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MENTAL HEALTH

Look for the warning signs

DR. R. PADMAVATI

With increasing number of children attempting suicide, how does one help?

Distressing issue: Pressure from parents can precipitate suicidal behaviour. Photo: SHANKER CHAKRAVARTY

AROUND 9.00 p.m., an 11-year-old boy is brought to the emergency room of a private nursing home. He was found hanging from the ceiling fan. Details from a weeping mother and a distraught father revealed that there had been an argument over the boy's poor academic performance and non-attendance of tuition classes earlier that evening.

Suicide in young children is far more common than one imagines. It has been estimated that one to two per 1,00,000 children under the age of 15 attempt suicide. The figures rise to 11 per 1,00,000 in older children. Wide ranges of 15 to 50 per cent of children who attempt suicide have tried to do so before. The impact of a child's suicide attempt is particularly distressing to parents.

Psychiatric disorders

A vast majority of children and adolescents who attempt suicide have psychiatric disorders. Children and teenagers who attempt suicide are eight times more likely to suffer from depression, three times more likely to have an anxiety disorder and six times more likely to have a substance abuse problem. A family history of suicidal behaviour also increases the risk. If the child is constantly dwelling on death and thinks that being dead would be kind of nice, he/she is more likely to make a serious attempt.

Many people think that the main reason children try to kill themselves is to manipulate others or as a "cry for help". However, when children and adolescents are actually asked right after the suicide attempts, their reasons are more like that of adults. For a third, their main reason is that they wanted to die. Another third wanted to escape from a hopeless situation or a horrible state of mind. Only about 10 per cent were trying to get attention and only two per cent saw getting help as the chief reason for trying suicide. The ones who truly wanted to die were more depressed, angrier and perfectionist.

Predicting suicide is very difficult. It is even more difficult in children and adolescents. There are difficult issues that need to be understood.

Suicidal thinking: This means a person is thinking about suicide but has no plan. This is not uncommon. About three to four per cent will have considered suicide in the last two weeks. This thought is likely to be more serious if the child has previously attempted suicide, is depressed or is feeling hopeless.

Suicidal plans: This indicates suicidal thinking associated with a "way to do it in the mind". For example, Nita, 15, is very depressed. She is waiting until Friday when her parents will go out and leave her alone at home. She has been collecting an assortment of tablets and her grandmother's heart medication for two weeks. She has also been working on a suicide note. She is scared she will tell someone. Another example is Arya, 12. He is upset that his mother would not allow him to go out with his friends. He feels his parents say "no" to everything that he asks for. He just "can't take it anymore". He has decided to break a light bulb, cut his wrists and just see what happens. If he dies, fine, that's okay with him. If he doesn't, maybe his parents will change their minds.

These are all suicidal plans. Some are well thought out like Nita's. Others like Arya's are impulsive. Very few of these children reach a healthcare service. Most are afraid to talk to their friends, parents or even school counsellors.

Suicide attempts: This means that there has been an actual attempt to hurt oneself. Some common methods are consumption of poisons, an overdose with assorted medicines, jumping from heights or burn injuries. The most frequent reason for these impulsive suicide plans are relationship problems. About 40 per cent of teenagers will have thought about suicide for only half hour or so before they try something.

The outcome of suicides could be classified under the following categories:

Medically non-serious, emotionally non-serious: Kavya, 17, is in love with her neighbour's son Rohit, who is two years older than her. He has told her that he is not interested in her and has even threatened to tell her parents. She decided to show him how much this has hurt her and swallowed two strips of paracetamol tablets and sent a message to Rohit's cell phone. She has no intention of hurting herself; she wanted to get Rohit's attention. The outcome of this is not serious medically and there is no psychiatric diagnosis. Kavya was not trying to kill herself and what she did was not going to hurt her.

