Why is suicidal behaviour increasing among elementary school children?

Eight-year-old Brian was raging. Something small had set him off, and he was trashing his room, breaking toys, ripping pictures off walls, turning over furniture and throwing the wreckage at his parents, Jeff Warner and Holly Sabara. Warner put their other sons, ages two and five, in the couple’s bedroom and told them not to come out.

“I don’t want to be here,” Brian wailed. “I want to die.”

Sabara left the room and called her local mental health crisis line in Guelph, Ont., to get advice on how to handle the situation with Brian, who had been diagnosed with ADHD and depression. The woman on the other line could hear the chaos in the background; she said they needed to get to the ER right away and called them an ambulance.

Meanwhile, Brian tried to kill himself. (Because reporting on suicide methods can lead to contagion, we are choosing not to share how.) Fortunately, Warner was able to stop him and keep him safe until the police and paramedics arrived.

“I felt like I was in a movie, thinking this can’t be happening to my family,” says Sabara. “We can’t be going to the hospital for a suicide attempt—he’s only eight. It was absolutely overwhelming.”

Between 2000 and 2017, only three children under the age of nine died by suicide in Canada. In March 2019, Amal Alshteiwi, a nine-year-old Syrian refugee who was living in Calgary, was added to this number. While suicide deaths among children in elementary school are rare, new research shows that suicidal thoughts and attempts are becoming increasingly common, though it’s not known why. Making a suicide attempt is the strongest predictor of dying by suicide in the future, and suicide is the second leading cause of death in children ages 10 to 14 in Canada, so there’s an urgent need to identify and address the causes.

In April 2019, JAMA Pediatrics published a study that found that the number of children under the age of 18 who had gone to emergency departments across the United States for suicide attempts and suicidal ideation each year had nearly doubled between 2007 and 2015, from 580,000 to 1.2 million. Even more troubling, 43 percent of visits were made by children between the ages of five and 11. “What’s alarming about this data is that it shows a very rapid, accelerating rise in ER visits for suicidal behaviour by younger children than previously identified,” says Brett Burstein, a paediatric emergency physician at Montreal Children’s Hospital and lead author of the study.

Unlike the U.S., Canada doesn’t have a national system for reporting medical services, but Burstein believes that the same trend can be seen here. He points out that there was a 55 percent rise in emergency department visits at Montreal Children’s Hospital for suicidal behaviour between 2015 and 2018 and a 53 percent increase in visits to CHEO, the paediatric hospital in Ottawa, between 2014 and 2018.

“When we see children at a very young age, their suicidal thoughts and gestures are less well formulated and may not even be potentially fatal or dangerous,” says Burstein. “But fairly quickly, after living with a problem for years, they become adolescents and young adults who have much more concrete ideas and ways to kill themselves.”

In 2017, the last year for which Statistics Canada data is available, 36 children ages 10 to 14 died by suicide. While the rate of boys dying by suicide in this age group has held steady since 2000, the rate of girls has been rising. Today, 10 to 14 is the only age category in which more females die by suicide than males. The same trend can be seen in the U.S., where suicide in this group tripled between 1999 and 2014.

“Something’s happening in younger girls that we need to pay attention to,” says Tyler Black, a child and adolescent psychiatrist at BC Children’s Hospital in Vancouver. “Whatever’s happening, it’s worrisome.”

Why are more young children displaying suicidal behaviour?

There are several theories on why more young children are contemplating suicide and acting on their thoughts. But there are no definite answers, as the increase has only recently been identified and suicidal behaviour among elementary school kids is an understudied area.

Mara Grunau, executive director of the Centre for Suicide Prevention in Calgary, says people are becoming more comfortable with the idea that children can have suicidal behaviour, but there are still a lot of deniers. When her organization launched Tattered Teddies, a workshop that helps people who work with children identify signs of suicide and understand how to help vulnerable kids, in 2008, people questioned why such a program was necessary. “Many people don’t believe that children are capable of suicide because they don’t necessarily have a mature understanding of death and the permanence of death, but we don’t believe that to be true,” she says. “When children engage in high-risk behaviour that edges toward suicidal behaviour, it needs to be taken seriously. Whether they understand the bigger picture or not is irrelevant.”

