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Safety First: Self Harm and
Suicide in Children and
Adolescents
Kari Hancock, MD
Child Psychiatrist
PAL Program Consultant
Objectives
• Defining terms
• Identify those at greatest risk for suicide and self
harm behavior
• Acute Management
• Identify treatment options for those at risk
• Review risk factors in treatment
Defining Terms: Parasuicide or Self
Injurious/Harm Behaviors
• Behavior may have no intention of death and intended purely for
other reasons (eg. relieve distress or to effect change in others or
the environment)
• “Parasuicide” used as a term to reduce pejorative language
associated with nonlethal deliberate self harm
• WHO has chosen “suicide attempt” as a term any time an
individual does not die, regardless of presence of suicidal intent
Posner, et al, Am J Psychiatry 2007; 164:1035-1043
Miller, et al, “Dialectical Behavior Therapy with
Suicidal Adolescents”, 2007
Defining Terms: Suicidal Ideation
• Passive thoughts about wanting to be dead or active
thoughts about killing oneself
• Not accompanied by preparatory behavior
Posner, et al, Am J Psychiatry 2007; 164:1035-1043
Defining Terms: Suicide Attempt
• Potentially self-injurious behavior, associated
with some intent to die, as a result of the act
• May or may not result in actual injury
Posner, et al, Am J Psychiatry 2007; 164:1035-1043
Self Harm Behaviors
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Is Common (~15% of all US teenagers)
It happens at home ¾ of the time
Doctors rarely know about it (<14%)
Friends/family do know about it (~75%)
N Madge, E Hewitt et al, 2008
From Klonsky ED and Muehlenkamp JJ 2007
Common Forms of Self Harm
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Cutting (70% of self injurers)
Scratching
Banging
Hitting
Burning
Self Poisoning
Most commonly on arms, followed by hands, wrists,
thighs, stomach
Reasons For Self Harm Behaviors
1. Affect Regulation (AKA “distress tolerance”)
---clearly the most common reason
2. Self Punishment
3. Interpersonal Influences
4. Anti-dissociation
5. Anti-suicide
6. Sensation Seeking
7. Reinforce Interpersonal Boundaries
From Klonsky ED and Muehlenkamp JJ 2007
Reinforcers for Self Harm
Negative reinforcers: Avoidance
• People
• School work/unpleasant activities
• Punishment
Positive reinforcers:
• Attention – making others angry or getting
noticed
• Feeling part of a group
• Release of endogenous opiates
Self Harm Behaviors in the Suicide
Spectrum
• Intentional self injury often occurs with
ambivalence or rapid changing intent
• Behavior that starts suicidal can evolve into a
nonsuicidal act and vice versa
• Intentional but nonsuicidal self injury can itself
be lethal
• Increases suicide risk 50-100 times within the
first 12 months after self injury
Miller, et al., “Dialectical Behavior Therapy for Suicidal Adolescents”, 2007.
Concerns about Adolescent Suicide
US High school students in past 12 months:
13.8%
10.9%
6.3%
1.9%
seriously considered suicide
made a suicide plan
attempted suicide
needed MD treatment for an attempt
Per 2009 YRBS by CDC
Suicidal Ideation (SI)
• Common in children and adolescents
• Disruptive disorders increase SI in
children < 12 years old
• Panic attacks risk factor for ideation in females
• Aggressiveness risk factor for ideation in males
• “Children involved in bullying, in any role, and
especially bully/victims and chronic victims, are at
increased risk for suicide ideation and suicidal/selfinjurious behavior in preadolescence” (Winsper, et al., JAACAP, vol
51:3, March 2012)
Increased Risk: Going from Ideation to
Attempt
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Severe or enduring hopelessness
Isolation
Reluctance to discuss suicidal thoughts
Preoccupation with death
Suicide in Children
• Understanding the finality of death is not an
essential ingredient in determining suicidality
• Understanding of death can fluctuate
• Preschoolers can be considered suicidal if they
wish to carry out a self destructive act with the
goal of causing death despite not knowing the
finality of death
• Suicidal behavior in prepuberty predicts suicidal
behavior in adolescents
Suicide Attempts
• More common in girls (1.6:1)
• 2 million US adolescents attempt suicide each
year
• Increase risk for an attempt: mood disorders,
anxiety disorders, substance abuse, runaway
behavior, LGTB youth
• 15-20% of female suicide attempters have a hx of
being abused
Concern About Suicide Attempts
• 31-50% of adolescent suicide attempters
reattempt suicide (Shaffer & Piacentini, 1994)
• 27% of males and 21% of females reattempt
