Suicidal Behavior in Preteens
By Tony Salvatore, M.A.
Police officers frequently have contact with suicidal adolescents and teens. It is far less common for them to become involved with younger children exhibiting suicidal behavior, but this may be changing.
Preteen suicides in the United States are rare but increasing. Suicidal behaviors ranging from ideation to nonfatal attempts also are becoming progressively more common in preadolescents.
If current trends continue, police officers and other first responders can expect to receive a growing number of mental health calls involving suicidal children. They also will have to cope with the aftermath of more suicides by children in coming years.
Suicide prevention training for police officers does not usually cover suicidal behavior and suicides in preteens. Agencies must remedy this. Officers may be among the first to encounter this problem in their communities.
It once was widely believed that young children did not take their own lives because they could not grasp the concept of suicide.1 However, in the late 1980s, research showed that suicide claimed a number of victims at an early age and that as many as 12 percent of school-age children experienced suicidal ideation.2
Mr. Salvatore directs suicide prevention and postvention efforts at Montgomery County Emergency Service in Norristown, Pennsylvania.
Even very young children engage in nonfatal suicidal behavior.3 This creates serious suicide risk in childhood that individuals carry into adolescence, young adulthood, and beyond.
Early childhood suicidality has made a mark on the health system in the United States. A review of admissions to 31 pediatric hospitals from 2005 to 2015 found almost 15,000 cases of suicidal ideation or suicide attempts by children 5 to 11 years of age.4
Assessments of children ages 10 to 12 presenting to emergency departments in three urban medical centers found 30 percent positive for suicide risk. One in five of the children had made a previous suicide attempt.5 This suggests that emergency departments should screen for suicide risk in all children, even as early as 10 years old.
Although they may have access to only a limited range of lethal means, young children are capable of suicide.6 In 2014, the Centers for Disease Control and Prevention (CDC) for the first time listed suicide as the 10th-leading cause of death for children ages 5 to 11.7 It was the ninth-leading cause of violence-related death for children ages 5 to 9 in 2015.8
Between 1993 and 2012, 657 children in the United States ages 5 to 11 years old died by suicide.9 This is an average of 33 child suicides per year.
Young children can develop suicide plans readily within their capability to carry out.10 One study found that 1 in 10 children ages 3 to 7 acknowledged thoughts of suicide, expressed what appeared to be plans, and acted in a manner that looked like an attempt.11
Early childhood suicidality is more common in boys and is associated with attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct disorder.12
In one study, victims mostly included black male children who died by hanging, strangulation, or suffocation.13 Data on suicides involving children 5 to 11 years old from 1993 to 1997 and from 2008 to 2012 showed a significant increase in suicides of young black children and a notable decline of suicides in white preadolescents between the two periods. This shift has not presented in other age groups. The increase in suicides among black children is a notable departure from the distribution of suicides by race for all ages and particularly for young children.14
Risk Factors and Warning Signs
Suicidal behavior in preschoolers relates to impulsivity, running away, hyperactivity, morbid ideas, high pain tolerance, not crying after injury, and parental neglect.15 A family history of suicidal behavior, exposure to physical and sexual abuse, preoccupation with death, and prior suicide attempts are additional factors to consider.16
Impulsivity is a prominent characteristic of preteen suicides. For children ages 5 to 11, “impulsive responding” to arguments, conflicts, relationship problems with family members and friends, and other adverse environmental and life situations is a trigger for early childhood suicide.17 Children may lack the ability to foresee their lives getting better or to comprehend the temporary nature of some problems.
Notably, mental illness plays a smaller role in suicidal behavior in preadolescents than in older children.18
It can prove difficult to decisively quantify preadolescent suicide because authorities may misclassify young children’s suicides as accidents or otherwise unintentional deaths.19 This represents a particular problem in the black community.20 Preteen suicide victims leave notes less often than teenagers do and have less access to lethal means, such as firearms, which can raise doubts about suicide as the cause of death.21
Misclassification also may result, at least in part, from old beliefs some coroners and medical examiners still share about the suicidal capability of young children. The fact that accidental deaths and unintentional injuries are the leading cause of death in children under age 14 also can influence this judgment.22 Individuals may not readily see preteen deaths by falls and even by hanging as suicides.
