Understanding Suicide Risk Among Children and Pre-teens: A Synthesis Workshop
NIMH convened a four-part virtual research roundtable series, “Risk, Resilience, & Trajectories in Preteen Suicide.” The roundtables took place between January and April 2021, and culminated in a synthesis meeting in June, 2021. The series brought together a diverse group of expert panelists to assess the state of the science and short- and longer-term research priorities related to preteen suicide risk and risk trajectories. Panelists’ expertise was wide ranging and included youth suicide risk assessment and preventive interventions, developmental psychopathology, child and adolescent mood and anxiety disorders, family and peer relationships, how social and cultural contexts influence youth’s trajectories, biostatistical and computational methods, multilevel modeling, and longitudinal data analysis. The linked agendas below list panelist names for each roundtable.
As of 2019, suicide was the fifth leading cause of death for children ages 5-12. While still a relatively rare event, the death of a child by suicide is a devastating and can have long-lasting effects on families, schools, medical providers, and communities. In addition, suicide rates for children have been increasing over time, especially for some subgroups such as Black youth. Despite these concerning trends, little is known about how to measure and mitigate child suicide risk given the limited research that has focused on this topic to date. The roundtable series sought to probe multiple, diverse areas of expertise to:
- Understand the phenomenology and assessment of suicidal ideation and behavior in younger children,
- Characterize suicide risk and protective factors across multiple domains, and
- Quantify risk states and understand risk trajectories across development and illness stages.
Roundtable 1: Phenomenology and Assessment of Preteen Suicide Ideation and Behavior
January 27 and January 29, 2021
Roundtable 1 discussions covered three major themes:
- Individual characteristics and developmental status.
- Development and refinement of screening and assessment measures.
- Contextual and setting-specific factors that may influence screening and assessment outcomes.
A range of individual factors may influence the evaluation of preteen suicide risk including variability in a preteen’s ability to report on their emotions and thoughts in a meaningful way; cognitive functioning as it relates to a preteen’s understanding of death and ability to comprehend complex questions included in suicide assessment tools; cultural differences in beliefs about, and communicating about death; and a preteen’s level of exposure to death, including suicide.
Preteen suicide screening and assessment measures need to be developmentally and culturally sensitive. Achieving this goal may require adapting screening measures and assessment approaches that are currently used with older youth and adults. Developmentally relevant approaches are likely to require gathering and integrating assessment data from multiple sources, consideration of key contextual factors when evaluating assessment responses, and establishing developmentally sensitive thresholds to determine a preteen’s current suicide risk level.
Family/social cultural context and the assessment setting may influence the sensitivity of preteen suicide risk evaluations. Important contextual factors to consider include whether the assessment or screening was planned or occurred within the context of a crisis; the ways in which the assessment setting may influence preteen and caregiver responses; the level of trust and cultural comfort the preteen or caregiver has in the evaluator and/or setting.
Roundtable 2: Measuring and Characterizing Suicide Risk and Protective Factors
March 3 – 4, 2021
Roundtable 2 discussions covered three major themes
- Identification of risk and protective factors for preteen suicide.
- Characterization of measurements of risk and protective factors and consideration of the setting, reporter (e.g. child, parent, teacher), and frequency of assessments.
- Identification of high-risk populations and development of culturally sensitive and appropriate assessments.
Panelists identified multiple risk factors at the individual and family level and in peer interactions. Suicidal thoughts and behaviors in preteens have been associated with less ability to construct future thinking about personal events, lower cognitive flexibility, and weaker cognitive control. Family processes such as less parental monitoring and more family conflict are strong predictors of poor suicide risk outcomes in youth with co-occurring psychiatric and substance use disorders. Observing family interactions in clinical settings can be informative in detecting poor communication skills. The divergence of parent and child reports of clinical symptoms and suicidality is a potential indicator of risk. Certain peer interactions have been found to discourage youth from seeking help from adults.
Panelists considered multiple examples of community-level risk factors and social and structural drivers of mental health. Trauma – both individual and intergenerational – and family separation can contribute to suicide risk. However, there are successful models for how community engagement, surveillance and strength-based interventions can mitigate risk and successfully reduce suicide rates. Sexual and gender minority (SGM) youth have, on average, higher rates of suicide ideation and attempts than their heterosexual/cisgender peers, lower family support, and higher rates of victimization. These risk factors can be reduced by promoting protective factors such as school affiliation, self-esteem, parent and school support, and positive messaging, highlighting that most SGM youth are thriving. Minoritized youth experience discrimination and victimization in online media. Exposure to online racism and victimization is associated with increased mood and anxiety symptoms and lower self-esteem; less is known about how these experiences may influence suicide risk.
