Clinical and Legal Aspects of Suicidal Children and Youth

Suicide in Children and Youth

While it is well known that adolescents can struggle through turbulent periods of mental health, although very rarely do we consider the suicide risk of younger children. In fact, in Canada the coroner can’t declare a suicide of anyone aged 9 or under (Statistics Canada, 2014) these deaths are likely classified accidents.

The suicide rate in children has remained relatively steady in the period between 2007 and 2011, the most recent year that Statistics Canada data is available. (Statistics Canada, 2014) The suicide rate in children and young adults aged 10-19 was a low of 5.89% of the total suicide rate in 2010 and a high of 6.29% in 2008.

Because children and young adults are often relatively healthy, suicide is the second leading cause of death for Canadians aged 1-24 at 20% of deaths, behind accidents at 35% (Statistics Canada, 2011). It is suspected that the suicide rate is in fact under-reported, because most provinces require the coroner to rule out all other causes of death first (Casey & Hunter, 2011), leaving a number of likely suicides classified as accidents.

Legal Considerations

Because children’s health and welfare is the responsibility of their parents, it is often easier for parents to access supports than for other populations. Parents can take their children to their family physician, the ER/local hospital or to agencies focused on children’s and youth mental health.

Beyond their peers, teachers are often the first individuals that suicidal young people will confide in; therefore it is important that they receive gatekeeper training such as the Question, Persuade, Refer (QPR) training or the two-day Applied Suicide Intervention Skills Training (ASIST) to help them recognize and respond adequately to suicidal ideation.

Clinical Concerns

Girls and women tend to have a higher rate of suicide attempts, than boys and men, often two to three times higher (Statistics Canada, 2012) however men die much more often. (Statistics Canada, 2014) This is due to their choice of suicide method; while women tend to favour poisoning, which is often non-lethal, men tend to favour hanging or – especially in the United States – firearms, which are more lethal.

This trend is changing however, the rate of hanging in women has increased by several percent in recent years. (Statistics Canada, 2012)

Most youth suicides happen at night and in the home, where access to the suicide method is available (Miller & Eckert, 2009) with the lethality of the suicide attempt roughly corresponding with the intent to die (Berman et. al., 2006) For instance, a youth with a stronger intention to die is more likely to use hanging or firearms than a youth with less intent.

Deficits in the mental health system have been identified (e.g. by Renaud, 2014) that focus on continuity of care, with individuals at risk or dying by suicide often not receiving the services they needed and under-diagnosis of mental health issues in youth.

Rudd et. al (2006) identifies a number of warning signs, which, distinct from the risk factors identified below, substantially increase likelihood of immediate suicidal behaviour. They include:

• Rage, anger, seeking revenge
• Engaging in reckless/risky behaviour
• Feeling trapped
• Increased alcohol use
• Withdrawing from peers and family
• Anxiety or agitation
• Large change in sleep pattern (insomnia or hypersomnia)
• Dramatic mood changes
• No reason to live; sense of purposelessness

Children are highest risk to suicide in the period transitioning out of hospitalization, so it should be used with caution. (Huey et al., 2004) If less intensive methods are available to stabilize the child they are preferred.

While bullying is commonly discussed in the media, a review of 94 youth suicides in Toronto showed bullying was an identified factor in the death in only 6.4% of cases, while conflict with parents, romantic and academic problems and criminal or legal problems accounted for a combined 59.5% of suicides. (Sinyor, Schaffer & Cheung, 2014)

A note on medication: While research had demonstrated that use of anti-depressants increased suicide risk in children and young adults, leading to a “black box” warning on anti-depressant medication, subsequent research showed that the resulting controversy led to under-prescribing of anti-depressants to children who actually needed them, raising the overall youth suicide rate. (BMJ, 2014)

Protective and Risk Factors (Miller & Eckert, 2009; Bridge, Goldstein & Brent, 2006)

Protective Factors

• Seeking help
• Strong coping skills (Walsh & Eggert, 2007)
• Effective social support systems
• Means restrictions
• Safety plans

Risk Factors

• Interpersonal conflict and loss Lethal and disciplinary problems
• Depression and hopelessness (Dube, Bhargava & Sood, 2014)
• Previous suicide attempts
• Social isolation and rejection (Frederick, Kirst & Erickson, 2012)
• Limited access to mental health facilities
• Poor problem-solving
• Low self-esteem (Wilburn & Smith, 2005)
• Poor family environment

Impulsiveness is a commonly cited factor in youth suicide (Witte, et. al., 2008), and while some suicides may be legitimately impulsive it’s important to rule out that an individual may have had undetected suicidal ideation or other long-standing risk factors before sudden warning signs or suicide attempts emerge.

