In the past few years, and especially since the beginning of the pandemic caused by SARS-CoV-2, there has been evidence of a deterioration of the mental health of children and adolescents. In particular, adolescents are exhibiting more depressive symptoms, self-harm and suicidal behaviours. This is an alarming situation and has become an important public health problema, especially after the beginning of the SARS-CoV-2 pandemic.1–3 In 2020, the Fundación de Atención de Niños y Adolescentes en Riesgo (ANAR, Foundation for the Care of At-Risk Children and Adolescents) received 145 % more calls from minors with suicidal ideation or who had attempted suicide, and the frequency of self-injuries increased by 180 % relative to the two previous years.3

In 2020, 14 children under 15 years committed suicide, double the number of the previous year, and the trend is worsening.4 In youth aged 15–29 years, suicide is already the second leading cause of death, only exceeded by malignant tumours.4–6 This increase in both the number of completed and attempted suicides, chiefly through the intentional drug poisoning,2,3,7,8 was identified as early as 2010.7

Beyond the realm of statistics, suicidal behaviour has a significant impact and is associated with a relevant degree of stigmatization, even discrimination, that hinders and complicates its management and prevention. Self-harm and associated suicidal behaviours have a short- and long-term impact not only in the life of the individuals that engage in them, but also on their family and social environment. Due to all of the above, there is a pressing need for tools allowing early detection in clinical practice. In addition, the approach to their management must be holistic, and interventions must include a community-based and public health component, including primary, secondary and tertiary prevention strategies.9 Paediatricians are one of the professional collectives most involved in this process, so it is crucial that they be sufficiently trained on the subject.

Self-harm refers to behaviours aimed at inflicting some form of physical injury on oneself. These behaviours are not always associated with suicidal ideation or intent. Self-injurious and suicidal behaviours may occur in the same person simultaneously or at different times. It is crucial for professionals to be able to discriminate between non-suicidal self-injury (NSSI) and suicidal behaviour, so they must receive adequate training, and should not avoid discussing or bringing up these subjects.9

Non-suicidal self-injury is defined as the deliberate, self-inflicted destruction of body tissue10 (Table 1). In addition to cutting, the most frequent behaviour, it may involve biting, burning, scratching or excessive rubbing, hitting or any other way to harm oneself, without the intent of ending one’s life. The underlying motivations attributed to these behaviours are that they serve as means to dampen or alleviate negative feelings, to punish oneself or to seek social positive reinforcement.11,12 All these possibilities must be considered, attempting to make the adolescent feel understood, avoiding judgmental or critical attitudes. These are some examples:

• Relief or reduction of negative feelings: when feeling intense anxiety or distress, patients may engage in NSSI to “replace” emotional pain by physical pain.

• Self-punishment: when feeling guilt, NSSI may be perceived as a form of compensation.

• Need of social positive reinforcement: with the aim of causing a change in their environment, patients may engage in NSSI, either to draw attention away from other situations or to avoid situations that they feel unable to confront (for instance, if they do not want to go to school, they expect they would not be forced to go) or to receive more attention from another person (for instance, after a breakup, or if they feel ignored by parents).

The prevalence varies between studies and countries, ranging from 15% to 25%, and is greater in the female sex.11,12 Since the 60s, there has been an increase in this type of injuries, especially in adolescents and young adults, and it is a source of growing concern, not only in the health care field but also in the education and in families.12 Although traditionally this type of behaviours have been associated with mental disorders (emotionally unstable personality disorder, eating disorder, depression or anxiety), more recent evidence has shown that they may also manifest in the absence of psychiatric comorbidity. Approximately half of these adolescents also have suicidal ideation and are at higher risk of having suicidal intent and attempting suicide, especially in the case of serious or recurring self-injury.12 Therefore, they are behaviours that need to be assessed by qualified professionals.

