Information
Editors
Self-Destructive Behaviour in Childhood and Adolescence
General remarks
- Self-destructiveness means thoughts or behaviour which is associated with taking a life-threatening risk (indirect self-destructive behaviour), suicidal thoughts, suicidal intentions or self-harm.
- The aim of the treatment of a self-destructive child is to deal with and manage the prevailing crisis situation and to prevent later self-destructiveness.
- Children plan and might carry out suicidal acts in many ways, such as by jumping from a high place or charging into the middle of traffic, but also by hanging or shooting themselves, or by consuming poisonous substances, including medicines and alcohol.
- Because of the methods used by children and adolescents, their suicidal attempts may be regarded as accidents or other mishaps, and thereby it is important to ask the child about his/her self-destructive behaviour.
- Suicides committed by youngsters are not recommended to be reported in newspapers and lectures concerning suicidal behaviour should not be addressed to minors.
Prevalence
- There is no reliable information on the prevalence of indirect self-destructive behaviour. Of children aged between 7 and 12 years, suicidal thoughs have been reported in different studies in 10% of girls and 17% of boys.
- Self-destructiveness of children has increased during the last few decades. Suicides before puberty are rare but thereafter they become increasingly frequent through adolescence.
- Boys commit suicides more commonly than girls.
- Children referred to the emergency unit for psychiatric consultation commonly display self-destructive behaviour.
- The risk of self-destructive behaviour to be repeated later in life is in general high, but the risk of an individual child or adolescent is difficult to assess.
Background factors
- Self-destructive children are generally depressed and their families may have many kinds of problems.
- Difficult experiences and a stressful life situation in general like parental divorce, loss of a loved one, bullying problems, ending of a romantic relationship, various problems at school as well as with parents predispose the youngster to self-destructive behaviour.
- Further risk factors are the use of alcohol and drugs, earlier self-destructive behaviour, minority sexual orientation as well as having experienced sexual or other type of abuse.
- Self-destructive behaviour is often more common in relatives than in general population.
Symptoms
- Self-destructiveness includes thoughts and expressed wishes to die, self-harming behaviour, as well as suicidal attempts and completed suicides.
- Children and adolescents in general overestimate the lethality of different suicidal methods, so the youngster with a significant degree of suicidal intent may fail to carry out a lethal act.
- Self-destructiveness expressed by children and adolescents should always be taken seriously. Manipulative threats of suicidal acts are not always easy to separate from serious suicidal ideation, and threats of suicide mean that the child is not able to deal with his/her emotions or problems.
- Always pay attention to possible depression, other psychic symptoms and substance abuse.
- Before puberty, self-destructiveness can manifest as running away or accident proneness.
- Conduct disorders, impulsiveness, strong self-criticism, great performance pressure at school or in studies, asocial behaviour, substance abuse or e.g. separation anxiety are associated with children's and, especially, adolescents' self-destructive behaviour Risk of Suicide in Adolescence.
- Children who threaten with suicide want their environment to realise how desperate they are, and, if their situation is not noted, they may carry out their plans.
Treatment
- Includes both the acute assessment and intervention as well as the psychiatric treatment of associated mental disorders carried out later. A self-destructive child or adolescent should always be referred for a psychiatric consultation.
- The seriousness of the self-destructiveness has to be assessed using the following information:
- Does the youngster understand what suicide means?
- How does the self-destructiveness manifest itself?
- In what kind of detail has the child or adolescent planned the suicidal act?
- Is the self-destructiveness associated with anxiety or agitation?
- Is the family capable of protecting the youngster from self-destructive impulses at all times?
- Evaluation of risk factors known to be associated with self-destructiveness.
- Emergency admission to the hospital is needed if
- Self-destructiveness is displayed constantly during consultation
- The psychological state of the youngster concerned is, in addition to the self-destructiveness, deviant or his/her behaviour is difficult to predict
- Parents/guardians cannot guarantee a safe environment and constant supervision until the consultation in the mental health services takes place
- Parents are not able to support the youngster because of their own psychological reactions.
- If emergency admission is not needed
- Refer the youngster for psychiatric consultation as soon as possible. Verify by phone that the consultation will take place without delay.
- Discuss safety-related issues with the parents and guide them to make sure that the child or adolescent does not have access to guns, alcohol, drugs or other harmful materials and that he/she will not remain without adult care and supervision.
- Advise the parents to contact the emergency unit if needed.
- Have contact with the family for example by phone until the consultation in the mental health services takes place. It is important to support the family in carrying out the planned actions because the tendency to deny the self-destructiveness of the youngster is high if the situation improves even slightly.
- The treatment is individually planned and generally initiated as crisis therapy, in outpatient or inpatient hospital care, and it is continued as individual or family therapy.
References
- Carballo JJ, Llorente C, Kehrmann L et al. Psychosocial risk factors for suicidality in children and adolescents. Eur Child Adolesc Psychiatry 2020;29(6):759-776. [PubMed]