Introduction

Adolescence is a vulnerable period for the development of mental health problems and specifically suicidal thoughts and behaviour. Although suicide deaths in children are relatively uncommon, the prevalence of both suicide and suicidal thoughts and behaviours increases throughout adolescence [1]. Suicide rates have increased in several countries throughout the world in recent years [2,3,4,5,6] and suicide is one of the leading causes of death among adolescents worldwide [7]. In this article, we are using the term ‘adolescents with suicidal behaviour’ to refer to adolescents with (a recent history of) suicidal ideation, suicide thoughts, suicide plans, and/or self-harm [8].

Important risk factors for suicidal behaviour in adolescents include, among others, social and educational disadvantage, childhood and family adversity (including trauma as child abuse, parental divorce or death), psychopathology, and social contagion [9, 10]. Two of the most important predictors of suicide in young people are engaging in self-harm [11,12,13,14] and making a suicide plan [15, 16]. Research on the perspective of adolescents of their suicidal behaviour and their specific needs is important but appears to be scarce when compared to research focusing on risk factors, risk assessment, prediction, and interventions [17,18,19].

However, taking into account adolescents’ own perspectives on their needs is very important. For example, young people repeatedly stress the importance of informal support, such as family, friends, and school during the times when they feel suicidal [20, 21]. Including these viewpoints is essential to guide the direction of policy and suicide prevention [20,21,22,23]. The self-perceived needs of adolescents to recover or to prevent relapse into suicidal behaviour seem to have become somewhat more important in research in the last years [24,25,26] but as far as we are aware the findings have not been assimilated in a review.

Also, potential gaps in our knowledge are undefined. In this scoping review, we present findings from studies that report on the self-perceived needs of adolescents with suicidal behaviour and also identify gaps in the research.

Methods

Protocol and registration

This scoping review was performed according to the PRISMA guidelines for such reviews and preregistered with the Open Science Framework on April 28, 2022 (https://osf.io/p43bq/) [27].

Eligibility criteria

To be included, articles needed to have included adolescents who were currently suicidal or engaged in self-harm or were so in the past. Adolescents were defined as young people aged 10–25 years, since this age range corresponds most closely to adolescent growth and development to young adulthood [28]. Studies were included if they described the needs of adolescents with suicidal behaviour according to their own opinion or expressed feelings. The term ‘needs’ could refer to all areas of life, such as healthcare, school, personal relationships, family, etc. Peer-reviewed journal articles of any type of study design were included, whereas evaluation studies of specific interventions were excluded, because adolescents’ opinions on specific treatments or interventions were beyond the scope of this review. Discussion articles that did not report new empirical research (e.g., commentaries and editorials) were excluded.

Information sources and search

To identify potentially relevant articles, the following databases were searched up to February 18, 2022 and this search was updated on May 1, 2023: Medline, Embase, Psycinfo, CINAHL, ERIC, Scopus, and Web of Science. A librarian was consulted to effectively search the databases for the three research domains: (1) adolescents or youth; (2) self-harm and/or suicidal behaviour; (3) needs, wishes, and demands. The final search strategy for PubMed can be found in Additional file 1. The search results were exported into EndNote, and duplicates were removed by the librarian. Reference lists of relevant articles and reviews were manually searched.

Selection of sources of evidence

All identified records were uploaded to a software program called Rayyan that facilitates the screening procedure in conducting literature reviews [29]. The selection procedure involved: (1) screening on title and abstract, and (2) full-text review. Titles and abstracts of each article were independently screened by two reviewers (ML and NvE). Disagreements during screening were resolved by discussion with a third reviewer (DvB). The same procedure was followed for the selection of the full-text articles.

Data charting and data items

The data extraction form was developed and revised during the data collection process in Microsoft Excel by two researchers (ML and NvE). Data were extracted regarding publication characteristics (country of origin, year of publication, and authors), study characteristics (purpose, setting, methods, and results) and participant characteristics (number, age range, and type of suicidal behaviour).

Critical appraisal

Two researchers (ML and NvE) recorded the characteristics and methodological quality of each study using the Critical Appraisal Skills Program (CASP) [30], selecting the specific checklist associated with the methodology of each particular article. A third researcher (DvB) independently checked a random subsample of 20% and the results were consistent with the first appraisal.

