ABSTRACT

Background: Confronted to the increasing suicide rate in children, clinicians have to better understand and predict suicide-related behaviours (SRBs) in children with and without depressive symptoms. Aims: To investigate associations among suicidal tendencies (thoughts and/or attempts), depression and children’s perceptions of subjective quality of life. Methods: This was a cross-sectional study of 157 children of 6 - 13-year-old. Results: Children who attempted or thought of suicide reported goodless subjective quality of life than nonsuicidal children did, and children who thought of or attempted suicide reported higher levels of depressive symptoms than nonsuicidal children. Limitations: A more rigorous approach to investigating suicidal ideation and depressive symptomatology as a diagnostic interview based on the DSM-IV-TR will be valuable to future progress in understanding children’s suicidality. Conclusions: Results may reflect the confirmation of depressive symptoms as risk factors for suicidality and underline the high importance of social and emotional life context among suicidal children. For this reason, more effective recognition and comprehension of the underlying affective and social conditions of children with suicidality have special importance to prevent future suicidal behaviour during adolescence.

1. Introduction

During the last several decades, suicide rate in young people has increased in several countries [1]. Recent worldwide annual suicide rates for children ages 5 - 14 are 0.5 per thousand for females and 0.9 per thousand for males [2]. In France, 37 completed suicide in children ages 5 - 14 were deplored in 2009 (cépi-DC, Inserm). Although the scientific literature suggests that children under 12 can display suicidal behavior and thinking [3,4], specific data describing suicidality in young children are relatively scarce and inconsistent [5]. Tishler et al. think this fact may be due in part to the ideas described previously, which children are too cognitively and/or developmentally immature to express suicidal feelings [6]. They add other reasons for the lack of these data in children younger than 12 years, including underreporting of known suicides (particularly by parents) and mistaken classification of completed suicide and attempts as accidents [7,8]. If the prevalence of completed suicide among children, particularly those under age 11, is effectively relatively low, suicidal ideation is much more common. But due to variations in the definitions, sample characteristics, and lack of accurate statistics, the prevalence rates of suicidal ideations and suicide attempts are difficult to estimate. However, it has been estimated that up to 25% of young people have had suicidal ideation and it is approximately estimated that the rate of suicide attempts is at least 20 times greater than that of completed suicide (WHO Mental Health, 2006). In 2003, suicide rates were 0.0 per 100,000 for ages 0 to 4 years, 0.6 per 100,000 for ages 5 to 14 years (250 deaths), and 9.7 per 100,000 for ages 15 to 24 years (3988 deaths). According to the same report, 68 children younger than 12 years committed suicide. The youngest child was aged 5 years old, and five 9 years old also committed suicide [9]. The suicide rate for children ages 5 to 14 years skyrocketed in the past (an increase of 267% from 1970s rates of 0.3 per 100,000 to rates of 0.8 per thousand in 1986). This rate then decreased in 1996 (302 deaths) to current levels (250 deaths) [5]. Even with this decrease, suicide remained the 12th leading cause of death among children 12 years and younger in 2003. In addition, suicide was the fourth leading cause of death for 12 years old [9]. Only a few studies examine the rates of attempted suicide for prepubertal youth [10,11]. Some studies examining suicidal ideation in young children also demonstrate some variability in frequency estimates and differences in age groupings. Gould found that 1.9% out of their sample of 1285 randomly selected children aged 7 - 12 years reported