Received: 22 September 2020 Revised: 28 January 2021 Accepted: 15 February 2021

DOI: 10.1111/appy.12452

SPECIAL ISSUE ARTICLE

Suicide prevention in childhood and adolescence: a narrative

review of current knowledge on risk and protective factors and
effectiveness of interventions

Danuta Wasserman MD, PhD1,2 | Vladimir Carli MD, PhD1,2 |

1,2 3
Miriam Iosue MPsych | Afzal Javed MD, PhD | Helen Herrman MD, PhD4

1
National Centre for Suicide Research and
Prevention of Mental Ill-Health, Karolinska
Institutet, Stockholm, Sweden
2
Section on Suicidology, World Psychiatric
Association (WPA), Geneva, Switzerland
3
Coventry and Warwickshire Partnership NHS
Trust, Coventry, UK
4
Orygen and Centre for Youth Mental Health,
The University of Melbourne, Melbourne,
Australia
Correspondence
Danuta Wasserman, MD, PhD, National
Centre for Suicide Research and Prevention of
Mental Ill-Health (NASP), Karolinska Institutet,
Granits väg 4, 171 77, Stockholm, Sweden.
Email: danuta.wasserman@ki.se
Abstract
Introduction: Suicide is a global mental health problem for people of all ages. While
rates of suicide in children and adolescents are reported as lower than those in older
populations worldwide, they represent the third leading cause of death in 15–19-year-
olds. The rates are higher among boys than girls worldwide, though the death rates for
girls exceed those for boys in Bangladesh, China, India, and Nepal. There has been a gen-
eral decrease in adolescent suicide rates over recent decades. However, increases are
reported in South East Asia as well as South America over the same time period.
Methods: A narrative review method has been used to summarize current knowledge
about risk and protective factors for suicide among children and adolescents and to
discuss evidence-based strategy for suicide prevention in this age group.
Results: Identified suicide risk and protective factors for children and adolescents
largely overlap with those for adults. Nevertheless, developmental characteristics
may strengthen the impact of some factors, such as decision-making style, coping
strategies, family and peer relationships, and victimization. The implementation of
evidence-based suicide preventive strategies is needed. Restricting access to lethal
means, school-based awareness and skill training programs, and interventions deliv-
ered in clinical and community settings have been proven effective. The effective-
ness of gatekeeper training and screening programs in reducing suicidal ideation and
behavior is unproven but widely examined in selected settings.
Discussion: Since most studies have been conducted in western countries, future research
should assess the effectiveness of these promising strategies in different cultural contexts.
The use of more rigorous study designs, the use of both short- and long-term follow-up
evaluations, the larger inclusion of individuals belonging to vulnerable groups, the evaluation
of online intervention, and the analysis of programs' cost-effectiveness are also required.

KEYWORDS
adolescents, children, suicide prevention, suicide risk factors

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
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© 2020 The Authors. Asia-Pacific Psychiatry published by John Wiley & Sons Australia, Ltd

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https://doi.org/10.1111/appy.12452
2 of 17
1 | I N T RO DU CT I O N
Suicide is a global mental health problem for people of all ages,
accounting for 800 000 deaths each year (World Health
Organization, 2019b). In 2016, the global age-standardized suicide
rate was 10.5 per 100 000 population, showing a 9.8% decrease since
2010 (World Health Organization, 2019a). Overall suicide rates also
decreased in South-East Asia (13.4 per 100 000, −4.2%) and in the
Western Pacific Region (8.4 per 100 000, −19.6%). The global age-
standardized suicide rate has been estimated to be 1.8 times higher in
males than in females. Nevertheless, there are countries such as
Bangladesh (6.7 vs. 5.5), China (8.3 vs. 7.9), and Myanmar (9.8 vs. 6.3)
where the suicide rates are higher among females. Furthermore, the
female age-standardized suicide rate in South-East Asia region is far
higher than the global female average (11.5 vs. 7.5 per 100 000).
Suicide rates are lowest in the youngest age groups (under
15 years of age) and highest in those aged 70 years or older (World
Health Organization, 2014). Nevertheless, significant numbers of chil-
dren and adolescents die from suicide. More than 60 000 children and
adolescents aged 10–19 across the world took their lives in 2016. Sui-
cide represents the third leading cause of death in 15–19-year-olds,
after road injury and interpersonal violence (World Health
Organization, 2019a).
The World Health Organization (2013) has recognized suicide
prevention as a major public health priority and advocated for the
development and implementation of comprehensive national strate-
gies, taking into special consideration youth and other vulnerable
groups. Furthermore, the current global crisis generated by the
COVID-19 pandemic is raising concerns about the risk for increased
suicide rates all over the world (Gunnell et al., 2020; Holmes
et al., 2020; D. Wasserman et al., 2020). Even if children are clini-
cally less affected by COVID-19, they are over-exposed to the indi-
rect effects of the pandemic, such as separations, losses, disruption
of school and social and health services (Clark et al., 2020;
Lee, 2020). Preliminary reports have already shown a surge in inci-
dence of attempted and completed suicide among children and ado-
lescents in England and South Asia (Ingram, 2020; Odd et al., 2020).
For this reason, the implementation of evidence-based suicide pre-
ventive strategies is much needed. Strategies need to be adapted to
the current context that is imposing restrictions on in-person inter-
ventions and is characterized by limited healthcare and economic
resources.
2 | METHODS
The current paper used a narrative review method to summarize current
knowledge about risk and protective factors for suicide among children
and adolescents and to discuss evidence-based strategy for suicide pre-
vention in this age group. The stress vulnerability model of suicidal
behavior (Mann & Arango, 1992; D. Wasserman & Sokolowski, 2016)
and the Universal-Selective-Indicated model for suicide prevention
(Institute of Medicine (US) Committee on Pathophysiology and
WASSERMAN ET AL.
Prevention of Adolescent and Adult Suicide, 2002; D. Wasserman &
Durkee, 2009) provide a theoretical framework.
Literature searches were conducted, using PubMed and Google
Scholar, in order to identify studies assessing the role of different risk
and protective factors, as well as those assessing the effectiveness of
suicide prevention strategies among children and adolescents. Articles
were included in the narrative review if they were published in English
language peer-reviewed journals and discussed cross-sectional,
cohort, case–control or interventional studies. When available, data
coming from large international surveys, systematic-review, and meta-
analyses were favored.
2.1 | Epidemiology of suicide and suicidal behavior
among children and adolescents
In almost all regions of the world, the rate of death from suicide in
youth under 14 years of age is approximately 0.6 per 100 000 (Dervic
et al., 2008) and suicide in childhood and early adolescence is consid-
ered to be uncommon. There are few studies only, most of them con-
ducted in developed countries that investigate suicide in this age
group (Dervic et al., 2008; Soole et al., 2015). The occurrence of sui-
cide is likely to be underestimated in these reports because of reluc-
tance of coroners to assign the cause of death in the death
certificates (Hawton & James, 2005).
Recently, Glenn et al. (2020) calculated a pooled suicide rate of
3.77 per 100 000 for children and youth aged 10–19 years. Suicide
rates increase during adolescence, reaching a rate of 6.04 per
100 000 in 15–19 years teenagers (vs. 0.93 per 100 000 in 10- to
14-year-olds). A stabilization or a decrease of adolescent suicide rates
has been described across much of the world (Kolves & De Leo, 2016;
McLoughlin et al., 2015). However, South America and East Asia show
the opposite trend (Kolves & De Leo, 2016).
Rates for 15–19 years old boys are more than twice those for
girls (8.41 vs. 2.98 per 100 000). This gender disparity is more evident
in late adolescence (0.76 vs. 0.64 per 100 000) (Glenn et al., 2020).
During childhood, suicidal ideation is rare. It slowly increases in
frequency until adolescence and then shows a sharp increase up to
young adulthood (Borges et al., 2012). Several studies show that
almost 30% of the adolescents participating had thought about sui-
cide and 4.2%–17% report attempted suicide at some point in their
lives (Carli et al., 2014; Evans et al., 2005; Kokkevi et al., 2012; Nock
et al., 2013; Uddin et al., 2019) (Table 1).
Suicide ideation and prior attempts represent major risk factors
for suicide in children (Soole et al., 2015) and adolescents
(McLoughlin et al., 2015). Hulten et al. (2001) reported that around
one fourth of European adolescent who attempted suicide made
another attempt within the following year. Nock et al. (2013)
described the transition from suicide ideation to attempt as happening
generally within the first year after onset. They estimated that approx-
imately one-third of adolescents with suicide ideation go on to
develop a suicide plan and approximately 60% of those with a plan
attempt suicide.
WASSERMAN ET AL. 3 of 17

