Suicidal

AACAP
OFFICIAL
ACTION
Practice Parameter for the Assessment and Treatment

of Children and Adolescents With Suicidal Behavior
ABSTRACT
These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and
attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how
the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/
case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the
community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other
gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed. J. Am. Acad. Child Adolesc.
Psychiatry, 2001, 40(7 Supplement):24S51S. Key Words: suicide, children, adolescents, suicide attempts, practice guidelines, suicide prevention, suicidal ideation, mood disorders.
Suicidal behavior is a matter of great concern for clinicians who

deal with the mental health problems of children and adolescents. The incidence of suicide attempts reaches a peak during
the mid-adolescent years, and mortality from suicide, which
increases steadily through the teen years, is the third leading
cause of death at that age. Clinicians need to know how to identify those at greatest risk for suicide from among the large number of suicide attempters who have a benign prognosis; how to
provide treatment for the suicidal patient; how to advise and
counsel the child, adolescent, and parental survivors of individual suicides; and how to provide expert consultation to educational and public health authorities on appropriate and
inappropriate directions for suicide prevention programs. The
parameter was written to aid clinicians in the assessment and
treatment of children and adolescents exhibiting suicidal behavior or harboring suicidal ideation.
This parameter was developed by David Shaffer, M.D., Cynthia R. Pfeffer,
M.D., and the Work Group on Quality Issues: William Bernet, M.D., Chair,
Valerie Arnold, M.D., Joseph Beitchman, M.D., R. Scott Benson, M.D., Oscar
Bukstein, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., David Rue, M.D.,
and Jon Shaw, M.D. AACAP Staff: Kristin Kroeger. The authors thank David
A. Brent, M.D., Markus Kruesi, M.D., Jane L. Pearson, Ph.D., and Anthony
Spirito, Ph.D., for their thoughtful review, and Jennifer Gutstein for her considerable assistance. This summary and the full text of the Practice Parameter for
the Assessment and Treatment of Children and Adolescents With Suicidal Behavior are available to Academy members on the World Wide Web (www.aacap.org).
The full text of this parameter was reviewed at the 1999 Annual Meeting of the
American Academy of Child and Adolescent Psychiatry and was approved by
AACAP Council on October 17, 2000.
Reprint requests to AACAP Communications Department, 3615 Wisconsin
Avenue, N.W., Washington, DC 20016.
0890-8567/01/40070024S2001 by the American Academy of Child
and Adolescent Psychiatry.
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EXECUTIVE SUMMARY
This summary provides an overview of the assessment and

treatment recommendations contained in the Practice Parameter for the Assessment and Treatment of Children and Adolescents With Suicidal Behavior. This summary includes many
of the most important points and recommendations that are
in these practice guidelines. However, the treatment and assessment of suicidal patients requires the consideration of many
important factors that cannot be conveyed fully in a summary,
and the reader is encouraged to review the entire document.
Each recommendation in the executive summary is identied as
falling into one of the following categories of endorsement, indicated by an abbreviation in brackets following the statement.
These categories indicate the degree of importance or certainty
of each recommendation.
Minimal Standards [MS] are recommendations that are
based on substantial empirical evidence (such as well controlled, double-blind trials) or overwhelming clinical consensus. Minimal standards are expected to apply more than 95%
of the time, i.e., in almost all cases. When the practitioner
does not follow this standard in a particular case, the medical
record should indicate the reason.
Clinical Guidelines [CG] are recommendations that are
based on empirical evidence (such as open trials, case studies)
and/or strong clinical consensus. Clinical guidelines apply approximately 75% of the time. These practices should always be
considered by the clinician, but there are exceptions to their
application.
Options [OP] are practices that are acceptable but not
required. There may be insufcient empirical evidence to support recommending these practices as minimal standards or
clinical guidelines. In some cases they may be the perfect thing
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 7 S U P P L E M E N T, J U LY 2 0 0 1
SUICIDAL BEHAVIOR
to do, but in other cases they should be avoided. If possible, the

practice parameters will explain the pros and cons of these
options.
Not Endorsed [NE] refers to practices that are known to
be ineffective or contraindicated.
SUICIDE
Suicide, exceedingly rare before puberty, becomes increasingly frequent through adolescence. Approximately 2,000
U.S. adolescents commit suicide each year.
The factors that predispose to completed suicide are many
and include preexisting psychiatric disorders and both biological and social-psychological facilitating factors. The overwhelming proportion of adolescents who commit suicide
(more than 90%) suffered from an associated psychiatric disorder at the time of their death. More than half had suffered
from a psychiatric disorder for at least 2 years.
Stress events often precede adolescents suicides, including a
loss of a romantic relationship, disciplinary troubles in school
or with the law, or academic or family difficulties. These
stresses may ensue from the underlying mental disorder itself
(e.g., trouble with the law) or they may be normative outcomes of uncontrollable events (e.g., a death in the family)
with which the adolescent with a mental disorder may not be
able to cope. An adolescent with an underlying mental disorder may be faced with a greater number of stressful events
than the average adolescent. Or he may perceive the events
that occur as more stressful.
Suicide is much more common in adolescent and young
adult males than females (the ratio grows from 3:1 in the rare
prepubertal suicides to approximately 5.5:1 in 15- to 24-yearolds), but many of the risk factors are the same for both sexes.
Mood disorders, poor parentchild communication, and a previous suicide attempt are risk factors for suicide in both boys
and girls, although a previous suicide attempt is more predictive
in males. Substance and/or alcohol abuse signicantly increases
the risk of suicide in teenagers aged 16 and older. Family pathology and a history of family suicidal behavior may also increase
risk and should be investigated.
African Americans currently have a lower rate of suicide than
whites, but the suicide rate of African-American adolescent and
young adult males has been rising rapidly. Native American and
Alaskan Native youth have historically had a very high rate of
suicide. Attempted suicide rates of Hispanic youth are greater
than those of white and African-American youth. Clinicians
should consider the cultural background of a suicidal youth and
assess cultural attitudes in the childs community. However, ethnic differences in the suicide rate may reect contagion in isolated groups rather than cultural differences.
SUICIDAL IDEATION
Suicidal thoughts are common in children and adolescents

of both genders and are by no means always associated with
other features of psychopathology. They usually come to clinical attention when enunciated as threats.
Disruptive disorders increase the risk of suicidal ideation in
children 12 years old and younger, and substance use or separation anxiety may provoke adolescent ideators of both sexes
to attempt suicide. Mood and anxiety disorders increase the
risk of suicidal ideation. Panic attacks are a risk factor for ideation or attempt in females, while aggressiveness increases the
risk of suicidal ideation or attempt in males. Adolescent suicide attempters may differ from ideators in having more severe
or enduring hopelessness, isolation, suicidal ideation, and
reluctance to discuss suicidal thoughts.
ATTEMPTED SUICIDE
Mood disorders (particularly early-onset major depressive

disorder), anxiety disorders, substance abuse, and runaway
behavior independently increase the risk of suicide attempts
in both sexes. Suicide attempts are more common in girls than
boys (approximately 1.6:1).
Suicide attempts are considerably less common than suicidal ideas, but they are the presenting complaint in a sizable
proportion of adolescents referred to mental health professionals. It is estimated that each year, approximately 2 million
U.S. adolescents attempt suicide, and almost 700,000 receive
medical attention for their attempt.
Teen suicide attempters are much more likely than those
who only ideate to have associated psychopathology, especially
a mood disorder, but the attempts often occur in the context
of a relatively brief adjustment reaction.
Having made a previous suicide attempt greatly increases
the risk of a boys eventually committing suicide, but the predictive effect in females is less substantial. Only half of all suicide completers have made a known suicide attempt before
their death; however, our information on previous attempts
remains incomplete, as many attempts go unreported. Gay,
lesbian, and bisexual youth are at increased risk for suicide
attempts, often having multiple risk factors (i.e., depression,
prior suicide attempts, substance abuse, sexual victimization,
family conflict, and ostracism at school), as are adolescents
who have been victims of childhood sexual or physical abuse.
Even the most skilled clinician can nd it difcult to differentiate between benign and ominous suicidal behavior. Many
adolescents who have made a medically serious attempt will
never do so again, while others who have made what seemed
like only a mild gesture may eventually commit suicide. The
term gesture, used by some clinicians to denote a nonlethal,
self-destructive action that is deemed a cry for help or a
manipulation without serious intent, is therefore misleading,
because it minimizes the potential risk for future suicidal
behavior. One cannot gauge future suicidal behavior. However, research has provided some broad indicators about risk
factors and the assessment of attempters (Tables 1 and 2) that
need to be considered by all clinicians [MS].
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AACAP PRACTICE PARAMETERS
TABLE 1
High-Risk Factors for Suicide in Adolescents
Males at much higher risk than females
Among males
Previous suicide attempts
Age 16 or older
Associated mood disorder
Associated substance abuse
Among females
Mood disorders
Previous suicide attempts
Immediate risk predicted by agitation and major depressive disorder
ASSESSMENT
Assessment of suicidal patients requires an evaluation of

the suicidal behavior and determination of risk for death or
repetition, as well as an assessment of the underlying diagnoses or promoting factors.
Identification of Risk
Clinicians should be aware of which adolescent suicide

attempters are at greatest risk for later suicide (Table 2) [MS].
These are older (16- to 19-year-old) male adolescents or adolescents of either gender, regardless of age, with a current
mental disorder or disordered mental state, such as depression,
mania or hypomania, or mixed states, especially when complicated by comorbid substance abuse, irritability, agitation, or
psychosis. Attempters who have made prior suicide attempts,
those who used a method other than ingestion or supercial
cutting, and those who still want to die are also at higher risk.
Clinicians should ascertain the suicidality of depressed adolescents (i.e., whether and how often they think about suicide
and whether they have ever attempted suicide). If suicidal ideation or recent suicidal behavior is present in a depressed teenager, he or she should continue to be monitored [MS].
Assessment information should always be drawn from several sources, including child or adolescent, parents or guardians, school reports, and any other individuals close to the
child. Structured or semistructured suicide scale questionnaires, whether delivered by the clinician or self-completed by
the child or adolescent, have limited predictive value. They
may complement but should never take the place of a thorough assessment or substitute for any aspect of assessment.
TREATMENT
Treatment must encompass the acute management of suicidal

behavior as well as treatment of associated mental disorders.
Acute Management
Emergency room and other crisis staff should establish a

relationship with the suicidal individual and family and establish the importance of treatment [MS].
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TABLE 2
Checklist for Assessing Child or Adolescent Suicide Attempters
in an Emergency Room or Crisis Center
Attempters at Greatest Risk for Suicide
Suicidal history
Still thinking of suicide
Have made a prior suicide attempt
Demographics
Male
Live alone
Mental state
Depressed, manic, hypomanic, severely anxious, or have a
mixture of these states
Substance abuse alone or in association with a mood disorder
Irritable, agitated, threatening violence to others, delusional, or
hallucinating
Do not discharge such patients without psychiatric evaluation.
Look for signs of clinical depression
Depressed mood most of the time
Loss of interest or pleasure in usual activities
Weight loss or gain
Cant sleep or sleeps too much
Restless or slowed-down
Fatigue, loss of energy
Feels worthless or guilty
Low self-esteem, disappointed with self
Feels hopeless about future
Cant concentrate, indecisive
Recurring thoughts of death
Irritable, upset by little things
Look for signs of mania or hypomania
Depressed mood most of the time
Elated, expansive, or irritable mood
Inated self-esteem, grandiosity
Decreased need for sleep
More talkative than usual, pressured speech
Racing thoughts
Abrupt topic changes when talking
Distractible
Excessive participation in multiple activities
Agitated or restless
Hypersexual, spends foolishly, uninhibited remarks
Source: American Foundation for Suicide Prevention (1999),
Todays suicide attempter could be tomorrows suicide (poster). New
York: American Foundation for Suicide Prevention, 1-888-333-AFSP.
Although there have been no randomized controlled trials to

determine whether hospitalizing high-risk suicide attempters
saves lives, clinicians should be prepared to admit suicide
attempters who express a persistent wish to die or who have a
clearly abnormal mental state [MS]. Inpatient treatment should
continue until their mental state or level of suicidality has stabilized [MS].
Regardless of the apparent mildness of the patients suicidal
behavior, the clinician must obtain information from a third
party. Discharge can be considered if the clinician is satised
SUICIDAL BEHAVIOR
that adequate supervision and support will be available over

