ADHD More Common Than Depression in Child Suicide

Fran Lowry

September 20, 2016

Young children who die by suicide are less likely to have depression and more likely than their adolescent counterparts to have attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD), new research shows.

An analysis of a national database that tracks violent deaths showed that among suicide decedents with known mental health problems, young children aged 5 to 11 years were more likely to experience ADD, with or without hyperactivity, and less likely to experience depression/dysthymia compared with children and adolescents aged 12 to 14 years.

"The major message of the study is that the circumstances preceding suicide in children are, to a large extent, similar to those for suicide in early adolescents, with a few key exceptions that tend to fall along developmental lines," lead author Arielle H. Sheftall, PhD, from Nationwide Children's Hospital, Columbus, Ohio, told Medscape Medical News.

"For example, elementary school-aged children who died by suicide were more likely to experience problems with family or friends, and among those with a current mental health problem, were more likely to be diagnosed with ADD/ADHD, whereas early adolescents who died by suicide were more likely to experience boyfriend or girlfriend problems and be diagnosed with depression or dysthymia," she added.

The study was published online September 19 in Pediatrics.

Impulsive Response to Stress

"Despite a recent increase in the suicide rate among young black children, suicide in elementary school-aged children is not well studied," senior author Jeffrey A. Bridge, PhD, also from Nationwide Children's Hospital, told Medscape Medical News.

The researchers used the National Violent Death Reporting System to examine characteristics and precipitating circumstances of suicide from 2003 to 2012 in 17 different states in two groups of children ― elementary school-aged children (5- to 11-year-olds) who died by suicide, and early adolescents (12- to 14-year-olds) who died by suicide.

They also examined potential racial differences in precipitating circumstances within each age group.

The investigators found similarities and differences between the two age groups that tended to track along developmental lines.

During the study period, there were a total of 693 suicides.

The investigators found that among approximately one third (n = 210) of the cohort with a current mental health problem, ADD/ADHD was more common in elementary school-aged children who died by suicide (59.3% vs 29.0%; P = .002) and that they were less likely to have depression/dysthymia (33.3% vs 65.6%; P = .001) compared with early adolescent decedents.

"The findings suggest that the children ages 5 to 11 who died by suicide may have been more vulnerable as a group and respond impulsively to interpersonal challenges," Dr Sheftall said.

In addition, the researchers found that 29% of all youth disclosed their intention for suicide to someone prior to their death.

Black Children at Greater Risk

Although there were no racial differences in terms of precipitating circumstances, compared with early adolescents who died by suicide, children who died by suicide were more likely to be male, black, to die by hanging, strangulation or suffocation, and to die at home.

"Unfortunately, our study was not designed to address questions about potential factors that may have contributed to the increase in suicide rates among black children," Dr Bridge said.

More research is needed to establish whether unique patterns of suicide risk exist in order that prevention efforts might incorporate diverse strategies according to the children's developmental level, race, or ethnicity, the researchers note.

The analysis also showed that although rates of alcohol use and illicit drug use were low and did not differ significantly between the two age groups, 3.9% of children and 7.5% of early adolescents who died by suicide tested positive for opiates. "These rates are higher than alcohol and other substances," said Dr Bridge.

"Parents, teachers, and healthcare providers need to be aware that although suicide is extremely rare in elementary school–aged children, a child can and sometimes will think about and even attempt suicide," Dr Bridge said.

"It's important to ask children directly about suicide if there is a safety concern about a child. Parents also need to know the warning signs of suicide. These warning signs include a child making suicidal statements, being unhappy for an extended period, suddenly withdrawing from friends or school activities, or being increasingly aggressive or irritable. If these warning signs are present, then parents should be concerned about those behaviors and consider taking the child to see a mental health professional," he said.

Child Psychiatrist Shortage

Unfortunately, getting to see a qualified mental health professional may not be easy, Dr Bridge noted.

"In fact, there is a national shortage of child psychiatrists, with the greatest disparities seen in rural areas and areas with a high percentage of children living in poverty. This shortage means that pediatricians and other non–mental health professionals often are on the front lines of diagnosing and treating mental health problems in children," he said.

"The problem is compounded in that most pediatricians do not treat mood and anxiety problems in children but instead refer these patients to child psychiatrists, where families face long wait lists. It's a vicious cycle."

"One of the key and practical findings of this study has to do with existing psychiatric disorders," David C. Rettew, MD, from the University of Vermont College of Medicine, Burlington, told Medscape Medical News.

"We have spent a great deal of energy trying to make people aware of the link between suicide and depression, but in this group of younger children who died by suicide, it was ADHD that showed the strongest link.

"This doesn't mean, however, that all suicides in younger children were impulsive spur-of-the-moment acts, especially given the fact that hanging and suffocation, which require some amount of time, were the most likely means of suicide in this youngest group," Dr Rettew said.

"Lately there has been a lot of attention devoted to antidepressants possibly causing increased suicidal thinking and behavior. While the authors surprisingly did not address the issue at all in their text, their data show that antidepressants were being taken in only a small percentage of the cases," he added.

"Unfortunately, this study does not give us a good lead as to why young African American children are disproportionately more likely to die by suicide, while older African Americans show comparatively lower rates," Dr Rettew added.

The study was supported by the National Institute of Mental Health, the National Institutes of Health, and the Centers for Disease Control and Prevention. Dr Sheftall, Dr Bridge, and Dr Rettew report no relevant financial relationships.

Pediatrics. Published online September 19, 2016. Full text

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