University of Groningen
Psychosocial risk factors for suicidality in children and adolescents
STOP Consortium; Carballo, J. J.; Llorente, C.; Kehrmann, L.; Flamarique, I.; Zuddas, A.;
Purper-Ouakil, D.; Hoekstra, P. J.; Coghill, D.; Schulze, U. M. E.
Published in:
European Child & Adolescent Psychiatry
DOI:
10.1007/s00787-018-01270-9
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STOP Consortium, Carballo, J. J., Llorente, C., Kehrmann, L., Flamarique, I., Zuddas, A., Purper-Ouakil,
D., Hoekstra, P. J., Coghill, D., Schulze, U. M. E., Dittmann, R. W., Buitelaar, J. K., Castro-Fornieles, J.,
Lievesley, K., Santosh, P., & Arango, C. (2020). Psychosocial risk factors for suicidality in children and
adolescents. European Child & Adolescent Psychiatry, 29(6), 759-776.
https://doi.org/10.1007/s00787-018-01270-9
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https://doi.org/10.1007/s00787-018-01270-9
REVIEW
Psychosocial risk factors for suicidality in children and adolescents
J. J. Carballo
1· C. Llorente
1· L. Kehrmann
1· I. Flamarique
2· A. Zuddas
3· D. Purper‑Ouakil
4· P. J. Hoekstra
5·
D. Coghill
6,7,8,9· U. M. E. Schulze
10· R. W. Dittmann
11· J. K. Buitelaar
12· J. Castro‑Fornieles
2,13,14· K. Lievesley
15,16,17·
Paramala Santosh
15,16,17· C. Arango
1on behalf of the STOP Consortium
Received: 19 September 2018 / Accepted: 20 December 2018 / Published online: 25 January 2019 © The Author(s) 2019
Abstract
Suicidality in childhood and adolescence is of increasing concern. The aim of this paper was to review the published
lit-erature identifying key psychosocial risk factors for suicidality in the paediatric population. A systematic two-step search
was carried out following the PRISMA statement guidelines, using the terms ‘suicidality, suicide, and self-harm’ combined
with terms ‘infant, child, adolescent’ according to the US National Library of Medicine and the National Institutes of Health
classification of ages. Forty-four studies were included in the qualitative synthesis. The review identified three main factors
that appear to increase the risk of suicidality: psychological factors (depression, anxiety, previous suicide attempt, drug
and alcohol use, and other comorbid psychiatric disorders); stressful life events (family problems and peer conflicts); and
personality traits (such as neuroticism and impulsivity). The evidence highlights the complexity of suicidality and points
towards an interaction of factors contributing to suicidal behaviour. More information is needed to understand the complex
relationship between risk factors for suicidality. Prospective studies with adequate sample sizes are needed to investigate
these multiple variables of risk concurrently and over time.
Keywords
Children · Adolescents · Youth · Suicidality · Risk · Resilience · Psychosocial · Web-based · Questionnaire
Introduction
Suicide is one of the major causes of death worldwide, and
approximately one million people commit suicide each year
[
1
]. The incidence of suicide attempts peaks during the
mid-adolescent years, and suicide mortality, which increases with
age steadily through the teenage years, is the third leading
cause of death in young people between the ages of 10 and
24 [
2
].
Suicidal acts and behaviours are a matter of great concern
for clinicians who deal with paediatric patients with mental
health problems. Despite its importance, research on
suici-dality among children and adolescents has been hampered
by the lack of clarity of definition. Beyond suicidal
idea-tion and suicide plans, there are a number of behaviours in
which there is an intention to die, including suicide attempts,
interrupted attempts, aborted attempts, and other suicidal
preparatory acts. Suicidal behaviours require, not only the
self-injurious act, but also there must be a suicidal intent. By
contrast, when individuals engage in self-injurious
iours for reasons other than ending their lives, this
behav-iour is termed non-suicidal self-injury. Deliberate self-harm
behaviours comprise self-injurious behaviours regardless
their intentionality.
The features of suicidality in children and adolescents
are different from those occurring in adults [
3
] and there is
a need for tools to identify those young people at higher risk.
Depression is a factor strongly associated with suicidality in
this population [
4
], but it is not present in all cases [
5
],
indi-cating that suicidal behaviour is a result of the interaction
of multiple factors. Furthermore, not all depressed children
and adolescents develop suicidal ideation or behaviour [
6
],
indicating the importance of, e.g. social and
temperamen-tal factors. Predicting which adolescents are likely to repeat
their suicidal behaviour would help to establish prevention
and intervention strategies for suicidality in children and
adolescents.
The members of the STOP Consortium are mentioned in acknowledgements.
* Paramala Santosh
paramala.1.santosh@kcl.ac.uk
Biological, psychological, and social factors contribute to
a risk profile in children and adolescents. However, the
spe-cific purpose of this paper is to review the literature focusing
on psychosocial risk factors and suicidality among children
and adolescents.
Methods
Search strategy
A systematic two-step search was carried out following the
PRISMA statement guidelines [
7
]. A PubMed search was
performed using the following terms: (suicidality, suicide,
and self-harm), combined with (infant, child, adolescent)
according to the US National Library of Medicine and the
National Institutes of Health classification of ages using the
filters (humans, clinical trial, randomized controlled trial,
English), and limiting the search up to December 2016. This
search detected 710 papers. In a second step, the references
found in the relevant papers were reviewed, identifying 8
additional publications that had not emerged in the initial
search.
Selection criteria
Three researchers (JJC, CL, LK) independently evaluated
the abstracts of the 710 studies (see Fig.
1
for flowchart of
the literature review). Definitions of suicidal behaviour have
varied over time and sometimes differ between the US and
Europe. For this review, we considered suicidality a
con-tinuum and we used the broader definition of the term
harm (which includes both suicidal and non-suicidal
self-injurious behaviour as described at the Introduction section).
Papers were selected when they met the following
criteria:
•
Original articles published in English language from
ini-tial online databases until December 2016.
•
Child and adolescent participants (under 18 years of
age). In publications that included adults, only those
that reported on children or adolescents separately were
considered.
•
Publications whose main aim was to examine risk factors
for suicidal behaviour/ideation or that included
psycho-social variables as risk factors.
Papers were excluded as follows:
•
Reviews, editorials, letters, meta-analyses, and guidelines
were not considered for this review.
•
Studies that investigated the benefit of a therapy
(phar-macological, psychotherapeutic, or community
interven-tion), or only analysed suicidal methods, or evaluated
psychometric properties of assessment instruments, were
excluded.
As a result of this selection process, 77 full-text articles
were further assessed.
Data extraction
The same three researchers (JJC, CL, and LK) reviewed the
selected manuscripts. For each study, the following data
were extracted: author names, year of publication, number
of subjects, age of subjects, inclusion criteria, methodology,
and outcome measures.
Data synthesis and analysis
Studies were classified according to the type of risk
fac-tors assessed (psychological facfac-tors, adverse life events,
and temperament and character factors) and as to sample
recruited (clinical vs non clinical samples). Adjusted results
were presented.
Results
Psychological factors
Twenty-five of the papers reviewed focused on
psychologi-cal issues as a key outcome measure, and we summarize
them below. Depression, previous suicidal attempts, and
substance abuse were embedded within a large proportion
of the reviewed literature, so we present the studies grouped
accordingly. These 25 studies are listed in Tables
1
and
2
(reporting studies based on clinical and non-clinical
sam-ples, separately).
Depression
Depression is considered a major factor in the aetiology
of suicidality in children and adolescents [
4
,
8
–
12
], and it
has been reported in both clinical and non-clinical samples.
Major depressive disorder was associated with a fivefold
higher risk for suicide attempts, even after controlling for
other disorders [
4
], gender, age, race, and socioeconomic
status [
8
,
13
]. In addition, results from a cross-sectional
study conducted by Spann et al. suggest that depressive
symptomatology (measured by means of the Beck
Depres-sion Inventory) mediate the relationship between
hopeless-ness and suicidal behaviours [
9
].
Nevertheless, non-depressed adolescents may also report
suicidal ideation and/or display suicidal behaviours [
5
,
14
].
Previous suicide attempt
Converging results from longitudinal studies indicate that a
previous suicide attempt is an important predictor of a future
suicide attempt, reported in both clinical and non-clinical
samples, increasing the risk more than threefold during
follow-up [
15
,
16
]. Similarly, results from other prospective
studies have shown that prior suicidal behaviour is strongly
associated with suicide plans [
17
], and a previous history of
non-suicidal self-injury may predict the occurrence of future
non-suicidal self-injury [
18
].