the next few days and if a responsible adult has agreed to sanitize the environment by securing or disposing of potentially
lethal medications and rearms [MS].
The most common method used by adolescents to commit
suicide in the United States is with a firearm. Ingestion of
medication is the most common method adolescents use to
attempt suicide. Availability and presence in the home of rearms and lethal medication must be determined during assessment, and parents must be explicitly told to remove rearms
and lethal medication [MS]. It is valuable for the clinician to
warn the adolescent (and the parents) about the dangerous
disinhibiting effects of alcohol and other drugs [CG].
The value of no-suicide contracts, in which the child or
adolescent agrees not to engage in self-harming behavior and to
tell an adult if he or she is having suicidal urges, is not known.
The child or adolescent might not be in a mental state to accept
or understand the contract, and both family and clinician
should know not to relax their vigilance just because a contract
has been signed.
If possible, an appointment should be scheduled for the
child or adolescent to be seen for a fuller evaluation before discharge from the emergency room. If this is not possible, a telephone contact for a parent or other caretaker should be obtained
and a procedure set up for clinical staff, if they have not been
contacted by the parent within a reasonable period of time, to
themselves initiate the contact [MS].
The clinician treating the suicidal child or adolescent during the days following an attempt should be available to the
patient and family (for example, receive and make phone calls
outside of therapeutic hours) or have adequate physician coverage if away [MS], have experience managing suicidal crises
[MS], and have support available for himself or herself [CG].
Once a therapeutic alliance is established and the adolescent
attends the rst treatment sessions, he or she is more likely to
continue treatment.
Psychotherapies
Psychotherapy, an important component of treatment for the

mental disorders associated with suicidal behavior, should be tailored to a childs or adolescents particular need [MS]. Cognitivebehavioral therapy (CBT), interpersonal psychotherapy for
adolescents (IPT-A), dialectical-behavioral therapy (DBT), psychodynamic therapy, and family therapy are all options [OP].
Psychopharmacology
As with psychotherapies, psychopharmacology to treat suicidal behavior should be tailored to a childs or adolescents
placement-specic needs. Lithium greatly reduces the rate of
both suicides and suicide attempts in adults with bipolar disorder. Discontinuing lithium treatment in bipolar patients is
associated with an increase in suicide morbidity and mortality.
Selective serotonin reuptake inhibitors (SSRIs) reduce suicidal ideation and suicide attempts in nondepressed adults
with cluster B personality disorders. They are safe in children
and adolescents, have low lethality, and are effective in treating
depression in nonsuicidal children and adolescents. There
have been some reports that SSRIs may have a disinhibiting
effect (especially in patients with SSRI-induced akathisia) and
increase suicidal ideation in a small number of adults not previously suicidal. Further controlled research is necessary to
determine whether there is an association in children and adolescents. However, it would be prudent to carefully monitor
children and adolescents on SSRIs to ensure that new suicidal
ideation or akathisia are noted [MS].
Tricyclic antidepressants should not be prescribed for the suicidal child or adolescent as a rst line of treatment [NE]. They
are potentially lethal, because of the small difference between
therapeutic and toxic levels of the drug, and have not been
proven effective in children or adolescents.
Other medications that may increase disinhibition or impulsivity, such as the benzodiazepines and phenobarbital, should be
prescribed with caution [OP]. Any and all medications prescribed to the suicidal child or adolescent must be carefully
monitored by a third party, and any change of behavior or side
effects must be reported immediately [MS].
PREVENTION
Public health approaches to suicide prevention have targeted suicidal children or adolescents, the adults who interact
with them, their friends, pediatricians, and the media.
Teenagers may be made aware of the existence of crisis hotlines [OP]. Although widely used, early studies, hampered by
methodological deficiencies, failed to show that hotlines
reduce the incidence of suicide. But it would be wise to assume
that their value remains untested. Research has uncovered
some hotline deciencies, but new studies are needed to determine whether correcting these problems can increase their
effectiveness.
Public health measures, such as restricting young peoples
access to rearms, may result in a short-term reduction in the
rates of suicide, but there is not yet evidence that this effect
would be lasting [OP]. Raising the minimum legal drinking age
for young adults appears to reduce the suicide rate in the affected
age group.
Suicide awareness programs in schools frequently minimize
the role of mental illness and, although designed to encourage
self-disclosure by students or third-party disclosure by their
friends, have not been shown to be effective either in reducing
suicidal behavior or increasing help-seeking behavior.
Because curriculum-based suicide awareness programs disturb
some high-risk students, a safer approach might be to focus on
the clinical characteristics of depression or other mental illnesses
that predispose to suicidality. In the absence of evidence to the
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contrary, talks and lectures about suicide to groups of children

and adolescents drawn from regular classes should be discouraged [NE]. This is because of their propensity to activate suicidal
ideation in disturbed adolescents whose identity is not usually
known to the instructor. Screening or suicide education programs for teenagers that do not include procedures to evaluate
and refer identified ideators or attempters are not endorsed
[NE]. Direct screening programs may identify those with underlying risk factors to a clinician for further evaluation [OP].
Primary practitioners, counselors, or others who may lack
the time, resources, or training to evaluate a childs or teenagers
mental state should make use of self-completion questionnaires to screen for depression, suicidal preoccupations, and
previous suicidal behavior in their ofce [CG]. There is ample
evidence that teenagers in mid to late adolescencethe group
that is at greatest risk for suicide attempt and completion
will, if asked directly, reveal this information. This practice can
be especially recommended to family practitioners, pediatricians, school counselors, juvenile justice professionals, and psychologists who wish to survey their populations for teenagers at
high risk for suicide. Those identied as being at risk should be
referred for further evaluation and treatment, if necessary, and
receive support and follow-up (i.e., phone calls, case manager if
available) during the transition period.
Clinicians engaged in public health practice should be able
to advise media reporters and editors on the dangers of excessive coverage of individual suicides [OP].
Finally, primary care physicians and gatekeepers should be
trained to recognize risk factors for suicide and suicidal behavior
and, when necessary, refer to a mental health clinician [CG].
POSTVENTION
After a suicide, the relative, friends, and teachers of the child

or adolescent who committed suicide may benet from intervention to facilitate grieving, reduce guilt and depression, and
decrease the effects of guilt and trauma. There may also be a call
to intervene to minimize the risk of imitative or copycat suicides,
but there is no agreement about how this should be done [CG].
LITERATURE REVIEW
The literature on child and adolescent suicidal behavior has

burgeoned since the early 1980s. Journal articles and books
published from 1980 through February 2000 were reviewed
via a National Library of Medicine search of the topics suicide and suicidal behavior in children and adolescents.
There were more than 20,000 publications listed in
PSYCInfo, Healthstar, and Medline during this period. Only
the most relevant articles are cited due to space constraints.
Key references are marked with an asterisk. The authors also
drew from their clinical knowledge and experience, writing,
and research in this subject area.
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HISTORICAL REVIEW
Until the late 1950s, the literature on suicide was conned to

case reviews, reviews of the demography of suicide drawn from
death certicate data, and speculation about the dynamics of
the behavior. The late 1950s saw the rst systematic psychological autopsy study that was carried out by Eli Robins and his
colleagues (1959) at Washington University, St. Louis, followed
by similar studies using the same techniques in other countries.
These studies formed a milestone because they gave evidence
for the importance of psychiatric disorder as the proximal cause
of most suicides.
The 1960s saw the start of a period of increasing young
male suicides that was to continue for three decades (National
Center for Health Statistics, 1999). Although the period was
marked by a growth in the suicide prevention movement in the
United States, with its emphasis on crisis intervention services,
relatively little informative research emerged.
By the early 1980s, the suicide rate in white, male teenagers
had more than doubled (National Center for Health Statistics,
1999), and this attracted public attention. The occurrence of
several clusters of suicides among children and adolescents
alarmed the general public and stimulated efforts to develop
methods of understanding and preventing youth suicide. A task
force of clinical and research experts was convened by the U.S.
Department of Health and Human Services of the Public
Health Service to develop policies to reduce rates of youth suicide, and its report was published in 1989 (Alcohol, Drug Abuse,
and Mental Health Administration, 1989). By that time, systematic research was being undertaken in several different centers,
and much of the research on suicide in the 1980s and 1990s
focused on suicide in individuals younger than the age of 19.
Epidemiological and phenomenological studies flourished;
efforts at suicide prevention among high school students proliferated, while at the same time substance abuse ratesalmost
certainly an important contributor to suicide in this age group
declined.
It is clear that we have a good deal of substantive information
on the characteristics of suicide victims, less about child and adolescent attempters, and little systematic evidence-based knowledge about the optimal treatment of the suicidal child or
adolescent. There have been very few randomized controlled
trials designed to assess different forms of treatment. As a result,
many of the suggestions for clinical management that are laid
out in these guidelines are based on the experience and observations of clinicians who have treated this common condition. The
clinician should be clear that this is a situation in which there is
an absence of research and not one in which adequate research
has produced ambiguous or negative ndings. It is the impression of many clinicians that the majority of suicide attempters
and their families benet from straightforward interventions dictated by the childs or adolescents mental state and family circumstances.
SUICIDAL BEHAVIOR
SUICIDE
Overall, approximately 2,000 U.S. adolescents (aged 1319

years) commit suicide each year (National Center for Health
Statistics, 2000).
EPIDEMIOLOGY
Age
In 1997, the age-specic mortality rate from suicide for 10- to

14-year-olds was 1.6 per 100,000 (National Center for Health
Statistics, 2000). Although 10- to 14-year-olds represented 7%
of the U.S. population, the 330 child suicides that occurred
among them represented only 1% of all suicides, with most
deaths in this group occurring in youth aged 12 to 14 years.
In 1997, the suicide mortality rate for 15- to 19-year-olds was
9.5 per 100,000 (National Center for Health Statistics, 2000).
That is approximately six times as high as in the younger age
group. The suicide rate among boys was 15.2 per 100,000 and
among girls, 3.4 per 100,000. The proportion of suicides that
occur in this age group (6.6% of the general population)
approaches the proportion of this age group in the general population (6%).
In 1997, the suicide mortality rate for 20- to 24-year-olds
was 13.6 per 100,000 (National Center for Health Statistics,
2000). This age group represents 7% of the total population
but accounts for 8% of all suicides.
Suicide rates (1997) in childhood and adolescence, grouped
by different gender and ethnic groups, are shown in Figure 1.
Gender
In the United States the ratio of male to female suicide in

young children is approximately 3:1, but thereafter the rate
increases rapidly for boys and only slightly for girls, so that
among 15- to 19-year-olds it is 4.5:1 and among 20- to 24year-olds it is greater than 6:1 (National Center for Health
Statistics, 2000).
Secular Changes
During the three decades between the early 1960s and the
late 1980s, the suicide rate among 15- to 19-year-old males
increased 3-fold. The increase was not universal, and there was
little change in the female rate. While the rate among 10- to 14year-olds (National Center for Health Statistics, 1999) has doubled since 1979, the rate is very low, so large proportionate
increases can result from a very small increase in cases (see Fig. 2
for details).
Teen suicide rates have increased for whites and AfricanAmerican males since the early 1960s (National Center for
Health Statistics, 1999). The rate among whites reached a peak in
Fig. 1 Suicide rates per 100,000 population (ages 1024), 1997. Source: National Center for Health Statistics (1999).
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Fig. 2 Adolescent suicide rates per 100,000 population (ages 1519), 19641997. The other groups include all
nonwhites. Sources: National Center for Health Statistics (1999); National Center for Health Statistics (2000).
1987 and has since declined. The African-American male suicide

rate increased dramatically after 1986, but since 1994 it too has
declined. The uctuations in the suicide rate appear to be real,
rather than due to any methodological artifact (e.g., due to
changes in reporting practices), because the rate of undetermined
(whether suicidal or accidental) deaths changed in parallel.
Suggested reasons for the increase in suicidal behavior among
teenage boys are increased availability of rearms (Boyd and
Moscicki, 1986; Brent et al., 1991) and increased substance use
in the youth population (Brent et al., 1987). Brent found that
rearms were twice as likely to be found in the homes of adolescent suicide victims as in the homes of attempters or psychiatric
controls (Brent et al., 1991), and Brent and Kellermann found
that rearms were signicantly more likely to be found in the
homes of those who completed suicide than in the homes of
neighborhood controls (Brent et al., 1993c; Kellermann et al.,
1992). However, it is not known whether, in certain communities, rearm ownership is independently associated with
other risk factors for suicide, and the ndings from Brent and
colleagues studies in the Pittsburgh area have not been replicated with adolescents elsewhere or in other countries.
Loaded guns were particularly potent risk factors for the
small number of suicides without diagnosed psychopathology
(Brent et al., 1993b; Kellermann et al., 1992). Laws restricting
access to rearms are associated with a signicant reduction in
unintentional rearm deaths in youth under 15, but the change
in homicides and suicides is inconsistent (Cummings et al.,
1997; Loftin et al., 1991).
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Although the rate of suicide by rearm increased more than

the rate of suicide by other methods (Boyd and Moscicki, 1986;
Brent et al., 1987), suicide rates increased markedly in many
other countries in Europe, in Australia, and in New Zealand,
where suicide by rearms is rare. In New Zealand, for example,
there has been an alarming increase in hanging. Therefore, there
may be some other factor at play in the worldwide increase in
young male suicides. Although it is possible, it seems implausible that different mechanisms should be coincidentally operating to promote the almost universally observed phenomenon of
increased risk of male youth suicide.
The reasons offered for the recent decline in suicide rates
include lowered substance and alcohol use rates among the
young (Centers for Disease Control and Prevention, 1998) and
greatly increased prescribing of antidepressants to depressed
individuals, with the largest increase in child, adolescent, and
young adult populations (Olfson et al., 1998).
Geography
Suicide rates in the United States are highest in the western

