In this study we inquire whether children and adolescents with suicidal ideation can be differentiated from children who attempt suicide on the basis of clinical symptoms or social grounds. From a total of 2181 consecutive outpatient referrals to a child and adolescent psychiatry service, 258 young persons who exhibited suicidal ideation are compared with 82 who had actually attempted suicide. We were unable to differentiate children with suicidal thoughts from those who attempted suicide on the basis of clinical symptoms alone. Both groups had similar high levels of symptoms of depression, anxiety, sleep disorder, and irritability. Conduct disorders were less common in both groups but 22% of the attempters abused illicit drugs or alcohol. Suicide attempts were more likely to be associated with chronic family discord and substance abuse. For boys, the odds of suicidal attempts were substantially increased if the subject had experienced loss. Results are discussed with reference to antecedents that may increase the odds of suicidal attempt and suggestions for future research are outlined.