CE Corner

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"CE Corner" is a continuing education article offered by the APA Office of CE in Psychology.

To earn CE credit, after you read this article, purchase the online exam at www.apa.org/ed/ce/resources/ce-corner.aspx

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CE credits: 1

Learning objectives: After reading this article, CE candidates will be able to:

  1. Describe the factors that lead to suicidal thoughts among children.
  2. Describe interventions that may help these children.
  3. Discuss the further research needed in the area.

In September, 9-year-old Jackson Grubb was found dead of apparent suicide by hanging. The West Virginia boy was reportedly a target of bullying at school.

It was not an isolated incident. Suicide is the third-leading cause of death for children ages 5 to 14 in the United States, according to the Centers for Disease Control and Prevention.

Yet most research focuses on adolescents and virtually ignores preadolescents, says David A. Jobes, PhD, a clinical psychologist and professor at The Catholic University of America. While practitioners can and do draw from the adolescent literature when treating suicidal children, no specific evidence-based treatments exist for suicidal behaviors in preadolescents.

"The field of suicide prevention acts as if the problem of suicide begins at 12 or 14," says Jobes, who recently published a review of the existing literature on prevalence rates and risk factors for suicidal thoughts and behaviors in children under 12 (Practice Innovations, 2016). "It feels like a collective denial that children can have these thoughts and feelings."

Circumstances drive suicide

While death by suicide is less common in younger children than in adolescents, such deaths do occur—an average of about 33 per year in the United States in children ages 5 to 11, research suggests. The true number is probably higher, Jobes adds, since it's likely that some suicides in youth are misreported as accidents.

Even when young children don't act on suicidal urges, such thoughts often signal serious problems. Unsurprisingly, children with depression are more likely to think about or attempt suicide. But Jobes cautions against assuming that suicide and depression always go hand in hand. Not everyone who has suicidal thoughts is clinically depressed. And other psychiatric disorders increase the risk of suicide in children and adolescents ages 6 to 18, including bulimia, anorexia, ADHD, autism, intellectual disability and oppositional defiant disorder, according to a paper by Susan Dickerson Mayes, PhD, at Penn State College of Medicine, and colleagues (Crisis, 2015). In fact, bulimia seems to be a greater risk factor for suicide than is depression, she found.

Such broad risk factors can make it difficult for parents and health-care providers to spot children at risk of suicide, says Guy Diamond, PhD, professor emeritus at the University of Pennsylvania School of Medicine and associate professor at Drexel University. "Suicide is so multi-determined, the field has not been able to identify reliable predictors of who might make a suicide attempt."

Compared to adults, children and adolescents with suicidal behaviors seem to be driven more by circumstantial factors, such as family discord, social failure or bullying, experts say. "For children, there's a much higher likelihood that circumstances are driving the suicide," Diamond says. "Interventions need to focus on addressing these environmental stressors as well as improving patients' coping skills."

Psychological interventions

When helping a child with suicidal thoughts, family members and clinicians must take care not to reinforce the child's behaviors with attention, says Francheska Perepletchikova, PhD, an assistant professor of psychology at Weill Cornell Medicine.

She recommends adults take a calm, matter-of-fact approach—keeping the child safe (by locking up sharp objects and medications, for example) while also making sure not to give in to the child under pressure. "There is always a balancing act of ensuring safety in the short-term versus decreasing suicidal behaviors in the long-term," she says.

Unfortunately, many clinical psychologists aren't sure how best to cross that balance beam. "I don't think most clinicians have the training or framework for how to treat suicidal thoughts and attempts in children," Diamond says.

Adults are sometimes skeptical that young children can even have suicidal thoughts, Jobes adds. "When a 6- or 7-year old says, ‘I want to kill myself,' they're often greeted with skepticism or dismissiveness," he says. "I can't help but think that clinicians are sometimes guilty of this, too."

New research is exploring treatments for children who have suicidal thoughtsWhen suicidal behavior is taken seriously, health-care providers often assume that admitting the child to a hospital is the best first line of defense. But there are suggestions that hospitalization might not be the best solution. In adults, a number of studies have shown that suicide risk spikes in the days immediately following discharge from the hospital, and might remain elevated for a year or more. A national survey in England and Wales by Louis Appleby, MD, and colleagues, for instance, examined suicide among people who had previous psychiatric hospitalizations. Nearly a quarter of those deaths occurred in the first week after admission, many while still in the hospital. Post-­discharge suicide was highest in the two weeks after leaving the hospital, with the highest number of deaths occurring on the first day (British Journal of Psychiatry, 2006).

