cALL 800-273-8255 or
text "sos" to 741741
Both negative and positive events can be sources of significant stress. Examples of events that cause positive stress include:
Examples of negatively stressful events include:
Some suicidal people never developed the skills necessary to successfully cope with stressful situations. They may also have personalities that are sensitive to becoming overwhelmed by negative circumstance. Other suicidal people may have had reasonable coping skills in place at one point, but find themselves worn down by circumstance to the point where they can no longer manage.
The most frequent stressful event leading up to suicide (what is often called a precipitating event) today is mental illness. It is estimated to account for about 90 percent of all suicides. As we discussed earlier, a newly diagnosed and/or poorly treated mental illness can trigger a suicide in some cases. In addition, a change in someone's existing mental illness (for the worse or better) can function as a precipitating event for suicide. Most people incorrectly assume that only deteriorating conditions should be monitored. However, as was previously discussed, people who have been severely depressed and are now starting to regain their energy may suddenly find themselves with enough energy to carry out suicide plans.
Depression is the most common mental illness in people who commit suicide, so we will briefly detour from the topic of suicide to discuss this common disorder, which is discussed in significant detail in our Depression topic center. According to the DSM-5 (the latest version of the manual used by clinicians to diagnose mental disorders) you must meet the following criteria in order to qualify for a diagnosis of Major Depression:
At least five of the following symptoms are present during the same period. At least (1) depressed mood or (2) loss of interest or pleasure must be present. Symptoms are present most of the day, nearly daily for at least 2 weeks.
It's helpful to know the criteria that professionals use to diagnose depression, but it is not a good idea to attempt to diagnose yourself. One reason why this is true is that the consequences of getting the diagnosis wrong can be quite negative. Depression is a serious condition that is associated with significant suicide risk and does end up being a lethal disorder sometimes. However, it is also a very treatable disease which can be addressed by either medical or psychological methods (or both). If you wrongly conclude that you are not depressed when you are, you might very well miss out on treatment opportunities that a diagnosing clinician could offer you.
Don't assume that you must feel sad and depressed in order to qualify for a diagnosis of major depressive disorder, as this is not the case. You may experience irritability during the required two-week period of symptoms. Or, you may experience your depression as physical pain. If you even meet one of the symptoms listed above (particularly the suicide symptom), it would be a very good idea to consult with a mental health professional. If you have several symptoms, you definitely should schedule an appointment.
In addition to major depressive
disorder, depressive symptoms may also be caused by bipolar
disorder, or may happen with another condition. Bipolar
disorder is typically characterized by alternating moods and
energy levels happening over months, weeks or days. Symptoms
may include periods of hyperactivity, fast speech, hyper
sexuality, lack of need for sleep, feelings of
inflated-well-being; and corresponding periods of depression
where some or all of the symptoms listed above are present.
Extensive information concerning bipolar disorder can be
found in our Bipolar Disorder topic center.
1. Depressed mood (sometimes irritability in children and adolescents) most of the day, nearly every day.
Even though these disorders have very different symptoms, they all share a main feature: intense, extreme, and disabling anxiety that appears in anticipation of or in response to situations which does not subside over time.
Individuals with anxiety disorders may feel overwhelmed, ashamed, or frustrated that they are unable to control their symptoms. Many individuals with severe anxiety symptoms also become socially isolated and/or try to relieve their feelings by using alcohol and/or other substances. These features of anxiety disorders can lead someone to attempt or commit suicide.
Post-Traumatic Stress Disorder
PTSD is an extreme reaction to a traumatic event. It is characterized by:
Individuals with PTSD have the highest rate of suicide when compared to all other anxiety disorders.
People with panic disorder experience ongoing and unexpected panic attacks. These are periods of intense anxiety characterized by unpleasant physical symptoms such as nausea, racing heartbeat, dizziness, etc. People with this condition are extremely anxious about having future panic attacks. They are also very worried about what might happen as a result of these attacks. They might worry about being trapped and being unable to get help, or driving and having a car accident because of the anxiety. Approximately 20% of suicide deaths are due to panic disorder. This is a rate that is below major depressive disorder and PTSD, but still relatively high. People with comorbid (co-occurring) panic disorder and depression are particularly at risk.
Schizophrenia is a disorder characterized by odd and often highly irrational or disorganized behavior, disorganized thinking, and a loss of touch with reality. 4 to 10% of people with schizophrenic disorders commit suicide. Suicide attempts among this group of people are more likely to be moderately to severely lethal with high levels of intent. In other words, individuals with schizophrenia who attempt suicide frequently do not survive.
Personality disorders are enduring patterns of behavior and ways of thinking that significantly impede functioning. Between 4 and 8% of people with a personality disorder complete suicide, and approximately 40 to 90% have attempted suicide.
Antisocial personality disorder is characterized by:
People with antisocial personality disorder are often highly impulsive. This can lead someone to engage in self-destructive behavior as a means of getting intense stimulation and to gain attention, without thinking through the possible outcome and consequences of their actions.
Borderline personality disorder (BPD) is characterized by ongoing instability in moods, relationships with others, self-image, and behavior. This disorder affects approximately 2% of adults, mostly young women. Individuals with BPD have a high rate of self-injurious behavior, suicide attempts, and completed suicide. Often, suicidal behaviors in BPD occur when the person is not showing any signs of depression. Because of this, some clinicians suggest that suicide in this population is more of an impulse control problem than some of the other mental illnesses discussed previously.
It's important to understand the link between mental illness and suicide. However, it is also important to remember that not everyone who attempts or completes suicide has a mental illness, and not all people with mental illness attempt or complete suicide. It's likely a combination of factors that send someone toward engaging in suicidal behavior.
At this point, if you are confused about the difference between risk factors, vulnerabilities, and triggers, don't worry. These are not "cut and dried" categories. The distinctions between them are often blurry. The important message we're trying to communicate here is that you can and should:
Though I've never lost a friend or family member to suicide, I have lost a patient (who I wrote about in a previous post, "The True Cause Of Depression"). I have known a number of people left behind by the suicide of people close to them, however. Given how much losing my patient affected me, I've only been able to guess at the devastation these people have experienced. Pain mixed with guilt, anger, and regret makes for a bitter drink, the taste of which I've seen take many months or even years to wash out of some mouths.
The one question everyone has asked without exception, that they ache to have answered more than any other, is simply: why? Why did their friend, child, parent, spouse, or sibling take their own life? Even when a note explaining the reasons is found, lingering questions usually remain: yes, they felt enough despair to want to die, but why did they feel that? A person's suicide often takes the people it leaves behind by surprise (only accentuating survivor's guilt for failing to see it coming).
People who've survived suicide attempts have reported wanting not so much to die as to stop living, a strange dichotomy, but a valid one nevertheless. If some in-between state existed, some other alternative to death, I suspect many suicidal people would take it. For the sake of all those reading this who might have been left behind by someone's suicide, I wanted to describe how I was trained to think about the reasons people kill themselves. They're not as intuitive as most think.
In general, people try to kill themselves for six reasons:
1. They're depressed. This is, without question, the most common reason people die by suicide. Severe depression is almost always accompanied by a pervasive sense of suffering as well as the belief that escape from it is hopeless. The pain of existence often becomes too much for severely depressed people to bear. The state of depression warps their thinking, allowing ideas like, "Everyone would all be better off without me" to make rational sense. They shouldn't be blamed for falling prey to such distorted thoughts any more than a heart patient should be blamed for experiencing chest pain; it's simply the nature of their disease. Because depression, as we all know, is almost always treatable, we should all seek to recognize its presence in our close friends and loved ones. Often, people suffer with it silently, planning suicide without anyone ever knowing. Despite making both parties uncomfortable, inquiring directly about suicidal thoughts, in my experience, almost always yields an honest response. If you suspect someone might be depressed, don't allow your tendency to deny the possibility of suicidal ideation prevent you from asking about it.
