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Cemetery, tombstones, tears and hidden silences: Suicide in children and adolescents

Published:December 17, 2021DOI:https://doi.org/10.1016/j.pedn.2021.12.005

      Highlights

      • Suicide is the second leading cause of death in children, adolescents, and young adults between 15 and 24 years.
      • Most children and teenagers who attempt suicide have a significant mental disorder.
      • Suicide attempts and suicide deaths are increasing among black youth.

      Abstract

      Recent studies have reported a deterioration in children's mental health since the onset of the COVID-19 pandemic, with an increase in anxiety and mood disorders leading to significant suicidal ideation and suicide rates. Suicide is complex, and individual tragedies and circumstances can diverge. Evidence suggests that the mental health and well-being of some children and youth were substantially affected because of and during the pandemic. Those with pre-existing mental health problems that experienced the most negative impacts compared to pre-pandemic data.

      Keywords

      The COVID-19 pandemic raised concerns about the mental health of a generation of children. However, the pandemic could represent the tip of a mental health iceberg - an iceberg we have ignored for a long time. Every child or young person who has died of suicide is a precious individual and their deaths represent a devastating loss, leaving a legacy for families that can affect future generations and the wider community. As with all child and youth deaths, it is important to understand what happened and why in all cases (). Between March and October 2020, the percentage of emergency department visits for children with mental health emergencies increased by 24% for children between 5 and 11 years, and 31% for children between 12 and 17 years. There was also a more than 50% increase in emergency department visits with suspected suicide attempts among girls between 12 and 17 years in early 2021 compared to the same period in 2019. In addition, many young people were affected by the loss of a loved one. Recent data show that more than 140,000 children in the United States have suffered the death of a primary or secondary caregiver during the COVID-19 pandemic, with children of color disproportionately affected (
      • American Academy of Child & Adolescent Psychiatry
      Pediatricians, child and adolescent psychiatrists and children’s hospitals declare national emergency in children's mental health.
      ).
      In this context, the impact of COVID-19 on the mental health of children and adolescents is a matter of great concern. Anxiety, depression, sleep and appetite disturbances, as well as impaired social interactions are the most common presentations. Compared to adults, this pandemic may continue to have increased long-term adverse consequences on the mental health of children and adolescents (
      • Meherali S.
      • Neelam Punjani V.
      • Louie-Poon S.
      • Rahim K.A.
      • Das K.K.
      • Salam R.A.
      • Lassi Z.S.
      Mental health of children and adolescents amidst COVID-19 and past pandemics: a rapid systematic review.
      ). It is important to note that suicide is the second leading cause of death in children, adolescents, and young adults between 15 and 24 years. Most children and teenagers who attempt suicide have a significant mental disorder, usually depression. Among younger children, suicide attempts are often impulsive. They can be associated with feelings of sadness, confusion, anger, or attention problems and hyperactivity disorder. Among adolescents, suicide attempts may be associated with feelings of stress, doubt, pressure to succeed, financial uncertainty, disappointment, and loss ().
      • Mayne S.L.
      • Hannan C.
      • Davis M.
      • Young J.F.
      • Kelly M.K.
      • Powell M.
      • Fiks A.G.
      COVID-19 and adolescent depression and suicide risk screening.
      found that testing positive for depressive symptoms and the risk of suicide increased by a small but significant amount during the COVID-19 pandemic. The increases were most noticeable among female adolescents, both for depression and for suicide risk screening, with some indication of an increase among non-Hispanic white and non-Hispanic black adolescents.
      Recent evidence suggests that suicide attempts (
      • Lindsey M.A.
      • Sheftall A.H.
      • Xiao Y.
      • Joe S.
      Trends of suicidal behaviors among high school students in the United States: 1991–2017.
      ) and suicide deaths (
      • Bridge J.A.
      • Horowitz L.M.
      • Fontanella C.A.
      • Sheftall A.H.
      • Greenhouse J.
      • Kelleher K.J.
      • et al.
      Age-related racial disparity in suicide rates among US youths from 2001 through 2015.
      ;
      • Jones J.D.
      • Boyd R.C.
      • Calkins M.E.
      • Ahmed A.
      • Moore T.M.
      • Barzilay R.
      • et al.
      Parent-adolescent agreement about adolescents’ suicidal thoughts.
      ) are increasing among black youth. Racial minority groups experience increased discrimination, prejudice, and stigmatization, which increases stress and negative mental health outcomes. Intersectionality theory emphasizes that these risks can be further amplified when individuals experience multiple minority groups, as in the case of some multiracial youth. Reflecting the intersecting racial identities is important in advancing our understanding of the risk of suicide among young people, as well as informing our perspective for implementing systemic changes to reduce the risk for the neediest young people (
      • Berger M.
      • Samyai Z.
      “More than skin deep”: Stress neurobiology and mental health consequences of racial discrimination.
      ;
      • Fox K.R.
      • Harris J.A.
      • Wang S.B.
      • Millner A.J.
      • Deming C.A.
      • Nock M.K.
      Self-injurious thoughts and behaviors interview—revised: Development, reliability, and validity.
      ). In this way, the pandemic is exposing many teenagers to trauma and testing their fragile resilience. Closing schools, canceling proms and separating friends. As if the pandemic were not enough, teenagers watched police violence and racial tensions reach their limit. After that, children and teenagers experienced deadly forest fires and other natural disasters that highlighted the threat of climate change. In this context, as COVID-19 runs through 2021, doctors desperately need a comprehensive public health strategy to manage the anticipated increase in demand for treatment. This will be particularly important when working with adolescents (
      • Psychiatry Times
      Teens in America: How the COVID-19 pandemic is shaping the next generation.
      ;
      • Meherali S.
      • Neelam Punjani V.
      • Louie-Poon S.
      • Rahim K.A.
      • Das K.K.
      • Salam R.A.
      • Lassi Z.S.
      Mental health of children and adolescents amidst COVID-19 and past pandemics: a rapid systematic review.
      ; ). Many are dealing with a variety of issues, including trauma, the effects of isolation, and a devastated sense of security. The unique conditions of COVID-19 may have created a new type of post-traumatic stress disorder - PTSD, rooted in fear of what might happen rather than what happened. As a result, the way PTSD is defined and diagnosed in the DSM-5 will likely need to change (
      • Mayne S.L.
      • Hannan C.
      • Davis M.
      • Young J.F.
      • Kelly M.K.
      • Powell M.
      • Fiks A.G.
      COVID-19 and adolescent depression and suicide risk screening.
      ;
      • Meherali S.
      • Neelam Punjani V.
      • Louie-Poon S.
      • Rahim K.A.
      • Das K.K.
      • Salam R.A.
      • Lassi Z.S.
      Mental health of children and adolescents amidst COVID-19 and past pandemics: a rapid systematic review.
      ; ).

      Contributors

      UPS, AOAR, MLRN, YTGPand MLRN have contributed to the initial pilot search, planning the methodology, and writing. NBV and MLRN have contributed to planning the methodology, data gathering, and reviewing the draft UPS and NNRL has contributed to planning the methodology and writing.AOAR and NNRL revised the manuscript critically. All authors approved the final version of the manuscript.

      Funding

      Logos University International – UNILOGOS, Miami, Florida – EUA and Brazilian National Council for Scientific and Technological Development (CNPq) – institution linked to the Brazilian Department of Science, Technology and Innovation to encourage research in Brazil.

      Declaration of Competing Interest

      The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

      Acknowledgments

      Doctoral Program in Nuerosciences and Human Development – Logos University International – UNILOGOS, Miami, Florida - EUA.

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