Psychiatric diagnosis in child and adolescent suicide

Suicide among children and younger and older adolescents in Norway: a comparative study

OBJECTIVE

To compare characteristics and risk factors of suicide in early adolescence (younger than age 15 years) and in late adolescence. The authors examined whether differences in risk factors or resilience might explain the different suicide rates in the two age groups.

METHOD

Information about all registered suicides of young people in Norway from 1990 through 1992 was gathered from several professional informants. Children younger than 15 years old who committed suicide (n = 14) were compared with late-adolescent suicides (15 through 19 years) (n = 115) and with controls (n = 889).

RESULTS

Younger compared with older adolescent suicides more often hanged themselves (93% versus 35%). Suicidal ideation (7% versus 39%) and precipitating events were described less frequently (29% versus 49%). Older adolescents more often had psychiatric disorders (77% versus 43%). Compared with controls, the risk factors for suicide were affective disorders (young adolescents: odds ratio [OR] = 23.8, 95% confidence interval [CI] = 2.3 to 1,183; older adolescents: OR = 19.6, CI = 10.6 to 38.8); disruptive disorders (young adolescents: OR = 3.4, CI = 0.0 to 340; older adolescents: OR = 6.1, CI = 3.0 to 12.7); and not living with two biological parents (young adolescents: OR = 3.1, CI = 0.6 to 14.7; older adolescents: OR = 2.5, CI = 1.6 to 3.8).

CONCLUSION

Children and young adolescents completing suicide were less exposed to known risk factors than older adolescents. The increased suicide risk was similar for both groups when they were compared with community controls. The low suicide incidence in childhood may be related to fewer risk factors, rather than to resilience to risk factors.

Separation/divorce and child and adolescent completed suicide

OBJECTIVE

To investigate factors that may modify the effect of separation/divorce on youth suicide.

METHOD

A case-control, psychological autopsy study of 120 of 170 consecutive suicides younger than age 20 and 147 community age-, sex-, and ethnic group-matched controls living in the greater New York area was conducted. Fifty-eight suicide victims and 49 community controls came from nonintact families of origin, indicating the permanent separation/divorce of the biological parents. Potential modifiers of separation/divorce include youth's age at separation, custodial parent's remarriage, nonresidential parent's frequency of contact, parent-child relationships, and parental psychopathology.

RESULTS

The relatively small impact of separation/divorce was further diminished after accounting for parental psychopathology. An interaction of separation/divorce and the father-child relationship emerged.

CONCLUSION

The dramatic increase in youth suicide during the past three decades seems unlikely to be attributable to the increase in divorce rates.

Predictors of suicide, accidental death, and premature natural death in a general-population birth cohort

BACKGROUND

Whether putative suicide risk factors, such as conduct and emotional disorders, are specific to suicide or are general associations of a continuum between subintentional and intentional self-destruction is not clear. We undertook an investigation of this issue in a UK population-based birth cohort.

METHODS

Using competing-risks analysis, we examined links between prospectively collected childhood and adolescent temperamental and behavioural variables and the risk of natural, accidental, and suicidal death, occurring between the ages of 16 and 50 years. Of the 5362 members of the cohort, full data were available for 3591. A panel of psychiatrists scored deaths on likely suicidal intention. These scores were used in a weighted logistic regression to examine independence of risk factors for (sub)intentional self-destruction.

FINDINGS

There were 167 deaths among the risk-set between the 16th and 50th birthdays. 120 were due to natural causes; of the other 47, the panel of psychiatrists judged that 36 were accidental deaths and 11 were suicides (certainty rating > or = 51%). Adolescent emotional instability and conduct problems had different associations with the various causes of premature death, being lowest for natural death (odds ratio 1.0 [95% CI 0.8-1.2] and 1.2 [1.0-1.5]), intermediate for accidental death (1.1 [0.8-1.5] and 1.3 [1.0-1.7]), and highest for suicidal death (2.0 [1.2-3.6] and 1.8 [1.3-2.5]). Emotional instability (boys 1.3 [1.0-1.7], girls 1.4 [1.0-1.9]) increased risk for subintentional or intentional self-destruction, as did low anxiety in adolescence (1.7 [1.3-2.5]) and nocturnal enuresis at age 4 (1.4 [1.2-1.7]) in boys, and conduct problems in girls (1.4 [1.0-2.0]).

