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Suicide in Children and Adolescents
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Book description

In an epoch when rates of death and illness among the young have steadily decreased in the face of medical progress, the persistently high rates of youth suicide and suicide attempts around the world remain a tragic irony and a challenge to both our clinical practice and theoretical understanding. How can these deaths be prevented? Can they be anticipated? Are there perceptible patterns of risk and vulnerability? What role do families, gender, culture, and biology play? What are the treatments for and outcomes of suicide attempters? To address these questions, experts from around the world in all areas of psychiatry, from epidemiology, neurobiology, genetics and psychotherapy, have brought together their current findings in Suicide in Children and Adolescents.


'This book moves beyond the traditional approach of viewing suicide as a diagnostic feature of depression, personality disorder or other diagnostic category … There are several clinically orientated chapters, which I would recommend anyone assessing potentially suicidal children to read … each chapter provides an authoritative account of the current literature, which is generally well appraised and I would definitely recommend this book to anyone who has any contact with suicidal youth …'.

Source: Psychological Medicine

'The authors have a wonderful way of making sense out of the complex interplay of biopsychosocial and psychodynamic forces that lead youth to end their lives. The topics of suicide evaluation and prevention are immensely helpful and very thorough …'.

Source: Doody's

'Knowledge is expanding rapidly in child and adolescent psychiatry and in suicidology alike. This new book summarizes and discusses the latest development in the field.'

Source: European Child and Adolescent Psychiatry

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  • Preface
    pp xiii-xiv
    • By Robert A. King, Professor of Child Psychiatry and Psychiatry, Yale Child Study Center at Yale University, Alan Apter, Director of the Feinberg Department of Child and Adolescent Psychiatry, Schneider Children's Medical Center of Israel; Professor of Psychiatry, Sackler School of Medicine, University of Tel-Aviv
  • 1 - The epidemiology of youth suicide
    pp 1-40
    • By Madelyn S. Gould, Professor, Psychiatry and Public Health (Epidemiology), Columbia University, New York State Psychiatric Institute, 1051 Riverside Drive Unit 72, New York, NY 10032 USA e-mail: tel: +1-212-543-5329, fax: +1-212-543-5966, David Shaffer, Irving Philips Professor of Psychiatry, Columbia University; Director of Child Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032 USA e-mail: tel: +1-212-543-5947, fax: +1-212-543-5966, Ted Greenberg, Research Scientist, Columbia University, New York State Psychiatric Institute, 722 West 168th Street, New York, NY 10032 USA e-mail: tel: +1-212-543-5931
  • View abstract


    This chapter reviews three major sources of data that are used to derive the epidemiology of completed suicide in children and adolescents. They are official mortality statistics, the psychological autopsy literature, and general population epidemiologic surveys of nonlethal suicidal behavior. Suicide is often associated with aggressive behavior and alcohol abuse and both are more common in males. Until 1979, the ethnic breakdown in the annual age-specific mortality statistics in the U.S. published by the National Center for Health Statistics (NCHS) was limited to whites and nonwhites. Firearms are the most common method and hanging the second most prevalent method of suicide in the U.S., regardless of age or ethnicity. The chapter focuses on the main risk factors for youth suicide evaluated by the psychological autopsy studies that employed direct interviews of family and/or peer informants.
  • 2 - Suicide and the “continuum of adolescent self-destructiveness”: is there a connection?
    pp 41-62
    • By Robert A. King, Professor of Child Psychiatry and Psychiatry, Yale Child Study Center, 230 South Frontage Road, POB 207900, New Haven, CN 06511 USA e-mail: tel: +1-203-785-5880, fax: +1-203-737-5104, Vladislav V. Ruchkin, Assistant Professor, Institute of Psychiatry, Northern State Medical University, Arkhangelsk, Russia; Hewlett Research Fellow, Program on International Child and Adolescent Mental Health, Yale Child Study Center, 230 South Frontage Road, POB 207900, New Haven, CN 06511 USA e-mail: tel: +1-203-785-2545, Mary E. Schwab-Stone, Associate Professor of Child Psychiatry and Psychology, Yale Child Study Center, 230 South Frontage Road, POB 207900, New Haven, CN 06511 USA e-mail: tel: +1-203-785-2545
  • View abstract