states and Alaska and lowest in the southern, north central, and
northeastern states. The ratio of white to African-American
rates is greatest in the South (Shaffer et al., 1994). Although
regional discrepancies between African Americans and whites
are diminishing, the lowest rates for both African-American and
white suicides remain in the Deep South and the Northeast
(Shaffer et al., 1994).
SUICIDAL BEHAVIOR
Methods
Firearms are the most common method by which Americans

of all ages, ethnicities, and genders commit suicide. However,
there are some signicant differences between genders in the use
of other methods. From 1980 to 1995, firearm suicides increased among young males, with the greatest proportional
increase being among African-American teenage males (300%
increase). The white teen suicide by rearm increase was 29%
(National Center for Health Statistics, 1999).
While Brent et al. (1987) found that autopsies of teenagers
who committed suicide by rearm were ve times as likely to
reveal detectable blood alcohol levels as those of teenagers who
used other suicide methods, this nding was not replicated in
the New York Teen Suicide Study (Fisher et al., 1995). In the
same vein, specic links between method choice and type of
psychopathology (e.g., alcohol abuse) have not been shown.
The methods used to commit suicide show great geographic
variation. This may reflect availability. For example, in the
northeastern United States, an area with strong rearm-control
laws, rearms are used more often in rural areas, where, presumably, more rearms are available for sporting purposes; jumping
from a height is more prevalent in urban areas, with their tall
buildings; and asphyxiation by carbon monoxide exhaust is
most common in suburban areas, where adolescents have access
to cars and garages.
Ingestions account for approximately 16% of 15- to 24-yearold female suicides, but for only 2% of suicides in males that
age (National Center for Health Statistics, 2000).
CLINICAL CHARACTERISTICS OF TEENAGERS
WHO COMMIT SUICIDE
Completed suicide occurs most commonly in older adolescents, but it can also occur in children as young as 6 years old
(Fig. 1). Psychological autopsy studies (Brent et al., 1999;
Marttunen et al., 1991; Shaffer et al., 1996a) show that approximately 90% of adolescent suicides occur in individuals with a
preexisting psychiatric disorder. In approximately half of these,
the psychiatric disorder has been present for 2 or more years.
The most common forms of psychiatric disorder found in
completed suicides are (1) some form of mood disorder, which
in boys is often comorbid with conduct disorder or substance
abuse, and (2) substance and/or alcohol abuse, particularly in
boys older than age 15. Comorbidity between different disorders is common. Many children and adolescents who committed suicide were notably irritable, impulsive, volatile, and
prone to outbursts of aggression. However, this pattern of
behavior is by no means universal. Anxious children without
comorbidity may have shown no overt signs of disturbance,
were often excellent students, and were well liked by peers. The
death of such teenagers often comes as a great surprise to their
relatives and friends, because they were known to be such
good young people. While perfectionism has been proposed

as a risk factor for suicidal ideation (Hewitt et al., 1997), recent
studies have failed to show that perfectionism, as distinct from
anticipatory anxiety, is an independent predictor of suicide.
Although some adolescentspredominantly girls suffering
from a major depressive disorderappear to have thought
about suicide for some time and will often have made some
preparation for their death, most adolescent suicides appear to
be impulsive (Lucas et al., 1995). The suicide is often preceded
by a stress event, such as getting into trouble at school or with a
law enforcement agency, a ruptured relationship with a boyfriend or a girlfriend, or a ght among friends. In many instances, these stress events can be seen as a byproduct of an
underlying mental disorder.
It also appears that a suicide can be precipitatedin presumably already suicidal youthby exposure to news of another
persons suicide or by reading about or viewing a suicide portrayed in a romantic light in a book, magazine, or newspaper
(Bollen and Philips, 1982; Gould and Shaffer, 1986; Hafner
and Schmidtke, 1989).
About a third of suicides have made a previous known suicide attempt (Brent et al., 1999; Shaffer et al., 1996a). Previous
attempts are more common in girls and among suicides suffering from a mood disorder at the time of their death. Suicide
must be distinguished from autoerotic asphyxia, which is
induction of oxygen deciency to enhance sexual excitement
and orgasm (Johnstone and Huws, 1997). However, autoerotic
deaths in teenagers are rare (Shaffer et al., 1996a). When autoerotic deaths do occur, the victims often have other forms of
psychopathology, such as depression and substance abuse
(Sheehan and Garnkel, 1988). It is possible, therefore, that
some autoerotic deaths are misclassied suicides.
Most suicide pacts occur between married couples and/or
other family members. They are most common in the middleaged and elderly population (Brown et al., 1995) and are very
uncommon in young people. Shaffer et al. (1996a) noted only
one suicide pact in 140 consecutive suicides occurring in the
New York/New Jersey/western Connecticut area over a period
of 2 years.
RISK FACTORS FOR SUICIDE
Psychiatric Disorders
Controlled studies of completed suicide suggest similar risk

factors for boys and girls (Brent et al., 1999; Shaffer et al.,
1996a), but with marked differences in their relative importance (Shaffer et al., 1996a).
Girls. The most significant risk factor is the presence of
major depression, which, in some studies, increases the risk of
suicide 20-fold (Shaffer et al., 1996a). The next most important risk factor is a previous suicide attempt, which increases
the risk signicantly.
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Boys. A previous suicide attempt is the most potent predictor, increasing the rate more than 30-fold (Brent et al., 1999;
Shaffer and Craft, 1999). It is followed by depression, substance abuse (alcohol or drugs), and disruptive behavior (Brent
et al., 1993b; Shaffer et al., 1996a).
Disruptive disorders are common in male teenagers who
commit suicide. In the New York (Shaffer et al., 1996a) and
Pittsburgh (Brent et al., 1999) studies, as many as one third of
male suicides had evidence of conduct disorder. The disruptive
disorder was commonly comorbid with a mood, anxiety, or
substance abuse diagnosis. A number of mechanisms may
account for the associations, including early deprivation or
other childhood experiences that predispose to both depression
and antisocial behavior, a temperamental predisposition to violent or impulsive behavior, or the secondary consequences of
the numerous stresses that often occur in the lives of young
people with a disruptive disorder.
Although the rate of suicide is greatly increased in schizophrenia, because of the rarity of the condition it accounts for
very few suicides in the child and adolescent age group. However, mental health professionals who care for individuals with
schizophrenia should be aware of their greater risk for suicide.
Psychosocial Stressors
Stressful life events often precede a suicide and/or suicide

attempt (de Wilde et al., 1992; Gould et al., 1996). They are
rarely a sufcient cause in suicide, and their importance lies in
their action as precipitating factors in young people who are at
risk by virtue of their psychiatric condition.
Controlled studies (Gould et al., 1996; Hollis, 1996) indicate that low levels of communication between parents and
children may act as a signicant risk factor. While family discord, lack of family warmth, and disturbed parentchild relationship are commonly associated with child and adolescent
psychopathology (violent behavior, mood disorder, alcohol
and substance abuse disorders) (Brent et al., 1994b; Pfeffer
et al., 1994), these factors do not play an especially important
role in suicide (Gould et al., 1996).
Cultural Factors
Until recent years, suicide was much more common among

whites than among African Americans at all ages. However, since
1987, the difference in rates between young African Americans
and whites has narrowed (Shaffer et al., 1994). This is because
the suicide rate in African-American and other minority males
has increased rapidly, while the rate among whites has been
steady or has declined. The suicide rates for male 15- to 19-yearolds in 1986 were 18.0 per 100,000 for whites and 7.1 per
100,000 for African Americans, but in 1996 the white male suicide rate declined to 16.3 per 100,000 and the African-American
male suicide rate increased to 11.5 per 100,000. The suicide rate
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for 15- to 19-year-old African-American males increased by

100% in this period, and the suicide rate for 20- to 24-year-old
African-American males increased by 300% (Shaffer et al.,
1994). The ratio of African-American to white suicides has
changed most in the central states, where the African-American
rate had been lowest (Shaffer et al., 1994).
From 1979 to 1992, the Native American male adolescent and
young adult suicide rate in Indian Health Service areas was the
highest in the nation: 62.0 per 100,000 (Wallace et al., 1996).
A number of reasons have been offered to explain the
increase in African-American suicide rates. These include
increased access to rearms in African-American communities.
However, rearm ownership has also increased among women,
and this has not led to a similar increase in the female suicide
rate (Murphy, 1998). Gould and colleagues (1996) found that
African-American adolescents who committed suicide had a
higher mean socioeconomic status than the general AfricanAmerican population. This led to the hypothesis that lowerclass, potentially more traditional and insular African-American
communities might provide an undetermined protective factor.
Other empirically unsupported explanations for the previous
low rate of African-American suicides included better social
support systems among African Americans and a greater sense
of group adherence in a minority, multigenerational support,
and the support provided by largely nonintegrated, insulated
African-American communities (Gibbs, 1997; Shaffer et al.,
1994). Theories contend that as these supports have weakened,
the African-American suicide rate has risen. Yet another explanation has been that ethnic differences in religious beliefs
account for the long-standing differences between AfricanAmerican and white rates, but that increased secularism in
African-American youth has led to a reduction in AfricanAmerican/white differences (Neeleman et al., 1998). Levels of
belief and fundamentalism (rather than the particular religion
ascribed to) have been found to be associated with reduced
acceptance of suicide (Neeleman, 1998) and increased optimism (Sethi and Seligman, 1993), and high levels of spiritual
belief in the African-American community have been correlated with the particularly low suicide rate in particular AfricanAmerican communities (Martin, 1984; Neeleman et al., 1998).
Martin (1984) and Neeleman et al. (1998) found that AfricanAmerican/white differences in suicidal ideation were no longer
present after controlling for spirituality.
When spirituality is controlled for statistically, the risk factors
for young African Americans appear similar to those for white
youth (i.e., long-term depression, substance abuse, and living
alone) (Juon and Ensminger, 1997). However, one should, in
general, be cautious about generalizing about cultural inuences. For example, while some Native American groups have a
suicide rate that is more than 20-fold higher than the nations
average (May, 1987), others have suicide rates equal to or less
than the national average. In some instances, this variability
SUICIDAL BEHAVIOR
could be a function of contagion within isolated groups rather

than a result of differences in beliefs, values, or practices.
Facilitating Factors
Why suicide should be an option for some young people

and not for others remains a mystery. Some of the factors that
may contribute to suicide include the following:
Maladaptive Attributional and Coping Styles. Perceptions of
hopelessness, negative views about ones own competence,
poor self-esteem, a sense of responsibility for negative events,
and the immutability of these distorted attributions may contribute to the hopelessness that has been repeatedly found to
be associated with suicidality.
Biological factors, specically dysregulation of the serotonergic system, are common in adult suicides (Greenhill et al., 1995;
Halperin et al., 1994; Kruesi et al., 1992; Mann, 1998; Mann
and Stoff, 1997; Pfeffer et al., 1998; Pine et al., 1995). Dysregulation is manifest by low levels of serotonin metabolites in CNS
uids, low concentrations of presynaptic serotonergic receptors,
and dense concentrations at postsynaptic receptors. These serotonin abnormalities have been localized to the ventrolateral prefrontal cortex and brainstem of suicide victims and attempters
(in postmortem positron emission tomography studies as well as
in vivo biological challenges) (Arango et al., 1997). This may be
related to polymorphisms in the gene for tryptophan hydroxylase (Amsel and Mann, 2001). If this nding is conrmed, it
could lead to the development of simple blood tests for suicidality. Serotonin appears to inhibit extreme uctuations of mood
and reactivity. The vulnerability to suicide of individuals with
these biological abnormalities may be mediated by impulsivity
and emotional volatility. As the ventral prefrontal cortex plays a
role in behavioral inhibition, it is conceivable that serotonin
irregularities in this area make it more difcult for a suicidal individual to control his or her suicidal impulses (Arango et al.,
1997). Studies to demonstrate the precise behavioral correlates of
serotonin dysregulation proles are still lacking.
Adolescents are not exact biological counterparts of adults.
Preliminary small-sample studies found that three quarters of
adolescent suicide attempters had CSF 5-hydroxyindoleacetic
acid (5-HIAA) concentrations that would indicate severe suicide risk in adults (Kruesi et al., 1988). In addition, these
studies suggest that low CSF homovanillic acid concentrations
might be more predictive in adolescents (Greenhill et al., 1995;
Kruesi et al., 1988). Nordstrom and colleagues (1994) suggested that knowing the biological status of suicide attempters
may have a practical value and that low CSF 5-HIAA concentrations examined shortly after a suicide attempt may differentiate between suicide attempters who will commit suicide or
repeat the attempt within a year and those who will not.
Parental Psychopathology. A family history of suicidal behavior
(Brent et al., 1996a; Gould et al., 1996), parental psychopathology, parental depression, and parental substance abuse (Brent
et al., 1994b; Gould et al., 1996) are all additional risk factors for
teen suicide. Whether these family histories indicate a genetic
vulnerability or environmental stressors, or a combination of the
two, is under study. Family history of suicidal behavior remains a
signicant risk factor when one statistically controls for effects of
parental psychopathology (Brent et al., 1996a).
Social-Psychological Factors. There is an accumulation of evidence that supports the observation that suicide can be facilitated
in vulnerable teenagers by exposure to real or ctional accounts of
suicide (Gould, 2001a; Velting and Gould, 1997), including
media coverage of suicide, such as intensive reporting of the suicide of a celebrity, or the ctional representation of a suicide
in a popular movie or television show. The risk is especially high
in the young (Gould, 1990; Gould et al., 1988; Gould and
Shaffer, 1986), and it lasts for approximately 2 weeks (Bollen
and Philips, 1982).
The phenomenon of suicide clusters, an excessive number of
suicides occurring in close temporal and geographic proximity,
is presumed to be related to imitation (Gould and Davidson,
1988). Suicide clusters often involve previously disturbed young
people who were aware of anothers death but who did not
know the victim personally (Gould, 2001b). Clusters usually
involve adolescents or young adults and account for only 1% to
5% of U.S. teen suicides (Gould et al., 1990a,b).
HIV-Positive Diagnosis and AIDS. It has been suggested that
human immunodeciency virus (HIV) infection increases the
risk of suicide and suicidal behavior in adolescents and young
adults (Cot et al., 1992; Kizer et al., 1988). However,
Dannenberg et al. (1996) found no increase in suicide risk during a median follow-up period of 17 months in HIV-positive
applicants for service in the United States military. Marzuk et al.
(1997) found the proportion of New York City suicides who
were HIV-positive (adjusted for demographic variables) was
higher than the estimated proportion of HIV-positive individuals living in New York City. However, as the information was
determined at autopsy, it was unknown whether all suicides were
aware of their HIV status and whether they had other risk factors for suicide. More than two thirds of HIV-positive suicide
victims had no HIV-related pathology at the time of autopsy,
and the investigators concluded that the high HIV-positive rate
among suicides could be accounted for by other common
underlying risk factors such as substance abuse or alcoholism.
One hypothetical model for how these various risk factors
t together is illustrated in Figure 3.
NONLETHAL SUICIDAL BEHAVIOR: EPIDEMIOLOGY
Suicide attempts involve any behavior that is intended to

