Safety First: Self Harm and Suicide in Children and Adolescents

Kari Hancock, MDChild PsychiatristPAL Program Consultant

Objectives

•Defining terms•Identify those at greatest risk for suicide

and self harm behavior •Acute Management•Identify treatment options for those at

risk•Review risk factors in treatment

Defining Terms: Parasuicide or Self Injurious/Harm Behaviors

• Behavior may have no intention of death and intended purely for other reasons (eg. relieve distress or to effect change in others or the environment)

• “Parasuicide” used as a term to reduce pejorative language associated with nonlethal deliberate self harm

• WHO has chosen “suicide attempt” as a term any time an individual does not die, regardless of presence of suicidal intent

Posner, et al, Am J Psychiatry 2007; 164:1035-1043Miller, et al, “Dialectical Behavior Therapy with Suicidal Adolescents”, 2007

Defining Terms: Suicidal Ideation• Passive thoughts about wanting to be dead or

active thoughts about killing oneself

• Not accompanied by preparatory behavior

Posner, et al, Am J Psychiatry 2007; 164:1035-1043

Defining Terms: Suicide Attempt•Potentially self-injurious behavior,

associated with some intent to die, as a result of the act

•May or may not result in actual injury

Posner, et al, Am J Psychiatry 2007; 164:1035-1043

Self Harm Behaviors

•Is Common (~15% of all US teenagers)•It happens at home ¾ of the time•Doctors rarely know about it (<14%)•Friends/family do know about it (~75%)

N Madge, E Hewitt et al, 2008

From Klonsky ED and Muehlenkamp JJ 2007

Common Forms of Self Harm

•Cutting (70% of self injurers)

•Scratching•Banging•Hitting•Burning•Self Poisoning

Most commonly on arms, followed by hands, wrists, thighs, stomach

Reasons For Self Harm Behaviors

1. Affect Regulation (AKA “distress tolerance”)---clearly the most common reason

2. Self Punishment3. Interpersonal Influences 4. Anti-dissociation5. Anti-suicide6. Sensation Seeking7. Reinforce Interpersonal BoundariesFrom Klonsky ED and Muehlenkamp JJ 2007

Reinforcers for Self Harm

Negative reinforcers: Avoidance•People•School work/unpleasant activities•PunishmentPositive reinforcers: •Attention – making others angry or

getting noticed•Feeling part of a group•Release of endogenous opiates

Self Harm Behaviors in the Suicide Spectrum

•Intentional self injury often occurs with ambivalence or rapid changing intent

•Behavior that starts suicidal can evolve into a nonsuicidal act and vice versa

•Intentional but nonsuicidal self injury can itself be lethal

•Increases suicide risk 50-100 times within the first 12 months after self injury

Miller, et al., “Dialectical Behavior Therapy for Suicidal Adolescents”, 2007.

Concerns about Adolescent SuicideUS High school students in past 12 months:

13.8% seriously considered suicide10.9% made a suicide plan6.3% attempted suicide1.9% needed MD treatment for an attempt

Per 2009 YRBS by CDC

Suicidal Ideation (SI)• Common in children and adolescents • Disruptive disorders increase SI in children < 12 years old• Panic attacks risk factor for ideation in females• Aggressiveness risk factor for ideation in

males• “Children involved in bullying, in any role, and

especially bully/victims and chronic victims, are at increased risk for suicide ideation and suicidal/self-injurious behavior in preadolescence” (Winsper, et al., JAACAP, vol 51:3, March 2012)

Increased Risk: Going from Ideation to Attempt

•Severe or enduring hopelessness•Isolation•Reluctance to discuss suicidal thoughts•Preoccupation with death

Suicide in Children

•Understanding the finality of death is not an essential ingredient in determining suicidality

•Understanding of death can fluctuate•Preschoolers can be considered suicidal if

they wish to carry out a self destructive act with the goal of causing death despite not knowing the finality of death

•Suicidal behavior in prepuberty predicts suicidal behavior in adolescents

Suicide Attempts

•More common in girls (1.6:1)•2 million US adolescents attempt suicide

each year•Increase risk for an attempt: mood

disorders, anxiety disorders, substance abuse, runaway behavior, LGTB youth

•15-20% of female suicide attempters have a hx of being abused

Concern About Suicide Attempts•31-50% of adolescent suicide attempters

reattempt suicide (Shaffer & Piacentini, 1994)