2. They're psychotic. Malevolent inner voices often command self-destruction for unintelligible reasons. Psychosis is much harder to mask than depression, and is arguably even more tragic. The worldwide incidence of schizophrenia is 1 percent and often strikes otherwise healthy, high-performing individuals, whose lives, though manageable with medication, are often derailed from their original promise. Schizophrenics are just as likely to talk freely about the voices commanding them to kill themselves as not, and also, in my experience, give honest answers about thoughts of suicide when asked directly. Psychosis, too, is treatable, and usually must be treated for a schizophrenic to be able to function at all. Untreated or poorly treated psychosis almost always requires hospital admission until the voices lose their commanding power.
3. They're impulsive. Often related to drugs and alcohol, some people become maudlin and impulsively attempt to end their own lives. Once sobered and calmed, these people usually feel emphatically ashamed. The remorse is often genuine, but whether or not they'll ever attempt suicide again is unpredictable. They may try it again the very next time they become drunk or high, or never again in their lifetime. Hospital admission is, therefore, not usually indicated. Substance abuse and the underlying reasons for it are generally a greater concern in these people and should be addressed as aggressively as possible.
4. They're crying out for help, and don't know how else to get it. These people don't usually want to die but do want to alert those around them that something is seriously wrong. They often don't believe they will die, frequently choosing methods they don't think can kill them in order to call attention to their challenges, but they are sometimes tragically misinformed. For instance, a young teenage girl suffering genuine angst because she feels lonely or has gotten into a devastating fight with her parents, may swallow a bottle of Tylenolnot realizing that in high enough doses, Tylenol causes irreversible liver damage. I've watched more than one teenager die a horrible death in an ICU days after such an ingestion when remorse has already cured them of their desire to die and their true goal of alerting those close to them of their distress has been achieved.
5. They have a philosophical desire to die. The decision to die by suicide for some is based on a reasoned decision, often motivated by the presence of a painful terminal illness from which little to no hope of reprieve exists. These people aren't depressed, psychotic, maudlin, or crying out for help. They're trying to take control of their destiny and alleviate their own suffering, which usually can only be done in death. They often look at their choice to die by suicide as a way to shorten a dying that will happen regardless. In my personal view, if such people are evaluated by a qualified professional who can reliably exclude the other possibilities for why suicide is desired, these people should be allowed to die at their own hands.
6. They've made a mistake. This is a recent, tragic phenomenon in which typically young people flirt with oxygen deprivation for the high it brings and simply go too far. The only defense against this, it seems to me, is education.
The wounds suicide leaves in the lives of those left behind by it are often deep and long lasting. The apparent senselessness of suicide often fuels the most significant pain. Thinking we all deal better with tragedy when we understand its underpinnings, I've offered the preceding paragraphs in hopes that anyone reading this who's been left behind by a suicide might be able to more easily find a way to move on, to relinquish their guilt and anger, and find closure. Despite the abrupt way you may have been left, guilt and anger don't have to be the only two emotions you're doomed to feel about the one who left you.
If you or someone you know is
exhibiting warning signs of suicide, call the U.S. National
Suicide Prevention Lifeline at 800-273-TALK (8255), contact
the Crisis Text Line by texting HOME to 741741, or seek help
from a medical or mental health professional. To locate a
mental health professional near you, visit the Psychology
Today Therapy Directory.
One of them was physically injured in the incident. In order to return to class, he asks to have space around his desk to allow him to stretch, because sitting still for too long would aggravate his injury.
How would you feel about his request? Would you understand why such an accommodation would help him heal? Expect his professors to oblige?
Now, the other students pain isnt visible its emotional.
He wasnt physically hurt, but he lost a loved one, and hes traumatized. Certain reminders have resulted in panic attacks, and hed rather not experience that again especially not when hes trying to move on with his life and get an education.
So he also makes a request, asking his professors if they can give him a warning before covering material that relates to the type of violence that took away his loved one.
How would you feel about this students request?
What hes asking for is a content warning, also commonly called a trigger warning. And its a huge source of debate.
You may have come across some of this debate recently after the University of Chicago dean of students sent out a letter to tell incoming freshman not to expect trigger warnings.
People actually dismiss the needs of people with chronic illnesses and physical and visible disabilities quite often, so I dont want to take away from that.
But it is noticeable that when it comes to an able-bodied person experiencing a temporary injury and needing support to heal, theres usually not much debate about whether or not they should be allowed in class with crutches, a cast, or extra space around their desk.
The sharp contrast between this acceptance and common attitudes towards trigger warnings reveals something disturbing about our societys approach to trauma and mental illness.
Just like its normal for the body to need healing after physical violence, its perfectly normal for someones mind to need healing after a traumatic event.
Thats why a diagnosis like Post Traumatic Stress Disorder (PTSD) exists not because somethings wrong with someone whos struggling after trauma, but because its natural for trauma to have an impact on ones mental health.
But we dont seem to understand that as a society. People like that dean and all of his supporters think that accommodations for traumatized students are unnecessary, and even wrong.
Ive been through both sexual violence and intimate partner violence, and my recovery is an ongoing process.
I dont experience panic attacks from reading about rape or partner abuse, but I do feel the impact when people are disparaging survivors of trauma. And Im sure as hell not going to criticize other survivors for needing a warning.
Thats because Ive also worked with many other survivors, and if theres one thing Ive learned about healing, its that its different for everyone. Theres no one right way to feel or respond to trauma.
But if youre opposed to the use of trigger warnings, clearly youve taken the side that states there is such a thing as a wrong way.
So lets not make the mistake of thinking this debate is only about trigger warnings. Lets dig into how people really feel about trauma and mental illness when they decide that trigger warnings are wrong.
1. We View Mental Illness as a Weakness
On most college campuses, theres a group of people who require protection from injury on a regular basis.
But we dont call them weaklings we call them athletes.
And you can bet that your school administration doesnt complain about having to coddle your star football players by giving them helmets and padding before they take a hit.
But when a survivor wants to protect their mental health by getting a warning before they face a difficult topic, people frequently use the word coddling to refer to their needs.
Just read some of the recent comments on an Everyday Feminism article about trigger warnings:
I cannot stand the wussification of American society.
These are common sentiments among those who oppose trigger warnings. They conflate being affected by trauma with being weak, and decide that those who need trigger warnings arent good enough to be among those who are unfazed.
This, in spite of the fact that so many survivors on college campuses arent there to avoid sensitive topics. Theyre there to learn, just like everyone else, and theyre determined to do this in spite of their personal obstacles, just like everyone else.
Some people need to work full-time while theyre in college in order to attend school. Some need scholarships. Hell, everyone needs to pay for it somehow, so some rely on that parental trust fund that will get them through debt-free.
I hope you wouldnt judge someone for having different financial needs than you do. Mental health needs are similar accommodating them simply allows different people with different sets of circumstances to access the same opportunities that you have.
Facing difficult topics sure doesnt make you weak. Facing them after directly experiencing trauma takes strength even with the help of a warning.
You know what could also help people face difficult topics? A lifetime without ever being personally affected by trauma.
But I wouldnt call you weak if thats the reason you dont need a warning.
2. We Define Strength as Emotional Unavailability
Strength and healing can show up in so many different ways. Nothing has taught me this important lesson more than working with other survivors of violence.
For instance, while I did peer advocacy counseling with Community United Against Violence (CUAV), the oldest LGTBQIA+ anti-violence organization in the US, I met survivors who needed to face their trauma head-on, survivors who needed more time before they could talk about it, survivors who checked out emotionally at the mention of their trauma, and more.
None of them were wrong. Each was on their own unique path of learning to cope with what theyd been through.