Drug and alcohol misuse
Cross-sectional and longitudinal studies evaluating alcohol
consumption among adolescents have consistently shown
that alcohol misuse is a risk factor for suicidal behaviour
in clinical and non-clinical samples [
5
,
8
,
18
,
19
].
Further-more, alcohol misuse may trigger suicidal ideation even in
the absence of high levels of depressive symptoms [
5
].
Relatedly, smoking and abuse of drugs (such as
canna-bis) may increase the risk of suicidal behaviour [
8
,
11
,
13
,
20
–
22
], and the risk increases even more when drugs are
used simultaneously with alcohol [
4
], which occurs quite
frequently [
23
].
Other psychiatric diagnoses
Suicidal behaviour in children and adolescents may occur in
relation to other psychiatric disorders, such as anxiety
disor-ders [
8
,
20
], eating disorders [
24
–
26
], bipolar disorder [
16
],
psychotic disorders [
25
,
27
], affective dysregulation [
5
],
sleep disturbances [
28
], and externalizing disorders [
29
]. A
growing interest has focused on the study of suicidal
behav-iour in autism spectrum disorders [
30
]. Risk for suicidality
seems to be increased as a function of the number of
comor-bid disorders [
4
]. In addition, as illustrated in a follow-up
study, rehospitalisation appears to be a strong indicator of a
future risk of a suicide attempt [
31
].
Other risk behaviours
Suicidality in this age range may be associated with low
instrumental and social competence, and having been in a
fight in which there was punching or kicking in the previous
year [
8
].
Adverse life events
Serious adverse life events have been reported as preceding
some suicides and/or suicide attempts [
8
,
14
,
32
]. They are
rarely a sufficient cause for suicide/suicide attempts in
isola-tion, and their importance lies in their action as precipitating
factors in young people who are at risk by virtue of, e.g. a
psychiatric condition and/or of other risk factors for
suici-dality as detailed below. In this vein, stress-diathesis models
proposed that stressful life events interact with
vulnerabil-ity factors to increase the probabilvulnerabil-ity of suicidal behaviour.
Nevertheless, stressful life events vary with age. In children
and adolescents, life events preceding suicidal behaviour are
usually family conflicts, academic stressors (including
bul-lying or exam stress), trauma and other stressful live events.
In this review, 11 studies assessed stressors that occur before
suicidal behaviour, with similar results for both studies using
clinical and non-clinical samples (see Tables
3
and
4
).
Fig. 1 Study selection flowchart
(using PRISMA guidelines) [7] 1499 records identified by Pubmed searches
8 additional records detected reviewing the references of
relevant papers
715 records, after duplicates were removed
710 abstracts reviewed
33 full text articles excluded: (12 did not meet the age criteria, 4 did not meet the study design criteria, 17 did not meet the objective criteria) 77 full text articles assessed
44 studies included in the qualitative synthesis
Table
1
Clinical v
ar
iables and psy
chological f act ors. Clinical sam ples Ref er ences Sam ple Type of s tudy Measur es Results Buhr en e t al. [ 26 ] N = 148 Ag e (mean): 15.2 yr . IC: firs t onse t of anor exia ner vosa Cr oss-sectional s tudy BDI EDI-2 K-S ADS SIAB-EX The bing e-pur ging subtype w as associated wit h suicidal ideation ( p = 0.0008) and self-injur ious beha viour ( p = 0.01) Br ent e t al. [ 18 ] N = 334 Ag e: 12–18 yr . IC: CDRS-R ≥ 40 and CGI-S ≥ 4 Pr ospectiv e s tudy BDI BHS CBQ C-C AS A CDRS-R K-S ADS SIQ-Jr Pr edict
ors of suicidal adv
erse e
vents included self-r
ated suicidal ideation (OR 1.02,
95% CI 1.01–1.04) and dr
ug or alcohol use (OR 1.9, 95% CI 0.9–3.9)
His tor y of non-suicidal self-injur y (OR 9.6, 95% CI 3.5–26.1) pr edicts non-suicidal self-injur y e vents Vitiello e t al. [ 12 ] N = 439 Ag e: 12–17 yr . IC: ma jor depr essiv e disor der Pr ospectiv e s tudy BHS CBQ C-C AS A CDRS-R K-S ADS-PL
MASC RADS SIQ-Jr
Suicidal e
vent w
as significantl
y associated wit
h high suicidal ideation le
vels at base -line (OR 2.0, 95% CI 1.1–3.8; p = 0.03) and ele vated depr essiv e sym pt omat ology at baseline (OR 2.0, 95% CI 1.0–3.9; p = 0.04) Blac k e t al. [ 23 ] N = 2389 Ag e: < 25 yr . IC: pr esenting t o Emer gency Depar tment wit h injur ies Re trospectiv e s tudy Recor ds fr om t he Canadian Hospit als Injur y R epor ting and Pr ev ention Pr og ram Dat abase about t he cir -cums tances of t he injur y 37.5% of self-har m injur ies r elated t o alcohol, in vol ved t he consum ption of alcohol along wit h o ther dr ugs Golds ton e t al. [ 4 ] N = 180 Ag e: 12–19 yr . IC: disc har ge fr om an in pa -tient unit Pr ospectiv e, natur al -istic s tudy FIS A ISC A Le thality of Suicide A ttem pt Rating Scale Incr easing r isk f or S A as a function of incr
easing number of disor
ders ( b = 0.90, SE = 0.08, χ 2 = 141.97, HR = 2.46, p < 0.0001) Relationship be tw
een specific contem
por aneous psy chiatr ic disor ders and S A: ma jor depr essiv e disor der [HR 5.53 (3.35, 9.12), p < 0.001], dy sth ymic disor der [HR 2.00 (0.99, 4.01), p = 0.047], depr essiv e disor der N OS [HR 2.51 (0.77, 8.17), p = 0.119], gener alized anxie ty disor der [HR 1.96 (0.69, 5.53), p = 0.200], phobias [HR 1.07 (0.22, 5.31), p = 0.931], panic disor der [HR 2.35 (1.08, 5.16), p = 0.027], ADHD [HR 1.52 (0.77, 3.00), p = 0.216], OCC [HR 0.997 (0.33, 3.00), p = 0.996], CD [HR 2.31 (1.32, 4.06), p = 0.003], subs
tance use disor
der [HR 1.62 (0.85, 3.06), p = 0.134] Asar no w e t al. [ 11 ] N = 210 Ag e: 10–18 yr .
IC: suicide attem
pt and/or ideation Cr oss-sectional s tudy CBCL CBQ CES-D Life Ev ents Scale YRBS Risk f act ors f or S A: se ver e depr essiv e sym pt
oms (OR [95% CI] 1.03 [1.00–1.05];
p <
0.05), e
xter
nalizing beha
viour (OR [95% CI] 1.04 [1.01–1.07];
p <
0.01),
thought pr
oblems (OR [95% CI] 1.04 [1.01–1.06];
p <
0.01), subs
tance use (OR
[95% CI]: 2.88 [1.43–5.79]; p < 0.01) Fisher and le Gr ang e [ 24 ] N = 80 Ag e: mean 16.1 yr . (SD: 1.6)
IC: bulimia ner
vosa, outpa -tient Cr oss-sectional s tudy EDE K-S ADS SA no t r elated t o comorbid psy chiatr ic diagnosis ( χ 2 = 0.66, p < 0.41) among subjects wit h bulimia ner vosa
Table 1 (continued) Ref er ences Sam ple Type of s tudy Measur es Results Golds tein e t al. [ 16 ] N = 405 Ag e: 7–17 yr .
