1 THE CARTER JENKINS CENTER PRESENTS. 2 Suicide in Children and Adolescents by Humberto Nagera M.D....

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THE CARTER JENKINS CENTERTHE CARTER JENKINS CENTER

PRESENTSPRESENTS

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Suicide in Children and AdolescentsSuicide in Children and Adolescents

byby

Humberto Nagera M.D.Humberto Nagera M.D.

Professor of Psychiatry, University of Professor of Psychiatry, University of South Florida.South Florida.

Professor Emeritus, University of Professor Emeritus, University of Michigan.Michigan.

Training and Supervising Psychoanalyst,Training and Supervising Psychoanalyst,

Tampa Bay Psychoanalytic Institute.Tampa Bay Psychoanalytic Institute.

Director, The Carter-Jenkins Center.Director, The Carter-Jenkins Center.

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A) General Statistics of Suicides in Children: A) General Statistics of Suicides in Children:

1) Suicide is relatively rare in pre-pubertal kids1) Suicide is relatively rare in pre-pubertal kids

2) But there are each year an estimated one2) But there are each year an estimated one

million million accidentalaccidental ingestions of toxic ingestions of toxic

substances by under fivessubstances by under fives

3) In the 5 to 14 age group there are 100,000 self-3) In the 5 to 14 age group there are 100,000 self-

poisonings each yearpoisonings each year

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4) In 1985, 232 children aged 5 to 14 years old 4) In 1985, 232 children aged 5 to 14 years old committed suicide (for a rate 0.7/100,000)committed suicide (for a rate 0.7/100,000)

5) In the 10 to 14 years old the rate is 1.6/100,0005) In the 10 to 14 years old the rate is 1.6/100,000 with 317 deaths in 1998with 317 deaths in 1998

6) But that rate increased to 10.9/100,00 in the 156) But that rate increased to 10.9/100,00 in the 15 to 19 group in 1998 with about 2160 deathsto 19 group in 1998 with about 2160 deaths

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7) From 1980 to 1998 the suicide rates in children7) From 1980 to 1998 the suicide rates in children

(10 to 14 years old) increased over 120%(10 to 14 years old) increased over 120%

8) The low incidence of fatalities (1:11,000 events in8) The low incidence of fatalities (1:11,000 events in

ages 5-14) suggests that the lethality of intent isages 5-14) suggests that the lethality of intent is

minimal when compared to ages 15-24, whereminimal when compared to ages 15-24, where

fatalities are 1:168 eventsfatalities are 1:168 events

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B) Statistics of Suicide in Adolescence:B) Statistics of Suicide in Adolescence:

1) Among adolescents aged 15 to 19 the suicide 1) Among adolescents aged 15 to 19 the suicide rate was 8.9/100,000 with 1,737 deaths in 1998rate was 8.9/100,000 with 1,737 deaths in 1998

2) The 1998 gender ratio for 15 to 19 years old was2) The 1998 gender ratio for 15 to 19 years old was 5:1 (males:females)5:1 (males:females)

3) Suicide is the third leading cause of death in the 3) Suicide is the third leading cause of death in the 15-24 age group (follows unintentional injuries 15-24 age group (follows unintentional injuries and homicide)and homicide)

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4) In this same group (15-24) there were 4,135 4) In this same group (15-24) there were 4,135

suicides, for a rate of 11.1 per 100,000suicides, for a rate of 11.1 per 100,000

5) Adolescents ratio of suicide attempts or 5) Adolescents ratio of suicide attempts or

gestures to completed ones is estimated at gestures to completed ones is estimated at

200:1200:1

6) This suggests that over one million attempts6) This suggests that over one million attempts

or gestures are made annually by US or gestures are made annually by US

adolescentsadolescents

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Suicide in Children and AdolescentsSuicide in Children and Adolescents Government report released on July 13/2002 stated:Government report released on July 13/2002 stated:

-Three millions American teenagers thought -Three millions American teenagers thought seriously about suicide and about one millionseriously about suicide and about one million attempted it!attempted it!

- Thus 13% of teenagers (14-17) considered - Thus 13% of teenagers (14-17) considered suicide in 2000suicide in 2000 - only 36% has received treatment or counseling- only 36% has received treatment or counseling - girls twice as likely as boys to say they thought - girls twice as likely as boys to say they thought about suicideabout suicide

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7) Clusters of teenagers suicides are occurring 7) Clusters of teenagers suicides are occurring more more frequently i e, one suicide triggers frequently i e, one suicide triggers

many many others.others. (The copy cat phenomena)(The copy cat phenomena)

8) Most suicide attempters’ motivation (all ages) is 8) Most suicide attempters’ motivation (all ages) is not necessarily a wish to die but:not necessarily a wish to die but: a) a desire to influence another persona) a desire to influence another person b) to make someone feel guiltyb) to make someone feel guilty c) to express anger or gain attentionc) to express anger or gain attention d) to escape a difficult situationd) to escape a difficult situation