As regards suicidal behaviour, it is important to differentiate between, in order of increasing severity, suicidal ideation, suicide threats, suicide attempts and, lastly, completed suicide.7,10 Suicide is a serious public health problem, and the World Health Organization (WHO) considers suicide prevention a global imperative. If affects low-, middle- and high-income countries and individuals, and it is estimated that approximately 70% of the individuals that die of suicide meet the diagnostic criteria for a psychiatric disorder, most frequently depression and bipolar disorder.13

The consumption of alcohol and other substances facilitates acting on suicidal ideation, and access to firearms is also a risk factor. It is estimated that 1 in 10 individuals that attempt suicide eventually die of this cause, and in adolescents and young adults, suicidal behaviours are much more frequent compared to other age groups. The spectrum could be conceived of as an iceberg, with completed suicide corresponding to the tip and suicidal behaviours constituting the more prevalent underlying problem. Intentional drug overdose is the most frequent reason for seeking emergency care related to mental health.13

The Sociedad Española de Urgencias de Pediatría (SEUP, Spanish Society of Paediatric Emergency Medicine) analysed trends in diagnosis related to psychiatric disorders in 16 paediatric emergency departments (PEDs) before and during the SARS-CoV-2 pandemic. Comparing to the March 2019-March 2020 period, in the March 2020-March 2021 period there was a 122% increase in the diagnosis of intentional drug overdose and a 56% increase in the diagnosis of suicide/suicidal attempt/suicidal ideation.17 Within the same society, the Working Group on Poisoning started a prospective study in 2021 in the paediatric patients that presented in the emergency department following intentional ingestion of toxic substances, with participation of 23 PEDs in 10 different autonomous communities. In the first 9 months under study, there were 281 documented attempts, with a clear predominance of female patients (90.1%) and a mean age of 14.8 years. The most salient finding was that one third of these patients (34.9%) did not have a pre-existing psychiatric diagnosis, which is not to say they did not have any mental health disorders. Another relevant finding was that half (57.7%) had attempted suicide before. In addition to intentional drug overdose, most patients (82.6%) reported engaging in NSSI14,15 (Fig. 1).

Figure 1.

Self-injury.

(0.23MB).

Adolescents are a vulnerable population due to the physical, emotional and social changes they undergo in addition to their need of autonomy and finding their own identity. Some are also exposed to risk situations, such as abuse or violence.15 Suicidal behaviour is complex and multifactorial, as it is associated with various risk factors and multiple and interrelated causes of a biological, psychological, cultural and socioeconomic nature, all of which may change over time16–20 (Table 2).

The pandemic has evinced the key role of social determinants in increasing the risk of health problems, both physical and mental (emotional and environmental). The main triggers in this period were social isolation, the interruption of daily life routines, the multiple restrictions to leisure activities and an excessive use of screens.16,17,20 In addition, some minors were exposed to disease or even death, precarious work, financial problems or overcrowding in their close environment. In some instances, they may have felt responsible for contagions. Overexposure to information on SARS-CoV-2 combined with great uncertainty in significant adults was associated with an increase in anxiety and depression symptoms. There has also been an increase in domestic violence, and mental health has worsened within families.16,17,20

However, not every adolescent has suffered symptoms of depression or anxiety, or engaged in self-harm or suicidal behaviour. This is because in addition to all these shared factors, there are also individual predisposing factors. The best known for suicidal behaviour are female sex, the presence of a psychiatric disorder, especially depression, and a history of previous suicide attempts.13 Having made one attempt is associated with a 32-fold probability of death by suicide in the following year, and 1 in 100 youth that attempt suicide will die from this cause in the next 7 years.11 The Save the Children report concluded that minors in households with fewer resources are most affected and are four times more likely to experience mental health problems and engage in suicidal behaviour.18

In addition to trying to reduce risk factors and triggers, the strengths of each adolescent and the surrounding environment must also be taken into account. Social and problem-solving skills, the development and appreciation of the importance of empathy, respecting diversity, tolerating frustration, resilience and emotion regulation are some of the skills that can be taught and could protect from future suicidal behaviour. Families, schools and health care institutions play a key role in this regard. Schools are very important regulators of behaviour in children and youth, and can buffer many sources of stress and anxiety in this age group. A family environment with positive parental roles, interpersonal relationships, sports and predictable routines are also protective factors in relation to mental health and suicidal behaviour.19