Consider what it means that many of us are so eager to have engagement with disturbing topics in settings like college classrooms, but dont want to actually acknowledge that these topics might disturb us.
Im one of those who strongly believes that we should be engaging with issues like sexual violence, abuse, and violent oppression. Thats why I write about them so much.
So my support of trigger warnings doesnt mean avoiding them altogether. I believe we should engage with them in a way that acknowledges their real impact.
If you think we should all approach traumatic topics with as much emotional engagement as wed have for a math problem, then what youre really asking is for people to disconnect from the emotions that naturally arise around emotional topics.
Theres nothing wrong with acknowledging that something is painful. But society says that people deserve to be punished for being delicate if they do.
Ive heard people compare survivors needing trigger warnings to military combat veterans, saying that veterans dont whine about society not taking care of their feelings.
But they say this as if veterans arent also suffering as if they dont have high rates of PTSD and suicide. Clearly, something needs to change if we believe that people are only strong if they endure painful feelings without support.
3. We Accept Suffering as Normal But Healing Is Asking for Too Much
The idea that survivors who need trigger warnings cant handle the real world is a common accusation. People say that weve all been through hard things, but the rest of the world is unfazed.
Its pretty sad that we can acknowledge that theres so much suffering in the world, but get angry at people who have the nerve to cope with that suffering in a way that others can see.
The attitude goes something like this: The rest of us have unhealed trauma, so why shouldnt you?
Are you using edgy humor to talk about painful issues without acknowledging that theyre painful? Thats cool, bro.
Are you breaking down only when nobody can see you cry? Fine, as long as you never admit to it.
But admit to needing support to face something without being re-traumatized? How dare you be so entitled.
One guy in the Everyday Feminism comments said that he used to have night terrors after being bullied but he got over it without needing trigger warnings, so he didnt see why anyone else should need them, either.
But he had just as much control over his night terrors as someone would over daytime panic attacks as in, not much control at all.
Do you know what it feels like to have a panic attack? Find out from Patrick Roche, then ask yourself if trying to avoid such a terrifying experience really amounts to being entitled.
Nobody should have to suffer through the impact of trauma without support to heal and the fact that its the norm for people to feel like they just have to suck it up and get over it does not make it okay.
Its okay to ask for what you need. But if you dont personally take that route, dont shame others for doing so.
4. We Think Trauma Defines Someone or Something
The way some people talk about opposing trigger warnings, youd think we were talking about something much more significant than a few words in front of a text.
According to them, its censorship! Its the end of free speech! Its destroying an entire generation! Its the downfall of society!
Lets cool down for a second and think about what this means.
Our society seems to think theres something wrong with identifying as a victim.
If youve been through something hard in the past, but you got over it, thats fine but acknowledge that it still affects you, and youre said to be doing a bad thing by victimizing yourself.
And some people say they oppose trigger warnings not because theyre against survivors, but to protect the integrity of the classroom. They say that warning that a text contains disturbing material could influence students to focus only on that disturbing material, making them think thats all the text is about.
This feeling makes sense if you think trauma is so significant that acknowledging its impact defines all of who someone or something is.
We think that being a victim means youre permanently broken, and that being a perpetrator of violence means youre not human, but a monster.
And thinking of violence this way means we dont have to face the fact that its an everyday part of our world instead, its such an unusual thing that acknowledging its impact means being unable to acknowledge anything else.
But I promise you thats not the case.
I can recognize that trauma has an impact on me without having it define the whole of who I am. I can say that one aspect of a text might have an emotional impact on its readers without claiming that that aspect is all there is to it.
A trigger warning is just a few words out of the entire course of a survivors day, one line to read over the course of their entire lives.
It doesnt define them. And we dont have to be so averse to victimhood that we cant even talk about it without it taking over everything.
5. We Think the Way We Handle Things Should Be the Only Way
As a society, we sure do love to judge people who do things differently than we do.
Find out someone has a different kind of culture, sex life, or relationship style than you do? Judge away!
And this unfortunate habit comes up in trigger warning debates, too.
Its interesting how our society has such a stigma against going to therapy, but bring up trigger warnings, and suddenly everyones a tireless advocate for exposure therapy.
Exposure therapy involves gradually facing reminders of your trauma in a safe, controlled environment under the supervision of a specialized therapist. It can help retrain your brain to face your triggers without being re-traumatized, but it doesnt force people to face things without their consent and it uses other coping techniques to avoid re-traumatization.
Having someone with PTSD toughen up to just deal with their triggers at any given time is not the same as exposure therapy.
For me, the fact that Im used to hearing stories of survival is part of the reason I can read reminders of my trauma without being thrown into a panic attack.
But am I going to tell everyone else that they need to go lead support groups and counseling sessions about the things theyve been through in order to heal? Hell no! Its not for everyone, and thats okay.
The fact is that what works for one person wont work for everyone. And believing that everyone should heal like you do doesnt make you an expert it kind of just makes you an asshole.
Do you know what happens when people decide their wellness practices are the only valid wellness practices?
They judge people who take medication for not trying yoga instead, or judge people who go to therapy for not just trying prayer, or judge people who cry in public for not keeping their tears behind closed doors.
See a pattern here?
Every single person has a different set of needs so there will always be someone who needs something you dont.
If directly facing difficulties has helped you, thats great. But youll save yourself and others a lot of trouble if you drop the idea that anyone who doesnt heal like you do deserves to be judged.
Maybe a trigger warning seems silly to you because you dont need it. Luckily for you, that means the presence or the absence of a trigger warning doesnt have an impact on your life.
So youll be just fine if you step back from this debate and let people ask for what they need without being judged.
All of this shows that we as a society really need a shift in how we understand emotional needs, mental health, and responses to violence and trauma.
The status quo says that we should all suck it up, get over it, keep moving forward without ever acknowledging the impact that trauma can have.
And we can learn a lot about our culture by noticing how controversial it is to suggest changing the status quo.
Welcome to the real world, youd say to someone whod like a warning before they face a sensitive topic.
Id like to invite you to face reality, too. The reality is that trauma affects many different people in many different ways.
Its okay to acknowledge painful feelings, to approach sensitive topics not only as sources of new ideas, but also sources of deep emotional reactions, and to accept that traumatic events affect our emotional and mental health.
A trigger warning wont stop you from facing painful realities but itll definitely help some people face them, and continue healing from the impact of them, too.
Maisha Z. Johnson is the Digital
Content Associate and Staff Writer of Everyday Feminism. You
can find her writing at the intersections and shamelessly
indulging in her obsession with pop culture around the web.
Maishas past work includes Community United Against
Violence (CUAV), the nations oldest LGBTQ
anti-violence organization, and Fired Up!, a program of
California Coalition for Women Prisoners. Through her own
project, Inkblot Arts, Maisha taps into the creative arts
and digital media to amplify the voices of those often
silenced. Like her on Facebook or follow her on Twitter
8.6% suicidal ideation (SI) was found among 349 urban 6 9 year olds in the top tercile of aggressive-disruptive behavior. SI was associated with more self-reported depression, ODD, conduct problems, and ADHD symptoms (ES 0.70 0.97) and 3.5 5 times more clinically significant symptoms. Parents rated more symptoms in older children associated with SI compared to parents of similar age children without SI, including greater somatic and behavior problems in 8 9 year olds with SI. Parent ratings did not differentiate SI and non-SI in 6 7 year olds. SI frequently co-occurred with thoughts about death. Children described anger, dysphoria and interpersonal conflict as motivators/triggers for SI and worries about safety/health as motivator/triggers for thoughts about death, suggesting that problems managing emotionally challenging situations are a specific factor in initiating SI. Universal and indicated interventions for children to strengthen emotional self-regulation and behavioral control are recommended to complement the current emphasis on suicide prevention among adolescents.
