Suicidal thinking in very young children.

In the current issue of the Journal of the American Academy of Child & Adolescent Psychiatry (November 2015) there is a research report, and accompanying commentary, about suicidality (that word refers to suicidal thoughts, gestures, attempts, and actual deaths) in very young children, age 3-7.

Fortunately, deaths by suicide in young children are very rare, however, this study suggests that suicidal thoughts are common among children with clinical depression and other forms of psychopathology.

When I began my career in the early 80s, psychologists and psychiatrists were just beginning to recognize that children, including young children, can suffer from all kinds of psychiatric disorders one sees in adults, including the whole range of mood disorders such as depression and bipolar illness. Prior to that time, most mental health professionals believed that if a child appeared depressed, it was strictly because there was something wrong with his or her family or social situation, not because of the biochemical/psychosocial reasons that seem to contribute to clinical depression.

We know much more about suicide in adults and in teenagers. We know, for example, that in the last 10 years or so, teen suicide rates are actually stable and are considerably lower than they were 30 years ago, in spite of the widespread myth that there is an epidemic of teen suicide. Similarly, suicide among the elderly is stable. On the other hand, in the last 10 years, suicide among middle-aged people has risen nearly 30%. It has always been true that adults are much more likely to die by suicide than teenagers and children. The short guide to the demographics of suicide deaths is: Older more than younger; whites more than blacks; men more than women.

When an individual has mental illness, particularly, but not exclusively, depression, suicidal thinking, suicide attempts, and deaths by suicide are a risk. Because we know that even young children can suffer from mental illness, including mood disorders, the question of how suicidality affects these children is something we know too little about.

We do not know enough, for example, about what it means for a young child to have suicidal thoughts. Children must develop an understanding that death is irreversible. In one study, most first-graders were able to demonstrate the concept of “killing oneself,” could name viable ways of doing it (guns, knives). Children between six and 10, generally, seemed to know that an act of suicide results in death and is permanent and final. But, we have had no studies to help us understand conceptions of suicide among 3- to 7-year-olds.

The results of the study are not easy to summarize. But, what this new study suggests is this: First, even though the researchers employed fairly broad definitions of suicidal thoughts, about 11% of the subjects, whose average was 5 years old, showed evidence of having had suicidal thoughts or verbalizations. Suicidal thoughts, behavior, expression of suicidal plans were associated with ADHD, oppositional defiant disorder, and conduct disorders at the time the subjects were studied. Although the researchers did not find a clear correlation with preschool suicidality and any specific diagnoses during subsequent years (elementary school), the presence of the range of suicidal thoughts and behavior in preschoolers predicted suicidal thinking later in school-aged years.

I would add a couple of things I will take home from reading the article. First, mental illness, including depression and the other mood disorders, are massive public health problems. They are illnesses. No one is immune. Not even the young children who we want to believe are all happy and carefree. Second, pediatricians and mental health professionals must carefully assess and consider that very young children can be significantly clinically depressed. It is hard to talk to young children about possible desires to die or harm themselves. But, we need to find a way to include some kind of screening for suicidal thinking in young patients. This will be a clear sign that they are suffering and in need of help.

Dale Wisely, Ph.D.