 14-16 17-18
24 (59%) 54 (61%) 235 (64%) 164**(77%)
Total, Female
477
6-10 11-13 14-16 17-18
31 (44%) 24 (60%) 111 (76%) 116*';' (85%)
Total, Male
282
(72%)
Total, Male and Female
759
(69%)
(67%)
16';' 24';' 83 28 151
(39%) (27%) (22%) (13%)
0 7 41" 8
( 0%) ( 8%) (11%) ( 4%)
1 3 12 12
( ( ( (
2%) 4%) 3%) 6%)
41 88 371 212
(100%) (100%) (100%) (100%)
(21%)
56
( 8%)
28
( 4%)
712
(100%)
6%) 2%) 5%) 4%)
7 2 8 7
(10%) ( 5%) ( 6%) ( 5%)
70 40 145 136
(100%) (100%) (100%) (100%)
Male 28** (40%) 13 (33%) 19 (13%) 8 ( 6%)
4 1 7 5
68
(18%)
17
( 4%)
24
( 6%)
391
(100%)
219
(20%)
73
( 7%)
43
( 4%)
1103
(100%)
( ( ( (
*p <0.05. "*p < 0.005. These percentile distributions of the results of Chi-square tests show an increase in Negro girls aged 6 to 10 and 11 to 13, and an increase in Puerto Rican-Mexican-Indian girls aged 14 to 16. For boys, there was a disproportionately high number of Negroes aged 6 to 10 and of whites aged 17 and 18.
Analysis of the subjects' occupations by age and sex showed that for males 17 and 18, the unemployment rate of 11 per cent was similar to the national average for 1969. 4
BEHAVIORAL DATA The older conflict between the sociologic and psychiatric evaluation of suicide has receded into a clinical approach that does not attempt to fit patients into a rigid categorization of psychodynamics. The diversity of individual problems was apparent in the patients' past history and in the precipitating event_ Inquiry was made concerning significant psychosocial disruption: loner, school dropout, juvenile delinquent, character or behavior disorder, brain damage-motor or mental, convulsive disorder, psychoneurosis, psychosis, significant or chronic mental disability or illness (Table 2)_ The 10 per cent incidence of behavior disorders would support Zrull's report of adolescent depression and suicide as a late manifestation of hyperactivity_21 A history of significant emotional stress at the time of the poisoning was obtained from the majority of older patients interviewed, and from 43 per cent of the youngest group (Table 3)_ These stressful situations
702
MATILDA
Table 2. Behavior disorder Character disorder "Loner" School dropout Delinquency Psychoneurosis Psychosis
115 66 58 58 44 41 22
(10%) ( 6%) ( 5%) ( 5%) ( 4%) ( 4%) ( 2%)
S.
MCINTIRE, CAROL
R.
ANGLE
Past History Chronic medical problems Convulsive disorder Brain damage Multiple problems No significant problems No information Total
22 21 12 77 341 226
2%) 2%) 1%) 7%) 31%) 20%)
1103
(100%)
Table 3. Age and Precipitating Stress AGE
PRESENT
ABSENT
6-10 11-13 14-16 17-18
47 93 405 282
(42%) (73%) (78%) (81%)
Total
827
(75%)
NOT REPORTED
TOTAL
41" ""(37%) (14%) 18 36 ( 7%) 20 ( 6%)
23 17 75 46
(21%) (13%) (15%) (13%)
111 128 516 348
(100%) (100%) (100%) (100%)
(10%)
161
(15%)
1103
(100%)
115
""'''''p <0.005, showing that although precipitating stress was recorded in 42 per cent of 6 to 1 0 year olds it was significantly more frequent in all patients over 10.
were listed on the questionnaire as humiliation, punishment, sense of failure, romance problems, pregnancy, family problems, loss of parent or significant other relative, and "other difficulties." In the youngest age group, acts of overt aggression and hostility and fear of retribution were the most common difficulties. This is the most transparent expres· sion of suicide as hate. Of the girls 17 or 18, 30 per cent were married, separated, widowed, unwed mothers, or unwed pregnant. In boys, homosexuality was frequently reported; this theme is expanded by Deisher et al. in their studies of the young male prostitute." Precipitating stress revolved around the "five P's:" parents, peers, privation, punctured romance, and pregnancy. Intent, meaning the deliberate attempt to poison oneself, was assessed by the reporters as shown in Table 4. In children 6 to 10,50 per cent of poisoning is called unintentional, but this naive interpretation is not supported by behavioral data; the 6 to 10 year old selects sedatives Table 4. AGE
INTENTIONAL
Age and Diagnosis of Intent
SUBINTEN-
UNINTEN-
TIONAL
TIONAL
6-10 11-13 14-16 17-18
14 68 333 233
(13%) (53%) (64%) (67%)
21 29 107 61
(19%) (23%) (21%) (17%)
Total
648
(59%)
218
(20%)
56'" 20 38 28 142
UNKNOWN
TOTAL
"'(50%) (16%) ( 7%) ( 8%)
20 11 35 25
(18%) ( 9%) ( 7%) ( 7%)
111 128 519 349
(100%) (100%) (100%) (100%)
(13%)
91
8%)
1103
(100%)
""'''''p <0.005, showing a significantly greater frequency (50 per cent) of pOisoning diagnosed as unintentional in ages 6 to 1O.