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9) Kessel in the Edinburgh study concluded that9) Kessel in the Edinburgh study concluded that

at least 80% of self poisonings were done at least 80% of self poisonings were done

believing that death will not occurbelieving that death will not occur

10) Many adolescents suicide deaths are probably 10) Many adolescents suicide deaths are probably unintentional unintentional

11) The adolescents were not victims of suicide11) The adolescents were not victims of suicide

but of pharmacological roulettebut of pharmacological roulette

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12) The best single correlate of lethality12) The best single correlate of lethality

is the probability of rescue that existedis the probability of rescue that existed

13) Many self-poisoning adolescents ensure that13) Many self-poisoning adolescents ensure that

they will be found soon after ingestionsthey will be found soon after ingestions

14) Alternatively they themselves notify 14) Alternatively they themselves notify

somebodysomebody

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15) Imitation through exposure (friends or media15) Imitation through exposure (friends or media

publicity) makes adolescents more publicity) makes adolescents more vulnerablevulnerable

to suicide (The copy cat phenomena)to suicide (The copy cat phenomena)

16) Exposure to suicide or suicidal behavior in16) Exposure to suicide or suicidal behavior in

the family, significant influences vulnerable the family, significant influences vulnerable

adolescentsadolescents

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17) Potentially suicidal adolescents may show:17) Potentially suicidal adolescents may show:

a) a dysphoric mooda) a dysphoric mood

b) aggressiveness or hostilityb) aggressiveness or hostility

c) frequent problems with peersc) frequent problems with peers

d) reaction to a crisis situationd) reaction to a crisis situation

e) inhibited personalitiese) inhibited personalities

f) marked loneliness and extreme quietnessf) marked loneliness and extreme quietness

g) extreme sensibility, lack of friendsg) extreme sensibility, lack of friends

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18) Suicidal youngsters have more psychiatric 18) Suicidal youngsters have more psychiatric

symptoms than the non-suicidal controlssymptoms than the non-suicidal controls

19) Symptoms of depression appeared in 76% of 19) Symptoms of depression appeared in 76% of

the suicide victims compared to 24% in the the suicide victims compared to 24% in the

controlscontrols

20) Many male suicidal adolescents do not meet20) Many male suicidal adolescents do not meet

DSM criteria for depression but are dysphoricDSM criteria for depression but are dysphoric

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21) Antisocial symptoms, previous history of 21) Antisocial symptoms, previous history of

suicidal tendencies, drug abuse are suicidal tendencies, drug abuse are

prominent among suicide victimsprominent among suicide victims

22) If high suicidal intent is present hospitalize22) If high suicidal intent is present hospitalize

the adolescent immediatelythe adolescent immediately

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23) Unsuccessful attempts go from nearly23) Unsuccessful attempts go from nearly

lethal to desperate low lethality cries for lethal to desperate low lethality cries for

help, to minor gestures clearly help, to minor gestures clearly

manipulative in intentmanipulative in intent

24) Suicide behavior occasionally is impulsive 24) Suicide behavior occasionally is impulsive

handling of stress in at times a neglectful handling of stress in at times a neglectful and and

unsupportive environmentunsupportive environment

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25) Death occasionally can be seen as retaliatory25) Death occasionally can be seen as retaliatory

abandonment, reunion, rebirth, self-abandonment, reunion, rebirth, self-

punishment, or confirmation of feeling alreadypunishment, or confirmation of feeling already

deaddead

26) Suicidal adolescents may feel they want to 26) Suicidal adolescents may feel they want to

cause pain in the life of a family member orcause pain in the life of a family member or

friends that cause him real or imagined hurtsfriends that cause him real or imagined hurts

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27) Adolescents may have funeral fantasies in 27) Adolescents may have funeral fantasies in

which others sit around in pain saying, “Whywhich others sit around in pain saying, “Why

did not I treat him better”,or “Why did I notdid not I treat him better”,or “Why did I not

tell him/her that he/she was a good tell him/her that he/she was a good

son/daughter”, etc.son/daughter”, etc.

28) Some suggest to have them read the part on 28) Some suggest to have them read the part on

“ “From here to Eternity”, where corporal Bloom From here to Eternity”, where corporal Bloom suicides. They can thus see the reality of suicides. They can thus see the reality of

their their

peers reactionspeers reactions

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29) Some adolescents take their lives suddenly 29) Some adolescents take their lives suddenly and without prior warning, at times and without prior warning, at times

when when they seem to be doing well they seem to be doing well (about to (about to graduate, etc)graduate, etc)

30) Any suicide attempt needs a thorough 30) Any suicide attempt needs a thorough

evaluation for depressive or psychoticevaluation for depressive or psychotic

featuresfeatures

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METHODS OF SUICIDE:METHODS OF SUICIDE:

1) Firearms, poisoning and hanging are the most 1) Firearms, poisoning and hanging are the most

common methods in the groups 5-14 and 15-24common methods in the groups 5-14 and 15-24

