Young Children With Suicidal Thoughts and Behaviors More Likely to Resolve Conflicts With Violence, Homicide, or Suicide: A Study of Internal Working Models Using Narratives

There is mounting evidence that young children who express suicidal ideation (SI) have a different conceptualization of death than their peers. This study characterizes 3- to 6-year-olds' depictions of violence, death, and suicidal themes in a story completion task as a function of their history of SI. Participants were 228 children with depression (3.0-6.9 years) who completed a comprehensive psychiatric assessment and four story stem narratives. For each narrative, an interviewer began a story with a conflict that the child was encouraged to resolve. Children's resolutions were coded for standard themes and negative atypical themes including violence and homicide, accidental harm or death, and suicidal ideation/acts. Themes were examined as a function of children's SI status: active-SI (n = 25), passive-SI (n = 28), or no history of SI (n = 175). Across the narratives, 89 children described at least one negative atypical theme: violence or homicide (n = 78), accidental harm or death (n = 22), and suicide (n = 13). The responses of children with active-SI included significantly more violence or homicide than children without SI. Moreover, current active-SI predicted suicidal themes. There were no group differences in accidental harm or death, nor in common aggressive or punitive acts (e.g., hitting, yelling, spanking), indicating specificity between active-SI and more intense violence and death-related themes. In sum, young children with active SI are more likely than their depressed peers without SI to incorporate violence, homicide, and suicide into their narratives around conflict resolution. These themes appear more salient to depressed children with SI and pervasive in their thoughts and problem-solving strategies. General Scientific Summary This study demonstrates that depressed young children who exhibit suicidal thoughts are more likely than their depressed peers without suicidal thoughts to resolve conflicts in narratives with violence or suicide. This work is the first to report on observed differences in young children's behavior based on their history of suicidal thoughts and indicates that these intense themes of violence and suicide are more pervasive in the thoughts and problem-solving strategies of depressed young children with suicidal thoughts relative to depressed peers without suicidal thoughts. These findings have implications for risk assessment in clinical settings and in understanding the development of suicidality.