Child and Adolescent Suicide:
Risks, Intervention and Prevention
Michael E. Mitchell, LCSW
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Child and Adolescent Suicide, 2014
DISCLOSURE
 The presenter DOES NOT have an interest in selling a
technology, program, product, and/or service to CME/CE
professionals.
 The presenter DOES have an interest in selling a technology,
program, product and/or service to CME/CE professionals.
 Michael Mitchell, LCSW has nothing to disclose with regard to
commercial relationships.
 The content of this presentation does not relate to any product of a
commercial interest. Therefore, there are no relevant financial
relationships to disclose.
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Child and Adolescent Suicide, 2014
Overview
What we know
Assessment and Treatment
Prevention
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Child and Adolescent Suicide, 2014
What we know
“There is but one truly serious philosophical problem, and that is suicide. Judging
whether life is or is not worth living amounts to answering the fundamental
question of philosophy”.
Camus- The Myth of Sisyphus

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Suicide: “…suicide is a
conscious act of self-induced
annihilation, best understood
as a multidimensional malaise
in a needful individual who
defines an issue for which
suicide is perceived as the best
solution”. (Leenaars,1999)
Child and Adolescent Suicide, 2014
The Stats…
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38,285 people die from suicide
10th cause of death (International
Classification of Diseases, 2009)
Guns, suffocation, poison
Gender
 Frequency: Males x4
 Method: Males >
 Fatality
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Maine: 2009
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Higher than homicide
15th Nationally
14th males
12th females
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http://webappa.cdc.gov/cgi-bin/broker.exe
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95% of people who die from
suicide have diagnosable
mental health issue
Few seek/receive behavioral
health treatment
Contact with health care
professional before attempt
Child and Adolescent Suicide, 2014
Suicides, by Age Group, Sex and
Mechanism
http://www.cdc.gov/violenceprevention/suicide/statistics/mechanism02.html
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Child and Adolescent Suicide, 2014
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Child and Adolescent Suicide, 2014
Maine Stats
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Child and Adolescent Suicide, 2014
Maine Data
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Child and Adolescent Suicide, 2014
Maine by County
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Child and Adolescent Suicide, 2014
Summary: Highest Risk
Male
Ages 15-65
Access to firearms
Hx of mental health issues
Substance abuse
Previous attempts
Internalized emotional regulation
High life stress
Isolation
Piscataquis, Knox, Waldo counties
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Child and Adolescent Suicide, 2014
Why suicide…
Psychological
pain: “psychache”
Constituents of
the Desire for
Death
Override
urge to live
Desire for death
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“Best
Solution”
• Perceived
Burdensomeness
• Thwarted
Belongingness
• Acquired Capacity
(Joiner,2005)
Child and Adolescent Suicide, 2014
Typical Motivations
Shneidman’s
3 Clarifications of Suicide
1. Acute suicidal crisis is
an interval of relatively
short duration: Time
2. The suicidal person is
ambivalent
3. Suicidal events are
interpersonal events
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a
desire to influence
another person
 to make someone
feel guilty
 to express anger or
gain attention
 to escape a difficult
situation
Child and Adolescent Suicide, 2014
Acquired Capacity to Enact Lethal Self-injury
(Joiner,2005)
Increased exposure to
pain
Decreased aversion to pain
Habituation to pain
Potential “positive” definition
Suicidal capacity
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Child and Adolescent Suicide, 2014
Suicide capacity
Perceived
burdensomeness
Thwarted
belongingness
Serious attempt
or completion
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Child and Adolescent Suicide, 2014
Suicide in Children and Adolescents
JIMMY, AGE 13 , a fraternal twin, was also
raised in a family that struggled with
substance abuse and depression.

Mother had a long history of using
alcohol, cocaine, and heroin. His parents
were never married, but when Jimmy
was five, his father took custody of the
boys after charges of neglect by the
mother.

Several allegations of neglect and
residence changes

By adolescence, Jimmy’s twin brother
was involved with the juvenile system.

