Suicide among children and adolescents: a warning to accomplish a global imperative

Every year, worldwide, over 800,000 people commit suicide, i.e., one death every 40 second. This is second leading cause of death among those aged 15 to 29 years. Considering the relevance of this problem, the World Health Organization had established as a global imperative the suicide prevention, and countries should consider suicide prevention as a high priority health care program. This program goal is to reduce suicide rates up to 10% by 2020.11. World Health Organization (WHO). Preventing suicide: a global imperative [Internet]. Genève: WHO; 2014. [cited 2019 May 30]. Available from: http://apps.who.int/iris/bitstream/handle/10665/131056/9789241564779_eng.pdf?sequence=1
http://apps.who.int/iris/bitstream/handl...

The goal of this editorial is to be an alert as this deadline is approaching and because recent data have pointed out an opposite direction regarding the accomplishment of this global imperative, especially concerning Brazilian children and adolescent population.

A study conducted in large Brazilian cities showed that suicide rate among adolescents increased by 24% between 2006 and 2015.22. Jaen-Varas D, Mari J, Asevedo E, Borschmann R, Diniz E, Ziebold C, et al. The association between adolescent suicide rates and socioeconomic indicators in Brazil: a 10-year retrospective ecological study. Braz J Psychiatry. 2019. Ahead of print. http://dx.doi.org/10.1590/1516-4446-2018-0223
http://dx.doi.org/10.1590/1516-4446-2018...
A total of 48,204 suicide attempts was registered in Brazil between 2011 to 2016. These occurrences affected 25.9% of women and 19.6% of men, considering only those aged 10 to 19 years.33. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Perfil epidemiológico das tentativas e óbitos por suicídio no Brasil e a rede de atenção à saúde. Bol Epidemiol. 2017;48(30): 1-14.

The suicidal behavior involves events, throughout a sequence, which has as an intention to cause self-injury that will end up in death, including suicide ideation (without specific plan or intention), suicide attempt, and suicide.

The suicide ideation is prior to other events and, for this reason, it can be considered an important indicative of risk for suicide. This is related to someone’s thinking of wishing to die by taken his/her own life,44. Jans T, Vloet TD, Taneli Y, Warnke A. Suicidio y conducta autolesiva. In: Rey JM, editor. Manual de Salud Mental Infantil y Adolescente de la IACAPAP. Ginebra: Asociación Internacional de Psiquiatría del Niño y el Adolescente y Profesiones Afines; 2017. not necessarily followed-up by preparation behavior. The younger the individual the lower this linear sequence of planning-ideation, especially for the own components related with human development.

In case of children, the ideation can be less specific and without planning due to own concept linked to death in this age range, which is even more limited among younger children. On the other hand, the impulsivity commonly in adolescence can be also contrary to suicide ideation with plan to bring about his/her own death.

Suicide attempt is related to actions that lead to someone’s own death, but with non-fatal outcome. These actions could have been abandoned, fail or interrupted44. Jans T, Vloet TD, Taneli Y, Warnke A. Suicidio y conducta autolesiva. In: Rey JM, editor. Manual de Salud Mental Infantil y Adolescente de la IACAPAP. Ginebra: Asociación Internacional de Psiquiatría del Niño y el Adolescente y Profesiones Afines; 2017. and they constitute the most important risk factor that, at this time, is defined as self-provoked violence, intentionally, that lead an individual to end with his/her own life.11. World Health Organization (WHO). Preventing suicide: a global imperative [Internet]. Genève: WHO; 2014. [cited 2019 May 30]. Available from: http://apps.who.int/iris/bitstream/handle/10665/131056/9789241564779_eng.pdf?sequence=1
http://apps.who.int/iris/bitstream/handl...

There is no doubt that death is an event that impact emotionally families, health professionals linked to those who have died and to the own society particularly death due to suicide. This is an experience perceived as tragic both because of death and for the ambiguous feelings caused to those who are in deep grief such as shame, angry, pain and homesick.55. Silva L, Afonso BQ, Santos MR, Baliza MF, Rossato LM, Szylit R. Care for families after suicide loss: nursing academic experience. Rev Bras Enferm. 2018;71(Suppl 5):2206-12.

In case of death by suicide of a child or an adolescent, this emotional impact can be even higher: how could a child attempt against his/her own life? What had happen within the last year that children and adolescent’s dreams are turning into the wishing to die?

Risk factors for suicidal behavior among childhood and adolescent are impulsivity, social isolation, dissatisfaction with body image, presence of mental disorders, asphyxia games, misunderstanding with friends, bullying, influence of digital media, ending of relationships, poor scholar performance, lack of well-established family structure and function, family history of depression and suicide. However, although these risks are alerting hints concerning mental health of this population, we must pay attention for multifactorial nature of this event, not falling in the equivocal of highlighting this issue by seeking to attribute the reason as a single cause to such a complex phenomenon.

In Brazil, a fact that was recently highlighted and should be taken into account as a priority in suicide prevention policies is the socioeconomic indicators, such as social inequality and unemployment as determining factor for suicide risk among Brazilian adolescents.22. Jaen-Varas D, Mari J, Asevedo E, Borschmann R, Diniz E, Ziebold C, et al. The association between adolescent suicide rates and socioeconomic indicators in Brazil: a 10-year retrospective ecological study. Braz J Psychiatry. 2019. Ahead of print. http://dx.doi.org/10.1590/1516-4446-2018-0223
http://dx.doi.org/10.1590/1516-4446-2018...

