Characteristics and Circumstances of Suicide Among Children Aged 6 to 9 Years: 2006–2021

Data for this study were drawn from NFR-CRS for 2006 to 2021. NFR-CRS is a web-based application used by CDR teams to record information collected and discussed during fatality review meetings.¹² The origins and structure of NFR-CRS and CDR, and their strengths and limitations, have been documented elsewhere.¹² CDR teams are multidisciplinary and often include, but are not limited to, representatives from law enforcement, child protective services (CPS), prosecutor or district attorney offices, coroner and medical examiner agencies, pediatricians or other health care providers, public health agencies, schools, and emergency medical services. Team members contribute information from their records to be documented in NFR-CRS. Variables include demographic and social characteristics of the child and family, circumstances of the death, and risk and protective factors. NFR-CRS is managed by the National Center for Fatality Review and Prevention, a program of Michigan Public Health Institute.

For this study, deaths were limited to children aged 6 to 9 years where the official manner of death on the death certificate was reported as suicide. No suicide deaths were reported in NFR-CRS for 2006 to 2021 for children aged ≤ 5 years. The narrative fields in NFR-CRS were reviewed by 2 reviewers to enhance completeness and accuracy of data. Fourteen deaths were excluded because age could not be confirmed or manner of death was incorrectly entered as suicide.

Statistical analyses were performed using SPSS Version 28.0. Descriptive analyses of the number and percentage of suicides among children aged 6 to 9 years by demographic characteristics and a range of precipitating circumstances were conducted. The social constructs of race and ethnicity are obtained from death certificates and reported here because of disparities in child suicide.⁸ For incident area, urban is defined as a large city or densely populated area; suburban is a residential district on the outskirts of a city; and rural is a community with low population densities.¹³ In addition, we used thematic analysis, a qualitative method used to systematically code and analyze textual data, to highlight proposed recommendations and/or initiatives that could be implemented to prevent suicides among children aged 6 to 9 years. One researcher carefully reviewed text responses and identified common themes. This research was ruled exempt by Michigan Public Health Institute’s institutional review board.

From 2006 through 2021, NFR-CRS documented 78 suicides among children aged 6 to 9 years from 32 states; 74% of decedents were male (Table 1). Most were aged 9 years (72%), followed by 8 years (19%) and 6 to 7 years (9%). Nearly half were non-Hispanic Black (42%), followed by non-Hispanic white (31%), Hispanic (any race; 17%), and non-Hispanic American Indian/Alaska Native or Asian/Pacific Islander (8%). The most common means was hanging (86%), with most incidents occurring at the child’s home (91%). When examining the geographic area where the incident occurred, most occurred in urban areas (45%), followed by suburban (21%) and rural (18%).

A death investigation was known to be conducted for 83% of child suicides. Autopsies were performed for 78%, 73% received toxicology testing, and 24% of death investigations found evidence of prior abuse or neglect (eg, suspicious bruising, fractures, prior CPS report, or substantiation identified at time of death). Any prior history of child maltreatment (eg, documentation through CPS, autopsy, law enforcement, medical records) was identified for 36% of child suicide decedents. Among decedents with a known history of child maltreatment (n = 28), 50% experienced neglect, 43% physical abuse, and 21% emotional or psychological abuse.

Among children who died by suicide, 19% had a known disability or chronic illness, with mental health or substance abuse problems the most common (53%). Almost one-third (30%) of decedents had ever received mental health services at any time before their death, 23% were currently receiving mental health services around the time of death, and 15% had been on medications for mental illness (eg, depression, anxiety) at the time of death. Prior suicide attempts were identified for 13% of child suicide decedents and 32% had disclosed suicidal intent. In 32% of deaths, records indicated the child’s family and/or friends felt the suicide was completely unexpected. Among the deaths that were completely unexpected (n = 25), 36% had communicated suicidal thoughts or intentions to others (data not shown).

The most common reported life stressors for child suicide decedents were school-related problems (39%). Among those with a known school-related problem (n = 30), 67% had behavioral problems, 30% had academic problems, and 23% had an indication of school suspensions or truancy (not mutually exclusive). Additional reported life stressors included argument with parents (23%), family discord (19%), bullying victimization (14%), death of a friend or loved one (13%), and parent or caregiver divorce or separation (9%).

