Characteristics and Precipitating Circumstances of Suicide Among Children Aged 5 to 11 Years in the United States, 2013-2017

IMPORTANCE Suicide is the eighth leading cause of death among children aged 5 to 11 years, with rates increasing during the past decade. A better understanding of factors associated with childhood suicide can inform developmentally appropriate prevention strategies. OBJECTIVE To examine characteristics and precipitating circumstances of childhood suicide. DESIGN, SETTING, AND PARTICIPANTS This qualitative study examined restricted-use data from the National Violent Death Reporting System (NVDRS) regarding child suicide decedents aged 5 to 11 yearsintheUSfrom2013to2017.TheNVDRSisastate-basedsurveillancesystemthatcollectsdata on suicide and violent deaths in 50 states, with restricted-use data available from 37 states. Details and context related to suicide deaths were identified through a content analysis of case narratives from coroner or medical examiner and law enforcement reports associated with each incident. EXPOSURES Characteristics and precipitating circumstances associated with suicide cited in the coroner, medical examiner, and law enforcement case narratives. MAIN OUTCOMES for mental health, prior suicidal and peer, school, or family-related RESULTS Analyses included 134 child decedents (101 [75.4%] males; 79 [59.0%] White individuals; 109 [81.3%] non-Hispanic individuals; mean [SD] age, 10.6 [0.8] years). Most suicides occurred in the child’s home (95.5% [n = 128]), and more specifically in the child’s bedroom. Suicide by hanging or suffocation (78.4% [n = 105]) was the most frequent method, followed by firearms (18.7% [n = 25]). Details on gun access were noted in 88.0% (n = 22) of suicides by firearm, and however, restricted-use data were only available from 37 states. 17 An earlier study on childhood suicide using NVDRS data was limited to data through 2012 for 17 states, whereas this study has provided a 5-year update with information from 37 states. 15,17 A total of 136 suicides for children aged 5 to 11 years were identified for the study period. Incidents where the underlying cause of death was missing or not coded as suicide based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) (X60-X84, Y87.0, and U03) 2 were reviewed by 3 authors (D.R., K.H., and J.B.). Of these 136 incidents, 2 were misclassified as suicide and were excluded, leaving 134 cases. Demographic information in the NVDRS including age, sex, and race/ethnicity was obtained from death certificate data.Race/ethnicitywasassessedtoidentifypotentialdisparitiesinsuicidedeaths,andcategorized based on the Office of Management Standards for the Classification of Federal Data on Race and Ethnicity. 18


Introduction
Youth suicide is a major public health concern. Although uncommon prior to adolescence, suicide was the eighth leading cause of death among children aged 5 to 11 years in the United States, 1 and accounted for 2.3 deaths per 1 million youth in 2019. 2 In a study examining US emergency department visits for youth with suicidal ideation and attempts, 43% of cases from 2007 to 2015 were in children aged 5 to 11 years. 3 An additional analysis reported rates in this age group increased 14.7% annually between 2012 to 2017. 4 Despite these troubling statistics, childhood suicide research has received limited attention compared with suicide in adolescents.
Evidence suggests suicide risks for adolescents such as psychopathology, [5][6][7] family factors, [8][9][10] and maltreatment 11,12 are also associated with childhood suicide, but there are notable differences. [13][14][15] In a study of youth aged 5 to 11 years and 12 to 18 years with a history of suicidal behavior, younger youth were more likely to experience bullying and have a family history of depression. 13 An additional study found that suicide decedents aged 5 to 11 years were more likely to be male, Black, to die at home by hanging or strangulation, be diagnosed with attention-deficit/ hyperactivity disorder (ADHD), and less likely to experience depression compared with decedents aged 12 to 14 years. 15 In response to a call for action from the National Institute of Mental Health task force on child suicide research, 16 the current study examines characteristics and precipitating circumstances of suicide in children using the National Violent Death Reporting System (NVDRS). 17 The NVDRS is a state-based surveillance system that collects data on suicide and violent deaths. 17 Information was obtained from coroner, medical examiner, and law enforcement reports associated with each death.
Although previous research has examined quantitative data elements to characterize childhood suicide, [13][14][15] this study's qualitative approach uniquely captures additional details and context related to each incident. A better understanding of underlying factors associated with childhood suicide can inform developmentally appropriate prevention strategies for this population.

Methods
This qualitative study analyzed NVDRS data on child suicide decedents between 2013 and 2017. At the time of the study, 50 US states participated in the NVDRS; however, restricted-use data were only available from 37 states. 17 An earlier study on childhood suicide using NVDRS data was limited to data through 2012 for 17 states, whereas this study has provided a 5-year update with information from 37 states. 15

Variables and Analysis
Descriptive statistics were conducted for sex, age, race/ethnicity, method of suicide, and injury location. Methods associated with grounded theory and thematic analysis, including open coding procedures, 20,21 were used to identify overarching themes describing the incident. Three authors (D.R., K.H., and J.B.) individually performed a content analysis of autopsy and law enforcement narratives to inductively identify characteristics and precipitating circumstances of suicide and group them into themes. Authors reflected an interdisciplinary team with backgrounds in epidemiology, public health, and clinical social work. A constant comparative approach was used to refine themes into more succinct categories. 20,21 Discrepancies in coding were resolved and data saturation confirmed by reaching mutual consensus after discussion between authors. Statistical analyses were performed with SPSS, version 26.0 (IBM Corp).

