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The Self-Harmful Child - Suicidal Behaviour

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After decades of rising suicide rates, the most recent statistics show that over the last 10 years, the rate among young people is declining.
 
Some speculate that anti-stigma campaigns are paying off--Teenagers are coming forward for help at an earlier stage, and thus heading off troubles before they get too big.  Others suggest that rising rates of anti-depressant prescriptions have had a beneficial effect.  Depression is the most common precursor to suicide, and if it is being treated more effectively, that might help.  Still others note that the population is aging, and so there are simply fewer teenagers in the population.
 
Whatever the reasons, it is still true that suicide is the second most common cause of death in teenagers, after accidents, and Canada has one of the highest rates in the industrialized world.  Boys kill themselves 3 times as often as girls, mostly because they choose more lethal methods--shooting, hanging, or jumping--all of which carry a low probability of rescue.  Girls, on the other hand, prefer overdosing on pills, and the chances of successful medical intervention are much greater.  Girls attempt suicide 3 times as often as boys.
 
While not all suicides are preventable, in 70-90% of cases, there is a pre-existing diagnosable psychiatric disorder, and if treated appropriately, in the context of a holistic management plan, the risk can be reduced significantly.



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Talk of suicide or attempts at suicide are not normal at any age.  One can debate the "right to die" in the context of terminal illness, but other than that, the wish to die is a sign of psychological disturbance.
 

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Suicidal talk and actions are extremely rare before adolescence.  If a close relative has recently died, the child may speak of wanting to join him or her in heaven.  In cases of severe abuse, a child may talk of wanting to run away or go to sleep for a long time.  Usually, this is a reflection of temporary mood states which settle down once the cause of the stress is removed.  If the child regresses to behaviour from an earlier stage of development (for example, stops talking, or wets the bed after toilet-training) or actually engages in self-harm (for example, biting or hitting oneself), then further monitoring may be warranted.


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Talking about wanting to die, or actions such as jumping from a high place or eating a large quantity of pills (with intent) should be regarded as Red Light behaviours.  While there are isolated case reports of children as young as 4 wanting to die, fortunately, such situations are extremely rare.


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Children do not understand the finality of death until age 8 or 9, so true intent to die is extremely rare before that.  Signs to watch for include:
  • talking about feeling worthless or being a burden to others
  • drawing or writing about death, especially in a repetitive manner
  • anxiety attacks that are new and intense
  • unexplained risk-taking behaviour (e.g., crossing the road without looking, even though they did that before).

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Older children are more capable of planning than younger children.  Therefore, in addition to the behaviours in the Yellow Light area, worrisome acts would include:
  • evidence of preparation, such as hoarding pills, bringing home a rope
  • asking questions about guns or other lethal weapons, in the context of sad or upset feelings (in other words, not just out of curiosity)
  • persistent drawings of blood, or different ways of dying

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With the onset of puberty, moods can become unstable.  You may observe any of the following warning signs of depression and/or possible thoughts of suicide:
  • changes in sleep, appetite, energy level, and concentration
  • loss of interest in hobbies
  • withdrawal from friends or family
  • poorly defined physical symptoms (headache, stomach ache)
  • decline in school marks and new school absences
  • listening to songs about death or visiting websites about death
  • reports of being bullied 
 
If these behaviours are new, persist for 2 weeks or longer, and are accompanied by distress or interference with usual habits and routines, then further assessment is warranted.

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Suddenly stopping extra-curricular activities or hobbies, along with total social withdrawal should be warning signs, but the most obvious red light activities include
  • Giving away prized possessions 
    • This is evidence that the young teen no longer cares about his or her (physical) attachments to the world
  • Leaving a suicide note 
    • Many teens may write dark poetry or short stories, but saying good-bye to loved ones, whether on-line or on paper is a Red Light action. 
  • Risky drug or alcohol use that is sudden, new, and extreme, may be a suicide attempt in disguise.

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All of the Yellow Light actions from Early Adolescence continue. In addition,
  • Drug or alcohol abuse may be an attempt at self-medicating unpleasant emotions. 
  • Unsafe sexual practices may be a hidden form of self-harm, as are risky driving and "extreme" sports. 
  • Internet practices may become addictive, and going to websites which refer to death or self-harm should be cause for concern.

