The prevalence of suicidal ideation and behaviors in preadolescent children is higher than previously estimated, and parents are often unaware of their child's suicidality, a cross-sectional analysis from the Adolescent Brain Cognitive Development (ABCD) study has found.

Family conflict and low parental monitoring appear to correlate with suicidality in this age group, the researchers say.

The study by Danielle C. DeVille, MA, of the Laureate Institute for Brain Research in Tulsa, Oklahoma, and colleagues was published online February 7 in JAMA Network Open.

The rate of death by suicide among US children aged 10 to 14 years almost tripled from 2007 to 2017, rising at an annual rate of 18%, according to the National Center for Health Statistics. Until recently, little has been known about the factors driving what is now the leading cause of child death.

The investigators studied ABCD study data from 2016 to 2018 on 11,814 children aged 9 and 10 years. Of these, 47.8% were girls, and 52% were white.

Parent and child reports of current and/or past suicidality and nonsuicidal self-injury (NSSI) were collected with an electronic version of the Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime Version. Diagnoses were determined on the basis of Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria.

After sociodemographic weighting, the approximate prevalence rate of lifetime history of passive suicidal ideation was 6.4%. The prevalence rates were 4.4% for nonspecific active suicidal ideation; 2.4% for active ideation involving intention, method, or plan; 1.3% for actual suicide attempts; and 9.1% for nonsuicidal self-injury.

The investigators also analyzed the data with respect to children's sex, family history, internalizing and externalizing of problems, and relevant psychosocial variables, such as financial adversity.

A high level of family conflict was significantly associated with suicidal ideation (odds ratio [OR], 1.12) and NSSI (OR, 1.09).

Children's reports of family conflict were assessed using the nine-item family conflict subscale of the Family Environment Scale, which assesses fighting, anger, criticism, competitiveness, yelling, and loss of temper.

Low parental monitoring significantly correlated with both suicidal ideation (OR, 0.97), attempts (OR, 0.91), and NSSI (OR, 0.95). Although the literature is sparse, there appears to have been an increase in both suicidal ideation and harm in younger children, coinvestigator Florence Breslin, MS, manager of clinical assessments and testing at the Laureate Institute, told Medscape Medical News. "It is unclear, since previous studies have grouped younger children in with adolescents," she said.

The researchers found a lack of caregiver agreement regarding more than 75% of children who reported suicidal ideation or behaviors, "indicating that most caregivers were unaware of or otherwise unable to report information regarding their child's suicidality," they write.

This disconnect may have important clinical implications, they add. "Our findings highlight the need to ensure that suicide assessments are conducted with children directly rather than solely with the child's caregivers. If possible, assessment of suicidal ideation should occur within a one-on-one interaction with the child."

Echoing that, Breslin said, "Hopefully, one of the outcomes from this paper is that parents, primary care providers, and pediatricians will start to ask young kids directly about these behaviors. Too often, pediatricians direct these questions only at the parent."

Breslin noted that although the investigators were initially surprised at the discrepancy between caregiver awareness and children's reports, "when we started to read the literature, we saw that this was not uncommon in other areas of mental health, such as anxiety and depression." These studies reveal a tendency for adults to dismiss children's negative feelings as "just something kids say but don't really mean."

Less discordance, however, emerged in families with a history of mental health problems, suggesting greater openness to discussing these topics.

As to the issue of progression, Breslin noted that some research places youngsters on a spectrum ranging from self-harm to suicidal ideation and attempt. "But though some youth will be part of a continuum, there are also some who will self-harm but never have suicidal ideation, and others who have suicidal ideation but will never self-harm," she said.

Breslin stressed the need for frontline healthcare providers to screen children earlier for mental health problems in general and especially to ask questions of the children themselves; parents are often unaware or dismissive of their offspring's negative emotions if they appear happy much of the time. "It will be important for professionals who assess large numbers of children to evaluate these feelings," she said. "I think that some of the increase in the rate of suicide we're seeing in teenagers could have been prevented if we picked up on these feelings at earlier ages."

The increase in suicide rates for children, adolescents, and young adults is reaching the level of a public health crisis, Robin Aupperle, PhD, an associate professor at the School of Community Medicine at the University of Tulsa, Oklahoma, told Medscape Medical News. "The results of the current study suggest that the rate of suicidal ideation and behaviors for children in preadolescence may be much higher than usually assumed," she said.

"This is extremely troubling, particularly given the relative lack of research concerning how to best intervene and prevent suicide at this young an age."

Aupperle, who was not involved in the study, pointed to the need for longitudinal data to identify predictive factors and provide keys to more accurate assessment and new treatment targets.

In 2018, Medscape Medical News reported that the percentage of children and adolescents who present at US pediatric hospitals for suicidal ideation or suicide attempts doubled from 2008 to 2015. And last year, Medscape Medical News reported that 15.9% of preadolescents engaged in suicidal ideation.

In a 2019 survey, half of parents were unaware that their adolescents had thought of suicide, and three quarters were unaware that they thought about death frequently. Adolescents often denied having thoughts of suicide when parents did ask about it.

The ABCD Study is supported by the National Institutes of Health (NIH) and other federal partners and by the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, the National Institute on Minority Health and Health Disparities, the NIH Office of Behavioral and Social Sciences Research, the NIH Office of Research on Women's Health, the Centers for Disease Control and Prevention, the National Institute of Justice, the National Science Foundation, and the National Endowment for the Arts. DeVille has disclosed no relevant financial relationships. Several coauthors have disclosed relationships with a variety of institutions, as listed in the original article. Aupperle has disclosed no relevant financial relationships.

JAMA Netw Open. Published online February 7, 2020. Full text

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