Preteen Suicides: Rare, Mysterious, and Devastating

Several years ago, Jeffrey Bridge, Ph.D., an epidemiologist at Nationwide Children’s Hospital in Columbus, Ohio, received a call from a journalist asking for a comment about an 8-year-old who died by suicide in a neighboring county.

What Bridge, a leading researcher in pediatric suicide, told the reporter then and reaffirmed to Psychiatric News now, is that death by suicide among elementary school–aged children is extremely rare. “In any given year, fewer than 10 children under 10 die by suicide in the United States,” he said. Suicide rates are a bit higher among 10- and 11-year-olds, Bridge said, but overall preteen suicides are far less common than adolescent suicides.

According to the Centers for Disease Control and Prevention (CDC), there were 59 suicides among children aged 5 to 11 years in 2017; five of these decedents were aged younger than 10.

Despite their rarity, preteen suicides do occur, and the reasons behind these suicides remain largely unknown. Investigators like Bridge are digging for answers. Some of the best data to date on risk factors for preteen suicide in the United States come from a 2016 study co-authored by Bridge and colleagues at Johns Hopkins University and the National Institute of Mental Health (NIMH). Using public surveillance information on violent deaths available from 17 states, they found evidence to suggest that impulsive behavior may be an important contributor for suicide in children under age 12. Among other factors, the investigators found that preteens who had died by suicide were more likely to have attention-deficit/hyperactivity disorder than adolescent suicide decedents and were far less likely to leave a suicide note.

Bridge cautioned that this work was merely a data comparison between different age groups and not a controlled study. “It’s too early to say that impulsivity is a risk factor for preteen suicide,” he said. “But it points us in a direction for future analyses.”

The other important finding from that 2016 analysis was that while overall suicide rates among preteens remained the same over the past two decades, rates decreased among white children but increased among black children. Between 2003 and 2012, over 36% of suicides by preteens were black children—double the 18% rate observed in the previous decade (1993-2002).

Interestingly, Bridge and colleagues conducted a follow-up analysis and found that this racial difference shifts after age 12: White adolescents were about twice as likely to die by suicide as black adolescents.

“There are significant [age related] racial disparities at play here,” noted Lisa Horowitz, Ph.D., M.P.H., a researcher and clinical psychologist at NIMH who has worked with Bridge on several studies, including the 2016 study. Again, given the preliminary nature of the 2016 study, it is unclear why suicide rates have risen for black children.

Though future work may confirm which risk factors put young black children at risk of suicide, there are measures doctors can take now to help all children, Horowitz said. One of the most important is to expand suicide screening for children.

“We know that a majority of people visit some health care provider in the weeks or months before a suicide attempt,” she told Psychiatric News. “We need to leverage the capabilities of hospitals and other medical settings if we want to achieve our goal of reducing the suicide rate in this country, which we have not been able to do for 60 years.”

One key medical setting is the emergency department, which is an important triage point for people with suicidal ideation. This includes preteens, as recently demonstrated in a study led by Horowitz and conducted across three U.S. children’s hospitals. For this study, a sample of children between 10 and 12 years old who were admitted to an emergency department were given a quick, four-question suicide screen known as Ask Suicide-Screening Questions (ASQ). Nearly 30% screened positive for suicide risk, and 17% reported a previous suicide attempt.

The Joint Commission—the independent agency that accredits hospitals—has recently established a national safety goal to screen all emergency-department patients for suicide risk regardless of why they were admitted (screening was previously recommended only if the patient had evidence of psychiatric symptoms). However, this safety goal does not define a set age range, and most hospitals limit suicide screening to individuals aged 13 and older, Horowitz told Psychiatric News.

One of the reasons children often go unscreened for suicide is that many health care professionals believe that talking to young children about suicide makes them think about it—a belief Horowitz said is false. “Asking children [about suicide] does not put thoughts in their heads; the research is strong on refuting that.” Horowitz believes a better age minimum for suicide screening in the emergency department would be 10, or even 8 if the child presents with behavioral problems. It will add work for emergency department clinicians, “but that’s why we created the ASQ,” she said. “Now we have a reliable pathway to screen children in just 20 seconds.”

Recognizing changes in a child’s sleep patterns and social behaviors, including increased irritability, can serve as a starting point for informed conversations about suicide, according to Bridge.

“If you are a parent, teacher, or therapist and observe these warning signs in a child, it’s important to have a direct conversation about suicide,” Bridge said. ■

More information about the Ask Suicide-Screening Questions is posted here. “Suicide in Elementary School-Aged Children and Early Adolescents” is posted here. “The Importance of Screening Preteens for Suicide Risk in the Emergency Department” is posted here.