Most models attempting to explain suicide focus on teens, adults, and elders. However, one theoretical paradigm suggests how suicidal behavior may arise in anyone, including young children. The interpersonal-psychological theory explains how overcoming the natural resistance to lethal self-harm can result in a suicide attempt.23
According to this theory, a suicide attempt may occur when two factors exist: 1) an intense desire to die and 2) the capacity for self-harm.24 The former arises from negative self-perceptions, a poor self-image, and unfavorable social comparisons.25 The latter is associated with a high tolerance to pain, diminished fear of severe injury, and lowered fear of death.26 This “acquired capability” becomes established over time through exposure to hurtful, painful, or violent experiences, such as self-injury, physical or sexual abuse, or bullying.27
Circumstances that contribute to suicidality in young children include—
- decreased self-esteem;
- belief that they hold responsibility for some family problem (e.g., divorce);
- feeling worthless or like a burden to the family;
- not feeling valued;28
- violent interactions between parents, which may cause children to believe they are worthless and expendable;29
- bullying and being bullied;30
- parental abuse and neglect, which may produce self-directed aggression;31
- having a sibling who attempted suicide;32 and
- experiencing conflict, aggression, and abuse in the household.33
Suicide threats and attempts relate to antisocial behavior and hostility toward parents in children 5 to 12 years of age.34 Abuse, neglect, or other trauma in the family may produce suicidal behavior in young children. Research shows that witnessing violence promotes suicidal ideation in urban 9- and 10-year-olds.35 Officers called to a household because of domestic violence must keep collateral suicide risk in mind during their investigations.
Bullying can generate an intense desire to die and the development of an acquired capability for lethal self-harm. Both victims and bullies themselves more likely will exhibit suicidal ideation or behavior compared with children not exposed to bullying.36
“Although they may have access to only a limited range of lethal means, young children are capable of suicide.”
Prior suicide attempts, self-injury, and mentally practicing a suicide plan represent other ways an individual may acquire the capability for a lethal attempt.37 Evidence suggests that these behaviors may significantly contribute to suicidality in young children.38
“Suicide competence” comes with making attempts over time.39 Many preadolescent suicide victims engaged in earlier suicidal behavior.40 Repeated tries facilitate future attempts as the individual accrues lethal experience and skill and sheds inhibitions to suicide.
Histories of multiple increasingly lethal suicide attempts are present in prepubertal children.41 Suicidal teens may have histories of past attempts starting as early as age 9.42
One study found self-injury in almost 8 percent of surveyed third graders (average age 7) and 4 percent of sixth graders (average age 11).43 In this age group, more boys than girls self-injured, and hitting oneself proved the most common method.44 Such behaviors reduce the natural inhibition to self-harm and enhance the risk of suicide.
Preadolescents can make basic suicide plans.45 Mentally going over the plan is one way to gain the ability to carry it out.46 This may occur even in very young children. Children can experience persistent suicidal ideation over time.47 This may be how suicidality in the very young progresses from vague thoughts of death to a concrete selection of means.48
No specific guidelines exist for police officers to use in identifying suicide risk in young children. However, when dealing with young children troubled by suicidal thoughts, officers should assure them that they are safe and not in trouble and that the officers are there to help. They should use terms children can understand and ask age-appropriate questions.
Screening for suicide risk in very young children is only recommended if high risk is evident or strongly suspected.49 Officers can ask general questions, such as “Do things ever get so bad that you think about hurting yourself?” or “Have you ever tried to kill yourself?”50 Suicide risk screening questions do not harm young children and have not been found to induce or intensify suicidality.51
Identifying suicide risk in this age group relies on interviews with the child, parental reporting, and self-reporting by the child.52 A flexible interview using questions that the child can answer is the recommended approach for determining suicide risk in prepubertal children.53 Parents will serve as the best sources in cases with very young children, and talking with them will avoid upsetting a possibly suicidal child.
