The Treatment of Suicide and Self-Injurious Behaviors in Children and Adolescents

  • Anna C. GilbertEmail author
  • Lena L.A. DeYoung
  • Christine M. Barthelemy
  • Gracie A. Jenkins
  • Heather A. MacPherson
  • Kerri L. Kim
  • Anastacia Y. Kudinova
  • Petya D. Radoeva
  • Daniel P. Dickstein
Child and Adolescent Psychiatry (M Singh and M Goldsmith, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Child and Adolescent Psychiatry
  2. Topical Collection on Child and Adolescent Psychiatry



Suicide is currently the second leading cause of death for 10–34 year-olds. Moreover, up to 20% of adolescents report engaging in non-suicidal self-injury (NSSI) at some point in their lifetime. Despite the urgent need, the literature on effective treatment options for children and adolescents struggling with suicide, NSSI, and other self-injurious behaviors (SIBs) is relatively limited. This article reviews the efficacy of current treatments for youth suicidality and SIBs.

Recent Findings

Most of the existing literature on treatment for suicidality and NSSI in children and adolescents is focused on psychotherapy, specifically cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), psychoeducation, family therapy, and school-based interventions. In contrast, psychopharmacology studies have focused on addressing disorders related to suicidality and NSSI such as major depressive disorder, rather than on the behaviors themselves.


Currently, there is no single treatment that is considered the gold standard for child and adolescents struggling with suicidality and NSSI. While individual psychotherapies, including CBT and DBT, and psychopharmacological agents, such as selective serotonin reuptake inhibitors (SSRIs), show promise in addressing suicide and related psychopathology, there is considerable need for novel approaches to address the underlying mechanisms leading to youth suicidality and NSSI.