Based on this panorama, what major ways can be taken by professionals (nurses, physicians, psychologist, occupational therapists, social assistants and educators) working in different levels of health care in order to promote actions based on guidelines for the global imperative in order to reduce suicide rates in this specific population?

An important reflection is the need of collaborative and integrated work process to understand the complexity of this phenomenon. This perspective of collective health, especially based on principles of Brazilian Public Health System, is believed to be the more adequate approach for such a huge public health issue. The principle of integrality gives fundament to the interconnection of public health policies with other units that act in favor of individuals’ health and, therefore, give the health sector the responsibility to organize prevention actions in health care services.

Other issue that lead to reflection is that, in relation to profile of deaths due to suicide in Brazil, within the period of 2011 to 2015, the Ministry of Health33. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Perfil epidemiológico das tentativas e óbitos por suicídio no Brasil e a rede de atenção à saúde. Bol Epidemiol. 2017;48(30): 1-14. pointed out as most used means of suicide: hanging, exogenous intoxication and gunshot. Iin this sense, the World Health Organization11. World Health Organization (WHO). Preventing suicide: a global imperative [Internet]. Genève: WHO; 2014. [cited 2019 May 30]. Available from: http://apps.who.int/iris/bitstream/handle/10665/131056/9789241564779_eng.pdf?sequence=1
http://apps.who.int/iris/bitstream/handl...
emphasizes the need of restrict the access to the means that individual can used for suicide such as pesticides and guns, being such restriction an important prevention strategy.

Recently there was the publication of the law 13.819/201966. Brasil, Leis, Decretos. Lei nº 13.819, de 26 de abril de 2019. Institui a Política Nacional de Prevenção da Automutilação e do Suicídio [Internet]. Brasília (DF): Diário Oficial da União; 2019. [citado 2019 Mai 30]. Disponível em: http://www.in.gov.br/web/dou/-/lei-n%C2%BA-13.819-de-26-de-abril-de-2019-85673796
http://www.in.gov.br/web/dou/-/lei-n%C2%...
that establishes National Prevention Policies of Auto-mutilation and Suicide in which requires compulsory notification by health units, sanitary authorities, and educational and tutelary institutions of suspicion or confirmation cases of self-provoked violence. This flow of notification, if integrated, can provide more reliable data and, therefore, improve planning for actions. However, the adequate education of professionals of all areas involved is paramount, in a sense that enable appropriate embracement, referral in the adequate time for specific health care, and also guarantee of identity confidentiality of children, adolescents and families.

It is important to reinforce that families, who still have weakness on their structure and function, should be not judged using an reductionist view focused on define them as responsible to the behavior of children and adolescents, but they should be recognize a single individual that requires professional health care. Such families should be encourage to provide mutual support to each member55. Silva L, Afonso BQ, Santos MR, Baliza MF, Rossato LM, Szylit R. Care for families after suicide loss: nursing academic experience. Rev Bras Enferm. 2018;71(Suppl 5):2206-12.in order to improve care potential, and respond to essential needs of their children, since their early young age.

Suicidal behavior in childhood and adolescence must be considered a high priority in public health care policies. Actions for prevention should be based on scientific evidences and professional knowledge of experts from education, research and care for such specific population. In addition to impact individuals and families, and to the risk of not accomplish the global imperative related to suicide prevention, the reduction of children and adolescent population, who would be economically active in future, can compromise and limit a country’s development.

References

  • 1. World Health Organization (WHO). Preventing suicide: a global imperative [Internet]. Genève: WHO; 2014. [cited 2019 May 30]. Available from: http://apps.who.int/iris/bitstream/handle/10665/131056/9789241564779_eng.pdf?sequence=1
    » http://apps.who.int/iris/bitstream/handle/10665/131056/9789241564779_eng.pdf?sequence=1
  • 2. Jaen-Varas D, Mari J, Asevedo E, Borschmann R, Diniz E, Ziebold C, et al. The association between adolescent suicide rates and socioeconomic indicators in Brazil: a 10-year retrospective ecological study. Braz J Psychiatry. 2019. Ahead of print. http://dx.doi.org/10.1590/1516-4446-2018-0223
    » http://dx.doi.org/10.1590/1516-4446-2018-0223
  • 3. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Perfil epidemiológico das tentativas e óbitos por suicídio no Brasil e a rede de atenção à saúde. Bol Epidemiol. 2017;48(30): 1-14.
  • 4. Jans T, Vloet TD, Taneli Y, Warnke A. Suicidio y conducta autolesiva. In: Rey JM, editor. Manual de Salud Mental Infantil y Adolescente de la IACAPAP. Ginebra: Asociación Internacional de Psiquiatría del Niño y el Adolescente y Profesiones Afines; 2017.
  • 5. Silva L, Afonso BQ, Santos MR, Baliza MF, Rossato LM, Szylit R. Care for families after suicide loss: nursing academic experience. Rev Bras Enferm. 2018;71(Suppl 5):2206-12.
  • 6. Brasil, Leis, Decretos. Lei nº 13.819, de 26 de abril de 2019. Institui a Política Nacional de Prevenção da Automutilação e do Suicídio [Internet]. Brasília (DF): Diário Oficial da União; 2019. [citado 2019 Mai 30]. Disponível em: http://www.in.gov.br/web/dou/-/lei-n%C2%BA-13.819-de-26-de-abril-de-2019-85673796
    » http://www.in.gov.br/web/dou/-/lei-n%C2%BA-13.819-de-26-de-abril-de-2019-85673796

Publication Dates

  • Publication in this collection
    29 July 2019
  • Date of issue
    May-Jun 2019
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