Suicide in Children and Adolescents

A study conducted in Egypt and involving 1,621 secondary-school adolescents found that 30% had experienced a strong wish to die during the year before the study. In Lebanon, 28.9% of school students across different governorates reported suicidal thoughts. A Moroccan study assessing the epidemiological aspects of suicide attempts among children identified 66 attempts, mostly among girls whose average age was 13. A study conducted in the emergency department of a hospital in Dubai found that suicide was the most common intention among people presenting to the department because of poisoning.

Suicide risks among children:

Although statistically rare, suicide among children can occur before puberty. It is therefore important not to underestimate children's understanding of what suicide means or dismiss the possibility that they may engage in suicidal behavior.

• By the age of nine, children usually have a comprehensive understanding of suicide.
• The younger the child, the less complex and more readily available the method tends to be.
• Suicide among children is often associated with conflict between parent and child.
• When assessing suicide risk in children before puberty, the professional should use language suited to the child's level and ask specific questions. They should seek collateral information and use it as part of the assessment, combining questions with empathetic reflections.

Questions may include:

1. Have you ever felt so distressed that you wished you were not alive or wanted to die?
2. Have you ever done something you knew was so dangerous that you might be hurt or kill yourself?

When asking these questions, we need to consider children's cognitive development, verbal skills, concepts of time, death, and suicide, and their understanding of cause and effect.

Suicide risks among adolescents:

Adolescence is a stage marked by impulsivity, intense emotions, and a search for identity. Well-known risk factors for suicide therefore tend to become more common during this period, including, for example, depression and severe anxiety. Drug use also increases during adolescence, further tipping the balance toward risk. Certain social pressures also intensify during this period, such as the end of romantic relationships, educational challenges, and pressure from parents.

We need to adopt prevention strategies that consider the different contexts of adolescents' lives, including their families, peers, and schools, and that reflect culturally diverse paths toward growth and resilience. Examples include recognizing the importance of belonging to and being accepted by friends, supporting and increasing independence within romantic relationships, and promoting activities.

Problem-solving approaches are also among the key strategies that should be considered for this age group, along with creating opportunities for young people. In addition, the search for meaning can help a person overcome pain and suffering. When we find hope, we become less inclined toward suicide. Hope is a key protective factor against suicidal behavior and a catalyst for recovery.

Non-suicidal self-harm among adolescents is a strong indicator of future suicide attempts.

We must also pay attention to warning signs among adolescents, which may include:

• Talking about or planning suicide.
• Expressing hopelessness about the future.
• Feeling intense emotional pain or distress.
• Displaying concerning behavioral signs or noticeable changes in behavior, particularly when the warning signs above are present. These specifically include:

1. Withdrawal or changes in relationships or social circumstances.
2. Changes in sleep, whether an increase or decrease.
3. Anger or hostility that seems out of character or out of context.
4. A recent increase in emotional reactivity or irritability.

In general, as suicidal intent and symptom severity increase, so does the risk of potentially engaging in suicidal behavior. Adolescents who have several risk factors, such as depression and substance use, who have a previous history of suicidal behavior, and who report current and specific suicidal thoughts should be considered at high risk.

Research and preliminary evidence suggest that the following factors may help protect adolescents: coping and problem-solving skills; experience of success and feelings of effectiveness; a strong sense of belonging and connection; social support; interpersonal relationships and competence; family warmth, support, and acceptance; success at school; a supportive school environment; school policies and practices against bullying; a strong cultural identity; and the enjoyment of self-determination and social justice.

Important points to note:

1. The suicide risk assessment process should not end simply because an adolescent denies having suicidal thoughts.
2. It is important to pay careful attention to immediate warnings when an adolescent has several enduring risk factors that continuously place them at substantial risk, along with signs suggesting imminent danger.
3. Having no history of suicide attempts does not mean that no risk exists.
4. Having a history of suicide attempts does not mean the adolescent is not serious and is merely trying to attract attention.
5. Having only a few risk factors does not mean suicide can be ruled out.
6. The presence of protective factors does not "cancel out" risk factors, particularly when there are several imminent risk factors, such as frequent, intense, and powerful thoughts and an expressed intention to die.

Within child and adolescent mental health policy on suicide prevention, intervention, and postvention, building a strong therapeutic alliance is one of the most important components of therapeutic work with adolescents experiencing suicidal thoughts. This means adopting an attitude characterized by warmth, trust, empathy, and care that works to instill hope.

Developing an empathetic relationship by openly acknowledging the level of pain and despair experienced by adolescents who often leave treatment prematurely or do not adhere to it is key to developing a strong alliance.