Keywords: suicidal ideation, urban children, emotional triggers, externalizing problems
The burden of suicide mortality has shifted increasingly towards younger aged individuals in the last half-century, and suicide is the third leading cause of death for young people ages 10 24 in the U.S. (Lubell, Kegler, & Karch, 2007). Although there are few deaths from suicide before adolescence, suicidal ideation in 4th grade was associated with a 1.5 times greater likelihood of making a suicide attempt by age 19 in a large urban cohort (Ialongo et al., 2004). In another epidemiological cohort, children with suicidal ideation before adolescence had higher rates of mood and substance use disorders as adults compared to those whose suicidal ideation began during adolescence (Steinhausen & Winkler, 2004). These associations suggest that targeting early risk factors for suicidal behavior may be an important suicide prevention strategy (Brown, Wyman, Brinales, & Gibbons, 2007). However, little is known about suicidal thinking and behavior in young children.
A developmental approach provides a useful framework for examining suicidal behavior across childhood. According to this approach, the manner in which children experience and express specific features of psychopathology depends on their cognitive, physiological, and social developmental level (Cicchetti & Toth, 1998). Dysphoric mood, for example, is a core symptom of depression across ages, but the manner in which children express dysphoria varies by age (Weiss & Garber, 2003). Developmental level can also influence the causes and consequences of psychopathology; cognitive factors such as a pessimistic explanatory style for negative life events, for example, may be more predictive of mood disorders for older than younger children (Nolen-Hoeksema, Girgus, & Seligman, 1992). A developmental approach also focuses attention on mechanisms of transmission of risk factors (Goodman & Gotlib, 1999). For example, depressed mothers negative attributions for child-centered events predict their adolescent childrens negative attributions for the same events, suggesting one mechanism whereby children internalize maladaptive self-talk associated with depression (Garber & Flynn, 2001). In addition to limited knowledge about risk factors for suicide in young children, the mechanisms whereby young children apply their knowledge about death and behaviors leading to death (Mishara, 1999) to initiate suicidal thinking are largely unknown.
The current state of knowledge in youth suicide prevention research is strong on epidemiological rates and psychiatric risk factors in adolescence (Foley, Goldston, Costello, & Angold, 2006; Gould et al., 1998; Kandel, Raveis, & Davies, 1991). Suicide deaths increase from about 1.2 per 100,000 for ages 1014 to 12.1 per 100,000 for ages 2024 (IOM, 2002). Increased suicide attempts for girls at age 13 are closely linked with emerging sex differences in depression and hormonal changes (Angold, Costello, Erkanli, & Worthman, 1999; Lewinsohn, Rohde, Seeley, & Baldwin, 2001). Mood, anxiety, and disruptive/conduct disorders are associated with suicidal ideation, attempts, and deaths from preadolescence through adolescence (Brent et al., 1993; Foley et al., 2006; Gould et al., 1998), and substance use disorders also increase risk for suicidal behaviors (Kandel, 1988). Severity of symptom-related impairment and total symptom load explains most of the risk for suicidal ideation and behavior in preadolescents and adolescents rather than a specific diagnostic profile (Foley et al., 2006).
For children younger than age nine, few studies have used designs that permit reliable estimates of the prevalence of suicidal behavior in different population groups. In small sample studies, children as young as preschool age have been identified with suicidal thinking and behavior (Connolly, 1999; McIntire, Angle, & Schlicht, 1977). Several studies have used clinical or convenience samples, many with over-representation of maltreated or prenatally drug-exposed children (e.g., Finzi et al., 2001; OLeary et al., 2006; Payne & Range, 1996). For example, 10% of eight year old maltreated children in a multi-state cohort had suicidal ideation based on a single questionnaire item (Thompson et al., 2005). In one study using a community sample, Pfeffer, Zuckerman, Plutchik, and Mizruchi (1984) reported that 8.9% of 6 12 year olds had suicidal ideation and 1% a prior suicide attempt; however, this sample had a mean age of 9.7 years and rates of suicidal ideation were not reported for younger children.
Depressive symptoms (OLeary et al., 2006; Pfeffer et al., 1984) and overall psychological distress (Thompson et al., 2005) are linked to suicidal thoughts in young children. The role of psychological distress is also underscored by the association between family conflict, maltreatment, and suicidal thinking in children (Asarnow, Carlson, & Guthrie, 1987; OLeary et al., 2006; Thompson et al., 2005). Childhood trauma also increases the risk for suicide in adulthood, suggesting that maladaptive coping with chronic emotional distress contributes to suicidal behaviors (Enns, Cox, Afifi, De Graff, Ten Have, & Sareen, 2006). There remains a large gap in knowledge about the mental health problems associated with suicidal behavior in young children, including the role of externalizing behavior patterns. In addition, the mechanisms linking psychological distress to suicidal thoughts have not been delineated.
One cognitive factor influencing childrens expression of suicidal thinking is the acquisition of a mature concept of death, with children before ten years of age demonstrating inconsistent knowledge of the irreversibility of death and causal factors leading to death (Slaughter & Griffiths, 2007). For example, whereas most 1st graders reported understanding that dead people do not become living again, 70% also believed that dead people can have experiences such as seeing or breathing (Mishara, 1999; Normand & Mishara, 1992). Due to a lack of mature concept of death, the essential features of suicidality in children according to many developmentalists are thoughts or behaviors centered on an intention to cause serious self-injury or death, irrespective of capacity to comprehend the lethality of self-injurious behaviors (Connolly, 1999; Pfeffer, 1997; Tishler, Reiss, & Rhodes, 2007). We were guided by that approach in defining suicidal ideation in the present study.
The association between thoughts about death and suicide suggests one cognitive mechanism that may account for some children initiating thoughts about suicide (Orbach, Feshbach, Carlson, Glabman, & Gross, 1983; Tishler et al., 2007). Preoccupation with death, either as excessive worry or attraction, has been linked to childrens suicidal ideation (Orbach et al., 1983; Orbach, Feshbach, Carlson, & Ellenberg, 1984; Pfeffer, 1986; Pfeffer et al., 1984). Children who are preoccupied with death, either through direct experience or as a symptom of depression, may be more likely to adopt thoughts about suicide (Orbach et al., 1983; Tishler et al., 2007). Although the nature of this association has not been evaluated, children with recurrent thoughts about death may initiate active thoughts about inducing self-harm or death if they experience additional acute distress.
In response to several gaps in knowledge of suicidal behavior in children, this study had four goals. First, we sought to determine rates of suicidal ideation and behavior in a community sample of 69 year olds in the top tercile (33%) of aggressive-disruptive behavior in urban classrooms identified through population-level screening. This screening for maladapting children was done to form the sample of a randomized trial to test an intervention for such high risk children (Rochester Resilience Project; Wyman, Cross, & Barry, 2004). We concentrated on suicidal ideation because we expected very low rates of suicide attempts. A second goal was to identify the mental health problems reported by children and parents, and to see which problems, if any, differentiated children with and without suicidal ideation. Increased knowledge of suicidal thinking for young children with elevated disruptive behavior problems has value for several reasons. Externalizing problems are risk factors for suicidal behavior in adolescents (e.g., Gould et al., 1998) but have received little attention in studies of suicidal thinking in children. The tendency for externalizing behavior patterns to be moderately stable over time (Hinshaw, 2002) also suggests that early manifestations of disruptive behavior may foreshadow ongoing risk for suicide both through a direct link with early onset of suicidal thinking and through an indirect link with later conduct problems. Another advantage of our design was to clarify risk factors for suicidal ideation among African American youths, which have been identified as a priority due to disproportionate increase in suicides for this group (CDC, 1998).