Suicide Self-injury Self-harm Child Adolescent Treatment 


Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999-2014. NCHS Data Brief. 2016;241(241):1–8.Google Scholar
  2. 2.
    Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B et al. Youth risk behavior surveillance - United States, 2017. MMWR Surveill Summ. 2018;67(8):1–114. doi:
  3. 3.
    Swannell SV, Martin GE, Page A, Hasking P, St John NJ. Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide Life Threat Behav. 2014;44(3):273–303. Scholar
  4. 4.
    Andover MS, Gibb BE. Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients. Psychiatry Res. 2010;178(1):101–5.CrossRefGoogle Scholar
  5. 5.
    Nock MK, Joiner TE Jr, Gordon KH, Lloyd-Richardson E, Prinstein MJ. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1):65–72. Scholar
  6. 6.
    Asarnow JR, Porta G, Spirito A, Emslie G, Clarke G, Wagner KD, et al. Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: findings from the TORDIA study. J Am Acad Child Adolesc Psychiatry. 2011;50(8):772–81. Scholar
  7. 7.
    Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1:S1.
  8. 8.
    David D, Cristea I, Hofmann SG. Why cognitive behavioral therapy is the current gold standard of psychotherapy. Front Psychiatry. 2018;9:4. Scholar
  9. 9.
    Vitiello B. Youth depression: are two treatments better than one? Lancet Psychiatry. 2019;6(9):714–5. Scholar
  10. 10.
    Alavi A, Sharifi B, Ghanizadeh A, Dehbozorgi G. Effectiveness of cognitive-behavioral therapy in decreasing suicidal ideation and hopelessness of the adolescents with previous suicidal attempts. Iran J Pediatr. 2013;23(4):467–72.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Taylor LM, Oldershaw A, Richards C, Davidson K, Schmidt U, Simic M. Development and pilot evaluation of a manualized cognitive-behavioural treatment package for adolescent self-harm. Behav Cogn Psychother. 2011;39(5):619–25. Scholar
  12. 12.
    Esposito-Smythers C, Spirito A, Kahler CW, Hunt J, Monti P. Treatment of co-occurring substance abuse and suicidality among adolescents: a randomized trial. JConsult ClinPsychol. 2011;79(6):728–39.Google Scholar
  13. 13.
    Silverstone PH, Bercov M, Suen VY, Allen A, Cribben I, Goodrick J, et al. Initial findings from a novel school-based program, EMPATHY, which may help reduce depression and suicidality in youth. PLoS One. 2015;10(5):e0125527. Scholar
  14. 14.
    Silverstone PH, Bercov M, Suen VYM, Allen A, Cribben I, Goodrick J, et al. Long-term results from the empowering a multimodal pathway toward healthy youth program, a multimodal school-based approach, show marked reductions in suicidality, depression, and anxiety in 6,227 students in grades 6-12 (aged 11-18). Front Psychiatry. 2017;8:81. Scholar
  15. 15.
    Glenn CR, Franklin JC, Nock MK. Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth. J Clin Child Adolesc Psychol. 2015;44(1):1–29. Scholar
  16. 16.
    Linehan MM, Heard HL, Armstrong HE. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1993;50(12):971–4.CrossRefGoogle Scholar
  17. 17.
    Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav. 2002;32(2):146–57.CrossRefGoogle Scholar
  18. 18.
    Mehlum L, Tormoen AJ, Ramberg M, Haga E, Diep LM, Laberg S, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014;53(10):1082–91. Scholar
  19. 19.
    • McCauley E, Berk MS, Asarnow JR, Adrian M, Cohen J, Korslund K et al. Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial. JAMA Psychiatry. 2018;75(8):777-85. Randomized clinical trial comparing the efficacy of DBT to IGST in adolescents with suicidality.
  20. 20.
    Fischer S, Peterson C. Dialectical behavior therapy for adolescent binge eating, purging, suicidal behavior, and non-suicidal self-injury: a pilot study. Psychotherapy (Chic). 2015;52(1):78–92. Scholar
  21. 21.
    Katz LY, Cox BJ, Gunasekara S, Miller AL. Feasibility of dialectical behavior therapy for suicidal adolescent inpatients. J Am Acad Child Adolesc Psychiatry. 2004;43(3):276–82. Scholar
  22. 22.
    Henggeler SW, Schoenwald SK, Liao JG, Letourneau EJ, Edwards DL. Transporting efficacious treatments to field settings: the link between supervisory practices and therapist fidelity in MST programs. J Clin Child Adolesc Psychol. 2002;31(2):155–67. Scholar
  23. 23.
    Huey SJ Jr, Henggeler SW, Rowland MD, Halliday-Boykins CA, Cunningham PB, Pickrel SG, et al. Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. J Am Acad Child Adolesc Psychiatry. 2004;43(2):183–90. Scholar
  24. 24.
    Schoenwald SK, Ward DM, Henggeler SW, Rowland MD. Multisystemic therapy versus hospitalization for crisis stabilization of youth: placement outcomes 4 months postreferral. Ment Health Serv Res. 2000;2(1):3–12.CrossRefGoogle Scholar
  25. 25.
    Siqueland L, Rynn M, Diamond GS. Cognitive behavioral and attachment based family therapy for anxious adolescents: phase I and II studies. J Anxiety Disord. 2005;19(4):361–81. Scholar
