Youth suicide is a tragedy. Fortunately, recent research (1) has shown that in children and in adolescents suicide rates have decreased, however, alongside this there has been an alarming change in the pattern of self-harm with increased rates of hanging (2) and a clear potential for fatality. There is, therefore, an urgent need to identify those populations at risk and to intervene proactively. An important, and perhaps overlooked, group is those young people with externalising behavioural disorders and conduct disorder, who are known to be at an increased risk of suicide. These children pose particular problems of engagement with child mental health services. Furthermore, suicide attempts in this group are often impulsive and reactive, and any risks are increased by the use of drugs and alcohol.
The paper in this issue of Acta Psychiatrica Scandinavica by Matthew Impey (3) is a meta analysis and systematic review of ADHD, suicide and attempted suicide. ADHD and suicidal behaviour are common; however, the authors set out to review the literature to determine whether a positive relationship exists more than one would expect by chance. A previous meta analysis (4) showed an association between ADHD and suicide; however, this more extensive study looked at not only completed suicides, but also other dimensions of suicidal behaviour such as suicide attempts and suicidal ideation. A positive, modest relationship was found. The authors highlight an interesting and important association of ADHD and age, with a strong association in the younger age group.
One must be mindful of the limitations of such a study including the small number of studies available, differing methodologies and differing measurement tools. The small number of papers reflects the fact that this is an understudied area. The authors note that the standardised ADHD rating scales do not generally enquire about self-harm and risk to self and others. Perhaps these areas should be routinely assessed either in questionnaires or certainly at clinical assessment.
It is becoming clearer, nonetheless, that there is an association between ADHD and attempted suicide and completed suicide. However, the mechanisms remain uncertain. At least one study indicates a link via depression. It is also very likely ADHD increases impulsivity and the risk of suicide in those experiencing stress. Co-morbid disorders are also important, particularly illicit drug use and alcohol. A related question is whether those with ADHD are at increased risk of drug or alcohol misuse. Even in the absence of clear identified mechanisms, ADHD needs to be recognised as a potential risk factor for attempted suicide. However, suicide attempts in children and adolescents with behavioural disorders and ADHD can be overlooked or missed altogether, as for instance in the case of a boy with ADHD who stole a bicycle to commit suicide by driving at a bus; fortunately, he survived but was arrested three days later, after recovering consciousness, for theft of the bicycle and causing an accident by reckless driving. This completely overlooked the fact that he had made a serious suicide attempt. Recognition of these covert suicide attempts could strengthen the association of ADHD and suicide.
What are the implications of this review for child and adolescent mental health services? One would hope that, following this review, clinicians will start to recognise the ADHD population as being at increased risk of suicide attempts and completed suicide. The implication is that clinicians need to routinely screen for suicide attempts in ADHD subjects, including the younger population. Hopefully, this may open up new ways of reducing the youth suicide rate even further.