In JAMA Network Open, Angelakis et al1 have conducted an important exploration of adverse childhood experiences (ACEs) and their association with suicide in the pediatric age group. The authors have undertaken a meta-analysis to quantify the association between ACEs and suicide ideation, attempts, and plans, offering odds ratios (ORs) to elucidate the relative contribution of several core ACEs to eventual suicidal phenomena. Core ACEs assessed include sexual, physical, and emotional abuse, emotional and physical neglect, and “combined abuse” (when the type of abuse and neglect were undefined). Their meta-analysis includes 79 studies with 337 185 participants and, compared with prior studies, offers the advantage of greater inclusiveness, and studied both community and clinical samples with documented psychopathology. The work of Angelakis et al1 should be recognized as a landmark study; they have conducted a comprehensive, methodologically rigorous analysis providing some of the most robust evidence linking core forms of ACEs with suicidal behaviors in children. This study is the largest to date confirming long-held child-psychiatric observations, lending credence to a nonbiological basis of that distress.2 A critical challenge remains: translating these findings into effective suicide risk-reduction interventions for children who experience maltreatment.
In the United States, suicide has been recognized as a major public health concern. Emergency departments (EDs) nationwide have witnessed a doubling in children presenting for suicidal behavior during just the 9-year period from 2007 to 2015,3 corresponding to an increase in actual completed suicides during the same time.4 In fact, suicide is the second leading cause of death among young adolescents, and the incidence rose by 113% from 1999 to 2017, the largest relative increase in any age group.5 National suicide prevention campaigns have not succeeded in slowing the rising rates of suicidal behavior and suicide deaths among children and adolescents.4
It is conceptually interesting to consider the relative contributions of each type of core ACE in terms such as ORs, and several strong associations emerge from this analysis, such as between sexual or physical abuse and suicide attempts (relative ORs, 3.41 and 2.18, respectively). However, there remains a fundamental challenge applying these data clinically to guide suicide prevention interventions. It is more clinically meaningful that all forms of abuse studied significantly increased the odds of suicidal behaviors. Furthermore, these core types of experiences often coexist. More important than the differences in ORs among adverse experience types is the study’s emphasis linking family dysfunction and suicidal distress among children and young adults. Identifying the presence of any of these core ACEs may be an opportunity not only to refer for social and psychiatric support but also to intervene early with targeted suicide risk reduction.
As the authors appropriately highlight, 54 of 79 included studies were cross-sectional or retrospective in design (eTable in the article’s Supplement), and most (63 of 79) were of low methodological quality. Accordingly, a direct causal relationship cannot be ascribed based on this analysis alone, although the association between ACEs and suicidality may seem intuitive. The phenomena of suicidality, as expressed by ideation, plans, and attempts, is far more complex. Which factors render some such patients vulnerable to suicidal thoughts, actions, and plans, whereas others possess protective factors conferring resilience to toxic environments and less vulnerability to distress? Some who experience abuse are paradoxically strengthened by adversities, later reporting no mental health psychopathology and succeeding in multiple life pursuits.6 This is highlighted in the present meta-analysis by several included studies reporting OR point estimates and 95% CIs of less than 1.00 (protective), particularly for the association between physical abuse and suicide attempts (eFigure 2 in the article’s Supplement). Identifying and building on protective factors in the face of ACEs may reveal strategies to conduct suicide prevention interventions more effectively, both for high-risk individuals and as part of broader public health suicide prevention programs.
This study’s primary outcome was the association between core types of childhood maltreatment and suicide attempts. Secondary outcomes of suicidal behavior were stratified in terms of suicide ideation, attempt, and plan. These distinctions are often conceptualized as a spectrum of severity, wherein severity of suicidal intent ranges from ideation to plans, then attempts, and ultimately completed suicide. Clinically, however, some patients with suicidal ideation, when experiencing intense negative affects and/or absent therapeutic alliances, have greater lethality and distress than those who have already attempted or planned suicide. The analytic stratification of these outcomes is somewhat academic, and although the authors did not analyze the association of any ACE with any suicidal behavior, it is clear from this meta-analysis that a pooled OR for this association would be highly significant. Moreover, the authors reach a few tenuous conclusions associating suicide attempts and childhood sexual abuse for young people from the community compared with children with a formal diagnosis of mental health problems; this association was stronger among studies with lower methodological quality. However, the overall metaregression model was not statistically significant (χ27 = 1.56; P = .16). Similarly, younger age was reported to be associated with a substantially higher likelihood for suicidal ideation among children who experienced sexual abuse, though again, this was the only significant covariate in an overall metaregression model that was not (χ27 = 1.68; P = .16). Therefore, all of these secondary associations, while perhaps hypothesis generating, should be interpreted with extreme caution.
This study highlights several long-unanswered questions regarding the complex association between child maltreatment and suicidal behaviors. What are the mediators of distress associated with ACEs? Are they restricted to the physical and emotional trauma of the maltreatment itself, or do they also derive from family factors permitting ACEs to occur? By extension, might a nonabusing parent’s silent complicity be a form of emotional neglect, and might this risk factor work in compound rather than isolation as conceptualized in this study (independent OR, 1.93)? What affects beyond anxiety, sadness (corresponding to the internalizing disorders of generalized anxiety and depression), and anger could prevail among abused and neglected children, especially those who are suicidal? Furthermore, individuals with a proclivity to these traits could be overrepresented among the perpetrators and victims of ACEs and children and young adults with externalizing disorders. Importantly, can and should the criteria for ACEs be refined further to consider the frequency, duration, and intensity of the adversity?6 Even under the assumption that all ACEs have a causative role, understanding the contribution of mediators along the causal pathway to suicidal behaviors may also inform risk-reduction strategies.
Even more complex than the association between ACEs and suicidality is incorporating these findings into direly needed suicide prevention interventions. Many children with suicide attempts and suicidal ideation first present to an ED.7 A progression from suicidal ideation to attempt can often be contained once a child arrives in an ED, when the distress level has peaked. However, future studies must focus on developing interventions well upstream of suicidality, when ACEs have first been identified, and that orient suicide prevention care to community resources temporally closer to the abuse before the ED presentation. Community and school authorities should be further empowered to identify and refer at-risk children and adolescents to community mental health clinicians, who in turn need to be sensitized to the strong and direct association between these risk factors and suicidality. The work of Angelakis et al1 should serve as a springboard for future investigations, including an examination of when ACEs weaken children’s and young adults’ emotional immunities to subsequent life stresses and interact synergistically with biologically based psychiatric disorders and ultimately suicide.
Published: August 5, 2020. doi:10.1001/jamanetworkopen.2020.13095
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Burstein B et al. JAMA Network Open.
Corresponding Author: Brett Burstein, MD, CM, PhD, MPH, Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 1001 Decarie Blvd, Montreal, Quebec H4C 3J1, Canada (email@example.com).
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Burstein B, Greenfield B. Childhood Maltreatment and Suicidality: One Link in a Tangled Chain Toward Risk Reduction. JAMA Netw Open. 2020;3(8):e2013095. doi:10.1001/jamanetworkopen.2020.13095
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