703
THE TAXONOMY OF SUICIDE AS SEEN IN POISON CONTROL CENTERS
twice as frequently as the 4 year old; at least 24 per cent of such children are referred to behavior clinics; 26 per cent have a significant history of past difficulties; 43 per cent give a history of current precipitating stress factors. Only 8.6 per cent of the 992 cases in patients aged 11 to 18 were considered "unintentional." The diagnosis of suicide attempt had been explained to the interviewers as, "did the subject mean to kill himself?" and the frequency of diagnosis is shown in Table 5. Table 5. Age and Diagnosis of Suicide AGE
FINAL DX
CONSIDERED NOT FINAL
NEVER CONSIDERED
71':"":'(69%)
NOT REPORTED
6-10 11-13 14-16 17-18
2 26 165 98
( 2%) (20%) (32%) (28%)
10 37 162 108
( 9%) (29%) (31%) (31%)
54" 134 118
(42%) (26%) (34%)
22 11 55 24
(20%) ( 9%) (11%) ( 7%)
Total
291
(26%)
317 (29%)
383
(35%)
112
(10%)
TOTAL
111 128 516 348
(100%) (100%) (100%) (100%)
1103 (100%)
*p <0.05. '*.p <0.005.
The frequency of the diagnosis of suicide increases with age.
The diagnosis of a suicide attempt by any observer was related to 1) age, (2) drug use-i.e., a "kick" or "trip" was rarely called a suicide attempt, (3) the history of prior psychosocial disruption, (4) precipitating stress, and (5) socioeconomic status, with significantly greater attention being given to the possibility of suicide attempt in patients from the upper socioeconomic group. What also seems to have been measured is the regional variation in interpretation of the term suicide, so that Edinburgh, continuing in their clear distinction of gestures from attempts, reported not a single suicide attempt in 131 poison ingestions by adolescents. The general classifications of toxic substances showed a distinctive pattern for each age group (Table 6). Aspirin, responsible for 37 per cent of poisoning in 4 year oIds, was ingested by only 11 per cent of 6 to 10 year olds but became increasingly popular with the 14 to 16 year old girls. Intent is suggested by the fact that 27 per cent of 6 to 10 year olds ingest sedatives, or twice as frequently as do 4 year olds. Young thrillseekers favor alcohol and glue inhalation over other hallucinogens, but drug abuse triples after age 13. Death occured in 5 patients, a mortality of 1 :220 self-poisonings. One patient, a 15 year old girl who had inhaled spray shortening, was in the group of 141 patients whose patent intent was intoxication alone. The other four deaths were a 12 year old Negro girl from bromides in an over-the-counter tranquilizer, a 13 year old white boy who ingested sodium arsenite herbicide because he was angry with his father, a 15 year old Negro girl (aspirin), and a 16 year old Mexican girl. Despite the incomplete data, it is suggested that lethality of intent was extremely low and death was the result of a toxicologic mishap.
" C
~
Table 6. AGE
ASPIRIN
SEDATIVEt
Age and Drug Use
AMPHETAMINE
MED., MISC.
MISC., OTHER
6-10 11-13 14-16 17-18
12 33 148 76
(11%) (26%) (29%) (22,;{)
30 39 191 143
(27%) (30%) (37%) (41,;{)
5 6 27 19
(5%) (5%) (5,;{ ) (5';{ )
14 10 35 29
(13%) ( 8%) ( 7,;{) ( 8,;{)
44 ''''(40%) 34 (28%) ( 8%) 6 ( 9%) 31
Total
269
(24%)
403
(37%)
57
(5%)
88
8,;{)
145
(13%)
Total, Female Total, Male
212 57
(30%) (15%)
268 135
(38%) (35%)
40 17
(6,;{) (4%)
60 28
8,;{) 7%)
81 64
(11 %) (16%)
"TRIPS"!
6 6 79 50':""
TOTAL
( 5%) ( 5%) (15,;{ ) (14%)
III 128 516 348
(100%) (100%) (100%) (100%)
(13%)
1103
(100%)
51 ( 7%) 90" "(23%)
712 391
(100%) (100%)
141
~
;,> >-l
t=:
Ij
;,>
':"'p <0,025.
*''':'p <0.005.
These Chi-square percentile values show an increase in "trips" at ages 14 to 18, particularly among boys, and a high rate of miscellaneous poisonings at ages 6 to 10. tBarbiturates, nonbarbiturate sedatives, tranquilizers !Alcohol, marijuana, hallucinogen, glue, and related inhalants.
:n ~
()
Z >-l
;:;
1'" ('J
;.~
o t"'
p:!