For 41% of child suicide deaths, CDR teams documented recommendations that could be implemented to prevent deaths from similar causes or circumstances in the future (Table 2). Among these, 4 key themes were identified: education and support for parents and caregivers (44%), improved mental and behavioral health services and resources (38%), development and implementation of school policies and programs (34%), and education and training for school staff (28%).

This study examined data from NFR-CRS to better understand suicide among children aged 6 to 9. As evidenced by findings from this and other studies, younger children can understand the concept of suicide,¹⁴ experience suicidal ideation and behavior,¹⁵ and die by suicide.^1,16 Consistent with previous research,^7,11 the current analysis found most child suicide decedents were male and died by hanging at their home. In addition, family discord was often a precipitating factor among decedents in this study.

The present study found nearly half of children who died by suicide were non-Hispanic Black. Although this racial inequity in suicide among younger children has been highlighted in prior research,^8,10 it is critical to understand why this inequity persists and how to better support young Black children and their families. Prior studies suggest suicide prevention initiatives must address systemic racism and trauma experienced by Black children.¹⁷ Further findings show that although schools may be an effective setting for suicide prevention for white children, Black children are negatively and systematically impacted by school disciplinary action and may not feel comfortable disclosing suicidal ideation to school staff.¹⁸ Rather, studies suggest suicide prevention in community settings, such as those that increase connections to culturally sensitive resources and trusted adults in the community, may be more effective for Black children.¹⁹ 

In this study, almost 9 in 10 children who died by suicide used hanging as a means at their home. Additionally, about 30% disclosed suicidal intent and more than 10% had history of prior attempts. Many suicide attempts among children occur during a short-term crisis, with little planning.^20,21 If a child has shared they are thinking about suicide, there is a window of opportunity to intervene. Taking this disclosure seriously and learning more about their despair and access to lethal means can provide important information on how to keep an environment as safe as possible.²² For hanging prevention, a potential strategy is to install products at home to minimize anchor points, such as break-away closet rods and tension shower rods.²³ Interventions may also remove bunk beds, which are frequently found in children’s bedrooms and are potential anchor points.²⁴ As has been recommended for other lethal means, another potential strategy to reduce hangings is to monitor a child’s exposure to suicide or suicide attempts via hanging, including representations in media.^25,26 

Findings from the current analysis also show that child suicides were often precipitated by school-related problems, including behavioral problems that can be indicative of externalizing disorders.²⁷ This underscores the importance of implementing suicide prevention initiatives in elementary schools, such as staff training and more equitable policies and practices related to school discipline (eg, restorative practices).^26,28–31 This also emphasizes the critical nature of collaborative and productive relationships between CDR teams and schools, which are vital for preventing future deaths.³² Further, we found that more than one-third of child suicide decedents in this study had a history of child maltreatment. Studies show child maltreatment has large impact on suicide ideation and attempts across the lifespan.³³ Findings from the present study highlight the importance of addressing experiences of child maltreatment early in life.

Consistent with prior research that found when a younger child dies by suicide, family members reported it was sudden and with little warning,^34,35 records indicated the death was completely unexpected by loved ones in one-third of child suicide deaths in the present study. Although such findings might be interpreted as an absence of suicide warning signs, it may be likely that warning signs were present and never recognized as such. For example, in the current analysis, among the child suicides that were “completely unexpected,” over one-third had communicated suicidal thoughts or intentions to others. Though the scientific community has begun to highlight the fact that children younger than age 10 are capable of suicide, it may be that the lay public is largely unaware of the capacity for suicide in children this young. Prior research has shown that many young people at risk for suicide may go undetected by parents and caregivers.³⁶ 

In the field of suicidology, there was recognition by clinicians and researchers that, despite a vast literature on risk factors for suicide, very little was known about which risk factors were most critical and about the temporal relationship of these factors to suicide attempts and deaths.³⁶ Therefore, in 2006, an American Association of Suicidology working group developed a set of suicide warning signs, analogous to those developed for life-threatening physical conditions such as heart attacks.^37,38 Distinct from risk factors, warning signs are meant to signify elevated probability for suicidal behavior in the near-term- minutes, hours, or days. Since the publication of the original warning signs, another expert-consensus panel was convened in 2012 to develop a similar set of warning signs for youth suicide (Table 3).³⁹ Communication of suicidal ideation or intent is among the most cardinal of youth warning signs for suicide, and such disclosures are critical opportunities for intervention.^37,40 The warning signs of anger or hostility that seems out of character or context, and agitation or irritability, can be misunderstood by the lay public, who might be more likely to associate suicide risk with sadness or depressed mood.^27,41 Therefore, these warning signs may be especially important for pediatricians to highlight for parents and caregivers.