2) Suicide by firearms is unfortunately the method 2) Suicide by firearms is unfortunately the method

that has increased most dramaticallythat has increased most dramatically

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3) Drugs used most commonly are:3) Drugs used most commonly are:

a) analgesics (Tylenol, Aspirin, etc)a) analgesics (Tylenol, Aspirin, etc)

b) tranquilizersb) tranquilizers

c) sedativesc) sedatives

d) antihistaminicsd) antihistaminics

e) up to recently anti-depressants (tricyclics…)e) up to recently anti-depressants (tricyclics…)

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PREDICTORS OF SUICIDE:PREDICTORS OF SUICIDE:

1) Previous suicidal behavior.1) Previous suicidal behavior.

2) Affective disorders and schizophrenia2) Affective disorders and schizophrenia

3) Family psychiatric disorders, especially3) Family psychiatric disorders, especially affective disorders affective disorders

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4) Exposure to parental, peers or relatives 4) Exposure to parental, peers or relatives suicidal ideas:suicidal ideas:

-or parental threats or attempts of suicide-or parental threats or attempts of suicide

-or parental severe emotional problems-or parental severe emotional problems

-or parental absence or death-or parental absence or death

-or parental divorce or separations-or parental divorce or separations

-or evidence of physical abuse-or evidence of physical abuse

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5) Other common factors are:5) Other common factors are:

-disputes with peers, boyfriends, girlfriends-disputes with peers, boyfriends, girlfriends

-arguments with a parent-arguments with a parent

-humiliations-humiliations

-punishment-punishment

-sense of failure-sense of failure

-pregnancy-pregnancy


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-loss of communication with one or both-loss of communication with one or both

parentsparents

-lack of religious ties-lack of religious ties

-anger-anger

-wish to go back to ward where staff is seen -wish to go back to ward where staff is seen

as more loving and reliable than those at as more loving and reliable than those at

homehome

-significant changes in eating or sleeping -significant changes in eating or sleeping

habitshabits

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-writing notes or poems about death -writing notes or poems about death

-giving away precious possessions-giving away precious possessions

-drug or alcohol abuse-drug or alcohol abuse

-dramatic personality changes-dramatic personality changes

-loss of interest in previously valued activities-loss of interest in previously valued activities

-school work deterioration, etc-school work deterioration, etc

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Conclusions and Treatment Suggestions:Conclusions and Treatment Suggestions:

1) Suicide, the third leading cause of death in1) Suicide, the third leading cause of death in

this group is preventablethis group is preventable

2) Important to confront the adolescent with2) Important to confront the adolescent with

their phantasies that their suicide will their phantasies that their suicide will

provoke remorse and guilt, or be a provoke remorse and guilt, or be a

punishment for those left behindpunishment for those left behind

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3) They need to understand what really will3) They need to understand what really will

happen and how after a while people will gohappen and how after a while people will go

on with their liveson with their lives

4) Describe comments that will be made such 4) Describe comments that will be made such

as “ He was a little crazy”, “The Lord knowsas “ He was a little crazy”, “The Lord knows

we tried”, etcwe tried”, etc

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5) Decrease access to firearms, drugs, etc5) Decrease access to firearms, drugs, etc

6) Do not let them paint themselves into a6) Do not let them paint themselves into a

corner since to save face they may docorner since to save face they may do

something dangeroussomething dangerous

7) Interventions need to be life saving while7) Interventions need to be life saving while

avoiding secondary gainsavoiding secondary gains

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8) May be useful to describe with examples 8) May be useful to describe with examples

the loss of function due to decrease the loss of function due to decrease

oxygenation, cutting through nerves, etcoxygenation, cutting through nerves, etc

9) Adolescents believe that adults will make 9) Adolescents believe that adults will make

things o.k, with no resulting damage things o.k, with no resulting damage

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THE ENDTHE END

This has been a Carter Jenkins Center This has been a Carter Jenkins Center service for the communityservice for the community

QUESTIONS?QUESTIONS?

Donations are gratefully accepted and Donations are gratefully accepted and are tax deductibleare tax deductible

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For any further information about: 1) 1) The Carter Jenkins CenterThe Carter Jenkins Center

2) 2) The monthly programs for the communityThe monthly programs for the community

3) 3) The monthly programs for the The monthly programs for the professionalsprofessionals

4) 4) Psychoanalytic Training in TampaPsychoanalytic Training in Tampa5) 5) The International (Virtual) Psychoanalytic The International (Virtual) Psychoanalytic

InstituteInstitute 6) 6) The International (Virtual) Psychoanalytic The International (Virtual) Psychoanalytic

Society,Society,

VISIT OUR WEB SITE AT:VISIT OUR WEB SITE AT:

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1 THE CARTER JENKINS CENTER PRESENTS. 2 Suicide in Children and Adolescents by Humberto Nagera M.D....

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