Gender differences in the disclosure of suicidal ideation among children and adolescents prior to suicide attempts

Gender differences in the disclosure of suicidal ideation among children and adolescents prior to suicide attempts | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Gender differences in the disclosure of suicidal ideation among children and adolescents prior to suicide attempts Natsumi Matsunari, Katsunaka Mikami, Yoko Suzuki, Shunya Takase, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7833585/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2026 Read the published version in Child Psychiatry & Human Development → Version 1 posted 9 You are reading this latest preprint version Abstract Suicide is the leading cause of death among individuals aged 15–19 years, and youth suicide in Japan is increasing. However, few studies have directly confirmed the actual situation of child and adolescent suicide attempters and their parents immediately after the attempts. We investigated whether children and adolescents disclosed suicidal ideation before their attempts through direct interviews with them and their families shortly after emergency department admission. This study was conducted in the Suicide Attempt Registry section of the “Registry Study of Child and Adolescent Mental Health in Japan” in collaboration with the National Kohnodai Medical Center, Japan Institute for Health Security. Patients aged < 18 years who attempted suicide were transported to the Tokai University Hospital Advanced Emergency Medical Center. Psychiatrists interviewed them and their families or guardians about the backgrounds of the attempts, focusing on whether the attempters had disclosed suicidal ideation to anyone. Overall, 76.0% of participants had not consulted anyone before their attempt, and 84.0% of these were male. Additionally, 86.0% of all patients reported being unable to discuss their suicidal ideation with family members beforehand. While these tendencies were more common among males, no statistically significant gender differences were found. In conclusion, children and adolescents who attempted suicide usually faced challenges in disclosing their suicidal ideation to their close circle, particularly family members. These findings were observed regardless of gender. In clinical practice, psychotherapy involving youths and their families is necessary to address youths' reluctance to openly discuss their problems with those close to them. adolescents children disclosure family relations suicide attempts suicide prevention 1. Introduction The number of suicides in Japan peaked at 34,427 in 2003, and subsequently began to decline after 2009, reaching 20,320 in 2024. However, it has been increasing since 2016 among individuals aged < 20 years, reaching 800 in 2024—exceeding 800 for the first time in 2023 since 1986 (National Police Agency, 2023 ). In Japan, suicide is the most common cause of death among males and females aged 10–19 years (Ministry of Health, Labour and Welfare, 2023 ), making it the only G7 nation where suicide ranks as the leading cause of mortality within this age group (Ministry of Health, Labour and Welfare., 2024). Consequently, suicide among children and adolescents has become one of the most significant mental health issues in Japan. Suicidal ideation refers to thoughts about one’s own death, with or without a specific intent or plan. Suicide attempts are characterized as self-destructive behavior carried out with explicit or inferred intent to die (Brent, 2016 ). Both of these factors are well-established as significant risk factors associated with eventual suicide completion (Bridge et al., 2006 ; Gould et al., 2003 ). A previous study examining suicidal ideation among adolescents aged 13–17 years revealed that 50% of parents of children who had ever contemplated suicide were unaware of their child’s suicidal ideation, and 75.6% were unaware that their child had a recurring desire to die. Of the children who were reported to have suicidal thoughts by their parents, 48.4% and 67.5% denied suicidal ideation and having any desire to die, respectively. The agreement between child and parent regarding suicidal thoughts was moderate (κ = 0.466), whereas the agreement concerning the thought of death or desire to die was low (κ = 0.171) (Jones et al., 2019 ). Another study found a negative correlation between high school students’ comfort in discussing their feelings and concerns with their parents and both the ideation and severity of suicidal behavior (Choe et al., 2023 ). A study conducted among adolescents aged 13–19 years at a university psychiatric hospital, using Shulman’s Self-Disclosure Scale, reported a negative correlation between self-disclosure measures to family, friends, and older adults and suicide planning, suicidal ideation, and self-harm. Moreover, difficulty in talking about oneself to those closest to them was associated with an increased risk of suicide attempts (Horesh et al., 2004 ). Among 1,704 college students enrolled at two public universities in the Midwest United States, 4% reported a previous suicide attempt, 2.2% indicated that they were likely to attempt suicide in the future, and 7.5% reported frequent thoughts of suicide within the past year. However, 41.4% of these participants reported they had never disclosed their potential suicide attempts to anyone (Becker et al., 2018 ). In this study, women were more likely than men to report a previous suicide attempt and to share their suicidal ideation with others. However, these studies are summaries of data obtained through questionnaires, and information was not collected directly from actual suicide attempters immediately after the attempts. Only a few studies have directly confirmed the actual situation of teenage suicide attempters and their parents immediately after the attempts. Based on the abovementioned previous studies and our research over the years (Mikami, 2022 ; Mikami et al., 2006 , 2014 ; Takahashi et al., 2020 ), we tested the hypothesis that suicide attempters among children and adolescents would have difficulty disclosing their suicidal ideation to those close to them prior to the attempt, and that this tendency would differ between genders. Therefore, the present study aimed to determine whether children and adolescents who attempted suicide had disclosed suicidal ideation to those close to them before the attempt, focusing on gender differences. We used data obtained directly from suicide attempters and their families or guardians immediately after their transport to an emergency department due to a suicide attempt. This study sought to clarify the clinical characteristics of children and adolescents who attempted suicide based on these data. 2. Materials and Methods 2.1 Participants This registry study reflects the results from clinical practice. It used data from the Registry of Suicide Attempters section of the “Registry Study of Child and Adolescent Mental Health in Japan,” a collaborative study with the National Kohnodai Medical Center Hospital, Japan Institute for Health Security. The data from the Registry of Suicide Attempters were obtained only from patients who were transported to the Tokai University Hospital Advanced Emergency Medical Center following a suicide attempt. Specifically, the Tokai University Hospital Emergency Center covers almost the entire western part of Kanagawa Prefecture and provides primary to tertiary emergency medical care. Patients admitted to the emergency department for attempted suicide were usually referred to the psychiatric department. Among the referred patients, the study participants were those aged < 18 years who were admitted between February 2019 and November 2024, excluding those who visited the emergency department without being admitted. Overall, 1304 patients were hospitalized for suicide attempts, among whom 100 were teenagers (75 [75.0%] females and 25 [25.0%] males). Regarding age distribution, 96.0% and 80.0% of the patients were at least 12 and 15 years old, respectively. 2.2 Assessment Patients of all ages who have had suicide attempts are evaluated and treated by a team of 3–4 psychiatrists (including a child psychiatrist). A trained psychiatrist conducted the initial examination while the patient was in the emergency room. Whenever possible, additional information about the patient, such as their life background, was obtained from the families. The following items were collected and recorded by child psychiatrists through direct interviews with the patients and their families or guardians: presence or absence of a psychiatric clinic at the time of admission, history of suicide attempts, history of self-injury, presence or absence of a counselor for suicidal ideation, history of abuse, history of parents’ divorce, criminal history of parents, drug abuse of parents, alcohol abuse of parents, means of attempts, duration between decision and execution of suicide attempt, parental awareness of the children's suicidal ideation, and the motive for the suicide attempt, among others. As part of standard clinical practice, physicians who interviewed patients transported to the hospital asked questions about the motives of suicide attempts. The motive for suicide was defined as “unclear or vague” if the patient answered “I am not sure” to the psychiatrist's question, “Why did you decide to commit suicide?” or if the patient could not directly explain the factors that triggered their suicidal ideation by listing multiple reasons. Other details that could be confirmed from the medical records, including the patient's age, sex, and number of days in the hospital and so on, were registered. We also assessed whether a student was attending school smoothly at the time of the suicide attempt. For instance, students who had frequent absences or were attending school in a separate room rather than their regular classroom were evaluated as not attending school smoothly. Diagnoses were made using the Structured Clinical Interview for DSM-IV (SCID-5)-TR and the SCID-5-Research version, as well as the SCID-5 Personality Disorders (items associated with borderline and antisocial personality disorders alone) whenever possible (Michael et al., 2017 , 2020 ). However, a complete diagnostic assessment using SCID was not possible due to time constraints. Discussions held during daily morning conferences were used to determine the final diagnosis. The prevalence of traits associated with autism spectrum disorder (ASD) were evaluated using the Autism-Spectrum Quotient (AQ) Japanese version (AQJ) (Baron-Cohen et al., 2001 ; Kurita et al., 2003 ) and/or medical data provided by previous psychiatrists. Furthermore, the cut-off score of AQ was 32/50 (Baron-Cohen et al., 2001 ). We defined suicide attempt as a self-destructive behavior with explicit or inferred intent to die (Brent, 2016 ). Data were obtained directly from the youths who attempted suicide and their parents or guardians. 2.3 Statistical Analysis Data was analyzed using IBM SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, N.Y., USA). Continuous variables were expressed as means and standard deviations. The Fisher’s exact test was used to analyze the categorical variables. Since none of the continuous variables in this study followed a normal distribution, the Mann–Whitney U test was employed for analysis. Univariate analysis was conducted using Fisher's exact test. The influence of gender on the disclosure of suicidal ideation was evaluated using logistic regression analysis, adjusting for age and history of self-injurious behavior. Statistical significance was considered at p < 0.05. 2.4 Ethics Approval This study was approved by the National Center for Global Health and Medicine (Approval No. NCGM-G-003042-10). Patient data from the hospital were registered with the approval of the Ethics Committee of Tokai University Hospital (Approval No. 18R214). The present research analysis of data from the registry study was reapproved by the Ethics Committee of Tokai University Hospital (Approval No. 24R171). This study was conducted according to the Declaration of Helsinki and Ethical Guidelines for Medical and Biological Research Involving Human Subjects. Informed consent was orally obtained from all patients and their family or guardians. 3. Results 3.1 Patient Background Table 1 presents the patient characteristics. Regarding the timing of the most recent suicide attempts, the highest frequency for females and males was 1 month ago and ≥ 2 years ago, respectively. The decision to attempt suicide was made within 24 h for 59.0% of patients, within 1 week for 18.0%, and > 1 week ago for 23.0%. Notably, 48.0% of males and 14.7% of females had decided to commit suicide > 1 week in advance, demonstrating a male predominance (p = 0.011). Among males, 52.0%, 4.0%, and 48.0% decided to attempt suicide within 24 h, within 1 week, and > 1 week ago, respectively. For individuals who had attempted suicide, 47.0% (44.0% of males and 48.0% of females) had been were receiving outpatient care at the time of transport. Among the remaining 53% without outpatient clinic access, 74.5% (81.8% of males and 66.7% of females) established contact with a psychiatrist upon transfer to the hospital. Females with a history of self-injurious behavior were significantly higher than males (p = 0.004). Overdose was the most common method of suicide attempt for both sexes; however, males were more likely to use more serious methods than overdose (p = 0.009). Overall, individuals who attempted suicide most frequently chose overdose, followed by jumping off and taking poison. This trend was observed for both genders. Ninety-four of the 100 participants in this study were students. Among these, 47.9% were not attending school smoothly at the time of their suicide attempts. Additionally, 11.7% of the students who were attending school smoothly had previously experienced difficulties with school attendance. Finally, 59.6% were either currently or had previously faced difficulties attending school smoothly. Table 1. Characteristics of male and female participants. Male Female p-value odds ratio § 95% Confidence interval Number of participants, n (%) 25 (25.0) 75 (75.0) Age mean（SD*） 15.48 (1.53) 15.52 (1.61) 0.757 ≥12 years (%) 24 (96.0) 72 (96.0) 0.690 1.000 0.177–5.654 ≥15 years (%) 20 (80.0) 60 (80.0) 1.000 1.000 0.427–2.337 Length of hospital † , mean (SD*) History of mental illness (%) 14(56.0) 39 (52.0) 0.819 1.175 0.555–1.513 History of suicide attempt (%) 9 (36.0) 40 (53.3) 0.168 1.371 0.937–2.007 Suicidal ideation disclose to anyone (%) 4 (16.0) 20 (26.7) 0.418 1.145 0.920–1.426 disclose to family (%) 2 (8.0) 12(16.0) 0.508 1.095 0.941–1.275 History of abuse ‡ (%) 6 (26.1) 6 (8.5) 0.065 0.807 0.627–1.040 History of protection ‡ (%) 4 (16.7) 5 (6.9) 0.221 0.896 0.741–1.083 Self-injurious behavior (%) 10 (40.0) 55 (73.3) 0.004 2.25 1.374–3.685 Parents history of divorce ‡ (%) 14 (56.0) 26 (35.1) 0.098 0.678 0.423–1.089 criminal records ‡ (%) 0 (0.0) 2 (2.7) 1.000 1.028 0.989–1.068 drug addiction ‡ (%) 0 (0.0) 1 (1.4) 1.000 1.014 0.987–1.042 alcohol addiction ‡ (%) 1 (4.3) 5 (6.8) 1.000 1.026 0.922–1.141 aware of children’s suicidal ideation (%) 4 (16.0) 17 (22.7) 0.580 1.086 0.880–1.341 Suicidal attempt method overdose (%) 13 (52.0) 60 (80.0) 0.009 2.400 1.305–4.414 others (%) 12 (48.0) 15 (20.0) 0.009 0.650 0.439–0.963 Determine to commit suicide (%) >1 week ago (%) 12 (48.0) 11 (14.7) 0.002 0.609 0.413–0.898 <24 h (%) 13 (52.0) 46 (61.3) 0.484 1.241 0.755–2.042 * SD, standard deviation. † Hospitalization length, excluding two cases of long-term hospitalization for social reasons, such as inability to find a new hospital, tended to be longer for female teenagers than for males. ‡ Missing date. § Female was set to 1 and male to 0 for analysis. 