Young children who express suicidal ideation understand death better than their peers

Findings refute common assumptions that depressed children who express suicidal ideation have a “less mature” understanding of death


Washington, DC, February 12, 2019

Four- to six-year-old children who express suicidal thoughts and behaviors have a better understanding of what it means to die than the majority of their peers, reports a study recently published in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP).

The authors found that children who express suicidal thoughts, the phenomenon known as suicidal ideation, were 3.6 times more likely to describe death as caused by violence than depressed children without suicidal ideation.

A bar graph showing the reaction levels of four emotions: sadness, anxiety, frustration and interest to death-themed narratives.
Emotional reactions to death-themed narratives.

“It’s an uncomfortable topic to contemplate, and in many ways, I think it’s easier to assume that children don’t really know what they’re saying, and therefore they can’t possibly mean the same things that adults mean when they talk about wanting to die,” said lead author Laura Hennefield, PhD, a postdoctoral research scholar at Washington University in St. Louis, MO, USA.

“We did find, however that even children as young as four years of age who expressed suicidal ideation had a solid understanding of what it means to die,” Dr. Hennefield added. “Although it remains unclear how to fully assess risk in these circumstances, our findings highlight the need to take children’s expressions of suicidal thoughts and behaviors seriously.”

The findings are based on data from a randomized controlled trial of Parent-Child Interaction Therapy Emotion Development to treat preschool depression. The sample included 22 depressed children with suicidal ideation; 57 depressed children without suicidal ideation; and 60 healthy peers of the same age.

During their baseline (pre-treatment) assessment, children completed an experimenter-led death interview to measure their understanding of five concepts of death including:

  • Universality (all living things eventually die);
  • specificity (only living things die);
  • irreversibility (death is permanent);
  • cessation (upon death bodily processes stop functioning); and
  • causality (there are events that can cause death).

Depressed children with suicidal ideation demonstrated a better understanding of these death components than either peer group. Further, 100 percent of depressed children with suicidal ideation were able to describe a reasonable event that could cause death compared to 61 percent of depressed children without suicidal ideation and 65 percent of healthy children.

Somewhat unexpectedly, the authors also found that both age and expressing suicidal ideation independently predicted children’s attribution of death to violent causes.

“When asked to describe an event that could cause death, older children, and children who expressed suicidal ideation, were much more likely to describe a violent cause such as shooting, stabbing, or being poisoned,” said Dr. Hennefield.

Senior author Joan Luby, MD, the study’s principle investigator and Director of the Early Emotion Development Program at Washington University School of Medicine added “We started this line of inquiry after observing higher than expected rates of suicidal ideation in our treatment study, which was something we had not previously seen in prior studies of preschool depression.

“This led us to add measures to investigate the meaning of this symptom to help guide caretakers and clinicians to respond. Very similar to the past studies of depression in preschoolers conducted in the Early Emotional Development Program and elsewhere, our findings suggest greater emotional awareness and capacities in younger children than previously understood.”

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Notes for editors
The article is "Changing Conceptions of Death as a Function of Depression Status, Suicidal Ideation, and Media Exposure in Early Childhood," by Laura Hennefield, PhD, Diana J. Whalen, PhD, Grace Wood, BA,

Mary C. Chavarria, BS, Joan L. Luby, MD (https://doi.org/10.1016/j.jaac.2018.07.909). It will appear in the Journal of the American Academy of Child and Adolescent Psychiatry, volume 58, issue 3 (March 2019), published by Elsevier.

Copies of this paper are available to credentialed journalists upon request; please contact Mary Billingsley at mbillingsley@aacap.org or +1 202 587 9672. Journalists wishing to interview the authors may contact Laura Hennefield, PhD, at lhennefield@wustl.edu or +1 917 301 3533.

About JAACAP
Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) is the official publication of the American Academy of Child and Adolescent Psychiatry. JAACAP is the leading journal focusing exclusively on today's psychiatric research and treatment of the child and adolescent. Published twelve times per year, each issue is committed to its mission of advancing the science of pediatric mental health and promoting the care of youth and their families.

The Journal's purpose is to advance research, clinical practice, and theory in child and adolescent psychiatry. It is interested in manuscripts from diverse viewpoints, including genetic, epidemiological, neurobiological, cognitive, behavioral, psychodynamic, social, cultural, and economic. Studies of diagnostic reliability and validity, psychotherapeutic and psychopharmacological treatment efficacy, and mental health services effectiveness are encouraged. The Journal also seeks to promote the well-being of children and families by publishing scholarly papers on such subjects as health policy, legislation, advocacy, culture and society, and service provision as they pertain to the mental health of children and families. www.jaacap.org

About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX Group, a global provider of information and analytics for professionals and business customers across industries. www.elsevier.com

Media contact
Mary Billingsley
JAACAP Editorial Office
+1 202 587 9672
mbillingsley@aacap.org