Clinical Context

Suicide is a major global threat to public health and is especially of concern in the United States, where suicide rates have been rising steadily, even in children and adolescents. Among US children aged 10 to 14 years, suicide is the second leading cause of death. However, little is known about suicidal ideation and behaviors during childhood.

The goal of the Adolescent Brain and Cognitive Development (ABCD) study is to assess mental health trajectories from childhood to adulthood by gathering data in multiple domains, including mental and physical well-being, brain imaging, behavioral and cognitive characteristics, and social and family environments. The aims of this analysis of a US population-based sample of children participating in the ABCD study were to identify and rank risk and protective factors for childhood suicidal thoughts and behaviors and to examine their association with self-agreement and caregiver agreement in reporting suicidality.

Study Synopsis and Perspective

Approximately 8% of 9- and 10-year-old children in the United States report having suicidal thoughts, and 1.3 in every 100 report a suicide attempt.

The nationally representative observational study of 7994 9- to 10-year-old children identified a series of risk and protective factors associated with childhood suicidality. Such factors, the authors note, can be used to identify vulnerable children and plan interventions to bolster their mental health.

"I think the rate of suicidality is one of our most important findings, particularly because it is more frequent than anybody anticipated," Sophia Frangou, MD, PhD, told Medscape Medical News. "But the conditions that make suicidality more or less likely were also interesting to us, specifically because these risks and protective factors are modifiable.

"There's very little that was actually known about suicidality in children. All previous samples have been in adolescents aged 14 and older. I think this is the only study that has a general epidemiological approach to this phenomenon," added Dr Frangou, professor of psychiatry, Icahn School of Medicine at Mount Sinai, New York City.

The study, by first author Delfina Janiri, MD, from the Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, and colleagues, was published online March 11 in Lancet Psychiatry.^[1] It follows the February 7 publication of a similar analysis in JAMA Open Network that used the same data set.^[2]

Second Leading Cause of Death

The rate of suicide has been steadily increasing in US children and adolescents, according to the National Institute of Mental Health. Suicide is the second-leading cause of death among children and youth between the ages of 10 and 14 years.

Previous research has shown that suicidal thoughts and behaviors in childhood predict adult psychiatric morbidity and mortality and may serve as markers of vulnerability to poor mental health throughout adulthood.^[3]

Identifying children who experience suicidal thoughts and who engage in suicidal behaviors, coupled with interventions to minimize the risk associated with these thoughts and behaviors, may play a critical role in shifting children's developmental trajectories toward healthier outcomes.

Previous research in adults has identified a number of risk factors for suicidal thoughts and behaviors. These factors, which tend to reflect higher levels of psychosocial adversity, psychopathology, and medical morbidity,^[4] have also been observed in adolescents.^[5] Nevertheless, data from large-scale epidemiologic studies are lacking regarding younger children.

"This knowledge gap is important because age could substantially influence how suicidal ideas and behaviours are reported and the nature of risk and protective factors involved," Dr Janiri and colleagues write. Identifying such protective factors and correlated intervention strategies may stem the risk for suicide in school-age children, they add.

For the study, the investigators turned to data from the ABCD study, the largest available population-based sample of 9- and 10-year-olds living in the United States.

Using the ABCD cohort, the researchers set out to identify and rank risk factors and protective factors for childhood suicidal thoughts and behaviors across multiple domains, including mental and physical well-being, brain imaging, behavioral and cognitive characteristics, and social and family environment.

"Generally speaking, suicidality in children, either ideation or behavior, is relatively rare. It's only in a large sample where you can begin to see how suicidality behaves in a general population of children," said Dr Frangou.

More Screen Time Detrimental

As part of the analysis, the researchers evaluated suicidal thoughts and behaviors in each child via independent reports based on the Kiddie Schedule for Affective Disorders and Schizophrenia for DSM-5 (KSADS-5). The KSADS-5 assesses a variety of features regarding suicidal ideation, suicidal planning, and suicide attempts.

Using risk factors for suicidal ideation/behaviors that had been identified in previous literature, the investigators selected a number of potential variables related to neighborhood environment, parental characteristics, family function, prenatal and obstetric history, physical and mental well-being, cognitive ability, and children's behavioral traits.

The final study sample included 7994 unrelated children (mean age, 9.9 years; 53% boys) for whom complete data on both child-reported and caregiver-reported suicidal thoughts and behaviors were available.