> Z <;1
t"'
OJ
THE TAXONOMY OF SUICIDE AS SEEN IN POISON CONTROL CENTERS
705
CONCEPT OF DEATH Pediatricians have been shown to avoid any discussion of death 10 and it appears a most alien suggestion that children be routinely interviewed. In this study, participants were asked to pursue the concept of death beyond the usual imagery of burial and the following suggestions offered for the interview: Ask the patient what he thinks it's like to be dead or what would happen to him if he died. Children may initially consider this a thoroughly ridiculous question, but if you emphasize your honest interest in their thoughts they will accept it as a valid, inoffensive inquiry. It is acceptable to offer alternatives appropriate to age, such as to ask an 8 year old if he thinks dying is like going to sleep: "Yes" "Do you think you could wake up again and come back?" "No, not alive" "Well, do you think that if you were dead that you could tell what was going on, like your mother crying over all the toys in your room, or what the family had for dinner?" "I guess so. Yes"
This would be coded as irreversible, but cognizant. Of the replies obtained from 515 children, there was a maturation with age from a concept of death as a reversible sleeplike state to an irreversible but cognizant state to total cessation with or without some form of spiritual continuation. Grouping the first two categories as immature and the latter two as mature, a mature concept is stated by most children over the age of 10 (Table 7). Table 7. Age and Concept of Death PERMANENT BUT WITH
AGE
SLEEPLIKE,
IRREVER-
POSSIBLY REVERSIBLE
SIBLE, BUT COGNIZANT
6-10 11-13 14-16 17-18
10 10 36 23
(36%) (18%) (15%) (13%)
Total
79 (15%)
5 3 15 6
(18%) ( 5%) ( 6%) ( 3%)
29 ( 6%)
TOTAL
SPIRITUAL CONTIN-
TOTAL
INTER-
UATION
CESSATION
VIEWED
9 23 76 43
(32{/{) (40%) (31%) (23%)
151 (29%)
4 21 118 113
(14%) (37%) (48%) (61 %)
256 (50%)
28 57 245 185
NOT REPORTED
(100o/c) (100%) (100%) (100%)
83 71 271 163
515 (100%)
588
The professed concept of death, however mature, may obviously differ from the emotional need to believe in the unique immortality of self. Given this premise, the admission of an immature concept by 16 per cent of 17 and 18 year olds seems particularly significant. This denial of total cessation is as important a consideration in the psychodynamics of suicide as is lethality of intent. It is inherent in the naive interpretation of self-destructive acts in the young: "He didn't know what he was doing." Intent is rarely lethal; it is not cessation of life but only escape from certain aspects of life that is sought,! More important, there may be total denial of the possibility of death.!5
706
MATILDA
S.
MCINTIRE, CAROL
R. ANGLE
The results of our survey show that self-poisoning in a child over 6 is rarely accidental and deserves inquiry by the responsible practitioner into the severity and chronicity of prior difficulties and disruptive events, the nature of the precipitating stress, and, most important, the motivation for the act. One needs to know what the child expected to happen to him physically as a result of the ingestion and what he expected to change in his life. The actual self-poisoning may be the end stage of long-standing problems, as stressed by Teicher and Jacobs,B. 19 or it may be an impulsive attempt to control interpersonal conflict. Poison control centers may offer as strong a lifeline to children and youth manifesting self-destructive behavior as suicide prevention centers extend to adults. Attention to the significance of self poisoning may intercept the continuum of self-destructive behavior at an earlier stage in the life cycle, when the survivors have the greatest potential of regaining their psychosocial equilibrium.
REFERENCES 1. Barter, J. T.: Self-destructive behavior in adolescents and adults: Similarities and differences. In Suicide Among the American Indians. U.S. Public Health Service publication No. 1903, June 1969, pp. 7-10. 2. Carabillo, E. A., Jr.: Federal drug abuse programs. Presented at the 12th annual meeting, American Association of Poison Control Centers, Chicago, October 20, 1969. 3. Deisher, R W., Eisner, V., and Sulzbacher, S. 1.: The young male prostitute. Pediatrics, 43:936-941,1969. 4. Department of Labor and Manpower Administrations: Unemployment Insurance Statistics, February 1970. 5. Dorpat, T. L., Jackson, J. D., and Ripley, H. S.: Broken homes and attempted or completed suicide. Arch. Gen. Psych., 12:212-216, 1965. 6. Jacobs, J., and Teicher, J. D.: Broken homes and social isolation in attempted suicides in adolescents. Int. J. Soc. Psychiat., 13:139-149, 1967. 7. Kastenbaum, R: Time and death in adolescence. In Feifel, H.: The Meaning of Death. New York, McGraw-Hill Book Co., 1959, pp. 99-113. 8. Kessel, N.: Self-poisoning. Brit. Med. J., 1: 1265-1270, 1336-1348, 1965. 9. Lester, D.: Sibling position and suicidal behavior. J. Indiv. Psycho!., 22:204-207,1966. 10. Lourie, R S.: The pediatrician and the handling of terminal illness. Pediatrics, 32:477479,1963. 11. McIntire, M. S., and Angle, C. R: The concept of death in midwestern children. (Manuscript in preparation.) 12. Nagy, M. H.: The child's view of death. In Feifel, H.: The Meaning of Death. New York, McGraw-Hill Book Co., 1959, pp. 73-98. 13. National Clearinghouse for Poison Control Centers: Statistics, 1968. 14. Schilder, P., and Wechsler, D.: The attitudes of children toward death. J. Gen. Psych., 45 :406-451, 1934. 15. Seiden, R H.: Suicide Among Youth. U.S. Public Health Service publication No. 1971, December 1969. 16. Shneidman, E. S.: Orientations toward death. In White, R W.: The Study of Lives. New York, Atherton Press, 1966, pp. 201-227. 17. Shneidman, E. S.: Orientation toward cessation: A re-examination of current modes of death. J. Forensic Sci., 13 :33-45, 1968. 18. Statistical Abstract of the United States, 1966, p. 54. 19. Teicher, J. D., and Jacobs, J.: Adolescents who attempt suicide: Preliminary findings. Amer. J. Psychiat., 122:1248-1257,1966. 20. Toolan, J. M.: Suicide and suicidal attempts in children and adolescents. Amer. J. Psychiat., 118:719-724,1962. 21. Zrull, J. P., cited in Pediatric News, 3:47,1969. Department of Pediatrics University of Nebraska College of Medicine Omaha, Nebraska 68105