Medically non-serious, emotionally serious: Dinesh, 16, has been depressed for the last year. His school performance has been falling steadily; he cannot concentrate. Most days, he does not even feel like going to school. He has been refusing to work around the house and just sits in his room listening to his stereo. His mother takes "pills" for a nervous condition and complains that they were too strong for her. So Dinesh thought that taking his mother's pills would be a good way to go. One evening, he swallowed a number of her pills. That night, when his mother was looking for her medication, he told her what he had done and was rushed to hospital. Dinesh was really trying to kill himself. He did not know that what he had done was not that serious.

Medically serious: emotionally non-serious: Ritika, 13, had a big fight with her best friend who told her that she would not talk to her for the "rest of her life". She came home to an empty house. Her mother had left a note saying that she was visiting friends and would be back late. Distressed Ritika decided to hang herself. Fortunately, she had left the apartment door open. A neighbour walked in to investigate why the door was ajar and found Ritika. She rushed the unconscious girl to the hospital and sent a message to her mother. Ritika did not really want to kill herself. She wanted to make a point but unfortunately she did not realise how dangerous hanging could be.

Medically serious, emotionally serious: Sandhya, 19, had been having bizarre experiences over several years. She would hear God's voice instructing her on her daily life. Her behaviour centred on these messages, even if they were not relevant to her life. One day she attempted to burn herself but survived due to the quick intervention of her family. Psychiatric assessment revealed that the attempt was made because the "voices" told her to. She was suffering from a major psychiatric illness.

Other causes

Some suicides occur unexpectedly, many others are predicted but seem to be virtually unpreventable. Most are a final outcome of a psychiatric illness, particularly a mood or psychotic disorder or alcoholism. Only a minority arise from stressful events in an otherwise emotionally healthy person.

Parental demand for high academic achievement has been known to precipitate suicidal behaviour. The end of May and beginning of June each year witness an increase in the number of youngsters trying to commit suicide. Failure in examinations, less than expected marks, deep disappointment are some of the causes. In several reports, there is evidence that someone known to the child has attempted suicide and a similar method is adopted. The negative effect of TV on the physical and mental health of children is well documented. Depiction of self-harm in the visual media often prompts imitative behaviour in children.

Despite advances in mental health sciences, most contemporary societies treat suicide as a matter of shame representing failure of personal responsibility, family cohesion or social systems. The distress in the event of a suicide attempt by an adolescent is far reaching, affecting virtually all family members. It is critical to watch for the tell tale signs of distress.

The writer is Consultant Psychiatrist Schizophrenia Research Foundation (SCARF) based in Chennai.

What parents can do

Most kids who commit or attempt suicide give some type of warning ahead of time. So as a parent, it is important that you are aware of some of the warning signs so that you can get your child the help he/she needs.

Watch and Listen: If your child seems depressed and withdrawn, it's a good idea to watch him or her carefully. Poor marks in school may be a signal that your teen is withdrawing at school.

Keep lines of communication open: Express your concern, love and support. If your child confides his/her concerns, it's important to show that you take them seriously. A fight with a friend may not seem like a big deal to you but for a teen the situation can seem immense. It is important not to minimise or discount what your child is going through. This may increase his or her sense of hopelessness. If your child will not speak to you about how he/she is feeling, it's a good idea to suggest that your child talks to someone he/she is comfortable with. Try to suggest a neutral person like a relative, school counsellor or your child's doctor.

Ask questions: Some parents are reluctant to ask teens if they have been thinking about suicide or hurting themselves. Some parents fear that by asking such questions they will plant the idea in the child's head. It's always a good idea to ask. Asking a person if he or she has suicidal thoughts is difficult. Sometimes it helps to let the person know why you're asking. For instance you might say, "I've noticed that you've been talking about wanting to be dead. Have you been thinking about trying to kill yourself?" Usually mentioning the topic is a relief.

Get help: If you learn that your child is thinking about suicide, get help immediately. Your child's doctor can refer you to a psychologist or psychiatrist.

What a friend can do?