CE Corner
Ce
prevalence rates and risk fac-
tors for suicidal thoughts and
behaviors in children under 12
(Practice Innovations, 2016).
“It feels like a collective denial
that children can have these
thoughts and feelings.”
Circumstances
drive suicide
While death by suicide is less
continuing education: common in younger children
RESEARCH ON SUICIDE than in adolescents, such
OVERLOOKS YOUNG CHILDREN deaths do occur—an average
and PSYCHOLOGISTS ARE of about 33 per year in the
WORKING TO CHANGE THAT United States in children ages
5 to 11, research suggests.
By Kirsten Weir
The true number is probably
higher, Jobes adds, since
it’s likely that some suicides
I
in youth are misreported as
n September, 9-year-old Jackson Grubb was found accidents.
dead of apparent suicide by hanging. The West Virginia Even when young children
boy was reportedly a target of bullying at school. don’t act on suicidal urges,
It was not an isolated incident. Suicide is the such thoughts often signal
third-leading cause of death for children ages 5 to 14 in serious problems. Unsurpris-
the United States, according to the Centers for Disease ingly, children with depression
Control and Prevention. are more likely to think about
Yet most research focuses on adolescents and virtu- or attempt suicide. But Jobes
ally ignores preadolescents, says David A. Jobes, PhD, cautions against assuming that
a clinical psychologist and professor at The Catholic suicide and depression always
University of America. While practitioners can and do go hand in hand. Not every-
draw from the adolescent literature when treating suicidal one who has suicidal thoughts
children, no specific evidence-based treatments exist for is clinically depressed. And
suicidal behaviors in preadolescents. other psychiatric disorders
“The field of suicide prevention acts as if the problem increase the risk of suicide
of suicide begins at 12 or 14,” says Jobes, who recently in children and adolescents
published a review of the existing literature on ages 6 to 18, including buli-
mia, anorexia, ADHD, autism,
intellectual disability and
CE credits: 1 oppositional defiant disor-
Learning objectives: After reading this article, CE candidates will der, according to a paper by
be able to: Susan Dickerson Mayes, PhD,
1 . Describe the factors that lead to suicidal thoughts among at Penn State College of Med-
Rhienna Cutler/ istockphoto
children. icine, and colleagues (Crisis,
New research is 2. Describe interventions that may help these children. 2015). In fact, bulimia seems
exploring treatments 3. Discuss the further research needed in the area. to be a greater risk factor for
for children who have
suicidal thoughts. For more on earning CE credit for this article, go to www.apa.org/ suicide than is depression, she
ed/ce/resources/ce-corner.aspx. found.
28  m o n i to r o n p s yc h o lo g y ● december 2016 m o n i to r o n p s yc h o lo g y
Such broad risk factors can
make it difficult for parents
and health-care providers to
spot children at risk of suicide,
says Guy Diamond, PhD,
professor emeritus at the Uni-
versity of Pennsylvania School
of Medicine and associate
professor at Drexel University.
“Suicide is so multi-deter-
mined, the field has not been
able to identify reliable pre-
dictors of who might make a
suicide attempt.”
Compared to adults, chil-
dren and adolescents with
suicidal behaviors seem to be
driven more by circumstantial
factors, such as family dis-
cord, social failure or bullying,
experts say. “For children,
there’s a much higher likeli-
hood that circumstances are
driving the suicide,” Diamond
says. “Interventions need to
focus on addressing these
environmental stressors as
well as improving patients’
coping skills.”
Psychological
interventions
When helping a child with
suicidal thoughts, family mem-
bers and clinicians must take
care not to reinforce the child’s
behaviors with attention, says
Francheska Perepletchikova,
PhD, an assistant professor
of psychology at Weill Cornell
Medicine.
She recommends adults
take a calm, matter-of-fact
approach—keeping the child
safe (by locking up sharp
objects and medications, for
example) while also making
sure not to give in to the child
under pressure. “There is
● december 2016 29
CE Corner
always a balancing act of ensur-
ing safety in the short-term versus
decreasing suicidal behaviors in
the long-term,” she says.
Unfortunately, many clinical
psychologists aren’t sure how
best to cross that balance beam.
“I don’t think most clinicians have
the training or framework for how
to treat suicidal thoughts and
attempts in children,” Diamond
says.
Adults are sometimes skepti-
cal that young children can even
have suicidal thoughts, Jobes
adds. “When a 6- or 7-year old
says, ‘I want to kill myself,’ they’re
often greeted with skepticism or
dismissiveness,” he says. “I can’t
help but think that clinicians are
sometimes guilty of this, too.”
When suicidal behavior is
taken seriously, health-care
providers often assume that
admitting the child to a hospital is
the best first line of defense. But
there are suggestions that hos-
pitalization might not be the best
solution. In adults, a number of
studies have shown that suicide
risk spikes in the days immedi-
ately following discharge from
the hospital, and might remain
elevated for a year or more. A
national survey in England and
Wales by Louis Appleby, MD,
and colleagues, for instance,
examined suicide among people
who had previous psychiatric
hospitalizations. Nearly a quarter
of those deaths occurred in the
first week after admission, many
while still in the hospital. Post-­
discharge suicide was highest in
the two weeks after leaving the
hospital, with the highest number
of deaths occurring on the first
day (British Journal of Psychiatry,
2006).
30  m o n i to r o n p s yc h o lo g y
Many clinicians also pre-
scribe antidepressants to treat
children with depression and
suicidal thoughts and behaviors,
Jobes says, though there is little
evidence that drugs alleviate
such thoughts—and they may do
more harm than good. In a recent
meta-analysis of 34 studies,
Andrea Cirpiani, PhD, at the Uni-
versity of Oxford, and colleagues
studied the effectiveness of 14
about ce antidepressants in children and
“CE Corner” is teenagers with major depressive
a continuing
disorder. They found that only
education article
offered by the APA
one, Prozac, had evidence of
Office of CE in effectiveness. And the evidence
Psychology. for Prozac varied widely from
study to study (The Lancet, 2016).