"Accidental poisoning" is a socially acceptable diagnosis, and this is presumably why more self-poisoning by adolescents is seen in poison control centers than in psychiatric clinics and suicide centers. Poison control centers, the only extensive network of reporting systems of self-poisoning, are a unique and often overlooked community resource in epidemiologic studies of suicide. Although 80,000 poisonings in children under 15 are reported annually to the National Clearinghouse for Poison Control Centers, almost all epidemiologic studies have been directed toward the child under 5 years of age. There are absolutely no data on the incidence of suicidal gestures and attempts in self-poisoning by children 5 to 15 years of age. Even more significant than the lack of mass epidemiologic and demographic data concerning poisoning events in older children and adolescents is the apparent disinterest in a meaningful classification of the phenomena leading to the event, just as there was long a resistance to the taxonomy of suicide. 16 A diagnosis of suicide attempt, as contrasted to a gesture or an affect reaction, implies both a lethality of intent and a mature concept of death as an irreversible cessation. Lethality is defined by Shneidman l7 as the probability of an individual's killing himself in the immediate future. In addition to classifying all deaths as intentioned, subintentioned, and unintentioned (as opposed to the traditional natural, accidental, suicidal, and homicidal), he has proposed the dimension of lethality to cut across the terms attempted, threatened, and completed suicide. Imputed lethality, ranging from high ':'Assistant Professor of Pediatrics. University of Nebraska College of Medicine; Director of Maternal and Child Health, Omaha-Douglas County Health Department, Omaha, Nebraska; Secretary, American Association of Poison Control Centers "":'Associate Professor of Pediatrics, University of Nebraska College of Medicine, Omaha, Nebraska This work was supported by a grant (MH-14532-01) from the Center for Studies of Suicide Prevention, National Institutes of Mental Health, U.S. Public Health Service. Pediatric Clinics of North America- Vol. 17, No.3, August, 1970
697
698
MATILDA
S.
MCINTIRE, CAROL
R.
ANGLE
to absent, or scaled from 4 to 0, may be ascribed to the specific acts and life style of any individual. The subject definitely wants to die and anticipates that his actions will result in death. Medium: The individual is ambivalent, playing some partial, covert, or unconscious role, as in drug abuse, foolhardiness, carelessness, or outright disregard of life-saving medical care. Low: The subject plays some small but not insignificant role, such as the adolescent "inhalers," who have no conscious wish to die and yet are willing to take unknown risks. Absent: No lethal intent. High:
Adolescence is a time of great change, crisis, and pressure with a tendency for impulsive overreaction. This crisis-pressure behavior can lead to manipulative and self-destructive behavior. Self-poisoning, as demonstrated by Kessel,8 is rarely of high lethality. His study in Edinburgh concluded that at least four fifths of self-poisonings are supported by the secure belief that death will not occur. Patients can go to the brink but not fall off. They are not attempting suicide but attempting to alter their life situation by playing the game of pharmacologic brinkmanship. Unfortunately, they do not know the toxicology of this pharmacologic game and so tragic results can ensue. It becomes even more relevant to consider what the child and adolescent means when he considers his own death. The concept of death in childhood matures from a sleep-like or reversible state to an irreversible state with cognizance of the world being left, and then to spiritual continuation or total cessation. 7 , 12, 14 The adolescent has a sense of personal immortality no matter what his stated concepts are; because his own death is so remote in time; he enjoys the invincibility of youth, Our own ongoing study of the maturation of the concept of death shows that the young child up to age 5 or 6 has an immature concept, the grade school child an awareness of the permanent state, and the older child and adolescent a mature concept,11 Psychodynamic investigation of poisoning in children and youth reveals a continuum of self-destructive behavior. Self-poisoning may be classified as (1) accidental, (2) "kick" or "trip," (3) suicidal or manipulative gesture, or (4) suicide-attempted or completed, The trip and the manipulative act are usually of low to medium lethality. The diagnosis of suicide attempt implies a high lethality, Unfortunately, a pharmacologic mishap may convert an act of low lethality to a completed suicide, Shneidman's classification of lethality avoids this particular dilemma and, more important, is an index of the degree of individual perturbation. This provides a basis for the psychodynamic diagnosis and the most expedient and effective therapy.