•27% of males and 21% of females reattempt within 3 months of their first attempt (Lewinsohn et al., 1996)

•TASA Study: N=124, open trial, 40% of suicidal events occurred within 4 wks of intake (Brent, et al., JAACAP, 48:10, October 2009)

Method of Suicide Attempt

•Ingestion, most commonly over the counter analgesics

•Superficial cutting of arms or neck•Attempts to hang self•Jump from a height•Stab self•Drown•Self immolate

Increased Risk: Going from Attempt to Completion

•Repeated suicide attempts•Medically serious attempts•Steps taken to prevent or promote discovery

Epidemiology for Completed Suicide

•3rd leading cause of death in adolescents•Approx 2000 US adolescent commit

suicide each year•90% who commit suicide had an

associated psychiatric disorder•More than half had a psychiatric disorder

for at least 2 years

Completed Suicide Epidemiology•Prepubertal suicides ratio 3:1 male to

female•Age 15-19 yr olds ratio 4.5:1 male to

female•American Indian/Alaska Native males

have the highest suicide rate

Risk Factors for Completed Suicide in Adolescent Males

•Previous suicide attempts (increases rate 30 fold)

•Age 16 or older•Associated mood disorder (increases 9

fold with major depressive disorder)•Associated substance abuse (increases 7

fold)•Disruptive behavior

Risk Factors for Completed Suicide in Adolescent Females

Mood disorders•Major depression increases risk 20 fold

(Shaffer et al., 1996a)

Previous suicide attempts

General Risk Factors For Suicide

•Family history of suicidal behavior (5 fold greater risk on adolescent boys, 3 fold greater risk on adolescent girls)

•Parental mental health problems•Parental substance abuse

General Risk Factors For Suicide

•Gay or bisexual orientation•Exposure to real or fictional accounts of

suicide is a risk factor for vulnerable teenagers

•Hx of child abuse•Personality disorder (antisocial,

borderline)•Chronic medical illnesses (eg. diabetes,

epilepsy)•Victim of bullying (eg. cyberbullying)

Immediate Risk Factors

•Agitation•Intoxication: Substance and/or alcohol

abuse significantly increases risk in age 16 and older

•Stressful life event

Events Preceding Adolescent Suicide

•Family difficulty •Loss of a romantic relationship•Disciplinary problems at school or legally•Academic difficulty•Giving away prized possessions

Most adolescent suicides appear to be impulsive

Common Methods Used in Completed Suicide in the US

Males:•Firearms – half of completed suicides

among 15-19 year olds

•Hanging •Carbon Monoxide Poisoning•JumpingFemales: •Firearms•Overdose on pills or ingesting poison

Assessment In The Office

•Questionnaires to screen for depression, suicidal preoccupations, and previous suicidal behavior

•Interview separately from the parent•Collateral History

Screening Scales• Broad Screening

PSC-17 Others like CBCL, BASC for a fee

• Narrow Screening/Diagnostic aide for depression PHQ-9 for adolescents SMFQ for kids over age 6 Others like CDI, CDRS-R for a fee

Can measure response to treatments

Initial Questions

•Is there anything that has been stressing you lately?

•How have things been going with school, friends, parents? HEADSS (Home, Education and Employment, Activities, Drugs, Sexuality, Suicide risk)

Ask The Questions Directly

•Has it stressed you out to the point of having thoughts about not wanting to live?

•Have you ever thought about killing yourself or wished you were dead?

•Have you ever done anything on purpose to hurt or kill yourself?

If Yes, Get More Details

•Nature of past and present thoughts and behaviors

•Intent•Who Knows•If you were to kill yourself, how would you

do it? •Accessibility of means (eg. weapons in the

home)•Response of the family•Stressful events/conflicts (eg. bullying)•Evaluate motivating feelings

Moderate to High Risk:

•Planned or recent attempt with high probability of lethality

•Statement of intent to kill oneself•Agitation•Severe hopelessness•Impulsivity and profoundly dysphoric mood

associated with mood disorder, psychosis or substance use

•Regret attempt not completed•Lack of social support

If Moderate or High Risk Of Suicide:

Immediate mental health evaluation necessary:

•ER •Hospitalization

•In WA state: calling the local crisis line to speak with a designated mental health professional (DMHP), anyone can make the referral

Age of consent for mental health care in WA state is 13

The following are referred to as voluntary admissions: • For all minors under 13 years of age, a parent must give consent. • A minor 13-18 years of age and their parents may jointly give

consent. • A minor 13-18 years of age may give consent for admission

without parental agreement.

