By Dr Norman Blumenthal
In response to the fatal suicides of preadolescent children in recent months, OHEL Children’s Home and Family Services is refocusing attention on these tragic events with an aim to significantly reduce, if not eliminate, their recurrence.
In the United States, 45,000 people die by suicide each year. One million more make such attempts every year (CDC). This requires our heightened focus.
The following is a summary of essential issues regarding suicidal intent and behavior among our youngest population.
Until fairly recently, suicide during childhood was so unthinkable that professionals and parents regarded such threats as attention seeking behavior not deserving of concern or alarm. While still rare, the prevalence of fatal suicides among children has risen so dramatically that there has been a seismic shift in the seriousness with which statements and risk factors are approached and understood.
Today suicide is the third leading cause of death for 5-14 year-olds following accidents and cancer. (CDC/National Center for Health Statistics, 2017). Hospitalization for school aged children and adolescents for suicidal thoughts or attempts has more than doubled between 2008 and 2015 (Journal of Pediatrics, 2018). These new realities are impacting significantly not only on those children at risk but to the importance that we place on children’s overall emotional wellbeing as well as the gravity with which we view mental illness and its treatment.
As it is with psychiatric disorders at large, suicidal ideation and behaviors are symptoms of a medical ailment no different than more commonly associated ones such as cancer and heart disease.
Serious illnesses at large are predominately caused by the confluence of genetic predispositions (often evident by family history), the presence of a medical disorder, and contributing environmental factors. For example, heart disease is caused by genetic predisposition, medical dysfunction such as blocked arteries and personal stress, sedentary lifestyle, poor diet, and the like.
Similarly, mental illness, including suicidal tendencies, are governed by genetic predispositions, the presence of a mental illness (e.g. depression, ADHD) and life stressors or painful events.
From these understandings and findings, it is imperative to emphasize that an adult or child who dies of a suicide should not be seen as any different than someone who fatally succumbs to any medical illness.
Contrary to popular myths, suicide is not simply a desperate act exclusively linked to unbearable pain or mistreatment. Most of the children who took their lives and became known to OHEL, have belonged to loving and stable families whose members have extended themselves tirelessly for their children. Rather, suicide is a complex behavior etiologically rooted in genetic predispositions, the presence of a psychiatric illness, and environmental stressors.
Suicide in pre-teens appears unique from that of older children and adults. While depression, severe anxiety, and comparable states of dysphoria are often the overriding conditions present with suicidal teens and adults, younger children who take their lives are often more beset by conditions characterized by impulsivity and unbridled behaviors including Attention Deficit Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorders (Sheftall, A. H. et al, Suicide in elementary aged children… Pediatrics, 2016, 138(4)).
It may be that the suicide was motivated less by a wish to die but rather via reckless experimentation or an effort to do something demonstrative that was not well thought out. Despite these known accompanying conditions, it cannot be overstated that most depressed adults and teens are not suicidal nor are most children with the aforementioned conditions inclined to harm themselves.
Immediate environmental risk factors associated with early childhood suicide include ruptures in interpersonal relationships including bullying or family conflict particularly parent-child. In addition, preoccupation with death evident both in verbalization and play as well as overt threats even in preschool seem associated as well with subsequent suicide attempts (Journal of the American Academy of Child Adolescent Psychiatry 2019;58(1):117–127).
Despite known risk factors for both adults and children, the ability to predict suicide, even by trained professionals, is woefully lacking (Franklin, J. et al Risk Factors for Suicidal Thoughts and Behaviors: A Meta-Analysis of 50 Years of Research. Psychological Bulletin, 11/14/16). This is often due to “false positives” or the higher number of individuals possessing the very same risk factors but not suicidal.
Another concern when a suicide occurs in one’s immediate setting or if it is highly publicized through the media or videos, is what is known as the “Werther Effect” or suicide contagion. It does not appear to be the case that children who are not suicidal will become self-harmful because of such exposure. However, for those in the throes of suicidal struggles, an event that is so profoundly brought to their attention can “tip the scale” and prompt comparable and personally dangerous behavior. When there is a highly publicized suicide or one in the child’s immediate neighborhood or school, it is essential that the treating providers are notified and implement necessary preventive measures.
All too often, there is a tendency in our community to treat suicide with dismissive disregard or jocularity. Suicide threats can be uttered as an attempt at amusement or merely to express more normative exacerbation. In light of the recent increase in these tragic deaths, the community at large should make an effort to refrain from alluding to suicide in a satirical manner or to express such wishes in a figurative fashion. For those afflicted with such thoughts and impulses, a fatal outcome is not something to take with levity or to be bantered about.
When a parent, school, or other caregiver is concerned that suicidal thoughts, expressions, or behaviors may be present, an immediate referral to a qualified mental health professional should be made.
Benjamin Franklin famously said “an investment in knowledge pays the best interest.” We have much to learn in order to conquer suicide at all ages much as we have polio, yellow fever, and the like. However, if we destigmatize this ailment, allow for open and shameless discussion, and redouble our efforts to effectively address mental illness, we can anticipate a time when childhood will be purely characterized by carefree play and dreams.
OHEL’s professional staff continues to work with families, schools, and rabbinical and lay leaders to educate, prevent, and respond to a heightened concern of suicide in all communities.
Dr. Norman Blumenthal has over 20 years of experience in the fields of trauma, loss, and bereavement. He is the Zachter Family Chair in Trauma and Crisis Counseling at OHEL, and director of the OHEL Miriam Center for Trauma, Bereavement, and Crisis Response.