suicidal ideation [12]. In contrast, Thompson found that approximately 10% of their sample of 1051 8 years old expressed suicidal ideation [13]. But this high level of suicidal ideation is not surprising, because the participants in the study by Thompson consisted of children who had previously been or were currently at high risk for maltreatment and/or abuse. On the other hand, some studies show that the most alarming suicidal ideation and attempts rates are seen in samples of child psychiatric inpatients: indeed, about 12% of normal school children 6 to 12 years old entertain suicidal thoughts, whereas 25% to 33% of outpatient and 72% to 79% of inpatient samples report suicidal ideation [14]. In support of this view, Rosenbaum Asarnow examined the suicidal ideation and attempts of 6- to 13-year-old psychiatric inpatients [15]. Seventeen in 55 (31%) of the children had a history of suicidal ideation, and 19 in 55 (34.5%) made at less an attempt. This suggests that the roots of suicidal behaviour may become salient in childhood and serve as the basis for future ideation and attempts [16]. Although young children appear to have some developmental and environmental protections from death by suicide, there is a dramatic increase in suicide rates in adolescence. Kovacs et al. have made a follow-up evaluation showing the rate of ideation remained relatively stable (62%) whereas the number of suicide attempts doubled [17]. Thus, we have some evidence of the persistence and consequences of suicide ideation in childhood. Identifying and measuring constructs that aid in distinguishing high-risk children seem particularly important, before these children enter the high-risk adolescent period. Research with adults provides strong evidence that psychiatric illness, particularly depression, has been consistently associated with suicidality [18]. This suggests that depressive children who have a suicide history may represent a particularly high-risk group for recurrent and increasingly dangerous suicidal behaviour. But depression alone; however, cannot account for many children who think about and attempt suicide. For example, it is possible to identify and discriminate among children who are depressed, those who are depressed and suicidal, and those who are suicidal but not depressed or also those who are depressed and nonsuicidal. Depression and suicidal ideation may overlap but they are distinguishable. And other variables are likely to mediate the depression-suicide relation. For example, Asarnow showed that suicidal behavior was associated with a tendency for children to perceive their families as low in control and cohesiveness and high in conflict [19]. Suicidal children also spontaneously generated significantly fewer cognitive mediational strategies for coping with stressful life events than nonsuicidal children. Another research examined family psychopathology, child maltreatment, family instability, negative family environment, and negative peer relationships as early negative life events, and self-esteem, locus of control, field dependence, hopelessness, and problem-solving deficits as cognitive variables with the aim to propose a model linking these variables with suicide [20]. In this study, we hypothesize that a potentially useful construct for differentiating suicidal (ideators and attempters) and nonsuicidal children is subjective quality of life. So, we have examined suicidal ideations and attempts in 6- to 13- year-old children and we have compared depressive symptoms and subjective quality of life according to suicidality. In keeping with our clinical practice, we predicted that suicidal children (ideators and attempters) would score higher on measures of depression and would hold a more negative subjective quality of life conception than their non-suicidal counterparts. Additional aims are 1) to better know which QOL’s domains are the most degraded in suicidal children; 2) to clarify the degree of association among depressive symptoms, suicide-related behaviours and subjective quality of life.