3.2 Disclosure of Suicidal Ideation Table 1 presents the data on whether participants consulted someone close to them before their suicide attempt. Among the participants, 76.0% (73.3% of females and 84.0% of males) who attempted suicide had not disclosed their suicidal ideation to anyone. Additionally, 86.0% of all participants (84.0% of females and 92.0% of males) had not discussed their suicidal ideation with their families before the attempt. Although males were frequent, they were not significant in either case. Among the 20.0% of patients who discussed their suicidal ideation prior to attempting suicide, families were the most common consultants, followed by friends. Of the participants who did not consult their families, 90.7% were unsure when they stopped consulting their families, and 4.7% had not discussed their suicidal ideation with their families since junior high school. Furthermore, 66.0% of participants (64.0% of males and 66.7% of females) reported that they did not routinely discuss concerns that corresponded to motives for suicide. The influence of gender on disclosure of suicidal ideation was evaluated using logistic regression analysis, adjusting for age and history of self-injurious behavior (Table 2). Males demonstrated a tendency to consult with those around them less frequently than females, with no significant sex differences. Table 2 . Risk factors for disclosure of suicidal ideation p-value odds ratio 95% confidence interval Gender 0.627 1.362 0.391–4.749 Age 0.639 1.075 0.794–1.456 Self-injurious behavior 0.054 3.27 0.978–10.938 * Female was set to 1 and male to 0 for analysis. 3.3 Psychiatric Diagnosis Table 3 present the participants’ psychotic diagnosis. Notably, these diagnoses included overlapping ones. The prevalence of traits associated with ASD was 17.0% among all participants, with males exhibiting a rate of 28.0%, with no statistically significant difference. Borderline personality disorder prevalence was 9.3% and 0% among females and males, respectively, with no significant gender difference. Table 3. Psychiatric diagnosis Psychiatric diagnosis Male Female p-value odds ratio* 95% Confidence interval Number of participants, n (%) 25 (25.0) 75 (75.0) Adjustment disorder 18 (72.0) 47 (62.7) 0.473 0.750 0.375–1.501 Depressive disorder 4 (16.0) 5 (6.7) 0.222 0.900 0.751–1.079 Dysthymia 0 (0.0) 2 (2.7) 1.000 1.027 0.990–1.067 Bipolar disorder 0 (0.0) 1 (1.3) 1.000 1.014 0.987–1.041 Panic disorder 0 (0.0) 2 (2.7) 1.000 1.027 0.990–1.067 Social anxiety disorder 0 (0.0) 4 (5.3) 0.569 1.056 1.001–1.115 Acute and transient psychotic disorder 0 (0.0) 1 (1.3) 1.000 1.014 0.987–1.041 Anorexia nervosa 0 (0.0) 2 (2.7) 1.000 1.027 0.990–1.067 Dissociative disorders 0 (0.0) 2 (2.7) 1.000 1.027 0.990–1.067 Autism spectrum disorder traits 7 (28.0) 10 (13.3) 0.123 0.831 0.641–1.078 Borderline personality disorder 0 (0.0) 7 (9.3) 0.187 1.103 1.026–1.186 No diagnosis 0 (0.0) 7 (9.3) 0.187 1.103 1.026–1.186 * Female was set to 1 and male to 0 for analysis. 3.4 Psychological and Social Factors in Suicide Attempts Table 4 shows the reasons for suicide attempts. No sex differences were found in the reasons for attempting suicide. “Unclear or vague” was the most frequent response for both genders, followed by family problems and friendships. Table 4. Reasons for suicide attempts. Reasons for suicide attempts Male Female p-value odds ratio* 95% Confidence interval Number of participants, n (%) 25 (25.0) 75 (75.0) Unclear or vague 10 (40.0) 24 (32.0) 0.475 0.882 0.618–1.259 Problems with family 2 (8.0) 17 (22.7) 0.144 1.190 1.005–1.408 Problems with peers 4 (16.0) 15 (20.0) 0.775 1.050 0.855–1.289 Problems with sexual relationships 1 (4.0) 5 (6.7) 1.000 1.029 0.930–1.137 Other interpersonal relationships 4 (16.0) 3 (4.0) 0.063 0.875 0.733–1.045 Problems with study 2 (8.0) 6 (8.0) 1.000 1.000 0.875–1.143 Other problems at school 1 (4.0) 3 (4.0) 1.000 1.000 0.912–1.097 Psychological symptoms 0 (0.0) 2 (2.7) 1.000 1.027 0.990–1.067 Crime 1 (4.0) 0 (0.0) 0.250 0.960 0.886–1.040 * Female was set to 1 and male to 0 for analysis. 4. Discussion This study revealed that 76.0% of children and adolescents hospitalized for suicide attempts did not disclose their suicidal ideation to anyone prior to the attempt, with 84.0% of these individuals being male. Additionally, 86.0% of all patients reported being unable to discuss their suicidal ideation with family members beforehand. While males frequently exhibited these characteristics, the results showed no statistically significant gender differences. To our knowledge, this is the first study to directly examine individuals aged < 18 years who attempted suicide and were transported to an emergency department, particularly inquiring about whether they had consulted with someone prior to the attempt. In the Saving and Empowering Young Lives in Europe Study, involving 1117 students in grades 9–11 across high schools in Israel, 74 reported a history of suicide attempts. Among them, 27 (36.4%) indicated that they had attempted suicide without informing their parents or anyone else (Levi-Belz et al., 2019 ). An Australian study revealed that 39% of the 513 patients aged 16–25 years with a history of psychiatric attendance and self-injurious behavior could not discuss their feelings of wanting to die with a professional (McGillivray et al., 2022 ). A systematic review on the disclosure of suicidal ideation and behaviors found that 50–60% of individuals do not disclose their suicidal ideation and behaviors to other people (Hallford et al., 2023 ). Our study showed that 76.0% of children and adolescents who attempted suicide had not expressed suicidal ideation to anyone, and 86.0% had not even told their families. These rates are higher than those reported in previous studies. The present study’s results may have been influenced by the fact that it was conducted with children and adolescents who had actually attempted suicide and were assessed immediately after the attempt. A previous study revealed that women were more likely than men to report a prior suicide attempt or disclose their suicidal ideation to others (Becker et al., 2018 ). Similarly, interview data from a psychological autopsy study of 35 youths who died by suicide in the Netherlands indicated that girls were more likely to explicitly convey their suicide ideation, intent, or behaviors to others, whereas boys' communication was typically ambiguous or diluted by humor (Balt et al., 2021 ). The current study hypothesized that there would be gender differences in the inability to disclose suicidal ideation before the attempt. Although this characteristic was prevalent in males, the results showed no statistically significant gender differences, indicating that both males and females are equally unable to disclose suicidal ideation before the attempt. Recently, Japan has shown a slight gender based difference in the number of suicides among youth aged < 20 years, which is notable worldwide (National Police Agency, 2023 ). These results may be due to an inability to discuss suicidal ideation immediately before the attempt, regardless of gender. The Korean Psychological Adventures Study found no gender differences among teenagers aged 10–19 years who failed to seek help before dying, which is similar to our study results (Lee et al., 2024 ). In our study, a significant proportion of children and adolescents who had attempted suicide provided vague or ambiguous answers when asked about the immediate causes of their actions. This phenomenon appears to be associated with insufficient maturity to engage in daily verbal discourse concerning their challenges. Our findings also showed that individuals who could not seek advice had refrained from doing so for an unknown period. These findings align with those of previous studies (Mikami, 2022 ; Mikami et al., 2006 , 2014 ; Takahashi et al., 2020 ), which revealed that individuals who could not discuss their problems with others had been overly concerned about their surroundings and had been hesitant to express their feelings openly since childhood. Although such youth were encouraged to consult those around them, they could not do so easily because they had no longstanding experience of consulting with others about their problems (Mikami, 2022 ). This longstanding difficulty in finding easy access to others could be a psychosocial predisposing factor for suicide among young people. In clinical practice, psychotherapy involves carefully tracing the process of the youth's reluctance to openly discuss their problems with those close to them since childhood. Considering the above, a question arises about what can be done to prevent the reattempted suicide of these youths who are unable to talk to others from an early age. Although reports exist on the prevention of reattempts for individuals who have attempted suicide, reproducibility is difficult, and evidence for such measures is lacking. For example, preventing reattempts through case management has shown only short-lived effects (Kim et al., 2018 ). While dialectical behavior therapy has shown efficacy in preventing reattempt among children with a history of suicide attempts (Busby et al., 2020 ), lack of administrative support and organizational investment, time spent on skill acquisition, and the long treatment period are challenges (Carmel et al., 2014 ; Loo et al., 2021 ). Recent systematic reviews analyzed studies that showed effectiveness in preventing suicide attempts and extracted common components of intervention strategies (Asarnow & Mehlum, 2019 ; Katsivarda et al., 2021 ; Meza et al., 2023 ). According to these reviews, the common components of intervention methods for preventing suicide attempts were as follows: i) the therapist should establish a relationship with the patient and family, ii) the family should be involved in the intervention process and understand the treatment techniques as well as the patient, and iii) each case should be treated individually. In the present study, family relationships, excluding vague or ambiguous answers, were the most frequent motive for suicide attempts, consistent with finding from previous studies in Japan (Mikami, 2022 ; Narishige et al., 2024 ). Given the abovementioned findings, one of the primary goals of suicide prevention efforts is to enhance the effectiveness of the family as a protective factor. (Mckeown et al., 1998 ; Resnick et al., 1997 ; Rubenstein et al., 1998 ). Smooth communication within the family during psychotherapy can strengthen the family's protective functions. Psychotherapy is considered necessary for youth and their families in clinical practice. Without everyday small talk, discussing troublesome matters becomes difficult. Therefore, rather than practicing how to discuss problems in psychotherapy, devising ways to increase opportunities for emotional expression in daily life is necessary. In the present study, 47.9% of students were not attending school smoothly at the time of their suicide attempts. When including students who had previously experienced difficulties attending school, a total of 59.6% were either currently or had previously faced difficulties attending school smoothly. Schools play the primary roles of fostering academic proficiency and camaraderie among students. Notably, if students feel satisfied with these aspects of school, they will develop a sense of closeness and belonging toward the school, which consequently becomes a protective factor for them (Borowsky et al., 2001 ). The compulsory education period ends at age 15 years in Japan, corresponding to the third year of junior high school. Approximately 80% of the participants in this study were aged ≥ 15 years. This stage is typically marked by a weakening of connections with educational institutions and an increase in suicide rates. Therefore, establishing a sense of community within the school environment and building positive relationships within the school are critical components of suicide prevention strategies for this age group. Regarding diagnostic characteristics, adjustment disorder was the most frequently observed condition in both male and female teenagers. This indicates that therapeutic intervention via pharmacotherapy is difficult in cases of suicide attempts among children and adolescents, even when a diagnosis is made. A diagnosis of ASD was suggested in 18% of all cases and 30% of male suicide attempt cases. Although not significantly different, the frequency was higher in males than in females, which was similar to the findings of previous reports (Mikami et al., 2009 ). Emergency medical services have recently gained attention as a window for youth to access psychiatric care (Asarnow et al., 2017 ; Mikami et al., 2009 , 2020 ). The emergency room serves as a point of initial