IC: bipolar disor
der Cr oss-sectional s tudy K-S ADS Risk f act ors f or S A: psy chiatr ic hospit alizations (OR 2.47, 95% CI 1.48–4.13, p = 0.001), his tor y of self-injur ious beha viour (OR 2.24, 95% CI 1.39–3.63, p = 0.001), mix ed episodes (OR 2.03, 95% CI 1.21–3.41, p = 0.007), comorbid panic disor der (OR 4.0, 95% CI 1.36–11.76, p = 0.01), comorbid subs tance use disor der (OR 2.76, 95% CI 1.21–6.28, p = 0.02), and psy chosis (OR 1.73, 95% CI 1.05–2.85, p = 0.03) W einer e t al. [ 21 ] N = 564 Childr en and adolescents IC: r esidential tr eatment and state cus tody Re trospectiv e s tudy Char t r evie w disc har ge placements Subs
tance use disor
ders incr ease t he r isk f or S A (gir ls: χ 2 = 10.13; p < 0.05; bo ys: χ 2 = 4.56; p < 0.01) St or ch e t al. [ 30 ] N = 102 Ag e: 7–16 yr . IC: y out h wit h ASD diag
-noses and co-occur
ring anxie ty pr oblems Cr oss-sectional s tudy
ADIS CBCL CIS-PV MASC PARS
Tw
enty per
cent of t
he whole sam
ple (20/102) endorsed eit
her t hinking a lo t about deat h or dying, ha ving suicidal t houghts, or ha ving a his tor y of a suicide attem pt The pr
esence of a comorbid diagnosis of ma
jor depr essiv e disor der/dy sth ymia and pos t-tr aumatic s tress disor der significantl y incr eases t he lik elihood of displa ying suicidal t
houghts and beha
viours Czyz e t al. [ 31 ] N = 373 Ag e: 13–17 yr .
IC: suicide attem
pters or ideat ors in pr evious mont h Pr ospectiv e s tudy (9 mont hs)
BHS CDRS-R PEPSS PESQ SIQ-Jr YSR
Rehospit alisation significantl y incr eased t he r isk of pos t disc har ge suicide attem pts dur ing f ollo w-up per iod (hazar d r atio = 3.13, p < 0.001) ADHD attention deficit/h yper activity disor der ; ADIS anxie ty disor der inter vie w sc hedule-c
hild and par
ent v ersions, ADS A dolescent Depr ession Scale, ASD autism spectr um disor der , BDI Bec k Depr ession In vent or y, BHS Bec k Hopelessness Scale, CBCL child beha vior c hec klis t, CBQ Conflict Beha vior Ques tionnair e, C-C AS
A Columbia Classification Algor
ithm of Suicide Assessment,
CD conduct disor der , CDRS-R Child Depr ession R ating Scale-R evised, CES-D Center f or Epidemiological S tudies of Depr ession, CI confidence inter val; CIS-PV Columbia Im pair ment Scale-Par ent Version, CGI-S Clinical Global Im pr ession-Se ver ity Subscale, EDE eating disor der ex amination, EDI-2 Eating Disor der In vent or y, FIS A follo w-up inter vie w sc hedule for adults, IC inclusion cr iter ia, ISC A inter vie w sc hedule f or c hildr en and adolescents, K-S ADS kiddie-sc hedule f or affectiv e disor ders and sc hizophr enia, MASC Multidimensional Anxie ty Scale f or Childr en, ODD
oppositional defiant disor
der , OR odds r atio, PARS P ediatr ic Anxie ty R ating Scale; PESQ P ersonal Exper ience Scr eening Ques tionnair e; PEPSS P er ceiv ed Emo tional/P ersonal Suppor t Scale, RADS R eynolds A dolescent Depr ession Scale, SA suicide attem pt, SIAB-EX str uctur ed inter vie w f or anor
exic and bulimic disor
ders, SIQ-Jr suicidal ideation q ues tionnair e adap ted f or adolescents, yr. y ears; YRBS y out h r isk beha vior sur ve y, YS R y out h self r epor t
Table 2 Psy chological f act ors. N on-clinical sam ples Ref er ences Sam ple Type of s tudy Measur es Results Sing ar eddy e t al. [ 28 ] N = 693 Ag e = 5–12 yr . IC: s tudents Cr oss-sectional s tudy CBCL 4-point Lik er t scale measur ed sui -cidal beha viour pol ysomnog ram Higher per
cent of REM sleep in subjects wit
h self-har m beha viours (p = 0.045), e ven af ter adjus ting f or demog
raphics and depr
ession Kelleher e t al. [ 27 ] N = 1112 Ag e: 13–16 yr . IC: s tudents Pr ospectiv e cohor t s tudy Adolescent psy cho tic Sym pt oms Scr eener Pa yk el Suicide Scale SDQ
Among adolescents who r
epor ted psy cho tic sym pt oms, 14% r epor ted a S A b y 3 mont hs (OR 17.91; 95% CI 3.61–88.82) and 34% b y 12 mont hs (OR 32.67; 95% CI 10.42–102.41). OR acute S A: 67.50 (95% CI 11.41–399.21) O’Connor e t al. [ 20 ] N = 2008 Ag e: 15–16 yr . IC: s tudents Cr oss-sectional sur ve y Version of t he C ASE q ues tionnair e Fact ors independentl y associated wit h self-har m Gir ls: smoking (OR r ang e 2.06–2.36 accor ding t o number of cig a-re ttes; p < 0.05), dr ug use (OR 1.95; 95% CI 1.19–3.18; p < 0.01), and anxie ty (OR 1.13; 95% CI 1.06–1.19; p < 0.001) Bo
ys: smoking (OR r
ang e 11.0–7.74 accor ding t o number of cig a-re ttes; p < 0.001) and anxie ty (OR 1.17; 95% CI 1.07–1.27; p < 0.001) Ar ria e t al. [ 5 ] N = 1249 Ag e: 17–19 yr . IC: firs t-y ear colleg e s tudents Pr ospectiv e cohor t s tudy BDI DI QRI SSAS
Suicidal ideation among individuals wit
hout high le vels of depr essiv e sym pt oms w as pr edicted b y: affectiv e dy sr egulation ( χ 2 18.6; OR 1.1;
95% CI 1.0–1.1), and alcohol use disor
der ( χ 2 7.9; OR 2.0; 95% CI 1.2–3.3; p < 0.01) Rosso w e t al. [ 19 ] N = 30532 Ag e: 15–16 yr . IC: s tudents Cr oss-sectional inter na -tional sur ve y Self-adminis ter ed q ues tionnair es Ele vated r isk of deliber ate self-har m among hea vy dr ink ers (ORs be tw een 1.7 and 4.2; p < 0.05) Spann e t al. [ 9 ] N = 176 Ag e: 13–19 yr . IC: s tudents Cr oss-sectional s tudy HSC RADS RCS SEQ When contr olling f or depr ession, no significant r elationship be tw een
hopelessness and suicidal ideation [
B = − 0.051, F(2, 167) = 0.422, p = 0.52] or attem pt [ B = − 0.04, F(2, 172) = 0.20, p = 0.66] Par k e t al. [ 13 ] N = 501 Ag e: adolescents IC: s tudents Cr oss-sectional s tudy PA CI SCL -90-R SSI Males: lif e satisf action, depr ession, and f amil y communication explained 28% of t he v ar iance. Lif e satisf action w as t he s trong es t pr edict or of suicidal ideation ( β = − 0.315, p < 0.001), follo wed by depr ession ( β = 0.247, p < 0.001) Females: depr
ession, smoking, and lif
e satisf action e xplained 38% of t he v ar iance. Depr ession w as t he s trong es t pr edict or of suicidal ideation ( β = 0.375, p < 0.001), f ollo wed b y smoking ( β = − 0.265, p < 0.001) W ilco x e t Ant hon y [ 22 ] N = 169 Ag e at firs t assessment : 8–15 yr . IC: s tudents Pr ospectiv e cohor t s tudy Self-adminis ter ed s tandar dized ques tions Ear ly -onse t (< 16 yr
.) of cannabis use incr
eased r isk of S A (cannabis-associated RR = 1.9; p =
0.04) and suicide ideation in f
emales (RR = 2.9; p = 0.006). N o association f or ear ly -onse t alcohol and tobacco use
Table 2 (continued) Ref er ences Sam ple Type of s tudy Measur es Results Beautr ais [ 14 ] N = 60 suicide com ple ters (ag e: 14–24 yr .); 125 medicall y ser ious S A (ag e: 13–24 yr .), and 151
non-suicidal community com
par
ison subjects (ag
e: 18–24 yr .) Cr oss-sectional s tudy Semi-s tructur ed inter vie w Thr eatening lif e e xper iences Suicide attem pters g roup v s non-suicidal subjects Male g ender (OR 9.9, 95% CI 3.5–28.0, p < 0.0001), lac k of f or mal educational q ualification (OR 7.0, 95% CI 2.8–17.7, p < 0.0001), mood disor der in t he pr eceding mont h (OR 4.4, 95% CI 1.4–14.0, p < 0.05), his tor y of psy chiatr ic car e (OR 2.6, 95% CI 1.04–6.8, p < 0.05), and e xposur e t o r ecent s tressful lif e e vents (OR 13.8, 95% CI 4.6–40.8, p < 0.0001) SA v
s non-suicidal subjects: lac