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Now that your teenager is becoming eligible to drive, you should be aware of how he or she is approaching that responsibility. Wanting to drive before they have a license, or without any lessons, may be a sign of "bravado" or independence, but it could also be an indicator of wanting to use the car as a lethal weapon.  In the context of persistent sadness or anxiety, such a request would be in the Red Light Zone.  This is the age at which actual attempts make their appearance with more frequency, so "gestures" such as cutting, burning, or taking pills are Red Light actions. 
 
In girls, self-starvation can be regarded as a method of slow suicide, even in the context of an eating disorder.


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  • Suicide has been shown to have a partly inherited or genetic component, so a family history is important to be aware of. 
  • Being male is also a significant risk factor.  Whether this is due to male hormones (testosterone) leading to more aggressive, impulsive behaviour is not known. 
  • Having a co-existing medical disorder or disability such as cancer, diabetes, or epilepsy is a risk factor, especially if it is physically obvious (e.g., facial deformity), or interferes with socialization. 
  • Past history of mental illness (depression/anxiety/psychosis) and past history of drug/alcohol abuse makes a person more vulnerable to suicide.
  • Having a learning disability may also decrease self-esteem to the point of having thoughts of suicide.

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  • High-conflict divorce and parental/marital discord may leave the child feeling guilty and trapped.  Caught in a loyalty bind, and with little control over custody/access decisions, the child may turn to suicide. 
  • An early history of loss, e.g., death of a parent before age 12, can leave the child feeling more vulnerable in the face of stress. 
  • Physical, sexual, or emotional abuse and neglect by parents can similarly lead to a teen feeling helpless.  For them, the only way out is to die.
  • If parental reaction to a previous suicide attempt was one of anger ("How could you do this to me after all I've done for you?"), then the child may feel that they've disappointed the parent, and will be more likely to make another attempt.

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  • Early and late teens in particular need to fit in with the peer group.  Therefore, if they are "different" for any reason--being gay, trans-gendered, too fat, too thin, too tall, too short, too smart, too slow--they are at risk of being isolated, excluded, or bullied. 
  • In boys, bullying tends to be direct--the child will be physically beaten up or obviously taunted.  With girls, the bullying is often "by exclusion"--not being invited to parties, or not being part of a clique--and more subtle.

  • The use of social media to spread rumours is particularly destructive because of the anonymity of the bully and the ease with which rumours can "go viral".   Recently, this has been devastating to a number of teens who took their life after being "outed" for being gay.

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  • Religion seems to offer some protective effect against suicide, with lower rates being reported among those who believe in God.  For some, the notion that suicide is a sin acts as a deterrent.  Or, it may be the support of the church community which is protective.
  • However, it is also true that differences between parents and children in their beliefs (e.g., marrying out of the faith) can cause severe conflict and guilt or anger, leading to suicide in the child, perhaps as revenge against the parent.
 

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  • Children who come from war-torn countries and who have either witnessed or been the victim of torture and violence are at higher risk of suicide. 
  • "Home-grown" violence in the form of date rape, being mugged, or other assaults, are also a risk factor, especially if flashbacks of the event plague the child.
 

Other

  • It is important to be aware that teenagers are more prone to the influence of "contagion" than adults or young children.  Thus, high-profile media reports of movie stars or rock stars who have died by suicide may influence the teen to seek posthumous fame or to identify with their idol. 
  • Losing a close friend or relative to suicide may also lower the taboo against it, and may lead the teen to want to "join" the deceased in heaven.  Suicide pacts are more common in adolescence because of peer influences--and poor judgement.

  • The strongest predictor of suicidal behaviour is past attempts, so any child who has tried once, needs to be carefully monitored and evaluated.

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Share the load!  You can never determine whether a drawing, song, poem, or even attempt is "serious" or not.  The most important components of addressing suicidality are: take the child to a professional; never promise confidentiality.
 
Your family doctor or pediatrician should be the starting place, since they can rule out whether physical illnesses like anemia, low thyroid, or infectious mononucleosis are causing the fatigue, loss of appetite, and insomnia that you have observed and are making you wonder whether your child is depressed.  The doctor can then determine if a mental health professional--psychologist, psychiatrist, or social worker--should be involved.  If the child has made an attempt, then the nearest Emergency Department should be the starting point.
 
