Advice for Parents on Suicide and Suicidal Behavior in Young People

From The Quarterly, Spring 2015

David Shaffer, M.D., is the Irving Philips Professor of Child Psychiatry & Professor of Psychiatry & Pediatrics at The College of Physicians & Surgeons, Columbia University. He is the Chief of the Division of Child & Adolescent Psychiatry at Columbia University Medical Center. Dr. Shaffer, a recipient of the 2006 Brain & Behavior Research Foundation Ruane Prize for Outstanding Achievement in Child & Adolescent Psychiatric Research & a 1992 NARSAD Distinguished Investigator Grantee, is a pioneer in the study of suicide & was the lead investigator in developing the Children’s Global Assessment Scale (C-GAS). He has led a team of colleagues & investigators in developing & modifying the Diagnostic Interview Schedule for Children (DISC) & the Columbia Teen Screen.

Over the course of your career, you have made a number of major discoveries about suicide. Let’s discuss some of these in the context of giving advice to parents. First, at what age does thinking about suicide––“suicidal ideation”––begin? It is not common in young children, correct?

Suicidal ideation doesn’t carry an awful lot of weight at a very young age. And suicidal behavior––as distinguished from talking about it––is very, very rare in young children. You rarely see suicide attempts before puberty. The nature of most attempts in the young child are basically doing things that one’s parents say are dangerous. These are things that children have learned will generate a response. If you want to scare your parents, you sit on the window ledge, or walk into traffic. The truth is, pre-pubescent children have got a different brain, it works in a completely different way, and their ability to express a full range of emotions and to plan things and do all the things that go into a successful suicide are just not available until adolescence. There are big leaps in cognitive abilities that come with adolescence—the ability to empathize with others, the ability to generalize, etc.

If I am the parent of a child who is troubled and I fear he or she is contemplating suicide, what should I be thinking and doing?

What I often say to parents in this situation is: what’s making the child think about that? Is there a family history? Is it exposure to somebody else who has committed suicide who might be setting an example or generating imitation? Has the child made direct threats? Each of those has ramifications. Regarding threats, one normally takes passive remarks such as “Oh, I’d rather be dead”––remarks in which one doesn’t say, “I’m going to kill myself”––as having not an awful lot of prognostic significance.

But here are things that you do worry about: risk factors that exist within the family—a family history of suicide; if the kid is drinking a lot, getting drunk— alcohol is a very major stimulus of suicide; if there are available methods in the household—a gun collection for example; if there’s any evidence that the child has poor emotional control—if he loses his temper very frequently, or easily gets upset; further, if there are crises, or significant “challenges”––it could be an examination, or having to appear in court, or it could be a planned separation by the parents. Such looming events often serve as a marker for a planned suicide. By marker I mean pending events that generate stresses that brew in the kid’s mind, and may result in an anticipatory suicide. Such thinking is much more related to “I’d rather be dead than have to face… XYZ” than someone pondering whether life is worth living or having existential doubts.

To summarize, I think one wants to know about the child’s usual mood; whether they’re doing anything dangerous. For a kid you’re worried about, alcohol is about as dangerous as you can get. Are there available methods? And, importantly, what has the underlying history of the child been like?

Of those who attempt suicide, what portion have diagnosable psychiatric conditions such as depression?

A fairly high proportion, whether or not they have actually been diagnosed.

I have seen figures as high as 90 percent. Do you trust that number?

No. I think it understates the impact of what I would call a stress-event—a current stress that is really worrying the person. Some people who experience stressors don’t have a psychiatric diagnosis, but they are ill-equipped to deal with the particular stress.

What are some popular misconceptions about suicide?

Referring back to the statistics showing how common it is in adolescence to have thoughts about suicide or to make an attempt: some people, without looking at what the figures mean, assume that if you make an attempt then “you’ve got suicide in you.” People often regard suicidality as a permanent mood state–– you’re walking around thinking about suicide all day long. But this is not how it happens. Thinking about suicide is episodic, and very brief. Many people will have such episodes, which are then dispelled by the rest of life––things turning out better than expected or simply changing their mind. There’s also a widespread belief that there’s nothing you can do to stop a suicide, because if you stop someone from doing it one way, they’ll find another way. But there is no evidence of that. In fact, the evidence is contrary to that. When you make access to a particular method more difficult, you don’t see increases in other methods.

Some of your earliest work showed the importance of emulation and imitation in suicide attempts.

Yes. There were young people who had committed suicide and next to their body were photos of people, usually famous, who previously had done the same. A sociologist confirmed this after Marilyn Monroe’s death. An extensive look revealed that the more coverage a notable suicide received in the press, the greater the imitation effect. What is sometimes called the cluster effect is explained by the fact that at any given time, suicidal ideation is extremely common and so there is a large pool of people thinking about it. In nearly all cases, people don’t act on the thought. But when you have a role model, a famous person who commits suicide, and the press coverage depicts it as a tragedy, and not a crime, it glamorizes the act. Seeing this, it’s possible for some people to think, “Look, she’s a heroine now!”

