Dr. Pfeffer: Historically, psychiatrists did not focus on identifying and treating risk factors for child and adolescent suicidal behavior. But after an increase in youth suicide rates in the 1980s, we started doing more research to get clarity about the issues. For example, we became aware that there were clusters of youth committing suicide—doing so in the same community and during the same time period. We suddenly recognized that hearing about a peer committing suicide would raise the risk for that peer’s close friends. This caused concern for mental health professionals and those in the community, who became interested in what factors promoted suicide among clusters of young people.
CCPR: Interesting. How different was that from how you were originally taught as a clinician?
Dr. Pfeffer: When I was in training as a child and adolescent resident, we were not taught about child and adolescent suicide. I started my research on this extensive problem when I worked to assess childhood psychiatric emergency cases. Children and their parents reported to me that children—who wanted to die—ran into traffic, attempted to jump off buildings or out of their apartment windows, overdosed, or attempted to hang themselves. People thought young children did not know about death and did not understand that it was permanent. But the issue is not whether these children understand death; it is that they want to die. We’ve come a long way since then. The National Institutes of Health (NIH), the Substance Abuse and Mental Health Services Administration (SAMHSA), and other foundations have supported research on this mental health issue and educated the community about ways to prevent youth suicide. However, it continues to be a significant problem and requires continued research for prevention.
CCPR: You mention the research that began on risk factors in the 1980s. What has the historical epidemiology on adolescent suicide looked like since then?
Dr. Pfeffer: Rates in adolescents, teens 15–18, were increasing throughout the 1980s, then decreased through about 2004. But the rates have been rising in the past 10 years, including among younger children. The causes for this are still to be determined (Ed note: The 2004 black box warning on antidepressants was associated with a drop in prescriptions and a rise in suicide rates), but suicide rates in prepubertal girls have increased significantly in the past 10 years (Curtin SC et al, MMWR Morb Mortal Wkly Rep 2017;66:816). Epidemiology statistics suggest that black American teens living in rural areas, particularly in the South, had a lower suicide rate than those in northern urban regions. A hypothesis was that black youth living in urban areas were dealing with more socioeconomic stressors. Today, while the suicide rates in the black youth population are still lower than those of white youths, they are rising. Additionally, there is evidence of increased rates of suicide among Asian American youth. This epidemiological information suggests that more work is needed to understand and prevent factors related to youth suicide.
CCPR: What is known about youth suicide risk factors?
Dr. Pfeffer: There are several broad categories of youth suicide risk factors: psychiatric disorders, family and social-related risk factors, and biological domains, including developmental, genetic, and neurodevelopmental risk factors. The most significant psychiatric risk factor for suicide or self-harm in children and adolescents is a history of suicidal behavior and ideation. Suicidal acts, especially near-lethal ones, place youth at particularly high risk for future suicide. Psychological autopsy studies point out that 90% of youth who committed suicide had a mental disorder: mostly mood disorders, especially major depression, and substance abuse (Nock MK et al, JAMA Psychiatry 2013;70(3):300). Suicidality in depression is heightened when there are psychotic features, such as in bipolar disorder with rapid cycling.
CCPR: Those are very important factors. Are there others we should be thinking about?
Dr. Pfeffer: Recently, Tourette’s disorder has been associated with increased suicide risk (Fernandez de la Cruz L, Biol Psychiatry 2016;82(2):111–118). There are high suicide rates associated with eating disorders, especially among girls, and other studies show higher rates with conduct disorder and ADHD. Youth suffering from schizophrenia are at significant risk for suicide. These conditions carry different risk levels. Another diagnostic area is autism spectrum disorder (ASD). Some children and adolescents with ASD, especially those who are high functioning, harbor suicidal thoughts and have attempted suicide. Such children and adolescents struggle with social stress and feelings of isolation and inadequacy.
CCPR: What are the family-related risk factors?
Dr. Pfeffer: Family turmoil is another big category, including acrimonious family interactions, separations and losses, and abuse. Family psychopathology is a significant factor, especially transmission of suicidal behavior through family generations. Youngsters are at higher risk when a parent is psychiatrically ill. Abuse is another significant risk factor, including physical abuse, but especially sexual abuse. It is essential to conduct a thorough family history assessment, and to gather this information systematically by asking about each close relative’s history of psychopathology. Ask parents if they have been depressed or anxious or had suicidal ideation or behavior, or other emotional problems. Specifically ask this about each close relative. Identifying these risk factors will help in treatment planning for the suicidal child or adolescent. Each family risk factor will elevate risk for suicide among youth.
CCPR: I know that bullying fits into social risk phenomena. Can you tell us more?
Dr. Pfeffer: Bullying is a more recently characterized risk factor in the US. The effect of bullying on suicide is a form of abuse by peers that happens verbally, physically, and through social media. This is observed among prepubertal children and adolescents. In the 1990s, Dr. Vincent Felitti and his colleagues studied the impact of early social stress, termed adverse childhood experiences (ACEs), and found significant impact of ACEs on development of later psychopathology and physical maladies (Felitti VJ et al, Am J Prev Med 1998;14(4):245–258).
CCPR: How is suicidal risk different in teens?
Dr. Pfeffer: Because most psychiatric disorders have adolescent onset, suicidal ideation and acts are more prevalent among adolescents. For example, bipolar disorder usually has an onset during adolescence, and it often first manifests as severe depression with intense suicidal ideation or serious suicide attempts. Adolescents have also accumulated more risk factors by that age. Furthermore, the greater developmental social independence that occurs during adolescence has many benefits and drawbacks. For example, adolescents can more successfully escape a hostile home environment. But, by leaving home, they may find themselves in new and vulnerable situations, such as school truancy, drug abuse, and exposure to sexually transmitted diseases. An important and frequent acute stress is the loss of a boyfriend or girlfriend. Another prevalent stressor is related to academic stress, which may be amplified by an unrecognized learning disability or inattention related to an anxiety disorder or attention deficit disorder.
CCPR: Are there specific risks among younger children?
Dr. Pfeffer: Prepubertal children, for better or worse, are more dependent on their parents and other relatives. When there are family problems related to parental psychopathology or other stresses on the parents, young children may be moved out of their parental home to live with relatives or foster families. Such children often suffer intense bereavement with depressive symptoms, longing for their parents, aggression, anxiety, hopelessness, and oppositional behavior. The hopelessness of losing parental nurturing may increase thoughts about dying and lead to kids planning methods to commit suicide.
CCPR: Are there other populations at risk who we haven’t mentioned yet?
Dr. Pfeffer: It is now recognized that the LGBTQ youth population is at high suicide risk, particularly for those who come out about their sexual orientation at an earlier age—by 10 or 11 for boys, or 12 or 13 for girls (Kann L et al, MMWR Surveill Summ 2016;65(9):1–202). Coming out as LGBTQ often occurs in mid-late adolescence. However, many LGBTQ teenagers may not want to come out for fear they’ll have to endure the social stressors and peer rejection. Those social stressors can lead to an increased risk for suicidal ideation or acts. Shame is a general risk factor for suicidality, which can occur when there is rejection by peers, family, and society. LGBTQ males and females require significant support from parents and school officials, and they may need psychiatric interventions to endure the long process of coming out and adjusting to being open about their sexual orientation.