Do not:
  • Assume they are joking
  • Tell them to try and feel differently
  • Agree to secrecy
 
Do:
  • Stay calm and non-judgemental
  • Emphasize the possibility of options to help either the situation or their ability to cope with a situation
  • Gently challenge hopelessness--after all, suicide is a permanent solution to what is often a temporary, or at least changeable situation
 
A comprehensive, multi-pronged approach involving individual therapy, family therapy, medication, education about mental or physical illness, and making the environment as safe as possible (both physically and emotionally) will usually be required.

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Share the load!  You can never determine whether a drawing, song, poem, or even attempt is "serious" or not.  The most important components of addressing suicidality are: take the child to a professional; never promise confidentiality.
 
Your family doctor or pediatrician should be the starting place, since they can rule out whether physical illnesses like anemia, low thyroid, or infectious mononucleosis are causing the fatigue, loss of appetite, and insomnia that you have observed and are making you wonder whether your child is depressed.  The doctor can then determine if a mental health professional--psychologist, psychiatrist, or social worker--should be involved.  If the child has made an attempt, then the nearest Emergency Department should be the starting point.
 
Do not:
  • Assume they are joking
  • Tell them to try and feel differently
  • Agree to secrecy
 
Do:
  • Stay calm and non-judgemental
  • Emphasize the possibility of options to help either the situation or their ability to cope with a situation
  • Gently challenge hopelessness--after all, suicide is a permanent solution to what is often a temporary, or at least changeable situation
 
A comprehensive, multi-pronged approach involving individual therapy, family therapy, medication, education about mental or physical illness, and making the environment as safe as possible (both physically and emotionally) will usually be required.

Back to top

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Share the load!  You can never determine whether a drawing, song, poem, or even attempt is "serious" or not.  The most important components of addressing suicidality are: take the child to a professional; never promise confidentiality.
 
Your family doctor or pediatrician should be the starting place, since they can rule out whether physical illnesses like anemia, low thyroid, or infectious mononucleosis are causing the fatigue, loss of appetite, and insomnia that you have observed and are making you wonder whether your child is depressed.  The doctor can then determine if a mental health professional--psychologist, psychiatrist, or social worker--should be involved.  If the child has made an attempt, then the nearest Emergency Department should be the starting point.
 
Do not:
  • Assume they are joking
  • Tell them to try and feel differently
  • Agree to secrecy
 
Do:
  • Stay calm and non-judgemental
  • Emphasize the possibility of options to help either the situation or their ability to cope with a situation
  • Gently challenge hopelessness--after all, suicide is a permanent solution to what is often a temporary, or at least changeable situation
 
A comprehensive, multi-pronged approach involving individual therapy, family therapy, medication, education about mental or physical illness, and making the environment as safe as possible (both physically and emotionally) will usually be required.

Back to top


Share the load!  You can never determine whether a drawing, song, poem, or even attempt is "serious" or not.  The most important components of addressing suicidality are: take the child to a professional; never promise confidentiality.
 
Your family doctor or pediatrician should be the starting place, since they can rule out whether physical illnesses like anemia, low thyroid, or infectious mononucleosis are causing the fatigue, loss of appetite, and insomnia that you have observed and are making you wonder whether your child is depressed.  The doctor can then determine if a mental health professional--psychologist, psychiatrist, or social worker--should be involved.  If the child has made an attempt, then the nearest Emergency Department should be the starting point.
 
Do not:
  • Assume they are joking
  • Tell them to try and feel differently
  • Agree to secrecy
 
Do:
  • Stay calm and non-judgemental
  • Emphasize the possibility of options to help either the situation or their ability to cope with a situation
  • Gently challenge hopelessness--after all, suicide is a permanent solution to what is often a temporary, or at least changeable situation
 
A comprehensive, multi-pronged approach involving individual therapy, family therapy, medication, education about mental or physical illness, and making the environment as safe as possible (both physically and emotionally) will usually be required.

Back to top

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Share the load!  You can never determine whether a drawing, song, poem, or even attempt is "serious" or not.  The most important components of addressing suicidality are: take the child to a professional; never promise confidentiality.
 
