Better assessment of the risk of child suicide

Articles in review: Ayer, L., Colpe, L., Pearson, J., Rooey, M. & Murphy, E. (2020). Advancing research in child suicide: A call to action, Journal of the American Academy of Child & Adolescent Psychiatry. 59(9), 1028-1035

Summary and relevance: The increasing rate of child suicide should be a call to action for mental health clinicians, educators and primary health care workers. There is an urgent need to better identify children who are at risk of suicide and to provide appropriate suicide prevention programs where necessary. This article seeks to review what is known about child suicide and assess the usefulness of applying more general theories of suicide, and knowledge about suicide among adolescents, to better understand, measure and mitigate suicide by children.

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Although still relatively uncommon, the suicide rate amongst children is increasing. In the USA, suicide is the ninth most common cause of death for children aged 5-11 years. A total of 634 deaths of children by suicide were recorded in the sixteen years between 2001 and 2017. These deaths occurred disproportionately amongst African American and Native American populations. Further, in an assessment of child suicide rates between 1993 and 2012, a noteworthy and concerning fluctuation was identified in that while suicide rates decreased among white children, the suicide rates in black children nearly doubled.

An attempted or completed child suicide has a devastating impact on families and communities, including an increased risk of parental suicide. Children who attempt suicide may experience post-traumatic stress and complicated grief. Suicidal thoughts in childhood are related to continued suicide ideation and attempt into adulthood.

Risk factors for child suicide

We really know very little about the risk factors for child suicide, which makes it difficult to predict risk or provide intervention targets. Some work undertaken in the 80s and 90s looked at suicide in children and adolescents in a combined study. Risk factors across this larger span of age groups included depression, psychomotor activity, a preoccupation with death and parental suicidality. Poor adjustment and mood disorders in children have increased risk factors for later suicide attempts. A study of this scale has not been repeated since.

A 2016 study cited in the article has produced some evidence to suggest that risk and protective factors appear to be quite different for children and adolescents. In comparison to adolescent deaths by suicide, a child who dies by suicide is more likely to:

• Be male
• Die as a result of strangulation or suffocation
• Die at home
• Have experienced family relationship problems

In contrast, adolescents are more likely to leave a note, more likely to be depressed and more likely to have experienced problems with boyfriends or girlfriends when compared to children. A similar prevalence of mental health concerns was noted between children and adolescents who died by suicide during the period of comparison.

The other thing to consider when assessing the suicide risk of children is the marked differences in neurological processes, emotion regulation cognition and impulse control which is noticed in the span of years that make up childhood. Developmental differences do need to be incorporated into planning and treating children identified as being at risk for suicide. With regard to the notice that children who attempt or complete suicide have a less mature understanding of death, a 2019 study of 3-6-year-olds with depression found that they have a more advanced understanding of death and the permanence of death than non-depressed peers.

General theories of suicide as applied to children

Currently, clinicians supporting suicidal children are using reference protocols developed for younger children and adolescents. Applying theories of general suicide, or approaches geared towards suicide prevention among young people does not fully explain the complexities and unique factors associated with childhood suicide. More research is needed to determine what preventative strategies work best for at-risk children.

Analysis of theories such as the Interpersonal Theory of Suicide (ITPS), with a focus on its notion of Acquired Capacity for Suicide (ACS) may offer some insight, particularly as the presence of pain, hopelessness, lack of connectedness and a lack of maturity may be associated with the experiences of suicidal children. However, development factors must be taken into account when attempting to apply theories of adult suicide to adolescents and therefore also children.

Supporting children to reduce suicide risk

Existing data shows that using family-based interventions to address more general childhood emotional and behavioural problems has helped children to regulate their emotions, cope better and develop problem-solving skills. Programs for children that are focused on enhancing emotional regulation, inhibitory control and the development of coping and interpersonal skills can benefit a variety of behavioural problems that can become apparent later, such as substance use, poor mental health and risky behaviours. These are useful pointers towards strategies that can be developed specifically for working with suicidal children.

The need for child suicide prevention and treatment is “so urgent that the field cannot afford to wait for” a perfect risk assessment tool. As the suicide rate in children increases, it is necessary to continue to take advantage of existing data sources and to support ethical research to provide us with a better way to predict and mitigate the risk of child suicide.