Around eight in every 100 children (8.4%; 673/7,994) aged 9-10 years in the USA report suicidal ideation (temporarily or regularly thinking about, considering, or planning suicide), according to a new nationally representative observational study of almost 8,000 children aged 9-10 years in the USA, published in The Lancet Psychiatry journal.
Importantly, less than two in every 100 (1.3%; 107/7,994) children aged 9-10 years reported a suicide attempt in the study, and around one in 100 (0.9%; 75/7,994) had past or current suicidal plans.
The study, which is the largest of its kind in the USA, identifies important risk and protective factors associated with childhood suicidal ideation which could be used to identify vulnerable children and plan interventions to promote mental health in school and at home.
"While a minority (around 8%) of 9-10 year olds express suicidal thoughts, the robust associations shown in this study with psychological problems (mostly anxiety and depressive problems) and family conflict provide practitioners with important information as to how they can intervene to help children and their families," says Dr Sophia Frangou from Icahn School of Medicine at Mount Sinai, USA, who co-led the research. "The same applies to the protective influences which involve higher parental supervision (ie, knowing where children are, what they are doing, and with whom) and positive school engagement, which are actionable and modifiable." 
She continues: "Although the best way of offering support to children is unclear, current evidence suggests that school-based programmes which aim to increase awareness, like the Mental Health Packs for Schools initiative in the UK, are likely to be successful public health interventions for reducing both suicidal behaviours and suicidal ideation." 
In the USA, suicide is the second leading cause of death in 10-14-year-olds, and the number of children's hospital admissions for suicidal thoughts or self-harm has more than doubled over the last decade, increasing from 0.67% in 2008 to 1.79% in 2015. However, suicidal thoughts and behaviours among children have to date received comparatively little attention compared to older age groups.
The researchers based their findings on data from 7,994 children (average age 9.9 years) taking part in the Adolescent Brain Cognitive Development (ABCD) study--which is following the largest nationally representative sample of 9-10 year-olds living in the USA .
To measure suicidal ideation for each child, caregivers and children were independently asked about current wellbeing and suicidal history as well as personal, family, and social characteristics using questionnaires.
Modelling was used to quantify the association between suicidal ideation and a wide array of personal, family, and social characteristics in children who had caregiver-reported (654 children) or child-reported (684 children) experiences of suicidal ideation (including 198 cases in which caregivers and children were in agreement on reports of suicide ideation), and those who had never expressed suicidal thoughts or behaviours according to caregiver and self-reports (6,854 children).
Although suicide planning and suicide attempts are relatively rare, the researchers found that factors associated with an increase in risk of suicidal thoughts included psychological problems (odds ratio [OR] 1?7-4?8, 95% CI 1?5-7?4) and exposure to child-reported family conflict (OR 1?4-1?8, 95% CI 1?1-2?5) .
Children, and particularly boys, who experienced suicidal ideation also reported on average spending around an hour longer using screen-based devices at weekends. However, the authors caution that more research is needed to understand whether the relationship between screen time and suicide ideation is causal (eg, the result of increased exposure to cyberbullying or negative social comparisons) or correlative (eg, linked with social withdrawal or avoidance).
Greater parental supervision (ie, knowing where children are, what they are doing, and with whom) and a child's positive view of school (ie, children who liked going to school) were identified as having a strong protective effect against suicide ideation, possibly because they can aid the development of identity, self-esteem, and resilience.
Importantly, the researchers only noted agreement between caregiver and child reports of suicide ideation in 17% of cases (198/1,140 children), indicating that suicidal thoughts and behaviours in children cannot be reliably assessed by parental report alone.
"Fears of stigmatisation, communication difficulties, and lack of social and family support may mean young children feel less comfortable talking about their mental health," explains senior co-author Dr Beatriz Luna from the University of Pittsburgh, USA. "This disconnect underscores the need for separate and independent assessment of suicide risk in children and parents." 
The authors note several limitations including that experience of suicidal thoughts and behaviours were based on self-reported data, which might not be accurate; and due to the cross-sectional nature of the ABCD data at this point, they are unable to address questions about the evolution of suicidal thoughts and behaviours over time. Additionally, because of the rarity of suicide attempts, it was not possible to distinguish between factors associated with suicidal thoughts and acts.
Writing in a linked Comment, lead author Dr Rory O'Connor (who was not involved in the study) from the University of Glasgow, UK, says, "If we are to develop effective suicide prevention interventions, it is essential that we identify and target these childhood risks. In particular, greater effort to protect children from early life adverse experiences is vital, given that family conflict was associated with between a 30% and 75% increased risk of suicidality, even when taking into account the effect of psychopathology...A key focus for future research should be factors that facilitate as well as impede the transition from suicidal thoughts to acts of suicide."
Peer-reviewed / Observational study / People
NOTES TO EDITORS:
This study was funded by the US National Institutes of Health. It was conducted by researchers from Icahn School of Medicine at Mount Sinai, New York, USA; Sant'Andrea Hospital and University of Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy; University of Pittsburgh, Pittsburgh, USA; and University of British Columbia, Vancouver, BC, Canada.
 Quotes direct from authors and cannot be found in the text of the Article.
 The ABCD study includes 11,875 children aged 9-10 years recruited to match national sociodemographic variation based on age, sex, race, socioeconomic status, and urbanicity. Participants were enrolled at 22 sites, covering an area representing over 20% of the entire US population in this age group.
 Factors associated with an increase in risk of suicidal thoughts included psychological problems measured using the Child Behavior Checklist, with higher total score indicating greater problems (odds ratio [OR] 1?7-4?8, 95% CI 1?5-7?4; total score 52.0 for child-reported suicidal ideation, 57.8 for caregiver reported suicidal ideation, 59.7 for concordantly-reported suicidal ideation, and 45.3 for never suicidal); and exposure to child-reported family conflict using the ABCD Family Environment Scale: Family Conflict Subscale, with higher scores indicating greater conflict (OR 1?4-1?8, 95% CI 1?1-2?5; score 2·8 for child-reported suicidal ideation, 2·6 caregiver reported suicidal ideation, 3·1 for concordantly-reported suicidal ideation, and 1·9 for never suicidal (table 2).
If you are reporting on this study, please consider including a link to information and support for your readers. In the USA, the National Suicide Prevention Lifeline can be contacted on 1-800-273-TALK (8255) or visit https://suicidepreventionlifeline.org/. In the UK, the number is 116 123, or email: firstname.lastname@example.org or visit http://www.samaritans.org For those outside the USA and UK, Befrienders Worldwide also provide support: http://www.befrienders.org/
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