TABLE 1 Prevalence of suicidal ideation and suicide attempts in different studies

Study Country/region Sample Suicidal ideation Suicide attempt

Carli et al., 2014
SEYLE
(Saving and Empowering
Young Lives in Europe)
Kokkevi et al., 2012
ESPAD
(European School Survey
Project on Alcohol and
Other Drugs)
Nock et al., 2013
National Comorbidity
Survey Replication
Adolescent Supplement
Uddin et al., 2019
Global School-based
Student Health Survey
11 European countries 12 395 high school students
Mean age = 14.91 ± 60.90
17 European countries 45 806 high school students
Age: 15–16 years
US 6483 adolescents (household
and school subsamples)
Age: 13–18 years
59 low-income and 229 129 students
middle-income Mean age: 14.6 ± 1.18
countries
Prevalence (positive on at Lifetime
least one item of the prevalence = 4.2%
Paykel Suicide
Scale) = 32.3%
Median prevalence of Median prevalence of
frequent self-harm any lifetime self-
thoughts = 7.4% (range reported suicide
2.1%–15.3%) attempt = 10.5%
(range 4.1%–23.5%)
Lifetime prevalence Lifetime
(serious thoughts prevalence = 4.1%
about killing
themselves) = 12.1%
12-month prevalence 12-month
(seriously considering prevalence = 17%
suicide) = 16.9%

Even if males are more likely to die by suicide, suicide ideation and
attempts occur more often among females. This is described as the gen-
der paradox in suicidal behavior (Canetto & Sakinofsky, 1998), attribut-
able in part to differences in preferred suicide means. Males tend to
choose more lethal methods (e.g., hanging and firearms) than those cho-
sen by females (e.g., self-poisoning) (Varnik et al., 2008). There are also
consistent reports of a higher prevalence of suicidal thoughts and
attempts among girls compared with boys (Carli et al., 2014; Evans
et al., 2005; Kokkevi et al., 2012; Nock et al., 2013; Uddin et al., 2019).
Considering the South East Asia and Western Pacific regions
(Tables 2 and 3), crude suicide rates in young people aged 10–19 years
vary from less than 1 or 2 per 100 000 (Brunei Darussalam, Fiji, Mal-
dives, Vietnam, China, Malaysia) to approximately 11–16 per 100 000
(Micronesia, India, New Zealand, Kiribati). These four countries are
among the 10 with the highest suicide rates in this age group world-
wide (World Health Organization, 2020).
While the suicide rate among children and adolescents is lower
than that in the general population globally, in several countries
(Bangladesh, Kiribati, Micronesia, New Zealand), there is no such dis-
crepancy. When considering females only, the suicide rates among
youth are higher than that in the general population in many countries
(Kiribati, Micronesia, New Zealand, Papua New Guinea, Philippines,
Solomon Islands, Vanuatu). Furthermore, there are several countries
in which the suicide rate for girls exceeds that for boys (Bangladesh,
India, China, Fiji, Maldives, Myanmar, Nepal, Timor Leste). India has
the highest suicide rate among 10–19 year old females (15 per
100 000), which is almost twice the rate among males in the same age
group (7.8 per 100 000). The gender disparity is particularly marked in
Bangladesh, where the suicide rate among girls is more than triple that
in boys (9.8 vs. 2.7 per 100 000).
Uddin et al. (2019) used the data of the data of the Global
School-based Student Health Surveys to estimate the prevalence of
suicide ideation among 13–17 years old students in 59 low- and
middle-income countries. The 12-month prevalence was lowest in
South East Asia (suicidal ideation: 8%, suicide planning: 9.9%, suicide
attempts: 9.2%) and highest in the Western Pacific countries (suicidal
ideation: 17.9%, suicide planning: 17.7%, suicide attempts: 20.5%).
The high prevalence of bullying victimization and physical fights, as
well as the intergenerational conflicts and family pressures deriving
from societal transition in countries with fast-growing populations
have been hypothesized to contribute to the disproportionate preva-
lence of suicide attempts in the Western Pacific region. In a meta-
analysis of 43 studies on Chinese adolescents, the prevalence of sui-
cide attempts ranged from 0.94% to 9.01%, with a pooled prevalence
of 2.94% (Hu et al., 2015). As for global figures, the prevalence of sui-
cide attempts was higher among girls than boys (3.17% vs. 2.50%).
2.2 | Risk and protective factors for suicide among
children and adolescents
Suicide is a complex phenomenon influenced by the impact of biologi-
cal, psychological, social, and environmental factors. The multifaceted
interactions of these factors are captured by the stress-diathesis
model (Mann & Arango, 1992; D. Wasserman & Sokolowski, 2016),
which has been used as framework for this narrative review. In this
model, the constitutional predisposition (“trait” or “diathesis”) for sui-
cide is thought to be determined by genetic factors or early life expe-
riences which so define the suicidal threshold. When state-dependent
factors (e.g., acute psychiatric conditions, alcohol or substance use or
interpersonal and social stressors) intervene, individuals with a low
suicide threshold are more likely to act than those with a higher
threshold. Although the vulnerability is conceived of as strongly
influenced by constitutional and early life factors, changes may still
occur. Indeed, suicidal acts are the result of a process of varying length.
The process may be as short as a few days only, or else extend over
weeks or months, during which risk and protective factors interplay to
decrease or enhance the resilience to stress and so alter the suicidal
threshold (D. Wasserman, 2016; D. Wasserman & Sokolowski, 2016).
The suicidal process is usually short in children and adolescents, related
4 of 17 WASSERMAN ET AL.