end the childs or adolescents life. Nonfatal suicidal acts by
ingestion, with nonlethal intent, are sometimes referred to as
parasuicide. It is estimated that each year, approximately 2 million U.S. adolescents attempt suicide, and almost 700,000
receive medical attention for their attempt (Centers for Disease
Control and Prevention, 1998).
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Fig. 3 This model suggests how suicide occurs and highlights types of targeted preventive interventions.
Suicide attempts in adolescence are approximately twice as

common in females as males (Centers for Disease Control and
Prevention, 1998). In the 1997 U.S. Youth Risk Behavior Survey of approximately 20,000 representational teenagers, suicide attempts were considerably more common in Hispanic
females (14.9%) than in either whites (10.3%) or African
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Americans (9.0%). Attempts were also more common among

Hispanic males (7.2%) than among whites (3.2%) or African
Americans (5.6%).
Suicidal ideation is very common among high school students, with approximately one in four females and one in six
males having seriously considered suicide in a 12-month
SUICIDAL BEHAVIOR
period. Hispanic students of both sexes were significantly

more likely than whites or African Americans to have seriously
considered suicide, made a suicide plan, attempted suicide, or
made an attempt requiring medical attention.
The reasons for the higher rate of suicidal ideation and
attempt behavior in Hispanic youth are not known. In their
longitudinal examination of the Chicago Woodlawn sample,
Juon and Ensminger (1997) found risk factors for suicidal
behavior in African Americans to be very similar to those found
in whites (i.e., depression and substance use and a number of
family variables).
completion method is largely determined by opportunity, but

local customs seem to play a role, for there are quite marked
and stablenational differences in preferred methods.
In assessing suicide-attempt behavior, attention is paid to
the unusualness of the attempt method, its medical seriousness, how often it has been repeated, and the steps taken to
prevent or promote discovery. Repeated attempts, attempts by
unusual methods (i.e., other than ingestions or supercial cutting), and medically serious attempts are predictive of further
suicide-attempt behavior and also seem to be predictive of
ultimate death by suicide (Beck et al., 1974a) (Table 1).
CLINICAL PRESENTATION OF SUICIDAL BEHAVIOR
Risk Factors
The spectrum of severity of suicidal behavior ranges from

suicidal ideation, through suicide threats and suicide attempts,
to completed suicide.
Risk factors for suicide attempts in both genders are mood or

anxiety disorders or substance abuse. Panic attacks in girls and
disruptive behavior in boys increase risk for suicidal ideation or
attempt.
It is very likely that serious family disturbances increase the
risk for attempted suicide. This can be inferred from the high
incidence of suicide in abused children (Brown et al., 1999;
Fergusson et al., 1996; Molnar et al., 1998; Silverman et al.,
1996). Suicidality is also common in runaway teenagers
(Deykin et al., 1985; Kaplan et al., 1997; Molnar et al., 1998;
Shaffer et al., 1996b), who often have a history of previous
child abuse. Child abuse is commonly associated with various
types of psychopathology and substance abuse, and it is not
clear whether the high prevalence of suicidality is a specic
consequence of that psychopathology or is more specically
related to a history of abuse. Physical and sexual abuse appear
to increase the risk of suicide attempt even when other factors
are controlled for (Fergusson et al., 1996; Statham et al., 1998).
Regardless of the mechanisms, a clinician who suspects that a
child or adolescent has been abused should assess past and present suicidal ideation or behavior. Conversely, because the
attributable risk is quite high (between 15% and 20% of female
attempters have a history of abuse), suicide attempters should
routinely be asked about previous or current experience of
physical and sexual abuse.
While there is no evidence that minority sexual orientation is
more common in completed teen suicides than in controls, there
is strong evidence that gay, lesbian, and bisexual youth of both
sexes are signicantly more likely to experience suicidal ideation
and attempt suicide. Research in ve sizable community samples
has demonstrated increased risk (Faulkner and Cranston, 1998;
Fergusson et al., 1999; Garofalo et al., 1998; Lock and Steiner,
1999; Remafedi et al., 1998). The increased risk for suicidal ideation and attempt behavior ranges from 2-fold (Faulkner and
Cranston, 1998) to 7-fold (Remafedi et al., 1998). Gay, lesbian,
and bisexual youths were also signicantly more likely to make
attempts requiring medical attention. Gay, lesbian, and bisexual
youths were shown in these studies to carry a number of risk fac-
Suicidal Ideation
Suicidal ideation includes thoughts about wishing to kill

oneself; making plans of when, where, and how to carry out
the suicide; and thoughts about the impact of ones suicide on
others. Not all young children appreciate that suicide may
result in irreversible death. There is no denite milestone for
understanding the irreversibility of death, which depends to a
large extent on what the child has been taught at home and on
the childs own experiences of death and illness. A childs
appreciation of the finality of death should not necessarily
inuence the clinician in judging the seriousness of suicidal
ideation. For example, a child who believes that someone who
dies returns to life a few hours later may be prone to engage in
self-harming behavior, not understanding the long-term consequences of the behavior.
Suicide Threats
Suicide threats are utterances made to others that indicate an

intent to commit suicide. They may be accompanied by
actions to initiate a suicide plan. In young children and adolescents, these are most commonly threats to jump out of a window (usually made when the child is near a window), to run
into trafc, or to stab himself or herself.
Methods of Attempt
The large majority of known suicide attempts in the United

States are by ingestions, most commonly of over-the-counter
analgesics, but the incidence of acts such as hanging, which if not
successful may not lead to a medical referral, is not known. Other
common attempt methods include supercial cutting of the arms
or neck, and, again, the prevalence of this is not known. Less
common methods include attempts by the child or teenager to
hang himself or herself, jump from a height, stab himself or herself, drown, or self-immolate. The choice of both attempt and
35S
tors for suicidal behavior, including high rates of drug and alcohol use, and were more likely to partake of substances earlier and
more frequently. Gay, lesbian, and bisexual youth were also more
likely to be bullied and victimized at school. The degree of association between sexual orientation and youth suicidal behavior
requires further study to determine effects when other risk factors, such as alcohol or substance use and family difculties, are
controlled for statistically.
Differences Between Completed and Attempted Suicide
Most of our knowledge about the clinical features of suicide

attempters and the methods used by suicide attempters is drawn
from cases seen in emergency rooms and clinics. The kind of
case that presents most commonly is a 15- to 17-year-old girl
who has taken a small- or medium-sized overdose of a readily
available medication, most commonly an over-the-counter
analgesic or available medication taken by another family
member. The behavior is usually impulsive and occurs in the
context of a dispute with family or boyfriend or girlfriend.
We do not know how typical this prole is, because it is only
very recently that investigators have started to collect information from community-based studies. These studies indicate
that the suicide attempt rate among boys is considerably higher
in the community than among patients who present in the
emergency room. One of the reasons for this may be that the
female-preferred methoda nonlethal ingestiondoes not
take immediate effect and is treatable. If the patient changes his
or her mind or admits to the attempt, he or she will nearly
always seek medical treatment for the medical effects of the
overdose. However, it seems likely that many boys attempt to
hang themselves and fail, and only rarely do they then seek or
need medical treatment. Our knowledge of the differences
between referred and nonreferred suicide attempters is limited
largely to demographic information, and clinical differences still
need to be described in greater detail.
Studies that have compared completed suicides with suicide
attempts have examined clinical cases and, after controlling for
gender, they have failed to show significant differences.
However, too much should not be made of these negative ndings, because serious attempters requiring inpatient care are
unlikely to be representative of suicide attempters in general.
There have been very few risk-factor comparisons between
completed and attempted suicides (Brent et al., 1988; Gould
et al., 1998; Shaffer et al., 1996a). Brent et al. found attempters
less likely than completers to be bipolar, have a rearm in the
home, have high suicidal intent, or have combinations of
mood and nonmood disorders. When suicide attempters and
suicides are compared, the attempters need to be drawn from a
geographically dened nonreferred sample, similar to the type
usually used in psychological autopsy studies of suicides. Two
attempter studies of that type (Andrews and Lewinsohn, 1992;
Gould et al., 1998) found broadly similar diagnostic proles to
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those reported in suicide completers (Shaffer et al., 1996a;

Brent et al., 1993a). Failure to nd robust differences between
the two groups may reect the requirement in some studies
that the attempted-suicide controls be people who made
serious attempts.
NATURAL HISTORY
Little is known about the natural history of suicidal behavior, but early onset of suicidal behavior in prepuberty predicts
suicidal behavior in adolescents (Pfeffer et al., 1991, 1993)
and early onset of major depressive disorder is associated with
suicidal behavior in adolescents (Kovacs et al., 1993) and
adults (Harrington et al., 1994; Rao et al., 1993). Attempts to
predict at the time of the rst attempt which adolescents are
likely to repeat their suicidal behavior have not been successful
(Goldston et al., 1996; Stein et al., 1998).
DEVELOPMENTAL FEATURES
Developmental factors are signicant mediators of the clinical presentation of suicidal behavior in children and adolescents
and are reflected in the epidemiology of suicidal behavior.
Suicidal behavior has been reported among preschool children
despite their immature cognitive appreciation of the nality of
death (Pfeffer and Trad, 1988; Rosenthal and Rosenthal, 1984).
Various suicidal methods are used by suicidal children and adolescents, but the younger the child, the less complex and the
more easily available are the methods used to enact suicidal
impulses. Differences between suicidal ideators and suicide
attempters are least marked for younger children (Carlson et al.,
1994). For example, suicidal ideation and suicide attempts
among prepubertal children both predict suicide attempts in
adolescence (Pfeffer et al., 1993). Social adjustment problems of
young suicide attempters consist mainly of disturbed intrafamilial relationships in prepubertal children, while peer-related
conicts are the most common among adolescents.
The modal ages of onset of the psychiatric symptoms and disorders that increase risk for suicidal behavior in adolescents (such
as major depression, substance abuse, bipolar disorder, schizophrenia, and personality disorders) vary across adolescence, with
all being more common in older adolescents. This may be the reason for the relative rarity of suicide in childhood and adolescence.
Suicide becomes increasingly common with age, reaching a peak
between the ages of 19 and 23 years. Adult suicide attempters are
eight times more likely than adolescent attempters to commit suicide during the rst 312 years after discharge from a psychiatric
hospital (Safer, 1997).
ASSESSMENT
Assessment of suicidal patients requires an evaluation of the

suicidal behavior and determination of risk for death or repetition as well as of the underlying diagnosis or promoting factors.
SUICIDAL BEHAVIOR
ASSESSMENT OF THE ATTEMPT
Determine the type of method used in the suicide attempt