INTERPRETATION

Suicide shares important risk factors with other causes of premature death. These findings suggest an aetiological continuum of self-destruction from subintentional to intentional. Research on premature mortality associated with psychological disorder should include all causes of death.

Management of suicidal behavior in children and adolescents

Many therapeutic approaches to managing suicidal behavior among youth have been used, including in-school education programs, screening programs, telephone hotlines, cognitive behavioral therapies, medication management, and inpatient milieux treatment programs. These interventions have been applied based on educational and therapeutic principles drawn from prior work with adolescents in varied scholastic and psychiatric settings. This article reviews: the assessment of risk factors among suicide attempters, emotional states, family, social isolation, interpersonal loss, substance and alcohol abuse, and treatment strategies.

Childhood suicidal behavior. A developmental perspective

This article provides an overview of the sociocultural and psychosocial features and implications for treatment of prepubertal suicidal children. It provides cross-sectional and longitudinal information about specific risk factors of prepubertal suicidal behavior with a focus on how these factors also predict future suicidal behavior. A developmental focus addresses issues of cognitive and emotional immaturity as related to early onset suicidal behavior.

Identification of suicide risk factors using epidemiologic studies

Suicide is a complex outcome of multiple, inter-related factors. This article presents the epidemiology of completed and attempted suicide and discusses the known risk factors for suicide within a framework designed to encourage a systematic approach to theory testing and prevention. Mental and addictive disorders, frequently in co-occurrence, are the most powerful risk factors for suicide in all age groups, accounting for over 90 percent of all completed suicides. In combination with proximal risk factors such as access to firearms or other lethal means, recent and severe stressful life events, and intoxication, they can form the necessary and sufficient conditions for suicide.

The failure of 'adult' interventions with adolescent depression: what does it mean for theory, research and practice?

The literature on the biological and phenomenologic presentation of major depressive disorder (MDD) in adolescents is reviewed and compared with that of depressed adults. Biological and psychosocial treatment approaches with adults and adolescents are then contrasted and the applicability of adult interventions to adolescents is examined. Some biological, cognitive, and experiential differences between adult and adolescent MDD may have treatment implications which have not yet been adequately addressed in the field. No effective treatments for adolescent MDD have, as yet, been developed or empirically tested. Based upon the results of this review, suggestions are made for the direction of future research.

Suicidality in eating disorders: clinical and psychological correlates

Although many authors have described eating disorders as often being associated with suicidal feelings and behavior, few studies to date have evaluated the prevalence and characteristics of suicidal behaviour in eating disordered patients. In the present study, in which a consecutive series of 495 out-patients was studied, 13% of the patients reported at least one suicide attempt and 29% reported current suicidal ideation; 26% of attempters reported multiple attempts. A history of suicide attempt was more prevalent among binge-eating/purging anorexics and among purging bulimics than in the other subgroups. In cases with anorexia nervosa, suicide attempters were older, had a longer illness duration, weighed less, had more often used drugs and/or alcohol and tended to be more obsessive than non-attempters. In cases with bulimia nervosa, attempters presented with more psychiatric symptoms and had more frequently been sexually abused.

Affect regulation and suicide attempts in adolescent inpatients

OBJECTIVE

To examine the relationship between affect dysregulation and self-destructive behaviors in adolescent suicide attempters.

METHOD

Measures of affect dysregulation, number of risk-taking behaviors in past year, presence of self-mutilative behaviors in past year, and number of different types of self-mutilative behaviors in past year were individually administered to adolescents admitted to an inpatient unit who were either suicide ideators (n = 25) or suicide attempters (n = 35).

RESULTS

Suicide attempters reported significantly higher levels of affect dysregulation and a greater number of different types of self-mutilative behaviors in the past year than suicide ideators. In addition, the number of different types of self-mutilative behaviors in the past year had the strongest relationship to suicide attempts.