TABLE 2 Suicide rates of the WHO South East Asia region (year 2016)

Age-standardized suicide Crude suicide rates,

rate, all ages (per Crude suicide rates, all 10–19 years old (per
Country 100 000) ages (per 100 000) 100 000)
Bangladesh Both sexes 6.1 5.9 6.2
Females 6.7 7.0 9.8
Males 5.5 4.7 2.7
Bhutan Both sexes 11.6 11.4 4.9
Females 8.9 8.5 4.6
Males 13.8 14.0 5.2
India Both sexes 16.5 16.3 11.2
Females 14.5 14.7 15.0
Males 18.5 17.8 7.8
Indonesia Both sexes 3.7 3.4 2.0
Females 2.2 2.0 1.3
Males 5.2 4.8 2.7
Maldives Both sexes 2.7 2.3 1.2
Females 1.6 1.3 1.4
Males 3.6 3.0 1.0
Myanmar Both sexes 8.1 7.8 4.7
Females 9.8 9.5 6.2
Males 6.3 5.9 3.3
Nepal Both sexes 9.6 8.8 6.0
Females 8.0 7.9 7.0
Males 11.4 9.7 5.0
Sri Lanka Both sexes 14.2 14.6 6.2
Females 6.2 6.4 6.2
Males 23.3 23.5 6.2
Thailand Both sexes 12.9 14.4 5.6
Females 4.8 5.9 1.8
Males 21.4 23.4 9.2
Timor-Leste Both sexes 6.4 4.6 3.0
Females 3.7 2.9 3.3
Males 9.0 6.2 2.8

Note: Sources: World Health Organization. (2019). Suicide in the world: global health estimates; World Health Organization, Global Health Observatory
(www.who.int/data/gho).

to lack of experience and as well as lack of effective coping styles for
tackling impulsivity and aggression in this age group. Similar risk and
protective factors have been identified for suicidal behavior in both
adults and adolescents, even if they may play a different role at differ-
ent ages (Brent et al., 1999; O'Neill et al., 2018).
2.3 | Genetic and neurobiological factors
associated with suicide in youth
Suicide and suicidal behavior cluster in families (Brent & Melhem, 2008;
Pedersen & Fiske, 2010; Tidemalm et al., 2011) due to genetic transmis-
sion (specific genes and loci), environmental transmission (e.g., modeling,
abuse), or to a gene–environment interaction (Zalsman et al., 2008).
Genetic factors seem to play a major role in this familial transmission,
with an estimated 30–50% heritability of suicidal behavior (Lutz
et al., 2017). This is at least partially independent of the inheritance of
other psychiatric conditions (Brent & Mann, 2005) and may be mediated
by the transmission of intermediate phenotypes, such as impulsive
aggression (Brent & Melhem, 2008). However, as for other psychopath-
ological traits, the heritability of suicidal behavior most probably is the
result of the contribution of multiple genes with small effect size
(Sokolowski et al., 2016).
A limited number of genetic and neurobiological studies have
been conducted on children and adolescents and most of these are
based on small samples. Given its involvement in depression and
WASSERMAN ET AL. 5 of 17

TABLE 3 Suicide rates of the WHO Western Pacific region (year 2016)

Age-standardized suicide Crude suicide rates,

rate, all ages (per Crude suicide rates, all 10–19 years old (per
Country 100 000) ages (per 100 000) 100 000)
Australia Both sexes 11.7 13.2 5.6
Females 6.0 7.0 3.9
Males 17.4 19.5 7.3
Brunei Darussalam Both sexes 4.5 4.6 0.6
Females 2.8 2.7 0.4
Males 6.2 6.4 0.7
Cambodia Both sexes 5.9 5.3 2.4
Females 3.2 2.9 1.6
Males 9.0 7.8 3.1
China Both sexes 8.0 9.7 1.9
Females 8.3 10.3 2.3
Males 7.9 9.1 1.5
Fiji Both sexes 5.5 5.0 1.2
Females 2.5 2.4 1.5
Males 8.8 7.5 0.9
Japan Both sexes 14.3 18.5 4.8
Females 8.1 11.4 3.0
Males 20.5 26.0 6.6
Kiribati Both sexes 15.2 14.4 16
Females 5.4 5.0 7.3
Males 25.9 24.1 24.2
Laos People's Democratic Republic Both sexes 9.3 8.6 6.3
Females 6.1 5.7 4.8
Males 12.9 11.4 7.8
Malaysia Both sexes 6.2 5.5 1.9
Females 3.6 3.2 0.9
Males 8.7 7.8 2.9
Micronesia (Federated States of) Both sexes 11.3 11.1 10.8
Females 6.2 6.3 7.8
Males 16.2 15.8 13.6
Mongolia Both sexes 13.3 13.0 6.9
Females 3.8 3.5 3.1
Males 23.3 22.6 10.7
New Zealand Both sexes 11.6 12.1 11.2
Females 6.2 6.6 8.1
Males 17.3 17.9 14.2
Papua New Guinea Both sexes 7.0 6.0 5.2
Females 3.8 3.3 3.8
Males 10.2 8.6 6.5
Philippines Both sexes 3.7 3.2 2.5
Females 2.3 2.0 2.1
Males 5.2 4.3 2.9
Republic of Korea Both sexes 20.2 26.9 4.4
Females 11.6 15.4 3.9
Males 29.6 38.4 4.9

(Continues)
6 of 17 WASSERMAN ET AL.

