Suicidal Ideation and Behaviors in Young Children: Findings from a Chart Review

Background and Purpose: Preschool age suicidality is the strongest predictor of school age suicidality, suggesting that it is more than a short-term phenomenon. To respond to increased reports of early childhood suicidality among outpatient population of children ages 2-7, this chart review study aimed to identify 1) ways in which early childhood suicidality manifests; and 2) correlates, such as contextual factors and diagnostic co-morbidities, among children treated for of suicidality.

Methods: The study includes 51 charts/children who had a safety plan developed during the course of their treatment in a community early childhood mental health center from Jan. 2019 – Sept. 2022. Based on current literature, we developed five categories of suicidal manifestation: passive suicidal ideation (general statements of wanting to die; e.g., “I wish I were dead”), active suicidal ideation (plan of how to die; e.g., “I want to run in front of a car and die”), suicidal behavior (e.g., choking oneself), preoccupation with death (death themes in play, drawing, and repetitive talking), and non-suicidal self-injury (e.g., repeated acts of biting/hitting/scratching). All 51 charts were coded independently by two raters. Any coding discrepancies in suicidal manifestation were discussed to reach agreement.

Results: The majority of the sample was male (75%), White (71%), with 37% receiving Medicaid and 16% living in a foster or adoptive placement or with a kinship caregiver. The average (SD) age was 60.55 (12.30) months at intake, ranging from 21 to 81 months. About one-third of the sample (n=17) exhibited suicidal behaviors; 35 children (69%) expressed either active (n=11) or passive (n= 24) suicide ideation; 19 (37%) demonstrated non-suicidal self-injury; and 7 (14%) exhibited a preoccupation with death. Children with suicidal self-harming behaviors and/or active suicide ideation (n=23, 45%), compared to those without such suicidal manifestation (n=28, 55%), were more verbally aggressive (83% vs. 61%, p = .08), likely to be expelled from preschool (17% vs. 4%, p = .09), and referred due to suicidal behavior (26% vs. 7%, p = .06), but no difference was found in clinical diagnoses. Children identified as suicidal at treatment initiation (n=25, 49%), compared to those identified during treatment (n=26, 51%), tended to be more physically aggressive (96% vs. 73%, p < .05), endorse sadness (56% vs. 31%, p = .07), exhibit negative self-talk (24% vs. 4%, p < .05 ), and be affected by trauma (88% vs. 69%, p = .10), however, there was no difference in clinical diagnoses.

Conclusions and Implications: The categorization of suicidality relied on documentation recorded in the chart by treating clinicians, affecting its validity. The relatively small sample size might compromise our statistical findings. Nevertheless, our study provides a rare opportunity to understand the nature of early childhood suicidality and its complex contextual and comorbid conditions. Future research utilizing standardized measures may provide a better clarity, assisting professionals tasked with identifying suicidal thoughts and behaviors in young children and intervening to ensure their safety and relief from distress.