A suicide risk screener for young children should consist of a few short questions about recent thoughts and behaviors. Police officers may not need to use a formal screener with young children, but looking at an example of such a tool can be helpful.
One set of suicide-screening questions has proven successful with children as young as 10 years of age.54
“…when dealing with young children troubled by suicidal thoughts, officers should assure them that they are safe and not in trouble and that the officers are there to help.”
Source: U.S. Department of Health and Human Services, National Institute of Mental Health, Ask Suicide-Screening Questions (ASQ) Toolkit, accessed October 13, 2020, https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit_155867.pdf.
A “yes” to the first four questions identifies positive suicide risk; a “yes” response to the fifth question indicates that the child is at acute suicide risk and in imminent danger. A question such as “Do you want to die?” confirms suicidal intent.55
The seeming lethality of the child’s actual or planned behavior does not determine the level of risk. An apparent presence of suicidal intent is what matters. A child may not know the degree of harm inherent to a particular method of suicide. Children also may minimize the danger of their plan because they do not want to get in trouble. Likewise, children previously hospitalized for past suicidal behavior may downplay their plan to avoid readmission.
Children having suicidal thoughts, voicing suicide threats, or acting in a manner indicating imminent danger must receive a comprehensive evaluation to assess their suicide risk. A psychiatrist or behavioral health clinician with appropriate training best accomplishes this.
If deemed at risk of suicide, police or emergency medical services should transport the children to a psychiatric hospital that treats preadolescents or to a pediatric hospital emergency department for safety, evaluation, and stabilization. Children determined to be suicidal are usually hospitalized.
When available, permission of parents or guardians is necessary to authorize evaluation of any child below the age that state law sets for self-consent for treatment. Otherwise, every state has a procedure for securing involuntary psychiatric evaluations for children in danger of lethal self-harm. A local mental health authority or crisis center can provide information for specific jurisdictions.
When a child is not in immediate danger, referrals to children’s crisis services are appropriate. In their absence, police officers can contact the crisis center or mobile crisis team serving their area. These resources will be familiar with children’s mental health services that may best meet the child’s needs. Counselors and psychologists working with elementary school-age children also can help identify programs that serve preadolescents.
Awareness and Prevention
Suicide prevention in the United States begins with mid-teens; younger children do not get much attention. This is likely because of their low rate of suicide and the persisting misconception that the very young lack the capacity to take their own lives.
While the total number of preteen suicides nationally is rising, individual states may report very few or no suicides in this age range. For example, Pennsylvania reports one suicide of a child under 10 years of age for the years 2013-2017.56 This minimizes awareness and promotes a false sense of security about suicide risk in the very young.
Research on suicidal behavior in preadolescents still lags far behind that on teens and adults.57 More research and understanding of suicidality in children hopefully will lead to more prevention programs.
Police officers, parents, preschool and elementary school educators, school nurses, and pediatric health care providers need to become aware of the rising prevalence of suicidal behavior in young children and educated on the signs of preadolescent suicidality. All need skills and tools to identify and address suicide risk in the very young.
As first responders, police will be involved in crisis intervention with suicidal children. However, departmental programs to reduce domestic violence, abuse, and bullying also can contribute to reducing suicide risk in young children. Community education by police should note the role of these issues in precipitating suicidal behavior in this age group.
Congressional Black Caucus, Emergency Task Force on Black Youth Suicide and Mental Health
Ring the Alarm: The Crisis of Black Youth Suicide in America
Despite widespread myths, young children exposed to negative experiences and life circumstances can develop the intent to die and the capability for lethal self-harm. Tragically, suicide is an increasingly frequent reality in early childhood and preadolescence. The incidence of suicide is climbing for children in the United States, especially among very young black children. Authorities need to become aware of these tragedies and take steps to prevent them.
“…departmental programs to reduce domestic violence, abuse, and bullying also can contribute to reducing suicide risk in young children.”
Mr. Salvatore can be reached at firstname.lastname@example.org.