2. Methods

2.1. Study Population

This was a cross-sectional study of 157 participants conducted in 2010 in South-West of France. The total sample (n = 157) consisted of 6 - 13 years old children, the mean age (±standard deviation, s) was 11.1 ± 1.1 year. The number of boys and girls was nearly equal (72 girls vs. 85 boys). Two groups were identified: 67 children were psychiatric inpatients (30 boys and 37 girls; 10.7 ± 0.8) and 90 normal-school children. (42 boys and 48 girls; 11.44 ± 0.7). Participants and their families/guardians were required to provide written consent before participation. Exclusion criteria included a diagnosis of pervasive developmental disorder, evidence of a major neurological condition, a psychotic disorder, bipolar disorder, or Attention Deficit Hyperactivity Disorder (ADHD) combined type.

2.2. Measures

Depressive symptoms were assessed using the Child Depression Inventory [21], a 27-item self-report inventory designed to measure the severity of depressive symptomatology in children between the ages of 7 and 17 years. This inventory has been widely used in previous studies. Each item of the CDI is composed of three choices. The child simply marks the choice that best describes his or her feelings or behavior over the past 2 weeks. This usually requires less than 15 minutes. Results can be scored and profiled in just 10 minutes more. The test provides a Total Score plus five Factor Scores: Negative Mood, Interpersonal Problems, Ineffectiveness, Anhedonia, and Negative Self-Esteem. A score that falls below a cut-off point, or is 1.0 to 2.0 standard deviations above the mean, is considered to be positive for depression (cut-off: 19). Scores can also be plotted as follows: minimal depression or none (0 - 9), mild depression (10 - 16), moderate (17 - 29), and severe depression (30 - 63). The French version of the CDI was validated by Moor & Mack [22] and the internal consistency of the French version of the CDI is in agreement with the literature (0.71 for no depressed subjects and 0.89 for depressed patients and the test-retest coefficients range from 0.74 to 0.83 (time interval two-three weeks) [23]. Suicidal tendencies were assessed as (0) “never had serious thoughts of suicide”, or (1) “ever had serious thoughts about suicide”, (2) “ever had a plan to commit suicide”, or (3) “ever attempted to commit suicide” (item n 9, CDI, Kovacs, 1985). The Kidscreen (Ravens-Sieberer, 2001) was used to evaluate subjective quality of life. It consists of 52 items, each scored on a five-point scale. The instrument includes total score and 10 subscale scores: Physical Well-being (5 items), Psychological Well-being (5 items), Moods & Emotions (7 items), Peers & Social Support (6 items), Parent Relation & Home life (6 items), Self Perception (5 items), Autonomy (5 items), School Environment (6 items), Social Acceptance (Bullying) (3 items) and Financial Resources (3 items). The Kidscreen-52 questionnaire was developed simultaneously in several different countries. It was tested in a large representative sample of children and adolescents [24]. The Kidscreen and its French version are well researched and have adequate psychometric properties [25].

2.3. Procedure

For psychiatric inpatients, referrals to the clinic were invited to participate in the study, with over 95% agreeing to participate. Once written consent was obtained, a child-and-adolescent psychiatrist and a supervised trainee clinical psychologist undertook the assessment procedure. For normal school children, referrals to the school were invited in the study, with approximately 50 % agreeing to participate. The questionnaires were administered to participants who completed the above self-report measures.

2.4. Data Analysis

Data analysis was performed using the Statistica package (Statsoft), version 10.

The comparison of the CDI and Kidscreen scores was studied with the one-way analysis of variance. The differences between categorical variables were studied with the chi-square test and univariate logistic regression analysis. The numeric variables were categorized into two groups (clinical and normal range functioning) when they were taken into univariate logistic regression analysis. Odds ratios (OR) and their 95% confidence intervals (95% CI) were calculated for significant associations. P-values less than 0.05 were interpreted as significant.

3. Results

3.1. Background Characteristics of the Subjects

As shown in table 1, about twenty per cent (n = 32) of all of the children had presented suicidal thoughts or threats, while 6.3% (n = 10) had ever made a suicide attempt. In this sample, 73.24% of the children didn’t present clinical range for depression and 85.35% reported a good subjective quality of life.

3.2. Associations with Suicidality

Children with suicidal thoughts, threats and attempts were pooled together (n = 42) and compared with nonsuicidal children (115). Sixteen boys (18.8%) and 26 girls (36.1%) were suicidal, but the gender difference was not significant. On the other hand, group ages comparison showed that 20 children less or equal 11 years old and 22 more 11 years old were suicidal and the group

ages difference was significant (p = 0.022).

As shown in table 2, factors being significantly associated with suicidality in chi-square comparisons were: group ages (p = 0.022): 36.6% of kids over 12 had suicidal thoughts or acts versus 20.6% of kids under 11 years; depression symptoms (p = 0.01): nearly 24% of children with suicidality and 8.7% of nonsuicidal children had a symptomatology of depression and a low Kidscreen level (0.001): 30% of children with suicidality, and 8.6% of nonsuicidal children, had a low level of quality of life. Furthermore, Kidscreen’s sub-scores of Self-perception, Mood and emotions and Autonomy were significantly associated with suicidality (p < 0.5). More than thirty seven percent of children with low score for self perception had suicidal thoughts as well as 42.59% with low score for moods and emotions and 34.84% with low scores for autonomy. No significant differences were found in the chi-square comparison in others subscales of Kidscreen. But in univariate logistic regression analysis, low level for Parent Relation & Home life with Kidscreen and strong level of depression with CDI were significantly associated with suicidality.

Table 3 compares the CDI scores and Kidscreen ratings of children with suicidality and nonsuicidal children using the analysis of variance. Children with suicidality had significantly higher CDI total score. Furthermore, they had significantly lower level on quality of life, es-