Before a final child welfare home visit
could be made, Jimmy was found
hanging in a closet during a family
gathering. Endangered Youth, 2006
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Little flowers
I shall remember forever and will never
forget.
Monday: my money was taken.
Tuesday: names called.
Wednesday: my uniform torn.
Thursday: my body pouring with blood.
Friday: it's ended.
Saturday: freedom.
The final diary pages of 13-year-old boy.
He was found hanging from the banister
rail at his home.
Child and Adolescent Suicide, 2014
Adolescent Suicide…
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Nationally
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Ages 1-24, 3rd leading cause
of death(4600 lives lost)
8% of girls and 3% of boys 1120 admitted to at least one
attempt in their life
Doubled from 1960 to 2001
Maine:
 Ages 15-19: 2nd
 Ages 10-14: 5th
 Ages 0-10: ?
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35% to 50% have made, or
will make, a suicide attempt
Age increases lethality
Gender difference
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2008 rates: 12.9 in males vs.
2.7 in females
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Females higher attempts
Males higher completed suicides
Male more lethal: gun, hanging,
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motor vehicle
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Females: pill (s) OD or cut wrist
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More deadly methods since the mid 1990s
Child and Adolescent Suicide, 2014
2009 CDC Youth Risk Behavior Survey
Suicide Ideations & Attempts:
 Grades 9
 19% of teens have suicidal
ideation- N= 13,601
 Suicidal ideation:
 19.0% with plan
 14.8% Suicide attempt
 8.8% with med attention
 2.6% Suicide attempt
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Child and Adolescent Suicide, 2014
Adolescent Risk Factors
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Family engagement
School engagement
ACE level
Social engagement
Mental Health
Substance use
Sexuality/gender
Pregnancy
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Temperament
Suicide
exposure/acceptability
Firearm access
Previous attempts
Cluster risk/Copycat
Psychiatric inpatient
Child and Adolescent Suicide, 2014
Adolescents, SSRIs and Suicide
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Early 2000s increased
concerns
October 2004, the FDA
issued a black-box
warning
December 2006 black-box
extended to young adults
Limited research
Psychological autopsy
studies
Effectiveness vs risk
Black-box warning
reconsidered
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
“The result of this study is that
antidepressants do show evidence
of an antidepressant effect in the
pediatric population and that the
risk of nonfatal suicidal acts or
suicidal ideation is less than that
estimated by the FDA in its earlier
analyses, yielding a clearly positive
benefit-to-risk ratio.”
http://www.psychiatrictimes.com
Child and Adolescent Suicide, 2014
Gender
Male
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School engagement
Weapon possession
Same sex attraction
High risk behavior
Higher SI tolerance
Lethal means
Female
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13 years of age show an
abrupt increase SI
Emotional well-being
Trauma
Somatic symptoms
Friend SI
Hx mental health tx
Beautrais, 2003
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Child and Adolescent Suicide, 2014
Gifted Adolescents
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Above average
grades/intelligence
More severe attempts
More likely to complete
High perfectionism
High expectations
Uneven abilities
Adult perspective in a
child’s life: Existential
Nihilism
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“Being gifted, I have a
strong sense of future,
because people are always
telling me how well I will do
when I grow up …My
feelings fluctuate from a
sense of responsibility for
everything to a kind of
"leave me alone-quit
pushing.“ (Delisle,1986)
Child and Adolescent Suicide, 2014
LBGT and Suicide
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LGB youth attempt
suicide 2-3x more
frequently than straight
peers.
Higher lethal intent
30.1 percent of
transgender individuals
reported attempted
suicide
No #s re: numbers of died
by suicide
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Higher rates of
depression, anxiety and SA
High rates of victimization
Severe family rejection
www.suicidology.org
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Child and Adolescent Suicide, 2014
Adolescent Summary
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Similar to adults
Life transition issues
Accumulative effect
Child issues
Adolescent perspective
Gender gap
Substance abuse
Sub-populations
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Child and Adolescent Suicide, 2014
Childhood Suicide Facts
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Fifth (Sixth) leading cause
of death in 5-14 yr. age
group
Statistics unclear
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Limited research
Early minimization/
misreported
Unintentional?
Experience fewer risk
factors than lateadolescent
Child and Adolescent Suicide, 2014
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Gabriel was removed from his mother's care in June 2008 and
placed for 10 months in foster care.
• In the summer of 2008 Gabriel was sexually abused by a
14 yr. old boy and subsequently began to act out sexually
on other children with whom he came into contact.
• Gabriel was placed in several foster homes
• He threw epic tantrums and told a therapist ''he was evil
and born to lie."
• A foster parent described Gabriel accordingly, "And when
he's bad, he's really, really bad, and his mood can change
suddenly.''
• Left in the care of the 19 year old son of foster parent, the
teen made Gabriel a bowl of soup and Gabriel threw the
soup in the garbage. The teen sent him to his room.
• Gabriel locked himself in the bathroom and wrapped a
detachable shower hose around his neck. By the time his
teenaged caregiver broke into the bathroom with a
screwdriver, Gabriel was unresponsive.
• Gabriel was 7 years old
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Child and Adolescent Suicide, 2014
Child’s Concept Of Death
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By 6-7 know everyone dies
Not final
Only for the sick
Like sleeping/can wake up
Media portrayal:
 Love loss
 Revenge
 Anger
 Pouting
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Child and Adolescent Suicide, 2014
Jacob, age 10, threatened to kill himself by jumping from the second floor
window
Therapist: You said that you are sick of life; that means that you suffer a
lot.
Jacob: They want me to do things at home, to take care of my brother.
They don’t let me play . . . I am sick of it.
Therapist:You told your teacher the other day that you want to die.
I want to kill myself. What do you mean?
