Suicidal Behavior In Preadolescents
Helene Jackson, Ph.D., Annaclare van Dalen, Ph.D.
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 & 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 (Bolger, 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 and 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).
Goal of the Study: 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.
The Sample: 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.
Differences in Parent and Child Reports: 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. 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.
Separation and Loss: 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.
Punishment: 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%).
Family Violence: 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.
Conclusions: 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 Principal Investigators of the study are: Helene Jackson, Ph.D., Associate
Professor, CUSSW and, Annaclare van Dalen, Ph.D., JBFCS.
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