We had two additional goals using qualitative methods. The first was to ascertain the degree of co-occurrence between thoughts about suicide and thoughts about death, which we expected would be associated in our community sample as they have been in clinical samples (Orbach et al., 1983). In addition, we combined qualitative (Ponterotto, 2002) and empirical methods to categorize the triggers and motivators children described for thoughts about suicide and death during interviews. We expected that difficulties in managing emotions would be the most common trigger described by children for suicidal thinking. If we were to find that thoughts about death and suicide co-occurred, yet were associated with different motivators and/or triggers, this finding would be consistent with the view that difficulty managing emotional experiences is a specific factor contributing to childrens initiating thoughts about suicide.
Participants were 349 1st 3rd graders in five schools in Rochester, NY recruited for a prevention trial (Rochester Resilience Project; Wyman et al., 2004). The intervention teaches children skills to enhance emotional and behavioral self-control and to apply those skills through in vivo coaching during the school day. Guided by a developmental epidemiology approach (Kellam, Koretz, & Moscicki, 1999), our evaluation focused on a representative subgroup of students in a defined ecological context, which minimizes selection bias and strengthens inferences about intervention effects (Brown, Kellam, Ialongo, Poduska, & Ford, 2007). In this case the defined population was 1st 3rd grade children in the top tercile (33%) of aggressive-disruptive behaviors rated by teachers. Across schools, most children were African American (5079%) and 76-86% were eligible for reduced school lunch fee.
Over two school years (2006 2008), all children in all 75 kindergarten 3rd grade regular education classes (n=1,968) were screened using the Teacher Observation of Classroom Adaptation Revised (Werthamer-Larsson, Kellam, & Wheeler, 1991), a structured interview administered by a trained member of the assessment team, who records the teachers rating of each childs performance on core classroom tasks during the preceding three weeks on a 6-point scale (never true to always true). Screening in 1st3rd grade classrooms occurred in late OctoberNovember of each year and in kindergarten classes in MarchApril of the year preceding childrens entry into first grade. The authority acceptance/aggressive behavior subscale was used to identify the target population (top tercile, or highest 1/3rd) using norms established in the same schools in the preceding year. A total of 749 children were targeted by screening; after exclusions (e.g., children relocating to another school were excluded; if multiple siblings were targeted one was randomly selected), 578 were eligible, and 349 children enrolled. There were no differences between enrolled and non-enrolled children on teacher screening ratings, sex, or on teacher ratings examined separately for boys and girls. The average age was 7.5 years (SD=1.07); 60.7% were males, 63% were African American, 20.6% Hispanic/Latino, 4% were White, and 12.3% were other race or multiracial.
Written consent from parents and verbal assent from children was obtained prior to assessments. The measures used for this study were completed during a baseline assessment prior to each childs random assignment to either intervention or control condition. The University of Rochester Institutional Review Board approved the study protocol, which included a safety protocol for responding to children identified with suicidal thoughts or behaviors.
Prior to intervention children were individually administered the Dominic Interactive (DI; Valla, Bergeron, & Smolla, 2000), a computerized self-report interview for 6 11 year old children that assesses symptoms of seven DSM-IV diagnostic categories: specific phobias, separation anxiety, generalized anxiety, depression, opposition (ODD), conduct problems, and attention deficit hyperactivity disorder (ADHD) (American Psychiatric Association, 1994). The DI uses both visual and auditory channels; color pictures accompanied by a soundtrack present Dominic, a child specific to the target childs sex and race, in situations illustrating different emotional and behavioral content. A voice-over describes Dominic with 91 symptoms, and the child is asked whether he/she feels or behaves like Dominic (yes/no). In addition to total symptoms, the DI has a clinical cut-point (probable diagnosis) for each diagnostic category, created to identify children with the highest 510% of symptomatology in a community sample (Valla et al., 2000). We used total symptom scores and placed children in one of two groups for each category: probable diagnosis or without a probable diagnosis.
DI symptom scores differentiate children with and without clinical diagnoses, and adequate test-retest reliabilities were found for the DSM-III version of the DI (Valla, Bergeron, Berube, Gaudet, & St-Georges, 1994). In a study of concurrent validity (Linares, Short, Singer, Russ, & Minnes, 2006), low-moderate correlations were reported between DI scales and scores on the Child Behavior Checklist (CBCL; Achenbach, 1991a) and the Conners Teacher Rating Scale-28 (CTRS-28; Conners, 1990) for externalizing symptoms. Internal consistency estimates for DI diagnostic categories are moderate to good (range .61.72; Linares et al., 2006).
Suicidal Thoughts and Behaviors Interview
Suicidal ideation (SI) and behavior was assessed through a structured interview given to each child who answered yes to the following DI item from the Depression scale: Do you think about death or about killing yourself? Childrens narrative responses were analyzed for the qualitative portion of this study. The interview, including scoring criteria, is available from the first author. The interview combines structured questions with age-appropriate prompts designed to elicit details about the childs thoughts and past behaviors. Children were asked 1) do you think about death? and 2) do you think about hurting or killing yourself? The interviewer used prompts to encourage the child to elaborate each response (e.g. can you tell more about that?). Children were also asked have you ever tried to hurt/kill yourself The interviewer recorded verbatim each childs narrative responses. The interview was administered to 84 children, i.e., 24.1% of the sample who responded affirmatively to the DI item. Interviewers initiated a safety protocol for any child who expressed suicidal thoughts or behaviors by notifying a designated school professional (e.g., social worker, psychologist) who contacted the child before the end of the school day to determine appropriate follow-up, which might include immediate notification of parents, contacting crisis services or obtaining additional ongoing school support services for the child.
The typical childs narrative in response to an affirmative answer about SI or thoughts about death was fairly brief and consisted of no more than several sentences. The responses were scored independently by two licensed psychologists for presence or absence of the following. Suicidal Ideation (SI): we employed Pfeffers (1981) definition of suicidality in children, i.e., thoughts about killing oneself or about engaging in behaviors that if carried out would lead to serious self-injury or death. For example, having thoughts about stabbing oneself was considered SI even if the child did not specifically indicate an intention to die. Method of Suicidality: defined as specific method of self-harm behavior described by child (e.g., stabbing oneself, jumping off a building); and Suicide Attempt, defined as a specific incident of deliberate action designed to cause serious self-injury or death. In scoring, the raters took into account the totality of a childs response. For example, one child answered yes to having thoughts about hurting/killing himself, but his subsequent comments indicated that he was afraid of being hurt while playing hard rather than having thoughts about intentional self-harm or wanting to die; this child was not scored with suicidal ideation by either rater. Inter-rater reliability (Kappa coefficients) for all three variables was 1.0 (p < 0.001). In addition, narratives were scored for Recurrent Thoughts about Death; inter-rater reliability (Kappa coefficient) was 0.97 (p < 0.001).
Youth Outcome Questionnaire (YOQ-2.0)
Each childs parent completed the 64-item YOQ-2.0 that evaluates childrens functioning across behavioral, emotional, and social areas (Burlingame, Wells, & Lambert, 1996). Parents rate how well each item (e.g. Appears sad or unhappy) describes their child during the past seven days using a five-point Likert scale (never almost always). The subscales are: Intrapersonal Distress, Somatic Problems, Interpersonal Relations, Social Problems, and Behavioral Dysfunction. Relative to symptoms on DSM diagnostic categories, the Intrapersonal Distress scale contains items describing dysphoria and anxiety; the Somatic Problems scale describes physical complaints, sleep and eating difficulties; the Interpersonal Relations scale includes items on relating and communicating with family and peers; the Social Problems scale includes items on stealing and property destruction, and the Behavioral Dysfunction scale describes oppositional problems, impulsiveness and distractibility. Higher scores on each scale reflect lower functioning. YOQ-2.0 subscales have moderate to high internal consistency, correlate with other measures (e.g., Children Behavior Checklist), and have adequate test-retest reliabilities (0.62 0.78) (Burlingame et al., 1996; Whoolery, 1997).