TABLE 3 (Continued)

Age-standardized suicide Crude suicide rates,

rate, all ages (per Crude suicide rates, all 10–19 years old (per
Country 100 000) ages (per 100 000) 100 000)
Samoa Both sexes 5.4 4.4 2.6
Females 2.2 1.9 1.6
Males 8.7 6.7 3.6
Singapore Both sexes 7.9 9.9 3.7
Females 4.9 6.1 3.3
Males 11.1 13.8 4.0
Solomon Islands Both sexes 5.9 4.7 4.7
Females 3.2 2.6 3.2
Males 8.5 6.8 6.0
Tonga Both sexes 4.0 3.5 2.5
Females 2.9 2.7 2.3
Males 5.2 4.3 2.6
Vanuatu Both sexes 5.4 4.5 4.4
Females 2.7 2.2 2.6
Males 8.1 6.6 6.0
Vietnam Both sexes 7.0 7.3 1.8
Females 3.4 3.7 1.0
Males 10.8 10.9 2.5

Note: Sources: World Health Organization. (2019). Suicide in the world: global health estimates; World Health Organization, Global Health Observatory
(www.who.int/data/gho).

aggression, the serotonergic system is the most well investigated.
Low levels of 5-HIAA, the main metabolite of serotonin, were found
in the cerebrospinal fluid and plasma of adults (Bach &
Arango, 2012) and adolescents (Tyano et al., 2006) with suicidal
behavior. An association is evident between polymorphisms of genes
encoding for a serotonin rate-limiting enzyme (TPH1), the serotonin
transporter (5-HTTLPR), and violent suicidal behavior (Antypa
et al., 2013; Fanelli & Serretti, 2019; Gonzalez-Castro et al., 2014;
D. Wasserman et al., 2007). As in adult samples, a higher expression
of serotonin 5-HT(2A) receptor has been reported in the post-
mortem brains of teenagers who died from suicide compared with
other causes (Pandey et al., 2002).
The vulnerability of suicidal subjects is also due to a reduced neu-
roplasticity that makes them unable to find coping strategies to deal
with their current stressed state and manifested in cognitive disabil-
ities in attention, learning, memory, decision-making, and a general
feeling of hopelessness (D. Wasserman & Sokolowski, 2016). The
brain-derived neurotropic factor (BDNF) is a neutrophin involved in
neuronal growth and plasticity of serotonergic and dopaminergic neu-
rons, while the tyrosine kinase B (TrkB) is its receptor. A meta-analysis
supports the association of BDNF Va166Met polymorphism with an
increased risk for suicide behavior in Asian and Caucasian populations
(Gonzalez-Castro et al., 2017). A decrease in plasma, but not serum,
BDNF levels represents a potential biomarker in suicide behavior
(Salas-Magana et al., 2017). Furthermore, a reduced expression of
BDNF and TrkB in post-mortem brain of teenage suicide victims has
been found compared with controls (Pandey et al., 2008), replicating
results among adults (Dwivedi et al., 2003).
Meta-analyses support the role of low serum cholesterol levels as
a marker of suicidality among adults (Lester, 2002; S. Wu et al., 2016).
Similarly, Plana et al. (2010) reported significantly lower serum choles-
terol levels among child and adolescent psychiatric inpatients who
had attempted suicide than among those without a history of suicide
attempts.
The hypothalamic–pituitary–adrenal (HPA) axis is involved in
stress-response and -modulation and for this reason has received par-
ticular attention. An overactivity of the HPA axis has been described
in post-mortem studies of adults who have died from suicide as well
as in results of dexamethasone suppression tests (DST) conducted
before the suicide (Young & Coryell, 2005). However, there are con-
flicting reports of HPA dysregulation among adolescents (Beauchaine
et al., 2015; Lewitzka et al., 2012; Zalsman, 2012). Age-related vari-
ables may explain discrepancies between studies in adolescents and
adults (Zalsman, 2012).
Inflammation parameters recently emerged as a potential bio-
marker for suicidal behavior in adults with both major depression and
bipolar disorder (Ekinci & Ekinci, 2017; Ivkovic et al., 2016; Velasco
et al., 2020). Similarly, Pandey et al. (2012) found an increase in
proinflammatory cytokine post-mortem in the brain of teenagers who
had died from suicide.
WASSERMAN ET AL.
2.4 | Family background
Familial aggregation of suicidal behavior may be related to psychosocial
and environmental conditions, such as traumatic losses, poor and inap-
propriate parenting styles or family disruption, as well as familial trans-
mission. Besides the inheritance of biological vulnerability to impulsivity,
aggression and mood disorders, other mechanisms may play a role in
the familial transmission of suicidal behavior, such as attachment fea-
tures, modeling, imitation, and social integration (Hua et al., 2020).
Parental death from external causes, especially when it occurs in
childhood, is strongly associated with subsequent suicidal behavior in
offspring (Hua et al., 2019). Parental suicide or suicide attempt signifi-
cantly increases the risk for suicidal thoughts and behavior in off-
spring, especially when the exposure happens at a young age and
when it concerns a child's mother rather than father (Geulayov
et al., 2012; Goodday et al., 2019). Pre- and post-loss features, such
as the quality of relationships, psychopathological conditions, and
social support can mediate the association between adolescent
bereavement and suicide risk (Andriessen et al., 2016). These become
important targets for suicide prevention strategies.
Parental psychopathology, particularly mood and substance use
disorders, is also associated with offspring suicidal thoughts and
behavior, even if this association seems to depend on the type and
quantity of exposure (Goodday et al., 2019).
Hardship in the family environment such as low perceived sup-
port, parent–child conflicts and lack of family cohesion are risk factors
for adolescent suicidality (King & Merchant, 2008), as well as child-
hood traumatic experiences (Zatti et al., 2017). Parent–child conflict is
the most commonly reported precipitant of child suicidal acts (Soole
et al., 2015). A recent US study found child-reported family conflict
(OR 1
4–1
8, 95% CI 1
1–2
5) as one of the most robust risk factors
for suicidality in children aged 9–10 years (Janiri et al., 2020). The psy-
chological unavailability of a mother during early childhood has been
associated with suicidal thoughts and behavior (Weich et al., 2009). A
parental bonding characterized by a low level of care and over-
protection (i.e., affectionless control) is consistently reported to be
associated with suicidal behavior among adolescents (Goschin
et al., 2013). A systematic review concluded that suicidal ideation in
adolescence is negatively associated with parental warmth, behavioral
control, and autonomy granting, and positively associated with psy-
chological control and harsh control (Gorostiaga et al., 2019). Similarly,
in a sample of 15–19 years old students in Hong Kong, suicide
ideation was found to be significantly associated with perceived
authoritarian parenting style, low parental warmth, high maternal over-
control, negative child-rearing practices, and a negative family climate
(Lai & McBride-Chang, 2001). Greater parental supervision was associ-
ated with reduced suicidality in US children (Janiri et al., 2020).
2.5 | Psychopathology
Youth suicidal behavior frequently occurs in the context of a psychiat-
ric disorder; at the same time, higher rates of psychopathology are
7 of 17
found among adolescents and young adults compared with children.
Soole et al. (2015) report that up to one-third of children younger than