Synthesis of the results

Two researchers (ML and NvE) independently listed what type of needs each study examined, and, through an iterative process and discussion with the other authors, grouped the needs into five categories and summarized the type of settings, populations, and study designs.

Results

Sources of evidence

After identifying 6819 articles, all of which included abstracts in English, 29 studies were included in the review. Of the 87 full-text articles, one article was written in French which we had translated into English. The PRISMA flow diagram in Fig. 1 gives an overview of the systematic source and selection process for the scoping review.

Fig. 1
figure 1

Flow diagram of the systematic search and selection process

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Eight studies were from the UK [21, 31,32,33,34,35,36,37], four from USA [38,39,40,41], three from Canada [42,43,44], two from each of Finland [45, 46], Ireland [47, 48], and Sweden [49, 50] one from each of Pakistan [51], Australia [52], New Zealand [23], South Africa [53], the Netherlands [54], Brazil [55] and Portugal [56], and one from Belgium, USA and Australia combined [57]. All studies were published between 2003 and 2023. Age of the participants ranged between 11 and 32 years at the time of study participation (all had experienced suicidality/self-harm while aged 10–25 years). A total of 1537 adolescents were included. The gender of participants was unknown for 538 adolescents. Of the remaining 999 adolescents, 166 were male and 828 female. Five adolescents defined there gender as ‘other’ (three as non-binary, one as transgender and one self-described as She/They). There were four studies that focused specifically on self-harm without intention to die [38, 41, 52, 57]. The remaining studies had included participants with an intention to die or participants who engaged in self-harm regardless of the intention or both. Seventeen studies recruited a clinical sample [23, 31, 32, 34,35,36,37, 39, 40, 43, 44, 47, 49,50,51, 54, 56], 11 studies recruited a non-clinical or mixed sample [21, 38, 41, 42, 45, 46, 48, 52, 53, 55, 57] and the sample of one study was not described [33].

The included studies were of variable quality, as shown in Table 1. Table 2 provides an overview of the study characteristics and the needs of adolescents with suicidal behaviour found in the reviewed literature.

Table 1 Critical appraisal of included studies
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Table 2 Study characteristics and the needs of adolescents with suicidal behaviour
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Synthesis of results

The needs of adolescents with suicidal behaviour found in the 29 articles can be categorized into the following themes: (1) connecting with others, (2) self-help strategies and personal growth, (3) mental health care, (4) school, and (5) general public.

Needs related to connecting with other people

The vast majority of ‘needs’ of adolescents with suicidal behaviour were related to connecting with other people [21, 23, 31,32,33,34, 36,37,38,39,40, 42,43,44,45, 47,48,49,50,51, 53, 54, 56, 57].

Support through connecting and recognition

In a study from New Zealand, connecting with others was described by adolescents as a key strategy to prevent self-harm. More precisely, connecting was described as helping with overcoming feelings of isolation, in dealing with negative thoughts and in increasing a sense of safety and being cared for [23]. Also, in the process from suicidality to recovery, supportive relationships with others were mentioned to be crucial [31, 42, 43]. According to the adolescents, supportive contacts can include parents, peers, family, extra-familial adults, and professionals, but also spiritual or religious connections [42, 43].

One study from the UK found that the initial recognition that help is needed often comes from connected external contacts, such as parents, friends, or schoolteachers, rather than from the adolescents themselves [31]. In another UK study, adolescents suggested that once they were engaged in regular meetings with an adult confidant (whether or not this was a professional), they eventually found the courage to reveal that they had been self-harming [33]. Although five young men (in a small qualitative sample of eight young men from the UK), indicated that they benefited from contact with an adult man; gender of the influential other was not seen as crucial in the process of recovery by these individuals [31]. Furthermore, having good accepting relationships with others also helped adolescents to feel more confident about themselves according to a Canadian study: “I got connected with one person…there was somebody there who thought something of me, more than that I was useless and never going to amount to anything….” [42].

