According to the literature review as well as our study results, suicidal attempts in the pediatric population are a very real and sensitive problem. In our pilot study, we tried to evaluate possible factors for young people related to attempts suicide. Our evaluated demographic data detected that the average age of children who attempted suicide was 15.02 ± 1.9 years. These data are in accordance with data from many other researchers in Europe and the US [6, 7, 8, 20], but differ from data collected by African researchers, where the average age of suicide attempt was found to be 17.5 years . The reason why children start to have suicidal thoughts at this age was explained by a study carried out in Singapore in 2015. The study revealed that children start to experience emotional difficulties during adolescence and learn to control them. However, children do not always manage to control strong emotions due to having weak defense mechanisms, and then, by invoking self-harm or attempting suicide, they attempt to let off accumulated emotional surplus, anxiety, anger, or fears .
During the study, we established that deliberate suicide attempts were more frequent among girls, and the number of boys attempting suicide was almost four times less. Despite this, boys used potentially more lethal methods to attempt suicide. These results confirm those obtained in other countries. In a study carried out in 2016 in South Korea, results indicated that the number of boys in the group of children who die by suicide was higher and the ways they did it were of an aggressive kind, i.e., by hanging or jumping from high altitudes. There were more girls in the reference group of children who attempted suicide; however, they did not successfully die by suicide, and the most common method used by girls for die by suicide was self-harm by cutting various body parts . During our study, it was found that the most common method chosen to attempt suicide was cutting. More aggressive methods, i.e., attempts to hang or strangle oneself, jump from a high altitude, drown, or shoot oneself were less frequent, but all were more commonly used by boys. Similar data were reported in a few scientific papers [23, 24]. A study carried out in the USA in 2015 established that the most common methods chosen by adolescents for die by suicide were hanging, self-harm (poisoning or cutting), and shooting. This study also disclosed that the frequency of the methods chosen for die by suicide varies depending on the age of the child, e.g., the number of hanging cases proportionally increased with an increase in the age of the child who attempted suicide . Unfortunately, we could not evaluate this because of the small number of cases with more aggressive methods in our group. The children involved in our study most often tried to commit suicide in March and, less frequently, in February. The peak of hospitalizations due to suicidal attempts was spring, with the rate in autumn being slightly lower. The meta-analysis performed in Greece in 2012 revealed that the seasonal character of suicides indicates serotonin’s responsibility for mood, and its lowest concentration in blood was detected in early spring. In this season, the amount of sunlight increases, resulting in a drastic increase in the blood serotonin level and therefore an increase in the speed of impulse to commit suicide .
By evaluating the living conditions of our study group, we revealed that most of the children who attempted suicide lived with a single parent because their parents were divorced, or, in general, resided outside the family. A considerably lower number of children were living in two-parent families. In a study carried out in the USA in 2013, young people aged from 13 to 18 years were interviewed to assess the spread of suicidal thoughts and plans. It was established that children who lived in single-parent families had suicidal thoughts more often in comparison to those who lived in two-parent families . The research work carried out in the USA in 2010 indicated that the lack of attention from parents and support in the family are key risk factors in determining suicidal thoughts and plans in children .
The results of our study confirm data presented by other researchers showing that life in an orphanage or with foster parents is very traumatic for adolescents and is likely to be a cause of suicidal thoughts and attempts. Based on social security data from the Lithuanian Statistics Department, about 0.8% of all people aged under 18 years in 2016 and 0.5% in 2019 were living in orphanages in Lithuania . However, our study revealed that suicide attempts were statistically significantly more likely to occur among orphans than among children living in families. This was also confirmed by a meta-analysis performed in England in 2017, where the spread of suicidal ideas, suicide attempts, and suicides committed among adolescents was analyzed. It was determined that the rates of attempted or dying of suicide in children residing in an orphanage were 3–4 times higher. There was no difference in the spread of suicidal ideas among children residing in orphanages and children who lived with their parents . The study of adolescents residing in orphanages or living with foster parents carried out in the state of Colorado in the USA in 2014 disclosed that more than 26.4% of these children had suicide attempts in their medical history, and 4.1% of attempts were lethal. This study also disclosed that a longer period of residence in an orphanage and more frequent changes in place of residence were associated with a greater risk of a child trying to commit suicide .