(more unusual attempts, i.e., method other than cutting or
small ingestion, carry a worse prognosis), the potential medical
lethality (not always a reliable predictor; some seriously suicidal
children and teenagers are poor judges of lethality), the degree
of planning involved, and the degree to which the chance of
intervention or discovery was minimized (signifying higher
intent). Previous suicide attempts make a further attempt more
likely; a pervasive and frequent degree of current suicidal ideation also denotes greater seriousness and a greater likelihood of
an associated mental illness. Availability of rearms or lethal
medications should be ascertained, and a recommendation for
removal or more secure storage should be made (Brent et al.,
1988) as an imperative part of assessment.
ASSESSMENT OF THE SUICIDAL IDEATOR
The key question is whether the child or adolescent is contemplating or has attempted suicide without anyones knowledge. Children and adolescents may be asked the following
diagnostic questions (Jacobsen et al., 1994):
Did you ever feel so upset that you wished you were not
alive or wanted to die?
Did you ever do something that you knew was so dangerous that you could get hurt or killed by doing it?
Did you ever hurt yourself or try to hurt yourself?
Did you ever try to kill yourself?
Did you ever think about or try to commit suicide?
Evaluating the presence and degree of suicide intent is a
complicated matter. Suicide intent involves a balance between
the wish to die and the wish to live (Beck et al., 1974a). Some
aspects of this address severity of the behavior, the efforts
made to conceal the behavior and avoid discovery, and the formulation of specic plans (e.g., Did you do anything to get
ready to kill yourself? Did you think what you did would kill
you?). However, children and adolescents systematically
overestimate the lethality of different suicidal methods, so that
a child or adolescent with a significant degree of suicidal
intent may fail to carry out a lethal act.
Another approach in assessing suicidal intent is to evaluate
motivating feelings, for example, the wish to gain attention, to
effect a change in interpersonal relationships, to rejoin a dead
relative, to avoid an intolerable situation, or to get revenge. If
these motivations have not been satised by the time of the
evaluation, serious suicidal intent may still be present.
RISK FACTORS FOR REPEATED SUICIDE ATTEMPT
OR SUICIDE
Factors that increase the risk of subsequent suicide attempts

and/or suicide after a recent attempt are shown in Table 1 and
include male gender, increasing age, living alone (i.e., run-
away, homeless, or isolated), having made previous attempts,

attempts with a method other than by ingestion or supercial
cutting, and having taken steps to avoid detection. There is
also a greater short-term risk of suicide if the current mental
state is abnormal.
ASSESSMENT OF THE UNDERLYING CONDITIONS
The conditions that lead to suicidal behavior include psychiatric diagnosis; social or environmental factors such as isolation, anger, and stress; cognitive distortions that accompany
depression, particularly hopelessness, which may also be an indicator of treatment dropout (Brent et al., 1997); and inappropriate coping styles (e.g., impulsivity or catastrophizing). A
history of family psychopathology, especially of suicidal behavior, bipolar illness, physical or sexual abuse, or substance abuse,
may give an indication of risk and of areas that will require
intervention (Fergusson and Lynskey, 1995a,b; Pfeffer et al.,
1994). Family discord and other life-event stresses involving
interpersonal relationship problems also require assessment.
Psychiatric diagnoses that are commonly associated with
suicidal behavior include depression, mania or hypomania,
mixed states or rapid cycling, or substance abuse. Patients who
are irritable, agitated, delusional, threatening, violent, deluded,
hallucinating, or voice a persistent wish to die pose a greater
short-term risk.
A history of rapid mood shifts, from brief periods of depression, anxiety, and rage, to euthymia and/or mania, which may
be associated with transient psychotic symptoms, including
paranoid ideas and auditory or visual hallucinations, has been
held to be strongly associated with a risk for further suicide
attempts. Diagnosing such adolescents is complex, and clinicians often use various diagnoses, including major depressive
disorder with psychotic features, bipolar disorder, schizoaffective disorder, and borderline personality disorder, to characterize adolescents with this broad array of symptoms.
Recurring suicidal behavior has been associated with hypomanic personality traits (Klein et al., 1996) and cluster B personality disorders (Brent et al., 1993a, 1994a). The personality
disorder that is most often diagnosed is borderline personality
disorder (Corbitt et al., 1996). The DSM-IV criteria for this
disorder include onset in early adulthood, repeated suicide
attempts, nonlethal forms of self-injury, and a pervasive pattern of impulsivity which, after controlling for a lifetime history of depression and substance abuse, appears to be strongly
associated with suicidality (Brodsky et al., 1997). Other criteria
include unstable mood, unstable interpersonal relationships
(that may alternate between idealization and denigration), varying concepts of self (which oscillate between grandiosity and
worthlessness), dissociative symptoms, irritability, and behavior that, while pleasurable, can also be self-damaging (e.g.,
excessive spending, impulsive sexual activity, dangerous driving). Many of these symptoms are also features of bipolar ill-
CHI July 2001 (Supplement), Shaffer, article #87486, 4 tables, 3 figures
37S
ness and other mood disorders, and whether or not borderline

personality disorder is a form of bipolar or other mood disorder remains an open question.
Gathering information from multiple sources and by varied
developmentally sensitive techniques is essential in evaluating
suicidal risk indicators. This may include interviews, play and
behavior observation, and use of standard, reliable, valid rating
scales. The reliability and validity of interview reporting of children and adolescents may be affected by their level of cognitive
development, which may inuence their reports of time and
cause, and by the type and intensity of emotions and severity of
psychological distress at the time of interview, which may inuence their memory of suicidal intent and their understanding of
the relationship between their emotions and behavior (Carlson
et al., 1994; Jacobsen et al., 1994). Conrmation of the childs
or adolescents suicidal behavior can be obtained from information gathered by interviewing others who know the child or
adolescent. However, there is often a disparity between child
and parent reports, with both children and adolescents being
more likely to tell of suicidal ideation and suicidal actions than
their parents (Brent et al., 1986).
SPECIALIZED SUICIDE SCALES AND
OTHER INSTRUMENTS
Self-administered suicide scales are useful for screening normal, high-risk, and patient populations. They cannot substitute for a clinical assessment, and their tendency is to be
oversensitive and underspecic. At this point, suicide scales
alone do not have a predictive value. A child or adolescent who
is positive on a suicide scale should always be assessed clinically.
Most scales have not been tested adequately in a child or adolescent population (see Garrison et al., 1991, and Goldston,
2000, for more information on individual scales). Table 3 lists
scales measuring suicidality, intent, or potentiality.
TREATMENT
PRINCIPLES OF TREATMENT
The successful treatment of suicidal children and adolescents depends on a number of factors, with safety considerations being of overriding importance (Pfeffer, 1990, 1997).
Because of the need to respond to a suicidal crisis, treatment
should ideally be provided within a wrap around servicedelivery system that includes resources for inpatient, shortand long-term outpatient, and emergency intervention
(Rotheram-Borus et al., 1996c).
ACUTE MANAGEMENT
The child or adolescent who has attempted suicide should

be hospitalized if his or her unstable condition makes behavior
unpredictable, indicating at least short-term serious risk.
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Mental status features predictive of short-term difficulty

include the inability to form an alliance with the clinician, a
lack of truthfulness or inability to discuss or regulate emotion
and behavior, psychotic thinking, current intoxication from
drugs or alcohol, or multiple previous serious suicide attempts.
Diagnostic features indicating the need for hospitalization
include major depressive disorder with psychotic features,
rapid cycling with irritability and impulsive behavior, psychosis
with command hallucinations, and alcohol or substance abuse.
Social factors affecting the decision to hospitalize a child or
adolescent include a lack of sufcient environmental support
to help stabilize the childs or adolescents psychiatric state.
The clinician should ask himself/herself whether the patient
can form an alliance to report suicidal intent or suicidal plans.
Can the clinician identify and decrease potential sources of
noncompliance, provide adequate family psychoeducation to
limit family conflicts and aberrant communication, reduce
social-skill and problem-solving deficits, and focus on cooccurring psychopathology (Berman and Jobes, 1991; Brent,
1997; Brent and Perper, 1995; Piacentini et al., 1995)? Being
aware of ones limitations in prediction and inuence over the
family and patient will promote a cautious approach.
EMERGENCY OR CRISIS-SERVICE INTERVENTION
AND TRIAGE DECISIONS
Children and adolescents with acute suicidal ideation or suicide attempts are frequently rst evaluated and treated in an
emergency service. It is here that the mental health professional
provides the important triage function of referring suitable
patients for subsequent treatment. Children and adolescents
should never be discharged from the emergency service without
the childs or adolescents caretaker having veried the childs or
adolescents account (Table 4). The caretaker also should be
seen to discuss making rearms and/or lethal medications inaccessible to the child (Kruesi et al., 1999). There is empirical evidence that unless this discussion is held, parents will not, on
their own initiative, take the necessary precautions (McManus
et al., 1997). Parents are more willing to secure rearms than to
remove them. Limiting the adolescents access to alcohol or
other potentially disinhibiting substances should also be discussed with the adolescent and family. Before discharge, the clinician must have a good understanding of the amount of
support that will be available for the child or adolescent if discharged to home. The clinician should recognize that treatment
recommendations are more likely to be followed if they match
the expectations of the family, if they are economically feasible,
and if the parent is well and available enough to support attendance. The familys experience in the emergency room may also
color the referral process (Rotheram-Borus et al., 1996a,b).
Rotheram-Borus et al. (1996b) described a brief emergency
room crisis intervention procedure for adolescent attempters
that resulted in improved compliance for at least the rst out-
Author
Adolescents
(adaptation for
Linehans 1985 Reasons
for Living Inventory
[RFL])
6- to 17-yr-olds
Osman et al., 1998
Pfeffer et al., 1979
Reynolds, 1991
Beck et al., 1979a
Beck et al., 1974a
Child Suicide Potential

Scale (CSPS)
Suicide Potential
Interview (SPI)
Scale for Suicide

Ideation (SSI)
Suicidal Intent Scale (SIS)
Clinician-administered instruments
Not yet studied in

adolescents or children
Limited research on
adolescents
11- to 18-yr-olds
6- to 12-yr-olds
Ages 14+
Tatman et al., 1993
Suicide Probability
Scale (SPS)
Reasons for Living
Inventory for
Adolescents (RFL-A)
Pfeffer et al., 2000
Adolescents
Reynolds, 1987
Suicidal Ideation
Questionnaire (SIQ)
Child-Adolescent
Suicidal Potential
Index (CASPI)
Adolescents
Shaffer et al., 1996b
Columbia Teen
Screen (CTS)
Children and adolescents
Kazdin et al., 1986
Adolescents
Ages
Hopelessness Scale
for Children (HSC)
Self-completion by child or adolescent

Beck Hopelessness
Beck et al., 1974b
Scale (BHS)
Scale
Measures intent to die in suicide

attempters
Measures frequency, intensity, and

duration of suicidal ideation
Evaluates suicide risk
Assesses suicidal behaviors and

risk factors
Assesses risk for suicidal

behavior
Measures life-afrming, adaptive

beliefs, which may distinguish
suicidal from nonsuicidal
Clinical index of suicide risk
Screens 11- to 18-yr-old students

for suicidal behavior, ideation,
and risk factors
Measures frequency and severity
of suicidal ideation in 11to 18-yr-old students
Assesses hopelessness
Assesses hopelessness
Purpose
15 items
4 pages,
19 items
17 pages
(battery of
8 scales)
4 pages,
22 items
30 yes/no items
14 items
30-item
(high school)
or 15-item
(junior high)
1 page
26 items
17 true/false
items
20 true/false
items
Length
TABLE 3
Instruments That Measure Child and Adolescent Suicidality
Diagnostic,
research,
screening
Clinical,
diagnostic,
research,
screening
Clinical,
research
Clinical,
research
Clinical,
research,
screening
Clinical,
research,
screening
Clinical
Clinical,
research,
screening
Clinical,
research,
screening
Clinical,
screening,
research
Research,
screening
Domains
Given to child and parent
Excellent reliability and

validity
Validity in adolescents
not shown
Gives clinician a blueprint
for beginning treatment
Cutoff points and validity