15 years who died from suicide presented detectable mental health
problems at the time of their death. The presence of any mental disor-
der is associated with a 10 times higher risk of suicide death among
12–26 years old youth in a recent meta-analysis (Gili et al., 2019).
Affective disorders, disruptive/conduct disorders, and substance
use disorders are the most common diagnoses reported in children
(Soole et al., 2015) and adolescents (Fleischmann et al., 2005) who
died from suicide. Comorbidity, especially between affective and sub-
stance use disorders, confers a higher suicide risk (Bilsen, 2018; Gili
et al., 2019). The higher prevalence of these disorders among adoles-
cents compared to children is thought to be one of the reasons suicide
risk increases with age (Soole et al., 2015). An early identification of
psychopathological symptoms is of key importance in youth suicide
prevention, especially when considering that even subthreshold symp-
tomatology may confer an increased suicide risk (Balazs et al., 2013).
2.6 | Personality and cognitive characteristics
Impulsivity is conceived as a relative inability to control one's behavior. It
has been attributed to a broad range of personal characteristics such as
poor planning, premature response—before considering consequences,
sensation-seeking, risk-taking, an inability to inhibit responses, and pref-
erence for immediate over delayed rewards (Gvion et al., 2015).
Impulsive-aggressive traits are associated with an increased risk for sui-
cide especially in young people (Turecki, 2005). A recent meta-analysis
confirmed that young people engaging in self-harm or suicidal behavior
are significantly more impulsive than those without such behavior; they
showed significantly higher impulsive decision making and deficits in
inhibitory control (McHugh et al., 2019). As pointed out by Bridge
et al. (2006), there is relatively little planning evident in many adolescent
suicide attempts. For this reason, the prevention of suicide for the impul-
sive subgroup may need to focus on restriction of lethal means of
suicide.
Impaired decision-making has been found in both adult and ado-
lescent suicide attempters (Bridge et al., 2012; Jollant et al., 2005).
Loss aversion, a strong preference for avoiding losses over making
equivalent gains, as assessed by using a mixed monetary gamble task,
has been associated with suicide risk. In cross-sectional analyses, loss
aversion was significantly lower among adolescent suicide attempters
compared with non-attempters, even when controlling for depression,
anxiety, stress, and gender. Furthermore, in prospective analyses, loss
aversion was a significant predictor of future suicide attempts
(Hadlaczky et al., 2018).
Hopelessness is significantly associated with suicidal ideation,
attempts and death (McMillan et al., 2007; Ribeiro et al., 2018).
Although this association has been reported in adolescents (Stewart
et al., 2005), some studies have found it to be mediated by depression
(Bridge et al., 2006; Goldston et al., 2001).
Perfectionism is also considered to be a risk factor for suicidal
ideation and behavior (Smith et al., 2018). Among adolescents,
8 of 17
perfectionism might moderate the relationship between suicide idea-
tion and thwarted belongingness or a sense of poor connection to
parents and friends, so increasing the risk for suicide (Sommerfeld &
Malek, 2019).
2.7 | Stressful life events and poor social
relationships
Among adolescents, stressful life events may act as precipitating fac-
tors for self-harm behavior (O'Connor et al., 2012). For this reason,
children and adolescents undergoing difficult life experiences need
adequate support.
Besides family losses and conflicts, poor peer relationships (Evans
et al., 2004) and a perception of poor school support (A. B. Miller
et al., 2015) also act as risk factors. Positive school involvement is
reported to reduce suicidality among children (Janiri et al., 2020).
There is a positive association between peer victimization and
both suicide ideation and suicide attempts among children and adoles-
cents; and a higher risk from cyberbullying compared with traditional
bullying (Barzilay et al., 2017; van Geel et al., 2014). Longitudinal ana-
lyses show a bi-directional association between different types of bul-
lying victimization and suicide ideation and attempts (Brunstein
Klomek et al., 2019). This underscores the importance of early use of
anti-bullying programs.
Childhood traumatic experiences including sexual, physical and
emotional abuse are associated with subsequent suicide attempts (Zatti
et al., 2017), with sexual abuse and emotional abuse playing an impor-
tant role in adolescent suicidal behavior (A. B. Miller et al., 2013).
Suicide clustering (i.e., temporal or spatial aggregation of suicides)
among adolescents occurs more often than in older age groups
(Niedzwiedz et al., 2014). It may be due to social transmission (partic-
ularly via person-to-person transmission and the media), perception
that suicidal behavior is widespread, socialization between young peo-
ple at risk, and social cohesion contributing to the diffusion of ideas
and attitudes (Hawton et al., 2020). The internet and social media also
play a major role in promoting suicidal behavior (Durkee et al., 2011).
Therefore, responsible and well-tailored media reporting and effective
prevention and postvention interventions are fundamental in
preventing suicide contagion.
2.8 | Lifestyle and behavior: Risk and protection
Several risk behaviors, such as tobacco smoking (Bronisch et al., 2008;
P. Wu et al., 2004), alcohol and drug use (Wilcox, 2004; P. Wu
et al., 2004), early sexual initiation and risky sexual behavior
(Gambadauro et al., 2018) have been associated with increased
suicidality among adolescents. A particular cluster of less noticeable
risk behaviors, characterized by high media use, sedentary lifestyle
and reduced sleep, has also been associated with symptoms of
depression, anxiety and suicidal ideation (Carli et al., 2014). On the
contrary, healthy lifestyles, such as a recommended amount of sleep
WASSERMAN ET AL.
(Chiu et al., 2018; Sarchiapone et al., 2014) and physical activity
(McMahon et al., 2017; Vancampfort et al., 2018), are associated with
better mental health and less suicidal ideation.
2.9 | Protective factors
The presence of protective factors reduces the risk of suicide attempt
among both at risk and not at risk adolescents (Borowsky et al., 2001).
The risk may be reduced by as much as 70%–85% when one or more
of these are present.
First is social connectedness, which includes perceived caring,
support, and quality of communication, and is described as a major
protective factor against suicide. Indeed family and school connected-
ness are consistently reported as negatively associated with suicidal
thoughts and behavior among children and adolescents (Whitlock
et al., 2014). The use of distraction and problem solving skills in
response to low mood is another identified factor. In a prospective
study of adolescents, this was associated with a decreased risk of
developing suicidal ideation (Burke et al., 2016). Positive self-esteem
also acts as a protective factor, especially when the interaction with
perceived social support is considered (Kleiman & Riskind, 2013;
Sharaf et al., 2009).