    This chapter examines the nature and extent of the associations between overt suicidal thoughts and behavior and various other forms of adolescent health-impairing behavior. It reviews the epidemiological data linking suicidal behavior and adolescent risk behaviors, evidence compatible with the notion of a continuum of self-destructiveness. Epidemiologic studies of self-reported risk behaviors provide empirical support for the relationship between suicidal ideation or attempts and other potentially health-compromising risk behaviors. Adolescent problem behaviors such as truancy, substance use, high-risk or early onset of sexual activity, and delinquency frequently co-occur. One likely important source of apparent association between suicidal behavior and other risk behaviors is their shared association with predisposing psychiatric conditions, such as depression, disruptive disorders, or anxiety. Much more knowledge is needed about the various developmental trajectories toward suicidality in order to inform prevention, screening, and early treatment interventions.
  • 3 - Adolescent attempted suicide
    pp 63-85
    • By Alan Apter, Professor of Psychiatry, Sackler School of Medicine, University of Tel-Aviv Medical School; Chairman, Dept. of Child and Adolescent Psychiatry, Schneider Children's Medical Center of Israel, 14 Kaplan St. Petah Tikva, Israel 49202 e-mail:, Danuta Wasserman, Professor of Psychiatry and Suicidology and Chairmen of the Department of Public Health Sciences, Karolinska Institute; Head of the Swedish National Centre for Suicide Research and Prevention of Mental Illness, National Institute for Psychosocial Medicine; Director of the WHO Collaborating, Centre for Suicide research and promotion of mental health, Karolinska Institute, Box 230, 171 77 Stockholm, Sweden e-mail: tel: +46-8-7287026, fax: +46-8-30-64-39
  • View abstract


    Attempted suicide is relatively rare under 12 years of age, although there may be isolated cases under the age of five. The repetition rate for referred attempted suicide may be estimated by the ratio of the number of suicide-attempt events to the number of people involved. In the World Health Organization (WHO) study, more than one-third of the young patients included in the study at the index-attempted suicide had a history of prior attempted-suicide behaviour. Data from the Stockholm WHO center illustrated reasons for suicide attempts. Among many young suicide attempters seen, instability in family situation and childhood circumstances was notable. A history of suicidal behavior is one of the most significant risk factors for completed suicide among adolescents. The extensive material from the WHO study on attempted suicide provides available information on the provision of aftercare treatment recommendations made to young people aged 15-19 following attempted suicide.
  • 4 - Familial factors in adolescent suicidal behavior
    pp 86-117
    • By David A. Brent, Academic Chief, Child and Adolescent Psychiatry, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Suite 112, Pittsburgh, PA 15213 USA; Professor of Psychiatry, Pediatrics and Epidemiology, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Suite 112, Pittsburgh, PA 15213 USA e-mail: tel: +1-412-624-5172, fax: +1-412-624-7997, J. John Mann, Dept. of Neuroscience/Psychiatry, NY State Psychiatric Institute, Columbia Presbyterian Medical Center, 722 W. 168th St., Box 28, New York, NY 10032 (011-61-3) 9527-2867 USA e-mail: tel: +1-212-543-5000 / 5571, fax: +1-212-543-6017 or (212) 781-0503
  • View abstract


    This chapter examines both genetic and family-environmental factors associated with suicide and suicidal behavior, with an emphasis on youthful suicidal behavior. A family history of suicide was associated with a higher rate of suicide attempts in patients with a wide variety of disorders, including schizophrenia, unipolar and bipolar disorder, depressive neurosis, and personality disorders. The choice of candidate genes to examine in studying the etiology of suicide is made easier by the extensive and rather consistent findings from post-mortem studies of suicide victims, and in vivo studies of suicide attempters. A parent who is a suicide attempter most likely has at least two sets of liabilities: difficulties with regulation of aggression and the presence of a mood disorder or other type of psychopathology. The familial transmission of suicidal behavior appears to be independent or interactive with the familial transmission of psychopathology.
  • 5 - Biological factors influencing suicidal behavior in adolescents
    pp 118-149
    • By Alan Apter, Professor of Psychiatry, Sackler School of Medicine, University of Tel-Aviv Medical School; Chairman, Dept. of Child and Adolescent Psychiatry, Schneider Children's Medical Center of Israel, 14 Kaplan St. Petah Tikva, Israel 49202 e-mail:
  • View abstract


    This chapter reviews the general situation, pointing out the areas that have the most relevance to adolescent suicidal behavior. There appears to be an intimate relationship between the serotonergic parameters of aggression, anxiety, and suicidal behavior, especially in young people. Based on genetic studies and findings relating serotonin to suicidal behavior, some researchers have suggested that the gene coding for the rate-limiting enzyme in serotonin metabolism, tryptophan hydroxylase (TPH), is a candidate gene for suicidal behavior. Regardless of the etiology of suicidal behavior in young people, suicide attempts are extremely rare before puberty. The influence of hormonal factors on suicidal behavior has not been well studied. There has been a great deal of interest in the relationship between carbohydrate (CHO) metabolism, 5-HT systems and aggression. The development of operational criteria for nosological diagnosis has enabled biological researchers to focus on more clearly defined disorders in their search for biological markers.
  • 6 - Psychodynamic approaches to youth suicide
    pp 150-169
    • By Robert A. King, Professor of Child Psychiatry and Psychiatry, Yale Child Study Center, 230 South Frontage Road, POB 207900, New Haven, CN 06511 USA e-mail: tel: +1-203-785-5880, fax: +1-203-737-5104
  • View abstract