1 Cynthia Pfeffer, The Suicidal Child (New York, NY: Guilford Press, 1986).
2 Cynthia Pfeffer, “Clinical Aspects of Childhood Suicidal Behavior,” Pediatric Annals 13, no. 1 (January 1984): 56-57, 60-61, accessed July 30, 2019, https://search.proquest.com/openview/7e149949fcff2fbe5985dec0cd5df151/1?pq-origsite=gscholar&cbl=34609.
3 Angelica L. Kloos et al., “Suicide in Preadolescents: Who is at Risk?” Current Psychiatry Report 9, no. 2 (April 2007): 89-93, accessed July 30, 2019, https://link.springer.com/article/10.1007/s11920-007-0076-9.
4 Gregory Plemmons et al., “Hospitalization for Suicide Ideation or Attempt: 2008-2015,” Pediatrics 141, no. 6 (2018), accessed July 30, 2019, https://pediatrics.aappublications.org/content/141/6/e20172426.
5 Elizabeth C. Lanzillo et al., “The Importance of Screening Preteens for Suicide Risk in the Emergency Department,” Hospital Pediatrics 9, no. 4 (April 2019): 305-307, accessed August 7, 2019, https://hosppeds.aappublications.org/content/9/4/305.
6 Arielle Sheftall et al., “Suicide in Elementary School-Aged Children and Adolescents,” Pediatrics 138, no. 4 (October 2016), accessed July 30, 2019, https://pediatrics.aappublications.org/content/138/4/e20160436.
7 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 10 Leading Causes of Death, United States, 2014, All Races, Both Sexes, accessed September 21, 2020, https://webappa.cdc.gov/cgi-bin/broker.exe.
8 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 10 Leading Causes of Injury Deaths by Age Group Highlighting Violence-Related Injury Deaths, United States, 2015, accessed September 21, 2020, https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_injury_death_highlighting_violence_2015-a.pdf.
9 Jeffrey A. Bridge et al., “Suicide Trends Among Elementary School-Aged Children in the United States From 1993 to 2012,” JAMA Pediatrics 169, no. 7 (2015): 673-677, accessed July 30, 2019, https://jamanetwork.com/journals/jamapediatrics/fullarticle/2293169.
10 Nicola Madge and John G. Harvey, “Suicide Among the Young: The Size of the Problem,” Journal of Adolescence 22, no. 1 (February 1999): 145-155, accessed July 30, 2019, https://doi.org/10.1006/jado.1998.0207.
11 Diana J. Whalen et al., “Correlates and Consequences of Suicidal Cognitions and Behaviors in Children Ages 3 to 7 Years,” Child & Adolescent Psychiatry 54, no. 11 (2015): 926-937, accessed July 30, 2019, https://jaacap.org/article/S0890-8567(15)00539-0/fulltext.
12 Whalen et al.
13 Bridge et al.
15 Perihan A. Rosenthal and Stuart Rosenthal, “Suicidal Behavior by Preschool Children,” American Journal of Psychiatry 141, no. 4 (April 1984): 520-525, accessed July 30, 2019, https://doi.org/10.1176/ajp.141.4.520.
16 Carl L. Tishler, Natalie Staats Reiss, and Angel R. Rhodes, “Suicidal Behavior in Children Younger than Twelve: A Diagnostic Challenge for Emergency Department Personnel,” Academic Emergency Medicine 14, no. 9 (September 2007): 810-818, accessed July 30, 2019, https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1553-2712.2007.tb02357.x?sid=nlm%3Apubmed.
17 Sheftall et al.
18 Rebecca Soole, Kairi Kõlves, and Diego DeLeo, “Suicide in Children: A Systematic Review,” Archives of Suicide Research 19, no. 3 (2015): 285-304, accessed July 30, 2019, https://www.tandfonline.com/doi/full/10.1080/13811118.2014.996694.
19 Beat Mohler and Felton Earls, “Trends in Adolescent Suicide: Misclassification Bias?” American Journal of Public Health 91, no. 1 (2001): 150-153, accessed July 30, 2019, https://ajph.aphapublications.org/doi/10.2105/AJPH.91.1.150.