Just like a number of interacting factors typically contribute to each individual suicide, such as genetics, mental illness, loss of a loved one and lack of social support, there are probably many factors at play in the overall increase in suicidal behaviour among children.

Bullying

“When we talk about suicide attempts among youth, the first questions that come up are ‘Is this bullying?’ and ‘Did Instagram do this?’” says Burstein. “The bottom line is, the causes are almost certainly multifactorial. It’s not always the obvious things that are necessarily the primary causes.”

Still, Burstein says there’s interest in identifying the role that social media, bullying and other youth-specific phenomenon might be playing. Children who are bullied and bullies themselves are at higher risk of suicide, and they may share other risk factors for suicide, such as experiencing trauma, living in poverty and having depression or anxiety. According to PREVNet, a Canadian network of bullying researchers, between 10 and 15 percent of children are chronically bullied and the same number are persistent bullies, though rates of bullying have remained relatively stable for decades.

Amal Alshteiwi’s parents say that bullying is what drove their daughter to suicide. “The kids were bullying my daughter and even asking her to kill herself,” Amal’s dad, Aref Alshteiwi, told CTV News through a translator, adding that they also called her “stupid” and “ugly.”

Amal’s parents moved her to a different school to avoid the bullying, but her tormenters told her she would be bullied there, too. After a few days at her new school, Amal died. “She was so afraid and intimidated by what happened before,” Amal’s mom, Nasra Abdulrahman, told the Calgary Herald through a translator.

Black says some children who consider suicide are enduring challenging situations from which they feel they can’t escape. “These kids believe their only possible ending is to die,” he says.

Cyberbullying and social media

While bullying has been around forever, cyberbullying is a relatively new and growing problem. Research shows that girls ages 12 to 14 are more likely to be victimized than any other demographic, potentially contributing to the high rate of suicide in this group. One study found that children who are cyberbullied are twice as likely to attempt suicide.

A JAMA Psychiatry commentary in May on the increased suicide rate among girls ages 10 to 14 in the U.S. urges more research into the role of social media, which some studies suggest may be associated with suicidality. “The fact that social media has become a primary forum for interpersonal engagement in adolescence—a developmental period when social contact is rising rapidly and becoming increasingly important to well-being—makes this an area of great potential influence and importance,” according to the authors.

As for why social media may affect girls more than boys, the authors have some ideas. Girls are more likely to use social media, and their online experiences are more likely to lead to bullying, interpersonal stress and depression.

Research by MediaSmarts found that about one-quarter of Canadian kids in grade four own mobile phones and nearly one-third of students in grades four to six have Facebook accounts, which means that many children take their bullies home in their backpacks and rarely get a break from the abuse.

Racism

Suicide rates among Indigenous youth are five to six times higher than those of non-Indigenous youth and have remained unchanged over the past three decades. Indigenous youth continue to be affected by intergenerational trauma and systemic discrimination, which contribute to the sustained high rate of suicide, according to a 2017 report by the Standing Committee on Indigenous and Northern Affairs.

In the U.S., a 2018 study in JAMA Pediatrics found that suicide rates are increasing among black children ages five to 11 and decreasing among white children of the same age. In fact, rates are twice as high among black children, but more research is needed to determine the reasons for the racial disparity, says lead author Jeffrey Bridges.

Stress

Stress among children has increased dramatically over the past few decades, and stress leads to distress, which precedes most suicide attempts, says Black. “We need to work really hard as a society to make life less stressful for kids,” he says. “We’re filling children’s time with activities and skills development and forgetting that resting, playing, exploring and being given opportunities to fail are experiences that children need to develop a sense of who they are and who they want to be.”