Results
Among the study's 134 decedents, the sample was predominantly male ( and more than half (52% [n = 13]) involved a handgun. Details on gun access were noted in 88.0% of suicides (n = 22) by firearm. In each case, the child obtained a firearm stored unsafely in the home.
In one example "the father kept his gun loaded in the front room where it was not stored securely" and in another "the victim's mother kept the pistol and ammunition unlocked in her nightstand." Suicide by poisoning or other means occurred in 3.0% of deaths (n = 4).
Four themes emerged regarding precipitating circumstances including (1) mental health and suicide-related concerns, (2) trauma, (3) family-related problems, and (4) school or peer-related problems ( Table 3). Thematic boundaries often overlapped because of the complexity associated with each decedent's situation ( Figure). For example, children with mental health concerns or a history of suicidal behavior often had traumatic histories related to adverse family situations. School problems frequently resulted in parent-child conflict and were more likely to occur in children with mental health concerns. Technology was intertwined across categories, either to communicate suicidal statements and death wishes, as a mechanism that exposed children to suicide, or related to disciplinary actions associated with school and behavioral problems.

Mental Health and Suicide-Related Concerns
A mental health concern was specified for 31.4% (n = 37) of suicide decedents. ADHD, depression, and cooccurring disorders were the most common diagnoses. Among these children, 78.4% (n = 29) were receiving mental health treatment at time of death, and 24.3% (n = 9) had a prior psychiatric hospitalization. A history of suicide attempts and ideation was reported for 11.9% (n = 14) and 23.7% (n = 28) of children, respectively. One case stated, "the victim had a history of suicidal ideations since the age of five." Previous suicidal statements and death wishes by decedents were noted in 25.4% (n = 30) of cases. In one example, parents received a call from school that the child was threatening to kill himself, and in another situation a child told her mother she was "better off dead," and that "she should kill herself" in the week prior to her death. Child decedents commonly communicated suicidal statements and death wishes to peers. In one case, a friend told officials the decedent was "upset over a girl at school and said he was going to kill himself. She did not take him seriously because he had said things like that in the past." In 10.2% (n = 12) of cases the child had previous exposure to suicide. One case noted that the child was present when a grandmother attempted suicide, while another child had a schoolmate who died by suicide several weeks prior to the child's death. Technology and the internet also played a role in exposing children to suicide. In one example, "the victim was observed by his mother playing suicide games on his electronic tablet" and in another "the victim's principal learned from students there was a suicide challenge on social media".

Trauma
Reports of trauma occurred in 27.1% (n = 32) of cases and included suspected or confirmed abuse or neglect, domestic violence, and death of a family member or friend. In 40.6% (n = 13) of these cases, children experienced multiple traumatic events. In one situation, "the child was the victim of domestic violence, and saw his mother battle substance abuse. The victim's mother overdosed and died in the weeks prior to the child's suicide." Another case reported "during the first two years of his life, the child was removed from his biological family numerous times due to issues of domestic violence, mental health, and abuse."

Family-Related Problems
One or more family-related circumstances including divorce and custody issues, other legal problems, parental substance abuse, and family history of psychological problems or suicide were documented in 39.8% (n = 47) of cases. In more than half of these cases (59.6% [n = 28]), these circumstances resulted in children living in single-parent households, blended families, or with other relatives. In one example, the child lived with his grandparents "who took custody of the child 6 years prior because their mother had severe mental health issues. The child has not seen his mother in 2-3 years, and never knew his biological father." In another case the child resided with his mother's boyfriend and children, because "his mother left approximately 4 years ago and is on the run, possibly for drug warrants. The child's father is incarcerated."

School or Peer-Related Problems
School and peer-related problems were found in 35.6% (n = 42) of cases and included expulsion or suspension, a recent change in schools, or history of special educational needs. Suspected or confirmed bullying was identified in 17.8% of children (n = 21). Although bullying was more prevalent than any other reported school or peer-related problem, bullying alone did not appear to be a contributing factor. Among children who experienced bullying, multiple known risk factors for suicide 22,23 cooccurred, including mental health problems and a history of suicidal thoughts and behavior. One case reported "the child was placed in a separate class due to behavioral issues and was being bullied at school. He had several mental health issues throughout his life. The child recently mentioned suicide to his school counselor."

On the Day of Suicide
Children were disciplined on the day of suicide in 32% (n = 38) of cases. Of these cases, schoolrelated issues (34.2% [n = 13]) and an argument between child and parent or guardian (39.5% [n = 15]) preceded the disciplinary action. The most common punishment involved the child being sent to their bedroom (47.4% [n = 18]) and/or having their technological device taken away (28.9% [n = 11]). One example noted, "the decedent argued with his mother over poor grades. He was sent to his room and his iPad was taken away. The mother found him hanging from his bunk bed. The decedent had a history of ADHD, depression, and suicidal behavior." A suicidal statement or death wish on the day of suicide was made by 11% (n = 4) of decedents. In one case, "text messages were discovered on the child's phone the day of suicide stating she intended to kill herself." In 76.9% (n = 29) of these children, similar remarks were made in the past. One situation noted, "the child told a friend on the day of death he was going to kill himself. Victim made suicidal statements before but never acted on them." In 58.4% (n = 22) of cases it was reported that an adult was present in the home at the time of suicide.