Prior to testing the relationship between suicidal ideation (SI) and symptoms, we examined sex and age differences on symptoms. Girls reported more symptoms of specific phobias (F (1,338)=15.40, p< 0.001), separation anxiety (F (1,338)=5.76, p< 0.05), generalized anxiety (F (1,338)=9.50, p< 0.01), and depression (F (1,314)=4.84, p< 0.05), compared to boys. Boys reported more symptoms of conduct problems (F (1,338)=5.53, p< 0.05). Parents reported more somatic problems for girls (F (1,293)=6.99, p< 0.01). In addition, 89 year old children reported more conduct problems than 67 year olds (F (1,338)=5.68, p< 0.05), and parents reported more somatic problems for 89 than 67 year olds (F (1,338)=4.85, p< 0.05).
For the primary analyses, we first examined demographic characteristics associated with SI using ?2 analyses and t-tests. To assess symptoms associated with SI, we used multiple analysis of covariance (MANCOVA), with age and sex as covariates, SI status entered as a between group factor, and DI or YOQ subscales as the dependent variables. Race/ethnicity was not included as a covariate due to low variability. For significant between group differences, we calculated an average standardized effect size for SI status based on regression models that included age and sex as covariates (ESs; Rosenthal, 1994). We extended our models by including interaction terms for SI status by age and by sex; simple slopes analyses were used to elucidate significant interaction terms (Preacher, Curran, & Bauer, 2006). We used logistic regression to test differences in clinically significant symptoms on the DI by SI status. In secondary analyses, we tested differences on symptoms between children reporting SI and thoughts about death without SI using analysis of covariance that included sex and age as covariates. Unless otherwise reported, all reported coefficients are significant at the 0.05 level or stronger. For the qualitative portion of this study, we used methods from grounded theory research (Strauss & Corbin, 1990) to categorize themes in childrens narratives.
Prevalence of Suicidal Thoughts/Behaviors
Overall, 8.60% (30/349) of children had suicidal ideation (SI). The proportion of children reporting SI was highly comparable for those who enrolled in 2006 07 (8.7%; 17/195) and 2007 08 (8.4%; 13/154). Table 1 summarizes rates of SI by sex, age, and race/ethnicity groups. Children with and without SI had comparable mean age. The proportion of girls with SI (10.95%) was directionally higher than boys (7.08%) but not significantly different (?2 (df=1) = 1.59, p< 0.21). Likewise, rates of SI were not different for children ages 67 (7.96%) versus ages 89 (9.76%) (?2 (df=1) = 0.35, p< 0.55), nor was there a linear relationship between age in months and the likelihood of reporting SI (B=0.01, S.E.=0.15, Wald statistic=0.55, p < 0.46).
Mean age (months) 91.73 89.92 Age 67 years 810 years Gender Girls Boys Race-Ethnicity Black (not Hispanic) White (not Hispanic) Hispanic Other/multiracial
Mean age (months)
Black (not Hispanic)
White (not Hispanic)
Of the 30 children reporting SI, seven (23%) described thoughts about using a specific method to kill or hurt themselves; three were in the 67 year old group and four in the 89 year old group. Stabbing oneself was the most common method described. One child (0.29% of the sample) reported a prior suicide attempt, and this child also reported SI. Our subsequent analyses focused solely on suicidal ideation.
Mental Health Problems Associated with Suicidal Ideation
Children with SI reported more overall mental health symptoms (Wilks Lambda (7,326) = 0.929, p < 0.001) and more symptoms of depression (ES=0.97), oppositional defiant disorder (ES=0.70), conduct problems (ES=0.74), and attention deficit hyperactivity disorder (ES=0.78) (summarized in Table 2). Children with SI reported directionally higher (p < 0.07), but non-significantly different levels of separation anxiety compared to children with no SI. The relationship between SI and self-report symptoms did not vary by sex or age.
Comparisons between children with and without suicidal ideation on mental health functioning reported by children (DI) and parents (YOQ).
Specific Phobia DI Separation Anxiety DI Generalized Anxiety DI Depression DI Oppositional (ODD) DI Conduct Problems DI ADHD DI Intrapersonal Distress - YOQ Somatic Problems - YOQ Interpersonal relations - YOQ Social Problems - YOQ Behavior Dysfunction - YOQ Note. DI= Dominic Interactive (child report);
YOQ = Youth Outcome Questionnaire (parent
Specific Phobia DI
Separation Anxiety DI
Generalized Anxiety DI
Oppositional (ODD) DI
Conduct Problems DI
Intrapersonal Distress - YOQ
Somatic Problems - YOQ
Interpersonal relations - YOQ
Social Problems - YOQ
Behavior Dysfunction - YOQ
Note. DI= Dominic Interactive (child report);
YOQ = Youth Outcome Questionnaire (parent
The relationship between parent reports of childrens functioning (YOQ) and SI was stronger for older than younger children. The main effect of SI status on total YOQ was not significant (Wilks Lambda (5,270) = 0.947, ns); however, we found a directionally positive age by SI interaction for total YOQ (Wilks Lambda (5,270) = 0.964, , p < 0.07) and significant age by SI interactions for the Intrapersonal Distress (F (1,279) = 4.82, p < 0.03), Somatic Problems (F (1,279) = 6.96, p < 0.009), and Behavior Dysfunction subscales (F (1,279) = 6.80, p < 0.01) (summarized in Table 2). In each case, parents rated 89 year olds with SI as having more emotional and physical distress symptoms and lower behavioral control and functioning, whereas parents of 6 7 year olds reported no differences (summarized in Table 3). On Intrapersonal Distress (i.e., dysphoria and anxiety), there was a directionally similar but non-significant (p < 0.07) relationship, with parents rating 8 9 year olds with SI as more distressed (Table 3). For children with SI, simple slopes analyses showed that greater age was associated with higher parent ratings of Intrapersonal Distress (ß = 0.43, p < .03) and Behavior Dysfunction (ß = 0.48, p < .01), and a trend towards more Somatic Problems (ß = 0.37, p < .07), whereas for children without SI age was not associated with parent ratings. No sex differences were found in the associations between SI and problems reported by children or parents. Analyses conducted separately for children enrolled in the first and second year showed comparable findings.
Table 3 1Note. For 67 year olds, df= 1,191; 2For
89 year olds, df=1,107. p<0.07;
*p<0.05; **p<0.01; ***p<0.001.
1Note. For 67 year olds, df= 1,191; 2For 89 year olds, df=1,107. p<0.07; *p<0.05; **p<0.01; ***p<0.001.
Children with SI were 5.8 times more likely to report clinically significant levels of depression symptoms, and 3.5 and 4.2 times more likely to report clinically significant levels of conduct and ODD problems, respectively (summarized in Table 4). Children with SI were 3.7 times more likely to report clinically significant levels of symptoms on one or more DI scales compared to children without SI (79.3% versus 51.0%, respectively).
Dominic Interactive Specific Phobia (41) 1.36 1.38 0.94
Qualitative Analyses of Narratives about Suicidal Ideation and Thoughts of Death
In this next section, we extend our examination by evaluating the association between SI and thoughts about death. Fifty-four children (15.5%) reported recurrent thoughts about death (54/349). We found substantial but not complete overlap between SI and thoughts of death. Of the 30 children with SI, 21 (70%) also reported thoughts about death. Children were 8.4 times more likely to report SI if they also reported thoughts about death (Relative Risk = 8.43, 95% CI: 4.23-17.09, p < 0.001). Children with SI, compared to those with thoughts of death and no SI (n=33), reported more oppositional (ODD) symptoms (F (1,58) = 3.91, p < 0.05); otherwise there were no differences between the two groups on symptoms reported by children or parents.