Many clinicians also prescribe antidepressants to treat children with depression and suicidal thoughts and behaviors, Jobes says, though there is little evidence that drugs alleviate such thoughts—and they may do more harm than good. In a recent meta-analysis of 34 studies, Andrea Cirpiani, PhD, at the University of Oxford, and colleagues studied the effectiveness of 14 antidepressants in children and teenagers with major depressive disorder. They found that only one, Prozac, had evidence of effectiveness. And the evidence for Prozac varied widely from study to study (The Lancet, 2016). What's more, SSRIs have been shown to increase the risk of suicide in a subset of children and teenagers, a finding that has earned the drugs a "black box" label warning from the FDA.

Instead of putting kids in hospitals or prescribing medications, Jobes argues that psychologists should be developing evidence- based therapies specific to children who express thoughts of suicide. "The clinical suicidology data overwhelmingly supports psychological interventions for suicide," he says.

His research focuses on a clinical intervention for suicide known as the Collaborative Assessment and Management of Suicidality (CAMS). The framework targets patient-defined suicidal "drivers," and emphasizes a collaborative assessment and treatment planning process between the patient and the clinician. The goal, he explains, is to enhance the therapeutic alliance and increase the patient's motivation to pursue treatment. The approach has been supported by several correlational studies and two randomized controlled trials, which Jobes summarized in a recent article (Suicide and Life-Threatening Behavior, 2012). While the CAMS approach was developed for and tested in adults, Jobes and his colleagues are adapting the process to adolescents and preadolescents, he says.

Other researchers are also exploring treatments for children. In a pilot study, Perepletchikova found that dialectical behavior therapy (DBT) showed promise as a treatment for treating suicidal thoughts in children (Child and Adolescent Mental Health, 2011). She and her colleagues are now wrapping up two randomized controlled trials further investigating DBT as a therapy for suicidal 7- to 12-year-olds with severe emotional and behavioral dysregulation.

Researchers in this field generally agree that when it comes to helping very young children with suicidal thoughts, buy-in from parents is extremely important. Yet more work is needed to understand how best to involve families in the treatment process—especially since problems at home are often at the root of a child's distress. "A lot of these kids can't or don't turn to their parents in times of stress," Diamond says.

Even when parents want to help, they may not understand or accept the severity of their child's situation. Jobes recalls a case in which a mother resisted the idea that she should remove the guns her 8-year-old son had received for his birthday. "Parental involvement can be the game changer, or it can make things 1,000 times worse," he says.

Prevention efforts

While evidence-based treatments for suicidal children are critically needed, experts also stress the importance of broader interventions to improve children's mental health. Schools—where children spend most of their waking hours—may be one place to do just that.

The Signs of Suicide (SOS) program, for instance, teaches students to recognize the signs of depression in themselves and their friends so they can seek help as needed, and also helps teachers and parents learn how best to support those kids. A study of the program by Elizabeth A. Schilling, PhD, at the University of Connecticut Health Center, and colleagues found that middle-school students with suicidal ideation had fewer suicidal behaviors after participating in the program in school (Suicide and Life-Threatening Behavior, 2014).

Similar benefits could extend from interventions that help students learn to better regulate their behavior and emotions, even without a focus on suicide prevention. Holly C. Wilcox, PhD, at Johns Hopkins School of Medicine, and colleagues studied young adults who, as kids, had participated in The Good Behavior Game, a classroom-based behavioral management strategy designed to help teachers reduce behavioral problems. They found that kids who received the program in first and second grades reported half the lifetime rates of suicidal ideation and attempts at ages 19 to 21, compared to matched controls (Drug and Alcohol Dependence, 2008).

"If we invest in upstream approaches [to improve mental health], it could have an enormous impact on suicide prevention," says Jeff Bridge, PhD, director of the Center for Suicide Prevention and Research at Nationwide Children's Hospital in Columbus.

While such programs to intervene are steps in the right direction, they don't let the field of psychology, or individual psychologists, off the hook, Jobes says.

A structured assessment, the Child Suicide Potential Scales, is available for assessing suicidal thoughts in children, and clinicians shouldn't shy away from putting it to use. But psychologists should also get serious about developing and testing effective treatments for suicidal ideation in children, he says. "It's heartbreaking when families put a child into the hospital, and a few days after they come out they kill themselves," Jobes says. "How can we abide this when we know psychotherapy can be effective?"

To directly access the citations in this article, go to our digital edition at www.apa.org/monitor/digital.

Further reading

  • Two Approaches to Treating Preadolescent Children With Severe Emotional and Behavioral Problems
    Perepletchikova, F., & Goodman, G. Journal of Psychotherapy Integration, 2014
  • The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence-Based Clinical Approach to Suicidal Risk
    Jobes, D.A. Suicide and Life-Threatening Behavior, 2012
  • Understanding and Treating Suicidal Risk in Young Children
    Anderson, A.R., Keyes, G.M., & Jobes, D.A. Practice Innovations, 2016