In a study of adolescents in a community sample from the UK who reported self-harm, the researchers asked the question ‘What do you think can be done to help prevent young people from feeling that they want to harm themselves?’ the most frequent response was ‘listening to them and talking to them’ (27% of 318) [21]. Adolescents in this study [21] underpinned the importance of someone who is ‘there for them’ and for providing support to those who feel like harming themselves: “People want to listen to their problems, give them confidence, be there for them, don’t let them down, show them you like them and you want to help them”. More girls than boys mentioned aspects relating to talking, listening, and providing general support [21]. Also, with regard to self-harm, adolescents in another UK study valued the presence of someone who can show individual acceptance, empathy, understanding, and unconditional positive regard. This was evident in both outpatient and inpatient relationships [36]. In an Irish community study, in response to the question ‘what can prevent self-harm?’, the majority of adolescents who self-harmed, also answered ‘talk to someone’ (39.6% of 71). For the most part, peers were the preferred source of help as there was the belief as they would understand better and speaking to a parent or other adult would result in actions that were unfavorable for the adolescent [48]. In a study from Pakistan, adolescents with experience of self-harm mentioned emotional ventilation and having a confidant as suggestions regarding type of help that they thought can benefit adolescents who self-harm: “I think discussion is important, those who do not do this suffocate themselves from inside, and sharing can help to relax” [51].

According to a Finnish study, adolescents in residential care thought any person who knows about the self-harm can help. That is, friends of similar age (including fellow self-harming adolescents), and loved ones and adults (including unknown adults, health and social care professionals, teachers, counselors, and parents). Adolescents in this study mentioned contact with friends as most helpful in preventing self-harm (46% of 53) [45].

Needs from health care providers

Studies found that adolescents need to perceive healthcare providers as ‘sincere’, ‘open’, ‘listening’, ‘understanding’, ‘always up front’, ‘reliable’, ‘non-judgmental’, ‘confidential’, and ‘completely consistent’ [33, 43]. In a study from the UK adolescents described they need staff to be genuinely interested and willing to engage in meaningful shared activities. Staff also need to show care and concern about the well-being of the adolescents and respond to incidents of self-harm in a validating and non-judgmental manner. Adolescents in this study described needing different responses at different times, and valued staff who were able to respond flexibly to these changes [37]. In a Dutch study, adolescents in secure residential youth care described what they experienced as responsive from their group workers in relation to suicidality. Their answers centered around experiencing proximity, commitment, trust, and connection [54]. In a Swedish study, having a good connection with a professional was reported as more important to adolescents than the professional being someone from a specific profession [49]. In addition, a study from the UK showed that, when professionals offer care perceived as genuine, this provides adolescents with a sense of safety and trust in ‘a parental figure’ who could notice and contain their distress. Adolescents need professionals to understand them, and particularly to understand the reasons for and background to self-harm in the context of their lives [34]. Moreover, adolescents would like professionals to see them from different perspectives and to focus more on their strengths than on their problem behaviour. Also, a study from USA found that adolescents need professionals to hear directly from them before seeking other sources of information, for example from their parents [39].

According to a South-African study, when adolescents were asked after a suicide attempt what they would have liked to have been different in hospital care, they mainly focused on medical staff-patient relationships. The majority of adolescents would have liked ‘more communication’ from the medical staff, ‘more time and attention’ from them, and ‘more caring and supportive treatment’. In a setting where social workers were available, adolescents also mentioned that they would have had preferred more time alone with their social worker to talk about their suicide attempt [53]. Adolescents in a Canadian study expected nurses to give them daily support in a human and individualized way, to work together with the adolescent to manage suicide risk, and to create a physical and social environment that promotes recovery [44]. In a Portuguese study, the aspects adolescents who had been admitted to a child psychiatric unit with suicidal behaviour valued most about their hospitalization had to do with ‘psychological support and health professionals’ (for example ‘knowing that people acknowledge and understand my pain’) [56]. In a study of adolescents receiving mental health care in USA, some adolescents said that they would like to be more informed about their treatment direction and be able to participate more actively in decisions about their treatment [39]. The most helpful responses from mental health professionals mentioned by adolescents with non-suicidal self-injury in a cross-cultural study in Australia, USA and Belgium were ‘supporting’, ‘engaging’, and ‘non-judging’ responses [57]. Furthermore, according to a study from USA, mental health professionals needed to know that each young person with non-suicidal self-injury is unique; they should help adolescents to feel comfortable and need to understand the reasons for self-harm [38].