We may want to reflect on the fact that Western society is currently framed in the so-called “welfare state”, which is characterised by material abundance but entails a series of affective and emotional deficiencies. The lack of quality time with children, the demands of work, an excessive number of activities focused on performance and efficiency, or the lack of communication or “real” social interactions lead to isolation. In this context, there is a risk to provide education focused exclusively on cognitive goals and neglecting social and emotional aspects. Learning strategies to be able to cope with situations and tolerate frustration, manage conflict or seek help and provide it to others promotes psychological wellbeing and resilience.20,21

Spain does not have a national suicide prevention plan, which translates to heterogeneity in the plans for management of suicide risk in different autonomous communities (ACs). Prevention does not depend exclusively on mental health services, the resources involved in suicide prevention in youth are diverse (Table 3), and the current trend can only be reversed with the participation and coordination of all of them.

The main gaps and limitations detected by the Asociación Española de Pediatría (AEP, Spanish Association of Pediatrics) on behalf of the collective of paediatricians as regards suicidal behaviour in adolescents are:

• Absence or heterogeneity of suicide prevention programmes in different ACs.

• Insufficient specific training on mental health and limited resources for professionals in contact with children and adolescents both in the health care field (paediatricians, PC physicians, nurses) and in schools (teachers, school counsellors).

• Increasing waiting lists and overwhelming demand in primary care, emergency care and mental health services for adolescents with suicidal behaviour.

• Lack of coordination between institutions and levels of care.

The training in mental health of paediatricians, especially in primary care, given their closeness and continuous contact with families, primary care general physicians and nurses, is crucial for prevention, as these are the professionals that provide care to children and adolescents routinely. The AEP advocates for making rotations in child and adolescent psychiatry mandatory for paediatrics residents, which is already required of primary care physicians. In addition, paediatricians and primary care physicians should receive training in mental health, not with the aim of having them all become specialists on the subject, but to acquire the basic knowledge necessary to detect cases and engage in primary and secondary prevention. This can be achieved by means of visiting clinical rotations, continuing education activities, remote consultations or periodic coordination meetings.

In the school setting, training programmes must be developed for the delivery of education on suicide prevention and early detection of suicide risk by specialists in the field to teachers, counsellors and administrators. Working on the development of emotional health and resilience from an early age is essential.

The goals of training in school-based professionals are:

• Knowing the risk factors and warning signs associated with suicidal behaviours in children and adolescents and being able to detect them.

• Establishing measures for management and follow-up in the case of suicidal behaviour: knowing how to address the behaviour, listen actively and efficiently with a supportive and tactful attitude, and confidentiality issues.

• Knowing measures to prevent worsening or potential imitation of a behaviour.

• Learning to communicate with families efficiently, tactfully and with ease.

• In schools, select and train groups of students to provide support, help detect cases in the school grounds and the social environment, including social networks.

Other professionals involved in suicide prevention are those working in emergency care services and social facilitators (police, firefighters, social workers, etc.).

In 2021, the Ministry of Health approved the Mental Health Action Plan for 2022–2026, which will start to be implemented in upcoming months.22 This document formulated action recommendations structured into 10 strategic lines: “Prevention, early detection and management of suicidal behaviour” is strategic line 3, while “Child and adolescent mental health” is strategic line 5 (Table 4). Other documents, such as the recommendations of the WHO23 or guidelines at the European level like those of the European Alliance Against Depression (EAAD),24 have also proposed measures of improvement to reduce de incidence of suicide in adolescents.

The American Academy of Pediatrics recommends starting universal screening for suicide risk at age 12 years to identify adolescents at risk of depression and/or suicidal ideation and deliver early intervention. Other groups have analysed the outcomes of the selective or universal application of a scale to screen for suicide risk in paediatric emergency departments.25–27 In Spain, the use of measurement instruments tested and validated for assessment of suicidal behaviour in adolescents is scarce. Recently, some ACs, such as the Basque Country, have proposed the application of a questionnaire for detection of depression symptoms at age 13–14 years in the routine checkups scheduled through the primary care Healthy Child Programme.

Table 5 presents the most important recommendations proposed by the Multidisciplinary Working Group on Paediatric Mental Health, with an emphasis on the need of a multidisciplinary approach.