Preadolescent Suicide, Mental Health, and Nonpharmaceutical Interventions

June 2021

This post discusses child suicide, the general risk factors, the particular impact of COVID–19, how organizations can respond to at–risk children and families, and how organizations can address trauma in responders.

General Causes of Child Suicide

The suicide of a child is tragic. Worldwide, suicide is one of the leading causes of death for children under 15 years old.¹ Almost all mental disorders are associated with an elevated risk of suicide attempts² and the more mental disorders a subject has, the higher the risk of a suicide attempt.

Suicide risk is further compounded by environmental stressors, such as academic performance demands, lack of family support, strict or authoritarian parenting, as well as sexual and psychological abuse of children and adolescents, and widespread substance misuse.³ Children are less likely than adolescents or adults to consume alcohol prior to suicide. Parent–child conflicts were the most common precipitant for child suicides.⁴

Attempt: the Most Significant Risk Factor

For every suicide, there are many more people who attempt suicide every year. The most important risk factor for suicide in the general population is a prior suicide attempt.⁵ Consistent with this, previous suicide attempts are an important risk factor for a child as well.

Perhaps surprisingly, compared to adolescents, there are lower rates of psychopathology among child suicides.⁶ Children aged 10–14 years have a lower prevalence of mental health problems associated with suicide compared with the age group 15–19 years.⁷ Perhaps because of these less obvious signs of risk (i.e., lack of substance use), suicide may be more underreported among children than in adolescents and adults.⁸ Explanations for under–reporting include social stigma and shame around suicide, coroners’ reluctance to determine a verdict of suicide in a child or the misconception that children are precluded from engaging in suicidal acts owing to their cognitive immaturity.⁹

COVID–19 Stressors Increasing Mental Health Issues

During this past year there has been an increase in mental health issues in children, as well as an increase in environmental stressors,¹⁰ which include nonpharmaceutical interventions (NPIs) used in response to COVID–19, such as lock–down, wearing masks, and social distancing.^11,12 In Colorado alone, there are approximately four suicide attempts by children per week,¹³ and younger children are displaying behavioral problems (e.g., developmental regression).¹⁴ In El Paso County, Colorado, youth suicide has doubled during the pandemic.¹⁵ A possible explanation is that some children reached the limit of their resilience when normal routines, social circles, friendships were stopped for a year.¹⁶

COVID–19 has negatively affected the wellbeing of children and adolescents.¹⁷ The pandemic itself can cause fears of COVID–19 infection, uncertainty, and potential economic problems.¹⁸ An online survey conducted by the National Center for Child Health and Development during 30 April 2020 to 5 May 2020 revealed that 39% of the children aged between 7 and 17 years (Total No. = 1,292) felt uncomfortable when thinking about COVID–19 and 32% were easily irritated.¹⁹  

The governmental mandate to stay home and maintain social distancing has limited peer contacts and places for play for children and adolescents. These social limitations and NPIs may slow down child development, result in reduced opportunities for stress regulation, and create social isolation.²⁰ In–person human interaction is critical for a child’s psychological development and wellbeing.²¹ Research addressing previous pandemics showed that 30% of children isolated or quarantined met criteria for PTSD, and any child quarantined or isolated during pandemics is at higher risk for acute stress disorder, adjustment disorder, and grief.²² Without improved mental health services for children, the damage to their mental health may last for years.²³ Between April 2019 and April 2021, there was a 90% increase in demand for pediatric behavioral health.²⁴

The psychological wellbeing of parents and children is affected by at least four factors, which can co–occur:²⁵ parental job loss, income loss, caregiving burden, and physical illness.²⁶ These factors are present during COVID–19, as parents are responsible for facilitating remote schooling while also addressing economic problems (e.g., working remotely, seeking employment, reduced work hours).

Assessing Children and Families for Risk

Organizations who have responsibilities for serving children, or families with children, should utilize actuarial risk assessment measures. Several brief screening tools are reliable for identifying those at risk for depression and suicide. These tools include:

• Ask Suicide–Screening Questions (ASQ), a four–question tool useful in identifying youth aged 10–21 years at risk for suicide. The ASQ is a 4–item screening instrument developed to identify suicide risk in pediatric patients with medical or surgical issues who present to the Emergency Department. The ASQ has a sensitivity of 96.9%, a specificity of 87.6%, and a negative predictive value of 99.7%.²⁷

• Columbia–Suicide Severity Rating Scale (C-SSRS) The C–SSRS characterizes current thoughts of suicide and past suicidal behaviors. It features a clinician–administered initial evaluation form, a since–last–visit version, and a self–report form. Studies have shown the C–SSRS to be sensitive, specific, and reflective of changes in patients’ conditions. The C–SSRS has also been translated into and validated in several languages. The C–SSRS, whose use is compulsory in U.S. Food & Drug Admins clinical trials, has been assessed for predictive validity in adolescents. This is the most relevant and prudent instrument for organizations that work internationally, in light of its being available in several languages. ²⁸

There are many other suicide risk instruments that can be considered contingent on the specific needs and clinical settings of the organization.