20 Darcy Haag Granello and Paul F. Granello, Suicide: An Essential Guide for Helping Professionals and Educators (Boston, MA: Allyn & Bacon, Inc., 2007).
21 Anne Freuchen, Dagfinn Ulland, and Terje Mesel, “Suicide Notes Written by Child and Adolescent Suicide Victims: A Qualitative Textual Analysis,” Scandinavian Psychologist 5, no. 9 (2018), accessed October 8, 2019, https://doi.org/10.15714/scandpsychol.5.e9; and Granello and Granello.
22 Matthew K. Nock et al., “Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement,” JAMA Psychiatry 70, no. 3 (March 2013): 300-310, accessed July 30, 2019, https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1555602.
23 Thomas Joiner, Why People Die by Suicide (Cambridge, MA: Harvard University Press, 2005).
25 Kimberly A. Van Orden et al., “The Interpersonal Theory of Suicide,” Psychological Review 117, no. 2 (April 2010): 575-600, accessed July 30, 2019, https://psycnet.apa.org/doiLanding?doi=10.1037%2Fa0018697.
27 Van Orden et al.
28 Xianchen Liu et al., “Clinical Features of Depressed Children and Adolescents with Various Forms of Suicidality,” The Journal of Clinical Psychiatry 67, no. 9 (October 2006): 1442-1450, accessed July 30, 2019, https://www.researchgate.net/publication/6776892_Clinical_Features_of_Depressed_Children_and_Adolescents_With_Various_Forms_of_Suicidality.
29 Roger Herring, “Suicide in the Middle School: Who Said Kids Will Not?” Elementary School Guidance and Counselling 25, no 2 (1990): 129-137, accessed July 30, 2019, https://www.jstor.org/stable/42868962.
30 Catherine Winsper et al., “Involvement in Bullying and Suicide-Related Behavior at 11 Years: A Prospective Birth Cohort Study,” Journal of the American Academy of Child & Adolescent Psychiatry 51 no. 3 (2012): 271-282, accessed July 30, 2019, https://doi.org/10.1016/j.jaac.2012.01.001.
31 Tishler, Reiss, and Rhodes.
32 David A. Brent et al., “Peripubertal Suicide Attempts in Offspring of Suicide Attempters with Siblings Concordant for Suicidal Behavior,” American Journal of Psychiatry 160, no. 8 (2003), accessed July 30, 2019, https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.160.8.1486.
33 Abby Ridge Anderson, Grace Keyes, and David A. Jobes, “Understanding and Treating Suicidal Risk in Young Children,” Practice Innovations 1, no. 1 (2016): 3-19, accessed July 30, 2019, https://www.researchgate.net/publication/299418771_Understanding_and_treating_suicidal_risk_in_young_children.
34 Helene Jackson and Ronald L. Nuttall, “Risk for Preadolescent Suicidal Behavior: An Ecological Model,” Child and Adolescent Social Work Journal 18, no. 3 (2001): 189-203, accessed July 30, 2019, https://link.springer.com/article/10.1023%2FA%3A1011058419113.
35 Catherine C. O’Leary, et al., “Suicidal Ideation Among Urban Nine and Ten Year Olds,” Journal of Developmental and Behavioral Pediatrics 27 no. 1 (2006): 33-39, accessed July 30, 2019, https://journals.lww.com/jrnldbp/Abstract/2006/02000/Suicidal_Ideation_Among_Urban_Nine_and_Ten_Year.5.aspx.
36 Winsper et al.
38 Kloos et al.
40 Helene Jackson, Peg McCartt Hess, and Annaclare van Dalen, “Preadolescent Suicide: How to Ask and how to Respond,” Families in Society 76, no. 5 (1995): 267-278, accessed July 30, 2019, https://doi.org/10.1177%2F104438949507600501.