k of f or mal educational q ualifica -tion (OR 6.0, 95% CI 2.6–13.9, p < 0.0001), mood disor der in t he pr eceding mont h (OR 17.1, 95% CI 7.0–41.5, p < 0.0001), his tor y of psy chiatr ic car e (OR 2.7, 95% CI 1.2–6.0, p < 0.05), and e xposur e t o recent s tressful lif e e vents (OR 8.4, 95% CI 3.3–20.9, p < 0.0001) Fat al v s non-f at al suicide attem pt : male g ender [OR 3.7, 95% CI 1.7–8.2, p <
0.001)], and mood disor
der in t he pr eceding mont h (OR 4.3, 95% CI 2.1–8.7, p < 0.0001) Ag erbo e t al. [ 25 ] N =
496 suicide victims and
24,800 matc hed contr ols Ag e: 10–21 yr . Cr oss-sectional s tudy Dat a fr om longitudinal Danish regis ters The s trong es t r isk f act or f or suicide com ple tion w as ment al illness in the y oung (attr ibut able r isk 15%) (95% CI 12–17): sc hizophr enia (IRR 33.1, 95% CI 16.5–66.3), affectiv e disor ders (IRR 24.3, 95% CI 6.64–88.7), eating disor
ders (IRR 84.9, 95% CI 7.17–1006), and
ot
her diagnoses (IRR 10.8, 95% CI 7.75–15.0)
King e t al. [ 8 ] N = 1285 Ag e 9–17 yr . IC: NIMH Me thods f or t he
Epidemiology of Child and Adolescent Ment
al Disor -ders (MEC A) S tudy Cr oss-sectional s tudy MEC A Ser
vice Utilization and Risk
Fact ors Ins truments Contr olling f or demog raphics: cur
rent mood (OR 11.4; 95% CI
6.9–19.0) or anxie ty disor der (OR 6.1; 95% CI 3.9–9.5), e ver ha ving smok ed mar
ijuana (OR 3.1; 95% CI 1.6–5.9), becoming dr
unk in the pas t 6 mont hs (OR 3.4; 95% CI 1.9–6.1), cur rentl y smoking > 1 cig ar ette/da y (OR 4.3; 95% CI 2.1–8.7) Adjus ting f or mood, anxie ty , or disr up tiv e disor der : becoming dr unk in the pas t 6 mont hs (OR 2.1; 95% CI 1.1–4.1), cur rentl y smoking > 1 cig ar ette/da y (OR 2.3; 95% CI 1.0–5.2) Hultén e t al. [ 15 ] N = 1264 Ag e: 15–19 yr . IC: S A Longitudinal s tudy WHO/EUR O Multicentr e S tudy on Suicidal Beha viour Repe tition mor e fr eq
uent among individuals who had used a “har
d” versus a “sof t” me thod (OR 1.51, 95% CI 1.11–2.05). Pr evious SA w as an independent pr edict or of r epe tition (OR 3.21, 95% CI 2.35–4.40) McK eo wn e t al. [ 17 ] N = 359 IC: s tudents Longitudinal s tudy CES-D Coddingt on Lif e Ev ents Scale f or Adolescents FACES-II K-S ADS Im pulsivity w as a significant pr edict
or of suicidal plans (OR 2.26; 95%
CI 1.27–4.02) but no
t of suicidal ideation or attem
pts
Pr
ior suicidal beha
viour w
as associated wit
h suicidal plans (OR 10.63;
Family conflicts
Family conflict has been associated with suicidal behaviour
[
18
], even after controlling for gender, age, and psychiatric
disorders [
8
]. Adolescents with a history of a suicide attempt
more frequently than controls report stress related to parents,
lack of adult support outside of the home, physical harm by a
parent, running away from home, and living apart from both
parents [
33
–
35
]. Other family situations associated with risk
for suicidality are: parental suicidal behaviour, early death,
mental illness in a relative, unemployment, low income,
neglect, parental divorce, other parent loss, and family
vio-lence [
20
,
25
,
29
,
36
].
Academic stressors
Students who perceive their academic performance as
fail-ing seem to be more likely to report suicidal thoughts, plans,
threats, and attempts or deliberate self-injury [
37
].
Perfec-tionism has been reported as a personality construct that may
be associated with suicidality in adult samples. However,
results from a pioneering study in children and adolescents
evaluating the Perfectionism Social Disconnection Model
suggest that the association between perfectionism and
sui-cidality is mediated by stressful life events (being bullied)
or by other psychological features such as learned
helpless-ness [
38
].
Trauma and other adverse life events
In addition to family conflicts or academic performance
problems, early traumatic experiences and other adverse life
events have been associated with suicidal behaviours. A
his-tory of childhood sexual abuse is associated with a 10.9-fold
increase in the odds of a suicide attempt between the ages
of 4 and 12 years and a 6.1-fold increase in the odds of an
attempt between the ages of 13 and 19 years [
36
].
Victims of bulling have higher rates of suicidal behaviour
and ideation [
39
,
40
], and some victims may be particularly
vulnerable to suicidal ideation due to parental
psychopathol-ogy and feelings of rejection at home [
41
].
Change of residence may result in loss of a familiar
envi-ronment as well as a breakdown of the social network, which
may induce stress and adjustment problems, and therefore,
increase the risk of suicidal behaviour [
42
].
Other stressful circumstances that may precede suicidal
behaviour are peer conflict, legal problems, physical abuse,
worries about sexual orientation, romantic breakups,
expo-sure to suicide/suicide attempts, and physical and/or
sex-ual violence among trafficked victims [
11
,
12
,
20
,
32
,
39
,
43
–
45
].
Table 2 (continued) Ref er ences Sam ple Type of s tudy Measur es Results Sour ander e t al. [ 29 ] N = 5302 Ag e: 8 yr . at assessment. Follo w-up dat a r ecor ded until ag e of 25 yr . IC: bir th cohor t s tudy Pr ospectiv e population-based s tudyCDI Rutter Ques
tionnair e Deat h cer tificates Finnish Hospit al Disc har ge R egis ter
Finnish Cause of Deat
h R
egis
ter
Among males, com
ple ted or ser ious S A w as pr edicted at t he ag e of 8 yr . b y R utter par ent t ot al scor e (OR 7.7; 95% CI 3.6–16.6; p < 0.001), R utter teac her t ot al scor e (OR 5.6; 95% CI 2.6–12.0; p < 0.001), psy chological pr oblems as r epor ted b y t he pr imar y teac her (OR 2.8; 95% CI 1.2–6.2; p < 0.01), conduct (OR 5.4; 95% CI 2.4–11.8; p < 0.001), h yper kine tic (OR 4.3; 95% CI 1.9–10.0; p < 0.001), and emo tional (OR 4.3; 95% CI 1.9–9.4; p < 0.001) pr ob -lems. Self-r epor ts of depr essiv e sym pt oms at t he ag e of 8 yr . did no t pr
edict suicidal outcome
BDI Bec k Depr ession In vent or y, CASE Child and A
dolescent Self Har
m in Eur ope, CBCL c hild beha vior c hec klis t, CES-D Center f or Epidemiological S tudies of Depr ession, CDI Childr en´s Depr ession In vent or y, DI Dy sr egulation In vent or y, FA CES-II F amil y A dap
tability and Cohesion Ev
aluation Scales, HSC Hopelessness Scale f or Childr en, IC inclusion cr iter ia, IRR incidence rate r atio, K-S ADS kiddie-sc hedule f or affectiv e disor ders and sc hizophr enia, MEC A me thods f or t he epidemiology of c
hild and adolescent ment
al disor ders, OR odds r atio, PA C I Pr e-Adolescent Clinical In vent or y, QRI Quality of R elationship In vent or y, RADS R eynolds Adolescent Depr ession Scale, RC S Religious Coping Scale, SA suicide attem pt, SDQ S trengt h and Difficulties Ques -tionnair e, SEQ Suicide Exper ience Ques tionnair e, SS AS Social Suppor t Appr aisals Scale, SSI Scale f or Suicidal Ideation, SCL -90-R Sym pt om Chec klis t-90-R, yr. y ears
Temperament and character
Some personality traits have been identified as predisposing
factors for suicidality. Neuroticism, perfectionism,
interper-sonal dependency, novelty-seeking, pessimism, low
self-esteem, a perception that one is worse off than one’s peers,
and self-criticism have been implicated as risk factors for
suicidality in adolescents [
20
,
37
,
46
–
49
]. Similarly,
mala-daptive coping styles have been described as a risk factor for
both depression and suicidal ideation [
50
].
