Pediatric Considerations for Suicidality
Incidence
Etiology/Assessment
Management
Pharmacologic Management
Adolescents with cancer tend to fight to live rather than succumb to death,
either natural death or suicide. Suicide in the absence of a major mental
disorder is as rare among adolescents as it is for adults.[1] Refusal of
treatment by adolescents has not been found to be a means of attempting
suicide. Rather, noncompliance is associated with the belief that life and
death are determined by fate, luck, or God. The adolescent believes that his
or her disease is outside of the realm of control and is in the hands of God
or some other force.
Incidence
In the general pediatric population, about 2,000 adolescents in the United
States die by suicide each year. Suicide consistently ranks as the second or
third leading cause of death for persons between the ages of 15 and 34 years.
One author suggests that before puberty, children are less vulnerable to suicide because of their cognitive immaturity, which makes planning and implementing a lethal attempt
difficult. Even accounting for underreporting, it is evident that the youth
suicide rate has more than doubled during the period from 1956 to 1993. The
increasing youth suicide rate has been attributed to the increase in and
prevalence of adolescent alcohol abuse; chronic and acute illnesses were not
described as major factors contributing to suicide.[1]
The suicide rate for male adolescents is 4 times as high as the rate for
females. The suicide rate for white adolescents is about twice as high as the
rate for blacks and Hispanics. In one study, 53% of 380 high school students
had thought about killing themselves, with 9% of this group having attempted
suicide. In another study, a representative sample of 11,631 high school
students reported that 27% of the students had seriously considered suicide,
with 16% having a plan in mind, 8% having made an attempt, and 2% making
attempts that required medical attention. The authors of this study
extrapolated from these results that 276,000 high school students make suicide
attempts requiring medical attention.[1] To date, little is known about the
actual prevalence of suicidal thinking and suicide attempts in childhood cancer.
Etiology/Assessment
Because little is known about suicide risk factors specifically in childhood
cancer, one could assess the risk factors for the general pediatric population
with the following:[2]
- Biologic factors include family history of psychiatric disorders such as
depression, schizophrenia, alcoholism, drug dependence, and conduct disorder.
Genetic predisposition to low levels of serotonin are associated with
depression.
- Predisposing life events include an early family history of parental abuse,
negative life event such as loss of a parent, childhood bereavement, and
disturbed, hostile interfamilial relationships. Many psychosocial factors and
negative life events have not been found to cause subsequent suicidal behavior.
- Psychosocial factors include the very nature of adolescence itself, with its
concurrent desire to experiment with drugs and alcohol. Conflict or confusion
about sexual orientation can be a factor in adolescent suicide. In addition,
characteristics such as perfectionism, impulsivity, inhibition, and isolation
all contribute to the likelihood of the adolescents having thoughts of suicide.
- Psychiatric disorders are found in 95% of all completed suicides in
adolescents. The following disorders are seen in most suicides: major
depressive illness, schizophrenia, alcoholism, drug dependence, and conduct
disorder. However, most individuals with psychiatric disturbances do not
commit suicide.
- Contagion is an expression that describes the phenomenon of young people
identifying with the suicidal behavior of others. Those who are in a
vulnerable state may imitate suicidal behavior. A completed suicide in a
childhood cancer setting should lead to support and monitoring of the victim's
peers.
- The availability of lethal weapons such as a gun in the house
can precipitate suicide.
- Precipitating events such as a diagnosis of cancer can change a state of potential
risk to actual suicide. In this instance there is usually:
- A preexisting
psychiatric disorder.
- A number of current life stressors.
- An upsetting
event such as academic failure.
- Life-threatening disease.
One author describes the hopelessness that may be felt by cancer survivors as
being instrumental in acts of suicide. She asserts that when an adolescent
cannot determine reasons to live, hopelessness occupies the thought process and
suicide presents a reasonable solution.[3]
Management
The management of suicide is carried out through the careful evaluation and
assessment of a child with cancer and his or her family. The
multiple factors that make life intolerable
for some children need to be addressed. Suicide prevention must include:
- Individual
assessment.
- Referral to appropriate health professionals.
- Appropriate
drug management.
- Individual psychiatric therapy coupled with family
therapy.
Pharmacologic Management
The evidence of continuity of childhood and adolescent depression and of
familial transmission of this disorder from parent to child would seem to argue
that the same agents used for adults would be effective in childhood. The
efficacy of antidepressants in children and adolescents has not been
established.[4]
Refer to the PDQ summary on Pediatric Supportive Care for more information.
References
-
Clark DC: Suicidal behavior in childhood and adolescence: recent studies and clinical implications. Psychiatr Ann 23 (5): 271-83, 1993.
-
Callahan J: Blueprint for an adolescent suicidal crisis. Psychiatr Ann 23 (5): 263-70, 1993.
-
Perrone J: Adolescents with cancer: are they at risk for suicide? Pediatr Nurs 19 (1): 22-5, 1993 Jan-Feb.
[PUBMED Abstract]
-
Ryan ND: The pharmacologic treatment of child and adolescent depression. Psychiatr Clin North Am 15 (1): 29-40, 1992.
[PUBMED Abstract]
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