Your family doctor or pediatrician should be the starting place, since they can rule out whether physical illnesses like anemia, low thyroid, or infectious mononucleosis are causing the fatigue, loss of appetite, and insomnia that you have observed and are making you wonder whether your child is depressed.  The doctor can then determine if a mental health professional--psychologist, psychiatrist, or social worker--should be involved.  If the child has made an attempt, then the nearest Emergency Department should be the starting point.
 
Do not:
  • Assume they are joking
  • Tell them to try and feel differently
  • Agree to secrecy
 
Do:
  • Stay calm and non-judgemental
  • Emphasize the possibility of options to help either the situation or their ability to cope with a situation
  • Gently challenge hopelessness--after all, suicide is a permanent solution to what is often a temporary, or at least changeable situation
 
A comprehensive, multi-pronged approach involving individual therapy, family therapy, medication, education about mental or physical illness, and making the environment as safe as possible (both physically and emotionally) will usually be required.

Back to top


Share the load!  You can never determine whether a drawing, song, poem, or even attempt is "serious" or not.  The most important components of addressing suicidality are: take the child to a professional; never promise confidentiality.
 
Your family doctor or pediatrician should be the starting place, since they can rule out whether physical illnesses like anemia, low thyroid, or infectious mononucleosis are causing the fatigue, loss of appetite, and insomnia that you have observed and are making you wonder whether your child is depressed.  The doctor can then determine if a mental health professional--psychologist, psychiatrist, or social worker--should be involved.  If the child has made an attempt, then the nearest Emergency Department should be the starting point.
 
Do not:
  1. Assume they are joking
  2. Tell them to try and feel differently
  3. Agree to secrecy
 
Do:
  1. Stay calm and non-judgemental
  2. Emphasize the possibility of options to help either the situation or their ability to cope with a situation
  3. Gently challenge hopelessness--after all, suicide is a permanent solution to what is often a temporary, or at least changeable situation
 
A comprehensive, multi-pronged approach involving individual therapy, family therapy, medication, education about mental or physical illness, and making the environment as safe as possible (both physically and emotionally) will usually be required.

Back to top

Back to top




Share the load!  You can never determine whether a drawing, song, poem, or even attempt is "serious" or not.  The most important components of addressing suicidality are: take the child to a professional; never promise confidentiality.
 
Your family doctor or pediatrician should be the starting place, since they can rule out whether physical illnesses like anemia, low thyroid, or infectious mononucleosis are causing the fatigue, loss of appetite, and insomnia that you have observed and are making you wonder whether your child is depressed.  The doctor can then determine if a mental health professional--psychologist, psychiatrist, or social worker--should be involved.  If the child has made an attempt, then the nearest Emergency Department should be the starting point.
 
Do not:
  • Assume they are joking
  • Tell them to try and feel differently
  • Agree to secrecy
 
Do:
  • Stay calm and non-judgemental
  • Emphasize the possibility of options to help either the situation or their ability to cope with a situation
  • Gently challenge hopelessness--after all, suicide is a permanent solution to what is often a temporary, or at least changeable situation
 
A comprehensive, multi-pronged approach involving individual therapy, family therapy, medication, education about mental or physical illness, and making the environment as safe as possible (both physically and emotionally) will usually be required.

Back to top


Share the load!  You can never determine whether a drawing, song, poem, or even attempt is "serious" or not.  The most important components of addressing suicidality are: take the child to a professional; never promise confidentiality.
 
Your family doctor or pediatrician should be the starting place, since they can rule out whether physical illnesses like anemia, low thyroid, or infectious mononucleosis are causing the fatigue, loss of appetite, and insomnia that you have observed and are making you wonder whether your child is depressed.  The doctor can then determine if a mental health professional--psychologist, psychiatrist, or social worker--should be involved.  If the child has made an attempt, then the nearest Emergency Department should be the starting point.
 
Do not:
  • Assume they are joking
  • Tell them to try and feel differently
  • Agree to secrecy
 
Do:
  • Stay calm and non-judgemental
  • Emphasize the possibility of options to help either the situation or their ability to cope with a situation
  • Gently challenge hopelessness--after all, suicide is a permanent solution to what is often a temporary, or at least changeable situation
 
A comprehensive, multi-pronged approach involving individual therapy, family therapy, medication, education about mental or physical illness, and making the environment as safe as possible (both physically and emotionally) will usually be required.

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