INCIDENCE OF POISONING BETWEEN AGES 6 AND 18 The incidence of poisoning in children under age 5 years is estimated to be 400,000 cases per year," and there are 600,000 annual self-poisonings in adults. The National Clearinghouse of Poison Control Centers ':'It could well be 10 times that.-Em'wRs.
THE TAXONOMY OF SUICIDE AS SEEN IN PorSON CONTROL CENTERS
699
focuses on reports of children under 5, but in 1968 it received 6152 reports of self-poisoning in children aged 5 to 14; 71,563 under age 5; and 19,332 over age 15. 13 Extrapolating from the 71,563 reports as a sample of the estimated 400,000 total poisonings under age 5, then the sampling of cases in children aged 5 to 14 would represent a minimum of 34,000 cases. In our own survey of annual admissions for poisoning, the ratio of adults to children under 5 at 25 centers was very close to the 3:2 ratio of 600,000 adults to 400,000 children. Further extrapolation of the ratio of children under 5 (2712) to those aged 6 to 18 (784) at these 25 centers would suggest an annual incidence of 116,000 poisonings in children between 6 and 18. In addition, there are multiple indicators that suggest a current and continuing increase in drug abuse in progressively younger children. 2
CHARACTERISTICS OF CASES OF SELF-POISONING The demographic characteristics of 1103 cases of self-poisoning in children aged 6 to 18 fit into four age groups of biologic maturation. The sex distribution of patients between 6 and 10 (Fig. 1) shows a predominance of males even greater than that found for poisoning under age 5. At age 12 there is a sudden spurt of self-poisoning by adolescent girls that decreases after age 16. The increase in males aged 17 and 18 presages the known increase with age of male involvement. Racial distribution (Table 1) for girls shows an increase in Negroes aged 6 to 13 and in Puerto Ricans, Mexicans, and American Indians aged 14 to 16, while the distribution of whites approached the national average by ages 17 and 18. In boys aged 6 to 10,40 per cent were Negro, with a progressive decrease in Negroes with age. Conversely, selfpoisoning by white males increases with age. Socioeconomic status based on the occupation of the head of the family correlates with the racial distribution. Unlike poisoning under age 5, there is a definite decrease in the upper socioeconomic group aged 6 to 10, suggesting the benefits of education and supervision. A broken home was reported by 35 per cent of subjects. This is at the low range of 38 to 84 per cent reported by Dm.·pat5 in a review of psychiatric literature of attempted and completed suicide in adolescents. At all ages death of the father was almost twice as frequent as death of the mother; any psychiatric inferences from this must consider the fact that mortality of white men aged 30 to 50 is twice the rate for women. 18 Disruption of the home was more frequent in the history of mid adolescent girls than any other group. As expected, a broken home was more common in Protestant families (40 per cent) as compared to Jewish (21 per cent) or Catholic (31 per cent), but there were no other significant religious differences. The importance of sibling placement, cited by Toolan 20 and Lester,9 who reported increased rates for the oldest and only, was not confirmed by this study.
700
MATILDA
150 140
S.
McINTIRE, CAROL
R.
ANGLE
"SUICIDE" AS SEEN IN POISON CONTROL CENTERS 1103 SELF-POISONINGS AGES 6-18
130 120 110 100 II)
UJ
90
II)
'"
80
'"
70
u
...J
I-
0
I-
60 50 40 30 20 10
AGE -YEARS
AGE -YEARS
MALE
FEMALE
Figure 1. Age and sex distribution of 11 03 patients seen in poison control centers for self-poisoning.
701
THE TAXONOMY OF SUICIDE AS SEEN IN POISON CONTROL CENTERS Table
WHITE
1.
Race, Age, and Sex PUERTO RICAN, MEXICAN, INDIAN
NEGRO
OTHER OR NOT REPORTED
TOTAL
Female 6-10 11-13 14-16 17-18
24 (59%) 54 (61%) 235 (64%) 164**(77%)
Total, Female
477
6-10 11-13 14-16 17-18
31 (44%) 24 (60%) 111 (76%) 116*';' (85%)
Total, Male
282
(72%)
Total, Male and Female
759
(69%)
(67%)
16';' 24';' 83 28 151
(39%) (27%) (22%) (13%)
0 7 41" 8
( 0%) ( 8%) (11%) ( 4%)
1 3 12 12
( ( ( (
2%) 4%) 3%) 6%)
41 88 371 212
(100%) (100%) (100%) (100%)
(21%)
56
( 8%)
28
( 4%)
712
(100%)
6%) 2%) 5%) 4%)
7 2 8 7
(10%) ( 5%) ( 6%) ( 5%)
70 40 145 136
(100%) (100%) (100%) (100%)
Male 28** (40%) 13 (33%) 19 (13%) 8 ( 6%)
4 1 7 5
68
(18%)
17
( 4%)
24
( 6%)
391
(100%)
219
(20%)
73
( 7%)
43
( 4%)
1103
(100%)
( ( ( (
*p <0.05. "*p < 0.005. These percentile distributions of the results of Chi-square tests show an increase in Negro girls aged 6 to 10 and 11 to 13, and an increase in Puerto Rican-Mexican-Indian girls aged 14 to 16. For boys, there was a disproportionately high number of Negroes aged 6 to 10 and of whites aged 17 and 18.