Jacob: I want to kill myself here in school.
Therapist: Why here in school?
Jacob: The school is responsible for all the children, and if something
happens to me in school, the principal will have to pay my parents a lot of
money, and my father would not have to work hard and they will find a
cure for my brother.
Therapist: What happens to people when they die?
Jacob: They are buried; they stink and rot and turn into bones. . . .
Therapist: What do you think will happen to you if you die?
Jacob: [Angrily] How do I know? I don’t know these things [pause]. I
will ask God to help my parents and cure my brother.
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Child and Adolescent Suicide, 2014
Pediatric Risk Factors
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Previous attempts
Psychopathology
 BPD
 Thought Disorder
 Severity
 Co-morbidity
Preoccupation with death
Poor social adjustment
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Family History
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younger age
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Environmental
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Psychopathology
Suicide
 6-fold increased risk
 More likely to attempt at a
Violence
School
Bullying
Predicts later suicide
behavior
Child and Adolescent Suicide, 2014
Complications…
Sub-clinical
presentations
 Little pre-suicide
indicators
 Unexpected
 Developmental
factors
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Child and Adolescent Suicide, 2014
Assessment and Treatment
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Child and Adolescent Suicide, 2014
DSM-V Suicide Assessment Dimension
Level of concern about
potential suicidal behavior:
(sum of items coded as
present)
1. 0: Lowest concern
2. 1-2: Some concern
3. 3-4: Increased concern
4. 5-7: High concern
Suicide risk factor groups:
Any history of a suicide attempt
Long-standing tendency to lose temper of become
aggressive with little provocation
Living alone, chronic severe pain, or recent (within 3
months) significant loss
Recent psychiatric admission/discharge or first
diagnosis of MDD, bipolar disorder or schizophrenia
Recent increase in alcohol abuse or worsening of
depressive symptoms
Current (within last week) preoccupation with, or
plans for, suicide
Current psychomotor agitation, marked anxiety or
prominent feelings of hopelessness
Screening and Assessment
Shneidman’s 3 clarifications of Constituents of the Desire for
Death
suicide
 Perceived Burdensomeness
1. Acute suicidal crisis is an
 Thwarted Belongingness
interval of relatively short
 Acquired Capacity
duration
(Joiner,2005)
2. The suicidal person is
ambivalent
3. Suicidal events are
interpersonal events
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Child and Adolescent Suicide, 2014
Screening
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Formal vs. Informal
Developmentally
appropriate
360 degree perspective
“Iceberg effect”
Prior/escalating attempts
Triggering life event
Referral
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Child and Adolescent Suicide, 2014
COLUMBIA-SUICIDE SEVERITY RATING SCALE
Screen Version Questions
for the past month
SUICIDE IDEATION DEINITIONS AND PROMPTS
•
Have you wished that you were dead or wished you could go to sleep and not wake up?
•
Have you actually had thoughts of killing yourself?
If YES to 2, ask questions 3, 4, 5, and 6. If NO on 2, go directly to question 6.
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Have you been thinking about how you might kill yourself?
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Have you had these thoughts and had some intention of acting on them?
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Have you started to work out or worked out the details of how to kill yourself?
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Do you intend to carry out this plan?
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Have you ever done anything, started to do anything, or prepared to do anything to end your life?
•
If YES, ask: How long ago did you do any of these?
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Over a year ago
•
Between three months and a year
•
Within the last three months?
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Child and Adolescent Suicide, 2014
Y N
Columbia: Children’s Version
SUICIDAL IDEATION
1. Wish to be Dead : Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.
Have you thought about being dead or what it would be like to be dead?
Have you wished you were dead or wished you could go to sleep and never wake up?
Do you ever wish you weren’t alive anymore?
2. Non-Specific Active Suicidal Thoughts
Have you thought about doing something to make yourself not alive anymore?
Have you had any thoughts about killing yourself?
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act
Have you thought about how you would do that or how you would make yourself not alive anymore (kill yourself)? What did you think about?
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan
When you thought about making yourself not alive anymore (or killing yourself), did you think that this was something you might actually do?
This is different from (as opposed to) having the thoughts but knowing you wouldn’t do anything about it.
5. Active Suicidal Ideation with Specific Plan and Intent
Have you ever decided how or when you would make yourself not alive anymore/kill yourself? Have you ever planned out (worked out the
details of) how you would do it?
What was your plan?
When you made this plan (or worked out these details), was any part of you thinking about actually doing it?
INTENSITY OF IDEATION : The following feature should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 being the least
severe and 5 being the most severe).
Most Severe Ideation: ___________ _________________________________________________
Type # (1-5) Description of Ideation
Most Severe
Most Severe
Frequency
How many times have you had these thoughts? Write response________________________________
(1) Only one time (2) A few times (3) A lot (4) All the time (0) Don’t know/Not applicable ____
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Child and Adolescent Suicide, 2014
____
Assessment
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Immediate risk
Lethality/instrumental
Intent, ideation, plan,
access, means
Risk factors, multiple
Protective factors
Care giver perspective
Support system
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Trajectory of Risk
Active
Resolution
Escalation
Time
Child and Adolescent Suicide, 2014
Intervention
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Safety, safety, safety…
Candid inquiry
Realities about death by
suicide
Safety plan: A, B, C
Decrease access to
firearms, drugs, etc.
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“ With everything you’re saying, I
wonder if you sometimes feel you
would be better off dead?”