Impulsivity has emerged as an important issue in
suici-dality [
17
,
20
,
51
,
52
], with 50% of adolescents having only
started thinking about self-harm less than an hour before the
act itself [
20
] (Tables
5
,
6
).
Discussion
Suicidality among children and adolescents is a topic of
increasing concern, and this is reflected in the strong/large
increase in the amount of literature assessing suicidality over
recent years. While deaths in these populations due to other
causes are decreasing, rates of suicide remain high [
2
]. This
highlights the importance of suicidality research and a move
to improving and developing suicide prevention strategies.
This review identifies several psychosocial risk factors
for suicidality (Table
7
).
The majority of publications reviewed in this present
work indicate that young people with suicidal behaviour had
significant psychiatric problems, mainly depressive
disor-ders and substance abuse disordisor-ders. The presence of a major
Table 3 Adverse life events. Clinical samples
Clinical samples
ADS Adolescent Depression Scale, BDI Beck Depression Inventory, BHS Beck Hopelessness Scale, CBCL child behavior checklist, CBQ Con-flict Behavior Questionnaire, C-CASA columbia classification algorithm of suicide assessment, CDRS-R Child Depression Rating Scale-Revised, CES-D Center for Epidemiological Studies of Depression, CGI-S Clinical Global Impression-Severity Subscale, CI confidence interval, IC inclusion criteria, K-SADS kiddie-schedule for affective disorders and schizophrenia, MASC Multidimensional Anxiety Scale for Children, OR odds ratio, PEPSS Perceived Emotional/Personal Support Scale, PESQ Personal Experience Screening Questionnaire, RADS Reynolds Adoles-cent Depression Scale, SA suicide attempt, SIQ-Jr Suicidal Ideation Questionnaire adapted for adolesAdoles-cents, SSB Spectrum of Suicide Behavior Scale, yr. years, YRBS youth risk behavior survey
References Sample Type of study Measures Results
Brent et al. [18] N = 334 Age: 12–18 yr.
IC: CDRS-R ≥ 40 and CGI-S ≥ 4
Prospective study BDI BHS CBQ CDRS-R K-SADS-PL SIQ-Jr
Family conflict is a predictor of suicidal adverse event (OR 1.1, 95% CI 1.03–1.16)
Vitiello et al. [12] N = 439 Age 12–17 yr.
IC: Major depressive disorder
Prospective study ADS BHS C-CASA CDRS-R K-SADS-PL MASC RADS SIQ-Jr
An acute interpersonal conflict identi-fied in 72.7% of cases of subjects with a suicidal adverse event (84% youth–parent conflict, 16% youth–peer conflict). Identifiable recent legal problem present in 13% of those subjects with a suicidal adverse event during follow-up
Qin et al. [42] N = 4160 SA; 79 completed suicides; 2370 matched controls
Age: 11–17 yr.
Prospective study Danish longitudinal
population registries
Attempted and completed suicide risk significantly increased with increasing changes of residence
Asarnow et al. [11] N = 210
Age: 10–18 yr. IC: SA and/or ideation. Cross-sectional study CBCLCBQ CES-D YRBS
Life Events Scale
Stressors associated with increased SA risk
Females: romantic breakups (OR 3.16; 95% CI 1.65–6.06; p < 0.001) and exposure to suicide/SA (OR 3.05; 95% CI 1.54–6.04; p < 0.001)
Males: romantic breakups (OR 5.12: 95% CI 1.61–16.24; p < 0.01) Kerr et al. [34] N = 220
Age: 12–18 yr. IC: inpatients Cross-sectional study BHSPEPSS PESQ RADS SIQ-JR SSB
Suicidal ideation associated with perceptions of lower family support among females (β = − 0.26, p = 0.002, and higher peer support among males (β = 0.24, p = 0.016)
Table 4 A dv erse lif e e vents. N on-clinical sam ples Ref er ences Sam ple Type of s tudy Measur es Results W an e t al. [ 44 ] N = 14211 Ag e: mean 15.1 yr . IC: s tudents Cr
oss-sectional school sur
ve
y
Par
ent–Child Conflict T
actics
Scale MSQA Screening Ques
tionnair e Students ’ e xposur e t o c hildhood abuse (ph ysical, emo tional or se xual) w as significantl y associated t o non-suicidal self-injur y beha viours (OR be tw een 2.43 and 4.95) Kiss e t al. [ 45 ] N = 387 Ag e: 10–17 yr . IC: pos t tr affic king ser vices admission Cr oss-sectional study Hopkins sym pt oms c hec klis t Scr eening Ques tionnair e Har var d T rauma Ques tionnair e Tr affic king e xper
iences associated wit
h suicidal ideation: se ver e ph ysical violence (A OR 3.68; 95% CI 1.77–7.67), se xual violence (A OR 3.43; 95% CI 1.80–6.54), extr emel y e xcessiv e w or k hours (A OR 2.69; 95% CI 1.38–5.26), r es tricted fr ee -dom (A OR 2.44; 95% CI 1.34–4.44), and t hr eats b y tr affic ker (A OR 3.59; 95% CI 1.92–6.73)
Pan and Spitt
al [ 32 ] N = 8182 IC: s tudents Cr oss-sectional study Global Sc hool-Based Healt h Sur ve y Association be tw
een suicidal ideation and r
eligious bull ying victimisation (A OR: 4.58, 95% CI 1.4–15.01) and r acial bull ying victimisation (A OR: 2.12, 95% CI 1.15–3.93) Fisher e t al. [ 40 ] N = 2141 Ag e: 12 yr .
IC: population-based bir
th cohor t Longitudinal study Str uctur ed inter vie w
CDI MASC WISC-IV
Association be tw een e xposur e t o fr eq uent bull ying b y peers bef or e ag e 12 and self-har m at 12 yr ., e ven af ter contr olling f or lif etime e xposur e t o ph ysical maltr eatment by adults, inter nalising and e xter nalizing pr oblems at ag e 5, and IQ at ag e 5 (bull ying victimisation r epor ted b y mo ther : RR 1.92, 95% CI 1.18–3.12; (bull ying victimisa -tion r epor ted b y c hild RR 2.44, 95% CI 1.36–4.40) Klomek e t al. [ 39 ] N = 5813 Ag e: 8 yr .
IC: population-based bir
th cohor t Pr ospectiv e s tudy
CDI Rutter Scale Finland’
s Cause of Deat h R egis try Finnish Hospit al Disc har ge Regis ter Adjus ting f or conduct sym pt
oms and depr
ession at ag e 8 yr ., association be tw een freq
uent victimisation and suicidal beha
viour among gir
ls (OR 5.2; 95% CI 1.4–19.6; p < 0.05) O’Connor e t al. [ 43 ] N = 2008 Ag e: 15–16 yr . IC: s tudents Pr ospectiv e s tudy Version of t he C ASE q ues tion -nair e W or ries about se xual or ient ation (OR 4.82, 95% CI 1.25–18.52, p = 0.022), his tor y of se
xual abuse (OR 5.26, 95% CI 1.01–27.48,
p =
0.049), f
amil
y Deliber
ate Self Har
m (OR 4.75, 95% CI 1.46–15.47, p = 0.010), anxie ty (OR 1.30, 95% CI 1.06–1.59, p = 0.011) and self-es teem (OR 0.82, 95% CI 0.69–0.98, p = 0.033) wer e associated wit h r epeat DSH dur ing t he 6-mont h f ollo w-up per iod Se xual abuse w as t he onl y pr edictiv e f act or f or firs t-time DSH (OR 7.19, 95% CI 1.18–43.96, p = 0.033) Herba e t al. [ 41 ] N = 1526 Ag e: mean 12.29 yr .