contact with psychiatric services for children and adolescents who have attempted suicide. In the present study, approximately 50% of male and female participants had no access to a psychiatric outpatient clinic at the time of transport. However, approximately 70% of those without access to medical care were able to connect with a psychiatrist by the time of discharge from the hospital. This indicates that emergency departments play an important role in connecting children and adolescents to psychiatric care. Given that family or school functioning serves as a protective factor against suicide (Borowsky et al., 2001 ; Mckeown et al., 1998 ; Resnick et al., 1997 ; Rubenstein et al., 1998 ), strengthening these systems is imperative as a therapeutic approach to prevent subsequent suicide attempts. Achieving this requires advancing treatment interventions through strong collaboration among multiple professionals in the community—including local public organizations, welfare institutions, educational institutions, medical institutions, and private organizations—rather than relying on individual stakeholders working independently. To strengthen this regional collaboration, multidisciplinary teams in the region should convene in one place with a shared purpose, with each team member taking on appropriate roles to address suicide prevention. This strategy can help provide increased support for the individuals and their families, while also fostering a psychological sense of belonging for the individuals. A comprehensive system providing appropriate support for suicide attempters through a multidisciplinary approach in the community is essential to creating effective public policy in Japan. Furthermore, facilitating an environment where children and adolescents can comfortably consult with those close to them about their everyday challenges, including suicidal ideation, is imperative. Establishing these systems and concurrently collecting data on the support process is essential to make evidence-based policy decisions regarding youth suicide prevention in Japan. The data should subsequently be used to build better support for youth and inform future clinical research. This study has some limitations. First, the data are limited to a single institution. In this regard, only a few facilities are available in Japan where child psychiatrists are involved in the care of children and adolescents who attempt suicide. Second, the sample size is relatively small. Among children and adolescents who attempted suicide nationwide, 4.52% were aged < 20 years (Ministry of Health, Labour and Welfare, 2023 ), and only 90 of the 1222 patients who attempted suicide at the facility were aged < 20 years. Third, this study did not include a comparison with healthy controls, which is an important area for future investigation. Lastly, the study participants consisted of 77.8% females and 22.2% males, suggesting potential sex bias in the sample. More men commit suicide than women, whereas more women attempt suicide than men. Furthermore, younger women tend to attempt suicide more frequently than younger men, a trend that was also observed in Japan [12]. 5. Conclusions Children and adolescents who attempted suicide usually faced challenges in disclosing their suicidal ideation to their close circle, particularly family members. These challenges were not associated with gender. Youth who have attempted suicide have experienced prolonged difficulty in discussing their challenges with those around them since childhood. This difficulty can be considered a psychosocial predisposing factor for suicide. Consequently, providing meticulous psychotherapy for both youth and their families is essential in clinical practice. Declarations Author Contributions: Conceptualization: Katsunaka Mikami, Masahide Usami, Noa Tsujii, Yoshinori Sasaki, Yuichi Onishi, Yuki Takahashi, Natsuru Watanabe, and Kenji Yamamoto; Investigation: Natsumi Matsunari, Yoko Suzuki, Shunya Takase, and Norimasa Sawaguchi; Writing – original draft: Natsumi Matsunari, and Katsunaka Mikami; Writing – review & editing: Natsumi Matsunari, Katsunaka Mikami, Yoko Suzuki, Shunya Takase, Norimasa Sawaguchi, Yuichi Onishi, Yuki Takahashi, Yoshinori Sasaki, Noa Tsujii, Masahide Usami, Natsuru Watanabe, and Kenji Yamamoto; Formal analysis: Natsumi Matsunari; Project administration: Katsunaka Mikami, Masahide Usami, Noa Tsujii, and Kenji Yamamoto; Supervision: Katsunaka Mikami. Funding: This study was supported by a grant from the National Center for Global Health and Medicine (grant number 24A1014). Ethics Approval: This study was approved by the National Center for Global Health and Medicine (Approval No. NCGM-G-003042-10). Patient data from the hospital were registered with the approval of the Ethics Committee of Tokai University Hospital (Approval No. 18R214). For the analysis of the data from the registry study, this research was reapproved by the Ethics Committee of Tokai University Hospital (Approval No. 24R171). This study was conducted according to the Declaration of Helsinki and Ethical Guidelines for Medical and Biological Research Involving Human Subjects. Consent to Participate: Informed consent was orally obtained from all patients and their family or guardians. Data Availability Statement: The datasets generated and analyzed during the current study are not publicly available due to the obligation of secrecy toward the participants. Conflicts of Interest: Katsunaka Mikami has received a financial support from Shionogi & Co., Ltd.; honoraria from Shionogi & Co., Ltd., Sumitomo Pharma Co., Ltd., and Takeda Pharmaceutical Co., Ltd.; expenses of travel and accommodation from Otsuka Pharmaceutical Co., Ltd.; and a consulting fee from Shionogi & Co., Ltd, EA Pharma Co., Ltd., Sumitomo Pharma Co., Ltd., and Otsuka Pharmaceutical Co., Ltd. Yuichi Onishi has received research honoraria from Takeda Pharmaceutical Co., Ltd. Yuki Takahashi has received financial support from Shionogi & Co. Noa Tsujii has held the position of endowed chair founded by Toyama Prefecture. He reports procuring personal fees from Otsuka, Shionogi, Takeda, Janssen, and Nobelpharma. Natsuru Watanabe has received honoraria from Viatris Inc. Kenji Yamamoto has received a financial support from JSPS KAKENHI Grant Number 22K07588, Shionogi & Co., Ltd, Otsuka Pharmaceutical Co., Ltd., Eisai Co., Ltd., Meiji Seika Pharma Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd., Merck Sharp & Dohme, Viatris Inc., Takeda Pharma Co., Ltd., Jansen Pharmaceutical K. K., Lundbeck Japan K.K., Daiichi Sankyo Co., Ltd, and OCTAWELL Co., LTD. The other authors declare that they have no competing interests that could affect this study. References Asarnow JR, Hughes JL, Babeva KN, Sugar CA (2017) Cognitive-Behavioral Family Treatment for Suicide Attempt Prevention: A Randomized Controlled Trial. J Am Acad Child Adolesc Psychiatry 56(6):506–514. https://doi.org/10.1016/j.jaac.2017.03.015 Asarnow JR, Mehlum L (2019) Practitioner Review: Treatment for suicidal and self-harming adolescents – advances in suicide prevention care. J Child Psychol Psychiatry Allied Discip 60(10):1046. https://doi.org/10.1111/jcpp.13130 Balt E, Mérelle S, van Bergen D, Gilissen R, van der Post P, Looijmans M, Creemers D, Rasing S, Mulder W, van Domburgh L, Popma A (2021) Gender differences in suicide-related communication of young suicide victims. PLoS ONE 16(5):e0252028. https://doi.org/10.1371/journal.pone.0252028 Baron-Cohen S, Wheelwright S, Skinner R, Martin J, Clubley E (2001) The autism-spectrum quotient (AQ): Evidence from Asperger syndrome/high-functioning autism, males and females, scientists and mathematicians. J Autism Dev Disord 31(1):5–17. https://doi.org/10.1023/a:1005653411471 Becker SP, Holdaway AS, Luebbe AM (2018) Suicidal Behaviors in College Students: Frequency, Sex Differences, and Mental Health Correlates Including Sluggish Cognitive Tempo. J Adolesc Health 63(2):181–188. https://doi.org/10.1016/j.jadohealth.2018.02.013 Borowsky IW, Ireland M, Resnick MD (2001) Adolescent suicide attempts: Risks and protectors. Pediatrics 107(3):485–493. https://doi.org/10.1542/peds.107.3.485 Brent DA (2016) Antidepressants and suicidality. Psychiatr Clin North Am 39(3):503–512. https://doi.org/10.1016/j.psc.2016.04.002 Bridge JA, Goldstein TR, Brent DA (2006) Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry Allied Discip 47(3–4):372–394. https://doi.org/10.1111/j.1469-7610.2006.01615.x Busby DR, Hatkevich C, McGuire TC, King CA (2020) Evidence-Based Interventions for Youth Suicide Risk. Curr Psychiatry Rep 22(2):5. https://doi.org/10.1007/s11920-020-1129-6 Carmel A, Rose M, Fruzzetti AE (2014) Barriers and Solutions to Implementing Dialectical Behavior Therapy in a Public Behavioral Health System. Adm Policy Ment Health 41(5):608–614. https://doi.org/10.1007/s10488-013-0504-6 Choe SY, Lengua LJ, McFall JP, Wyman PA (2023) Adolescents’ Comfort in Disclosing to Caregivers Predicts Suicidal Thoughts and Behaviors Directly and Indirectly Through Difficulties in Emotion Regulation. J Youth Adolesc 52(8):1721–1737. https://doi.org/10.1007/s10964-023-01785-8 Gould MS, Greenberg T, Velting DM, Shaffer D (2003) Youth suicide risk and preventive interventions: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 42(4):386–405. https://doi.org/10.1097/01.CHI.0000046821.95464.CF Hallford DJ, Rusanov D, Winestone B, Kaplan R, Fuller-Tyszkiewicz M, Melvin G (2023) Disclosure of suicidal ideation and behaviours: A systematic review and meta-analysis of prevalence. Clin Psychol Rev 101:102272. https://doi.org/10.1016/j.cpr.2023.102272 Horesh N, Zalsman G, Apter A (2004) Suicidal Behavior and Self-Disclosure in Adolescent Psychiatric Inpatients. J Nerv Mental Disease 192(12):837–842. https://doi.org/10.1097/01.nmd.0000146738.78222.e5 Jones JD, Boyd RC, Calkins ME, Ahmed A, Moore TM, Barzilay R, Benton TD, Gur RE (2019) Parent-Adolescent Agreement About Adolescents’ Suicidal Thoughts. Pediatrics 143(2):e20181771. https://doi.org/10.1542/peds.2018-1771 Katsivarda C, Assimakopoulos K, Jelastopulu E (2021) Communication-based suicide prevention after the first attempt. A systematic review. Psychiatriki. https://doi.org/10.22365/jpsych.2021.003 Kim H, Park J, Kweon K, Ahn J (2018) Short- and Long-term Effects of Case Management on Suicide Prevention among Individuals with Previous Suicide Attempts: A Survival Analysis. J Korean Med Sci 33(32):e203. https://doi.org/10.3346/jkms.2018.33.e203 Kurita H, Osada H, Koyama T, Miyamoto Y, Kanai chieko, Shimizu kaoru (2003) Reliability and validity of Autism-Spectrum Quotient Japanese Version(AQ-J). Japanese J Clin psychiatry 32(10):1235–1240 Lee YJ, Kweon Y-S, Kang YH, Yoon KH, Lee M-S, Bhang S-Y, Hong HJ (2024) Suicide warning signs that are challenging to recognize: A psychological autopsy study of Korean adolescents. Child Adolesc Psychiatry Mental Health 18:41. https://doi.org/10.1186/s13034-024-00731-1 Levi-Belz Y, Gavish‐Marom T, Barzilay S, Apter A, Carli V, Hoven C, Sarchiapone M, Wasserman D (2019) Psychosocial Factors Correlated with Undisclosed Suicide Attempts to Significant Others: Findings from the Adolescence SEYLE Study. Suicide Life-Threatening Behav 49(3):759–773. https://doi.org/10.1111/sltb.12475 Loo JL, Keng S-L, Ramírez-Espinosa IG, Hadi N, Ramírez-Gutiérrez NM, J. A., Shoesmith W (2021) Dialectical behavior therapy in the Asia-Pacific Rim region. Asia-Pacific Psychiatry 13(1):e12437. https://doi.org/10.1111/appy.12437 McGillivray L, Rheinberger D, Wang J, Burnett A, Torok M (2022) Non-disclosing youth: A cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional. BMC Psychiatry 22:3. https://doi.org/10.1186/s12888-021-03636-x Mckeown RE, Garrison CZ, Cuffe SP, Waller JL, Jackson KL, Addy CL (1998) Incidence and Predictors of Suicidal Behaviors in a Longitudinal Sample of Young Adolescents. J Am Acad Child Adolesc Psychiatry 37(6):612–619. https://doi.org/10.1097/00004583-199806000-00011 Meza JI, Zullo L, Vargas SM, Ougrin D, Asarnow JR (2023) Practitioner Review: Common elements in treatments for youth suicide attempts and self-harm – a practitioner review based on review of treatment elements associated with intervention benefits. J Child Psychol Psychiatry 64(10):1409–1421. https://doi.org/10.1111/jcpp.13780 Michael BF, Janet BW, Williams (2017) Lorna Smith Benjamin. In: Spitzer RL (ed) SCID-5-PD Structured Interview for DSM-5 Personality Disorders. IGAKU-SHOIN Ltd Michael BF, Janet BW, Williams RS, Karg, Spitzer RL (2020) SCID-5-PD Structured Interview for DSM-5 Personality Disorders. IGAKU-SHOIN Ltd Mikami K (2022) Prevention of suicide reattempts among children and adolescents: Consideration based on the risk and protective factors. Psychiatria et Neurologia Japonica 124(5):330–339 Mikami K, Inomata S, Hayakawa N, Ohnishi Y, Enseki Y, Ohya A, Haruki Y, Kishi Y, Shinohara Y, Ichimura A, Matsumoto H (2009) Frequency and clinical features of pervasive developmental disorder in adolescent suicide attempts. Gen Hosp Psychiatry 31(2):163–166. https://doi.org/10.1016/j.genhosppsych.2008.12.003 Mikami K, Inomata S, Onishi Y, Orihashi Y, Yamamoto K, Matsumoto H (2020) Gender differences in the suicide attempts of adolescents in emergency departments: Focusing on individuals with autism spectrum disorder. Adolesc Psychiatry 9(3):232–240. https://doi.org/10.2174/2210676609666190617144453 Mikami K, Kishi Y, Matsumoto H (2006) An adolescent patient after a suicide attempt: Importance of recognizing and intervening the psychosocial predisposing factors in suicide. Clin Psychiatry 48:331–338 Mikami K, Onishi Y, Matsumoto H (2014) Attempted suicide of an adolescent with autism spectrum disorder. Int J Psychiatry Med 47(3):263–271. https://doi.org/10.2190/PM.47.3.g Ministry of Health, Labour and Welfare (2023) Summary of vital statistics in Japan 2023 . https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/geppo/nengai23/dl/gaikyouR5.pdf Ministry of Health, Labour and Welfare (2024) White paper on suicide prevention 2024 . https://www.mhlw.go.jp/content/2024-1-1-06.pdf Narishige R, Otaka Y, Tateno A (2024) Characteristics of Japanese teenage suicide attempters: A retrospective study comparing suicide attempters with young adults. BMC Psychiatry 24(1):774. https://doi.org/10.1186/s12888-024-06234-9 National Police Agency (2023) Statistics of suicide victims in Japan in 2023 . https://www.npa.go.jp/safetylife/seianki/jisatsu/R06/R5jisatsunojoukyou.pdf Resnick MD, Bearman PS, Blum R, Wm., Bauman KE, Harris KM, Jones J, Tabor J, Beuhring T, Sieving RE, Shew M, Ireland M, Bearinger LH, Udry JR (1997) Protecting Adolescents From Harm: Findings From the National Longitudinal Study on Adolescent Health. JAMA 278(10):823–832. https://doi.org/10.1001/jama.1997.03550100049038 Rubenstein JL, Halton A, Kasten L, Rubin C, Stechler G (1998) Suicidal behavior in adolescents. Am J Orthopsychiatry 68(2):274–284. https://doi.org/10.1037/h0080336 Takahashi Y, Mikami K, Akama F, Onishi Y, Yamamoto K, Matsumoto H (2020) Suicide leap of an 11-year-old girl with autism spectrum disorder. Global Pediatr Health 7:2333794X20960278. https://doi.org/10.1177/2333794X20960278 Additional Declarations Competing interest reported. Katsunaka Mikami has received a financial support from Shionogi & Co., Ltd.; honoraria from Shionogi & Co., Ltd., Sumitomo Pharma Co., Ltd., and Takeda Pharmaceutical Co., Ltd.; expenses of travel and accommodation from Otsuka Pharmaceutical Co., Ltd.; and a consulting fee from Shionogi & Co., Ltd, EA Pharma Co., Ltd., Sumitomo Pharma Co., Ltd., and Otsuka Pharmaceu-tical Co., Ltd. Yuichi Onishi has received research honoraria from Takeda Pharmaceutical Co., Ltd. Yuki Takahashi has received financial support from Shionogi & Co. Noa Tsujii has held the position of endowed chair founded by Toyama Prefecture. He reports procuring personal fees from Otsuka, Shionogi, Takeda, Janssen, and Nobelpharma. Natsuru Watanabe has received honoraria from Viatris Inc. Kenji Yamamoto has received a financial support from JSPS KAKENHI Grant Number 22K07588, Shionogi & Co., Ltd, Otsuka Pharmaceutical Co., Ltd., Eisai Co., Ltd., Meiji Seika Pharma Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd., Merck Sharp & Dohme, Viatris Inc., Takeda Pharma Co., Ltd., Jansen Pharmaceutical K. K., Lundbeck Japan K.K., Daiichi Sankyo Co., Ltd, and OC-TAWELL Co., LTD. The other authors declare that they have no competing interests that could affect this study. Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2026 Read the published version in Child Psychiatry & Human Development → Version 1 posted Editorial decision: Revision requested 14 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviews received at journal 16 Dec, 2025 Reviewers agreed at journal 13 Dec, 2025 Reviewers invited by journal 14 Nov, 2025 Editor assigned by journal 31 Oct, 2025 Submission checks completed at journal 13 Oct, 2025 First submitted to journal 11 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Katsunaka Mikami has received a financial support from Shionogi \u0026 Co., Ltd.; honoraria from Shionogi \u0026 Co., Ltd., Sumitomo Pharma Co., Ltd., and Takeda Pharmaceutical Co., Ltd.; expenses of travel and accommodation from Otsuka Pharmaceutical Co., Ltd.; and a consulting fee from Shionogi \u0026 Co., Ltd, EA Pharma Co., Ltd., Sumitomo Pharma Co., Ltd., and Otsuka Pharmaceu-tical Co., Ltd.\nYuichi Onishi has received research honoraria from Takeda Pharmaceutical Co., Ltd.\nYuki Takahashi has received financial support from Shionogi \u0026 Co.\nNoa Tsujii has held the position of endowed chair founded by Toyama Prefecture. He reports procuring personal fees from Otsuka, Shionogi, Takeda, Janssen, and Nobelpharma. \nNatsuru Watanabe has received honoraria from Viatris Inc.\nKenji Yamamoto has received a financial support from JSPS KAKENHI Grant Number 22K07588, Shionogi \u0026 Co., Ltd, Otsuka Pharmaceutical Co., Ltd., Eisai Co., Ltd., Meiji Seika Pharma Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd., Merck Sharp \u0026 Dohme, Viatris Inc., Takeda Pharma Co., Ltd., Jansen Pharmaceutical K. K., Lundbeck Japan K.K., Daiichi Sankyo Co., Ltd, and OC-TAWELL Co., LTD.\nThe other authors declare that they have no competing interests that could affect this study.","formattedTitle":"Gender differences in the disclosure of suicidal ideation among children and adolescents prior to suicide attempts","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe number of suicides in Japan peaked at 34,427 in 2003, and subsequently began to decline after 2009, reaching 20,320 in 2024. However, it has been increasing since 2016 among individuals aged\u0026thinsp;\u0026lt;\u0026thinsp;20 years, reaching 800 in 2024\u0026mdash;exceeding 800 for the first time in 2023 since 1986 (National Police Agency, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In Japan, suicide is the most common cause of death among males and females aged 10\u0026ndash;19 years (Ministry of Health, Labour and Welfare, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), making it the only G7 nation where suicide ranks as the leading cause of mortality within this age group (Ministry of Health, Labour and Welfare., 2024). Consequently, suicide among children and adolescents has become one of the most significant mental health issues in Japan.\u003c/p\u003e\u003cp\u003eSuicidal ideation refers to thoughts about one\u0026rsquo;s own death, with or without a specific intent or plan. Suicide attempts are characterized as self-destructive behavior carried out with explicit or inferred intent to die (Brent, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Both of these factors are well-established as significant risk factors associated with eventual suicide completion (Bridge et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Gould et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2003\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e A previous study examining suicidal ideation among adolescents aged 13\u0026ndash;17 years revealed that 50% of parents of children who had ever contemplated suicide were unaware of their child\u0026rsquo;s suicidal ideation, and 75.6% were unaware that their child had a recurring desire to die. Of the children who were reported to have suicidal thoughts by their parents, 48.4% and 67.5% denied suicidal ideation and having any desire to die, respectively. The agreement between child and parent regarding suicidal thoughts was moderate (κ\u0026thinsp;=\u0026thinsp;0.466), whereas the agreement concerning the thought of death or desire to die was low (κ\u0026thinsp;=\u0026thinsp;0.171) (Jones et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Another study found a negative correlation between high school students\u0026rsquo; comfort in discussing their feelings and concerns with their parents and both the ideation and severity of suicidal behavior (Choe et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). A study conducted among adolescents aged 13\u0026ndash;19 years at a university psychiatric hospital, using Shulman\u0026rsquo;s Self-Disclosure Scale, reported a negative correlation between self-disclosure measures to family, friends, and older adults and suicide planning, suicidal ideation, and self-harm. Moreover, difficulty in talking about oneself to those closest to them was associated with an increased risk of suicide attempts (Horesh et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Among 1,704 college students enrolled at two public universities in the Midwest United States, 4% reported a previous suicide attempt, 2.2% indicated that they were likely to attempt suicide in the future, and 7.5% reported frequent thoughts of suicide within the past year. However, 41.4% of these participants reported they had never disclosed their potential suicide attempts to anyone (Becker et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In this study, women were more likely than men to report a previous suicide attempt and to share their suicidal ideation with others. However, these studies are summaries of data obtained through questionnaires, and information was not collected directly from actual suicide attempters immediately after the attempts. Only a few studies have directly confirmed the actual situation of teenage suicide attempters and their parents immediately after the attempts.\u003c/p\u003e\u003cp\u003eBased on the abovementioned previous studies and our research over the years (Mikami, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mikami et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2006\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Takahashi et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), we tested the hypothesis that suicide attempters among children and adolescents would have difficulty disclosing their suicidal ideation to those close to them prior to the attempt, and that this tendency would differ between genders. Therefore, the present study aimed to determine whether children and adolescents who attempted suicide had disclosed suicidal ideation to those close to them before the attempt, focusing on gender differences. We used data obtained directly from suicide attempters and their families or guardians immediately after their transport to an emergency department due to a suicide attempt. This study sought to clarify the clinical characteristics of children and adolescents who attempted suicide based on these data.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Participants\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis registry study reflects the results from clinical practice. It used data from the Registry of Suicide Attempters section of the \u0026ldquo;Registry Study of Child and Adolescent Mental Health in Japan,\u0026rdquo; a collaborative study with the National Kohnodai Medical Center Hospital, Japan Institute for Health Security. The data from the Registry of Suicide Attempters were obtained only from patients who were transported to the Tokai University Hospital Advanced Emergency Medical Center following a suicide attempt. Specifically, the Tokai University Hospital Emergency Center covers almost the entire western part of Kanagawa Prefecture and provides primary to tertiary emergency medical care. Patients admitted to the emergency department for attempted suicide were usually referred to the psychiatric department. Among the referred patients, the study participants were those aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years who were admitted between February 2019 and November 2024, excluding those who visited the emergency department without being admitted. Overall, 1304 patients were hospitalized for suicide attempts, among whom 100 were teenagers (75 [75.0%] females and 25 [25.0%] males). Regarding age distribution, 96.0% and 80.0% of the patients were at least 12 and 15 years old, respectively.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Assessment\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatients of all ages who have had suicide attempts are evaluated and treated by a team of 3\u0026ndash;4 psychiatrists (including a child psychiatrist). A trained psychiatrist conducted the initial examination while the patient was in the emergency room. Whenever possible, additional information about the patient, such as their life background, was obtained from the families.\u003c/p\u003e\u003cp\u003eThe following items were collected and recorded by child psychiatrists through direct interviews with the patients and their families or guardians: presence or absence of a psychiatric clinic at the time of admission, history of suicide attempts, history of self-injury, presence or absence of a counselor for suicidal ideation, history of abuse, history of parents\u0026rsquo; divorce, criminal history of parents, drug abuse of parents, alcohol abuse of parents, means of attempts, duration between decision and execution of suicide attempt, parental awareness of the children's suicidal ideation, and the motive for the suicide attempt, among others.\u003c/p\u003e\u003cp\u003eAs part of standard clinical practice, physicians who interviewed patients transported to the hospital asked questions about the motives of suicide attempts. The motive for suicide was defined as \u0026ldquo;unclear or vague\u0026rdquo; if the patient answered \u0026ldquo;I am not sure\u0026rdquo; to the psychiatrist's question, \u0026ldquo;Why did you decide to commit suicide?\u0026rdquo; or if the patient could not directly explain the factors that triggered their suicidal ideation by listing multiple reasons.\u003c/p\u003e\u003cp\u003eOther details that could be confirmed from the medical records, including the patient's age, sex, and number of days in the hospital and so on, were registered. We also assessed whether a student was attending school smoothly at the time of the suicide attempt. For instance, students who had frequent absences or were attending school in a separate room rather than their regular classroom were evaluated as not attending school smoothly.\u003c/p\u003e\u003cp\u003eDiagnoses were made using the Structured Clinical Interview for DSM-IV (SCID-5)-TR and the SCID-5-Research version, as well as the SCID-5 Personality Disorders (items associated with borderline and antisocial personality disorders alone) whenever possible (Michael et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2017\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, a complete diagnostic assessment using SCID was not possible due to time constraints. Discussions held during daily morning conferences were used to determine the final diagnosis. The prevalence of traits associated with autism spectrum disorder (ASD) were evaluated using the Autism-Spectrum Quotient (AQ) Japanese version (AQJ) (Baron-Cohen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Kurita et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) and/or medical data provided by previous psychiatrists. Furthermore, the cut-off score of AQ was 32/50 (Baron-Cohen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe defined suicide attempt as a self-destructive behavior with explicit or inferred intent to die (Brent, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Data were obtained directly from the youths who attempted suicide and their parents or guardians.