Preadolescent suicidal ideation may be one of the most common symptoms found in seriously mentally ill young children (Brent, Kalas, Edelbrock, Costello, Dulcan, & Conover, 1986; Hendin, 1986; Pfeffer, Conte, Plutchik, & Jerrst, 1979; Pfeffer,1987; Plutchik and van Praag, 1990; Shaffer, 1974). Despite reports of a 60% prevalence rate of suicidal activity in psychiatric outpatient children (Carlson & Cantwell, 1982), few systematic studies of suicidal ideation and behaviors in this population have been conducted.
Awareness of the prevalence and correlates of suicidal thoughts and behaviors among preadolescents is of particular concern to social workers who provide most of the mental health services to children and their families. Identified factors that place children at risk for suicidal behavior include mood disorders (Brent et al.,1986; Harrington, Fudge, Rutter, Pickles, & Hill, 1993; Pfeffer, Lipkins, Plutchik, & Mizruchi, 1988; Pfeffer, Klerman, Hurt, Lesser, Peskin, & Siefker, 1991), prior suicide attempts (Eisenberg, 1984; Weissman, 1974), age (BoIger, Downey, Walker, & Steininger, 1989; Hoberman & Garfinkel, 1988), substance abuse (Hoberman & Garfinkel, 1988), gender (Hendin, 1986), concept of death as transient (Pfeffer, Klerman, Hurt, Kakuma, Peskin, & Siefker, 1993), a history of physical arm sexual abuse (Browne & Finkelhor, 1986; Wozencraft at al., 1991), preoccupation with death (Pfeffer and Trad, 1988), running away (Rotheram-Borus & Bradley, 1991), assaultive behavior (Pfeffer et al., 1979) conduct disorders (Apter, Bleich, Plutchik, Mendelsohn, & Tyano, 1988), and a broad range of additional psychopathology (Brent et al., 1986).
The goal of this study is to test the validity of a developmental/ecological model of factors associated with preadolescent suicidality through the use of a standardized preadolescent suicide questionnaire. We hypothesized that specific risk factors such as family stressors, childhood traumas, and child risk characteristics are associated with greater risk for suicidality. We further hypothesized that specific protective factors such as child enabling characteristics, social, and family supports are associated with lower risk for suicidality.
Data were collected at the Jewish Board of Family and Children's Services, Madeleine Borg Community Services, Pelham clinic over a period of 3 years. To date, we have conducted a preliminary analysis of the 66 parent and child combinations who agreed to participate in the study. The sample consists of 75 preadolescents (61 boys and 14 girls, and 71 parents/caretakers). The majority of families were referred either from their child's school or from some other agency.
Participating parents range in age from 27 to 58 years with a mode of 34; children's ages range from 4 to 12 years, with a mode of 9. Subjects are predominantly minorities (49% Hispanic; 30% Black; 21% Caucasian) and Catholic (52%). Surprisingly (most likely because of ethnic shifts in the neighborhood population), only 6% identified themselves as Jewish. As expected, mothers were far more likely to accompany their child(ren) to the clinic than were fathers. A substantial number of caretakers identified themselves as single parents (32%); fifty-two percent were unemployed. Sixty-eight percent were receiving public assistance. The most likely reason for referral to the clinic was behavior problems (67%)
About half of the preadolescents participating in the study (45%) reported some form of suicidal behavior (thoughts, threats or actions), either currently, or within six months prior to their interviews. In contrast, only 27% of the parents reported observing such activities in their children.
Among our child respondents, suicidal behavior included thoughts, threats, and actions. Thoughts included: "wishing I was never born"; "wanting to hurt myself"; "wanting to hit or scratch myself"; and "wanting to kill myself; drop dead; fall asleep and not be there". Threats included: "I'm going to cut my wrists"; "I'm going to kill myself"; "I'm going to run in front of a car"; "I'm going to cut my head off"; "I'm going to go to heaven to be with daddy"; and "I'm going to stab myself with this pencil". Actions included: hitting or banging one's head hard against the wall; running in front of traffic; scratching oneself; biting oneself; cutting one's face with a knife; putting a rope around one's neck; and attempting to hang oneself
Examples of reported assaultive behavior also included thoughts, threats, and actions. Thoughts included wishing someone was dead, and thinking about harming or killing another. Threats included: "I'm going to hurt or kill someone". Actions included: threatening another child with a knife; scratching; setting fires; fighting with peers and siblings; bumping; kicking; throwing objects; breaking windows and furniture; stealing property; punching; pushing; biting; and trying to choke another.