Discussion
Research on childhood suicide is limited, impeding our ability to develop critical prevention strategies. This study uniquely provides an in-depth examination of circumstances surrounding suicide in young children through a qualitative analysis of autopsy and law enforcement reports from behavior, trauma, and peer-, school-, or family-related problems. These findings further suggest a progression toward suicidal behavior, especially for youth with a history of psychopathology and suicidal behavior. Suicides were commonly preceded by a negative or precipitating event on the day of death, such as an argument between the child and a family member and/or disciplinary action.
Consistent with prior research, 15,22,23 most child decedents were older, White, and male.
Although suicide rates are traditionally higher in White than Black youth, racial disparities in childhood suicide rates have been identified. 14,24 The current study revealed most children died by hanging or suffocation in their bedroom. The second most frequent method of suicide in children was by firearm. In all cases, the firearm was stored unsafely in the child's home, underscoring the known association between firearm accessibility and suicide. [25][26][27] School or peer-related issues were documented in more than one-third of cases. Suspected or confirmed bullying was reported more than any other school or peer-related problem, and in most cases overlapping risks for suicide such as mental health conditions and prior suicidal behavior were noted. These findings align with previous research suggesting the correlation between bullying and suicidal behavior is often mediated by other factors. 29-31 One study in youth aged 6 to 18 years found Mental health concerns were identified in roughly 30% of cases, and 78% of these decedents were receiving mental health treatment. Similar to existing evidence, behavioral and mood disorders were the most frequent diagnoses. 6,7,15 Approximately 12% of decedents reported a prior suicide attempt, which is similar to rates noted in previous studies. 41-43 Decedents often had a history of suicidal ideation and/or making suicidal statements or death wishes, and expressed these comments on the day of suicide, suggesting suicidal statements should be taken seriously in younger children.
Several decedents experienced prior exposure to suicidal behavior, and 1 in 4 had a history of trauma. Strengthening relations between parents or caregivers and children can act as a protective factor for youth suicidal behavior. 8,9,[32][33][34][35] Family dissonance and instability was a common theme, Shared by all

Public Health and Clinical Implications
The figure shows the 4 themes of precipitating circumstances for child suicide (mental health and suicide-related concerns, trauma, family-related problems, and school or peer-related problems) and the various thematic boundary overlaps found in this study.
suggesting family-based interventions could be impactful in preventing childhood suicidal thoughts and behaviors. 50-54 One program, the Family Intervention for Suicide Prevention (FISP)/Safety-Acute(A), is a cognitive behavioral intervention for youth and parents or caregivers designed to decrease the risk of youth suicidal ideation and behavior. 52 Attachment-Based Family Therapy (ABFT) 53 and the Family-Based Crisis Intervention (FBCI) 54 are additional empirically supported family therapy models designed to improve interpersonal family relations associated with depression and the risk for suicide.
Although close to one-third of suicide decedents had a documented mental health diagnosis, psychological autopsy studies report more than 90% of youth suicide decedents have a mental health condition, 55 suggesting more robust mental health screening and suicide risk assessment is needed. Universal routine screening paired with lethal means safety counseling in pediatric primary care settings is recommended by suicide prevention researchers and the American Academy of Pediatrics to better detect at-risk youth. [56][57][58][59] Screening children during a primary care visit can also inform parents about potential problems requiring intervention and facilitate referrals to specialty mental health services. [56][57][58] Our finding that ADHD was the most common mental health diagnosis is particularly important given research showing childhood-diagnosed ADHD is a significant risk factor for future suicidal behavior. [60][61][62][63] One study found children aged 4 to 6 years with ADHD were 3.6 times more likely to attempt suicide through the age of 18 years relative to children without a diagnosis. 61 Standard treatments for ADHD in children include medication and behavioral therapy. 64 A behavioral management program for children aged younger than 12 years shown to effectively reduce ADHD symptoms 62,63 is the Incredible Years (IY) intervention. 65,66 Although lacking demonstrated effectiveness in specifically reducing suicidal thoughts and behavior, IY addresses important developmental components critical to youth suicide prevention strategies. 67 In 24% of cases, decedents experienced at least 1 traumatic event, which supports research linking childhood trauma and youth suicidal behavior. [68][69][70][71] A meta-analysis found experiences of childhood maltreatment were associated with 2.5 to 4.0 greater odds for suicidal behavior compared with control groups. 68 Taken together, findings suggest a trauma-informed approach toward youth suicide prevention may be warranted. An evidence-based intervention for children exposed to trauma is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), which may provide a promising integrated treatment for youth with trauma and cooccurring suicidal behavior. 72