Characterization of suicidal behavior among children in a depressive episode : case series study

Introdução: O comportamento suicida infantil está relacionado com vicissitudes específicas da infância, representadas por fatores de risco, incluindo fatores predisponentes, internos e ambientais. Objetivo: Caracterizar o comportamento suicida em crianças de 5 a 12 anos com diagnóstico de episódio depressivo. Métodos: Quinze participantes, com idades entre 5 e 12 anos, foram avaliados em um centro de saúde mental da infância e adolescência de Belo Horizonte, MG, Brasil. Todos os participantes tinham histórico de tentativa de suicídio e estavam em um episódio depressivo no momento da avaliação. Resultados: As vulnerabilidades relacionadas às próprias crianças foram automutilação, agressão, perda de uma figura familiar importante, abuso sexual, distúrbios da sexualidade, uso de álcool ou outras drogas e maus-tratos. Em relação a estrutura e dinâmica familiar, foram encontrados fatores como doença psiquiátrica na família, conflito ou violência familiar, abandono ou rejeição, histórico de comportamento suicida na família, pais usuários de álcool e outras drogas e pais separados. Os fatores relacionados à escola foram assédio moral, dificuldades/atrasos escolares, bom desempenho escolar, mau comportamento, agressão física, abandono escolar e agressividade. Os principais métodos utilizados nas tentativas de suicídio foram lesões por objetos pontiagudos ou contundentes e autoenvenenamento intencional. Conclusão: As comorbidades psiquiátricas e o histórico prévio de distúrbios na família e na escola são fatores importantes a serem considerados em relação ao comportamento suicida em crianças com episódios depressivos. Descritores: Suicídio, criança, transtorno depressivo. Abstract


Introduction
Suicidal behavior in childhood is an action intended to harm oneself and includes suicide gestures, suicide attempts, and completed suicide. 1 Suicide is a complex and multifaceted behavior, that has not yet been thoroughly examined among children. 2 Suicide in childhood is not a random phenomenon. 3  Furthermore, the condition is underreported, because the episode is usually recorded as an accident. 5 Attempted suicide by children and adolescents is a manifestation of their suffering, which in general is the result of psychiatric disorders and of the difficulty in providing proactive treatment and assessment strategies. 5 A family history of suicidal behavior is also one of the precursors of suicidal behavior in children, as are depression, suicidal ideation, behavioral problems, and child ill-treatment. 6 The effect of childhood illtreatment and its relation to suicide is aggravated by the intergenerational transmission of abuse, so abuse is not only a risk factor for suicidal behavior for people who are abused as children, but also for their offspring. 7 It is noteworthy that half of the children who committed suicide had diagnosed psychiatric illness, with mood disorders and social adjustments being the most relevant. 3 Patients younger than 12 years usually attempt suicide for the first time with drug intoxication as the main method of perpetration. These children predominantly have anxiety and depression disorders, strongly associated with cognitive dysfunction as a factor of vulnerability. 5 In Australia, 50% of children aged 10-14 years and 57% of adolescents aged [15][16][17] years who died by suicide had a mental disorder. 8 It has been found that between 50 and 75% of children and adolescents who commit suicide have mood disorders and depressive disorders are the most prevalent in the suicidal behavior of children and adolescents, 9,10 which is why we chose to study this association in the present study. Based on these considerations, this case series study aims to characterize suicidal behavior during depressive episodes in children aged 5 to 12 seen at a child and adolescent mental health center.
In addition to psychiatric factors, interactions between psychosocial, environmental, and contextual factors seem to be associated with suicide in childhood.
Evidence-based knowledge of the myriad aspects of child suicide is crucial to understanding child suicide and to development of targeted suicide prevention.

Materials and methods
A case series study was carried out to describe the suicidal behavior of children with a diagnosis of a depressive episode. This method provides a detailed description of clinical cases containing important characteristics. 12 A case series study can be used to search for a rare event, such as suicidal behavior among children, taking a specific subset of the topic addressed from a large sample. Reports and case series should aim to contribute additional benefits to current practices or chart possible new directions for research into a particular subject, in which a single or a few individuals may be representative, and/or propose innovative ways to approach a disease or treatment.
They may also help formulate new hypotheses that can be tested using other study designs and, in certain situations, be an initial study for larger studies. 13,14 This case series study was conducted at CEPAI  15,16 Therefore, this case series study was conducted with children from 5 to 12 years of age.
A pre-established roadmap was developed to standardize data collection. Data collection was performed by actively searching for information present in the medical charts selected and registered at CEPAI.
Information relevant to characterize the cases was extracted from written medical records (not electronic medical records). Those that recorded depressive episode as the main diagnosis on admission to the CEPAI were considered cases with a depressive episode. The researchers did not inspect cases with ICD depressive episodes.

Results
This case series study was based on the records of 9 girls and 6 boys whose main diagnosis was F32 (depressive episodes), with a mean age of 10 years.  Figure 1).

Discussion
Analysis of the history of vulnerabilities highlighted the relevance of the association between self-harm and suicide attempts, since this was the most frequent element in the personal histories of the children in the cases studied. A history of non-suicidal self-harm is associated with an increased likelihood of suicide attempt and is a risk factor for suicidal behavior. 17,18 One systematic review showed a positive association between parental loss and suicidal behavior, 19 as was observed in six of the cases studied. Death of parents during childhood was associated with a prolonged risk of suicide among children whose father had died of suicide or other causes in a cohort study in three Scandinavian countries. 20 The consequences of parental death in childhood are far-reaching, and suicide risk trajectories can be influenced by early life conditions.
Parents users of alcohol and other drugs  In relation to family dynamics and structure, five cases were reported of family conflict or violence and in four cases parents were users of alcohol and drugs.
In this regard, the literature shows that dysfunctional families, family conflict, and parents who use alcohol and other drugs are associated with suicidal behavior in children. 21,22 Conflicts between parents and children appear to be a major precipitating factor for children and more frequent compared to adolescents. 2  In this study, it was observed that suicidal ideation Mood disorders are the psychiatric disorders most associated with suicide, and this association is more common among girls, 9 12 There is also no control group for comparison, they do not quantify the prevalence in the population and the methodology for diagnosis and intensity of symptoms is not standardized. 12 Another limitation of the study is that cases that presented to the emergency service or those transferred directly to the hospital were not included. It is therefore suggested that all results be interpreted carefully. It is hoped that the present article will encourage production of more studies on suicidal behavior in this age group, which are still very scarce.

Disclosure
No conflicts of interest declared concerning the publication of this article.