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Statistical Analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eData was analyzed using IBM SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, N.Y., USA). Continuous variables were expressed as means and standard deviations. The Fisher\u0026rsquo;s exact test was used to analyze the categorical variables. Since none of the continuous variables in this study followed a normal distribution, the Mann\u0026ndash;Whitney U test was employed for analysis. Univariate analysis was conducted using Fisher's exact test. The influence of gender on the disclosure of suicidal ideation was evaluated using logistic regression analysis, adjusting for age and history of self-injurious behavior. Statistical significance was considered at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Ethics Approval\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study was approved by the National Center for Global Health and Medicine (Approval No. NCGM-G-003042-10). Patient data from the hospital were registered with the approval of the Ethics Committee of Tokai University Hospital (Approval No. 18R214). The present research analysis of data from the registry study was reapproved by the Ethics Committee of Tokai University Hospital (Approval No. 24R171). This study was conducted according to the Declaration of Helsinki and Ethical Guidelines for Medical and Biological Research Involving Human Subjects. Informed consent was orally obtained from all patients and their family or guardians.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Patient Background\u003c/h2\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eTable\u0026nbsp;1 presents the patient characteristics. Regarding the timing of the most recent suicide attempts, the highest frequency for females and males was 1 month ago and \u0026ge;\u0026thinsp;2 years ago, respectively. The decision to attempt suicide was made within 24 h for 59.0% of patients, within 1 week for 18.0%, and \u0026gt;\u0026thinsp;1 week ago for 23.0%. Notably, 48.0% of males and 14.7% of females had decided to commit suicide\u0026thinsp;\u0026gt;\u0026thinsp;1 week in advance, demonstrating a male predominance (p\u0026thinsp;=\u0026thinsp;0.011). Among males, 52.0%, 4.0%, and 48.0% decided to attempt suicide within 24 h, within 1 week, and \u0026gt;\u0026thinsp;1 week ago, respectively.\u003c/p\u003e\n \u003cp\u003eFor individuals who had attempted suicide, 47.0% (44.0% of males and 48.0% of females) had been were receiving outpatient care at the time of transport. Among the remaining 53% without outpatient clinic access, 74.5% (81.8% of males and 66.7% of females) established contact with a psychiatrist upon transfer to the hospital.\u003c/p\u003e\n \u003cp\u003eFemales with a history of self-injurious behavior were significantly higher than males (p\u0026thinsp;=\u0026thinsp;0.004). Overdose was the most common method of suicide attempt for both sexes; however, males were more likely to use more serious methods than overdose (p\u0026thinsp;=\u0026thinsp;0.009). Overall, individuals who attempted suicide most frequently chose overdose, followed by jumping off and taking poison. This trend was observed for both genders.\u003c/p\u003e\n \u003cp\u003eNinety-four of the 100 participants in this study were students. Among these, 47.9% were not attending school smoothly at the time of their suicide attempts. Additionally, 11.7% of the students who were attending school smoothly had previously experienced difficulties with school attendance. Finally, 59.6% were either currently or had previously faced difficulties attending school smoothly.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Characteristics of male and female participants.\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"720\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 272px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eodds ratio\u003c/strong\u003e\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003einterval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 272px;\"\u003e\n \u003cp\u003eNumber of participants, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e25 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e75 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 272px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 18.0447%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 21.9973%;\"\u003e\n \u003cp\u003e mean（SD*）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e15.48 (1.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e15.52 (1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.757\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e \u0026ge;12 years (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e24 (96.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e72 (96.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.177\u0026ndash;5.654\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e \u0026ge;15 years (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e20 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e60 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.427\u0026ndash;2.337\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003eLength of hospital\u003csup\u003e\u0026dagger;\u003c/sup\u003e, mean (SD*)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 11.5142%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003eHistory of mental illness (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e14(56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e39 (52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.819\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.555\u0026ndash;1.513\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003eHistory of suicide attempt (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e9 (36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e40 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.937\u0026ndash;2.007\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 21.9973%;\"\u003e\n \u003cp\u003eSuicidal ideation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.0061%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e \u0026nbsp;disclose to anyone (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e4 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e20 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.920\u0026ndash;1.426\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e \u0026nbsp;disclose to family (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e2 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e12(16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.508\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.941\u0026ndash;1.275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003eHistory of abuse\u003csup\u003e\u0026Dagger;\u003c/sup\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e6 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e6 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e0.807\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.627\u0026ndash;1.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003eHistory of protection\u003csup\u003e\u0026Dagger;\u003c/sup\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e4 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e5 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e0.896\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.741\u0026ndash;1.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003eSelf-injurious behavior (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e10 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e55 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e1.374\u0026ndash;3.685\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20.5366%;\"\u003e\n \u003cp\u003eParents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4608%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.0061%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e history of divorce\u003csup\u003e\u0026Dagger;\u003c/sup\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e14 (56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e26 (35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e0.678\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.423\u0026ndash;1.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e criminal records\u003csup\u003e\u0026Dagger;\u003c/sup\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.989\u0026ndash;1.068\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e drug addiction\u003csup\u003e\u0026Dagger;\u003c/sup\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.987\u0026ndash;1.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e alcohol addiction\u003csup\u003e\u0026Dagger;\u003c/sup\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e5 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.922\u0026ndash;1.141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e aware of children\u0026rsquo;s suicidal ideation (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e4 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e17 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.880\u0026ndash;1.341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003eSuicidal attempt method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.0061%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 21.9973%;\"\u003e\n \u003cp\u003e overdose (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e13 (52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e60 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e2.400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e1.305\u0026ndash;4.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 21.9973%;\"\u003e\n \u003cp\u003e others (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e12 (48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e15 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e0.650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.439\u0026ndash;0.963\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003eDetermine to commit suicide (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.0061%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.8978%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9912%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e \u0026gt;1 week ago (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e12 (48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e11 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e0.609\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.413\u0026ndash;0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.3722%;\"\u003e\n \u003cp\u003e \u0026lt;24 h (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.4757%;\"\u003e\n \u003cp\u003e13 (52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5305%;\"\u003e\n \u003cp\u003e46 (61.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.5541%;\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8742%;\"\u003e\n \u003cp\u003e1.241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 12.8891%;\"\u003e\n \u003cp\u003e0.755\u0026ndash;2.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003cstrong\u003e*\u003c/strong\u003e SD, standard deviation.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eHospitalization length, excluding two cases of long-term hospitalization for social reasons, such as inability to find a new hospital, tended to be longer for female teenagers than for males.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026Dagger;\u003c/sup\u003e Missing date.\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003csup\u003e\u0026sect;\u003c/sup\u003eFemale was set to 1 and male to 0 for analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Disclosure of Suicidal Ideation\u003c/h2\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eTable\u0026nbsp;1 presents the data on whether participants consulted someone close to them before their suicide attempt. Among the participants, 76.0% (73.3% of females and 84.0% of males) who attempted suicide had not disclosed their suicidal ideation to anyone. Additionally, 86.0% of all participants (84.0% of females and 92.0% of males) had not discussed their suicidal ideation with their families before the attempt. Although males were frequent, they were not significant in either case. Among the 20.0% of patients who discussed their suicidal ideation prior to attempting suicide, families were the most common consultants, followed by friends. Of the participants who did not consult their families, 90.7% were unsure when they stopped consulting their families, and 4.7% had not discussed their suicidal ideation with their families since junior high school. Furthermore, 66.0% of participants (64.0% of males and 66.7% of females) reported that they did not routinely discuss concerns that corresponded to motives for suicide.\u003c/p\u003e\n \u003cp\u003eThe influence of gender on disclosure of suicidal ideation was evaluated using logistic regression analysis, adjusting for age and history of self-injurious behavior (Table\u0026nbsp;2). Males demonstrated a tendency to consult with those around them less frequently than females, with no significant sex differences.\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Risk factors for disclosure of suicidal ideation\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"555\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eodds ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 196px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% confidence interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.627\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e1.362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 196px;\"\u003e\n \u003cp\u003e0.391\u0026ndash;4.749\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.639\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e1.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 196px;\"\u003e\n \u003cp\u003e0.794\u0026ndash;1.456\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eSelf-injurious behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 196px;\"\u003e\n \u003cp\u003e0.978\u0026ndash;10.938\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e Female was set to 1 and male to 0 for analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Psychiatric Diagnosis\u003c/h2\u003e\n \u003cp\u003eTable 3 present the participants\u0026rsquo; psychotic diagnosis. Notably, these diagnoses included overlapping ones. The prevalence of traits associated with ASD was 17.0% among all participants, with males exhibiting a rate of 28.0%, with no statistically significant difference. Borderline personality disorder prevalence was 9.3% and 0% among females and males, respectively, with no significant gender difference.