Analysis of the subjects' occupations by age and sex showed that for males 17 and 18, the unemployment rate of 11 per cent was similar to the national average for 1969. 4
BEHAVIORAL DATA The older conflict between the sociologic and psychiatric evaluation of suicide has receded into a clinical approach that does not attempt to fit patients into a rigid categorization of psychodynamics. The diversity of individual problems was apparent in the patients' past history and in the precipitating event_ Inquiry was made concerning significant psychosocial disruption: loner, school dropout, juvenile delinquent, character or behavior disorder, brain damage-motor or mental, convulsive disorder, psychoneurosis, psychosis, significant or chronic mental disability or illness (Table 2)_ The 10 per cent incidence of behavior disorders would support Zrull's report of adolescent depression and suicide as a late manifestation of hyperactivity_21 A history of significant emotional stress at the time of the poisoning was obtained from the majority of older patients interviewed, and from 43 per cent of the youngest group (Table 3)_ These stressful situations
702
MATILDA
Table 2. Behavior disorder Character disorder "Loner" School dropout Delinquency Psychoneurosis Psychosis
115 66 58 58 44 41 22
(10%) ( 6%) ( 5%) ( 5%) ( 4%) ( 4%) ( 2%)
S.
MCINTIRE, CAROL
R.
ANGLE
Past History Chronic medical problems Convulsive disorder Brain damage Multiple problems No significant problems No information Total
22 21 12 77 341 226
2%) 2%) 1%) 7%) 31%) 20%)
1103
(100%)
Table 3. Age and Precipitating Stress AGE
PRESENT
ABSENT
6-10 11-13 14-16 17-18
47 93 405 282
(42%) (73%) (78%) (81%)
Total
827
(75%)
NOT REPORTED
TOTAL
41" ""(37%) (14%) 18 36 ( 7%) 20 ( 6%)
23 17 75 46
(21%) (13%) (15%) (13%)
111 128 516 348
(100%) (100%) (100%) (100%)
(10%)
161
(15%)
1103
(100%)
115
""'''''p <0.005, showing that although precipitating stress was recorded in 42 per cent of 6 to 1 0 year olds it was significantly more frequent in all patients over 10.
were listed on the questionnaire as humiliation, punishment, sense of failure, romance problems, pregnancy, family problems, loss of parent or significant other relative, and "other difficulties." In the youngest age group, acts of overt aggression and hostility and fear of retribution were the most common difficulties. This is the most transparent expres· sion of suicide as hate. Of the girls 17 or 18, 30 per cent were married, separated, widowed, unwed mothers, or unwed pregnant. In boys, homosexuality was frequently reported; this theme is expanded by Deisher et al. in their studies of the young male prostitute." Precipitating stress revolved around the "five P's:" parents, peers, privation, punctured romance, and pregnancy. Intent, meaning the deliberate attempt to poison oneself, was assessed by the reporters as shown in Table 4. In children 6 to 10,50 per cent of poisoning is called unintentional, but this naive interpretation is not supported by behavioral data; the 6 to 10 year old selects sedatives Table 4. AGE
INTENTIONAL
Age and Diagnosis of Intent
SUBINTEN-
UNINTEN-
TIONAL
TIONAL
6-10 11-13 14-16 17-18
14 68 333 233
(13%) (53%) (64%) (67%)
21 29 107 61
(19%) (23%) (21%) (17%)
Total
648
(59%)
218
(20%)
56'" 20 38 28 142
UNKNOWN
TOTAL
"'(50%) (16%) ( 7%) ( 8%)
20 11 35 25
(18%) ( 9%) ( 7%) ( 7%)
111 128 519 349
(100%) (100%) (100%) (100%)
(13%)
91
8%)
1103
(100%)
""'''''p <0.005, showing a significantly greater frequency (50 per cent) of pOisoning diagnosed as unintentional in ages 6 to 1O.
703
THE TAXONOMY OF SUICIDE AS SEEN IN POISON CONTROL CENTERS
twice as frequently as the 4 year old; at least 24 per cent of such children are referred to behavior clinics; 26 per cent have a significant history of past difficulties; 43 per cent give a history of current precipitating stress factors. Only 8.6 per cent of the 992 cases in patients aged 11 to 18 were considered "unintentional." The diagnosis of suicide attempt had been explained to the interviewers as, "did the subject mean to kill himself?" and the frequency of diagnosis is shown in Table 5. Table 5. Age and Diagnosis of Suicide AGE
FINAL DX
CONSIDERED NOT FINAL
NEVER CONSIDERED
71':"":'(69%)
NOT REPORTED
6-10 11-13 14-16 17-18
2 26 165 98
( 2%) (20%) (32%) (28%)
10 37 162 108
( 9%) (29%) (31%) (31%)
54" 134 118
(42%) (26%) (34%)
22 11 55 24
(20%) ( 9%) (11%) ( 7%)
Total
291
(26%)
317 (29%)
383
(35%)
112
(10%)
TOTAL
111 128 516 348
(100%) (100%) (100%) (100%)
1103 (100%)
*p <0.05. '*.p <0.005.