Next, we examined childrens narrative responses to the interview to identify and contrast the motivators and triggers described for SI and thoughts of death. We used methods from grounded theory research (Strauss & Corbin, 1990). This format included theme generation and reduction through open and axial coding. We used the following definition for motivators and triggers: thoughts, experiences or emotional states described by children as preceding, accompanying, or being the reason for their thoughts about suicide or death. First, we used an open-coding approach to examine each narrative and give a conceptual name to each separate theme. After this data fracturing, those themes were grouped into categories using axial coding designed to link together the separate concepts. For example, different emotional states described as motivators for suicidal thoughts (e.g., frustration, anger, sadness) were linked together under a single theme. Definitions and scoring criteria are available from the first author. To identify the most common themes and the reliability of the criteria, two raters independently scored each narrative accompanying childrens descriptions of SI or thoughts of death for the presence of each theme. A childs narrative could be scored with more than one theme. One of the raters had not been involved in identifying the themes or developing their definitions.
The specific themes identified in the narrative analyses, exemplars of each theme from actual narratives, the proportion of children with SI and thoughts of death whose narratives contained each theme, and inter-rater reliabilities are summarized in Table 5. The inter-rater reliabilities were uniformly high (0.84 1.0). The motivators and triggers for SI centered on experiences of strong emotions such as anger or sadness, being in conflict situations, or anticipating losses or abandonment. Anger or Dysphoria and Interpersonal Conflict (e.g., fights with siblings, being bullied) were the most common themes associated with SI, with 40% and 37% of the narratives, respectively, containing those themes. The theme of Loss/ Abandonment was identified in 9.5% of the narratives. Overall, 76.7% of the narratives of children with SI contained one or more of the preceding themes.
Anger or Dysphoria sometimes I get angry and just want to
kill myself Interpersonal Conflict I want to kill myself when my mom gets mad
at me Loss/Abandonment I think about killing myself because no
one cares about me Illustrative example Personal Safety Concerns getting shot, stabbed, killed Family Member Died/Injured I think about my grandma who
died Worries about Family Member I think about my mom dying 1Note. Inter-rater reliability (Kappa
Anger or Dysphoria
sometimes I get angry and just want to
I want to kill myself when my mom gets mad
I think about killing myself because no one cares about me
Personal Safety Concerns
getting shot, stabbed, killed
Family Member Died/Injured
I think about my grandma who died
Worries about Family Member
I think about my mom dying
1Note. Inter-rater reliability (Kappa coefficient)
Compared to thoughts about suicide, children described distinctly different triggers and motivators for their thoughts about death. Those themes centered on worries about their own safety and worries about the safety and well being of their family members. Personal Concerns about Safety was the most frequent trigger/motivator, found in 48% of the narratives, followed by Family Member Died/Injured (17%) and Worries about Family Member (18%). Children frequently referenced actual violent events such as having witnessed a robbery or having a family member killed or injured as a result of community violence. Overall, 75.5% of children with thoughts of death had one or more of the preceding themes.
To our knowledge, this is one of the first studies of suicidal ideation (SI) in a community sample of children younger than age 9. We found an 8.6% rate of SI in urban, predominantly low-income children with an average age of 7.5 years, selected to be representative of the top tercile (33%) of aggressive-disruptive behavior. Whereas prior studies of suicidal behavior in young children have used clinical or convenience samples, many with over-sampling of maltreated or prenatally drug-exposed children (Finzi, et al., 2001; OLeary et al., 2006; Payne & Range, 1996), our sample was selected through a population-based screening of all 1st 3rd grade regular education classrooms in five schools. Suicidal ideation was assessed using a two-stage method that combined a standardized questionnaire item and individual interviews to assess suicidal thinking. Our finding that 8.6% of these maladapting children had SI is likely to be a conservative estimate given that we did not sample children with a special-education designation for behavioral or emotional problems. An 8 9% rate of SI is comparable to or even higher than the 3- and 6-month prevalence rates for SI found in community samples of older preadolescents and adolescents (e.g., Gould et al., 1998). Suicidal thinking in young children outside clinical settings warrants increased recognition, including how to determine the potential for life-threatening behavior, respond effectively and identify effective prevention approaches.
The self-reported mental health symptoms associated with SI in our sample were comparable to those risk factors for suicidal thoughts and behavior in community samples of older youth (Foley et al., 2006; Gould et al., 1998; Kandel, 1988). Children with SI reported more symptoms of depression as well as a broad spectrum of behavior problems including ODD, conduct problems, and ADHD. Children with SI were nearly six times more likely to report clinically significant levels of depression and three to four times more likely to report clinically significant levels of ODD and conduct problem symptoms. The relationship between parent ratings of childrens symptoms and childrens suicidal ideation status was stronger for older than younger children. Parent ratings differentiating 8 9 year olds with and without SI were congruent with childrens self-reported symptoms of oppositional problems, ADHD and somatic complaints, whereas parents did not differentiate between 6 7 year olds with and without SI.
Based on childrens self-report of symptoms, our findings suggest that there is substantial continuity in the mental health risk factors associated with suicidal ideation in older youth and those risk factors in 6 9 year olds with elevated externalizing problems. However, parent ratings may not capture internalizing symptoms associated with SI in this age-group or some behavioral problems associated with SI among children at the younger end of this age range. Regarding the lack of consistency between children and parents on distress symptoms associated with SI, our findings are consistent with the prior literature in several ways. Among eight year olds at risk for, or having experienced, maltreatment, children were two times more likely to report SI than their caregivers, who were in concordance with child ratings of SI about one-quarter of the time (Thompson et al., 2006). Moreover, caregiver-child agreement on SI was associated with perceptions of externalizing and somatic problems but not internalizing problems. Studies in the child clinical and developmental literatures also indicate that agreement tends to be low between parents and children about the psychological symptoms that children are experiencing, particularly for anxiety and depression (Schniering, Hudson, & Rapee, 2000; DiBartolo, Albano, Barlow, & Heimberg, 1998). More to the point, younger child age is associated with less agreement between parents and children on symptoms (e.g., Edelbrook, Costello, Dulcan, Kalas, & Conover, 1985; Grills & Ollendick, 2003). Combined with the preceding information, our finding of a linear increase in levels of intrapersonal distress and behavior problems reported by parents for children with SI suggests that developmental changes during early school age may enhance parents sensitivity to problems in children associated with suicidal thinking. Increased verbal skills, particularly verbalization about emotional experiences (Riggs, Greenberg, Kusche, & Pentz, 2006), may be one important developmental change linked to parents awareness of distress among children experiencing suicidal ideation.
Our analyses of childrens narratives about their SI suggest that difficulty managing emotions in the context of adversity may be an important proximate risk factor explaining how specific children initiate thoughts about hurting or killing themselves. Anger and dysphoria were the most frequent precipitants or emotional states referenced by children for their suicidal thoughts, in the context of interpersonal problems such as family conflict, being bullied, or fears about parents leaving. The theme of difficulty managing emotions also helps illuminate the association between SI and seemingly disparate individual-level risk factors as depression and disruptive behavior problems. Both depression and disruptive behavior disorders have been conceptualized as disorders involving difficulties in the regulation of emotional experience (Cicchetti & Toth, 1998; Dodge & Pettit, 2003). Children exhibiting symptoms of those disorders have difficulties effectively managing every-day emotional challenges and maintaining emotional equilibrium, although the manifest behavioral expressions of emotional dysregulation for those disorders vary, ranging from withdrawal to aggressive outbursts. Intense emotional activation often limits cognitive flexibility and adaptability (Gross, 1998), which may also contribute to a childs vulnerability to adopting thoughts about suicide as a response to stress.