Peers with lived experience as source of support

Adolescents in a South-African study who attempted suicide expressed the need for a support group where they could talk to other adolescents with the same experience [53]. In a study in Canada, a specific group based on a psychosocial/psychoeducational intervention for people with recurrent suicide attempts was appreciated, because it provided an understanding peer group [43]. Irish adolescents stressed the importance of having other young people who have experienced mental health difficulties in the past working alongside professionals in any service for young people [47].

Needs related to adolescents’ self-help strategies and personal growth

Some of the identified needs were related to adolescents’ coping skills or personal growth on the path from suicidal behaviour to recovery [23, 31, 32, 35, 41,42,43, 45, 46, 51, 56].

Self-help strategies

A New Zealand study showed that when feeling the urge to self-harm, adolescents mentioned that how helpful a specific strategy is dependent on a range of different factors at a specific moment, such as mood, interests, and setting (e.g., home or school). Therefore, it is important for adolescents to have an understanding of their own triggers with an accompanying diverse set of strategies [23]. In a UK study, when asked about ways of stopping self-harm, adolescents in mental health care described how they had managed to develop their coping techniques. They reported activities, such as art, music, and going for walks reportedly helped them to delay and distract from self-harm [35]. Immediately moving to another place was also noted as an important self-help strategy [23]. In another UK study, reliance on self-help in stopping self-harm seemed more salient to the young people than clinical services, and was generally preferred [35]. Finally, in a study from the USA, adolescents reported a desire for an app-based technology to track patterns and deliver personalized suggestions for self-management of self-harm [41].

Personal growth

A Canadian study showed that adolescents who attempted suicide identified the following aspects as important on their road to recovery: learning that there are choices you can make in relation to your mental health, and that feelings are a part of the human experience. Feelings needed to be identified and tolerated to be understood and learned from:

“to be more comfortable with myself...”; “living a life that is really mine by the choosing, not by what society deems successful; or something astronomical and my first thought won’t be dying, or cutting or getting drunk or getting high, it will be to cry and move on” [43].

Getting rid of the guilt about their mental illness was mentioned by adolescents as important in a Finnish study [46], and in a Swedish study, being of value to others and finding a context in which other people regarded the respondents as healthy were reported as important to adolescents [50]. In addition, a sense of control, independence, and autonomy are important in the process to recovery, even though this sometimes conflicts with needing good and supportive relationships [31, 49].

Needs related to aspects of mental health care

Another theme related to specific aspects of needs related to mental health services, such as access to appropriate youth mental health care [21, 44, 46, 47, 49, 50, 52, 56].

Accessibility of care

Regarding access to professional care, in a Swedish study, adolescents reported that they would like to have a phone number, or a place they could visit, for immediate needs for contact, and information about the way the reception or Health Centre works. There appeared to be a need for several possible routes to accessing professional care: some adolescents preferred contact by phone, some by email, and others wanted to visit in-person. The importance of immediate help being available after making contact was also mentioned [49]. In addition, in an Irish study, the importance of having services that are easily accessible to adolescents and having easy access to mental health professionals at any facility for young people was also highlighted [47].

Online services

Adolescents in a New Zealand study highlighted the value of helplines and online forums, because it made them able to connect anonymously with someone, with few consequences for being open and honest [23]. In an Australian study, adolescents were asked to identify preferred sources of potential online support for self-injurious behaviour, using a list of possible sources. The most popular suggestion was for ‘an online service with direct links to professionals in real time via instant messaging’. Regarding online services in general, the following aspects were mentioned as important: guidance, information, reduced isolation, online culture, facilitation of help-seeking, access, and privacy [52].