What should we do about this phenomenon?

I think the moral is, the less talk about suicide, the better. Rather than the reverse. I think most of our work on press coverage supports that.

Less talk on whose part?

On everybody’s part. Suicide is not an intuitive thought or action that occurs to everybody. It is given value and usage. Sometimes, accounts of a suicide will go so far as to describe in detail what the person did. Young children and adolescents have relatively few approved options, if they want to assert themselves. Troubled kids, I mean. If you’re in a school in which a student has committed suicide, the general advice is, let there be a prayer, or a discussion about something terrible that’s happened, some tragedy that’s affected this lovely boy who we all knew and loved—and that’s that. In other places, people start talking about the causes. And once you get a big assembly where everyone is talking about causes, you get an amazing amount of scapegoating—perhaps understandably. So you get teachers who are blamed; other kids are made to be scapegoats; so are parents. Quite a lot of damage can be done. I don’t think there’s any evidence that this damage is a good thing.

This brings to mind the recent suicide “clusters” that were reported among high school teens in Palo Alto, California, in the heart of high-pressure Silicon Valley.

The important thing is: most kids who commit suicide are facing some kind of problem. I would suggest that rather than blame the educational environment or the culture at large, it is more useful to think more about the situation in which the affected child finds himself. The right thing for a parent to do is to help the troubled child and give advice on how they can get out of the fix they are in. I think the most important message for parents is: when a kid is talking about suicide, or when a kid leaves a piece of paper on the desk that has the word suicide in it, or even may threaten suicide, the thing to do is not to start immediately on life and death, but to try and get some understanding of the event that is either looming or has taken place, that is worrying the kid. And then try to work through some options and also to demonstrate support. Suicide equals a worry about something, not necessarily a giving up on everything.

Very often the worry will be made worse by parental distress––by the parent who says, “Oh, that is something you should be worried about.” Parents must try to get things into a less lethal, less threatening kind of mode.

How?

The way you move in that direction is, you say, “OK, now we’ve got this problem between you and so-and-so….What kinds of things have you thought of to get over this?” You can then get the kid to be the parent. Then: when we’ve gone through the whole long list of things that could be done, “Which do we think is the best?” So it’s really very basic; you try to get the kid involved by letting him ask questions as well as give you answers; and you try to show that the kind of anxieties he’s having are very common in life.

When I’m teaching medical residents, I always say: when a kid has an “event,” that’s a goldmine for you. All of a sudden, out of the blue, they do something. If you can really explore the things which upset them, and the nature of their response, you’re getting to something treatable.

And what kind of treatments are available?

CBT––cognitive behavioral therapy––is one method that is used. There has been a good deal of interest recently in an even shorter course of therapy, called IPT––interpersonal psychotherapy. (Its co-developer and champion is Foundation Scientific Council member Dr. Myrna Weissman). It starts off in a very intriguing way: you write a list of who are the most important people in your life. The therapist takes them up, one by one, and says, “Now, if you have to think of any problem you have with that person, what is it?” That’s the first session. There’s some evidence that the first session does all the work. You’re restoring some kind of proportionality to the situation, bringing it back into normal life, in a way.

Is it a way of saying, “These people are important to me—I realize that I really don’t want to die”?

I don’t think I would bring the word “die” into it at all. Because I think once you start introducing a bridge between a common problem and death, you’re really just reinforcing the value of it, almost normalizing death as a potential response to a common problem.

If a parent is concerned, then, and the child has issues, should a therapist be consulted?

The word therapist is used so broadly. I think you want a psychiatrist because the real issue is you want somebody who’s good at making a diagnosis. And that’s the specialty of psychiatry. Also, many clinical psychologists are extremely well educated and I think they are very much in tune with diagnosis. They don’t get into medication, but they know which kinds of disorders require medication. Often they are available within the school and then they can actually influence irritants to the child which are occurring in the school.

You’ve made us more aware of the potential danger of talking about suicide. If I am the parent of a troubled child and I’ve heard your remarks––“less talk about suicide is better” —now I’m scared to bring it up.

I don’t think that’s a terrible thing. I think you may want to bring it up because it has happened to somebody else. I think the parts of suicide that you do want to bring up are not necessarily the tragic components, because those can increase the martyr-like role of somebody who has taken their life. The parts to discuss are what’s known about the difficulties that this person had in their life.

Most important, I think you want to get into the habit of having your child coming to you with a problem. A lot of liberal parents are very reasonable about that. And they’re good listeners. The thing you want, above all, is for the kid to talk to you and you to talk to the kid. You’ve got to develop that––a strategy of being a good listener. And it’s easy. You just say, “Oh, that’s interesting. Tell me more about that— what happened?”