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/caption\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003ePsychiatric diagnosis\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"709\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychiatric diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eodds ratio*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 279px;\"\u003e\n \u003cp\u003eNumber of participants, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e25 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e75 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 279px;\"\u003e\n \u003cp\u003eAdjustment disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e18 (72.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e47 (62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.375\u0026ndash;1.501\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 279px;\"\u003e\n \u003cp\u003eDepressive disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e4 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e5 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.751\u0026ndash;1.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 266px;\"\u003e\n \u003cp\u003eDysthymia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.990\u0026ndash;1.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 266px;\"\u003e\n \u003cp\u003eBipolar disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.987\u0026ndash;1.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 266px;\"\u003e\n \u003cp\u003ePanic disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.990\u0026ndash;1.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 279px;\"\u003e\n \u003cp\u003eSocial anxiety disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.569\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.001\u0026ndash;1.115\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 279px;\"\u003e\n \u003cp\u003eAcute and transient psychotic disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.987\u0026ndash;1.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 266px;\"\u003e\n \u003cp\u003eAnorexia nervosa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.990\u0026ndash;1.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 279px;\"\u003e\n \u003cp\u003eDissociative disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.990\u0026ndash;1.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 279px;\"\u003e\n \u003cp\u003eAutism spectrum disorder traits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e7 (28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e10 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.831\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.641\u0026ndash;1.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eBorderline personality disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e7 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.026\u0026ndash;1.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 266px;\"\u003e\n \u003cp\u003eNo diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e7 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.026\u0026ndash;1.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e Female was set to 1 and male to 0 for analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4 Psychological and Social Factors in Suicide Attempts\u003c/h2\u003e\n \u003cdiv class=\"gridtable\"\u003eTable 4 shows the reasons for suicide attempts. No sex differences were found in the reasons for attempting suicide. \u0026ldquo;Unclear or vague\u0026rdquo; was the most frequent response for both genders, followed by family problems and friendships.\u003cbr\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eReasons for suicide attempts.\u003cbr\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReasons for suicide attempts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eodds ratio*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003eNumber of participants, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e25 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e75 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003eUnclear or vague\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e10 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e24 (32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.475\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e0.882\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.618\u0026ndash;1.259\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003eProblems with family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e17 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1.190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.005\u0026ndash;1.408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003eProblems with peers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e4 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e15 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1.050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.855\u0026ndash;1.289\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003eProblems with sexual relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e5 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.930\u0026ndash;1.137\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003eOther interpersonal relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e4 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.733\u0026ndash;1.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003eProblems with study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e6 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.875\u0026ndash;1.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003eOther problems at school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.912\u0026ndash;1.097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 243px;\"\u003e\n \u003cp\u003ePsychological symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.990\u0026ndash;1.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003eCrime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e0.960\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.886\u0026ndash;1.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv class=\"gridtable\"\u003e\u003cbr\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\u003c/table\u003e\n \u003cp\u003e* Female was set to 1 and male to 0 for analysis.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study revealed that 76.0% of children and adolescents hospitalized for suicide attempts did not disclose their suicidal ideation to anyone prior to the attempt, with 84.0% of these individuals being male. Additionally, 86.0% of all patients reported being unable to discuss their suicidal ideation with family members beforehand. While males frequently exhibited these characteristics, the results showed no statistically significant gender differences. To our knowledge, this is the first study to directly examine individuals aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years who attempted suicide and were transported to an emergency department, particularly inquiring about whether they had consulted with someone prior to the attempt.\u003c/p\u003e\u003cp\u003eIn the Saving and Empowering Young Lives in Europe Study, involving 1117 students in grades 9\u0026ndash;11 across high schools in Israel, 74 reported a history of suicide attempts. Among them, 27 (36.4%) indicated that they had attempted suicide without informing their parents or anyone else (Levi-Belz et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). An Australian study revealed that 39% of the 513 patients aged 16\u0026ndash;25 years with a history of psychiatric attendance and self-injurious behavior could not discuss their feelings of wanting to die with a professional (McGillivray et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). A systematic review on the disclosure of suicidal ideation and behaviors found that 50\u0026ndash;60% of individuals do not disclose their suicidal ideation and behaviors to other people (Hallford et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Our study showed that 76.0% of children and adolescents who attempted suicide had not expressed suicidal ideation to anyone, and 86.0% had not even told their families. These rates are higher than those reported in previous studies. The present study\u0026rsquo;s results may have been influenced by the fact that it was conducted with children and adolescents who had actually attempted suicide and were assessed immediately after the attempt.\u003c/p\u003e\u003cp\u003eA previous study revealed that women were more likely than men to report a prior suicide attempt or disclose their suicidal ideation to others (Becker et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Similarly, interview data from a psychological autopsy study of 35 youths who died by suicide in the Netherlands indicated that girls were more likely to explicitly convey their suicide ideation, intent, or behaviors to others, whereas boys' communication was typically ambiguous or diluted by humor (Balt et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The current study hypothesized that there would be gender differences in the inability to disclose suicidal ideation before the attempt. Although this characteristic was prevalent in males, the results showed no statistically significant gender differences, indicating that both males and females are equally unable to disclose suicidal ideation before the attempt. Recently, Japan has shown a slight gender based difference in the number of suicides among youth aged\u0026thinsp;\u0026lt;\u0026thinsp;20 years, which is notable worldwide (National Police Agency, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These results may be due to an inability to discuss suicidal ideation immediately before the attempt, regardless of gender. The Korean Psychological Adventures Study found no gender differences among teenagers aged 10\u0026ndash;19 years who failed to seek help before dying, which is similar to our study results (Lee et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our study, a significant proportion of children and adolescents who had attempted suicide provided vague or ambiguous answers when asked about the immediate causes of their actions. This phenomenon appears to be associated with insufficient maturity to engage in daily verbal discourse concerning their challenges. Our findings also showed that individuals who could not seek advice had refrained from doing so for an unknown period. These findings align with those of previous studies (Mikami, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mikami et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2006\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Takahashi et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), which revealed that individuals who could not discuss their problems with others had been overly concerned about their surroundings and had been hesitant to express their feelings openly since childhood. Although such youth were encouraged to consult those around them, they could not do so easily because they had no longstanding experience of consulting with others about their problems (Mikami, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This longstanding difficulty in finding easy access to others could be a psychosocial predisposing factor for suicide among young people. In clinical practice, psychotherapy involves carefully tracing the process of the youth's reluctance to openly discuss their problems with those close to them since childhood.\u003c/p\u003e\u003cp\u003eConsidering the above, a question arises about what can be done to prevent the reattempted suicide of these youths who are unable to talk to others from an early age. Although reports exist on the prevention of reattempts for individuals who have attempted suicide, reproducibility is difficult, and evidence for such measures is lacking. For example, preventing reattempts through case management has shown only short-lived effects (Kim et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). While dialectical behavior therapy has shown efficacy in preventing reattempt among children with a history of suicide attempts (Busby et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), lack of administrative support and organizational investment, time spent on skill acquisition, and the long treatment period are challenges (Carmel et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Loo et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Recent systematic reviews analyzed studies that showed effectiveness in preventing suicide attempts and extracted common components of intervention strategies (Asarnow \u0026amp; Mehlum, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Katsivarda et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Meza et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). According to these reviews, the common components of intervention methods for preventing suicide attempts were as follows: i) the therapist should establish a relationship with the patient and family, ii) the family should be involved in the intervention process and understand the treatment techniques as well as the patient, and iii) each case should be treated individually. In the present study, family relationships, excluding vague or ambiguous answers, were the most frequent motive for suicide attempts, consistent with finding from previous studies in Japan (Mikami, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Narishige et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Given the abovementioned findings, one of the primary goals of suicide prevention efforts is to enhance the effectiveness of the family as a protective factor. (Mckeown et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Resnick et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Rubenstein et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). Smooth communication within the family during psychotherapy can strengthen the family's protective functions. Psychotherapy is considered necessary for youth and their families in clinical practice. Without everyday small talk, discussing troublesome matters becomes difficult. Therefore, rather than practicing how to discuss problems in psychotherapy, devising ways to increase opportunities for emotional expression in daily life is necessary.