Interestingly, we found significant differences between parent and child reports of symptomatology in three of the subscales included in the questionnaire; suicidality, aggressiveness and passive aggressiveness. Among fathers, mothers and children, the children were most likely to report suicidal, aggressive and passive aggressive behaviors. Not surprisingly, fathers were least likely to perceive their child's behavior as either aggressive or passive aggressive, perhaps demonstrating their belief that "boys will be boys". These data are consistent with reports in the literature that show large discrepancies between child and parental reports of various manifestations of psychopathology (Rosenthal, & Rosenthal, 1984). The findings strongly support the importance of obtaining multiple sources of data when evaluating the mental health status of children.
We have begun to compare the suicide and non-suicide group to identify correlations between preadolescent suicidality and/or assaultive behavior, and such factors as neighborhood and family violence, sexual and physical abuse, parental separations and loss, family background, concept of death, and so forth. Because of the discrepancies found between parent and child reports, we are, initially, analyzing the child and parent data separately. Unfortunately, the small sample sizes preclude meaningful comparison between the suicidal and nonsuicidal groups. We can, however, report a few interesting preliminary findings.
Parental separations and death have often been cited as risk factors for child suicidality (Pfeffer, 1986; Pfeffer, Klerrnan, Hurt, Lesser, Peskin, & Siefker, 199l). We were surprised, therefore, to find that the death of the mother, divorce, father absence, or frequency of parental separations were not significantly associated with either a child's suicidality or assaultive behavior. In our study, only four children reported that their fathers had died. Although we are dealing with a very small sample size, we believe it is interesting that the one child who reported his father's death by homicide was suicidal, while the three children who reported their father's death of natural causes were not.
According to the suicide literature, most suicide attempts in young children and adolescents are related to a crisis over parental discipline (Leenaars, 1993). Thus, it was interesting to find that two forms of severe punishment, one physical, and the other psychological, were significantly related to the likelihood of suicidal and for assaultive behavior in our child respondents.
We found that children in our study who were frequently beaten by their fathers were almost twice as likely to be suicidal (67% vs. 37%) (p<.04) than those who were not so disciplined. We also found that children who reported having been punished by being isolated in their rooms for extended periods of time were almost twice as likely as their peers who did not report such abusive punishment to demonstrate suicidal behavior (67% vs. 32%) and about one-and-one-half times as likely to demonstrate assaultive behavior (95% vs. 66%).
We were surprised to find that parents who express their hostility to each other covertly may have a more devastating effect on a child than parents who express their hostility overtly in the form of arguments or violence. We found no significant differences in reported rates of suicidal behavior between children who frequently witnessed arguments or violence between his or her parents, were frequently blamed for family problems, or were picked on by siblings. We did, however, find that children who reported that their parents frequently did not speak to one another were almost twice as likely as their peers who did not report such parental behavior to report suicidal behavior (62% vs. 33%) (p<.02).
Almost as interesting as the associations we did find are those we did not find. Although factors such as sexual abuse (Briere & Runtz, 1986) and concept of death (Pfeffer, 1986) have been identified as risk factors for suicidality we found no such associations in this study.
We continue to analyze the data to identity further specific factors that place children at risk for suicidality. Still to be analyzed are the associations between suicidal and assaultive behavior, and factors such as substance abuse, single parenting, neighborhood violence, mental and physical illness, and race/ethnicity.
The 45% prevalence rate of suicidal activity found among the preadolescent outpatients in our study strongly supports the need to track this population through adolescence. This study will provide a basis from which to follow and compare this cohort of suicidal and non-suicidal preadolescents as they approach and enter adolescence, the age of greatest risk for completed suicide. Findings from such a study will begin to address critical questions about the long-term implications of suicidal behaviors in preadolescent children.
The study Principal Investigators are: Helene Jackson, Ph.D., Associate Professor, Columbia University School of Social Work; and, Annaclare vanDalen, Ph.D., Jewish Board of Family and Children's Services.
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