Young children who express suicidal ideation understand death better than their peers

The authors found that children who express suicidal thoughts, the phenomenon known as suicidal ideation, were 3.6 times more likely to describe death as caused by violence than depressed children without suicidal ideation.

"It's an uncomfortable topic to contemplate, and in many ways, I think it's easier to assume that children don't really know what they're saying, and therefore they can't possibly mean the same things that adults mean when they talk about wanting to die," said lead author Laura Hennefield, PhD, a postdoctoral research scholar at Washington University in St. Louis, MO, USA.

"We did find, however that even children as young as four years of age who expressed suicidal ideation had a solid understanding of what it means to die," Dr. Hennefield added. "Although it remains unclear how to fully assess risk in these circumstances, our findings highlight the need to take children's expressions of suicidal thoughts and behaviors seriously."

The findings are based on data from a randomized controlled trial of Parent-Child Interaction Therapy Emotion Development to treat preschool depression. The sample included 22 depressed children with suicidal ideation; 57 depressed children without suicidal ideation; and 60 healthy peers of the same age.

During their baseline (pre-treatment) assessment, children completed an experimenter-led death interview to measure their understanding of five concepts of death including:

• Universality (all living things eventually die);
• specificity (only living things die);
• irreversibility (death is permanent);
• cessation (upon death bodily processes stop functioning); and
• causality (there are events that can cause death).

Depressed children with suicidal ideation demonstrated a better understanding of these death components than either peer group. Further, 100 percent of depressed children with suicidal ideation were able to describe a reasonable event that could cause death compared to 61 percent of depressed children without suicidal ideation and 65 percent of healthy children.

Somewhat unexpectedly, the authors also found that both age and expressing suicidal ideation independently predicted children's attribution of death to violent causes.

"When asked to describe an event that could cause death, older children, and children who expressed suicidal ideation, were much more likely to describe a violent cause such as shooting, stabbing, or being poisoned," said Dr. Hennefield.

Senior author Joan Luby, MD, the study's principle investigator and Director of the Early Emotion Development Program at Washington University School of Medicine added "We started this line of inquiry after observing higher than expected rates of suicidal ideation in our treatment study, which was something we had not previously seen in prior studies of preschool depression.

"This led us to add measures to investigate the meaning of this symptom to help guide caretakers and clinicians to respond. Very similar to the past studies of depression in preschoolers conducted in the Early Emotional Development Program and elsewhere, our findings suggest greater emotional awareness and capacities in younger children than previously understood."