\u003c/p\u003e\u003cp\u003eIn the present study, 47.9% of students were not attending school smoothly at the time of their suicide attempts. When including students who had previously experienced difficulties attending school, a total of 59.6% were either currently or had previously faced difficulties attending school smoothly. Schools play the primary roles of fostering academic proficiency and camaraderie among students. Notably, if students feel satisfied with these aspects of school, they will develop a sense of closeness and belonging toward the school, which consequently becomes a protective factor for them (Borowsky et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). The compulsory education period ends at age 15 years in Japan, corresponding to the third year of junior high school. Approximately 80% of the participants in this study were aged\u0026thinsp;\u0026ge;\u0026thinsp;15 years. This stage is typically marked by a weakening of connections with educational institutions and an increase in suicide rates. Therefore, establishing a sense of community within the school environment and building positive relationships within the school are critical components of suicide prevention strategies for this age group.\u003c/p\u003e\u003cp\u003eRegarding diagnostic characteristics, adjustment disorder was the most frequently observed condition in both male and female teenagers. This indicates that therapeutic intervention via pharmacotherapy is difficult in cases of suicide attempts among children and adolescents, even when a diagnosis is made. A diagnosis of ASD was suggested in 18% of all cases and 30% of male suicide attempt cases. Although not significantly different, the frequency was higher in males than in females, which was similar to the findings of previous reports (Mikami et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEmergency medical services have recently gained attention as a window for youth to access psychiatric care (Asarnow et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Mikami et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2009\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The emergency room serves as a point of initial contact with psychiatric services for children and adolescents who have attempted suicide. In the present study, approximately 50% of male and female participants had no access to a psychiatric outpatient clinic at the time of transport. However, approximately 70% of those without access to medical care were able to connect with a psychiatrist by the time of discharge from the hospital. This indicates that emergency departments play an important role in connecting children and adolescents to psychiatric care.\u003c/p\u003e\u003cp\u003eGiven that family or school functioning serves as a protective factor against suicide (Borowsky et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Mckeown et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Resnick et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Rubenstein et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e1998\u003c/span\u003e), strengthening these systems is imperative as a therapeutic approach to prevent subsequent suicide attempts. Achieving this requires advancing treatment interventions through strong collaboration among multiple professionals in the community\u0026mdash;including local public organizations, welfare institutions, educational institutions, medical institutions, and private organizations\u0026mdash;rather than relying on individual stakeholders working independently. To strengthen this regional collaboration, multidisciplinary teams in the region should convene in one place with a shared purpose, with each team member taking on appropriate roles to address suicide prevention. This strategy can help provide increased support for the individuals and their families, while also fostering a psychological sense of belonging for the individuals. A comprehensive system providing appropriate support for suicide attempters through a multidisciplinary approach in the community is essential to creating effective public policy in Japan. Furthermore, facilitating an environment where children and adolescents can comfortably consult with those close to them about their everyday challenges, including suicidal ideation, is imperative. Establishing these systems and concurrently collecting data on the support process is essential to make evidence-based policy decisions regarding youth suicide prevention in Japan. The data should subsequently be used to build better support for youth and inform future clinical research.\u003c/p\u003e\u003cp\u003eThis study has some limitations. First, the data are limited to a single institution. In this regard, only a few facilities are available in Japan where child psychiatrists are involved in the care of children and adolescents who attempt suicide. Second, the sample size is relatively small. Among children and adolescents who attempted suicide nationwide, 4.52% were aged\u0026thinsp;\u0026lt;\u0026thinsp;20 years (Ministry of Health, Labour and Welfare, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and only 90 of the 1222 patients who attempted suicide at the facility were aged\u0026thinsp;\u0026lt;\u0026thinsp;20 years. Third, this study did not include a comparison with healthy controls, which is an important area for future investigation. Lastly, the study participants consisted of 77.8% females and 22.2% males, suggesting potential sex bias in the sample. More men commit suicide than women, whereas more women attempt suicide than men. Furthermore, younger women tend to attempt suicide more frequently than younger men, a trend that was also observed in Japan [12].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eChildren and adolescents who attempted suicide usually faced challenges in disclosing their suicidal ideation to their close circle, particularly family members. These challenges were not associated with gender. Youth who have attempted suicide have experienced prolonged difficulty in discussing their challenges with those around them since childhood. This difficulty can be considered a psychosocial predisposing factor for suicide. Consequently, providing meticulous psychotherapy for both youth and their families is essential in clinical practice.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003eConceptualization:\u0026nbsp;Katsunaka Mikami, Masahide Usami, Noa Tsujii, Yoshinori Sasaki, Yuichi Onishi, Yuki Takahashi, Natsuru Watanabe, and Kenji Yamamoto;\u0026nbsp;Investigation: Natsumi Matsunari, Yoko Suzuki, Shunya Takase, and Norimasa Sawaguchi; Writing – original draft: Natsumi Matsunari,\u0026nbsp;and Katsunaka Mikami; Writing – review \u0026amp; editing: Natsumi Matsunari, Katsunaka Mikami, Yoko Suzuki, Shunya Takase, Norimasa Sawaguchi, Yuichi Onishi, Yuki Takahashi, Yoshinori Sasaki, Noa Tsujii, Masahide Usami, Natsuru Watanabe, and Kenji Yamamoto; Formal analysis: Natsumi Matsunari;\u0026nbsp;Project administration:\u0026nbsp;Katsunaka Mikami, Masahide Usami, Noa Tsujii, and Kenji Yamamoto; Supervision: Katsunaka Mikami.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was supported by a grant from the National Center for Global Health and Medicine\u0026nbsp;(grant number 24A1014).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u0026nbsp;\u003c/strong\u003eThis study was approved by the National Center for Global Health and Medicine (Approval No. NCGM-G-003042-10). Patient data from the hospital were registered with the approval of the Ethics Committee of Tokai University Hospital (Approval No. 18R214). For the analysis of the data from the registry study, this research was reapproved by the Ethics Committee of Tokai University Hospital (Approval No. 24R171). This study was conducted according to the Declaration of Helsinki and Ethical Guidelines for Medical and Biological Research Involving Human Subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003eInformed consent was orally obtained from all patients and their family or guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003eThe datasets generated and analyzed during the current study are not publicly available due to the obligation of secrecy toward the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e Katsunaka Mikami has received a financial support from Shionogi \u0026amp; Co., Ltd.; honoraria from Shionogi \u0026amp; Co., Ltd., Sumitomo Pharma Co., Ltd., and Takeda Pharmaceutical Co., Ltd.; expenses of travel and accommodation from Otsuka Pharmaceutical Co., Ltd.; and a consulting fee from Shionogi \u0026amp; Co., Ltd, EA Pharma Co., Ltd., Sumitomo Pharma Co., Ltd., and Otsuka Pharmaceutical Co., Ltd.\u003c/p\u003e\n\u003cp\u003eYuichi Onishi has received research honoraria from Takeda Pharmaceutical Co., Ltd.\u003c/p\u003e\n\u003cp\u003eYuki Takahashi has received financial support from Shionogi \u0026amp; Co.\u003c/p\u003e\n\u003cp\u003eNoa Tsujii has held the position of endowed chair founded by Toyama Prefecture. He reports procuring personal fees from Otsuka, Shionogi, Takeda, Janssen, and Nobelpharma.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNatsuru Watanabe has received honoraria from Viatris Inc.\u003c/p\u003e\n\u003cp\u003eKenji Yamamoto has received a financial support from JSPS KAKENHI Grant Number 22K07588, Shionogi \u0026amp; Co., Ltd, Otsuka Pharmaceutical Co., Ltd., Eisai Co., Ltd.,\u0026nbsp;Meiji Seika Pharma Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd., Merck Sharp \u0026amp; Dohme, Viatris Inc., Takeda Pharma Co., Ltd., Jansen Pharmaceutical K. K.,\u0026nbsp;Lundbeck Japan K.K., Daiichi Sankyo Co., Ltd,\u0026nbsp;and\u0026nbsp;OCTAWELL Co., LTD.\u003c/p\u003e\n\u003cp\u003eThe other authors declare that they have no competing interests that could affect this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAsarnow JR, Hughes JL, Babeva KN, Sugar CA (2017) Cognitive-Behavioral Family Treatment for Suicide Attempt Prevention: A Randomized Controlled Trial. J Am Acad Child Adolesc Psychiatry 56(6):506\u0026ndash;514. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaac.2017.03.015\u003c/span\u003e\u003cspan address=\"10.1016/j.jaac.2017.03.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAsarnow JR, Mehlum L (2019) Practitioner Review: Treatment for suicidal and self-harming adolescents \u0026ndash; advances in suicide prevention care. J Child Psychol Psychiatry Allied Discip 60(10):1046. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpp.13130\u003c/span\u003e\u003cspan address=\"10.1111/jcpp.13130\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBalt E, M\u0026eacute;relle S, van Bergen D, Gilissen R, van der Post P, Looijmans M, Creemers D, Rasing S, Mulder W, van Domburgh L, Popma A (2021) Gender differences in suicide-related communication of young suicide victims. PLoS ONE 16(5):e0252028. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0252028\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0252028\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaron-Cohen S, Wheelwright S, Skinner R, Martin J, Clubley E (2001) The autism-spectrum quotient (AQ): Evidence from Asperger syndrome/high-functioning autism, males and females, scientists and mathematicians. J Autism Dev Disord 31(1):5\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1023/a:1005653411471\u003c/span\u003e\u003cspan address=\"10.1023/a:1005653411471\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBecker SP, Holdaway AS, Luebbe AM (2018) Suicidal Behaviors in College Students: Frequency, Sex Differences, and Mental Health Correlates Including Sluggish Cognitive Tempo. J Adolesc Health 63(2):181\u0026ndash;188. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jadohealth.2018.02.013\u003c/span\u003e\u003cspan address=\"10.1016/j.jadohealth.2018.02.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorowsky IW, Ireland M, Resnick MD (2001) Adolescent suicide attempts: Risks and protectors. Pediatrics 107(3):485\u0026ndash;493. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/peds.107.3.485\u003c/span\u003e\u003cspan address=\"10.1542/peds.107.3.485\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrent DA (2016) Antidepressants and suicidality. Psychiatr Clin North Am 39(3):503\u0026ndash;512. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.psc.2016.04.002\u003c/span\u003e\u003cspan address=\"10.1016/j.psc.2016.04.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBridge JA, Goldstein TR, Brent DA (2006) Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry Allied Discip 47(3\u0026ndash;4):372\u0026ndash;394. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1469-7610.2006.01615.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1469-7610.2006.01615.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBusby DR, Hatkevich C, McGuire TC, King CA (2020) Evidence-Based Interventions for Youth Suicide Risk. Curr Psychiatry Rep 22(2):5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11920-020-1129-6\u003c/span\u003e\u003cspan address=\"10.1007/s11920-020-1129-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarmel A, Rose M, Fruzzetti AE (2014) Barriers and Solutions to Implementing Dialectical Behavior Therapy in a Public Behavioral Health System. Adm Policy Ment Health 41(5):608\u0026ndash;614. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10488-013-0504-6\u003c/span\u003e\u003cspan address=\"10.1007/s10488-013-0504-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoe SY, Lengua LJ, McFall JP, Wyman PA (2023) Adolescents\u0026rsquo; Comfort in Disclosing to Caregivers Predicts Suicidal Thoughts and Behaviors Directly and Indirectly Through Difficulties in Emotion Regulation. J Youth Adolesc 52(8):1721\u0026ndash;1737. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10964-023-01785-8\u003c/span\u003e\u003cspan address=\"10.1007/s10964-023-01785-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGould MS, Greenberg T, Velting DM, Shaffer D (2003) Youth suicide risk and preventive interventions: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 42(4):386\u0026ndash;405. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.CHI.0000046821.95464.CF\u003c/span\u003e\u003cspan address=\"10.1097/01.CHI.0000046821.95464.CF\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHallford DJ, Rusanov D, Winestone B, Kaplan R, Fuller-Tyszkiewicz M, Melvin G (2023) Disclosure of suicidal ideation and behaviours: A systematic review and meta-analysis of prevalence. Clin Psychol Rev 101:102272. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cpr.2023.102272\u003c/span\u003e\u003cspan address=\"10.1016/j.cpr.2023.102272\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoresh N, Zalsman G, Apter A (2004) Suicidal Behavior and Self-Disclosure in Adolescent Psychiatric Inpatients. J Nerv Mental Disease 192(12):837\u0026ndash;842. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.nmd.0000146738.78222.e5\u003c/span\u003e\u003cspan address=\"10.1097/01.nmd.0000146738.78222.e5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJones JD, Boyd RC, Calkins ME, Ahmed A, Moore TM, Barzilay R, Benton TD, Gur RE (2019) Parent-Adolescent Agreement About Adolescents\u0026rsquo; Suicidal Thoughts. Pediatrics 143(2):e20181771. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/peds.2018-1771\u003c/span\u003e\u003cspan address=\"10.1542/peds.2018-1771\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKatsivarda C, Assimakopoulos K, Jelastopulu E (2021) Communication-based suicide prevention after the first attempt. A systematic review. Psychiatriki. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.22365/jpsych.2021.003\u003c/span\u003e\u003cspan address=\"10.22365/jpsych.2021.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim H, Park J, Kweon K, Ahn J (2018) Short- and Long-term Effects of Case Management on Suicide Prevention among Individuals with Previous Suicide Attempts: A Survival Analysis. J Korean Med Sci 33(32):e203. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3346/jkms.2018.33.e203\u003c/span\u003e\u003cspan address=\"10.3346/jkms.2018.33.e203\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKurita H, Osada H, Koyama T, Miyamoto Y, Kanai chieko, Shimizu kaoru (2003) Reliability and validity of Autism-Spectrum Quotient Japanese Version(AQ-J). Japanese J Clin psychiatry 32(10):1235\u0026ndash;1240\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee YJ, Kweon Y-S, Kang YH, Yoon KH, Lee M-S, Bhang S-Y, Hong HJ (2024) Suicide warning signs that are challenging to recognize: A psychological autopsy study of Korean adolescents. Child Adolesc Psychiatry Mental Health 18:41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13034-024-00731-1\u003c/span\u003e\u003cspan address=\"10.1186/s13034-024-00731-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLevi-Belz Y, Gavish‐Marom T, Barzilay S, Apter A, Carli V, Hoven C, Sarchiapone M, Wasserman D (2019) Psychosocial Factors Correlated with Undisclosed Suicide Attempts to Significant Others: Findings from the Adolescence SEYLE Study. Suicide Life-Threatening Behav 49(3):759\u0026ndash;773. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/sltb.12475\u003c/span\u003e\u003cspan address=\"10.1111/sltb.12475\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLoo JL, Keng S-L, Ram\u0026iacute;rez-Espinosa IG, Hadi N, Ram\u0026iacute;rez-Guti\u0026eacute;rrez NM, J. A., Shoesmith W (2021) Dialectical behavior therapy in the Asia-Pacific Rim region. Asia-Pacific Psychiatry 13(1):e12437. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/appy.12437\u003c/span\u003e\u003cspan address=\"10.1111/appy.12437\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcGillivray L, Rheinberger D, Wang J, Burnett A, Torok M (2022) Non-disclosing youth: A cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional. BMC Psychiatry 22:3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12888-021-03636-x\u003c/span\u003e\u003cspan address=\"10.1186/s12888-021-03636-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMckeown RE, Garrison CZ, Cuffe SP, Waller JL, Jackson KL, Addy CL (1998) Incidence and Predictors of Suicidal Behaviors in a Longitudinal Sample of Young Adolescents. J Am Acad Child Adolesc Psychiatry 37(6):612\u0026ndash;619. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00004583-199806000-00011\u003c/span\u003e\u003cspan address=\"10.1097/00004583-199806000-00011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeza JI, Zullo L, Vargas SM, Ougrin D, Asarnow JR (2023) Practitioner Review: Common elements in treatments for youth suicide attempts and self-harm \u0026ndash; a practitioner review based on review of treatment elements associated with intervention benefits. J Child Psychol Psychiatry 64(10):1409\u0026ndash;1421. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpp.13780\u003c/span\u003e\u003cspan address=\"10.1111/jcpp.13780\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMichael BF, Janet BW, Williams (2017) Lorna Smith Benjamin. In: Spitzer RL (ed) SCID-5-PD Structured Interview for DSM-5 Personality Disorders. IGAKU-SHOIN Ltd\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMichael BF, Janet BW, Williams RS, Karg, Spitzer RL (2020) SCID-5-PD Structured Interview for DSM-5 Personality Disorders. IGAKU-SHOIN Ltd\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMikami K (2022) Prevention of suicide reattempts among children and adolescents: Consideration based on the risk and protective factors. Psychiatria et Neurologia Japonica 124(5):330\u0026ndash;339\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMikami K, Inomata S, Hayakawa N, Ohnishi Y, Enseki Y, Ohya A, Haruki Y, Kishi Y, Shinohara Y, Ichimura A, Matsumoto H (2009) Frequency and clinical features of pervasive developmental disorder in adolescent suicide attempts. Gen Hosp Psychiatry 31(2):163\u0026ndash;166. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.genhosppsych.2008.12.003\u003c/span\u003e\u003cspan address=\"10.1016/j.genhosppsych.2008.12.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMikami K, Inomata S, Onishi Y, Orihashi Y, Yamamoto K, Matsumoto H (2020) Gender differences in the suicide attempts of adolescents in emergency departments: Focusing on individuals with autism spectrum disorder. Adolesc Psychiatry 9(3):232\u0026ndash;240. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2174/2210676609666190617144453\u003c/span\u003e\u003cspan address=\"10.2174/2210676609666190617144453\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMikami K, Kishi Y, Matsumoto H (2006) An adolescent patient after a suicide attempt: Importance of recognizing and intervening the psychosocial predisposing factors in suicide. Clin Psychiatry 48:331\u0026ndash;338\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMikami K, Onishi Y, Matsumoto H (2014) Attempted suicide of an adolescent with autism spectrum disorder. Int J Psychiatry Med 47(3):263\u0026ndash;271. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2190/PM.47.3.g\u003c/span\u003e\u003cspan address=\"10.2190/PM.47.3.g\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare (2023) \u003cem\u003eSummary of vital statistics in Japan 2023\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/jinkou/geppo/nengai23/dl/gaikyouR5.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/geppo/nengai23/dl/gaikyouR5.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare (2024) \u003cem\u003eWhite paper on suicide prevention 2024\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/content/2024-1-1-06.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/content/2024-1-1-06.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNarishige R, Otaka Y, Tateno A (2024) Characteristics of Japanese teenage suicide attempters: A retrospective study comparing suicide attempters with young adults. BMC Psychiatry 24(1):774. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12888-024-06234-9\u003c/span\u003e\u003cspan address=\"10.1186/s12888-024-06234-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Police Agency (2023) \u003cem\u003eStatistics of suicide victims in Japan in 2023\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.npa.go.jp/safetylife/seianki/jisatsu/R06/R5jisatsunojoukyou.pdf\u003c/span\u003e\u003cspan address=\"https://www.npa.go.jp/safetylife/seianki/jisatsu/R06/R5jisatsunojoukyou.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eResnick MD, Bearman PS, Blum R, Wm., Bauman KE, Harris KM, Jones J, Tabor J, Beuhring T, Sieving RE, Shew M, Ireland M, Bearinger LH, Udry JR (1997) Protecting Adolescents From Harm: Findings From the National Longitudinal Study on Adolescent Health. JAMA 278(10):823\u0026ndash;832. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.1997.03550100049038\u003c/span\u003e\u003cspan address=\"10.1001/jama.1997.03550100049038\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRubenstein JL, Halton A, Kasten L, Rubin C, Stechler G (1998) Suicidal behavior in adolescents. Am J Orthopsychiatry 68(2):274\u0026ndash;284. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/h0080336\u003c/span\u003e\u003cspan address=\"10.1037/h0080336\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTakahashi Y, Mikami K, Akama F, Onishi Y, Yamamoto K, Matsumoto H (2020) Suicide leap of an 11-year-old girl with autism spectrum disorder. Global Pediatr Health 7:2333794X20960278. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/2333794X20960278\u003c/span\u003e\u003cspan address=\"10.1177/2333794X20960278\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"child-psychiatry-and-human-development","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chud","sideBox":"Learn more about [Child Psychiatry \u0026 Human Development](http://link.springer.com/journal/10578)","snPcode":"10578","submissionUrl":"https://submission.nature.com/new-submission/10578/3","title":"Child Psychiatry \u0026 Human Development","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"adolescents, children, disclosure, family relations, suicide attempts, suicide prevention","lastPublishedDoi":"10.21203/rs.3.rs-7833585/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7833585/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSuicide is the leading cause of death among individuals aged 15\u0026ndash;19 years, and youth suicide in Japan is increasing. However, few studies have directly confirmed the actual situation of child and adolescent suicide attempters and their parents immediately after the attempts. We investigated whether children and adolescents disclosed suicidal ideation before their attempts through direct interviews with them and their families shortly after emergency department admission. This study was conducted in the Suicide Attempt Registry section of the \u0026ldquo;Registry Study of Child and Adolescent Mental Health in Japan\u0026rdquo; in collaboration with the National Kohnodai Medical Center, Japan Institute for Health Security. Patients aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years who attempted suicide were transported to the Tokai University Hospital Advanced Emergency Medical Center. Psychiatrists interviewed them and their families or guardians about the backgrounds of the attempts, focusing on whether the attempters had disclosed suicidal ideation to anyone. Overall, 76.0% of participants had not consulted anyone before their attempt, and 84.0% of these were male. Additionally, 86.0% of all patients reported being unable to discuss their suicidal ideation with family members beforehand. While these tendencies were more common among males, no statistically significant gender differences were found. In conclusion, children and adolescents who attempted suicide usually faced challenges in disclosing their suicidal ideation to their close circle, particularly family members. These findings were observed regardless of gender. In clinical practice, psychotherapy involving youths and their families is necessary to address youths' reluctance to openly discuss their problems with those close to them.\u003c/p\u003e","manuscriptTitle":"Gender differences in the disclosure of suicidal ideation among children and adolescents prior to suicide attempts","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-25 10:15:03","doi":"10.21203/rs.3.rs-7833585/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-14T14:20:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T23:57:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178442045817354348061427194438735470419","date":"2026-02-11T06:38:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T05:11:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284181286034966101357400397547068768832","date":"2025-12-14T02:35:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-14T06:24:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-01T01:09:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-13T15:10:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child Psychiatry \u0026 Human Development","date":"2025-10-11T08:49:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"child-psychiatry-and-human-development","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chud","sideBox":"Learn more about [Child Psychiatry \u0026 Human Development](http://link.springer.com/journal/10578)","snPcode":"10578","submissionUrl":"https://submission.nature.com/new-submission/10578/3","title":"Child Psychiatry \u0026 Human Development","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"12c8b206-3247-4aaf-859d-8165c8533fcd","owner":[],"postedDate":"November 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:06:28+00:00","versionOfRecord":{"articleIdentity":"rs-7833585","link":"https://doi.org/10.1007/s10578-026-02008-4","journal":{"identity":"child-psychiatry-and-human-development","isVorOnly":false,"title":"Child Psychiatry \u0026 Human Development"},"publishedOn":"2026-04-24 15:59:32","publishedOnDateReadable":"April 24th, 2026"},"versionCreatedAt":"2025-11-25 10:15:03","video":"","vorDoi":"10.1007/s10578-026-02008-4","vorDoiUrl":"https://doi.org/10.1007/s10578-026-02008-4","workflowStages":[]},"version":"v1","identity":"rs-7833585","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7833585","identity":"rs-7833585","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}