Involuntary admission: • In the event of any minor 13 years of age or older (and/or his/her

parent) refuses admission, the minor may be evaluated and detained involuntarily by a DMHP (DMHP) in accordance with RCW 71.34.

• If the DMHP makes a decision that the minor does not require inpatient treatment, the parent can seek review of that decision made by the DMHP in court. RCW 71.34

DMHP Referral •When called upon to assess whether a minor

needs involuntary treatment, a DMHP may take the minor or cause the minor to be taken into custody and transported to an Evaluation and Treatment facility providing inpatient treatment. RCW 71.34.600-660

• If the minor is not taken into custody for evaluation and treatment, the parent can seek review of the decision made by the DMHP in court. RCW 71.34.600-660

Checklist for assessing child or adolescent suicide attempters in an emergency room or crisis center

Attempters at Greatest Risk for Suicide• Suicidal History Demographics• • Still thinking of suicide • Male• • Have made a prior suicide attempt • 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 a patient without a psychiatric

evaluation.

AACAP Practice Parameters, “Suicidal Behavior”, July 2001

After ER Visit

High failure rate to keep mental health referral appointment after ER discharge

•Medical practitioner can enhance continuity and adherence by maintaining contact even after referrals are made

Lower Risk But Risk Still Exists

•Self harm with no suicidal intent •Depressive symptoms with no suicidal

thoughts•Dysfunction or distress from emotional or

behavioral symptoms •Desire to resolve recent stressor/conflict•Hope for the future•Good social support

Approach to Self Harm Behavior

•Adolescents found disclosure made the situation worse in some cases; they found health services to be judgemental and stigmatizing

• It is important to maintain a non-judgemental, sensitive, open-minded and respectful attitude with the focus kept on the person and not their self-harm behavior

InnovAiT, Vol. 1, No. 11, pp. 750 – 758,

2008

BATHE

•Establish the Background situation “tell me what has been happening”

•Find out how it is Affecting them emotionally “how does that make you feel?”

•Establish the main problem “what is Troubling you the most?”

•Ask about current ways of coping “how are you Handling this?”

•Use Empathic listening throughout

If Lower Risk:

•Validation and letting them know you will help

•Refer for further evaluation and treatment

•Inform appropriate people when there is a risk of suicide – safety takes precedence over confidentiality

•Help family identify potential precipitants and begin process of problem solving

Acute Management

•Adequate supervision and support available

•Securing or disposing potentially lethal means (most common method is firearm)

•Limiting access to alcohol or disinhibiting substances

•Value of “no suicide contracts” not known•Phone calls during transition time•Safety Planning

Safety/Crisis Plan

•Identify triggers•Identify early warning signs•Identify possible interventions (eg.

distress tolerance skills)•People to turn to for help

Mental health referral appointment

Example for an Adolescent

My triggers are:• Pressure to do things that are above my ability• Feeling unwanted/rejected by friends.• Social worries• When others aren’t concrete about what they expect from me. My early warning signs are:• I become argumentative.• I bite my lip or fingers• I sigh loudly• I raise my voice When my parents/caregivers notice my early warning signs, they can:• Talk to me• Ask how I am feeling• Ask “how can I help”• Give me a hugWhen I notice my early warning signs, I will try to:• Play guitar• Listen to IPOD• Practice deep breathing• JournalIf I am unable to help myself or accept help from my family/caregivers, then our crisis plan is:• Call therapist• Call grandparents • Call county crisis line • Call 911 if emergency.