“Sometimes kids who deal with these
things have seriously thought about
how to kill themselves, have you?”

“You talk a lot about your death,
have you ever thought about what it’s
really like for people after a suicide?”
Child and Adolescent Suicide, 2014
Treatment Focus
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Amplify ambivalence
Buy time
Build alternative skills
Diminish acquired ability
Challenge perceived
burdensomeness
Increase belonging
Developmentally adjusted
Put it in the light!
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Screen
Assess
Intervene
Follow
Child and Adolescent Suicide, 2014
up
Factors in Child and Adolescent Assessments
What’s going with the child?
What’s going on with the family
What is needed to resolve the
situation?
How do I factor into the
intervention?
Child and Family Assessment
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Crisis Dispositions
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11 Crisis programs
Emergency Room
Family doctor
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Home with nothing
Home with treatment
Crisis bed
Inpatient
Involuntary
Placement impact
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Post intervention risk
Don’t assume people
understand
On-going relationship
Ideation-attemptcompletion
Re-enforcing
“institutionalized
nurturance”
Child and Adolescent Suicide, 2014
Types of Family’s Experience
Break thru- 1st contact with crisis system
Experienced- Many contact and familiar with process
Respite- Break down of natural supports
Primary problem- Family chaos is significantly
contributing to the child’s presenting problem
Child and Family Assessment
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Prevention
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Early intervention
Candid confrontation
Realistic alternatives
Intercept points
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Transitions
Breakthroughs
Outcries
Micro and Macro
education
School, PCPs, sports,
providers
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Child and Adolescent Suicide, 2014
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Child and Adolescent Suicide, 2014
Questions
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Child and Adolescent Suicide, 2014
References
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Works Cited
Beautrais, A. (2003). Suicide and Serious Suicide Attempts in Youth: A Multiple-Group Comparison Study .
American Journal of Psychiatry, Jun;160(6):1093-9.
Borowsky, I., Ireland, M., & Resnick, M. (March 2001). Adolescent suicide attempts: risks and protectors.
Pediatrics, 485-493.
Delisle, J. (1986). Death with honors: Suicide among gifted adolescents. Journal of Counseling and Development,
64: 558-560.
Dore, M., Aselthine, R., Franks, R., & Schultz, M. (January 2006). Endangered Youth: A report on suicide among
adolescents involved with the child welfare and juvenile justice system. www.chdi.org: CHILD WELFARE LEAGUE
OF AMERICA.
Greydanus, D. . Suicide in Children and Adolescents. Michigan State University, College of Human Medicine.
Greydanus@kcms.msu.edu.
Joiner, T. (2205). Why People Commit Suicide. Cambridge MA: Harvard University Press.
Leenaars, A. (2010). Edwin S. Shneidmanon Suicide. Suicidology Online , 1:5-18.
Leenaars, A. (1999). Lives and deaths: Selections from the works of Edwin S. Shneidman's. Philadelphia:
Brunner/Mazel.
Mishara, B. L. (2003). How the media influences children’s conceptions of suicide. Journal of Crisis Intervention
and Suicide Prevention, 24:128-130.
Pfeiffer, C. (1986). The Suicidal Child. Guilford Press.
Pompeii M, M. I. (2005). Childhood Suicide Care Issues in Comprehensive Pediatric Care, 28:63-68.
Shneidman's, E. (1992). A conspectus for conceptualizing the suicidal scenario. In r. Maris, A. Berman, J.
Maltsberger, & R. Yufit,. Assessment and prediction of suicide (pp. 50-65). New York: Guilford Press.
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Child and Adolescent Suicide, 2014
Contact information
Michael Mitchell, LCSW
Clinical Director
Crisis and Counseling Centers
10 Caldwell Rd
Augusta, Me 04330
207-626-3448
x1143
mmitchell@crisisandcounseling. org
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Child and Adolescent Suicide, 2014