Suicide and young children

Until recently, suicidal behaviour among children and adolescents was not considered a problem of great concern. However, recent newspaper reports about youth suicide has made the general public more aware of, and alarmed about, the occurrence of suicide in children and adolescents – Pfeffer, 1986

This is how Cynthia Pfeffer MD begins her book, The Suicidal Child, which was published in the USA in 1986. Upon first reading this, we could easily interpret it as a current statement about recent media reports relating to suicide in children and young people. While we have been concerned about youth suicide for some time now, suicide risk in children has not yet received the attention it deserves. There is no doubt that the thought of a child dying by suicide is confronting. In many ways, it challenges ideals we hold as a society about how children grow and develop. Additionally, the idea of children dying by suicide confronts us as members of families and communities with a shared responsibility to keep children safe from harm.

The data on suicide deaths of children

Despite the work of practitioners such as Pfeffer during the 1980s in recognising the risks for children and calling for more research, it has only been in the past decade in Australia that the Bureau of Statistics (ABS) has begun to collect data relating to suicide deaths of children under the age of 11. We know that the accuracy of this data varies depending on coronial reporting practices, resulting in some uncertainty about the actual deaths (ABS, 2017). In 2017 suicide remained the leading cause of death of children aged 5–17 years, with 98 deaths occurring in this age group. This represented a 10.1 per cent increase in deaths from 2016. Nearly 80 per cent of those deaths were of young people aged 15–17 (ABS, 2017). In the period between 2010 and 2014, 305 deaths of children aged 5–17 were recorded, with 88 of those deaths being children aged 5–14 (43 males, 45 females).

Aboriginal and Torres Strait Islander children were overrepresented (84 of the total deaths) compared to non-indigenous children in this group (ABS, 2016). This was highlighted recently with the release of the Western Australian Coroner’s Report on the Inquest into the deaths of 13 children and young people in the Kimberley Region. The Coroner found that 12 of the 13 deaths occurred by way of suicide. Of the 13 deaths investigated, five were of children aged between 10 and 13. A total of 42 recommendations were made as a result of the Inquest (Western Australian Coroner’s Office, 2019).

As is the case for adolescents and adults, suicidal behaviour or death in children is complex and multifactorial, with no one factor able to account entirely for it. Statistically speaking, this is because the number of deaths by suicide is small, research is scant and with small numbers of case studies to draw upon, the evidence is not solid. Research efforts in relation to suicidal behaviour, and particularly in relation to children, are also limited due to ethical constraints.

Efforts to extrapolate from what is known about adult or even adolescent suicides is not always accurate or helpful as children differ considerably in relation to their stage of physical, sexual, cognitive and social development. Risk and protective factors that apply to adolescents and adults may not necessarily apply to children and children bring their own particular risk and protective factors. Suicidal behaviours and deaths in children are also likely to be underestimated. This can be due to social stigma, shame, reluctance by officials to determine a verdict of suicide, and a misconception that children are precluded from engaging in suicidal acts due to cognitive immaturity (Kolves, 2010).

Children’s understanding of suicide

Research has indicated that from the age of eight, children can understand the concept of suicide and are capable of carrying it out (Kolves, 2010, citing Mishara, 1998; Fortune & Hawton, 2007). Mishara (2003) argued that for children to understand suicide they must first understand death. He suggested that preschool children first conceive of death as reversible, as not universal or inevitable. This may be based upon portrayals of death in fairy tales, where characters can be reawakened or brought back to life with magic powers. Children do not retain this immature understanding of death for long and by the age of six or seven, two-thirds of children understand that everyone dies and most know that we must all die one day. The question of when a death is considered to be a suicide has been a source of debate and a recent review of the role of coroners in determining this was undertaken by Jowett, Carpenter and Tait (2018). The authors include a specific section related to children and note the challenges associated with the controversy of whether children can formulate concepts of the finality of death. They cite the work of Brian Mishara in his 1999 study as suggestive that children aged 6–12 “generally know enough to [commit] suicide with the knowledge that this will result in permanent death” (Jowett, Carpenter & Tait, 2018, p. 20). They also note that children are likely to learn about suicide from media reports as well as conversations with adults and older children.