3 | SUICIDE PREVENTION
I N T E R V E N T I O N S F O R C H I LD R E N A N D
ADOLESCENTS
Suicide prevention strategies can be categorized according to three
different levels (Institute of Medicine (US) Committee on Patho-
physiology and Prevention of Adolescent and Adult Suicide, 2002;
D. Wasserman & Durkee, 2009). Universal strategies have as the
target everyone in a defined population (e.g., a school, a county, a
local community) and are aimed at increasing awareness about sui-
cide and mental health, removing barriers to care, or promoting
help-seeking behaviors and protective factors such as social support
and coping skills. They may also act to support parenting, improve
education or training opportunities, or enhance conditions in
schools (e.g., school climate) or in other settings that are conducive
to good mental health (National Academies of Sciences &
Medicine, 2019). Selective strategies address specific groups that
are at increased risk for suicidal behavior, such as adolescents with
mental health problems and harmful use of substances. Finally, indi-
cated strategies target high-risk individuals who are already dis-
playing signs of suicidal behavior. A separate article in this issue
specifically discusses indicated strategies; however, a brief overview
is also given at the end of this section.
A systematic review of psychosocial suicide prevention interven-
tions for youth aged 12–25 years supported the implementation of
these interventions in schools, community, and healthcare settings.
Moreover, the review concluded that they are safe and unlikely to
have detrimental effects (Calear et al., 2016).
WASSERMAN ET AL.
3.1 | Restricting access to lethal means
Suicide in children and adolescents most commonly takes place in
their usual residence and hanging is the most commonly used method
(Glenn et al., 2020; Kolves & de Leo, 2017; Soole et al., 2015). How-
ever, differences emerge when considering different genders and geo-
graphical areas. Globally, boys most commonly use hanging and
firearms while girls more typically use poisoning by pesticides or
drugs, and jumping from heights (Kolves & de Leo, 2017). Country dif-
ferences also exist: including more frequent use of firearms in the
United States, more deaths by jumping from a height in Hong Kong
and Singapore, and a wider use of pesticide poisoning in rural areas of
several countries in the Asian and Pacific regions including China and
India (Glenn et al., 2020; Samuel & Sher, 2013; Soole et al., 2015;
Zhang & Li, 2011). Restricting the access to these lethal means is demon-
strated to be an effective universal suicide prevention strategy (Zalsman
et al., 2016). A significant association between a decline in firearm avail-
ability in households and suicide in children and adolescents has been
reported in the United States. Each 10% decrease in households with
firearms corresponded to a drop of 8.3% in the rate of firearm suicide
and of 4.1% in the rate of overall suicide among children 0–19 years of
age (M. Miller, Azrael, et al., 2006). Structural interventions at jumping
sites and restricting access to highly hazardous pesticides have also
proven effective (Gunnell et al., 2017; Pirkis et al., 2013).
3.2 | Awareness and skill-training
School has a major role in the development of children and adoles-
cents. Therefore, it represents a privileged setting for mental health
promotion and suicide prevention. School-based awareness and skills
training programs are by far the most common universal strategies
implemented for youth suicide prevention. The awareness raising
interventions provide reliable information about mental health and
suicide, aiming to decrease stigma related to these issues and facilitate
help-seeking behaviors. Skills training is aimed at strengthening pro-
tective factors such as coping and problem-solving strategies, emo-
tional awareness, and decision making.
Many universal school-based interventions have been developed.
There is promising evidence about the effectiveness of a number of
these interventions, although most have been assessed in studies of
limited quality (Robinson et al., 2018).
Signs of Suicide (SOS) include a curriculum designed to raise aware-
ness of suicide and a screening for depression and other risk factors asso-
ciated with suicidal behavior (Aseltine Jr & DeMartino, 2004). SOS has
been evaluated in randomized control trials (RCTs) with US high school
students. At the 3-month follow-up, participants in the program were con-
siderably less likely (40%–64%) to report a suicide attempt than those in
the control group (Aseltine et al., 2007; Schilling et al., 2016). Furthermore,
increased knowledge about depression and suicide and more adaptive
attitudes toward these problems were reported.
The Youth Aware of Mental health (YAM) is a universal mental
health promotion and suicide prevention programme for students
9 of 17
aged 13–17 years (C. Wasserman et al., 2012). In 5 one-hour
classroom sessions, mental health is explored through discussion and
role-plays guided by two trained adult instructors and drawing on
pedagogical materials (slides, posters, and a booklet for each partici-
pant to keep). YAM has been evaluated in a RCT involving more than
11 000 European high school students (D. Wasserman et al., 2015).
At 12-month follow-up, YAM participants showed half the incidence
of suicide attempts (OR = 0.45) and suicidal ideation (OR = 0.50) com-
pared to the students in the control condition. A similar reduced inci-
dence was not found for the other two tested interventions (i.e., QPR
- Question Persuade and Refer and a screening program with referral).
A further analysis demonstrated that YAM efficacy may be explained
by its ability to promote adaptive coping strategies (Kahn et al., 2020).
In a meta-analysis on youth suicide prevention, among the few
included studies evaluating school-based and workplace interventions,
YAM and SOS appeared to be promising even if requiring further eval-
uation (Robinson et al., 2018).
The Good Behavior Game (GBG) is a classroom behavior manage-
ment strategy, aimed at socializing children for the student role and
reducing aggressive and disruptive behavior. It targets kindergartners
or first-graders and it is implemented by the classroom teacher.
Although this program is not specifically aimed at suicide prevention,
it has an impact on major risk factors such as aggression and poor
social integration. Indeed, a long-term follow-up study has reported a
reduced risk for suicide ideation and attempts among youth aged
19–21 years exposed to the GBG compared with controls (Wilcox
et al., 2008).
Studies of school-based interventions in low-resource settings
are rare. The SEHER trial from India reported benefits from a lay
counselor-coordinated intervention targeting the social environment
(school climate). It found large and incremental effects with time
in reducing bullying and depression symptom severity (Shinde
et al., 2020). Promising findings related to psychosocial interventions
for children and adolescents living in areas of armed conflict were
reported (Tol et al., 2013). Further work is important considering the
large numbers of children and young people living in these and other
conditions of adversity, especially in low- and middle-income coun-
tries. Systematic reviews support the implementation of school-based
