Most people value life over everything else and, in most cases, will do anything to preserve it, therefore when we hear that someone commits suicide, it is very difficult to fathom. Frequently it brings up feelings of shock, rage, or sadness. It is challenging for most people to grasp why someone would voluntarily end their life. Most people have experienced pain and suffering at one point in their lives and maybe momentarily have thought, “what would it be like to not be here anymore?” In most situations, if these thoughts come up, they are usually fleeting and can be shaken off.
Suicide in youth typically has a bigger impact on families and communities. For those that have been affected, it ends up being very painful and difficult to overcome. Many of these families suffer in silence because the pain, loss, and guilt they experience make it hard for them to share and talk about. Most physicians and specialists dealing with this challenging situation will need to listen empathically and be attuned to those going through this difficult time. This is a skill that we can all improve on.
Recent research helps us see the scope of this problem. Suicide in children under 12 years is rare, occurring about 1 in a million, although the impact is always devastating. During adolescence, the suicide rates increase significantly; 2 per 100,000 under 14 years of age and 10 per 100,000 in the 15–19-year-old population.
During 2019-2020, deaths by firearms (homicides, suicides, and accidental deaths) became the number one cause of death in youth, superseding motor vehicle accidents in this age group. U.S. 2020 data shows Firearm deaths in children 1-19 years old were 56.2 per million vs. 0.5 and 0.3 in the United Kingdom and Japan, respectively. Suicide became the third leading cause of death in adolescence. These numbers challenge our society, which begs the question, how do we keep our children safe?
Developmentally, the very young struggle to understand certain aspects of death, including the following components: inevitability, universality, irreversibility, cessation, and causation. Children 4-7 years old first comprehend irreversibility, and lastly, the concept of causation of death. It is important not to dismiss young children when they bring up the concept of death or wanting to die. Instead, we need to help them understand what they are experiencing and how we can support them during these moments of fragility.
The precipitants and causes of suicide in very young children are frequently tied to family and school problems or occur during the period of transition. In a recent systematic review of 63 studies of over 50,000 participants, there were clear associations between loneliness, social isolation, and mental health issues that led to depression, social anxiety, and post-traumatic stress disorder. The recent COVID19 Pandemic has contributed to significant social isolation and loneliness. Other precipitants and risk factors include recurrent suicidal attempts, irritability, substance use, and hopelessness.
Frequently, people ask, “how is it possible that a person gets to the point where suicide is the only option?” Even more so in children. The answer is complex and likely involves multiple factors that come together at a specific moment. The Interpersonal Theory of Suicide concludes that; feelings of not belonging, being a burden to others, repeated exposure, tolerance to painful events and desensitization, and decreased fear of death from previous attempts can lead to suicide. Other factors include lack of connectedness and immaturity of brain functions, including cognitive, impulse control, and emotional dysregulation during adolescence.
So, what can we do to help prevent suicide in children? Certainly, understanding child development, prevalence, and risk factors are important. But we must construct and implement better, more effective suicide prevention approaches. I will now focus on suicide prevention, using an interesting paradigm that I came across and that I find useful.
I generally tend to gravitate towards storytelling to understand and share information. Recently, I came across an interesting article by David Brent, MD, who uses the example of Holden Caulfield from the novel “The Catcher in the Rye” (J.D. Salinger 1951). Holden is a depressed and lonely kid that has lost hope and, at times, contemplates suicide. At one point, he fantasizes that he can save thousands of kids playing in a rye field by preventing them from falling off a nearby cliff; he sees himself standing at the cliff’s edge, ready to catch them before they fall.
Dr. Brent notes that we can use this analogy in suicide prevention of children by expanding Holden’s good intentions and using more effective approaches to saving children. He proposes four ways that we can augment these efforts:
- Leading kids away from the cliff: Prevention approaches, attending to child maltreatment, Adverse Childhood Experiences (ACE), family and school-based interventions, educating pediatricians and other primary care physicians on screening and referring children with suicidality.
- Going to the rye field where the children are playing instead of waiting for them at the cliff. This is akin to improving access to care.
- Working as part of a team. No one can do this work alone; it takes a team! Here he emphasizes the successful Zero Suicide Initiative (ZSI) that has been used worldwide and implements evidenced-based approaches that attempt to mitigate silos and ensure close follow-up with those at risk.
- Building a fence around the cliff. We can improve barriers to protect children with a strong emphasis on gun safety. Our country’s current attitudes and laws frequently make firearms accessible in homes. While also considering that firearms are the number one cause of death in youth, we might need to shift our focus to a more viable solutions for gun safety, including better and more secure weapon storage.
I believe that as caring adults, we all want to do a better job in improving suffering, addressing mental health issues, and diminishing the risk of suicide in youth. We can join Holden, not only in his wishes but in our efforts, by becoming more effective catchers in the rye.
References:
Master Clinician Review: Saving Holden Caulfield:
Suicide Prevention in Children and Adolescents by David A. Brent, MD
Rapid Systematic Review: The Impact of Social Isolation
and Loneliness on the Mental Health of Children and
Adolescents in the Context of COVID-19 by Maria Elizabeth Loades, et.al.
Suicidal and Self-Harming Preschoolers by
Kanita Dervic, MD, and Maria A. Oquendo, MD, PhD
