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1 in 10 Preschoolers Have Suicidal Thoughts, Behaviors
Medscape Medical News, Psychiatry
November 24, 2015

About 1 in 10 children as young as age 3 years may have suicidal thoughts or suggestive behaviors, and these linger into middle childhood for 3 of 4 children, particularly for those with depression or externalizing disorders, new research suggests.

Although the meaning of suicidal cognitions and behaviors at this young age remains unclear, the results suggest that they are a "clinically important phenomenon" that should not be ignored, investigators Diana J. Whalen, PhD, and colleagues write.

"Our findings suggest that clinicians may need to start asking about suicidal thoughts and behaviors in young children, particularly among those with early-onset psychiatric disorders. While we do not know exactly what suicidal thoughts and behaviors mean in young children, they are likely a signal of distress and should be taken seriously," Dr Whalen told Medscape Medical News.

The study was published in the November issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Significant and Robust Predictor
The investigators examined the correlates and consequences of suicidal cognitions and behaviors (SI) in 306 children enrolled in the prospective longitudinal Preschool Depression Study.

The children and their parents completed a baseline assessment when the children were 3 to 7 years of age. At least one follow-up assessment was conducted when the children were 7 to 12 years of age. Many children in the study had early-childhood depression and other forms of psychopathology, the investigators point out.

SI was present in 34 (11%) of the children at baseline; 25 of these children (75%) continued to experience SI at the school-age follow-up assessment (roughly 4 years later), they report.

The findings suggest that early-childhood SI is a "significant and robust predictor" of school-age SI, inasmuch as children aged 3 to 7 years who reported SI were more than three times as likely to continue reporting SI later in childhood, even after controlling for past and current psychiatric diagnoses, demographic factors, and maternal psychopathology, the authors note.

Early-childhood SI was more common in boys and was highly associated with a variety of maternal psychopathology, but not maternal or family history of suicide attempts. Early-childhood SI was also associated with attention-deficit/hyperactivity disorder and oppositional defiant disorder/conduct disorder (ODD/CD).

"This finding extends existing research on early-childhood SI by demonstrating that SI occurring during ages 3 to 7 years confers significant risk for continuation into the school-age period, particularly alongside early ODD/CD," the authors write.

"Despite these findings and a growing body of developmental work, it remains unclear exactly what young children mean when they say that they want to die or harm themselves, and a conceptual understanding of death was not tested in the current study," the investigators write. "Yet, data indicate that death/suicidal statements, behaviors, and actions among young children are strongly associated with distress and psychopathology as well as later suicidal ideation at school age, underscoring the need to attend to this symptom as an important marker of risk," they add.

A key limitation of this study is the relatively small number of young children experiencing childhood SI, the authors note. Also, the children were recruited on the basis of their having pronounced symptoms of depression; therefore, prevalence rates may be higher than would be expected for young children who had fewer symptoms of psychopathology. The SI information relied primarily on parental report, a method with several known shortcomings, including reporter bias, Dr Whalen and colleagues note.

Findings "Striking and Disturbing"
Despite these limitations, the coauthors of a linked editorial say the finding that some children as young as 3 years experience distress and despair to a degree significant enough to lead them to express the wish to die or to attempt to hurt themselves is "striking and disturbing."

The numbers of children who express suicidal thoughts and engage in these behaviors are "larger than we might have guessed," note Charles H. Zeanah, MD, and Mary Margaret Gleason, MD, of the Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine, New Orleans, Louisiana. "What this investigation could not address but is a central clinical concern is the meaning of suicidal behavior in young children," they point out.

They note that the authors' examples of young children's suicidal cognitions and behaviors include a child who hides a knife under his pillow and repeatedly says that he does not deserve to live, and another child who wants to "go to heaven" to join a beloved grandparent.

"These are quite different scenarios that imply very different levels of concern about risk and would be evaluated differently at different points in development, although contextual details can amplify or diminish concern about risk for self-harm in either of these children," Dr Zeanah and Dr Gleason note.

"The challenge emanating from this report," they conclude, "is neither to dismiss the findings because they violate notions of young children as carefree and happy nor to understand and respond to young children who display suicidal cognitions and behaviors in the same way we understand and respond to older children and adolescents who display suicidality. What the findings do call for is our best clinical efforts to recognize important indicators of serious psychopathology and distress, to discern relevant contextual features, and to intervene immediately when needed to maintain safety and relieve distress and disability."

The study was supported by the National Institutes of Health. Dr Whalen has disclosed no relevant financial relationships. One coauthor has served as a consultant to Pfizer, Amgen, Roche, and Takeda on psychosis-related work.

J Am Acad Child Adolesc Psychiatry. 2015;54:884-885, 926-937. Abstract,
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