    The psychodynamic perspective seeks to understand the meaning of suicidal behavior in terms of feelings, motives, and their conflicts, in the context of past and present interpersonal relationships. Loss plays a particularly important role, both as an immediate precipitant of adolescent suicide and as a potential antecedent to the vulnerability to depression and suicide. Closely related to the development of attachment and maintenance of self-esteem are important self-regulatory capacities, such as the capacity for bodily self-care, self-protection, and self-soothing. Adolescents who are ambivalently attached to their families may have a propensity to turn to friends and romantic partners with particular intensity in order to find a substitute for the parental tie, but unfortunately frequently re-create the same stormy patterns in these new relationships. The psychodynamic perspective on youth suicide helps to supplement other biological, sociological, phenomenological, and nosological approaches.
  • 7 - Cross-cultural variation in child and adolescent suicide
    pp 170-197
    • By Michael J. Kelleher, National Suicide Research Foundation, Perrott Avenue, College Road, Cork, Ireland, Derek Chambers, Research & Resource Officer, National Suicide Review Group, Western Health Board, Office 10 Orantown Centre, Oranmore, Galway, Ireland e-mail: tel: +353-91-787056
  • View abstract


    This chapter explores the relationship between cultural influences and child and adolescent suicide in several empirical ways. International variations in suicide rates from countries around the world reflect the different social conditions and changes in each country. The current social trends towards large-scale globalization, increased economic security, and the shift towards postmodernist values provide the best perspective for understanding worldwide differences in youth suicide. The prevalence of different methods of suicide varies across societies, reflecting both ease of access and cultural influences. The importance of availability or access to means of self-harm is emphasized by trends in gender-specific suicidal behavior. Differences in child-rearing practices and the quality of child-parent attachments may be an important potential influential on cross-national variations in youth suicide rates. Culture also influences the timing, development, and shape of children's concept of death in general and suicide in particular.
  • 8 - An idiographic approach to understanding suicide in the young
    pp 198-210
    • By Alan L. Berman, Executive Director, American Association of Suicidology, 4201 Connecticut Ave., N.W., Washington, DC, 20008 USA e-mail: tel: +1-202-237-2280, fax: +1-202-237-2282
  • View abstract


    This chapter presents case studies which are heuristic tools for understanding and teaching about suicide. As catalogued by Canada's Suicide Information and Education Center (SIEC), 12% of the over 1900 references appearing in the literature prior to 1970 included case illustrations. The psychological autopsy, taken alone, has been used as a teaching tool since the first of two in-depth cases was presented and discussed in the Bulletin of Suicidology, the forerunner to Suicide and Life Threatening Behavior, in the fall of 1970. Case studies also have value in teaching about biological bases to suicide. The case study provides us the raw data for inductive reasoning. It humanizes our epidemiological and psychiatric statistics, statistics which too often fail us when we consider the tragedy of the suicidal adolescent. The single case study design allows us to formulate treatment dynamics and plans and explore different theory-based formulations.
  • 9 - Assessing suicidal behavior in children and adolescents
    pp 211-226
    • By Cynthia R. Pfeffer, Professor of Psychiatry, Director of the Childhood Bereavement Program, Weill Medical College of Cornell University, New York Presbyterian Hospital, 21 Bloomingdale Road, White Plains, NY 10605 USA e-mail:
  • View abstract


    This chapter discusses a systematic approach based on an understanding of developmental issues that are important for evaluating children and adolescents for suicidal behavior. Individuals from the age of 11 years through adulthood have developed operational concepts that enable them to think in abstract terms. Their concepts about lethality should be similar to those of adults in appraising the dangerousness of a behavior. The clinical assessment of suicidal behavior of children or adolescents must consider the developmental level of the cognitive capacity of a specific child or adolescent. In general, the assessment of suicidal behavior requires a sufficient amount of time to evaluate multiple factors that are associated with suicidal behavior. The concept of state-dependent recall is relevant in interviewing children and adolescents about their suicidal states. Play is a natural method of identifying suicidal behavior in children and young adolescents.
  • 10 - Suicide prevention for adolescents
    pp 227-250
    • By Israel Orbach, Professor, Department of Psychology, Bar-llan University, Ramat-Gan, Israel 52900 e-mail: tel: +972-353-18174, fax: +972-353-50267
  • View abstract