To earn CE credit,
What’s more, SSRIs have been
after you read this
article, purchase
shown to increase the risk of
the online exam at suicide in a subset of children
www.apa.org/ed/ and teenagers, a finding that has
ce/resources/ce- earned the drugs a “black box”
corner.aspx.
Upon successful
label warning from the FDA.
completion of Instead of putting kids in hos-
pitals or prescribing medications,
the test—a score
of 75 percent or Jobes argues that psychologists
higher—you can should be developing evidence-
immediately print
based therapies specific to
your CE certificate.
children who express thoughts of
The test fee is suicide. “The clinical suicidology
$25 for members data overwhelmingly supports
and $35 for psychological interventions for
nonmembers.
suicide,” he says.
For more
information, call His research focuses on a clin-
(800) 374-2721. ical intervention for suicide known
as the Collaborative Assessment
and Management of Suicidality
(CAMS). The framework targets
patient-defined suicidal “drivers,”
and emphasizes a collaborative
assessment and treatment plan-
ning process between the patient
and the clinician. The goal, he
explains, is to enhance the ther-
apeutic alliance and increase the
patient’s motivation to pursue
treatment. The approach has
● december 2016
been supported by several prevention. Holly C. Wilcox, PhD,
correlational studies and two ran- at Johns Hopkins School of
domized controlled trials, which Medicine, and colleagues studied
Jobes summarized in a recent young adults who, as kids, had
article (Suicide and Life-Threat- participated in The Good Behav-
ening Behavior, 2012). While the ior Game, a classroom-based
CAMS approach was developed behavioral management strategy
for and tested in adults, Jobes designed to help teachers reduce
and his colleagues are adapting behavioral problems. They found
the process to adolescents and that kids who received the pro-
preadolescents, he says. Further gram in first and second grades
Other researchers are also reading reported half the lifetime rates
exploring treatments for children. of suicidal ideation and attempts
In a pilot study, Perepletchikova Two Approaches at ages 19 to 21, compared to
to Treating
found that dialectical behavior Preadolescent matched controls (Drug and Alco-
therapy (DBT) showed promise as Children With hol Dependence, 2008).
a treatment for treating suicidal Severe Emotional “If we invest in upstream
thoughts in children (Child and and Behavioral approaches [to improve mental
Adolescent Mental Health, 2011). Problems health], it could have an enormous
Perepletchikova, F.,
She and her colleagues are now & Goodman, G. impact on suicide prevention,”
wrapping up two randomized Journal of says Jeff Bridge, PhD, director of
controlled trials further inves- Psychotherapy the Center for Suicide Prevention
tigating DBT as a therapy for Integration, 2014 and Research at Nationwide Chil-
suicidal 7- to 12-year-olds with A variety of other psychiatric disorders The Collaborative
dren’s Hospital in Columbus.
severe emotional and behavioral increase the risk of suicide in children Assessment and While such programs to
dysregulation. and adolescents ages 6 to 18, including Management of intervene are steps in the right
Researchers in this field gen- Suicidality (CAMS): direction, they don’t let the field of
depression, bulimia, anorexia, ADHD, An Evolving
erally agree that when it comes to psychology, or individual psychol-
helping very young children with
autism, intellectual disability and Evidence-Based ogists, off the hook, Jobes says.
suicidal thoughts, buy-in from par- oppositional defiant disorder. Clinical Approach
to Suicidal Risk A structured assessment, the
ents is extremely important. Yet Jobes, D.A. Child Suicide Potential Scales, is
more work is needed to under- Suicide and available for assessing suicidal
stand how best to involve families worse,” he says. teachers and parents learn how Life-Threatening thoughts in children, and clinicians
Behavior, 2012
in the treatment process—espe- Prevention efforts best to support those kids. A shouldn’t shy away from putting it
cially since problems at home are While evidence-based treatments study of the program by Eliz- Understanding to use. But psychologists should
often at the root of a child’s dis- for suicidal children are critically abeth A. Schilling, PhD, at the and Treating also get serious about developing
tress. “A lot of these kids can’t or needed, experts also stress the University of Connecticut Health Suicidal Risk in and testing effective treatments
don’t turn to their parents in times importance of broader interven- Center, and colleagues found that Young Children for suicidal ideation in children,
Anderson, A.R.,
of stress,” Diamond says. tions to improve children’s mental middle-school students with sui- he says. “It’s heartbreaking when
Keyes, G.M.,
Even when parents want to health. Schools—where children cidal ideation had fewer suicidal & Jobes, D.A. families put a child into the hos-
help, they may not understand or spend most of their waking behaviors after participating in Practice Innovations, pital, and a few days after they
accept the severity of their child’s hours—may be one place to do the program in school (Suicide 2016 come out they kill themselves,”
situation. Jobes recalls a case in just that. and Life-Threatening Behavior, Jobes says. “How can we abide
which a mother resisted the idea The Signs of Suicide (SOS) 2014). this when we know psychother-
Gawrav Sinha/ istockphoto
that she should remove the guns program, for instance, teaches Similar benefits could extend apy can be effective?” ■
her 8-year-old son had received students to recognize the signs from interventions that help
for his birthday. “Parental involve- of depression in themselves and students learn to better regulate
● To directly access the citations in
ment can be the game changer, their friends so they can seek their behavior and emotions, this article, go to our digital edition at
or it can make things 1,000 times help as needed, and also helps even without a focus on suicide www.apa.org/monitor/digital.
m o n i to r o n p s yc h o lo g y ● december 2016 31