Needs related to schools

Three studies described self-perceived needs of adolescents with suicidal behaviour related to schools [21, 40, 55]. In a UK study, when asked ‘What do you think can be done to help prevent young people from feeling that they want to harm themselves’, many responses of adolescents in a school-based survey with lived experience of self-harm indicated factors concerning school-related issues (35% of 318), such as alleviating the pressure of exams, having someone to talk to about issues apart from the teacher, reducing bullying (e.g., more effective policies) and teachers having more awareness of pupils having emotional problems [21]. In a Brazilian study, adolescents expressed a demand for a responsive and careful dialog, stating that the school (staff) needs support to discuss the topic of self-injury, as adolescents who harm themselves do not speak out [55]. Finally, a study from the US found that, when returning to school after hospitalization for self-harm, adolescents wished for a gradual return to catching up on work and support around work completion [40].

Needs related to the general public

Other needs identified by adolescents were related to reducing taboo and stigma around suicidal behaviour [21, 33, 51]. For example, male adolescents in a UK study indicated the importance of breaking the taboo against males seeking help for mental health problems [31]. Another UK study found that, when asked what could be done in the future to help others who self-harm, adolescents emphasized, among other things, the need to increase knowledge about self-harm in the wider population: “There should be more posters around. You see a lot of things on the television, alcoholics get a lot of help, like ring AA, but there’s no help towards self-harm” [33]. Finally, in a study from Pakistan, adolescents said that they could be encouraged and motivated through use of positive stories from lives of famous people in the media: “There should be stories of those who wanted to attempt suicide but then found a better way, stories with some message or moral” [51].

Discussion

This scoping review was conducted to answer the question ‘What are the self-perceived needs of adolescents with suicidal behaviour?’ An extensive and systematic search through peer-reviewed empirical literature identified 29 relevant studies. These studies differed in terms of purpose, participant demographics, method, and context. Almost half of the studies (13 of 29) were published in the last two years, which indicates that studying young people with lived experience of suicidal behaviour has become a lot more common in recent years and is increasingly considered important.

Unfortunately, there is a paucity of evidence regarding effective interventions for young people with suicidal behaviour [18]. Although the self-perceived needs of adolescents with suicidal behaviour discussed below are important to take into account, they should be seen as possible starting points for prevention, but they are not proven effective interventions in themselves.

Needs

The identified needs of adolescents with suicidal behaviour covered a wide range of topics. Of the 29 studies reviewed, the majority of needs of adolescents with suicidal behaviour were concentrated on social support and connecting with other people. Supportive connections could be with peers, parents, health care professionals, or any other kind of contacts. Previous research, often quantitative cross-sectional studies, indicates that greater social support is associated with lower suicide risk [58,59,60]. In addition to these findings, this scoping review showed that among adolescents with suicidal behaviour, there are also self-perceived needs for connection and social support, either preceding self-harm or during the aftercare of these episodes. Contact with peers who had similar experiences was mentioned in a number of studies as an important form of support [43, 47, 53]. Internet forums and social media are increasingly used as places where adolescents find peers who have also self-harmed to communicate about their suicidal feelings and distress [61]. This can be helpful, but at the same time can lead to potential harm in terms of normalizing, triggering, and contagion effects [61,62,63,64]. It is important to think about how peer support can be strengthened and used in an effective, safe, and structural way for adolescents who may benefit from this. In addition, a stronger focus is needed on letting adolescents themselves think about beneficial ways peer support can help them.

A substantial part of the included articles described adolescents’ needs for beneficial self-help strategies and personal growth [23, 31, 32, 35, 42, 43, 45, 46, 51, 56]. The majority of these articles emphasize the importance (of having or mastering a diverse set) of self-help coping and distraction techniques for when suicidal tension or the urge to self-harm is high. These topics touch on mental health care where such techniques can be learned, practiced, and discussed. People in close contact with an adolescent with suicidal feelings should also realize the importance of such self-help strategies. Peers or gatekeepers may also be ideally suited to discuss or demonstrate certain techniques with an adolescent. Results of several studies indicate that adolescents often prefer self-help over reliance on clinical services [20, 35]. As a consequence, it seems very important to equip adolescents and their peers with the right tools to maintain their feeling of self-control and independence.