Children were eight times more likely to have suicidal thinking if they also reported recurrent thoughts about death. Whereas prior studies have linked concerns about death and SI in clinical samples (e.g., Pfeffer, 1986), this study expands that association to a community sample. Compared to SI, childrens thoughts about death were associated with distinctly different triggers and motivators, the latter centering on concerns about personal safety, safety of family members, and violence. Compared to those with thoughts of death without SI, children with SI reported more oppositional problems, whereas the two groups had comparable levels of other symptoms. Recurrent thoughts about death have been suggested as a possible predisposing cognitive factor for SI (Tishler et al., 2007). Our cross-sectional findings cannot elucidate whether thoughts of death predispose a child to adopting suicidal thoughts. Future prospective studies should examine if children who are preoccupied with death (e.g., after violence exposure) are at elevated risk for suicidal thinking if they experience acute emotional distress. How adversity experiences contribute to suicidal thinking needs further clarification to elucidate the association between suicidal ideation and poverty (Foley et al., 2006) as well as the reasons for climbing rates of suicidal behavior in African American males (CDC, 1998).
Currently, the field of youth suicide prevention is strongest in developing and evaluating strategies (e.g., screening, gatekeeper training) to identify adolescents who are suicidal, or at high risk for suicide, to facilitate referral for mental health treatment (Brown, Wyman, Guo, & Pena, 2006; Eggert, Randell, Thompson, & Johnson, 1997; Gould & Kramer, 2001; Wyman et al., 2008). Our findings suggest that many young children with SI may be overlooked by this focus on suicidal behavior beginning in adolescence. In light of evidence that longer delay between onset and treatment for mental health problems predicts poorer outcomes (Kessler et al., 2007), not addressing SI in younger children may have high costs. Early manifestations of externalizing problems and poor socialization may be useful targets for suicide prevention due to their direct association with SI among young children and the potential for ongoing behavior problems into adolescence that increase risk for suicidal behavior at that phase of development (Gould et al., 1998). Recent results from a prevention trial support that view: children who received a 1st grade classroom intervention aimed at strengthening socialization and reducing aggressive behavior (Good Behavior Game) had lower rates of SI and fewer suicide attempts by age 1921 (Wilcox et al., 2008). In addition, the effects of the Good Behavior Game on reducing suicidality were not specific to early maladapting children. This study suggests that universal prevention programs that reduce behavior problems and improve socialization over time may decrease risk for suicidal behavior and serve to complement indicated interventions for children with specific elevated problems such as externalizing problems and depression. We suggest the following foci for future research. Studies are needed to determine the prevalence of suicidal thinking and behavior in different subgroups of children, including factors that govern continuity and change in suicidality. In addition, intervention trials are needed to test specific mechanisms that may account for reducing risk for suicidal behavior in order to develop more effective suicide prevention strategies (Brown, Wyman, et al., 2007).
Several limitations of this study should also be noted. We employed a definition of SI tailored to the developmental level of 6 9 year olds (Pfeffer, 1981), which included thoughts about self-injurious behaviors without necessarily the intention to kill oneself. How well this definition captures a developmental precursor of SI assessed in studies of older youth that focus on intention to die is unclear. However, we note that several studies of older youth have also used broader definitions of suicidality (e.g., Foley et al., 2006). There are also limitations in comparing the mental health symptoms assessed in this study with assessments yielding psychiatric diagnoses used in community samples of older youth (e.g, Foley et al., 2006; Gould et al., 1998). This study used measures of symptoms by children and domains of functioning reported by parents, and we cannot draw conclusions about relationships between diagnoses and suicidal ideation in our sample. Our findings also may not generalize to children outside of the top tercile of aggressive-disruptive behavior. We conducted our study in a community with high rates of violence and family poverty. To what extent those contextual factors affect prevalence rates of suicidal thinking and alter associations between individual-level mental health risk factors and suicidal behavior is unknown and is another needed focus for future research.
We are grateful to the families and staff of the Rochester City School District, including our long-term colleague Mr. Gary Hewitt. We also thank the following individuals: Suzanne Coglitore and Mariya Petrova from the Resilience Project Team; and David B. Goldston, Thomas G. OConnor and Anne J. Russ for helpful comments and improvements. We acknowledge support from the National Institute of Mental Health under grants R01 MH068423, and T32MH018911-18, and from the NIMH/NIDA under grants P20MH071897 (Developing Center for Public Health and Population Interventions for Preventing Suicide; E D Caine, PI) and R01MH40859.
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Melinda Paige, Ph.D., LPC, NCC, CPCS, an assistant professor in Clinical Mental Health Counseling at Argosy University, Atlanta, tells Bustle that it's common for media coverage to be difficult for people who have lost someone to suicide or experienced suicidal thoughts themselves. "It can bring back those feelings, the grief they're experiencing. It also seems to trigger anger for many people. To help with the anger, it's important to know that suicide is an act of desperation," she says. "Its somebody in a great deal of pain psychologically who feels like theyre taking themselves out of a situation where theres causing more pain."
Dr. Soroya Bacchus, M.D., tells Bustle that copycat suicides are a concern for professionals although not for the reasons we may suspect. People aren't simply mimicking the behavior they see on the news, she says. Instead, coverage of suicide often reminds people of their own loneliness or depression. If you're thinking about suicide, she says, you should tell someone whether it's a help line, a psychiatrist or a trusted loved one. Dr. Bacchus also emphasizes the importance of treatment and recovery. "Suicide and depression are treatable! People go around and this is normal. It is not the way people are supposed to be. It's treatable," she tells Bustle via email.
If you're feeling upset, it's OK more than OK to log off. Paige says to take time off from work or other obligations if you need to. "Depression is a serious mental illness. If someone suffered from it and if theres a trigger like the media, its important to pull out," she says. But on top of disengaging with media, being engaged through in-person connections is helpful. "Anything you can do to reach out and verbalize your suffering and be heard" is critical, she says. She suggests reaching out to friends, family, or loved ones, or through your faith community, or signing up for counseling, even if it's only for a few sessions. "Increased self-care," in her words, can also be incredibly helpful "doing those things you find soothing and taking care of yourself."
If you love someone who lives with depression, a news cycle centered on suicide can hit too close to home. But Paige says it's important to be there for the people you love, especially if you suspect they may be struggling. "What we do when someone tells us about our pain, we get uncomfortable. We talk about ourselves, we distance ourselves. Empathy means to be with," she says. "Though its natural to make it about something in your life, to say 'I understand' or 'I've experienced that pain,' it isn't the same as true empathy." Paige suggests using the phrase, "I'm just so glad you told me," as a means of showing your friend that they're seen.
Unless you're a mental health professional, you won't be able to fully counsel someone through a depressive episode but you can help them get the support they need. "Typically people think if I ask, 'Are you OK'?, it can be triggering, but it's not," Paige says. "It's OK to ask, if this is a discussion that's come up before, 'Are you considering suicide or ending your life'?. That doesnt cause someone to do it. It can be a relief to have someone acknowledge their suffering." It's also critical, if you think a loved one may need support, to reach out social withdrawal is a major warning sign of suicidality, and someone who is struggling may not feel capable of reaching out for help.
It's OK to not have an answer, or a solution, to their pain. "I'm amazed at how people say, 'Maybe go to church' or 'Maybe there's something you did last week that's causing these feelings.' Just listen. Don't offer any advice, or minimize it. I see a lot of patients who come in and their loved ones are trying to trivialize it because they're uncomfortable," Dr. Bacchus says.
Mental illness isn't easy, and if you're feeling unwell because of a news cycle filled with discussion about suicide, you aren't alone.
If you or someone you know are
experiencing suicidal thoughts, call 911, or call the
National Suicide Prevention Hotline at 1-800-273-8255 or
text SOS to the Crisis Text Line at 741741.