being tested (see Spirito
et al., 1988b)
High sensitivity
and specicity
Notes
SUICIDAL BEHAVIOR
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TABLE 4
Checklist Before Discharging an Adolescent
Who Has Attempted Suicide
Before discharging a patient from the ER or crisis center, always:
Caution patient and family about disinhibiting effects of drugs or
alcohol
Check that rearms and lethal medications can be effectively
secured or removed
Check that there is a supportive person at home
Check that a follow-up appointment has been scheduled
patient follow-up visit. The aim of the intervention was to provide a good experience between the family and emergency service staff, set realistic expectations about follow-up treatment,
and obtain a commitment from the adolescent suicide
attempters and their relatives to return for further evaluation. It
included a series of emergency room staff training sessions to
reduce staff perceptions that the family was to blame for the
teenagers behavior and to encourage staff to explain emergency service procedures to the patient. A videotape was shown
to the attempter and family to increase their understanding of
adolescent suicidal behavior and its treatment. Finally, a family
treatment session was provided by a crisis therapist who negotiated a contract with the suicidal adolescent and family and
who served some case management functions between the
family and the follow-up treatment provider. The research was
not able to identify which of these components led to an
increase in initial compliance.
There should always be a detailed discussion with the patient
and family about the specic issues or situations that might promote further suicidal behavior if stress is unavoidable and the
type of coping behavior that can be used to obviate a further
attempt. Helping the family to identify potential precipitants,
beginning to problem-solve on how to prevent reoccurrence, is
really the beginning of treatment. If the patient and family cannot effectively do this, it becomes a matter of concern. A written
or verbal no-suicide contract is commonly negotiated at the
start of treatment in the hope that it will improve treatment
compliance and reduce the likelihood of further suicidal behavior (Brent, 1997; Rotheram, 1987). The no-suicide contract can
be used as a probe to understand the patients and familys ability to institute change. However, the clinician should know that
there have been no empirical studies that have evaluated the efcacy of a contract (Reid, 1998). The usual form of a contract is
that the child or adolescent should promise not to engage in suicidal behavior and should inform the parents, therapist, or other
responsible adult if he or she has thoughts of suicide or develops
plans to commit suicide (Simon, 1991). It is hoped that a contract will increase the patients and familys commitment to
treatment, but it should never substitute for other types of intervention. If there is a disturbance of mental state, the clinician
should never rely on a no-suicide contract (Egan et al., 1997;
Fergusson and Lynskey, 1995b).
40S
Limitations must be considered when using a no-suicide

contract (Miller et al., 1998). It should be used only if a comprehensive assessment of the suicidal patients mental state
and a consideration of the developmental state indicate that the
patient understands the commitment. It should not be seen as
more than an adjunct to the management of patients with low
intent. Even if the patient agrees to such a contract, suicide risk
may persist. It should also be appreciated that a no-suicide contract may lessen a patients communication of stress and dysphoria, decrease the potential for developing a therapeutic alliance,
and impair risk management. Coercive communications, such
as unless you promise not to attempt suicide, I will keep you in
the hospital or tell your parents about your behavior, should be
avoided, because this may encourage deceit and deance.
Treatment compliance may be improved by offering denite,
closely spaced follow-up appointments, being exible in arranging appointments if a crisis should arise, and reminding the
family and patient by telephone or note about the next appointment. If an appointment is missed, the patient and parent
should be contacted. Hopeless and depressed children and adolescents, who may be not be able to commit to a lengthy treatment process, may be better engaged by offering short-term
treatment plans with dened intervention goals. While offering
condentiality for some issues, it is essential that the clinician
communicate to the patient that if the clinician feels that suicidal thinking or behavior is imminent, such information will
be shared with the parents.
INPATIENT CARE AND PARTIAL HOSPITALIZATION
There is no evidence that exposure to other suicidal psychiatric inpatients will increase the risk of suicidal behavior (King
et al., 1995). Determining when a patient is ready for discharge from the hospital or crisis center will usually include an
evaluation of the severity of existing suicidal ideation and
intent. Implicit coersions, e.g., telling the patient that he/she
will not be discharged until he/she can state that he/she is not
suicidal, should be avoided. Attention to clearly dysfunctional
family patterns or parental psychiatric illness may improve the
childs or teenagers later outpatient care (King et al., 1997).
Partial hospitalization offers intensive multidisciplinary treatments and skilled observation and support. It can be a good
alternative to acute psychiatric hospitalization if the child or adolescent is considered to be disturbed but containable in a supportive home or other residential setting. Partial hospitalization may
provide more time than acute hospitalization to stabilize the
emotional condition and address environmental stresses and
problems. It may be used as a step-down from acute psychiatric
hospitalization.
OUTPATIENT TREATMENT
Outpatient treatment should be used when the child or adolescent is not likely to act on suicidal impulses, when there is
SUICIDAL BEHAVIOR
sufcient support at home, and when there is someone who can

take action if the adolescents behavior or mood deteriorates.
SPECIFIC PSYCHOTHERAPIES
Suicidal children and adolescents report feeling intense, painful, and distressing depression and worthlessness; anger; anxiety; and a hopeless inability to change or nd a solution to
frustrating circumstances (Kienhorst et al., 1995; Ohring et al.,
1996). They may respond impulsively to their sense of desperation by attempting to commit suicide. Psychotherapeutic techniques aim to decrease such intolerable feelings and thoughts
and to reorient the cognitive and emotional perspectives of the
suicidal child or adolescent (Kernberg, 1994; Spirito, 1997).
Working with suicidal children and adolescents is best done by
a clinician who is available to the suicidal patient and family, has
skill and training in managing suicidal crises, relates to the
patient in an honest and consistent way, can objectively understand the suicidal patients attitudes and life problems, and conveys a sense of optimism and activity (Katz, 1995; Pfeffer,
1990). Given these personal attributes, the therapist may use
various models of psychotherapy, although relatively few empirical studies have evaluated their efcacy.
Cognitive-Behavioral Therapy
Suicidal children and adolescents often experience negative

cognitions about themselves, their environment, and their
future. Cognitive-behavioral therapy (CBT) has been shown to
be an effective intervention for depressive symptoms (Clarke
et al., 1999; Elkin et al., 1989; Shea et al., 1992; Weissman,
1979). Experience with teenagers is much more limited. In a single set of studies, short-term CBT appeared to be more effective than family or supportive therapy (Brent et al., 1997) in
depressed teenagers. But after 2 years, differences between the
groups were no longer apparent (Birmaher et al., 2000). The efcacy of CBT in suicidal adolescents has not yet been examined,
but in the above studies all therapies reduced suicidal ideation.
Brent and colleagues created a CBT treatment manual (Brent
and Poling, 1989, revised 1997), modifying the approach of
Beck and colleagues (1979b) for depressed adolescents. The
treatment comprised 12 to 16 weekly sessions followed by a 6month booster phase of monthly or bimonthly sessions.
Parents and adolescents received a psychoeducational manual
about mood disorders and their treatments and were offered a
session just to discuss these issues. The active intervention was
described as a collaborative guided discovery to monitor and
modify automatic thoughts, assumptions, and beliefs (Brent,
1997). Concrete examples were used to illustrate the cognitivebehavioral treatment model that involves exploring concerns
about autonomy and trust, cognitive distortions, and negative
self-concepts, attributions, and cognitions.
Since suicidal individuals are thought to often have difculty
in communicating and negotiating their needs and wishes
(McLeavey et al., 1994) and to frequently resort to passive avoidant coping strategies (Adams and Adams, 1991), Brents treatment model encouraged more assertive and direct methods of
communicating, as well as increasing the teenagers ability to
conceptualize alternative solutions to problems. Meetings with
parents were sometimes held to augment the treatment. Brent
(1997) advocates adjunctive use of psychopharmacology if
depressed adolescents have not improved after 4 to 6 weeks of
cognitive-behavioral treatment.
Brents study provides no evidence of the efcacy of CBT
for teenagers who had made a suicide attempt, who were not
included in this study. However, the intervention was reported
to be as effective as systemic family therapy and nondirective
supportive therapy in reducing suicidal ideation in depressed
adolescents (Brent et al., 1997) during the 12- to 16-week treatment period.
Interpersonal Psychotherapy
Suicidal behavior in children and adolescents is frequently

associated with interpersonal conict, and treatment of this
may reduce suicidal risk.
Interpersonal psychotherapy (IPT) is a time-limited psychotherapy that addresses interpersonal problems, which are categorized into issues of loss, interpersonal role disputes, role
transitions, and interpersonal decits. It was originally developed
for major depression (Klerman et al., 1984) and was designed to
be administered over 12 to 16 weeks. Mufson and Moreau have
modied it for use with depressed adolescents (Mufson et al.,
1999) and found it more effective than a control therapy. The
treatment may be appropriate for suicidal depressed adolescents
with interpersonal problems.
IPT focuses on current interpersonal relationships and on
the immediate social context. Unlike CBT, which addresses the
distortions of thinking that may provoke maladaptive behavior, IPT focuses on the style and effectiveness of interpersonal
interactions. The adolescents treatment is administered weekly
over 12 weeks. Frequent telephone contacts are maintained
with adolescent patients, and parents are often involved.
The initial phase involves an evaluation of symptoms, diagnosis, and history of interpersonal relationships. Special attention is paid to changes in relationships immediately prior to the
onset of depressive symptoms. The therapist educates the
patient about the symptoms of depression and places the symptoms within a framework of interpersonal distress, such as reactions to loss, interpersonal role disputes (conflicts with a
signicant other person), role transitions (change in life status,
such as change of grade or school, moving, change in a relationship), and interpersonal decits (lack of social skills that lead
to problems starting and sustaining interpersonal relationships). Some of the interpersonal issues for adolescents that are
addressed by IPT-A include separation from parents, conicts
with parental authority, development of close relationships with
41S
members of the opposite sex, initial experience with death of a

relative or friend, and peer pressures. Specic issues of adolescents living in single-parent households are addressed (Mufson
et al., 1993), and the family may be included in the treatment.
The middle phase addresses the patients own interpersonal
problems. The therapist supports efforts to decrease the
patients pessimism and efforts to achieve new solutions to
interpersonal dilemmas. The treatment emphasizes options for
change that had been precluded by symptoms of depression.
The termination phase supports the patients newly achieved
and recognized independence in managing interpersonal concerns. It aims to assist the patient in recognizing and diminishing effects of future depressive symptoms.
Mufson and colleagues (1993) caution that IPT for adolescents was developed for nonpsychotic, nonsuicidal depressed
adolescents. However, it is a useful treatment for addressing the
adolescents use of suicidal behavior as a method of communicating anger, distress, or resolving conict, and its ability to
help adolescents with suicidal ideation will depend on the adolescents ability to establish a therapeutic alliance and commit
to informing the therapist about suicidal preoccupations and
intent and going to an emergency service if necessary.
Dialectical-Behavioral Therapy
Dialectical-behavior therapy (DBT) is the only form of psychotherapy that has been shown in a randomized controlled
trial to reduce suicidality in adults with borderline personality
disorder (Linehan, 1993a,b). This treatment is based on a biosocial theory in which suicidal behaviors are considered to be
maladaptive solutions to painful negative emotions (Linehan,
1993a) but that also have affect-regulating qualities and elicit
help from others (Linehan, 1993a).
The treatment involves developing problem-oriented strategies
to increase distress tolerance, emotion regulation, interpersonal
effectiveness, and the use of both rational and emotional input to
make more balanced decisions (Linehan, 1993b). It usually
involves individual and group sessions over the course of a year.
Recently, a modied and manual-based form of this treatment was used with suicidal adolescents with a diagnosis of borderline personality (Miller et al., 1997). DBT for adolescents
(DBT-A) required the participation of a relative in the skills
training group who was charged with improving the home
environment and teaching other relatives to model and reinforce adaptive behaviors for the adolescent. DBT-A has been reduced from 1 year to two 12-week stages, covers fewer skills,
and uses simpler language for skills training. In a nonrandomized comparative-treatment study with adolescents who were
suicidal and diagnosed as borderline, there was a suggestion that
DBT-A is acceptable to teenagers and reduces rates of psychiatric hospitalization (Miller et al., 1997).
The treatment comprises four components or modules: (1) a
Core Mindfulness Skills module to diminish identity confusion
42S
and self-dysregulation; this includes teachings of Zen meditation

to enhance emotional control; (2) an Interpersonal Effectiveness
Skills module to enable interpersonal problem-solving through
assertiveness training and to make the adolescent more aware of
his or her goals in an interpersonal situation; (3) a Distress
Tolerance module to reduce impulsivity by teaching acceptance
and tolerance of painful situations with self-soothing and distraction from pain and by generating ideas about the positive
and negative aspects of painful situations; and (4) an Emotion
Regulation Skills module to identify emotions, reduce emotional
vulnerability, and increase positive events.
Individual therapy is given weekly and focuses on reviewing
a weekly diary documenting suicidal and self-destructive
behavior, behaviors that interfere with treatment and quality of
life, and use of new skills. The therapist conducts a behavioral
analysis of each behavior problem with the goal of understanding its function and the situations that provoked it, identifying
constructive solutions, and avoiding problems. During the rst
12 weeks of treatment, telephone consultations with the therapist include discussions about skills that may be useful to
decrease suicidal behaviors, report positive behaviors and
events, and resolve conicts with the therapist.
In the second 12 weeks of treatment, patient consultation
groups focus on adolescents helping each other to utilize skills
to cope with life circumstances.
Psychodynamic Psychotherapy
Conict resolution is a basic issue in psychodynamic psychotherapy. It aims to resolve internal conicts related to early experiences with rejection, severe discipline, and abuse. It also aims
to improve self-esteem by enabling suicidal children or adolescents to become more self-reliant and less inhibited by the belief
that they are responsible for creating their problematic circumstances. There are no studies that address the efcacy of this
approach, which is probably the most commonly administered
form of therapy and seems to encourage long-term involvement
by the child or adolescent patient.
Family Therapy
As indicated above, family discord, poor communication,

disagreements, lack of cohesive values and goals, and irregular
routines and activities (Miller et al., 1992) are common in suicidal children and adolescents, who often feel isolated within
the family. Some have suggested that they view themselves as
expendable to the family and that this is a motivating force for
self-annihilation (Miller et al., 1992; Pfeffer, 1986; Sabbath,
1969). Family intervention may decrease such problems,
enhance effective family problem-solving and conflict resolution, and reduce blame directed toward the suicidal child or
adolescent. Family-based cognitive therapy aims to reframe the
familys understanding of their problems, to alter the familys
maladaptive problem-solving techniques, and to encourage
SUICIDAL BEHAVIOR
positive family interactions (Rotheram-Borus et al., 1994).