We noticed a tendency for the number of children living in orphanages in Lithuania to decrease, but the problem is still significant. Unfortunately, we could not find data about the incidence of living in foster care among people aged under 18 years in Lithuania. This practice is very “young” in our country and we suggest that the occurrence is less than 4.1%, in contrast to our study group.
During our study, possible social factors associated with suicide attempts and risk factors associated with dying of suicide were assessed. Different kinds of humiliation are very common among adolescents living or spending time together as well as during direct contact on internet websites. Our data indicate that more than half of the children who attempted suicide had undergone previous continuous bullying, and about 25% of these children disclosed that they were the victims of abuse or violence. According to official statistics, about 25% of school children are victims of bullying, and 3.5–6% of children experience violence at least once. Based on the data, the incidence of bullying and violence is possibly higher among children and adolescents who attempt suicide. Almost one-fifth of the study group had a previous experience of suicide within their close surroundings and more than one-third had experienced parental alcoholism or another kind of addiction. The main reason given by the children as a cause of suicide was a conflict in the family . A study carried out in the USA in 2001 disclosed that in the prevention of child and adolescent suicides, it is very important to identify suicide risk factors within the domestic environment, such as interpersonal relation issues, family conflict, lack of support, conflict with friends, separations and suicide cases in domestic surroundings . Scientific findings show that children with negative emotional and psychological experiences and emotional dissatisfaction are at a significantly higher risk of dying by suicide in comparison with children living within a positive emotional environment [30, 31].
Numerous studies have revealed the association of health status with a person's life quality. During our study, it was disclosed that three-quarters of the study group had comorbidities. In most of the cases, comorbidity disease had a psychiatric origin.
Data from an epidemiological study conducted in Lithuania in 2003–2007 showed that 13.1% of children aged 7–16 have mental health problems according to ICD-10-AM . The results of our study revealed that the incidence of comorbidities, especially psychiatric, is several times more common in children who have attempted suicide. In our study, we found that the most common comorbidity disease among the research subjects was depression, and no less than one-third of all children who attempted suicide suffered from depression. The results of the study performed in Lithuania 2002 suggest that 57.4% of the female adolescent suicide attempters and 9.3% of their non-suicidal peers in the comparison group were diagnosed clinical depression . The abovementioned disorders, as established in a study carried out in Germany in 2018, are associated with an increased risk of suicide in both adults and children . A study carried out in the USA in 2015 proposed that 13 to 18 years of age is a critical time frame when depression can develop. There are no comprehensive data on the mechanisms to explain why some children develop depression and some do not; however it is likely that stressful events, e.g., strained interpersonal relations, conflicts with friends, pressure, and genetic predisposition have significant impacts on this. It has also been shown that the reaction of girls to stress originating from interpersonal relations is more intensive and they are exposed to a higher risk of developing depression .
After assessing other health conditions in our study group members, we found that no less than three-quarters of the children who attempted suicide had self-harmed themselves cutting or burning various body parts. Based on data found in the scientific literature, children who had suicidal thoughts and attempted suicide often self-harmed themselves [8, 24].
The circumstances of attempts were evaluated with attention paid to the speed of making the decision compared with the recurrence of attempt and choice of method for the attempt. The methods of suicide were discussed earlier, but then assessing the data, we found that more than a half of the children had tried to commit suicide spontaneously and the remaining portion had planned their suicide. Research carried out in Denmark in 2016 disclosed that children, in comparison with adults, more often try to commit suicide spontaneously. This finding was explained by the fact that the understanding of time differs in children compared with adults; therefore, when making decisions, only the current difficulties and short-term consequences of their behavior are considered . Suicide attempt relapse was detected in one-third of our study group. A study carried out in Denmark in 2016 identified previous attempts to commit suicide as a key risk factor in determining potential repeated suicide attempts . A review of pediatric suicides performed in the USA in 2019 for a 25-year period-analyzed child and adolescent suicides and identified that one-quarter of children who die of suicide had previously attempted to commit suicide .
The main limitations of the study are impossibility to evaluate possible factors related to suicide as well related to suicide attempt in adolescents due to lack of those data in the Statistical Yearbook of Lithuania and epidemiological data of the study covering a large party, but not all the country of Lithuania.