Many other identified needs were focused on the connection with adolescents’ health care providers and the need of adolescents for health care providers to understand them [33, 34, 37, 39, 43, 44, 49, 53, 54, 56]. However, when suicidal tension is high, it is not always easy for health care providers to develop a good, collaborative therapeutic relationship. Also, finding the balance between safety of the patient and patient autonomy is often very challenging. It is, for example, important that health care providers know how and when to use ‘therapeutic risk taking’ (the avoidance of coercive measures to ensure safety in patients who self-harm and instead allow more room for patient autonomy), thereby using shared decision-making to maintain a strong therapeutic relationship to enable recovery [65].

Interestingly, only a small proportion of the identified needs in this review were related to adolescents’ schools or study programs [21, 40, 55]. However, other studies have shown that school-based suicide prevention interventions can be effective [66, 67]. Given that a large proportion of adolescents spend a lot of time in school or college, this topic needs more research in relation to the self-perceived needs of adolescents in such settings.

Finally, a few articles discussed the needs of adolescents in the area of the ‘general public’ [21, 33, 51]. Adolescents remarked on the need to reduce stigma regarding self-harm in society, to increase knowledge about self-harm in the wider population, and for a greater focus on recovery through promotion of stories of well-known/famous people in society overcoming their difficulties [21, 33, 51]. Public awareness campaigns can be used to reduce stigma and taboo in the general public [68,69,70,71]. Such campaigns appear to be most effective when they are delivered as part of a broad suicide prevention strategy [68]. The evaluation of a campaign by the Dutch helpline 113 suicide prevention showed that public awareness of the helpline was predominantly in younger people [72]. This specific example shows that it is very important to think about methods to tackle taboo and stigma among all layers of the population and to make information accessible to all target groups.

Limitations

Overall, there were approximately five times as many female as male participants in the included studies, which is somewhat greater than the sex ratio usually found for young people who self-harm [73]. This is probably explained by the greater participation of females in interview studies on sensitive topics [74, 75]. Furthermore, the studies included in this review were predominantly studies from Anglo countries with Western adolescents. Demographic characteristics regarding sexual orientation or gender identity of the participants were not presented in the studies. Furthermore, we included not only the studies that literally asked about needs, but also studies in which young people with lived experience provided any information about something that was helpful or what they experienced as positive during periods of suicidality. Due to this broad view, the variability in the nature of research focus and aims of the included papers presented a challenge for synthesizing the results of this review. However, we have employed every effort to synthesize the literature in a comprehensive way. Also, for further research, it is important to focus not only on ‘needs’ and thus the positive, helping aspects for the whole picture of prevention in young people with suicidal behaviour, but also on the aspects that have been unhelpful or criticisms that young people have. However, we believe that a focus on needs and on how to fulfill them is important to develop prevention targeted on youth. Although we deliberately chose the age group 10–25 years, age boundaries are arbitrary and the self-perceived needs founded in this review may also be relevant to emerging adults who were older than 25 years. Several studies show this slightly older age group also has self-perceived needs related to, among others, positive relationships and meaningful connections [76,77,78,79,80]. Finally, the reviewed studies varied in quality, but we tried to provide insight into the quality of each study using critical appraisal (see Table 1).

Conclusions

This scoping review identified studies on the needs of adolescents with suicidal behaviour in peer-reviewed literature. These can broadly be categorized into the following categories of needs: the importance of connecting with other people; adolescents’ self-help strategies and personal growth after self-harm; aspects of mental health care; school; and needs related to society in relation to taboo on suicidal behaviour. Male adolescents with suicidal behaviour were underrepresented as participants in most studies included in this review, so more research into their needs is required. The findings of this study imply that adolescents should be more involved in shaping peer-related suicide prevention. It is important to teach adolescents the right tools and self-help strategies to help them maintain a sense of self-control and independence. More work needs to be done around educating the public about self-harm and suicide prevention and fighting stigma and taboo throughout society. In addition, it is important that health care professionals listen openly and without judgment, that there are multiple routes for getting mental health care, and that online help is available. Also, further research should focus on additional high-risk groups for suicidal behaviour, e.g., non-western adolescents (immigrant and refugee youth), LGBTQ + adolescents, and foster youth but could also focus on a broader group of adolescents, such as those with mental health issues (and without suicidal behaviour). The results of this scoping review may provide leads to develop or strengthen suicide-related prevention taking into account the self-perceived needs of adolescents with suicidal behaviour.