IC: population-based cohor
t
Pr
ospectiv
e s
tudy
Peer nomination Yout
h self-r epor t Com par ed t o c hildr en unin vol ved in bull ying, bull y-victims ( p = 0.39) and victims (p = 0.85) did no t r epor t incr eased le
vels of suicide ideation. V
ictims of bull ying wit hout par ent al inter nalising disor ders w er e similar t o t hose unin vol ved in bull ying to r epor
t suicide ideation (OR 1). V
ictims wit h r ejection at home r eac hed OR f or
suicide ideation close t
o 8 Mar tin e t al. [ 37 ] N = 2603 Ag e: 13 yr . (T1), 14 yr . (T2), and 15 yr . (T3). IC: s tudents Pr ospectiv e s tudy A sing le-item measur e of per -ceiv ed academic per for mance Cr oss-sectional anal
ysis: holding locus of contr
ol and self-es teem cons tant, a s tudent who per ceiv es t
heir academic per
for mance as “f ailing” is mor e lik ely t o r epor t suicide t houghts (OR be tw
een 1.58 and 1.91), plans (OR be
tw
een 1.91 and 2.15),
thr
eats (OR be
tw
een 1.65 and 1.86), deliber
ate self-injur y (OR be tw een 1.53 and 2.15), or S A (OR be tw
een 2.56 and 3.29). Longitudinal anal
ysis: per ceiv ed academic per for mance at T1 is no t a significant pr edict or of an y suicide v ar iables at T2 or T3, ex cep t f or a w
eak association wit
h suicide t
hr
eats at T2 (OR 1.87, 95% CI 1.03–3.40,
p <
Table 4 (continued) Ref er ences Sam ple Type of s tudy Measur es Results W ild e t al. [ 35 ] N = 2946 Ag e: 12–26 yr . IC: s tudents Cr oss-sectional study BDI SEQ Self-adminis
ter ed q ues tionnair e Fact
ors associated wit
h S
A and ideation: high depr
ession scor es (ideation v s none: RRR 2.85, 95% CI 1.89–4.31, p < 0.001; attem pt v s none: RRR 3.77, 95% CI 1.95– 7.30, p < 0.001), and lo w f amil y self-es teem scor es (ideation v s none: RRR 1.47, 95% CI 1.04–2.07, p < 0.05; attem pt v s none: RRR 3.68, 95% CI 1.87–7.23, p < 0.001) Lo w f amil y self-es teem differ entiated S A fr om ideation (RRR 2.50, p = 0.02) Ag erbo e t al. [ 25 ] N =
496 suicide victims and
24,800 matc hed contr ols Ag e: 10–21 yr . Cr oss-sectional study Dat a fr om longitudinal Danish regis ters Associated par ent al f act ors: par ent al suicide (f at her : IRR 11 2.30, 95% CI 1.10–4.80; mo ther : IRR 4.75, 95% CI 2.10–10.8), admission f or a ment al illness (f at her : IRR 1.56, 95% CI 1.12–2.19; mo ther : IRR 1.73, 95% CI 1.29–2.32), t he loss of a mo ther due t o o
ther causes of deat
h (IRR 2.06, 95% CI 102–4.19) or emig ration (IRR 2.09, 95% CI 1.11–3.96) King e t al. [ 8 ] N = 1285 Ag e 9–17 yr . IC: NIMH Me thods f or t he
Epidemiology of Child and Adolescent Ment
al Disor -ders S tudy Cr oss-sectional study MEC A Ser
vice Utilization and
Risk F act ors Ins trument Mor e s tressful lif e e vents in S A t han ideation ( p < 0.05) Adjus ting for demog raphics and the pr esence of a mood, anxie ty , or disr up tiv e disor der F amil y en vir onment : P oor v s good (OR 2.0; 95% CI 1.2–3.4), f air v s good (OR 1.3;
95% CI 0.7–2.3) Physical discipline: some v
s none (OR 1.2; 95% CI 0.6–2.0) Pr imar y car et ak er : no spouse v s spouse (OR 0.7; 95% CI 0.4–1.3) Par ent al monit or ing: lo w v
s high (OR 3.0; 95% CI 1.3–7.0), middle v
s high (OR 2.4; 95% CI 1.1–5.3) Famil y his tor y of psy chiatr ic disor der (OR 1.2; 95% CI 0.7–2.2) McK eo wn e t al. [ 17 ] N = 359 IC: s tudents Pr ospectiv e s tudy K-S ADS
CES-D FACES-II Coddingt
on Lif e Ev ents Scale f or Adolescents Famil y cohesion pr otects fr om S A (OR 0.90; 95% CI 0.86–0.95), t hough no t fr om
plans (OR 0.99; 95% CI 0.93–1.04) or ideation (OR 1.00; 95% CI 0.95–1.05) Undesir
able lif
e e
vents pr
edict suicidal plans (OR 1.09; 95% CI 1.01–1.18), but no
t
suicidal ideation (OR 1.06; 95% CI 0.96–1.17) and attem
pts (OR 1.03; 95% CI 0.88–1.21) W agner e t al. [ 33 ] N = 1050 (147 S A; 261 depr essed/suicidal ideat ors; 642 contr ols) Ag e 12–21 yr . Cr oss-sectional study In vent or y of dail y s tresses Self-adminis ter ed Ques tionnair e Fact ors r elated t o S A: s tresses r elated t o par ents, lac k of adult suppor t outside of t he home, pr oblems wit h police, ph ysical har m b y a par ent, r unning a wa y fr om home, living apar t fr om bo th par ents, kno
wing someone who had com
ple ted suicide Sour ander e t al. [ 29 ] N = 5302 Ag e: 8 yr . at assessment Follo w-up dat a r ecor ded until ag e of 25 yr . IC: bir th cohor t s tudy Longitudinal study Self-adminis ter ed Ques tionnair e Finnish Hospit al Disc har ge Regis ter
Finnish Cause of Deat
h R
egis
ter
Among males, com
ple ted or ser ious S A pr edicted at t he ag e of 8 yr . b y living in a non-int act f amil y (OR 3.8; 95% CI 1.7–8.2; p < 0.001) AO R adjus ted odds r atio, BDI Bec k Depr ession In vent or y, CASE Child and A
dolescent Self Har
m in Eur ope, CDI Childr en ’s Depr
ession Scale, CES-D Center f
or Epidemiological S tudies of Depr ession, CI confidence inter val, DSH deliber ate self-har m, FA CES-II F amil y A dap
tability and Cohesion Ev
aluation Scales, IC inclusion cr iter ia, IQ intellig ence q uo tient, IRR incidence r ate ratio, K-S ADS kiddie-sc hedule f or affectiv e disor ders and sc hizophr enia, MASC Multidimensional Anxie ty Scale f or Childr en, MEC A me thods for the epidemiology of c hild and adolescent ment al disor ders, MSQA Multidimensional Sub-healt h Ques tionnair e of A dolescents, OR odds r atio, RR relativ e r isk , RRR relativ e r isk r atio, SA suicide attem pt, SEQ Self-Es teem Ques tion -nair e, WISC-IV W ec hsler intellig ence scale f or c hildr en, f our th edition, yr. y ears
Table 5 T em per ament and c har acter . Clinical sam ples BDI Bec k Depr ession In vent or y, BHS Bec k Hopelessness Scale, BIS Bar ratt Im pulsiv eness Scale, CAPS Child and A dolescent P er fectionism Scale, IC inclusion cr iter ia, JT CI Junior T em per a-ment Char acter In vent or y, K-S ADS kiddie-sc hedule f or affectiv e disor ders and sc hizophr enia, M.I.N .I Plus mini inter national neur opsy chiatr ic inter vie w, NSSI non-suicidal self-injur y, SA sui -cide attem pt, SIQ
Suicidal Ideation Ques
tionnair e, yr. y ears Ref er ences Sam ple Type of s tudy Measur es Results Mir ko vic e t al. [ 50 ] N = 167 Ag e: 13–17 yr .