Proximal risk factors were also identified and discussed. Most studies assess suicidality over months and years, even though acute risk may unfold over the course of a much shorter time (e.g., 24 hours). This gap may be addressed with real time monitoring using smartphone data as well as wearable sensors to measure cardiac rhythms, cortisol, and neuroinflammatory markers. Another approach to capturing acute stress is to use body mapping, a technique that includes drawing and painting, to measure somatic symptoms. Puberty onset can affect systems regulating stress response. Researchers may need to consider proximal experiences and environmental stressors related to suicide risk in the context of pubertal status.
Understanding and measuring protective factors is important for mitigating suicide risk. Family training, including psychoeducation and enhancing emotion regulation and problem-solving skills, can all mitigate suicide ideation and attempts, as can youth relationships with trusted adults. The panel also considered two examples of multilevel systemic programs for culturally sensitive, community-driven suicide prevention in India and Alaska Native communities that focus on protective factors. Religiosity is a complex protective factor, especially for Black youth. Church participation and faith beliefs can contribute to feelings of optimism, hope, and persistence against adversity. Religious beliefs can also affect attitudes about suicide acceptability.
Round Table 3: Risk States and Risk Trajectories in Preteen Suicide
March 31 – April 1, 2021
Roundtable 3 discussions covered four major themes:
- Sampling and methodological approaches to studying preteen suicide risk.
- Techniques for and examples of leveraging data from multiple studies or data sources.
- Approaches to developing models of preteen suicide risk and risk trajectories.
- Current opportunities and priorities for future data collection and analytic strategies.
While suicide among children and preteens is tragic, and while rates among younger youth may be increasing, the low base rate of events poses substantial challenges for studying and understanding risk and risk trajectories, especially among subgroups of children who are differentially affected. Epidemiological analyses of birth cohort data, suicidal and self-harm surveillance, psychological autopsy studies, and meta-and secondary data analyses of health services patterns all show promise as methodological approaches to better examine and understand preteen suicide risk. Research that involves extensive/intensive data collection with smaller samples of key populations (e.g., mixed methods approaches) might be a strategy for understanding unique risk factors and sources of inequities.
Panelists discussed the assumptions and challenges to analyses that integrate multi-informant data, how to select procedures that allow for both common and unique variables, and strategies for harmonizing data from studies that use different measures to assess related constructs. Risk calculators and automated machine learning approaches can be used to integrate multiple factors, holding promise for the identification of high-impact predictors for individual and group suicide risk.
In considering models of suicide risk, panelists discussed criteria that are critical to ensure appropriate model selection for longitudinal studies and to incorporate intersectionality into those models. Future efforts must construct models that avoid simply documenting group differences. There is growing awareness that social determinants of (mental) health, including discrimination and oppression, affect communities at risk, and that community strengths can promote protection.
Existing data sets – such as those that track exposure to systems such as child welfare and justice systems, as well as big data derived from electronic health records and other healthcare administrative databases – serve as potential resources for identifying specific factors related to suicide risk in preteens. Data harmonization and data pulling strategies, such as integrative data analysis, can be used to leverage power for low base rates and small subsample questions. Efforts to develop new harmonization techniques in existing data sets should employ methodologies that minimize limitations while maximizing statistical efficiency.
June 15 and 23, 2021
The public synthesis meeting began with a review of the preceding three roundtables. Following those summaries, NIMH Director, Dr. Joshua Gordon, and Department of Health and Human Services Assistant Secretary, Dr. Rachel Levine, discussed the importance of research on preteen suicide risk and risk trajectories and how this research could compliment ongoing HHS and NIMH efforts to promote and protect mental health throughout the life course. Drs. Gordon and Levine also took questions from the webinar audience. A recording of the July 15th meeting is available via the weblink below. On July 23, 2021, roundtable panelists met to synthesize previous discussions and suggest potential ways to address research gaps, including those related to assessment approaches, frameworks or models of preteen suicide risk, protective mechanisms, the use of mixed methods research to advance understanding of risk/protective factors.
The NIMH Suicide Research Team