An additional risk factor to consider is suicide contagion. There have been documented cluster suicides where the glorification and glamorization of one youth (or celebrity’s) suicide encourages others to do the same.

Further Training / Reading

I’ve written about the Counseling on Access to Lethal Means (CALM) training, it is short, free, available online and focuses on intervention strategies with youth.

Additionally, the Children’s Hospital of Eastern Ontario (CHEO) produced a guide to help parents with suicidal children that is a valuable read.

Bibliography

Berman, A. L., Jobes, D. A., & Silverman, M. M. (2006). “Adolescent suicide: Assessment and intervention” Washington, DC: American Psychological Association.

BMJ. (2014) “Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study” doi: http://dx.doi.org/10.1136/bmj.g3596

Bridge, J.A., Goldstein, T.R., & Brent, D.A. (2006) Adolescent suicide and suicidal behaviour. Journal of Child Psychology and Psychiatry. 47(3/4): 372-394

Casey, L., Hunter, P. (2011) “Suicide may be substantially underreported in Ontario” Toronto Star. Retrieved electronically from http://www.thestar.com/news/gta/2011/12/02/suicide_may_be_substantially_underreported_in_ontario.html on February 9, on February 9, 2015

Dube, S., Bhargava, D., Sood, P. (2014) “Comparative Study on Mental Health Among Youth” International Journal of Multidisciplinary Approach and Studies. 1(5).

Frederick, T.J., Kirst, M., & Erickson, P.G. (2012) “Suicide attempts and suicidal ideation among street-involved youth in Toronto” Advances in Mental Health. 11(1):8-17

Huey, S.J., Jr., Henggeler, S.W., Rowland, M.D., Halliday-Boykins, C.A., Cunningham, P.B., Pickrel, S.G., et al. (2004). “Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies.” Journal of the American Academy of Child and Adolescent Psychiatry, 43, 183–190.

Miller, D., Eckert, T. (2009) “Youth Suicidal Behavior: An Introduction and Overview” School Psychology Review. 38(2):153-167

Renaud, J., Seguin, M., Lesage, A., Marquette, C., Choo, B., Turecki, G. (2014) Canadian Journal of Psychiatry. 59(10):523-530

Rudd, M. D., Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M., Mandrusiak, M., et al. (2006). “Warning signs for suicide: Theory, research, and clinical applications” Suicide and Life-Threatening Behavior, 36, 255–262

Sinyor, M., Schaffer, A., Cheung, A.H. (2014) “An Observational Study of Bullying As a Contributing Factor of Youth Suicide in Toronto” Canadian Journal of Psychiatry. 59(12):632-638

Statistics Canada. (2014) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on January 29, 2015.

Statistics Canada. (2012) “Suicide rates: an overview” Retrieved electronically from http://www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm on February 9, from February 9, 2015

Statistics Canada. (2011) “Percentage distribution for the 5 leading causes of death in Canada, 2011” from CANSIM, table 102-0561. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on February 9, 2015.

Wilburn, V.R., Smith, D.E. (2005) “Stress, Self-Esteem and Suicidal Ideation in Late Adolescents” Adolescence. 40(157).

Walsh, E., Eggert, L.L. (2007) “Suicide risk and protective factors among youth experiencing school difficulties” International Journal of Mental Health Nursing. 16:349-359

Witte, T.K., Merrill, K.A., Stellrecht, N.E., Bernert, R.A., Hollar, D.L., Schatschneider C., Joiner T.E. Jr. (2008) “’Impulsive’ youth suicide attempters are not necessarily all that impulsive.” Journal of Affective Disorders. 107(1-3):107-16