IC: suicide attem
pters, in patients Cr oss-sectional s tudy K-S ADS
Adolescent Coping Scale Life Ev
ents Ques tionnair e Columbia-Suicide Se ver ity R ating Scale When adjus ting f or ag e, se x, s tressful lif e e
vents and depr
ession, non-pr oductiv e coping did no t pr ov e a significant r isk f act or f or suicidality in t he multiv ar iate anal ysis ( β = 0.03, SE = 0.021; t = 1.669, df = 111, p = 0.095) Csorba e t al. [ 47 ] N = 90 Ag e: 14–18 yr . IC: depr essiv e outpatients Cr oss-sectional s tudy JT CI M.I.N .I Plus Suicidal-depr essiv e adolescents e xhibited significantl y higher no velty -seeking com par ed t o “pur e” depr essiv e clinical peers (Mann–Whitne y U: 665.5; p = 0.007) Dougher ty e t al. [ 52 ] N = 56 Ag e: 13–17 yr . IC: in patients wit h a his tor y of NSSI 3 Cr oss-sectional s tudy
BIS Lifetime P
ar asuicide Count II Tw o Choice Im pulsivity P ar adigm Go-S top P ar adigm Hospit alization anal yses: com par ed t o t he NSSI-onl y g roup, t he NSSI + SA g
roup had significantl
y higher r atings on Bar ratt Im pulsiv eness Scale ( F = 7.68; df = 1.54; p = 0.008; obser ved po wer = 0.78; Cohen ’s d = 0.77), and g reater pr ef er ence f or t he smaller -sooner r ew ar ds dur ing t he T wo Choice Im pulsivity P ar -adigm ( F = 5.47; df = 1.54; p = 0.023; obser ved po wer = 0.63; Cohen ’s d = 0.62) Follo w-up anal yses: t he NSSI + SA g roup sho wed a significantl y gr eater pr ef er ence f or t he im pulsiv e smaller -sooner c hoices (main effect of Gr oup: F 1.26 = 6.37, p = 0.018; obser ved po wer = 0.68; Cohen ’s d = 0.88) Enns e t al. [ 48 ] N = 78 Ag e: 12–18 yr . IC: in
patients; suicidal ideation
or beha viour as r eason f or admission Pr ospectiv e s tudy CAPS SIQ Cor relations be tw een t
he Suicidal Ideation Ques
tionnair
e scor
es
and personality measur
es: neur oticism (0.39, p < 0.001), self-cr iticism (0.38, p < 0.01), dependency (0.29, p < 0.01), self-or iented per fectionism (0.12, p = NS), and sociall y pr escr ibed per fectionism (0.32, p < 0.01) Neur oticism ( B = 0.194; W ald = 6.26; p = 0.01) w as pr edictiv e of psy chiatr ic r eadmission wit hin 1 y ear Hor esh e t al. [ 51 ] N = 65 Ag e: 13–18 yr . IC: in patients Cr oss-sectional s tudy
BDI BHS Child Suicide P
otential Scale Ov er t A gg ression Scale Im pulsiv eness-Contr ol Scale No significant differ ences in im pulsiv eness f or t he depr essed suicidal g roup v ersus t he depr essed non-suicidal g roup [ F (1, 30) = 1.09, p = 0.05] Im pulsiv
eness and agg
ression cor related significantl y and posi -tiv ely wit h suicidal beha viour (agg ression: r = 0.50, p < 0.01; im pulsiv eness: r = 0.40, p < 0.05) among bor der line personality disor
der adolescents, but no
t in depr
depressive disorder increases the risk of suicide attempts
[
4
]. Nevertheless, mood disorders do not explain all suicidal
ideation and behaviours [
5
], and important distinctions must
exist between depressed adolescents who have experienced
suicidal ideation but have never attempted suicide and those
who have done so. The evidence clearly highlights the
com-plexity of suicidality and points towards an interaction of
factors contributing to suicidal behaviour. Previous history
Table 6 Temperament and character. Non-clinical samples
CASE Child and Adolescent Self Harm in Europe, CES-D Center for Epidemiological Studies of Depression, CI confidence interval, IC inclu-sion criteria, OR odds ratio, SA suicide attempt, yr. years
References Sample Type of study Measures Results
O’Connor et al. [20] N = 2008 Age: 15–16 yr. IC: pupils
Cross-sectional study Version of the CASE
ques-tionnaire Optimism protects girls from self-harm (OR 0.93; 95% CI4 0.88–0.97; p < 0.005) Chabrol and
Saint-Martin [46] N = 312Age: 14–18 yr. IC: students
Cross-sectional study CES-D
Youth Psychopathic traits Inventory
Affective component of psycho-pathic traits is an independent predictor of suicidal ideation (β = 0.17, t = 3.04, p = 0.002) Martin et al. [37] N = 2603
Age: 13 yr. (time 1), 14 yr. (time 2), and 15 yr. (time 3).
IC: students
Prospective study A single-item measure of perceived academic per-formance
Rosenberg’s Self-esteem Scale
Nowicki–Strickland Locus of Control Scale for Children
Low self-esteem associated with suicide thoughts (OR between 2.39 and 3.48), plans (OR between 2.76 and 3.55), threats (OR between 2.51 and 3.72), deliberate self-injury (OR between 1.99 and 2.58), and SA5 (OR between 2.26 and 4.30). External attributional style
associ-ated with suicide thoughts (OR between 1.86 and 2.39), plans (OR between 1.91 and 2.74), threats (OR between 1.72 and 1.95), deliberate self-injury (OR between 2.06 and 3.34), ad SA (OR between 1.79 and 2.90) Barber [49] Study I
N = 2619
Age: 11–20 yr. IC: students Study II
N = 2111
Age: 12–17 yr. IC: students
Cross-sectional study Study I:
Structured Question-naire. Youth suicide rate obtained from 1994 World Health Organization statistics
Study II:
Self-administered question-naires
Study I: correlations between adjustment and suicide: Males: total adjustment
r(7) = 0.74, p < 0.05; self-esteem r(7) = 0.87, p = 0.01; school adjustment r(7) = 0.81, p < 0.05; social adjustment NS
Females: all adjustment analyses NS
Study II: in males, suicidality was significantly associated with the interaction social compari-son × depressed affect (t = 9.4, p < 0.001), social comparison (t = − 4.5, p < 0.001) and with the interaction social com-parison × self-esteem (t = 9.5, p < 0.001). Among females, suicidality was significantly associated with depressed affect (t = 4.3, p < 0.001), the interaction social compari-son × depressed affect (t = 5.0, p < 0.001), self-esteem (t = − 2.2, p < 0.05), social comparison (t = − 3.7, p < 0.001), and inter-action social comparison × self-esteem (t = 5.2, p < 0.001)
of suicide attempts can identify a population at risk [
15
,
17
],
as does the concurrence of different disorders [
4
].
However, predicting which adolescents are likely to
repeat their suicidal behaviour is still an area that needs
fur-ther development. The natural history of suicidal behaviour
among children and adolescents is not completely
deline-ated. Clearly, more information is needed to understand the
complex relationship between risk factors for suicidality and
to be able to establish prevention strategies for suicidality in
children and adolescents. Prospective studies with adequate
sample sizes are needed to investigate these multiple
vari-ables of risk concurrently and over time.
Drug and/or alcohol misuse may also increase the risk
for suicide attempt [
8
,
11
,
18
]. Acute intoxication may even
trigger the suicidal act in vulnerable individuals by
increas-ing impulsiveness, enhancincreas-ing depressive thoughts and
sui-cidal ideation, limiting cognitive functions and ability to
see alternative coping strategies, and reducing barriers to
self-inflicted harm [
53
]. In this vein, drug and/or alcohol
misuse may act as proximal but also distal risk factors for
suicidality and also may mediate or moderate the influence
of other risk factors on suicidality [
54
]. Moreover, common
neurobiological vulnerability has been described in
depres-sion, impulsivity and drug and/or alcohol use disorders such
as a greater serotonergic impairment [
53
], which may help
explain their frequent co-association and also their
relation-ship with suicidal behaviour, a violent behaviour associated
with disturbances in the serotonergic system [
53
].
In addition, vulnerability to suicidal behaviour may be,
at least to some degree, mediated by some personality traits,
such as neuroticism and impulsivity [
17
,
20
,
48
,
51
,
52
].
The association of poor emotional regulation strategies and
behavioural impulsivity with suicidal behaviour leads to
consider the existence of affective regulation vulnerability
among children and adolescents at risk for suicidality.