The frequency of the diagnosis of suicide increases with age.
The diagnosis of a suicide attempt by any observer was related to 1) age, (2) drug use-i.e., a "kick" or "trip" was rarely called a suicide attempt, (3) the history of prior psychosocial disruption, (4) precipitating stress, and (5) socioeconomic status, with significantly greater attention being given to the possibility of suicide attempt in patients from the upper socioeconomic group. What also seems to have been measured is the regional variation in interpretation of the term suicide, so that Edinburgh, continuing in their clear distinction of gestures from attempts, reported not a single suicide attempt in 131 poison ingestions by adolescents. The general classifications of toxic substances showed a distinctive pattern for each age group (Table 6). Aspirin, responsible for 37 per cent of poisoning in 4 year oIds, was ingested by only 11 per cent of 6 to 10 year olds but became increasingly popular with the 14 to 16 year old girls. Intent is suggested by the fact that 27 per cent of 6 to 10 year olds ingest sedatives, or twice as frequently as do 4 year olds. Young thrillseekers favor alcohol and glue inhalation over other hallucinogens, but drug abuse triples after age 13. Death occured in 5 patients, a mortality of 1 :220 self-poisonings. One patient, a 15 year old girl who had inhaled spray shortening, was in the group of 141 patients whose patent intent was intoxication alone. The other four deaths were a 12 year old Negro girl from bromides in an over-the-counter tranquilizer, a 13 year old white boy who ingested sodium arsenite herbicide because he was angry with his father, a 15 year old Negro girl (aspirin), and a 16 year old Mexican girl. Despite the incomplete data, it is suggested that lethality of intent was extremely low and death was the result of a toxicologic mishap.
" C
~
Table 6. AGE
ASPIRIN
SEDATIVEt
Age and Drug Use
AMPHETAMINE
MED., MISC.
MISC., OTHER
6-10 11-13 14-16 17-18
12 33 148 76
(11%) (26%) (29%) (22,;{)
30 39 191 143
(27%) (30%) (37%) (41,;{)
5 6 27 19
(5%) (5%) (5,;{ ) (5';{ )
14 10 35 29
(13%) ( 8%) ( 7,;{) ( 8,;{)
44 ''''(40%) 34 (28%) ( 8%) 6 ( 9%) 31
Total
269
(24%)
403
(37%)
57
(5%)
88
8,;{)
145
(13%)
Total, Female Total, Male
212 57
(30%) (15%)
268 135
(38%) (35%)
40 17
(6,;{) (4%)
60 28
8,;{) 7%)
81 64
(11 %) (16%)
"TRIPS"!
6 6 79 50':""
TOTAL
( 5%) ( 5%) (15,;{ ) (14%)
III 128 516 348
(100%) (100%) (100%) (100%)
(13%)
1103
(100%)
51 ( 7%) 90" "(23%)
712 391
(100%) (100%)
141
~
;,> >-l
t=:
Ij
;,>
':"'p <0,025.
*''':'p <0.005.
These Chi-square percentile values show an increase in "trips" at ages 14 to 18, particularly among boys, and a high rate of miscellaneous poisonings at ages 6 to 10. tBarbiturates, nonbarbiturate sedatives, tranquilizers !Alcohol, marijuana, hallucinogen, glue, and related inhalants.
:n ~
()
Z >-l
;:;
1'" ('J
;.~
o t"'
p:!
> Z <;1
t"'
OJ
THE TAXONOMY OF SUICIDE AS SEEN IN POISON CONTROL CENTERS
705
CONCEPT OF DEATH Pediatricians have been shown to avoid any discussion of death 10 and it appears a most alien suggestion that children be routinely interviewed. In this study, participants were asked to pursue the concept of death beyond the usual imagery of burial and the following suggestions offered for the interview: Ask the patient what he thinks it's like to be dead or what would happen to him if he died. Children may initially consider this a thoroughly ridiculous question, but if you emphasize your honest interest in their thoughts they will accept it as a valid, inoffensive inquiry. It is acceptable to offer alternatives appropriate to age, such as to ask an 8 year old if he thinks dying is like going to sleep: "Yes" "Do you think you could wake up again and come back?" "No, not alive" "Well, do you think that if you were dead that you could tell what was going on, like your mother crying over all the toys in your room, or what the family had for dinner?" "I guess so. Yes"
This would be coded as irreversible, but cognizant. Of the replies obtained from 515 children, there was a maturation with age from a concept of death as a reversible sleeplike state to an irreversible but cognizant state to total cessation with or without some form of spiritual continuation. Grouping the first two categories as immature and the latter two as mature, a mature concept is stated by most children over the age of 10 (Table 7). Table 7. Age and Concept of Death PERMANENT BUT WITH
AGE
SLEEPLIKE,
IRREVER-
POSSIBLY REVERSIBLE
SIBLE, BUT COGNIZANT
6-10 11-13 14-16 17-18
10 10 36 23
(36%) (18%) (15%) (13%)
Total
79 (15%)
5 3 15 6
(18%) ( 5%) ( 6%) ( 3%)
29 ( 6%)
TOTAL
SPIRITUAL CONTIN-
TOTAL
INTER-
UATION
CESSATION
VIEWED
9 23 76 43
(32{/{) (40%) (31%) (23%)
151 (29%)
4 21 118 113
(14%) (37%) (48%) (61 %)
256 (50%)
28 57 245 185
NOT REPORTED
(100o/c) (100%) (100%) (100%)
83 71 271 163
515 (100%)
588
The professed concept of death, however mature, may obviously differ from the emotional need to believe in the unique immortality of self. Given this premise, the admission of an immature concept by 16 per cent of 17 and 18 year olds seems particularly significant. This denial of total cessation is as important a consideration in the psychodynamics of suicide as is lethality of intent. It is inherent in the naive interpretation of self-destructive acts in the young: "He didn't know what he was doing." Intent is rarely lethal; it is not cessation of life but only escape from certain aspects of life that is sought,! More important, there may be total denial of the possibility of death.!5
706
MATILDA
S.