Supporting Providers and Responders

Turning to providers, personal life, professional life, and mental health are all impacted by exposure to suicide or suicide attempts.²⁹ This suicide exposure causes emotional distress to responders and providers.³⁰ Due to these impacts, it is critical for organizations whose personnel are exposed to suicide attempts and suicide completion to ensure they receive a psychological debriefing, ideally by a traumatologist.

Conclusion

Organizations that work with children and families will want to be aware of risks and causes related to child and adolescent suicide, in particular the impact of COVID-19 on child mental health. Proactive evaluation of children and families, in addition to support of responders and providers, will help to create the best environment to care for children and support their mental health.

Clinical staff at Intermodal Interventions are available for consultation to religious organization care providers.

A. R. Ascano, JD, MS, LPC

R. P. Ascano, Ph.D., LP

Fellow American College of Forensic Psychology

Intermodal Interventions

P.O. Box 60203

Colorado Springs, CO 80960

Office: 719-424-4653

After hours: 719-219-8626

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About A. R. Ascano

A. R. Ascano is a Licensed Professional Counselor in Colorado. Her education includes a Master of Science in Clinical Psychology, a Juris Doctorate, and she is completing a PhD in Developmental Psychology. During her time as an attorney, her practice was child-focused as a guardian ad litem and custody investigator. She has continued this child-focused practice as a counselor with an emphasis on traumatic stress and adverse childhood experiences.

About R. P. Ascano

RP Ascano, has two master's degrees, a Ph.D. in Psychology, with a Post-Doctorate in Forensic Psychology. Additional credentials include:

• Fellow, American College of Forensic Psychology
• Fellow, American Academy of Experts in Traumatic Stress (Retired)

He was an Assistant Professor of Forensic Psychiatry for 32 years at UND, School of Medicine, Department of Psychiatry and Behavioral Science.

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¹ Wasserman, D. (Ed.). (2009). Oxford textbook of suicidology and suicide prevention. Oxford University Press.

² Miché, M., Hofer, P. D., Voss, C., Meyer, A. H., Gloster, A. T., Beesdo–Baum, K., & Lieb, R. (2018). Mental disorders and the risk for the subsequent first suicide attempt: results of a community study on adolescents and young adults. European child & adolescent psychiatry, 27(7), 839–848.

³ Wasserman, D. (Ed.). (2009). Oxford textbook of suicidology and suicide prevention. Oxford University Press.

⁴ Soole, R., Kõlves, K., & De Leo, D. (2015). Suicide in Children: A Systematic Review. Archives of suicide research : official journal of the International Academy for Suicide Research, 19(3), 285–304. https://doi.org/10.1080/13811118.2014.996694

⁵ World Health Organization (2018) Fact sheet of suicide. www.who.int/mediacentre/factsheets/fs398/en/

⁶ Soole, R., Kõlves, K., & De Leo, D. (2015). Suicide in Children: A Systematic Review. Archives of suicide research : official journal of the International Academy for Suicide Research, 19(3), 285–304. https://doi.org/10.1080/13811118.2014.996694

⁷ Soole, R., Kõlves, K., & De Leo, D. (2014). Factors related to childhood suicides: Analysis of the Queensland Child Death Register. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 35(5), 292.

⁸ Pritchard, C., & Hansen, L. (2005). Child, adolescent and youth suicide or undetermined deaths in England and Wales compared with Australia, Canada, France, Germany, Italy, Japan, and the USA for the 1974–1999 period. International journal of adolescent medicine and health, 17(3), 239–254.

⁹ Kõlves, K., & De Leo, D. (2014). Suicide rates in children aged 10–14 years worldwide: Changes in the past two decades. British Journal of Psychiatry, 205(4), 283-285. doi:10.1192/bjp.bp.114.144402

¹⁰ Yasgur, B. S. (2021, June 4). Child suicides drive Colorado hospital to declare state of emergency. Medscape.  Retrieved from https://www.medscape.com/viewarticle/952464?src=WNL_mdpls_210604_mscpedit_psych&uac=8603EX&spon=12&impID=3420817&faf=1)

¹¹ NPIs include social distances, closures, stay at home mandates. See https://www.cdc.gov/nonpharmaceutical-interventions/index.html

¹² Fegert, J. M., Vitiello, B., Plener, P. L., & Clemens, V. (2020). Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child and adolescent psychiatry and mental health, 14, 1–11.