Of this group, 673 children (8.4%) reported any past or current suicidal ideation. Seventy-five (0.9%) had any past or current suicidal plans, and 107 (1.3%) had any past or current child-reported suicide attempts.

Data from caregivers showed that 650 of the children (8.1%) reported any past or current suicidal ideation, 46 (0.6%) reported any past or current suicidal plans, and 39 (0.5%) reported past or current suicide attempts.

Regression modeling was used to quantify the association between suicidal ideation and personal, family, and social characteristics. These models showed that several factors were linked to an increased risk for suicidal thoughts, including psychological problems (odds ratio [OR], 1.7-4.8; 95% confidence interval [CI], 1.5-7.4) and exposure to child-reported family conflict (OR, 1.4-1.8; 95% CI, 1.1-2.5).

The risk for suicidality was greater among children who reported more weekend screen time (OR, 1.3; 95% CI, 1.2-1.7). Suicidality in children was associated with an average of 1 additional hour of screen time on the weekends compared with those who did not report suicidality.

Protective Factors

Caregiver-reported suicidality was positively associated with the caregiver's educational level (OR, 1.3; 95% CI, 1.1-1.5) and male sex in children (OR, 1.5; 95% CI, 1.1-2.2).

In contrast, parental supervision, such as knowing where children are, what they are doing, and with whom, had a strong protective effect against suicidal ideation (OR, 0.8; 95% CI, 0.7-0.9). Similarly, positive school involvement was also protective against suicidal ideation (OR, 0.8; 95% CI, 0.7-0.9).

Despite the strength of these findings, the investigators note that the study only showed agreement between caregiver and child reports of suicidal ideation in 17% of cases, a finding that indicates that suicidal thoughts and behaviors in children cannot be reliably assessed by parental report alone.

The study findings, the investigators note, support current societal concerns about suicidality in young children. However, the authors also point out that although the rate of suicidal thoughts is high, suicide attempts are rare.

The study helps shed valuable light on the factors associated with suicidality in children. Notably, child psychopathology and family conflict emerged as the 2 most robust risk factors, regardless of informant.

On the positive side, the study identified factors that may help mitigate the risk for reported suicidality, including higher levels of parental supervision and more positive school engagement.

These findings are similar to findings from studies of suicidality in adolescents, further cementing the role that positive parental and school-based experiences play in protecting against youth suicidality.

"This is not necessarily about spending hours and hours with children, but about parents letting children know they're interested in what they're doing, who they're seeing, and who their friends are," Dr Frangou said.

Although the investigators note that the optimal method of offering support to at-risk children remains unclear, previous evidence suggests that school-based awareness programs may be a powerful intervention for reducing suicidal behaviors and ideation.^[6]

"This study says of all of the things you can think about in terms of public health interventions, focusing on the school environment and on children who are vulnerable are the most worthwhile," she added.

Troubling Findings

Commenting on the findings for Medscape Medical News, Jennifer Hoffmann, MD, who was not involved in the research, found the results troubling.

"I think it's a common misconception that young children don't have the ability to plan suicide or the understanding of death to decide to kill themselves," said Dr Hoffmann, a pediatric emergency medicine physician at the Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois. "But young children can have suicidal thoughts and feelings, as seen in this study."

Dr Hoffmann noted that her work has uncovered other risk factors for suicide in children.

"My research has focused on the relationship between living in high-poverty areas and suicide among youth, and I found that children aged 5 to 14 living in the highest-poverty counties are twice as likely to die by suicide as those living in the wealthiest counties. So that may be one risk factor," she said.

She noted that more research is needed to determine the most effective treatment and prevention strategies for young children.

"Currently, many of the screening tools for suicidal thoughts are geared towards older children. So school- and home-based prevention programs need to be developed and rigorously studied," she said.

The study was funded by the National Institutes of Health. Dr Frangou and Dr Hoffmann have disclosed no relevant financial relationships.

Lancet Psychiatry. Published online March 11, 2020.

Clinical Implications

• Suicidal ideation was reported by 8% of children aged 9 to 10 years in a US population-based sample, with the strongest risk factors for suicidality being child psychopathology and child-reported family conflict.
• Clear, attainable targets for early intervention and prevention strategies could include increasing school and parental awareness of child psychopathology and providing parenting education and family support.
• Implications for the Healthcare Team: The poor agreement between a child's self-report and their caregiver reports of suicidal ideation and behaviors suggests problems with disclosure and awareness that should be considered when evaluating suicide risk in young children.

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