  26. 26.
    Diamond GS, Reis BF, Diamond GM, Siqueland L, Isaacs L. Attachment-based family therapy for depressed adolescents: a treatment development study. J Am Acad Child Adolesc Psychiatry. 2002;41(10):1190–6. Scholar
  27. 27.
    Diamond GS, Wintersteen MB, Brown GK, Diamond GM, Gallop R, Shelef K, et al. Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2010;49(2):122–31.PubMedGoogle Scholar
  28. 28.
    Asarnow JR, Berk M, Hughes JL, Anderson NL. The SAFETY program: a treatment-development trial of a cognitive-behavioral family treatment for adolescent suicide attempters. J Clin Child Adolesc Psychol. 2015;44(1):194–203. Scholar
  29. 29.
    Asarnow JR, Baraff LJ, Berk M, Grob CS, Devich-Navarro M, Suddath R, et al. An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment. Psychiatr Serv. 2011;62(11):1303–9. Scholar
  30. 30.
    Wharff EA, Ginnis KM, Ross AM. Family-based crisis intervention with suicidal adolescents in the emergency room: a pilot study. Soc Work. 2012;57(2):133–43.CrossRefGoogle Scholar
  31. 31.
    Wharff EA, Ginnis KB, Ross AM, White EM, White MT, Forbes PW. Family-based crisis intervention with suicidal adolescents: a randomized clinical trial. Pediatr Emerg Care. 2019;35(3):170–5. Scholar
  32. 32.
    Markowitz JC, Weissman MM. Interpersonal psychotherapy: principles and applications. World Psychiatry. 2004;3(3):136–9.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Mufson L, Weissman MM, Moreau D, Garfinkel R. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56(6):573–9. Scholar
  34. 34.
    Mufson L, Dorta KP, Wickramaratne P, Nomura Y, Olfson M, Weissman MM. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 2004;61(6):577–84. Scholar
  35. 35.
    Rossello J, Bernal G. The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. J Consult Clin Psychol. 1999;67(5):734–45. Scholar
  36. 36.
    Tang TC, Jou SH, Ko CH, Huang SY, Yen CF. Randomized study of school-based intensive interpersonal psychotherapy for depressed adolescents with suicidal risk and parasuicide behaviors. Psychiatry Clin Neurosci. 2009;63(4):463–70. Scholar
  37. 37.
    Aseltine RH Jr, James A, Schilling EA, Glanovsky J. Evaluating the SOS suicide prevention program: a replication and extension. BMC Public Health. 2007;7:161. Scholar
  38. 38.
    • Schilling EA, Aseltine RH Jr, James A. The SOS Suicide Prevention Program: further evidence of efficacy and effectiveness. Prev Sci. 2016;17(2):157–66. Replicated earlier studies examining the SOS program in a sample of adolescents with a history of SAs. CrossRefPubMedGoogle Scholar
  39. 39.
    Muehlenkamp JJ, Walsh BW, McDade M. Preventing non-suicidal self-injury in adolescents: the signs of self-injury program. J Youth Adolesc. 2010;39(3):306–14. Scholar
  40. 40.
    King CA, Kramer A, Preuss L, Kerr DC, Weisse L, Venkataraman S. Youth-nominated support team for suicidal adolescents (version 1): a randomized controlled trial. J Consult Clin Psychol. 2006;74(1):199–206. Scholar
  41. 41.
    Yen S, Ranney ML, Tezanos KM, Chuong A, Kahler CW, Solomon JB, et al. Skills to enhance positivity in suicidal adolescents: results from an open development trial. Behav Modif. 2019;43(2):202–21. Scholar
  42. 42.
    Yen S, Weinstock LM, Andover MS, Sheets ES, Selby EA, Spirito A. Prospective predictors of adolescent suicidality: 6-month post-hospitalization follow-up. Psychol Med. 2013;43(5):983–93. Scholar
  43. 43.
    Gibbons RD, Hur K, Bhaumik DK, Mann JJ. The relationship between antidepressant prescription rates and rate of early adolescent suicide. Am J Psychiatry. 2006;163(11):1898–904.CrossRefGoogle Scholar
  44. 44.
    Valuck RJ, Libby AM, Sills MR, Giese AA, Allen RR. Antidepressant treatment and risk of suicide attempt by adolescents with major depressive disorder: a propensity-adjusted retrospective cohort study. CNS Drugs. 2004;18(15):1119–32. Scholar
  45. 45.
    Olfson M, Shaffer D, Marcus SC, Greenberg T. Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry. 2003;60(10):978–82. Scholar
  46. 46.
    Schneeweiss S, Patrick AR, Solomon DH, Mehta J, Dormuth C, Miller M, et al. Variation in the risk of suicide attempts and completed suicides by antidepressant agent in adults: a propensity score-adjusted analysis of 9 years' data. Arch Gen Psychiatry. 2010;67(5):497–506. Scholar
  47. 47.
    Cooper WO, Callahan ST, Shintani A, Fuchs DC, Shelton RC, Dudley JA, et al. Antidepressants and suicide attempts in children. Pediatrics. 2014;133(2):204–10. Scholar
  48. 48.
    March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: treatment for adolescents with depression study (TADS) randomized controlled trial. JAMA. 2004;292(7):807–20.CrossRefGoogle Scholar
  49. 49.
