Pediatric emergency medicine trisk 4174 4174
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Suicide is the final common pathway for various situations in which
the child experiences a pervasive sense of helplessness, with a
perceived absence of alternative solutions. To the distressed child,
suicide appears to be the only solution to his or her problems and
the family’s problems. Most suicide attempts occur in depressed
children; others occur with children experiencing major losses, such
as serious illness or death in the family or in children with
depression with associated impulsivity. A small but significant
percentage of suicide attempts occur in psychotic children and
adolescents ( Table 126.9 ).
Children have differing conceptions of death at various ages. Up
to age 5, death is seen as a reversible process in which the activities
of life still occur. From 5 to 9 years, the irreversibility of death is
beginning to be understood, but death is personified rather than
seen as an independent event. It is not until about age 9 that death
is seen as irreversible in the adult sense of being both final and
inevitable. Even then, however, the child may imagine his or her own
death as being reversible. Under such circumstances, a suicide
attempt may have a different meaning than for an adult, where
suicide corresponds to a definite end of one’s life.
While it is common for psychiatric symptoms to be present for
weeks to months before an attempt and the vast majority of patients
who suicide meet criteria for a psychiatric or substance abuse
diagnosis at the time of their death, the time between a patient
deciding to kill themselves and carrying out the act is often quite
short and often occurs in the midst of an acute crisis. Studies of
survivors of potentially lethal attempts suggest that close to 25% act
on their decision within 5 minutes, another nearly 25% act between
5 and 19 minutes, while another nearly 25% act between 20 minutes
and 1 hour. This means that effective prevention efforts include the
strategies of identifying and treating psychiatric disorders prior to the
development of suicidal ideation as well as efforts to restrict access
to the most lethal and common means of suicide attempts.
Emergency physicians must provide clear guidance around
means restriction including firearms and potentially dangerous
medications. Over 80% of pediatric patients who suicided by firearm
