1234 Chapter 31: Child Psychiatry to suicidal behaviors, although to date, the evidence has not been consistent. Current studies are seeking to investigate cor relations between genetic vulnerability and environment and timing interactions as multiple variables that may interact to increase the risk of suicidal behavior. Biological Factors. A relationship between altered central serotonin with suicide as well as impulsive aggression has been found in children and adolescents, and has been demonstrated in adults. Studies have documented a reduction in the density of serotonin transporter receptors in the prefrontal cortex, and serotonin receptors among individuals with suicidal behaviors. Postmortem studies in adolescents who have completed suicide show the most significant alterations in the prefrontal cortex and hippocampus, brain regions that are also associated with emo- tion regulation and problem solving. These studies have found altered serotonin metabolites, alteration in 5-HT2a binding and decreased activity of protein kinase A and C. Decreased levels of serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) have also been found in the cerebrospinal fluid of depressed adults who attempted suicide by violent methods. Meta-analyses suggest an association between the short S-allele of the sero- tonin transporter promoter gene and depression as well as sui- cidal behavior, particularly when combined with adverse life events, Psychosocial Factors. Although severe major depressive illness is the most significant risk factor for suicide, increas- ing its risk by 20 percent, many severely depressed individuals are not suicidal. A sense of hopelessness, impulsivity, recur- rent substance use, and a history of aggressive behavior, have been associated with an increased risk of suicide. A wide range of psychopathological symptoms are associated with exposure to violent and abusive homes. Aggressive, self-destructive, and suicidal behaviors seem to occur with greatest frequency among youth who have endured chronically stressful family lives. The most significant family risk factor for suicidal behav- ior is maltreatment, including physical and sexual abuse and neglect. The single largest association is between sexual abuse and suicidal behavior. Large community studies have provided data suggesting that youth at risk for suicidal behavior include ‘those who feel disconnected, isolated, or alienated from peers. Sexual orientation is a risk factor, with increased rates of sui- cidal behavior of two to six times among youth who identify themselves as gay, lesbian, or bisexual. Protective factors miti- gating the risk of suicidal behavior are youth who have a strong connection to school and peers even in the face of other risk factors. a : Diagnosis and Clinical Features The characteristics of adolescents who attempt suicide and those who complete suicide are similar and up to 40 percent of suicidal persons have made a previous attempt, Direct ques- tioning of children and adolescents about suicidal thoughts is necessary, because studies have consistently shown that care- givers are frequently unaware of these ideas in their children, Suicidal thoughts (i.e, children talking about wanting to harm themselves) and suicidal threats (c.g., children stating that they want to jump in front of a car) are more common than suicide completion. ‘Most older adolescents with suicidal behavior meet criteria for one or more psychiatric disorders, often including major depressive disorder, bipolar disorder, and psychotic disorders. Youth with mood disorders in combination with substance abuse and a history of aggressive behavior are at particularly high risk for suicide. The most common precipitating factors in younger adolescent suicide completers appear to be impendi disciplinary actions, impulsive behavioral histories, and access to loaded guns, particularly in the home. Adolescents without ‘mood disorders with histories of disruptive and violent, aggres- sive, and impulsive behavior may be susceptible to suicide dur- ing family or peer conflicts. High levels of hopelessness, poor problem-solving skills, and a history of aggressive behavior are tisk factors for suicide. A less common profile of an adolescent who completes suicide is one of high achievement and perfec- tionistic character traits facing a perceived failure, such an aca- demically proficient adolescent humiliated by a poor grade on an exam, Findings from a World Health Organization mental health survey reveals that a range of psychiatric disorders increase the risk of suicidal ideation across the lifespan. Youth with psychi- atric disorders characterized by severe anxiety and poor impulse control are at higher risk to act on suicidal ideation. In psychi- atrically disturbed and vulnerable adolescents, suicide behavior may represent impulsive responses to recent stressors. Typical precipitants of suicidal behavior include conflicts and argu- ‘ments with family members and boyfriends or girlfriends. Alco- hol and other substance use can further predispose an already vulnerable adolescent to suicidal behavior. In other cases, an adolescent attempts suicide in anticipation of punishment after being caught by the police or other authority figures for a for- bidden behavior. About 40 percent of youth who complete suicide had pre- vious psychiatric treatment, and about 40 percent had made a previous suicide attempt. A child who has lost a parent by any ‘means before age 13 is at higher risk for mood disorders and suicide, The precipitating factors include loss of face with peers, a broken romance, schoo! difficulties, unemployment, bereave- ‘ment, separation, and rejection. Clusters of suicides among adolescents who know one another and go to the same school have been reported, Suicidal behavior can precipitate other such attempts within a peer group through identification—so-called copycat suicides. Some studies have found a transient increase in adolescent suicides after television programs in which the main theme was the suicide of teenager. ‘The tendency of disturbed young persons to imitate highly pub- licized suicides has been referred to as Werther syndrome, after the protagonist in Johann Wolfgang von Goethe's novel, The Sorrows of Young Werther. The novel, in which the hero kills himself, was banned in some European countries after its publication more than 200 years ago because of a rash of suicides by young men who read it; some ‘dressed like Werther before killing themselves or let the book open at the passage deseribing his death, In general, although imitation may play a role in the timing of suicide attempts by vulnerable edoles- cents, the overall suicide rate does not seem to increase when media ‘exposure increases. In contrast, direct exposure to peer suicide is ass ‘| ciated with increased risk of depression and posttraumatic stress di order rather than suicide.