    Brent DA, Greenhill LL, Compton S, Emslie G, Wells K, Walkup JT, et al. The Treatment of Adolescent Suicide Attempters study (TASA): predictors of suicidal events in an open treatment trial. J Am Acad Child Adolesc Psychiatry. 2009;48(10):987–96. Scholar
  50. 50.
    Brent D, Emslie G, Clarke G, Wagner KD, Asarnow JR, Keller M, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299(8):901–13. Scholar
  51. 51.
    Melvin GA, Tonge BJ, King NJ, Heyne D, Gordon MS, Klimkeit E. A comparison of cognitive-behavioral therapy, sertraline, and their combination for adolescent depression. J Am Acad Child Adolesc Psychiatry. 2006;45(10):1151–61. Scholar
  52. 52.
    Iftene F, Predescu E, Stefan S, David D. Rational-emotive and cognitive-behavior therapy (REBT/CBT) versus pharmacotherapy versus REBT/CBT plus pharmacotherapy in the treatment of major depressive disorder in youth; a randomized clinical trial. Psychiatry Res. 2015;225(3):687–94. Scholar
  53. 53.
    Goodyer I, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, et al. Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. BMJ. 2007;335(7611):142. Scholar
  54. 54.
    Davey CG, Chanen AM, Hetrick SE, Cotton SM, Ratheesh A, Amminger GP, et al. The addition of fluoxetine to cognitive behavioural therapy for youth depression (YoDA-C): a randomised, double-blind, placebo-controlled, multicentre clinical trial. Lancet Psychiatry. 2019;6(9):735–44. Scholar
  55. 55.
    Dubicka B, Elvins R, Roberts C, Chick G, Wilkinson P, Goodyer IM. Combined treatment with cognitive-behavioural therapy in adolescent depression: meta-analysis. Br J Psychiatry. 2010;197(6):433–40. Scholar
  56. 56.
    • Cullen KR, Klimes-Dougan B, Westlund Schreiner M, Carstedt P, Marka N, Nelson K, et al. N-Acetylcysteine for nonsuicidal self-injurious behavior in adolescents: an open-label pilot study. J Child Adolesc Psychopharmacol. 2018;28(2):136–44. First study to examine NAC as a treatment for NSSI specifically. CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Murrough JW, Soleimani L, DeWilde KE, Collins KA, Lapidus KA, Iacoviello BM, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571–80. Scholar
  58. 58.
    Price RB, Mathew SJ. Does ketamine have anti-suicidal properties? Current status and future directions. CNS Drugs. 2015;29(3):181–8. Scholar
  59. 59.
    Reinstatler L, Youssef NA. Ketamine as a potential treatment for suicidal ideation: a systematic review of the literature. Drugs R D. 2015;15(1):37–43. Scholar
  60. 60.
    Cullen KR, Amatya P, Roback MG, Albott CS, Westlund Schreiner M, Ren Y, et al. Intravenous ketamine for adolescents with treatment-resistant depression: an open-label study. J Child Adolesc Psychopharmacol. 2018;28(7):437–44. Scholar
  61. 61.
    Trebaticka J, Hradecna Z, Bohmer F, Vavakova M, Waczulikova I, Garaiova I, et al. Emulsified omega-3 fatty-acids modulate the symptoms of depressive disorder in children and adolescents: a pilot study. Child Adolesc Psychiatry Ment Health. 2017;11:30. Scholar
  62. 62.
    Grosso G, Galvano F, Marventano S, Malaguarnera M, Bucolo C, Drago F, et al. Omega-3 fatty acids and depression: scientific evidence and biological mechanisms. Oxidative Med Cell Longev. 2014;2014:313570. Scholar
  63. 63.
    Lewis MD, Hibbeln JR, Johnson JE, Lin YH, Hyun DY, Loewke JD. Suicide deaths of active-duty US military and omega-3 fatty-acid status: a case-control comparison. J Clin Psychiatry. 2011;72(12):1585–90. Scholar
  64. 64.
    NIMH. A prioritized research agenda for suicide prevention: an action plan to save lives. Rockville, MD2014.Google Scholar
  65. 65.
    2012 National Strategy for Suicide Prevention: Goals and objectives for action: A report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Publications and Reports of the Surgeon General. Washington (DC)2012.Google Scholar
  66. 66.
    Posner K, Oquendo MA, Gould M, Stanley B, Davies M. Columbia classification algorithm of suicide assessment (C-CASA): classification of suicidal events in the FDA's pediatric suicidal risk analysis of antidepressants. Am J Psychiatry. 2007;164(7):1035–43. Scholar
  67. 67.
    Nock MK, Joiner TE, Jr., Gordon KH, Lloyd-Richardson E, Prinstein MJ. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1):65–72.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Anna C. Gilbert
    • 1
    • 2
    Email author
  • Lena L.A. DeYoung
    • 1
    • 2
  • Christine M. Barthelemy
    • 1
    • 2
  • Gracie A. Jenkins
    • 1
    • 2
  • Heather A. MacPherson
    • 1
    • 2
  • Kerri L. Kim
    • 1
    • 2
  • Anastacia Y. Kudinova
    • 1
    • 2
  • Petya D. Radoeva
    • 1
    • 2
  • Daniel P. Dickstein
    • 1
    • 2
  1. 1.PediMIND Program, Bradley HospitalEast ProvidenceUSA
  2. 2.Division of Child Psychiatry, Department of PsychiatryWarren Alpert Medical School of Brown UniversityProvidenceUSA

Personalised recommendations