within 3 months of their first attempt (Lewinsohn et al.,
1996)
• TASA Study: N=124, open trial, 40% of suicidal
events occurred within 4 wks of intake (Brent, et al., JAACAP,
48:10, October 2009)
Method of Suicide Attempt
• Ingestion, most commonly over the counter
analgesics
• Superficial cutting of arms or neck
• Attempts to hang self
• Jump from a height
• Stab self
• Drown
• Self immolate
Increased Risk: Going from Attempt to
Completion
• Repeated suicide attempts
• Medically serious attempts
• Steps taken to prevent or promote
discovery
Epidemiology for Completed Suicide
• 3rd leading cause of death in adolescents
• Approx 2000 US adolescent commit suicide
each year
• 90% who commit suicide had an associated
psychiatric disorder
• More than half had a psychiatric disorder for at
least 2 years
Completed Suicide Epidemiology
• Prepubertal suicides ratio 3:1 male to female
• Age 15-19 yr olds ratio 4.5:1 male to female
• American Indian/Alaska Native males have the
highest suicide rate
Risk Factors for Completed Suicide in
Adolescent Males
• Previous suicide attempts (increases rate 30
fold)
• Age 16 or older
• Associated mood disorder (increases 9 fold with
major depressive disorder)
• Associated substance abuse (increases 7 fold)
• Disruptive behavior
Risk Factors for Completed Suicide in
Adolescent Females
Mood disorders
• Major depression increases risk 20 fold (Shaffer et
al., 1996a)
Previous suicide attempts
General Risk Factors For Suicide
• Family history of suicidal behavior (5 fold
greater risk on adolescent boys, 3 fold greater
risk on adolescent girls)
• Parental mental health problems
• Parental substance abuse
General Risk Factors For Suicide
• Gay or bisexual orientation
• Exposure to real or fictional accounts of suicide
is a risk factor for vulnerable teenagers
• Hx of child abuse
• Personality disorder (antisocial, borderline)
• Chronic medical illnesses (eg. diabetes, epilepsy)
• Victim of bullying (eg. cyberbullying)
Immediate Risk Factors
• Agitation
• Intoxication: Substance and/or alcohol abuse
significantly increases risk in age 16 and older
• Stressful life event
Events Preceding Adolescent Suicide
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Family difficulty
Loss of a romantic relationship
Disciplinary problems at school or legally
Academic difficulty
Giving away prized possessions
Most adolescent suicides appear to be impulsive
Common Methods Used in Completed
Suicide in the US
Males:
• Firearms – half of completed suicides among
15-19 year olds
• Hanging
• Carbon Monoxide Poisoning
• Jumping
Females:
• Firearms
• Overdose on pills or ingesting poison
Assessment In The Office
• Questionnaires to screen for depression, suicidal
preoccupations, and previous suicidal behavior
• Interview separately from the parent
• Collateral History
Screening Scales
• Broad Screening
 PSC-17
 Others like CBCL, BASC for a fee
• Narrow Screening/Diagnostic aide for depression
 PHQ-9 for adolescents
 SMFQ for kids over age 6
 Others like CDI, CDRS-R for a fee
 Can measure response to treatments
Initial Questions
• Is there anything that has been stressing
you lately?
• How have things been going with school,
friends, parents? HEADSS (Home,
Education and Employment, Activities,
Drugs, Sexuality, Suicide risk)
Ask The Questions Directly
• Has it stressed you out to the point of having
thoughts about not wanting to live?
• Have you ever thought about killing yourself or
wished you were dead?
• Have you ever done anything on purpose to hurt
or kill yourself?
If Yes, Get More Details
• Nature of past and present thoughts and
behaviors
• Intent
• Who Knows
• If you were to kill yourself, how would you do it?
• Accessibility of means (eg. weapons in the home)
• Response of the family
• Stressful events/conflicts (eg. bullying)
• Evaluate motivating feelings
Moderate to High Risk:
• Planned or recent attempt with high probability
of lethality
• Statement of intent to kill oneself
• Agitation
• Severe hopelessness
• Impulsivity and profoundly dysphoric mood
associated with mood disorder, psychosis or
substance use
• Regret attempt not completed
• Lack of social support
If Moderate or High Risk Of Suicide:
Immediate mental health evaluation necessary:
• ER
• Hospitalization
• In WA state: calling the local crisis line to speak
with a designated mental health professional
(DMHP), anyone can make the referral
Age of consent for mental health care
in WA state is 13
The following are referred to as voluntary admissions:
• For all minors under 13 years of age, a parent must give consent.
