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Emotional Triggers and Psychopathology Associated with Suicidal Ideation in Urban Children with Elevated Aggressive-Disruptive Behavior

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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.
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Emotional Triggers and Psychopathology Associated with
Suicidal Ideation in Young Urban Children with Elevated
Aggressive-Disruptive Behavior
Peter A. Wyman1, Patricia A. Gaudieri1, Karen Schmeelk-Cone1, Wendi Cross1, C. Hendricks
Brown2, Luke Sworts1, Jennifer West1, Katharine C. Burke1, and Janaki Nathan1
1Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester,
NY
2Center for Family Studies, Department of Epidemiology and Public Health, University of Miami,
Miami, FL
Abstract
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
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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 mother’s negative attributions for child-centered events predict
their adolescent children’s 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 10–14 to 12.1 per 100,000 for ages 20–24 (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; O’Leary 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 (O’Leary 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; O’Leary
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 children’s 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 &
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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 children’s 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 6–9 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 children’s initiating thoughts about suicide.
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Method
Participants
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 (50–79%) 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 teacher’s rating of
each child’s performance on core classroom tasks during the preceding three weeks on a 6-
point scale (never true to always true). Screening in 1st–3rd grade classrooms occurred in late
October–November of each year and in kindergarten classes in March–April of the year
preceding children’s 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 child’s 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.
Measures
Dominic Interactive—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 child’s 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 5–10%
of symptomatology in a community sample (Valla et al., 2000). We used total symptom scores
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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?”
Children’s 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 child’s
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 child’s
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 child’s 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 Pfeffer’s (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 child’s 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 child’s parent completed the 64-item
YOQ-2.0 that evaluates children’s 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
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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).
Statistical Analyses
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, 8–9 year old children reported
more conduct problems than 6–7 year olds (F (1,338)=5.68, p< 0.05), and parents reported
more somatic problems for 8–9 than 6–7 year olds (F (1,338)=4.85, p< 0.05).
For the primary analyses, we first examined demographic characteristics associated with SI
using χ2 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 children’s narratives.
Results
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 (Χ2 (df=1)
= 1.59, p< 0.21). Likewise, rates of SI were not different for children ages 6–7 (7.96%) versus
ages 8–9 (9.76%) (Χ2 (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).
Of the 30 children reporting SI, seven (23%) described thoughts about using a specific method
to kill or hurt themselves; three were in the 6–7 year old group and four in the 8–9 year old
group. Stabbing oneself was the most common method described. One child (0.29% of the
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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.
The relationship between parent reports of children’s 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 8–9 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 (β = 0.43, p < .03) and Behavior
Dysfunction (β = 0.48, p < .01), and a trend towards more Somatic Problems (β = 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.
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).
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 children’s 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
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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 children’s descriptions of SI or thoughts
of death for the presence of each theme. A child’s 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.
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.
Discussion
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; O’Leary 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
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(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 children’s symptoms and children’s suicidal ideation status was stronger for older
than younger children. Parent ratings differentiating 8 – 9 year olds with and without SI were
congruent with children’s 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 children’s 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 children’s 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 child’s vulnerability to adopting thoughts about suicide as a
response to stress.
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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, children’s 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 19–21 (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
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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.
Acknowledgments
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. O’Connor 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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Table 1
Sample characteristics and rates of suicidal ideation.
Suicidal Ideation No Suicidal Ideation
(N=30) (N=319)
n%an%a
Mean age (months) 91.73 89.92
Age
6–7 years 18 8.0 208 92.0
8–10 years 12 9.8 111 90.2
Gender
Girls 15 10.9 122 89.1
Boys 15 7.1 197 92.9
Race-Ethnicity
Black (not Hispanic) 19 8.6 201 91.4
White (not Hispanic) 3 21.4 11 78.6
Hispanic 5 6.9 67 93.1
Other/multiracial 3 7.0 40 93.0
aRow percent
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Table 2
Comparisons between children with and without suicidal ideation on mental health functioning reported by children (DI) and parents (YOQ).
Mental Health Symptom
Scale – Source
Suicidal Ideation No Suicidal Ideation Group Age X Group
(n=30) (n=319) F1ES F1
Mean (SD) Mean (SD)
Specific Phobia – DI 2.53 (1.00) 2.31 (1.86) 0.00 0.07 1.02
Separation Anxiety – DI 5.13 (1.61) 4.29 (2.20) 2.72+0.36 0.38
Generalized Anxiety – DI 8.93 (2.19) 7.85 (3.36) 1.99 0.29 0.002
Depression – DI 12.29 (2.64) 8.57 (4.09) 17.25*** 0.97 0.75
Oppositional (ODD) – DI 4.50 (2.38) 3.12 (2.12) 12.87*** 0.70 1.78
Conduct Problems – DI 3.79 (3.90) 1.86 (2.65) 13.03*** 0.74 0.03
ADHD – DI 10.10 (3.81) 7.02 (3.98) 14.03*** 0.78 0.05
Intrapersonal Distress - YOQ 27.48 (9.73) 26.24 (10.13) 1.46 0.13 4.82*
Somatic Problems - YOQ 11.72 (3.97) 11.31 (3.78) 1.11 0.02 6.96**
Interpersonal relations - YOQ 8.29 (5.77) 7.56 (6.92) 1.01 0.12 2.67
Social Problems - YOQ 8.56 (2.99) 9.06 (3.39) 0.03 0.17 1.41
Behavior Dysfunction - YOQ 19.76 (8.01) 20.23 (8.95) 0.33 0.04 6.80**
Note. DI= Dominic Interactive (child report); YOQ = Youth Outcome Questionnaire (parent report)
1For Dominic df = 1,336; For YOQ df= 1,279.
