According to the Centers for Disease Control, suicide was the fifth leading cause of death in preadolescent children in 2019 — up from the 10th leading cause in 2008. However, we know considerably less about self-injurious thoughts and behaviors (SITBs) in preadolescents compared to older children. Given this worrisome increase in the prevalence of preadolescent suicide over the last decade, the National Institute of Mental Health has identified preadolescent suicide as a priority for research and intervention.
Richard Liu, PhD, Director of Suicide Research in the Division of Child and Adolescent Psychiatry at Mass General, and his colleagues have recently published several studies shedding light on some of the factors specific to suicide in children. Research on suicide in younger children is limited, and we cannot assume that the factors influencing SITBs in preadolescents are the same as observed in adolescents. Importantly, he notes that it is essential to look not only at suicide attempts but to include information on suicidal ideation and non-suicidal injury (NSSI), given recent data indicating that NSSi may be a stronger predictor of future suicidal behavior than a history of suicide attempt.
Review of the Current Literature
In a systematic review and meta-analysis, Liu and colleagues identified studies providing data on the prevalence and correlates of preadolescent self-injurious thoughts and behaviors (SITBs). The analysis includes 58 studies and over 600 million individuals.
In community samples, lifetime prevalence rates were 15.1% for suicidal thoughts, 2.6% for suicide attempts, and 6.2% for non-suicidal self-injury among preadolescents (younger than 13 years of age). Based on these numbers, the researchers estimate that approximately 17.0% of preadolescents with suicidal ideation transition to attempting suicide.
Only sex emerged as a moderator of prevalence of suicidal ideation and suicide attempts; samples including more male individuals had higher lifetime prevalence of STIBs. Among specific disorders, ADHD was the second strongest clinical correlate of suicidal ideation, a finding which is consistent with the widely held view that externalizing disorders are more characteristic of suicidal behaviors in preadolescents than in adolescents. However, the authors note that across specific disorders, depression had the strongest association to suicidal ideation and a medium association to suicide attempts. Thus, depression should not be discounted in preference to externalizing disorders in evaluating preadolescent suicidal thoughts.
Parental support was a particularly protective factor during childhood, whereas child maltreatment was an important correlate of risk for suicidal ideation.
Data from the Adolescent Brain Cognitive Development Study
In another study, Hannah Lawrence, PhD from McLean Hospital, in collaboration with Taylor Burke, PhD and Richard Liu, PhD at Mass General, evaluated sociodemographic and diagnostic predictors of suicidal ideation and attempts in a nationally representative sample of preadolescent youth enrolled in the Adolescent Brain Cognitive Development (ABCD) Study. Rates and predictors of psychiatric treatment utilization among suicidal youth also were examined.
The analysis included 11,875 9- and 10-year-old children living in the United States. In the ABCD study, children and their parents/guardians provided information on children’s lifetime history of suicidal ideation, suicide attempts, and psychiatric illness history. Parents also reported on sociodemographic characteristics and mental health service utilization. Multivariate logistic regression analyses were employed to evaluate sociodemographic and diagnostic correlates of suicidal ideation, suicide attempts among youth with suicidal ideation, and treatment utilization among those with suicidal ideation and suicide attempts.
In this study, lifetime prevalence rates were 14.33% for suicidal ideation and 1.26% for suicide attempts.
Suicidal ideation was less commonly reported in females (OR = 0.71), and in those who identifying as Hispanic (OR = 0.73) or Black (OR = 0.77). The sociodemographic characteristics associated with increased odds of suicidal ideation included sexual minority status (OR = 3.81), being multiracial (OR = 1.39), and lower family income.
Suicide attempts were more commonly reported in sexual minority youth (OR = 2.55) and those with lower family income.
Comorbid psychopathology was associated with higher odds of both suicidal ideation and suicide attempts. Having any psychiatric condition was associated with greater odds of suicidal ideation (OR = 2.67), with the odds of suicidal ideation increasing when youth experienced two or more disorders (OR = 3.79). The following disorders emerged as significant predictors of suicidal ideation: MDD (OR = 4.47), GAD (OR = 1.85), conduct disorder (OR = 1.78), oppositional defiant disorder (OR = 2.00), and ADHD (OR = 1.43).
In children with suicidal ideation, having a single psychiatric diagnosis did not increase the odds of suicide attempt. However, having two or more psychiatric diagnoses significantly increased the odds of suicide attempts (OR = 2.17).
