Very little is known about childhood suicide. There has been a recent spate of research and writing on adolescent suicide, but only a few empirical articles on suicide risk in preteens. Until recently, it was believed that children never committed suicide. Most adults want to believe that early childhood is an idyllic time of happiness and carefree living. Even among adults who recognized that childhood for some children can be fraught with stress and pain, most believed that children were not capable of making life-and-death decisions such as suicide. Recent research has dispelled that myth.

Suicide in children is on the rise. In a 20-year period between 1970 and 1990, suicide rates tripled among children ages 5-14 years. Suicide rates among this group are relatively low, accounting for about 1% of all completed suicides. Nevertheless, although children kill themselves at lower rates than the rest of the population, suicide is the third leading killer among children ages 10-14 years (behind accidents and cancer). And although completed suicide is relatively uncommon, suicidal behaviors are quite prevalent. Every year, about 12,000 children ages 5-14 years are admitted to psychiatric hospitals for suicidal behavior. One study found that 33% of a group of 39 outpatient psychiatric children (ages 6-12 years) had contemplated, attempted, or threatened suicide (Pfeffer, 1984). Even children with no psychiatric history appear to have suicidal thoughts; about 12% of elementary school children admit to suicidal ideas, threats, or attempts (Pfeffer, Zuckerman, Plutchik, & Mizruchi, 1984). Unlike in the adult population, both suicidal attempts and completed suicides are more common among boys than among girls.

It should be noted that although suicide is underreported among all age groups, this is particularly true for children. Children seldom leave suicide notes, and they typically have less access to suicidal methods (e.g., guns, pills). When child suicides do occur, they often are officially reported as accidents.

Bryan was a hyperactive 9-year-old with a learning disability. He was diagnosed with ADHD when he was 6, after his mother was hospitalized briefly because of "nerves." Bryan had extreme difficulty in school, was labeled a severe behavioral problem by his teachers, and had been through a series of medications designed to help him "slow down and focus." He got into everything, and his family went to extreme measures to limit his access to anything that he might get into trouble with, not only locking up guns and knives, but also locking the shed where power tools, the ladder, the lawnmower, and other items were stored. Last year, Bryan watched a neighbor using an electric hedge trimmer. When the neighbor went inside the house for a moment, Bryan picked up the trimmer and starting hacking away at trees. He received severe cuts on his forearm and leg and had to be rushed to the hospital, where he received over a hundred stitches.

The children in Bryan's class were extremely frustrated with him as well, and he was constantly teased and made fun of. After the hedge trimmer incident, his classmates teased him relentlessly, calling him names and running up behind him and making noises like the trimmer. Bryan responded to these attacks by lashing out at his classmates, both verbally and physically. He spent a lot of time in the principal's office, the counselor's office, and detention. He told his school counselor that he wished he could make friends, and in a rare moment of self-reflection, he became extremely tearful and agitated and stated that he believed that he would never have a friend or be loved by anyone-even his mother was sorry he had been born.

Two days later, Bryan's body was found by his sister with a gunshot wound to his head. He had picked the lock on his father's gun cabinet, found a pistol, and shot himself. His parents believe that he was being his natural inquisitive self-that he picked the lock because he was bored, and when he found the gun, he couldn't resist playing with it. His school counselor believes that Bryan's act was intentional but that he was incapable of understanding the finality of suicide. Therefore, the school has avoided using the term suicide, since that implies that Bryan meant to take his life and understood the finality of the decision.

It is impossible to know whether Bryan killed himself intentionally or whether he understood the finality of the decision. In cases like this one, the death is typically ruled accidental. Interviews conducted with coroners found that they are often reluctant to rule childhood deaths as suicide, even in cases of dearly self-inflicted injuries, because there is a general belief that children do not fully understand the implications of their actions and therefore are incapable of committing suicide (Mishara, 1999). The coroner's ruling of Bryan's death as accidental is consistent with this belief.

Developmental Considerations of Childhood Suicide Risk

As was noted in the case of Bryan, one of the most salient aspects of understanding suicide risk in children is determining whether children have an understanding of the permanence of suicide and death. This question was originally raised toward the end of World War II by researchers who interviewed children about what they thought happens when a person dies. Two researchers (Anthony, 1940; Nagy, 1948) developed a series of stages through which children progress in their acquisition of a mature understanding of death. Children with immature belief systems did not believe that death was permanent, inevitable, or universal. These early researchers attempted to delineate stages that were fixed to chronological age, with very little success.

Research during the 1970s found that beliefs about death were not necessarily related to chronological age. Both Koocher (1973) and Melear (1973) found that cognitive development, rather than chronological age, determined conceptualizations of death. Other research found that exposure to death increased the likelihood of mature understandings of the concept. Raimbault (1975) found that terminally ill children had advanced understandings of death, even at very young ages.

More recently, Normand and Mishara (1992) attempted to understand what children know about death and when they know it. They found that 87% of elementary school age children understood the concept of the universality of death, and 90% understood the finality. In their study, all children had a mature concept of death by the age of 10 years. When asked about suicide, only 10% of first graders knew what the word suicide meant, but when fifth graders were interviewed, 95% had an understanding of the word.

In 1999, Mishara extended the original study. He found that students in first grade had relatively immature concepts of death, although the majority understood the permanence of death. Students in fifth grade had a very mature understanding of death. There was strong evidence that as children matured, they grew in their understanding of death. They concluded that most of the children in this and the 1992 (Normand & Mjshara) studies understood the permanence and finality of death, even at very young ages. Additionally, Mishara (1999) found that 100% of children in second grade and higher understood the concept of suicide or "killing oneself," including the permanence of the act. Therefore, it might be inappropriate to argue that self-injurious behaviors in children should not be called suicides or suicide attempts because of their immature belief systems. It appears that most children over the ages of 7 or 8 years—at least those in the studies reviewed here—do understand that self-injurious behaviors can lead to permanent death. However, it should be noted that in a 1994 study, suicidal hospitalized children ages 8-10 were less likely to understand the finality of death than were their nonsuicidal same-aged peers (Carlson, Asarnow, & Orbach, 1994). Thus, it appears that immature conceptualizations of death may be a risk factor for childhood suicide.