Harrington et al. (1998) found that a time-limited home-based
intervention for suicidal children and adolescents had limited
efcacy for children and adolescents without major depressive
disorder. Psychoeducational approaches can help parents clarify their understanding of childhood and adolescent suicidal
behavior, identify changes in mental state that may herald a
repetition, and reduce the extent of expressed emotion or anger
(Brent et al., 1993d). The clinician can harness the power of the
family to help restrict access to lethal medication and rearms
and to convey the importance of treatment.
PSYCHOPHARMACOLOGICAL INTERVENTIONS
In meta-analyses of adult studies, Tondo and colleagues

(1997) found that lithium maintenance treatment greatly
reduces (8.6-fold) the recurrence of suicide attempts in adults
with bipolar or other major affective disorders. Furthermore,
when lithium is discontinued there is a 7-fold increase in the
rate of suicide attempts and a 9-fold increase in the rate of suicide. Tondo et al. noted that the effects of lithium on reducing
suicidal risk may be unique and may be due to its central serotonin-enhancing qualities. However, lithium prescriptions for
children and adolescents require careful third-person supervision, as overdoses may be lethal.
Other mood stabilizers, such as valproate and carbamazepine, are also widely used to treat bipolar disorders in children
and adolescents, although their efcacy has yet to be empirically demonstrated. However, as with adults, depressed suicidal
children and adolescents with a history of bipolar disorder
should rst be treated with a mood stabilizer before receiving
an antidepressant.
If lithium efficacy is eventually shown in adolescents,
research will also be needed to determine the length of time
necessary to treat suicidal children and adolescents. Psychopharmacological treatment can also be given for the associated
disorders that are frequently present, although there is no evidence that this reduces the risk of later completed or attempted
suicide. Furthermore, one must be careful about the risk of
inducing suicidal ideation or behavior through psychopharmacological activation or disinhibition.
Studies in depressed adults have found that selective serotonin
reuptake inhibitors (SSRIs) reduce suicidal ideation (e.g., Letizia
et al., 1996) and separately reduce the frequency of suicide
attempts in nondepressed patients with cluster B personality disorders and a history of suicide-attempt behavior. In a controlled
trial of the depot neuroleptic upenthixol, Montgomery and
Montgomery (1982) noted a signicant reduction in suicideattempt behavior in adults who had made numerous previous
attempts. Similar studies have yet to be conducted on adolescents, although trials of SSRIs in depressed adolescents indicate
that these drugs are safe and effective in treating adolescent
depression (Emslie et al., 1997; Ryan and Varma, 1998). Because
SSRIs, such as uoxetine, appear to be more effective in treating
adolescent depression (Emslie et al., 1997) than tricyclic antidepressants (Ryan and Varma, 1998) in placebo-controlled methodologically appropriate studies, it is reasonable to regard SSRIs
as a rst-choice medication for suicidal children and adolescents
(see also the American Academy of Child and Adolescent Psychiatrys Practice Parameters for the Assessment and Treatment
of Children and Adolescents With Depressive Disorders, 1998).
In contrast to the highly lethal potential of tricyclic antidepressants when taken in overdoses, SSRIs have low lethal potential.
However, in the past decade there has been much controversy over whether the SSRI antidepressants can induce suicidal ideation and/or behavior in a small minority of cases. A
number of case reports appeared in 19901991 describing
patients who had developed suicidal preoccupations after starting treatment with fluoxetine (e.g., King et al., 1991 [children]; Masand and Dewan, 1991; Masand et al., 1991; Teicher
et al., 1990 [adults]). These reports were not supported by
meta-analyses and reanalyses of large SSRI treatment trials of
depressed, bulimic, or anxious patients (Beasley et al., 1991;
Letizia et al., 1996; Montgomery et al., 1995). The conclusion
was reached that suicidal ideation is a common feature of depression and that its prevalence in SSRI-treated depressed
patients is no greater than expected.
However, one reanalysis (Mann and Kapur, 1991) of data
presented in certain of these studies suggested that new ideation
was significantly more common in SSRI-treated depressed
patients who had not previously reported suicidal ideation.
Furthermore, in a naturalistic challenge study, Rothschild and
Locke (1991) were able to reinduce suicidal ideas in a small
series of patients who had rst experienced ideation after starting treatment with uoxetine. These patients had also experienced akathisia as a complication of uoxetine treatment, and
a relationship between suicidality and uoxetine-induced akathisia has been noted by others (Hamilton and Opler, 1992).
At this stage, the wisest course of action for the practitioner
is to be particularly observant during the early stages of uoxetine treatment of a depressed adolescent, to inquire systematically about suicidal ideation before and after treatment is
started, and to be especially alert to the possibility of suicidality
if SSRI treatment is associated with the onset of akathisia.
Clinicians should be cautious about prescribing medications
that may reduce self-control, such as the benzodiazepines and
phenobarbital. Phenobarbital also has a high lethal potential if
taken in overdose (Carlsten et al., 1996). Montgomery (1997)
noted that benzodiazepines may disinhibit some individuals
who then exhibit aggression and suicide attempts, and there are
suggestions of similar effects from the antidepressants, maprotiline and amitriptyline, the amphetamines, and phenobarbital
(Carlsten et al., 1996). Amphetamines or other stimulant medication should be prescribed only when treating suicidal children and adolescents with ADHD. Stimulants are the rst line
of treatment for children with ADHD. Tricyclics should not
be prescribed, because of their greater lethal potential.
43S
In summary, lithium or a mood stabilizer can be labeled as

the rst line of pharmacological treatment for children and
adolescents with bipolar disorder and should be prescribed
before an antidepressant. SSRIs are the preferred psychopharmacological treatment for childhood and adolescent depression, with caution that suicidal youth on SSRIs must be watched
for any increase in agitation or suicidality. Stimulant medications should be prescribed only for children and adolescents with ADHD. While medications may be essential in
stabilizing and treating the suicidal child and adolescent, all
administration must be carefully monitored by a third party
who can report any unexpected change of mood, increase in
agitation or emergency state, or unwanted side effects, and
who can regulate dosage.
PREVENTION
COMMUNITY-BASED SUICIDE PREVENTION
The principal public health approaches to suicide prevention have been (1) crisis hotlines; (2) method control; (3) indirect case-nding by educating potential gatekeepers, teachers,
parents, clergy, and peers to identify the warning signs of an
impending suicide; (4) direct case-nding among high school
or college students or among the patients of primary practitioners by screening for conditions that place teenagers at risk
for suicide; (5) media counseling to minimize imitative suicide;
and (6) training professionals to improve recognition and treatment of mood disorders.
CRISIS HOTLINES
Although crisis hotlines are available almost everywhere

in the United States, research so far has been fairly limited
and has failed to show that crisis hotlines have an impact on
the incidence of suicide. Possible reasons for this include
the following:
1. Actively suicidal individuals (males and individuals with an
acute mental disturbance) do not call hotlines, because
they are acutely disturbed, preoccupied, or intent on not
being deected from their intended course of action.
2. Suicidal individuals may fail to reach the hotline. Hotlines
are often busy, and there may be a long wait before a call is
answered, so callers disconnect.
3. The advice given through a hotline may be stereotyped,
inappropriate for the callers needs, or perceived as unhelpful by the caller.
4. Gender preferences in seeking help result in the large
majority of callers being females, whereas males are at the
greatest risk for suicide.
While each of these deciencies is potentially modiable, to
date there have been no systematic attempts to do so. Research
studies in this area have been sparse and are sorely needed.
44S
METHOD RESTRICTION
Method preference varies by gender and by nationality. In the

United States the most common method for committing suicide
is by rearm, and it has been suggested that reducing rearm
availability will reduce the incidence of suicide (Moscicki, 1995).
However, a natural experiment in Great Britain makes this
unlikely. The favored suicide method, self-asphyxiation with coal
gas, became impossible after the introduction of natural gas.
This resulted in a marked, but not permanent, decline in the suicide rate. Within a decade, the suicide rate had returned to previous levels, and suicides were being committed by alternate
means. There is, as yet, no good evidence that reducing access to
rearms by gun security laws has a signicant impact on suicides
attributable to rearms, although they do have an impact on
accidental deaths from firearms (Cummings et al., 1997).
Raising the minimum legal drinking age for young adults does
appear to reduce the suicide rate in the affected age group
(Birckmayer and Hemenway, 1999).
INDIRECT CASE-FINDING THROUGH EDUCATION
Controlled studies (Shaffer et al., 1991; Spirito et al., 1988a;

Vieland et al., 1991) have failed to show that classes for high
school students about suicide increase students help-seeking
behavior when they are troubled or depressed. On the other
hand, there is evidence that previously suicidal adolescents are
perturbed by exposure to such classes (Shaffer et al., 1990). Such
educational programs seem, therefore, to be both an ineffective
mode of case-nding and to carry with them an unjustied risk
of activating suicidal thoughts.
DIRECT CASE-FINDING
Direct case-nding is an excellent and cost-effective way to

identify possibly at-risk children and adolescents in a school
setting (Reynolds, 1991; Shaffer et al., 1996b). It may also be
used in detention centers or foster care facilities. The direct
screening may target all children and has been used in various
high schools across the country (Reynolds, 1991; Shaffer et al.,
1996b); it is highly sensitive.
There is evidence that adolescents willif asked in a nonthreatening wayprovide accurate information about their
own suicidal thoughts or behaviors. A sensible approach to suicide prevention, therefore, is to systematically screen 15- to 19year-olds (the age group at greatest risk for such attempts) for
(1) previous suicide attempts; (2) recent, serious, suicidal preoccupations; (3) depression; or (4) complications of substance
or alcohol use. Clearly, screening programs need to go beyond
identifying a teenager with a high-risk prole. Youth identied
in this way should be referred for evaluation and, if necessary,
treatment. Contingency arrangements may need to be made to
assist uninsured adolescents with help if it is needed.
SUICIDAL BEHAVIOR
MEDIA COUNSELING
The Centers for Disease Control and Prevention (from a

1994 workshop) and the American Foundation for Suicide
Prevention (1999) have issued sensible guidelines for reporters
and editors, pointing to the risks of exaggerated or prominent
coverage of youth suicide in general and of the risks in focusing
attention on an individual suicide. These sensible guidelines,
excerpted in Appendix 2, should be known to child and adolescent clinicians who are engaged in public health practice, even
though there is as yet no good evidence that their application is
effective in reducing the suicide rate.
TRAINING
After a 2-day course of training on how to evaluate mood disorders and suicidality, preliminary and as-yet-unreplicated studies
in Sweden (Rihmer et al., 1995) suggest that educating primary
practitioners to better identify and treat mood disorders
results in a reduction in the number of suicides and suicide
attempts (among females) and an increase of antidepressant prescriptions and hospitalizations. Because the optimal treatment of
adolescent depression is not as well understood as that of adult
depression, this is an option that may prove to be useful but that,
at the moment, is still preliminary. Educating all clinicians who
encounter adolescents, not just mental health clinicians, in how
to recognize and, if necessary, refer the suicidal child or adolescent
is a worthwhile end in itself, regardless of its impact on suicide.
POSTVENTION
When a parent or sibling commits suicide, the bereaved prepubertal child is at risk for symptoms of anxiety and depression.
A sizable proportion of these children do in fact develop anxiety
disorders involving posttraumatic stress disorder (PTSD) and
mood disorders involving major depression (Pfeffer et al.,
1997). Having a friend or acquaintance commit suicide increases the likelihood of major depression, anxiety disorder, suicidal ideation, and PTSD onset in adolescents in the 6 months
immediately following the suicide (Brent et al., 1996b; Pfeffer,
1997). Prior psychiatric disorder and a family history of psychiatric disorder, particularly affective illness or previous exposure
to suicidal behavior, increase vulnerability for adolescents
exposed to a peers suicide (Brent et al., 1996b). Parental psychiatric symptoms such as depression, PTSD, or other anxiety
states are directly related to the severity of bereaved childrens
propensity for symptoms of anxiety or depression (Pfeffer,
1997). Actually witnessing the suicide or viewing the scene
afterward increases the risk of adolescent PTSD and anxiety disorder (Brent et al., 1996b). While intervention is exceedingly
important in this immediate period, long-term support and services are also necessary. Three years after an adolescent suicide,
adolescent friends who spoke to the victim the day before the
suicide and felt they had knowledge of the impending suicide
and failed to prevent it are most likely to continue to suffer from