• A minor 13-18 years of age and their parents may jointly give
consent.
• A minor 13-18 years of age may give consent for admission without
parental agreement.
Involuntary admission:
• In the event of any minor 13 years of age or older (and/or his/her
parent) refuses admission, the minor may be evaluated and
detained involuntarily by a DMHP (DMHP) in accordance with
RCW 71.34.
• If the DMHP makes a decision that the minor does not require
inpatient treatment, the parent can seek review of that decision
made by the DMHP in court. RCW 71.34
DMHP Referral
• When called upon to assess whether a minor
needs involuntary treatment, a DMHP may take
the minor or cause the minor to be taken into
custody and transported to an Evaluation and
Treatment facility providing inpatient treatment.
RCW 71.34.600-660
• If the minor is not taken into custody for
evaluation and treatment, the parent can seek
review of the decision made by the DMHP in
court. RCW 71.34.600-660
Checklist for assessing child or adolescent suicide
attempters in an emergency room or crisis center
Attempters at Greatest Risk for Suicide
• Suicidal History Demographics
• • Still thinking of suicide • Male
• • Have made a prior suicide attempt • Live alone
• Mental State
• • Depressed, manic, hypomanic, severely anxious, or have a mixture
• of these states
• • Substance abuse alone or in association with a mood disorder
• • Irritable, agitated, threatening violence to others, delusional, or
• hallucinating
• Do not discharge such a patient without a psychiatric
evaluation.
AACAP Practice Parameters, “Suicidal Behavior”, July 2001
After ER Visit
High failure rate to keep mental health referral
appointment after ER discharge
• Medical practitioner can enhance continuity and
adherence by maintaining contact even after
referrals are made
Lower Risk But Risk Still Exists
• Self harm with no suicidal intent
• Depressive symptoms with no suicidal thoughts
• Dysfunction or distress from emotional or
behavioral symptoms
• Desire to resolve recent stressor/conflict
• Hope for the future
• Good social support
Approach to Self Harm Behavior
• Adolescents found disclosure made the situation
worse in some cases; they found health services
to be judgemental and stigmatizing
• It is important to maintain a non-judgemental,
sensitive, open-minded and respectful attitude
with the focus kept on the person and not their
self-harm behavior
InnovAiT, Vol. 1, No. 11, pp. 750 – 758, 2008
BATHE
• Establish the Background situation “tell me
what has been happening”
• Find out how it is Affecting them emotionally
“how does that make you feel?”
• Establish the main problem “what is Troubling
you the most?”
• Ask about current ways of coping “how are you
Handling this?”
• Use Empathic listening throughout
If Lower Risk:
• Validation and letting them know you will help
• Refer for further evaluation and treatment
• Inform appropriate people when there is a risk
of suicide – safety takes precedence over
confidentiality
• Help family identify potential precipitants and
begin process of problem solving
Acute Management
• Adequate supervision and support available
• Securing or disposing potentially lethal means
(most common method is firearm)
• Limiting access to alcohol or disinhibiting
substances
• Value of “no suicide contracts” not known
• Phone calls during transition time
• Safety Planning
Safety/Crisis Plan
• Identify triggers
• Identify early warning signs
• Identify possible interventions (eg. distress
tolerance skills)
• People to turn to for help
Mental health referral appointment
Example for an Adolescent
My triggers are:
• Pressure to do things that are above my ability
• Feeling unwanted/rejected by friends.
• Social worries
• When others aren’t concrete about what they expect from me.
My early warning signs are:
• I become argumentative.
• I bite my lip or fingers
• I sigh loudly
• I raise my voice
When my parents/caregivers notice my early warning signs, they can:
• Talk to me
• Ask how I am feeling
• Ask “how can I help”
• Give me a hug
When I notice my early warning signs, I will try to:
• Play guitar
• Listen to IPOD
• Practice deep breathing
• Journal
If I am unable to help myself or accept help from my family/caregivers, then our crisis plan is:
• Call therapist
• Call grandparents
• Call county crisis line
• Call 911 if emergency.