A very useful source of information that provides insight into the extent to which children are considered to be experiencing suicidality is the Kids Helpline data. Records of help-seeking to Kids Helpline reveal that children start making contact very young in relation to suicide (from the age of seven) with numbers rapidly increasing between the ages of 11 and 14. Further, in a consultation undertaken by Kids Helpline, children aged 14 years and under were found to be just as likely to have made a suicide plan or attempted suicide as those in the older group. Eighty-two per cent of the 136 participants aged 14 years and younger reported having made a suicide plan and 54 per cent reported attempting suicide (Batchelor, 2017). This is supported by 2018 Kids Helpline data which revealed that 10 per cent of calls from children aged 5–12 years were suicide-related.

A consultation survey undertaken by Your Town in 2016 included information relating to help-seeking by children and young people when they experienced suicidal thoughts or had a plan. Of concern, the researchers found that less than half of the respondents had received any kind of help, with younger children (aged 14 and younger) significantly less likely to have received help than older teenagers (aged 15–19 years). This was despite children in the younger group being just as likely to have made a suicide plan or attempted suicide as those in the older group. Given the complexities associated with understanding and preventing suicide and a tendency to not believe that children are able to conceptualise death by suicide, this is perhaps not surprising.

Models of suicidality

There are few models developed for understanding suicidality in children, however, the stress-vulnerability model could be applicable. This model recognises the complexity of suicidality, including genetic make-up as well as acquired susceptibility which contributes to a person’s predisposition or vulnerability. Early traumatic life experiences, chronic illness, chronic alcohol and substance abuse, and environmental factors such as for example, social position, culture and diet, all play a part in the development of vulnerability (Wasserman, 2012).

The risk and protective factors framework can also provide a useful approach to understanding the factors which may play a role in suicide. Risk factors are characteristics or conditions that tend to increase the likelihood of suicide, while protective factors may mediate or reduce the impact of those risk factors. While this framework may be useful in understanding the types of factors which may impact, it is important to recognise that it is a model developed for population level understandings rather than understanding the specific circumstances related to an individual child (Commonwealth Department of Health and Aged Care, 2000).

It is clear, however, that suicidal behaviours occur within a complex web of factors which come together to increase the likelihood of risk of harm. It helps us to understand that no single factor leads to suicide, but rather a combination of factors. Suicidal behaviour has been considered to be a developmental process that begins at an earlier phase of the life cycle than when this behaviour becomes most obvious, so a focus on understanding risks and opportunities for prevention of those risks has been recognised (McClanahan & Omar, 2012; Wasserman, et al., 2012). It is important to note that risk factors relating to suicide are largely unstudied in pre-pubertal children and have usually been inferred from adolescent studies. However, inferences should only be made with considerable caution (Gvion & Apter, 2016).

There is limited research explicitly looking at protective factors in relation to preventing children’s suicide. Westefeld, et al. (2010) identify four key factors which may protect children from suicide:

1. Strong family relationships characterised by warmth, support and the absence of abuse, or the identification and early treatment of abused children.
2. Early identification and treatment of children with psychological disorders, particularly depression.
3. Postvention efforts that reduce contagion following suicide.
4. Information made widely available to parents, teachers, school administrators and mental health providers to reduce the risk of adults dismissing early warning signs due to the intuitive inconsistency between children and suicide.

It could also be argued that protective factors identified to support positive children’s mental health more broadly also apply to suicide prevention for children. Headspace offers a comprehensive review of the risk and protective factors impacting on children.

What can be done?

While it is no doubt difficult to confront the issue of suicide risk in children, it is clear that increasing the awareness of adults about these risks can promote opportunities for children’s needs to be heard and taken seriously. There are many ways that children can be supported so that their needs can be met and in so doing the risk of suicide may be reduced. Psychologists working with children and families are very well placed to provide psychoeducation in relation to these risks and to proactively work with family members to encourage increased awareness and support to children to both prevent and respond effectively to children who may be experiencing suicidality.

In conclusion, it seems appropriate to return to the words of Pfeffer: “since children are relatively resilient and labile, they are likely to respond favourably to kind and thoughtful interventions. Many interventions are possible… An important feature of treatment is the involvement of a network of people. The network should be a system that offers constant observation of the child, protection from self-harm, and an opportunity for the child to communicate about his or her worries” (p. 273).

The author can be contacted at L.O’[email protected]