mental health promotion interventions in low- and middle-income
countries (Barry et al., 2013; Fazel et al., 2014). Structured and long-
lasting interventions seem more effective. Multicomponent interven-
tions not focused on single problem behaviors but adopting a social
competence approach, also showed positive effects.
3.3 | Gatekeeper programs
These programs aim to teach gatekeepers such as school teachers
how to recognize signs and symptoms of a suicidal crisis and refer
identified “at risk” subjects to appropriate help resources. QPR is one
of the most frequently employed gatekeeper programs in schools
(QPR Institute, 2020). Several studies have shown a positive change
in knowledge and attitudes toward suicide among trained teachers
10 of 17
and school staff compared with controls (Reis & Cornell, 2008; Tomp-
kins et al., 2010; Wyman et al., 2008). Nevertheless, the effectiveness
in reducing suicide ideation and attempts among youth has not been
proven (D. Wasserman et al., 2015).
3.4 | Screening interventions
In screening programs, specific tools are administered and defined
cut-offs are used to identify people who may be at risk for suicide.
Although some concerns exist about the possible detrimental effect
of asking suicide-related questions, two studies conducted in US and
Australia demonstrated that youth receiving suicide questions did not
show increased levels of distress, depressive feeling or suicidal ideation
compared with controls (Gould et al., 2005; Robinson et al., 2011).
The Columbia Suicide Screen (CSS) is a commonly implemented
brief self-report questionnaire assessing lifetime suicide attempts
and the 3-month prevalence of suicidal ideation, negative mood,
and substance use. A sensitivity of 0.75 and specificity of 0.83 have
been reported for the CSS in a sample of high school students in
New York (Shaffer et al., 2004). Many other validated instruments
for suicide risk assessment have been developed. However, the sensi-
tivity and specificity of these assessments vary greatly. The evidence
for their effectiveness in detecting at risk children and adolescents,
both in schools and primary care, is limited (O'Connor et al., 2013;
Pena & Caine, 2006; Zalsman et al., 2016). However, the evaluation of
screening programs' effectiveness cannot rely only on the accurate
identification of subjects at risk. It should also take into consideration
the availability and level of access to referral resources. Indeed, the
availability of health and mental health resources constitutes a major
limitation for the implementation of suicide screening program in low-
and middle-income countries.
3.5 | Interventions for high-risk youth
A wide range of interventions have been developed that aim to pre-
vent death from suicide among youth at high risk, including those
who have engaged already in suicidal behavior. They vary greatly in
terms of intervention setting, approach, and length.
C-CARE (Counselor—Care, Assess, Respond, Empower) and CAST
(Coping and Support Training) offer an example of school-based inter-
ventions for high-risk adolescents (Randell et al., 2001; Thompson
et al., 2001). In this combined program, potential high school dropouts
are assessed through a computer assisted suicide assessment interview.
Identified at-risk students are referred to a motivational counseling ses-
sion and to a skill-training intervention delivered in small groups that aim
to improve self-esteem, decision-making, personal control, and interper-
sonal communication. Compared with usual care, C-CARE and CAST
were effective in reducing suicidal ideation, depression, hopelessness,
and attitude toward suicide. Furthermore, the participants showed an
increase in personal control, problem-solving coping, and perceived
family support (Randell et al., 2001; Thompson et al., 2001).
WASSERMAN ET AL.
Another school-based intervention, Reframe IT, consists of
internet-based cognitive-behavioral sessions administered once a week.
The program also uses videos and other materials and activities. Pilot
studies report a decrease in suicidal ideation, depressive symptoms,
and hopelessness, and an improvement in problem-solving and coping
strategies (Hetrick et al., 2014; Robinson et al., 2016).
Within the health care setting, brief interventions aimed at defin-
ing a safety plan and promoting adherence to treatment for mental ill
health is widely implemented. The Youth-Nominated Support Team
(YST) is aimed at improving the management of suicidal adolescents
after psychiatric hospitalization (King et al., 2009). The adolescent
nominates parent-approved adults as support persons. Psycho-
education and information about his or her psychopathology and
treatment plan are provided to the support persons, who are asked to
maintain regular contact for 3 months following hospitalization. Prom-
ising results were reported for YST as an adjunct to usual treatment,
including a more rapid decrease in suicidal ideation in multiple suicide
attempters, an improvement in functional impairments, a trend to
greater treatment utilization and a reduced overall mortality (King
et al., 2009; King et al., 2019).
As safe as possible (ASAP) is a brief app-supported intervention
aimed at preventing suicide among hospitalized suicidal adolescents.
Before the discharge, the adolescents receive a 3-h intervention con-
sisting in the development of a safety plan and the promotion of dis-
tress tolerance and emotion regulation skills. The adolescents are
encouraged to use a smartphone app to reinforce these skills. Early
trials have not yet yielded evidence of efficacy (Kennard et al., 2018).
More structured psychotherapeutic interventions are also
implemented in the treatment and management of suicidal youth. Evi-
dence exists supporting the use of cognitive behavior therapy (CBT)
with suicidal adolescents (Iyengar et al., 2018; Ougrin et al., 2015;
Spirito et al., 2011). CBT for depressed and suicidal adolescents pro-
motes coping and problem solving skills and emotion regulation, while
modifying automatic thoughts and cognitive distortions and improving
interpersonal relationships (Spirito et al., 2011; Stanley et al., 2009).
Dialectical behavior therapy (DBT) is a psychotherapeutic treatment
designed for patients with borderline personality disorder and it has been
adapted to be used with suicidal adolescents with borderline personality
traits (A. L. Miller, Rathus, & Linehan, 2006). DBT-A is focused on achiev-
ing skills for emotion regulation, interpersonal effectiveness, distress tol-
erance, and mindfulness. DBT-A combines individual therapy, family
therapy and family skills training. DBT showed promising results in
reducing self-harm, suicidal ideation, and depressive symptoms (Iyengar
et al., 2018; Mehlum et al., 2014; Ougrin et al., 2015).
Family-based interventions are also widely implemented in youth
suicide prevention (Frey & Hunt, 2018). Safe Alternatives for Teens and
Youth (SAFETY) is a CBT and DBT family intervention designed for ado-
lescent suicide attempters accessing emergency services (Asarnow
et al., 2015; Asarnow et al., 2017). Besides the development of a safety
plan, the program aims at enhancing protective family and social support
and building coping and emotion regulation skills. The results of a RCT,