¹³ Brentzel, C. (2021, June 2). Colorado kids in dire need of mental health care are being sent out of state.  KRDO.com. Retrieved from https://krdo.com/news/2021/06/02/colorado-kids-in-dire-need-of-mental-health-care-are-being-sent-out-of-state/

¹⁴ Yasgur, B. S. (2021, June 4). Child suicides drive Colorado hospital to declare state of emergency. Medscape.  Retrieved from https://www.medscape.com/viewarticle/952464?src=WNL_mdpls_210604_mscpedit_psych&uac=8603EX&spon=12&impID=3420817&faf=1)

¹⁵ Kerridge, K.  (2021, April 6). Children’s Hospital: Youth suicides doubled in El Paso County during pandemic; more resources coming.  KKTV.com. Retrieved from https://www.kktv.com/2021/04/06/childrens-hospital-youth-suicides-doubled-in-el-paso-county-during-pandemic-more-resources-coming/

¹⁶ Yasgur, B. S. (2021, June 4). Child suicides drive Colorado hospital to declare state of emergency. Medscape.  Retrieved from https://www.medscape.com/viewarticle/952464?src=WNL_mdpls_210604_mscpedit_psych&uac=8603EX&spon=12&impID=3420817&faf=1)

¹⁷ Lee, J. (2020). Mental health effects of school closures during COVID–19. The Lancet Child & Adolescent Health, 4(6), 421; Patrick, S. W., Henkhaus, L. E., Zickafoose, J. S., Lovell, K., Halvorson, A., Loch, S., ... & Davis, M. M. (2020). Well-being of parents and children during the COVID–19 pandemic: a national survey. Pediatrics, 146(4).

¹⁸ Sher, L. (2020). The impact of the COVID-19 pandemic on suicide rates. QJM: An International Journal of Medicine, 113(10), 707–712.

¹⁹ National Center for Child Health and Development. 2020. Reports of national online survey of children’s quality of life and health in the COVID-19 pandemic. Retrieved from: https://www.ncchd.go.jp/center/activity/covid19_kodomo/survey.html#report

²⁰ Isumi A, Doi S, Yamaoka Y, Takahashi K, Fujiwara T. Do suicide rates in children and adolescents change during school closure in Japan? The acute effect of the first wave of COVID-19 pandemic on child and adolescent mental health. Child Abuse Negl. 2020;110(Pt 2):104680. doi:10.1016/j.chiabu.2020.104680

²¹ World Health Organization. (2004). The importance of caregiver–child interactions for the survival and healthy development of young children: A review.

²² Sprang, G., & Silman, M. (2013). Posttraumatic stress disorder in parents and youth after health–related disasters. Disaster medicine and public health preparedness, 7(1), 105–110.

²³ Children’s Commissioner. (2021). The state of children’s mental health services 2020/21. Retrieved from https://www.childrenscommissioner.gov.uk/wp-content/uploads/2021/01/cco-the-state-of-childrens-mental-health-services-2020-21.pdf

²⁴ Yasgur, B. S. (2021, June 4). Child suicides drive Colorado hospital to declare state of emergency. Medscape/  Retrieved from https://www.medscape.com/viewarticle/952464?src=WNL_mdpls_210604_mscpedit_psych&uac=8603EX&spon=12&impID=3420817&faf=1)

²⁵ Gassman–Pines, A., Gibson–Davis, C. M., & Ananat, E. O. (2015). How economic downturns affect children's development: an interdisciplinary perspective on pathways of influence. Child Development Perspectives, 9(4), 233–238.

²⁶ Johnson, R. C., Kalil, A., & Dunifon, R. E. (2012). Employment patterns of less–skilled workers: Links to children’s behavior and academic progress. Demography, 49(2), 747–772; Blakey, S. M., & Abramowitz, J. S. (2017). Psychological predictors of health anxiety in response to the Zika virus. Journal of clinical psychology in medical settings, 24(3), 270–278; Gassman–Pines, A., & Schenck–Fontaine, A. (2019). Economic strain and job loss. In: Fiese BH, ed. APA Handbook of Contemporary Family Psychology. Washington, DC: American Psychological Association; 2018: 457–470.

²⁷ Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., Wharff, E. A., Ginnis, K., Cannon, E., Joshi, P., & Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): A brief instrument for the pediatric emergency department. Archives of pediatrics & adolescent medicine, 166(12), 1170–1176. https://doi.org/10.1001/archpediatrics.2012.1276

²⁸ Ryan, E. P., & Oquendo, M. A. (2020). Suicide Risk Assessment and Prevention: Challenges and Opportunities. Focus (American Psychiatric Publishing), 18(2), 88–99. https://doi.org/10.1176/appi.focus.20200011.  See https://www.hrsa.gov/behavioral-health/columbia-suicide-severity-rating-scale-c-ssrs for further information on the C-SSRS.

²⁹ Lopes de Lyra, R., McKenzie, S. K., Every–Palmer, S., & Jenkin, G. (2021). Occupational exposure to suicide: A review of research on the experience of mental health professionals and first responders. PLos One. doi: 10.1371/journal.pone.0251038

³⁰ Lopes de Lyra, R., McKenzie, S. K., Every–Palmer, S., & Jenkin, G. (2021). Occupational exposure to suicide: A review of research on the experience of mental health professionals and first responders. PLos One. doi: 10.1371/journal.pone.0251038

Featured Image by Rebecca Sidebotham.