Example for Younger ChildCRISIS TRIGGERS, WARNING SIGNS, AND INTERVENTIONS My triggers are: 1. When kids call me names2. Getting scratched/hurt3. Feeling scared or mad4. Waiting a long time My early warning signs are:1. Yelling2. Telling people to 'stop'3. Posturing at people4. Having trouble listening to people Things I can do when I notice my early warning signs:1. Punch a pillow2. Take a big breath3. Color, and/or distract myself4. Eat a snack If I am unable to help myself I can call:1. My Aunt Kelly2. Therapist3. After-Hours Crisis Line - 206.726.2191

Psychotherapy Tailored to Particular Needs = Decreasing Risk Factors

•Cognitive Behavioral Therapy•Interpersonal Psychotherapy•Dialectical Behavioral Therapy (only

psychotherapy effective in reducing suicidal behavior in adults with borderline personality disorder)

•Psychodynamic therapy•Family Therapy

Psychopharmacology

Medications can help with associated symptoms, but will not resolve suicide ideation itself

Lithium

•Reduced recurrence of suicide attempts in adults with major depression or bipolar disorder by 9 fold

•Discontinuation associated with 7 fold increase in suicide attempts and 9 fold increase in rates of suicide

•Multiple side effects•Overdose fatal

SSRI’s As Reducing Suicides• In the U.S: every 1% increase in adolescent use of

antidepressants correlates with a decrease of 0.23 suicides per 100,000

• Population studies in Sweden, Italy, Netherlands, Australia, and U.S. all show decreased youth suicide rates with increasing antidepressant use

• 14% increase in U.S. youth suicides in 2004, the year SSRI usage started falling due to the black box warnings

Olfson, M et al. Arch Gen Psych 2003

Gibbons R et al. Arch Gen Psych 2004

Gibbons RD, Brown CH, et al 2007

SSRIs – FDA Columbia Review• 24 studies with SSRI’s submitted to FDA

▫ 4582 children

• For all diagnoses: Suicidality overall risk ratio 1.95 (95%CI=1.28-2.98)▫ Statistic in the Black Box Warning

• For Major Depression: Suicidality overall risk ratio 1.66 (95%CI=1.02-2.68)

• No youth fatalities occurred in a clinical trial

T Hammad, T Laughren, 2006

SSRI suicidality differences

Risk Ratio 95% confidence interval▫Venlafaxine RR 8.84 (1.12-69.5)▫Sertraline RR 2.16 (0.48-9.62)▫Paroxetine RR 2.15 (0.71-6.52)▫Mirtazepine RR 1.58 (0.06-38.37)▫Fluoxetine RR 1.53 (0.74-3.16)▫Citalopram RR 1.37 (0.53-3.50)

T Hammad, T Laughren, J Racoosin 2006

How I Make Sense of SSRI Suicidality

• Agitation/anxiety is a SSRI side effect▫ Common side effect, happens early on▫ If make depressed or anxious person more anxious, logical to

get some suicidal thoughts

• SSRI induced suicidal thoughts CAN happen, but they usually don’t▫ Why I check in with patient 1-2 weeks after starting medicine

Bridge et al, JAMA 2007

Starting An SSRI•Start low, go slow•Change one medicine at a time•Use a full dose range, wait 4-6 weeks

before each increase•Check in with patient 1-2 weeks after

starting to ensure no new suicidality

Reality of the Situation

•Suicidal risk can only be reduced, not eliminated

•Risk factors only provide guidance in assessment

•Adolescents may have their own agenda – information provided can be subjective

•Safety planning is key

Key Points To Take Away: If there is any question, err on the side of safetyDefinitely send to the ER or call for MHP:• If suicidal ideation is persistent• Serious lethality in thought or attempt• Agitation with suicidal thoughts • Clear lack of social support with safety plan• Efforts made to minimize chance of

intervention or discovery with an attempt• Regret of attempt completion • Severe hopelessness

TABLE 4Checklist before discharging an adolescent who has attempted suicide.Before Discharging a Patient from the ER or Crisis Center, Always:• Caution patient and family about disinhibitingeffects of drugs or alcohol• Check that firearms and lethal medications can beeffectively secured or removed• Check that there is a supportive person at home• Check that a follow-up appointment has beenscheduled

AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents With Suicidal Behavior, July 2001

Helpful ReferencesShain, et al., “Suicide and Suicide Attempts in

Adolescents” Pediatrics, vol 120/3, Sept 2007.www.aacap.org: AACAP Practice Parameters for

the Assessment and Treatment of Children and Adolescents With Suicidal Behavior, July 2001

www.teenscreen.org: community based mental health screening program

www.thetrevorproject.org: offers resources for LGBT youth

www.afsp.org/schools: American Foundation of Suicide Prevention – resources for schools