major depression and PTSD (Brent et al., 1996b). Clinicians
need to work carefully with adolescents who are harboring guilt
and must recognize that the effects of an adolescent suicide are
far-reaching. Bereavement should be distinguished from
depression and psychiatric disorder. As an adolescent suicide
attempt also may increase risk of suicidal behavior and psychiatric disorder in friends and acquaintances (Hazell and Lewin,
1993), clinicians need to work with adolescents whose friend or
acquaintance has attempted suicide as well.
The goal of the clinician is to decrease the likelihood of others
identifying with the suicidal behavior of the deceased as a coping
strategy in dealing with adversity (Brent, 1997). Psychoeducational counseling may reduce the risk for suicidal behavior
in these circumstances. Intervention is also needed to promote
grief and mourning and to decrease the childs or teenagers personal sense of guilt, trauma, and social isolation (Pfeffer, 1997).
This treatment can be given in individual meetings, at group sessions with other teenagers, or in conjunction with parents who
need help to support the adaptive capacities of their children and
adolescents. School professionals sometimes offer programs of
this kind and can be invaluable in identifying grieving friends
who may need help.
CONFLICT OF INTEREST
As a matter of policy, some of the authors of AACAP practice

parameters are in active clinical practice and may have received
income related to treatments discussed in these parameters. Some
authors may be involved primarily in research or other academic
endeavors and also may have received income related to treatments discussed in these parameters. To minimize the potential
for these parameters to contain biased recommendations due to
conict of interest, the parameters were reviewed extensively by
Work Group members, consultants, and Academy members;
authors and reviewers were asked to base their recommendations
on an objective evaluation of the available evidence. Authors and
reviewers who believed that they might have a conict of interest
that would bias, or appear to bias, their work on these parameters
were asked to notify the Academy.
SCIENTIFIC DATA AND CLINICAL CONSENSUS
Practice parameters are strategies for patient management,

developed to assist clinicians in psychiatric decision-making.
These parameters, based on evaluation of the scientic literature
and relevant clinical consensus, describe generally accepted
approaches to assess and treat specic disorders or to perform
specic medical procedures. The validity of scientic ndings
was judged by design, sample selection and size, inclusion of
comparison groups, generalizability, and agreement with other
studies. Clinical consensus was determined through extensive
45S
review by the members of the Work Group on Quality Issues,

child and adolescent psychiatry consultants with expertise in the
content area, the entire Academy membership, and the Academy
Assembly and Council.
These parameters are not intended to dene the standard of
care, nor should they be deemed inclusive of all proper
methods of care or exclusive of other methods of care directed
at obtaining the desired results. The ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all the circumstances presented by the patient
and his or her family, the diagnostic and treatment options
available, and available resources. Given inevitable changes in
scientic information and technology, these parameters will be
reviewed periodically and updated when appropriate.
APPENDIX 1: SELECTED WEB SITES WITH SUICIDE
FACTS AND RESOURCES
The following is a list of Web sites that may be relevant to

the clinician seeking more information or to the family and
friends of a suicidal youth. These Web sites were obtained by
an Internet search on the keywords suicide and suicide prevention through various search engines on May 1, 1999. The
list below is by no means comprehensive. Sites were selected
that represent well-known organizations dealing with suicide
and mental illness in the United States and other Englishspeaking countries.
American Academy of Child and Adolescent Psychiatry
http://www.aacap.org/
Facts for Families
Teen Suicide: http://www.aacap.org/publications/factsfam/
suicide.htm
The Depressed Child: http://www.aacap.org/publications/
factsfam/depressd.htm
Manic-Depressive Disorder in Teens: http://www.aacap.
org/publications/factsfam/bipolar.htm
Gay and Lesbian Teens: http://www.aacap.org/publications/
factsfam/63.htm
American Association of Suicidology
http://www.aifs.org.au/external/ysp/ysplinks.html (Guide to
many excellent Australian Web sites listing prevention strategies and resources.)
Canadian Association for Suicide Prevention
Community Lifelines: http://www3.sympatico.ca/masecard/

(Nonprot national Canadian association; text in French
and English.)
Centers for Disease Control and Prevention
CDC Prevention Guidelines

Programs for the Prevention of Suicide Among Adolescents
and Young Adults (1994): http://aepo-xdv-www.epo.cdc.gov/
wonder/prevguid/m0031525/m0031525.htm
Suicide Contagion and the Reporting of Suicide: Recommendations From a National Workshop (1994): http://aepo-xdvwww.epo.cdc.gov/wonder/prevguid/m0031539/m0031539.htm
Youth Suicide Prevention Programs: A Resource Guide
(1992): http://aepo-xdv-www.epo.cdc.gov/wonder/prevguid/
p0000024/p0000024.htm
CDC Recommendations for a Community Plan for the
Prevention and Containment of Suicide Clusters (1988):
http://aepo-xdv-www.epo.cdc.gov/wonder/prevguid/p0000214/p0000214.htm
National Center for Injury Prevention and Control: Suicide
and Violence (fact sheet): http://www.cdc.gov/ncipc/dvp/suifacts.
htm
National Depressive and Manic-Depressive Association
http://www.ndmda.org/
Suicide: http://www.ndmda.org/suicide.htm
Suicide and Depressive Illness Booklet: http://www.ndmda.
org/suicide.htm
(Many excellent links on suicide and child and adolescent
depression and manic depression for family and patients.)
National Institute of Mental Health
http://www.suicidology.org/
American Foundation for Suicide Prevention
http://www.afsp.org/ (Excellent site with links to research

articles and youth suicide facts; has information for those
interested in pursuing research.)
American Psychiatric Association
Teen Suicide: http://www.psych.org/ (Good summary for

parents and peers listing where to get help.)
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Australian National Youth Suicide Prevention Strategy

Communications Project
Suicide Research Consortium: http://www.nimh.nih.gov/

research/suicide.htm (Has suicide fact sheet, epidemiological
information, bibliographies, and information for those
interested in pursuing research.)
Prevention Yellow Pages
Suicide: http://www.tyc.state.tx.us/prevention/40001ref.html
#SUI (Reference list for many recent research articles on
programs designed to prevent youth suicide.)
SUICIDAL BEHAVIOR
Suicide Information and Education Centre
http://www.siec.ca/ (Extensive resources provided, as well as

answers to frequently asked questions and library resources.)
Site for Survivors
1000 Deaths (by Christine Smith): http://www.1000deaths.

com/
E-mail Support for Survivors
suicide-survivors-request@research.canon.com.au
APPENDIX 2: MEDIA GUIDELINES FOR CLINICIANS
AND REPORTERS
GENERAL CONCERNS AND RECOMMENDATIONS
Source: Centers for Disease Control and Prevention, Prevention

Guidelines Database (1994), Suicide Contagion and the Reporting of Suicide: Recommendations From a National Workshop
MMWR 43(RR-6):918 (http://aepo-xdv www.epo.cdc.gov/
wonder/prevguid/m0031539/m0031539.htm).
The following concerns and recommendations should be
reviewed and understood by health professionals, suicidologists, public ofcials, and others who provide information for
the reporting of suicide:
Suicide is often newsworthy, and it will probably be
reported. The mission of a news organization is to report to
the public information on events in the community. If a suicide is considered newsworthy, it will probably be reported.
Health care providers should realize that efforts to prevent
news coverage may not be effective, and their goal should be
to assist news professionals in their efforts toward responsible
and accurate reporting.
No comment is not a productive response to media representatives who are covering a suicide story. Refusing to speak
with the media does not prevent coverage of a suicide;
rather, it precludes an opportunity to inuence what will be
contained in the report. Nevertheless, public ofcials should
not feel obligated to provide an immediate answer to difcult questions. They should, however, be prepared to provide
a reasonable timetable for giving such answers or be able to
direct the media to someone who can provide the answers.
All parties should understand that a scientic basis exists for
concern that news coverage of suicide may contribute to the
causation of suicide. Efforts by persons trying to minimize suicide contagion are easily misinterpreted. Health ofcials must
take the time to explain the carefully established, scientic basis
for their concern about suicide contagion and how the potential for contagion can be reduced by responsible reporting.
Some characteristics of news coverage of suicide may contribute to contagion, and other characteristics may help prevent
suicide. Clinicians and researchers acknowledge that it is not

news coverage of suicide per se, but certain types of news coverage, that promote contagion. Persons concerned with preventing suicide contagion should be aware that certain
characteristics of news coverage, rather than news coverage
itself, should be avoided.
Health professionals or other public ofcials should not try to
tell reporters what to report or how to write the news regarding suicide. If the nature and apparent mechanisms of suicide
contagion are understood, the news media are more likely to
present the news in a manner that minimizes the likelihood
of such contagion. Instead of dictating what should be
reported, public ofcials should explain the potential for suicide contagion associated with certain types of reports and
should suggest ways to minimize the risk for contagion.
Public ofcials and the news media should carefully consider
what is to be said and reported regarding suicide. Reporters
generally present the information that they are given.
Impromptu comments about a suicide by a public ofcial can
result in harmful news coverage. Given the potential risks,
public ofcials and the media should seek to minimize these
risks by carefully considering what is to be said and reported
regarding suicide.
ASPECTS OF NEWS COVERAGE THAT CAN PROMOTE
SUICIDE CONTAGION
Source: American Foundation for the Prevention of Suicide,

Gould MS, Kramer R. Reporting a suicide. American Foundation
for the Prevention of Suicide, 120 Wall Street, 22nd Floor, New
York, NY 10025; (212) 363-3500; www.afsp.org.
The American Foundation for Suicide Prevention has issued
the following good suggestions, developed by Madelyn Gould,
Ph.D., and Rachel Kramer, Sc.D., for how journalists might be
able to minimize the risk of inducing suicidal behavior.
It is misleading to present suicide as the inexplicable act of
an otherwise healthy person. Acknowledge the multidetermined nature of suicide, particularly the underlying psychiatric problems that may not be immediately apparent to
an outside observer.
Communicate that suicide is preventable by providing models
of effective treatment. Provide resources for further information and help.
Question whether the suicide is unusual or newsworthy.
People may not need to be informed about all suicides.
Be mindful that pictures of the victim and/or grieving relatives and friends may foster a pathological identication
with the victim and inadvertently glorify the death.
Avoid excessive and prominent coverage.
Try to oversee headlines. Inappropriate headlines can detract from an otherwise helpful story.
Limit detailed description of method, to avoid modeling
behavior.
47S
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AACAP

Practice Parameter for the Assessment and Treatment

Suicidal behavior is a matter of great concern for clinicians who

This summary provides an overview of the assessment and

to do, but in other cases they should be avoided. If possible, the

Suicidal thoughts are common in children and adolescents

Mood disorders (particularly early-onset major depressive

AACAP PRACTICE PARAMETERS

Assessment of suicidal patients requires an evaluation of

Clinicians should be aware of which adolescent suicide

Treatment must encompass the acute management of suicidal

Emergency room and other crisis staff should establish a

Although there have been no randomized controlled trials to

that adequate supervision and support will be available over

Psychotherapy, an important component of treatment for the

AACAP PRACTICE PARAMETERS

contrary, talks and lectures about suicide to groups of children

After a suicide, the relative, friends, and teachers of the child

The literature on child and adolescent suicidal behavior has

Until the late 1950s, the literature on suicide was conned to

Overall, approximately 2,000 U.S. adolescents (aged 1319

In 1997, the age-specic mortality rate from suicide for 10- to

In the United States the ratio of male to female suicide in

AACAP PRACTICE PARAMETERS

1987 and has since declined. The African-American male suicide

Although the rate of suicide by rearm increased more than

Suicide rates in the United States are highest in the western

Firearms are the most common method by which Americans

good young people. While perfectionism has been proposed

Controlled studies of completed suicide suggest similar risk

AACAP PRACTICE PARAMETERS

Stressful life events often precede a suicide and/or suicide

Until recent years, suicide was much more common among

for 15- to 19-year-old African-American males increased by

could be a function of contagion within isolated groups rather

Why suicide should be an option for some young people

Suicide attempts involve any behavior that is intended to

AACAP PRACTICE PARAMETERS

Suicide attempts in adolescence are approximately twice as

Americans (9.0%). Attempts were also more common among

period. Hispanic students of both sexes were significantly

completion method is largely determined by opportunity, but

CLINICAL PRESENTATION OF SUICIDAL BEHAVIOR

The spectrum of severity of suicidal behavior ranges from

Risk factors for suicide attempts in both genders are mood or

Suicidal ideation includes thoughts about wishing to kill

Suicide threats are utterances made to others that indicate an

The large majority of known suicide attempts in the United

AACAP PRACTICE PARAMETERS

Most of our knowledge about the clinical features of suicide

those reported in suicide completers (Shaffer et al., 1996a;

Assessment of suicidal patients requires an evaluation of the

ASSESSMENT OF THE ATTEMPT

Determine the type of method used in the suicide attempt

Factors that increase the risk of subsequent suicide attempts

away, homeless, or isolated), having made previous attempts,

CHI July 2001 (Supplement), Shaffer, article #87486, 4 tables, 3 figures

AACAP PRACTICE PARAMETERS

ness and other mood disorders, and whether or not borderline