Example for Younger Child
CRISIS TRIGGERS, WARNING SIGNS, AND INTERVENTIONS
My triggers are:
1. When kids call me names
2. Getting scratched/hurt
3. Feeling scared or mad
4. Waiting a long time
My early warning signs are:
1. Yelling
2. Telling people to 'stop'
3. Posturing at people
4. Having trouble listening to people
Things I can do when I notice my early warning signs:
1. Punch a pillow
2. Take a big breath
3. Color, and/or distract myself
4. Eat a snack
If I am unable to help myself I can call:
1. My Aunt Kelly
2. Therapist
3. After-Hours Crisis Line - 206.726.2191
Psychotherapy Tailored to Particular
Needs = Decreasing Risk Factors
• Cognitive Behavioral Therapy
• Interpersonal Psychotherapy
• Dialectical Behavioral Therapy (only
psychotherapy effective in reducing suicidal
behavior in adults with borderline personality
disorder)
• Psychodynamic therapy
• Family Therapy
Psychopharmacology
Medications can help with associated
symptoms, but will not resolve suicide
ideation itself
Lithium
• Reduced recurrence of suicide attempts in adults
with major depression or bipolar disorder by 9
fold
• Discontinuation associated with 7 fold increase
in suicide attempts and 9 fold increase in rates
of suicide
• Multiple side effects
• Overdose fatal
SSRI’s As Reducing Suicides
• In the U.S: every 1% increase in adolescent use of
antidepressants correlates with a decrease of 0.23
suicides per 100,000
• Population studies in Sweden, Italy, Netherlands,
Australia, and U.S. all show decreased youth suicide
rates with increasing antidepressant use
• 14% increase in U.S. youth suicides in 2004, the year
SSRI usage started falling due to the black box
warnings
Olfson, M et al. Arch Gen Psych 2003
Gibbons R et al. Arch Gen Psych 2004
Gibbons RD, Brown CH, et al 2007
SSRIs – FDA Columbia Review
• 24 studies with SSRI’s submitted to FDA
▫ 4582 children
• For all diagnoses: Suicidality overall risk ratio 1.95 (95%CI=1.28-2.98)
▫ Statistic in the Black Box Warning
• For Major Depression: Suicidality overall risk ratio 1.66 (95%CI=1.022.68)
• No youth fatalities occurred in a clinical trial
T Hammad, T Laughren, 2006
SSRI suicidality differences
Risk Ratio 95% confidence interval
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Venlafaxine
Sertraline
Paroxetine
Mirtazepine
Fluoxetine
Citalopram
RR 8.84
RR 2.16
RR 2.15
RR 1.58
RR 1.53
RR 1.37
(1.12-69.5)
(0.48-9.62)
(0.71-6.52)
(0.06-38.37)
(0.74-3.16)
(0.53-3.50)
T Hammad, T Laughren, J Racoosin 2006
How I Make Sense of SSRI Suicidality
• Agitation/anxiety is a SSRI side effect
▫ Common side effect, happens early on
▫ If make depressed or anxious person more anxious, logical to get
some suicidal thoughts
• SSRI induced suicidal thoughts CAN happen, but they
usually don’t
▫ Why I check in with patient 1-2 weeks after starting medicine
Bridge et al, JAMA 2007
Starting An SSRI
• Start low, go slow
• Change one medicine at a time
• Use a full dose range, wait 4-6 weeks before each
increase
• Check in with patient 1-2 weeks after starting to
ensure no new suicidality
Reality of the Situation
• Suicidal risk can only be reduced, not eliminated
• Risk factors only provide guidance in assessment
• Adolescents may have their own agenda –
information provided can be subjective
• Safety planning is key
Key Points To Take Away:
If there is any question, err on the side of safety
Definitely send to the ER or call for MHP:
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If suicidal ideation is persistent
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Serious lethality in thought or attempt
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Agitation with suicidal thoughts
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Clear lack of social support with safety plan
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Efforts made to minimize chance of
intervention or discovery with an attempt
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Regret of attempt completion
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Severe hopelessness
TABLE 4
Checklist before discharging an adolescent who has attempted
suicide.
Before Discharging a Patient from the ER or Crisis
Center, Always:
• Caution patient and family about disinhibiting
effects of drugs or alcohol
• Check that firearms and lethal medications can be
effectively secured or removed
• Check that there is a supportive person at home
• Check that a follow-up appointment has been
scheduled
AACAP Practice Parameters for the Assessment and Treatment of Children and
Adolescents With Suicidal Behavior, July 2001
Helpful References
Shain, et al., “Suicide and Suicide Attempts in
Adolescents” Pediatrics, vol 120/3, Sept 2007.
www.aacap.org: AACAP Practice Parameters for the
Assessment and Treatment of Children and
Adolescents With Suicidal Behavior, July 2001
www.teenscreen.org: community based mental health
screening program
www.thetrevorproject.org: offers resources for LGBT
youth
www.afsp.org/schools: American Foundation of
Suicide Prevention – resources for schools