    The eruption of the suicide epidemic at adolescence is of great concern and has led the efforts to initiate programs for prevention for the young. This chapter presents major approaches, principles, and techniques of suicide prevention programs prevalent in schools and prevention centers. It focuses on a selection of theories with an emphasis on those which provide insights into the subjective experience of the suicidal individual. It is necessary to identify what in the suicidal process itself and in its dynamics permits reversing the self-destructive behavior. M. M. Silverman and R. W. Maris have extended Haddon's injury control models for public health into suicide prevention. This involves the classical tripartite model of primary, secondary, and tertiary intervention. Various suicide prevention programs employ different tactics. It should be based on national policies and cultural values integrating enhancement of life in everyday living.
  • 11 - Cognitive behavioral therapy after deliberate self-harm in adolescence
    pp 251-270
    • By Richard Harrington, University Department of Child Psychiatry, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK e-mail: tel: +44-161-727-2401, Younus Saleem, University Department of Child Psychiatry, Royal Manchester Children's Hospital, Pendlebury, Manchester UK tel: +44+161-727-2401
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    The kinds of cognitive behavioral interventions that are provided for adolescents who have taken a deliberate overdose, or who have deliberately harmed themselves in other ways, will depend to a large extent on the circumstances in which attempts occur. In over 80% of community and referred cases of suicide attempts, there are associated psychiatric disorders, most often depressive, anxiety, and behavioral disorders. Cognitive behavioral therapies (CBT) have a number of features that make them particularly useful in the treatment of suicidal adolescents. The choice of technique depends on many factors, including the young person's developmental level, the nature of the problem being treated, and the therapist's psychological model of the causes of the adolescent's problems. Cognitive restructuring forms an important part of many CBT programs. Problem-solving techniques are likely to be of value in helping adolescents to deal with the stresses that are commonly associated with deliberate self-harm.
  • 12 - Follow-up studies of child and adolescent suicide attempters
    pp 271-293
    • By Julie Boergers, Clinical Assistant Professor, Brown Medical School, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 USA e-mail: Julie tel: +1-401-444-4515, fax: +1-401-444-7018, Anthony Spirito, Director, Clinical Psychology Training Program, Potter Building, Box G-BH, Brown University, Providence, RI 02906 USA e-mail: tel: +1-401-444-1833, fax: +1-401-444-1888
  • View abstract


    This chapter summarizes findings from follow-up studies of adolescent suicide attempters, and reviews four major areas: continued psychiatric disturbance, rates of repeat attempts, rates of completed suicide, and treatment compliance. Many studies present data on combined adolescent and adult samples, but adult findings are probably not generalizable to adolescents. The chapter highlights data on general adjustment, academic functioning, social functioning, behavior, and psychopathology. There is a high level of continued behavioral dysfunction among adolescent suicide attempters, suggesting that, for most, the suicide attempt is not an isolated problem. The risk factors for repeat attempts include gender, severity of the initial attempt, affective and conduct disorders, and family conflict. In the literature on adult suicidal behavior, the use of survival analysis has been recommended in order to clarify risk factors. To improve the cost-effectiveness of interventions, studies which provide a more in-depth investigation of the postattempt course are also needed.
  • 13 - Children and adolescents bereaved by a suicidal death: implications for psychosocial outcomes and interventions
    pp 294-312
    • By Cornelia L. Gallo, Assistant Clinical Professor of Child Psychiatry, Yale Child Study Center, 230 South Frontage Road, POB 207900, New Haven, CN 06511 USA, Cynthia R. Pfeffer, Professor of Psychiatry, Director of the Childhood Bereavement Program, Weill Medical College of Cornell University, New York Presbyterian Hospital, 21 Bloomingdale Road, White Plains, NY 10605 USA e-mail:
  • View abstract


    This chapter focuses on the psychosocial impact of a family suicide on children and adolescents, and discusses intervention strategies at the individual, family, and community level. Bereavement early in life increases children's susceptibility to depression, anxiety, and social adjustment problems such as school dysfunction and delinquency. Like bereaved spouses, parents of adolescent suicides were at higher risk for depression than controls, and, at follow-up three years later, mothers of suicide victims were still at an increased risk for recurrent depression. Bereavement is generally associated with increased likelihood of mood disorders in children and adolescents but distinguishing between the symptoms of bereavement and major depressive disorder is often difficult. A significant number of children today have experienced a suicidal death of a relative. The reactions and responses to a suicidal death are complex and include an increased risk of depression and posttraumatic stress disorder (PTSD).


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