Stressful life events may act as precipitating factors for
suicidal behaviour. Our review identified several
circum-stances, such as family problems and peer conflicts that
may exceed the coping strategies of some adolescents [
8
,
18
,
20
,
25
,
29
,
33
–
36
]. Nevertheless, it is important to note
that some investigations suggest that it is the accumulation
of stressful life events, and not the presence of one isolated
Table 7 Studies investigating risk factors for suicidality among children and adolescents by type of self-injurious thought and/or behaviour
Variable Suicide attempt Suicidal behaviour Suicidal ideation/plan Non-suicidal self-injury Self-injurious behaviour Clinical variables Depression [4, 8, 9, 11–14, 29, 35] [9, 12] [5, 9, 12–14, 35] [12]
Previous suicide attempt [15, 16] [17]
Previous suicidal ideation [18] [12, 18] [18] [18] [12, 18]
Alcohol and substance use [21] [2, 4, 5, 8, 11, 13, 18–20, 22] [5] [23]
Eating disorders [26] [26] [26]
Psychiatric disorders [4, 8, 27] [30] [20]
Hospitalization [16]
Sleep disturbances [20]
Adverse life events
Family conflicts [8, 12, 17, 18] [12, 18] [8, 12, 17, 18, 34] [12, 18]
Interpersonal and legal problems [12] [12] [12] [12]
Change of residence [42] Romantic break-up [11] Exposure to suicidal behaviour [11, 29]
Bullying [39] [32, 41, 44] [40]
Abuse [45] [43]
Sexual orientation [43]
Academic performance [37]
Temperament and character
Novelty seeking [47]
Impulsiveness [4, 52] [52] [17] [52]
Neuroticism, pessimism,
perfec-tionism, dependence [48] [20]
Low self esteem [37] [37] [37]
stressful life event that appears to be related to later
sui-cidal behaviours [
55
]. However, as not all children exposed
to stressful life events develop suicidal behaviours, some
authors state that suicidality is not simply a logical response
to extreme stress [
54
], which in turn leads to the
hypoth-esis of a stress diathhypoth-esis model of suicidal behaviour [
56
].
Thus, from a suicidal behaviour prevention standpoint,
further investigation is needed to clarify the relationship
between stressful life events and suicidality in the
paediat-ric population.
Limitations
The conclusions that can be made regarding the strength of
association between the risk factors presented in this review
and suicidality are limited due to the relatively small amount
of prospective studies that have been conducted to date [
4
,
5
,
12
,
15
,
17
,
18
,
22
,
27
,
29
,
31
,
37
,
39
,
40
,
43
,
48
]. In
addi-tion, the majority of clinical studies used/studied/observed
small populations. Publication bias is likely to be present as
studies reporting no association between a risk factor and
suicidal behaviour may not have been published. Suicidality
was not measured by means of the same instrument across
all the studies. Similarly, different instruments were used to
measure psychopathology or to determine other
psychoso-cial variables, which is another limitation. The age range of
participants and sociodemographic variables differs between
the different studies making direct comparisons and
sum-maries across studies difficult/troublesome.
In conclusion, this review has pulled together relevant
scientific literature addressing psychosocial risk factors
for suicidality in children and adolescents. It suggests that
various components and factors may contribute to the risk/
development of suicidality and suicidal behaviour in a young
person, e.g. impulsivity, mood disorder, substance abuse,
history of self-injury, and family and/or peer conflicts, to be
considered as a cumulative/interactive process. The
identifi-cations of paediatric patients at high risk for suicidality and
elements of resilience will improve preventative measure in
targeted subgroups.
Acknowledgements The members of the STOP Consortium are:
Alastair Sutcliffe. University College London, Institute of Child Health, London, United Kingdom. Sarah Curran. St George’s University Hospi-tal, London, UK. Laura Selema. Institute of Psychiatry, Psychology and Neurosciences (IoPPN), King’s College London, London, UK. Rob-ert Flanagan. Institute of Psychiatry, Psychology and Neurosciences (IoPPN), King’s College London, London, UK. Ian Craig. Institute of Psychiatry, Psychology and Neurosciences (IoPPN), King’s College London, London, UK. Nathan Parnell. Institute of Psychiatry, Psychol-ogy and Neurosciences (IoPPN), King’s College London, London, UK. Keren Yeboah. Institute of Psychiatry, Psychology and Neurosciences (IoPPN), King’s College London, London, UK. Regina Sala. Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London, London, UK. Jatinder Singh. Institute of Psychiatry, Psychol-ogy and Neuroscience (IoPPN), King’s College London, London, UK.
Federico Fiori. Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London, London, UK. Centre for Interven-tional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London, UK. HealthTracker Ltd, Gillingham, UK. Florence Pupier. CHRU Mont-pellier; Hôpital Saint Eloi, Médecine Psychologique de l’Enfant et de l’Adolescent, Montpellier, France. Loes Vinkenvleugel. Radboud University Medical Centre, Nijmegen, The Netherlands. Jeffrey Glen-non. Radboud University Medical Centre., Nijmegen, The Netherlands. Mireille Bakker. Radboud University Medical Centre, Nijmegen, The Netherlands. Cora Drent. University of Groningen, University Medical Center Groningen, Department of Child and Adolescent Psychiatry, The Netherlands. Elly Bloem. University of Groningen, University Medical Center Groningen, Department of Child and Adolescent Psy-chiatry, The Netherlands. Mark-Peter Steenhuis. University of Gro-ningen, University Medical Center GroGro-ningen, Department of Child and Adolescent Psychiatry, The Netherlands. Ruth Berg. Central Institute of Mental Health, Mannheim, Germany. Alexander Häge. Central Institute of Mental Health, Mannheim, Germany. Mahmud Ben Dau. Central Institute of Mental Health, Mannheim, Germany. Konstantin Mechler. Central Institute of Mental Health, Mannheim, Germany. Sylke Rauscher. Central Institute of Mental Health, Man-nheim, Germany. Sonja Aslan. University of Ulm, Ulm, Germany. Simon Schlanser. University of Ulm, Ulm, Germany. Ferdinand Kel-ler. University of Ulm, Ulm, Germany. Alexander Schneider. Univer-sity of Ulm, Ulm, Germany. Paul Plener. UniverUniver-sity of Ulm, Ulm, Germany. Jörg M. Fegert. University of Ulm, Ulm, Germany. Jacqui Paton. University of Dundee, UK. Murray, Macey. University College London, UK. Noha Iessa. World Health Organization, London, UK. Kolozsvari, Alfred. HealthTracker Ltd, Gillingham, UK. Furse, Helen. HealthTracker Ltd, Gillingham, UK. Penkov, Nick. HealthTracker Ltd, Gillingham, UK. Claire Baillon. Assistance Publique—Hopitaux de Paris: Robert Debré Hospital, Paris, France. Hugo Peyre. Assistance Publique—Hopitaux de Paris:Robert Debré Hospital, Paris, France. David Cohen. Assistance Publique—Hopitaux de Paris: Groupe Hos-pitalier Pitié-Salpêtrière, Paris, France. Olivier Bonnot. Assistance Publique—Hopitaux de Paris: Groupe Hospitalier Pitié-Salpêtrière, Paris, France. Julie Brunelle. Assistance Publique—Hopitaux de Paris: Groupe Hospitalier Pitié-Salpêtrière, Paris, France. Nathalie Franc. CHRU Montpellier; Hôpital Saint Eloi, Médecine Psychologique de l’Enfant et de l’Adolescent, France. Pierre Raysse. CHRU Montpel-lier; Hôpital Saint Eloi, Médecine Psychologique de l’Enfant et de l’Adolescent, France. Véronique Humbertclaude. CHRU Montpel-lier; Hôpital Saint Eloi, Médecine Psychologique de l’Enfant et de l’Adolescent, France. Alberto Rodriguez-Quiroga. Child and Adoles-cent Psychiatry Department, Hospital General Universitario Gregorio Marañón, CIBERSAM, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), School of Medicine, Universidad Complutense, Madrid, Spain. Covadonga Martínez Díaz-Caneja. Child and Adoles-cent Psychiatry Department, Hospital General Universitario Gregorio Marañón, CIBERSAM, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), School of Medicine, Universidad Complutense, Madrid, Spain. Ana Espliego. CIBERSAM, Madrid, Spain. Jessica Merchán. CIBERSAM, Madrid, Spain. Cecilia Tapia. CIBERSAM, Madrid, Spain. Immaculada Baeza. Fundació Clínic per la Recerca Biomèdica, Barcelona, Spain. Soledad Romero. Fundació Clínic per la Recerca Biomèdica, Barcelona, Spain. Amalia La Fuente. Univer-sity of Barcelona, Spain. Ana Ortiz. Fundació Clínic per la Recerca Biomèdica, Barcelona, Spain. Manuela Pintor. Cagliari University Hospital, Cagliari, Italy. Franca Ligas. University of Cagliari, Cagli-ari, Italy. Francesca Micol Cera, University of CagliCagli-ari, CagliCagli-ari, Italy. Roberta Frongia, Cagliari University Hospital, Cagliari, Italy. Bruno Falissard. Univ. Paris-Sud, INSERM U669, AP-HP, Paris, France. Ameli Schwalber. Concentris, Germany. Juliane Dittrich. Concentris, Germany. Andrea Wohner. Concentris, Germany. Katrin Zimmermann.