CONCLUSION

Suicidal behavior among adolescent psychiatric patients is related to poor affect regulation. A risk factor for suicidal behavior in adolescents is a broad range of self-mutilative acts in the year preceding the suicide attempt.

Differences between urban and rural suicides

As part of a nation-wide psychological autopsy we examined the differences in DSM-III-R mental disorders, recent life events and other characteristics between urban (n = 143) and rural (n = 85) completed suicides in a random sample of 229 cases from the National Suicide Prevention Project in Finland for the period 1987-1988. Psychoactive substance use disorders (48% vs. 34%), cluster B personality disorders (24% vs. 9%) and psychiatric comorbidity (66% vs. 42%) were found more commonly among urban than rural suicides. Urban suicides were also more often reported to be preceded by a recent separation (25% vs. 8%), whereas rural suicide victims tended to have lacked a close companion of the opposite sex (36% vs. 18%) and to have had physical disorders (56% vs. 40%). Overall, urban and rural suicides may vary with regard to the prevalence of some mental disorders, their comorbidity, and physical disorders, as well as the preceding life situation. This variation may also imply the need for differences in strategies for suicide prevention in each setting.

The Emanuel Miller Memorial Lecture 1994. Depressive disorders in childhood: an impressionistic landscape

To convey an impressionistic landscape of depressive disorders in childhood, studies of clinically referred and diagnosed patients as well as community samples, and data from experimental investigations are used to consider five questions: Are depressive syndromes morbid states in childhood? Should we be concerned about depression in childhood? How do very early-onset depressions arise? What happens to depressed children as they grow up? And how can we help youngsters who suffer from depression? The information is discussed with respect to its implications for the management of clinically depressed children, as well as the prevention of very early-onset depressive disorders.

Characteristics of out-patient adolescents with suicidal tendencies

Suicidal adolescent out-patients were compared with non-suicidal subjects with respect to background factors, psychopathology and treatment received. Data for suicidal ideation, suicide attempts, psychiatric diagnoses (DSM-III-R) and other patient-related factors were collected prospectively during treatment of 122 male and 138 female out-patients aged 12-22 years. In total, 42% of subjects displayed suicidal tendencies, and 18% had attempted suicide. According to polychotomous regression, mood disorder, previous psychiatric treatment and low level of psychosocial functioning at treatment entry were associated with suicide attempts and with suicidal ideation for both sexes. Suicidal patients were more often receiving psychotropic medication and had more total appointments (mean number 15 vs. 9) than non-suicidal patients. Suicidal and non-suicidal patients kept their scheduled appointments to the same extent (66% vs. 65%). Treatments which meet the needs of disordered suicidal adolescents need to be developed.

Childhood and adolescent depression: a review of the past 10 years. Part I

OBJECTIVE

To qualitatively review the literature of the past decade covering the epidemiology, clinical characteristics, natural course, biology, and other correlates of early-onset major depressive disorder (MDD) and dysthymic disorder (DD).

METHOD

A computerized search for articles published during the past 10 years was made and selected studies are presented.

RESULTS

Early-onset MDD and DD are frequent, recurrent, and familial disorders that tend to continue into adulthood, and they are frequently accompanied by other psychiatric disorders. These disorders are usually associated with poor psychosocial and academic outcome and increased risk for substance abuse, bipolar disorder, and suicide. In addition, DD increases the risk for MDD. There is a secular increase in the prevalence of MDD, and it appears that MDD is occurring at an earlier age in successive cohorts. Several genetic, familial, demographic, psychosocial, cognitive, and biological correlates of onset and course of early-onset depression have been identified. Few studies, however, have examined the combined effects of these correlates.

CONCLUSIONS

Considerable advances have been made in our knowledge of early-onset depression. Nevertheless, further research is needed in understanding the pathogenesis of childhood mood disorders. Toward this end, studies aimed at elucidating mechanisms and interrelationships among the different domains of risk factors are needed.