Helicopter parenting can also have devastating consequences. “We want to create opportunities for our kids to fail because we want them to build resilience,” says Grunau. “We don’t want to do everything for them. We want them to struggle and wrestle because that’s how they build resilience.”

Mental illness

Mental illness is the most important risk factor for suicide in the general population, and about half of children who die by suicide have a mental health diagnosis. Between 10 and 20 percent of Canadian children develop a mental health disorder, but its prevalence has remained the same since 2006, so it’s unlikely to explain the increase in suicidal behaviour.

Conflict

A 2015 review of studies on suicide among children under the age of 14 found that they were less likely than adolescents to have mental illness and that parent-child conflict was the most common contributing factor to their deaths. Another study, published in Pediatrics in 2016, found that relationship problems with friends or family members factored into 60 percent of suicide deaths for children ages five to 11.

“The younger the child, the less likely the suicide is due to a noticeable mental illness and the more likely it’s due to stress caused by conflict,” says Black.

This is particularly heartbreaking because children often perceive conflict in very inaccurate ways. “Children have excellent antennas but very broken receivers,” says Black. “When there’s conflict in the home, children can perceive themselves as the cause of the conflict or misinterpret the reason for the conflict, even if it doesn’t involve them. Families need to work hard to make sure that children are explicitly told ‘If I ever upset you, please tell me. It’s never my intention. I care about you so much.’”

Grunau adds that adverse childhood experiences (ACEs), such as being abused or neglected or witnessing intimate partner violence, are correlated with suicidal behaviour.

Impulsivity

The 2016 Pediatrics study also found that, among those with a mental health diagnosis, children were more likely to have attention deficit disorder and less likely to have depression than early adolescents. The authors suggest that impulsivity may play a role in the suicide deaths of children.

Black agrees and says that one of the most common drivers of suicidal behaviour among young children is an uncontrolled response to distress. “A child is told something they didn’t want to hear or asked for something they didn’t get and they become so overloaded with distress and can’t handle it that they quickly decide that they want to hurt themselves or die,” he explains.

Sabara believes that this may have played a role in Brian’s suicidal behaviour, which continued after the earlier incident. “Whenever we would say ‘no’ or he would have to do something he didn’t want to do, it would trigger an emotional response,” she says. “Sometimes he would just sob on the floor for an hour or two after an incident and, over and over again, say ‘I want to die. I don’t want to be here. I want to go away. I gotta get outta here.’ When Brian got upset, he would try to escape the chaos in his head and sensory overload, and I think that was a lot of what would drive him to want to hurt himself.”

Warning signs

Changes in behaviour

Young children aren’t very good at hiding their feelings, so when they’re thinking about suicide, there are often easy-to-spot signs. One of the biggest indicators is a change in behaviour that goes beyond normal highs and lows. “If your child has always been peaceful and easygoing and all of a sudden has bouts of anger or frustration, that’s a red flag,” says Grunau. “It can go the other way, too, like if they have always been larger than life and suddenly become quiet.”

If your child seems particularly difficult and defiant, that could also be a sign. “An increase in conflict is a harbinger,” says Black. “If it feels like the child is always fighting with you about everything, it’s unlikely that their intention is to be a jerk; it’s more likely that their ability to tolerate stress is decreasing.”

Disengagement

Withdrawing from friends and activities is another big indicator. If swimming is their favourite activity and they no longer want to go to lessons or ask for play dates with their best friend anymore, it could be a sign that something is going on. Complaints of boredom can also be cause for concern. While it’s normal to complain that there’s nothing to do every once in a while, if your child does so more often than not, it’s worth looking into. “Boredom isn’t a natural state for a child,” says Black. “In child psychiatry, it’s considered a symptom of sadness.”

Risk-taking

High-risk behaviour, like biking in traffic or climbing out a window onto the roof, can also suggest suicidal behaviour. In addition to his suicide attempts, Brian would self-harm by punching himself and banging his head on the floor and hurt his brothers by charging at and choking them, all of which are violent acts that may be indicative of suicidal ideation.