+p<0.07;
*p<0.05;
**p<0.01;
***p<0.001.
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Table 3
Comparisons between 6 – 7 and 8 – 9 year old children with and without suicidal ideation on mental health functioning reported by parents.
Ages 6–7 years Ages 8–9 years
YOQ subscale Suicidal ideation No suicidal
Ideation Group Suicidal
Ideation No suicidal
Ideation Group
(n=18) (n=208) (n=12) (n=111)
Mean (SD) Mean (SD) F1ES Mean (SD) Mean (SD) F1ES
Intrapersonal Distress 23.94 (9.19) 26.00 (9.49) 0.70 0.22 33.78 (7.46) 26.67 (11.27) 3.540.66
Somatic Problems 10.19 (2.56) 11.30 (3.84) 1.72 0.34 14.44 (4.69) 11.33 (3.67) 4.65*0.76
Interpersonal relations 6.56 (5.81) 7.43 (6.45) 0.34 0.15 11.75 (4.06) 7.80 (7.73) 2.990.65
Social Problems 8.06 (3.21) 9.03 (3.43) 1.32 0.30 9.44 (2.46) 9.11 (3.32) 0.05 0.08
Behavior Dysfunction 16.25 (7.23) 20.40 (8.96) 2.970.45 26.00 (5.10) 19.92 (8.960) 4.04*0.71
1Note. For 6–7 year olds, df= 1,191;
2For 8–9 year olds, df=1,107.
p<0.07;
*p<0.05;
**p<0.01;
***p<0.001.
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Table 4
Clinically significant symptoms reported by children as a function of suicidal ideation vs. no suicidal ideation.
Suicidal Ideation No Suicidal Ideation Suicidal Ideation vs.
None
(n=30) (n=319)
Dominic Interactive
Scale % (n) % (n) OR (95% CI) p
Specific Phobia 6.7 (5) 12.9 (41) 1.36 (.51, 3.63) .57
Separation Anxiety 40.0 (12) 32.6 (104) 1.38 (.65, 2.93) .42
Generalized Anxiety 13.3 (4) 14.1 (45) 0.94 (.33, 2.70) 1.00
Depression 41.4 (12) 10.9 (34) 5.79 (2.59, 13.00) .000
Opposition 24.1 (7) 7.0 (22) 4.21 (1.66, 10.72) .006
Conduct Problems 23.3 (7) 9.1 (29) 3.53 (1.42, 8.86) .013
ADHD 10.0 (3) 5.6 (18) 1.86 (.55, 6.32) .41
Clinically significant
on any scale 79.3 (23) 51.0 (158) 3.69 (1.50, 9.05) .003
J Abnorm Child Psychol. Author manuscript; available in PMC 2009 November 30.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Wyman et al. Page 19
Table 5
Motivators/triggers described by children for suicidal ideation and recurrent thoughts of death and inter-rater
reliabilities.
Suicidal Ideation (n=30)
Theme Illustrative example n/group (%) IRR1
Anger or Dysphoria “sometimes I get angry and just want to kill
myself” 12/30 (40.0%) 1.0
“If I get mad I feel like I want to jump off a
building”
when I get sad about my mom and dad breaking
up”
Interpersonal Conflict I want to kill myself when my mom gets mad at
me” 11/30 (36.7%) 0.95
“when I am bullied on the bus”
“I want to kill myself to get away from my
brother”
Loss/Abandonment I think about killing myself because no one cares
about me” 4/30 (9.5%) 1.0
Recurrent Thoughts of Death (n=54)
Theme Illustrative example n/group ( %) IRR1
Personal Safety Concerns “getting shot, stabbed, killed” 26/54 (48.2%) 0.84
“I think about death, it scares me, I think about
gunshots”
“I think about getting sick and dying”
Family Member Died/Injured “I think about my grandma who died” 9/54 (16.7%) 0.88
Worries about Family Member “I think about my mom dying” 10/54 (18.5%) 0.88
1Note. Inter-rater reliability (Kappa coefficient)
J Abnorm Child Psychol. Author manuscript; available in PMC 2009 November 30.
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