Pediatric emergency medicine trisk 1045

Clinical Considerations
Suicidal behavior involves thoughts or actions that may lead to self-inflicted
death or serious injury. A distinction is made between suicidal ideation and
suicidal attempts in which deliberate attempts to take one’s life occurred.
The increasing trend toward suicidal behavior by children and adolescents is
alarming ( Table 126.10 ).

Clinical Recognition
Table 126.11 indicates the high-risk situations for suicidal behavior in which
direct questioning about suicide should occur. The first two situations
immediately alert the physician to the danger of suicidal behavior. The other
situations involve a different chief complaint, masking possible suicidal
ideation or behavior. All ingestions that are not clearly accidental,
intoxicated drivers, drivers involved in single vehicle crashes, and patients
who present with trauma from engaging in high-risk behaviors should be
screened for suicidal behavior. Overtly depressed children, depressed
children who present with somatic complaints, and children who have acted
violently are also at risk. Psychotic children present a special problem and
may present with inadvertent suicide attempts as the result of impaired
judgment, hallucinations, and delusions of persecution. The isolated,
withdrawn child may harbor suicidal thoughts that are uncovered only by
direct questioning.


TABLE 126.10
CHILDHOOD AND ADOLESCENT SUICIDE: NATURE OF THE
PROBLEM
Adolescent suicide
44% rise in suicide rate, adolescents ages 15–19 yrs, since 1970
4,000 completed adolescent and young adult suicides, since 2000
Estimated 400,000 adolescent attempts, since 2000 (1:50–1:100 attempts

succeed)
Suicide is the third leading cause of death, ages 15–24 yrs (after accidents,
homicides)
Childhood suicide
Serious problem
Younger children attempt suicide as a result of depression and/or poor
judgment
Increase in attempted and completed suicides, children ages 6 yrs and
older
Suicide attempts via ingestions (children ages 5–14 yrs) five times more
common than all forms of meningitis
Additional data
Girls attempt at least three times more often than boys
Boys succeed at least two times more often than girls
80% of attempts are pill ingestions
More lethal means—gun, knife, jumping, running into car—more common
with boys
Many car “accidents” are not accidents


TABLE 126.11
CHILDHOOD AND ADOLESCENT SUICIDE: HIGH-RISK
SITUATIONS FOR SUICIDE ATTEMPTS
Suicide attempt just made
Suicidal threat made
“Accidental” ingestion
Child complains of depression
Psychotic child
Significant withdrawal by child
History of aggressive or violent behavior

History of substance abuse
History of previous suicide attempt(s)
Medical concerns, but child appears depressed
Highly lethal method of suicide attempt
Availability of or access to firearms
In school-aged children, certain risk factors have been identified that
distinguish children with suicidal behavior from other children with
emotional problems ( Table 126.12 ). Suicidal children are likely to be
depressed and hopeless. Self-esteem is low, and they see themselves as
worthless. The want to die is present, as are preoccupations with death. The
family history may include past episodes of parental depression and suicidal
behavior. Suicidal children tend to view death as temporary and pleasant
rather than irreversible.
Assessment
All patients require a thorough medical assessment in order to identify and
treat any potential physical sequelae. Consider obtaining urine toxicology for
drugs of abuse and serum screens for acetaminophen and salicylates on all
suicidal teenage patients, as a concealed ingestion may be present or the
patient may be self-medicating with drugs of abuse.


TABLE 126.12
CHARACTERISTICS ASSOCIATED WITH CHILDHOOD AND
ADOLESCENT SUICIDE ATTEMPTS
Positive family history
Hopelessness
Low self-esteem
Active desire to die
Depression
Anger/desire for revenge

TABLE 126.13
ASSESSING CHILDHOOD/ADOLESCENT SUICIDE ATTEMPTS:
FOUR MAJOR DIMENSIONS
Medical lethality
Suicidal intent
Impulsivity
Strengths/supports
The psychiatric evaluation should include an assessment of the actual and
believed medical lethality of the act, the suicidal intent, the impulsivity of
the act, and the strengths and supports within the family ( Table 126.13 ).
The lethality of a suicide attempt by itself may be misleading because
suicidal children may over- or underestimate the harm intended. In general,
more violent methods of attempted suicide (e.g., hanging, shooting,
jumping) often reflect greater suicidal intent ( Table 126.14 ). However, the
physician cannot conclude that attempts with low lethality are not serious
attempts until they have specifically asked about and assessed the child’s
suicidal intent, that is, determined how seriously the child wanted to end
their life ( Table 126.15 ). These questions should be asked of the child
without the parents in the room.
The physician should gather as much information as possible about the
attempt itself to help infer the degree of suicidal intent on the part of the