comparing its effectiveness against enhanced treatment as usual, support
the efficacy of SAFETY in preventing SA (Asarnow et al., 2017).
WASSERMAN ET AL.
In a meta-analysis, clinical interventions (e.g., cognitive-behavioral
therapy, dialectical behavioral therapy, family therapy, and brief contact
interventions) were found to reduce suicidal ideation and self-harm among
youth (Robinson et al., 2018). However, this effect was mostly shown in
post-intervention evaluations and to a lesser extent at follow-up.
3.6 | Digital interventions
Digital health interventions have a great potential to increase early
detection of mental health needs and access to care. Computerized
cognitive behavioral therapy has been shown to improve depression
and anxiety symptoms among adolescents and young adults (Hollis
et al., 2017). Other types of digital interventions appear to be less
effective, even if the presence of some kind of supervision from
school or mental health professionals seems to increase their effi-
cacy (Garrido et al., 2019). Furthermore, the level of engagement in
these interventions is enhanced by game-like and interactive con-
tents, while it is decreased by non-appealing interfaces and techni-
cal glitches. Among adults, self-guided digital interventions for
suicidal ideation proved to be effective immediately post-interven-
tion, while studies among adolescents are still scarce (Torok
et al., 2020).
4 | C O N CL U S I O N S
Despite a decrease in suicide rates worldwide among the general pop-
ulation, some countries show the opposite trend in adolescent suicide
rates (Kolves & De Leo, 2016; World Health Organization, 2019a).
Adolescent suicide represents a serious public health problem in the
South East Asian and Western Pacific regions. Considering children
and youth aged 10–19 years, several countries in these regions show
a higher suicide rate than the average worldwide rate (3.77 per
100 000) (Glenn et al., 2020). Furthermore, there are several countries
in which suicide rates among the youngsters are very similar to or
even higher than those found in the general population. In several
countries, the rate of deaths from suicide among girls exceeds that
among boys.
Risk and protective factors for suicide among children and adoles-
cents largely overlap with those for adults. Nevertheless, developmen-
tal characteristics may strengthen the impact of some factors, such as
decision-making, coping strategies, family and peer relationships, and
victimization. The study of these factors and genetic and biological
factors is limited in children and adolescents, even compared with that
in adults. A better understanding of the role played by different risk
and protective factors is vital for the development and implementa-
tion of effective suicide preventive strategies (Borowsky et al., 2001;
Janiri et al., 2020). Since this is likely to vary between settings and
localities even within one country, an analysis of available epidemio-
logical data is recommended to help identify personal and socio-
environmental factors to be included as primary target of suicide
prevention interventions. Therefore, the improvement of analytic
11 of 17
methods and the quality of suicide epidemiological data should be
pursued at local, national, and international level.
Several strategies are demonstrated to be effective in preventing
suicide in the general population (Zalsman et al., 2016). Many of
these, including awareness and psychosocial programs, restricting
access to lethal means, and the pharmacological and psychological
treatment of depression also need consideration for children and
young people. Overall considered, psychosocial suicide prevention
interventions and in particular school-based awareness and skill train-
ing interventions that address both suicidality and underlying psycho-
pathological and interpersonal problems (e.g., depression, substance
use, family conflicts, and peer victimization) are strongly rec-
ommended. Indeed, many of these interventions are demonstrated to
have an impact on a wide range of risk and protective factors. Fur-
thermore, these universal preventive strategies facilitate intervention
at an early stage of the suicidal process, enhancing the chances of suc-
cess. At the population level, in order to ensure the long-term effec-
tiveness of these interventions, it is important to develop a
sustainability plan that takes into account available human and finan-
cial resources. Multimodal interventions in community settings
(e.g., including gatekeeper training, psychoeducation, screening, and
outreach interventions) also showed to have a general positive impact
on suicide on rates of suicide and suicidal behavior (Robinson
et al., 2018). Brief interventions for suicidal youth, delivered both in
the school and health care setting, are able to improve coping strate-
gies and emotion regulation skills. Among psychotherapeutic interven-
tions for suicidal adolescents, CBT and DBT, also digitally delivered,
showed to be effective.
Despite promising findings, only a few youth suicide prevention
interventions have been assessed in low- and middle-income countries
(Robinson et al., 2018), making it difficult to extend the conclusions on
their effectiveness to different cultural and economic contexts. Future
research is urgent in these countries, and in all countries will benefit from
the use of more rigorous study designs, the use of both short- and long-
term follow-up evaluations, the larger inclusion of individuals belonging
to vulnerable groups (e.g., indigenous young people, LGBTQ) and the
evaluation of programs' cost-effectiveness (Calear et al., 2016; Robinson
et al., 2018). Further development and evaluation of online interventions
are also needed (Robinson et al., 2018), especially when considering the
mental health and social effects of the current long-lasting global crisis
due to the pandemic.
Suicide prevention in childhood and adolescents may be challenging
but it is possible and an urgent priority. In most of the discussed studies,
no detrimental effects of the interventions were reported, while suicidal
ideation and behavior were shown to decrease. Furthermore, several
youth suicide prevention programs have demonstrated a positive impact
on mental health and suicide related knowledge, social integration, cop-
ing strategies, and help-seeking attitudes that in turn may decrease the
risk for suicide. These positive outcomes may relate in various ways to
different components of the different strategies, indicating that a combi-
nation of interventions is likely to represent an effective approach to
building a local, national or international suicide prevention program
(Katz et al., 2013; Zalsman et al., 2016).
12 of 17
CONF LICT OF IN TE RE ST
The authors have no conflicts of interest to disclose.
DATA AVAI LAB ILITY S TATEMENT
Data sharing is not applicable to this article as no new data were cre-
ated or analyzed in this study.
ORCID
Danuta Wasserman https://orcid.org/0000-0002-8436-3989
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How to cite this article: Wasserman D, Carli V, Iosue M,
Javed A, Herrman H. Suicide prevention in childhood and
adolescence: a narrative review of current knowledge on risk
and protective factors and effectiveness of interventions. Asia
Pac Psychiatry. 2021;e12452. https://doi.org/10.1111/appy.
12452