41 David A. Brent et al., “Familial Transmission of Mood Disorders: Convergence and Divergence with Transmission of Suicidal Behavior,” Journal of the American Academy of Child & Adolescent Psychiatry 43, no. 10 (October 2004): 1259-1266, accessed July 30, 2019, https://jaacap.org/article/S0890-8567(09)61580-X/pdf.
42 James J. Mazza et al., “An Examination of the Validity of Retrospective Measures of Suicide Attempts in Youths,” Journal of Adolescent Health 49, no. 5 (November 2011): 532-537, accessed July 30, 2019, https://www.jahonline.org/article/S1054-139X(11)00127-3/fulltext.
43 Andrea L. Barrocas et al., “Rates of Nonsuicidal Self-Injury in Youth: Age, Sex, and Behavioral Methods in a Community Sample,” Pediatrics 130, no. 1, 39-45, accessed July 30, 2019, https://pediatrics.aappublications.org/content/130/1/39.
44 Ibid. The opposite proved true for teenage subjects; significantly more ninth-grade girls than boys engaged in self-injury, and cutting/carving skin comprised the majority of occurrences.
45 Whalen et al.
47 Whalen et al.
48 David A. Brent et al., “Psychopathology and its Relationship to Suicidal Ideation in Childhood and Adolescence,” Journal of the American Academy of Child & Adolescent Psychiatry 25, no. 5 (September 1986): 666-673, accessed July 30, 2019, https://jaacap.org/article/S0002-7138(09)60292-2/fulltext.
49 Barbara Heise, Arwen York, and Brandon Thatcher, “Child Suicide Screening Methods: Are We Asking the Right Questions? A Review of the Literature and Recommendations for Practice,” The Journal for Nurse Practitioners 12, no. 8 (2016): 411-417, accessed July 30, 2019, https://www.npjournal.org/article/S1555-4155(16)00063-5/fulltext.
50 Amy J. Wise and Paul M. Spengler, “Suicide in Children Younger than Age Fourteen: Clinical Judgment and Assessment Issues,” Journal of Mental Health Counseling 19, no. 4 (1997): 318-335, accessed July 30, 2019, https://www.researchgate.net/publication/234753038_Suicide_in_Children_Younger_than_Age_Fourteen_Clinical_Judgment_and_Assessment_Issues.
51 Selvi B. Williams, et al., “Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the U.S. Preventive Services Task Force,” Pediatrics 123, no. 4 (April 2009), accessed July 30, 2019, https://pediatrics.aappublications.org/content/123/4/e716.
52 Heise, York, and Thatcher.
53 Leslie K. Jacobsen et al., “Interviewing Prepubertal Children About Suicidal Ideation and Behavior,” Journal of the American Academy of Child & Adolescent Psychiatry 33, no. 4 (May 1994): 439-452, accessed July 30, 2019, https://doi.org/10.1097/00004583-199405000-00001.
54 Lisa Horowitz et al., “Ask Suicide-Screening Questions (ASQ): A Brief Instrument for the Pediatric Emergency Department,” Archives of Pediatric & Adolescent Medicine 166, no. 12 (October 2012): 1170-1176, accessed July 30, 2019, https://jamanetwork.com/journals/jamapediatrics/fullarticle/1363508; and Lisa Horowitz et al., “Screening Youth for Suicide Risk in Medical Settings: Time to Ask Questions,” American Journal of Preventive Medicine 47, no. 3, S2 (September 2014): S170-S175, accessed July 30, 2019, https://doi.org/10.1016/j.amepre.2014.06.002.
55 Tishler, Reiss, and Rhodes.
56 Pennsylvania Department of Health, Enterprise Data Dissemination Informatics Exchange (EDDIE), accessed October 8, 2019, https://www.health.pa.gov/topics/HealthStatistics/EDDIE/Pages/EDDIE.aspx.
57 John S. Westefeld et al., “Suicide Among Preadolescents: A Call to Action,” Journal of Loss and Trauma 15, no. 5 (2010): 381-407, accessed July 30, 2019, https://www.tandfonline.com/doi/full/10.1080/15325024.2010.507655.