After accounting for all diagnoses and controlling for sociodemographic variables in a multivariate analysis, only social anxiety (OR = 2.39) remained a significant predictor of suicide attempts, whereas separation anxiety was associated with lower odds of suicide attempts (OR = 0.47).
In this group, 35% of youth who reported suicidal ideation and 55% of youth who had attempted suicide received psychiatric treatment. Treatment utilization among suicidal youth was lower among those who identified as female, Black, and Hispanic.
Moving Forward
While suicide is rare in preadolescents compared to adolescents, these findings indicate that self-injurious thoughts and behaviors are by no means rare in younger children. The finding in both of these studies of high rates of suicidal ideation and even suicide attempts in preadolescents — coupled with increasing rates of preadolescent suicide in the United States — underscore the need to clarify predictors of suicide risk in children and to identify predictors which differentiate children who experience a suicide attempt from those with suicidal ideation
Previous studies have observed that rates of suicidal ideation and suicide attempts are more common among female adolescents than their male peers; however, this does not appear to be the case in preadolescents.
Consistent with patterns observed in adolescents and young adults, sexual minority youth are at elevated risk for self-injurious thoughts and behaviors. These studies extend this literature, showing that in youth as young as 9 and 10 years or age, those identifying as a sexual minority were nearly four times as likely to report suicidal ideation and had a twofold greater odds of having made a suicide attempt than those identifying as their heterosexual peers.
In terms of diagnostic predictors of suicidal ideation and suicide attempts, having at least one psychiatric condition was associated with greater odds of lifetime suicidal ideation, and the strongest effects were seen for youth who had two or more disorders, which predicted both suicidal ideation and suicide attempts. Individual diagnoses were less consistent predictors of suicidal ideation and suicide attempts in this age group. While the meta-analysis indicated that depression and ADHD were associated with increase risk for suicidal ideation and suicide attempts, the ABCD study observed that major depressive disorder was associated with increased odds of suicidal ideation but not suicide attempts among youth with suicidal thoughts.
The findings of these studies shed light on important sociodemographic and diagnostic considerations which will help to guide the development of targeted prevention efforts. More specifically, prevention approaches in preadolescents may benefit from a greater focus on sexual minority youth and youth from low-income families, as well as youth with multiple psychiatric comorbidities.
Future research must also address the fact that preadolescents with suicidal ideation or suicide attempts received treatment at lower rates than their adolescent counterparts. This may reflect a lack of recognition among parents and providers of the seriousness of expressions of suicidality in this age group. Regular screening for suicidal thoughts and behaviors in settings where youth are regularly seen (e.g., primary care, school) coupled with referrals to mental health services may help to lower rates of suicidal ideation and behavior among preadolescent youth.
Read More
Lawrence HR, Burke TA, Sheehan AE, Pastro B, Levin RY, Walsh RFL, Bettis AH, Liu RT. Prevalence and correlates of suicidal ideation and suicide attempts in preadolescent children: A US population-based study. Transl Psychiatry. 2021 09 22; 11(1):489.
Liu RT, Walsh RFL, Sheehan AE, Cheek SM, Sanzari CM. Prevalence and Correlates of Suicide and Nonsuicidal Self-injury in Children: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2022 Jul 1;79(7):718-726.
In the News
Preteen Suicide a ‘Worrying Trend,’ and Research Is Lacking (MedPage Today)
Richard T. Liu, PhD is the Director of Suicide Research in the Division of Child and Adolescent Psychiatry at MGH, Director of Big Data Studies in the Depression Clinical and Research Program at MGH, and an Associate Professor of Psychology at Harvard Medical School. The primary focus of his research is on depression, suicide, and non-suicidal self-injury (NSSI) in childhood through emerging adulthood, with a particular emphasis on characterizing dynamic processes of risk underlying onset and recurrence of these clinical concerns.
Taylor Burke, PhD is is the Director of Pediatric Computational Health in the Center for Precision Psychiatry at MGH, Associate Director of Suicide Research in the Division of Child and Adolescent Psychiatry at MGH, and an Assistant Professor of Psychology at Harvard Medical School. The primary aim of Dr. Burke’s research is to advance the prediction and prevention of self-injurious thoughts and behaviors (SITBs) among youth and young adults.