Talk of death

Talking about death, as Brian did, can also be a sign of suicidal thoughts. “Children will say things referencing their own deaths, and any threats of killing themselves or dying need to be taken seriously,” says Grunau.

Even saying things like “You’d be better off without me” or “I hate my life” or drawing pictures with dark or violent imagery should be addressed. “It’s always worth probing,” says Grunau. “Try to get them to talk about how they’re feeling.”

How to help a suicidal child

If your child is showing signs of suicidal behaviour, it’s important to talk to them about it and seek professional help for them. If your child is in immediate danger of hurting themselves, call 911. If you’re unsure what to do, talk to your family doctor or call your local crisis line, nursing line or Canadian Mental Health Association branch.

“Early intervention is key,” says Grunau. “Reach out and get the help you need. Don’t allow your own sense of ‘Oh, this is all my fault’ to get in the way of moving things forward. It’s not your fault—all parents want the best for their children.”

Sometimes children talk about suicide and have no intention to die, but it still suggests an underlying issue. For example, Black says a child who tells you that they’re going to kill themselves may be trying to express seriousness of thought or demonstrate power. “It’s definitely a suicidal thought, but there’s also a rescuing thought that comes with it because you wouldn’t tell your parents about it unless you wanted help,” he says. “‘I want to die’ is almost saying ‘I’m really in distress. I’m really hurting. I really need help.’”

Before the age of 10, Black suggests regularly asking your kids about stress and distress. Your questions can be as simple as “How have things been going for you?” or “Is anything stressing you out right now?” He suggests following that up with questions about hopelessness.

When kids are over the age of 10, Black says parents should start asking them about suicidal thoughts once in a while to make sure they’re OK and help normalize the conversation. He suggests opening the discussion with something like “Every now and then, people have sad thoughts. Have you had any negative thoughts about death or dying?”

Parents may worry that talking about suicide will upset their children, but the opposite is true. In fact, a study found that asking about suicidal thinking significantly reduces distress in children who are thinking about it and has no effect on those who are not. “When you say it’s OK to talk about this or people can have these thoughts, you reduce the child’s distress that there’s something wrong with them,” says Black.

Suicide prevention is also making its way into the classroom. As part of a pilot study, Manitoba children in grades four through six are now receiving Thrival Kits, which encourage mental health promotion activities such as personal reflection, mindfulness meditation, stress reduction and coping strategies.

When you’re supporting a child with suicidal behaviour, it’s important to get some support for yourself, whether it’s speaking with a counsellor, enlisting the help of family members or getting respite care for your child so that you can catch your breath. “When a child is sick with anything, it’s very, very stressful on the whole family,” says Grunau. “You can only help your child if you stay well yourself. You need to be supported as a parent. If your child had cancer, you wouldn’t think you could do it on your own.”

Sabara agrees. She and her husband now help other families navigate the system and find the support they need. “You can’t hide this because you need the support of everyone else around you,” she says. “Find someone else who understands what’s going on because it can be very isolating.”

Brian, who is almost 14 now, has learned to pause before reacting and remove himself from stressful situations thanks to the support he received in a private residential treatment facility. He hasn’t mentioned suicide in a long time, but Sabara suspects that it will come up again.

“Brian still has many hurdles ahead of him,” she says. “He has puberty and the teen years. He has his 20s and experimenting with substances. I know what kind of journey we’re in for and expect that we’ll encounter suicide again, but we’re going to be there to support him.”

If you are thinking about or affected by suicide, call the Canada Suicide Prevention Service anytime at 1-833-456-4566 or text 45645 between 4 p.m. and 12 a.m. ET. Children who are thinking about or affected by suicide can call Kids Help Phone at 1-800-668-6868, text 686868 or visit kidshelpphone.ca/live-chat for a live chat.

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