MCINTIRE, CAROL
R. ANGLE
The results of our survey show that self-poisoning in a child over 6 is rarely accidental and deserves inquiry by the responsible practitioner into the severity and chronicity of prior difficulties and disruptive events, the nature of the precipitating stress, and, most important, the motivation for the act. One needs to know what the child expected to happen to him physically as a result of the ingestion and what he expected to change in his life. The actual self-poisoning may be the end stage of long-standing problems, as stressed by Teicher and Jacobs,B. 19 or it may be an impulsive attempt to control interpersonal conflict. Poison control centers may offer as strong a lifeline to children and youth manifesting self-destructive behavior as suicide prevention centers extend to adults. Attention to the significance of self poisoning may intercept the continuum of self-destructive behavior at an earlier stage in the life cycle, when the survivors have the greatest potential of regaining their psychosocial equilibrium.
REFERENCES 1. Barter, J. T.: Self-destructive behavior in adolescents and adults: Similarities and differences. In Suicide Among the American Indians. U.S. Public Health Service publication No. 1903, June 1969, pp. 7-10. 2. Carabillo, E. A., Jr.: Federal drug abuse programs. Presented at the 12th annual meeting, American Association of Poison Control Centers, Chicago, October 20, 1969. 3. Deisher, R W., Eisner, V., and Sulzbacher, S. 1.: The young male prostitute. Pediatrics, 43:936-941,1969. 4. Department of Labor and Manpower Administrations: Unemployment Insurance Statistics, February 1970. 5. Dorpat, T. L., Jackson, J. D., and Ripley, H. S.: Broken homes and attempted or completed suicide. Arch. Gen. Psych., 12:212-216, 1965. 6. Jacobs, J., and Teicher, J. D.: Broken homes and social isolation in attempted suicides in adolescents. Int. J. Soc. Psychiat., 13:139-149, 1967. 7. Kastenbaum, R: Time and death in adolescence. In Feifel, H.: The Meaning of Death. New York, McGraw-Hill Book Co., 1959, pp. 99-113. 8. Kessel, N.: Self-poisoning. Brit. Med. J., 1: 1265-1270, 1336-1348, 1965. 9. Lester, D.: Sibling position and suicidal behavior. J. Indiv. Psycho!., 22:204-207,1966. 10. Lourie, R S.: The pediatrician and the handling of terminal illness. Pediatrics, 32:477479,1963. 11. McIntire, M. S., and Angle, C. R: The concept of death in midwestern children. (Manuscript in preparation.) 12. Nagy, M. H.: The child's view of death. In Feifel, H.: The Meaning of Death. New York, McGraw-Hill Book Co., 1959, pp. 73-98. 13. National Clearinghouse for Poison Control Centers: Statistics, 1968. 14. Schilder, P., and Wechsler, D.: The attitudes of children toward death. J. Gen. Psych., 45 :406-451, 1934. 15. Seiden, R H.: Suicide Among Youth. U.S. Public Health Service publication No. 1971, December 1969. 16. Shneidman, E. S.: Orientations toward death. In White, R W.: The Study of Lives. New York, Atherton Press, 1966, pp. 201-227. 17. Shneidman, E. S.: Orientation toward cessation: A re-examination of current modes of death. J. Forensic Sci., 13 :33-45, 1968. 18. Statistical Abstract of the United States, 1966, p. 54. 19. Teicher, J. D., and Jacobs, J.: Adolescents who attempt suicide: Preliminary findings. Amer. J. Psychiat., 122:1248-1257,1966. 20. Toolan, J. M.: Suicide and suicidal attempts in children and adolescents. Amer. J. Psychiat., 118:719-724,1962. 21. Zrull, J. P., cited in Pediatric News, 3:47,1969. Department of Pediatrics University of Nebraska College of Medicine Omaha, Nebraska 68105