The current analysis showed that one quarter of suicides of children was precipitated by an argument, suggesting that suicidal behavior among children younger than age 10 years might develop and escalate rapidly in response to adverse events, such as an argument with a parent or caregiver. Even with knowledge of warning signs of suicide among youth, it is recommended that parents and caregivers be made aware that children may react very strongly, and suicidal intent may escalate quickly. For children who are demonstrating warning signs or risk factors for suicide, safety planning interventions adapted for children are important crisis intervention tools for pediatricians and other clinicians.⁴² Additionally, it is recognized that lethal means interventions can be as or more effective than clinical approaches and are perhaps especially important in situations where suicide warning signs have gone unrecognized.⁴³ Some researchers have suggested lethal means safety interventions are more scalable than some effective psychotherapeutic interventions, and therefore more capable of reducing overall suicide rates.⁴⁴ Pediatricians and other clinicians can implement lethal means counseling with parents and caregivers.^45,46 

Although not the most common precipitating circumstance, in this study, the death of a friend or loved one was a contributing factor for 13% of child suicide decedents. Prior studies have reported experiencing the death of a parent, family member, or close friend, especially by suicide, is an highly traumatic event for a child and has lasting impacts across the lifespan.^47,48 Suicide prevention strategies for children who have experienced loss may include bereavement support that is widely and immediately available, easily accessible, and offered on a routine and extended basis.⁴⁹ For children who are suicide loss survivors, comprehensive postvention services have also been recommended as essential to the prevention of subsequent suicide.⁵⁰ 

Further, NFR-CRS results showed that a death investigation was conducted for 83% of child suicides. A comprehensive, complete, and standardized death scene investigation, including full medical, academic, and social history, is critical to understanding child suicide.⁵¹ In addition, it is recommended that a full autopsy and toxicology be conducted to understand disease processes the child had as well as any substances that were used before the death.⁵² Notably, not all decedents in the present study received toxicology testing, as testing practices and availability of resources may vary across the United States.⁵³ Moreover, conducting age-appropriate key informant interviews has been suggested to gain a deeper understanding into the child’s needs and thinking.⁵⁴ For these standardized, in-depth, and complete death scene investigation to be conducted, providing financial resources, additional staffing, and training to law enforcement, coroners, and medical examiners has been suggested.⁵⁵ 

This study was subject to limitations. First, suicides among children aged 6 to 9 years represented in NFR-CRS may be an undercount.⁵⁶ Underascertainment of the true number of suicides among children aged 6 to 9 may be because of documented misclassification of suicide as other manners of death (eg, undetermined), a particularly relevant issue for younger children who die.⁵⁷ This limits the strength of findings in that we may not have a full understanding of both the burden of suicide in this age group and the prevalence of contributing circumstances. Second, national mortality data include suicides of children as young as 5 years;¹ however, no suicide deaths among children aged 5 years were reported in NFR-CRS, limiting our ability to describe suicides among those as young as 5 years. Third, completeness of data in NFR-CRS varies across states and jurisdictions, limiting generalizability. Finally, this is a descriptive study of children aged 6 to 9 who have died of suicide, with no population comparison, and therefore cannot be used to identify risk factors or make conclusions regarding causality. Future research is needed to better understand the causes and risk factors of child suicide.

This study used 16 years of data from NFR-CRS to better understand suicide among children aged 6 to 9 years. Findings can be used by pediatricians, policymakers, and program planners to develop nuanced prevention efforts unique to this age group, ultimately creating healthier communities for all children. In addition, given a greater proportion of child suicide decedents were non-Hispanic Black, studies have suggested program planners consider both age-appropriateness and the impacts of social (eg, racism) and structural inequities in their approaches to prevention, encompassing both community and school-based strategies.¹⁹ For pediatricians and clinicians, results emphasize the importance of lethal means counseling, safety planning, and educating caregivers on the distinct warning signs of suicide for children.^39,45 It is perhaps especially important to address any misperceptions that younger children are incapable of engaging in suicidal behavior.

CDR

child death review

CPS

child protective services

NFR-CRS

National Fatality Review-Case Reporting System

NVDRS

National Violent Death Reporting System