Suicidal Behavior in

Latency-Age Children
An Empirical Study

Cynthia R. Pfeffer, M.D., Hope R. Conte, Ph.D.,

Robert Plutchik, Ph.D., and Inez Jerrett, M.A.

Abstract. Fifty-eight children, ages 6 to 12 years, consecutively admitted to a psychiatric hos-

pital unit were evaluated for suicide potential. A battery of' specially constructed scales was
utilized to assess variables that might he correlated with suicide potential. Some degree of su-
icidal risk was found in 72% of the children. Factors significantly correlating with suicidal
behavior were depression, feelings of hopelessness and worthlessness, the wish to die, preoc-
cupations with death, the concept that death is temporary and pleasant, and severe depres-
sion and suicidal behavior in the parents.

T h e purpose of this study is to identify high-risk factors that corre-

late with suicidal behavior in latency-age children. Although Na-
tional Vital Statistics do not classify suicide as a cause of death in
children under 10 years, there are recent indications that suicidal
threats and attempts in latency-age children are not as uncommon
as previously thought (Pfeffer, 1978; Shaffer, 1974). Lomonaco

Dr. Pfeffer is Assistant Clinical Professor of Psychiatry and Pediatrics; Dr. Conte is Assistant Pro-
fessor of Psychiatry; Dr. Plutchik is Professor of Psychiatry; and Ms. Jerrett is Research Assistant, all
at Bronx Municipal Hospital Center-Albert Einstein College of Medicine. Reprints may be requested
from Dr. Pfeffer, The New York Hospital4onzell Medical Center, Westchester Division, 21
Bloomingdale Road, White Plains, New York 10605.
This paper was presented at the Twenty-Fifth Annual Meeting of the American Academy of Child
Psychiatry, San Diego, Calfornia, October, 1978.
The authors would like to thank Paulina F. Kerberg, M.D., and Joseph Richman, Ph.D., who were
consultants f o r this study. The assistance of the child psychiatry fellows and child psychology trainees
who participated in this study was appreciated.
0002-7138/79/1804-0679 $01.23 1979 American Academy of Child Psychiatry.

679
680 Cynthia R. Pfefler et al.

and Pfeffer (1974) observed that approximately one third of the

latency-age children evaluated for psychiatric hospitalization were
referred primarily because of suicidal threats and attempts. Green
(1978) also documented that 40% of the abused children he stud-
ied exhibited life-threatening self-destructive behavior. O u r obser-
vations and experience in evaluating and treating suicidal children
stimulated us to describe our population of suicidal latency-age
children and to attempt to delineate systematically factors that may
indicate high risk for childhood suicidal behavior.
Many variables have been cited in relation to childhood suicidal
behavior, but little firm evidence exists about the relative
significance of these factors. Toolan (1975) emphasized that de-
pression in the vast majority of cases is a significant factor in at-
tempted suicide of children. Such a statement may be confusing
since adequate diagnostic criteria for recognizing childhood de-
pression have not been defined. Furthermore, Cytryn and
McKnew (1972), Poznanski and Zrull (1970), and Toolan (1962)
recognized that a child’s depression may be masked by hyperactive
or delinquent behaviors.
Shaw and Schelkun (1965), in their attempt to set guidelines for
evaluating risk of suicidal behavior in adolescents and children,
noted such constitutional and developmental correlates as intense
emotional reactions, low frustration tolerance, and suggestibility.
Ackerly ( 1 967) observed that children who threatened and at-
tempted suicide showed signs of serious emotional disturbance. He
considered that the child who threatened suicide is expressing “a
complex interplay of psychic forces resulting from the vicissitudes
of his aggressive drives and his narcissistic orientation to life” (p.
242). He believes that when a child has attempted suicide, a bor-
derline or psychotic state prevails with “a major break with reality,
a massive disruption of adaptive mechanisms, and a withdrawal of
libido from the world” (p. 242). However, his study includes only
suicidal children, and he did not compare his population with
nonsuicidal children with various degrees of psychopathology.
Family stress arising from disorganization, separation, and death
have been associated with suicidal behavior in children. Morrison
and Collier (1969) viewed suicidal behavior as a symptom of acute
emotional distress which reflects long-standing problems. Sabbath
( 1969) proposed that adolescent suicidal behavior was often precip-
itated by the adolescent’s perception of his parents’ wish to be rid
of him. Lukianowicz (1968) stated that the most important external
Suicidal Behavior in Latency-Age Children 68 1

factor was “disturbed relations with the parents” and the main etio-
logical factor in suicidal behavior of children was “abnormal paren-
tal personality” (p. 430).
We decided, therefore, to assess the child’s ego functioning, the
specific types of stressful environmental factors that exist, the
child’s affective state, and his understanding of death, and to relate
these variables to suicidal behavior.

METHOD

Child Suict.de Potential Scales

Based on clinical experience and a review of the literature, vari-
ables most likely to be relevant to suicidal behavior in children were
identified and eight structured Child Suicide Potential Scales were
constructed. Each scale contains a number of items that can yield a
score for each variable to be analyzed. To identify relationships be-
tween variables on these scales and the degree of dangerousness of
suicidal behavior, correlations were computed between a child’s
scores on these scales and his score on the 5-point spectrum of sui-
cidal behavior scale.
This battery was administered by the child’s therapist as a sup-
plement to the standard clinical evaluation of the children. These
scales are described in table 1. They cover the following seven
areas: spectrum of suicidal behavior, precipitating events, affects
and behavior, family background, concept of death, ego func-
tioning, and ego defense mechanisms.
Suicidal behavior was defined as thoughts or actions which may
lead to death or serious injury. T h e spectrum of suicidal behavior
scale is described in table 2.
A detailed case report was written for each child. In order to as-
sess the degree of interjudge reliability, 30 of the case reports were
randomly selected and another clinician read the reports and inde-
pendently estimated the degree of suicide potential without knowl-
edge of the therapist’s rating in the spectrum of suicidal behavior
scale. There was agreement in 94%of the ratings. In the remaining
cases, the ratings differed by 1 point on this 5-point scale.
Coefficient alpha was used to evaluate the internal reliability of the
other scales. T h e reliability coefficients are as follows: affects and
+
behavior (past) .98, concept of death + 3 6 , affects and behavior
(recent) + 3 2 , family background + .71, precipitating events+
682 Cynthia R. Pfeffer et al.

Table 1
Child Suicide Potential Scale
Scale
1. Spectrum of Suicidal Behavior
2. Precipitating Events
3. Affects and Behavior (recent)
4. Family Background
Affects and Behavior (past)
Concept of Death
Ego Functioning
Ego Defense Mechanisms
Purpose
Classifies suicidal behavior along a 5-point
spectrum of severity ranging from nonsui-
cidal to serious attempts.
Documents environmental stress during 6
months preceding the child’s evaluation. Ex-
amples: school problems, household changes,
quality of friendships, losses.
Documents emotional states and symptomatic
behavior during 6 months preceding the
child’s evaluation. Examples: anxiety, sad-
ness, hopelessness, temper tantrums, defiance,
running away, firesetting.
Documents family events and parental psy-
chopathology. Examples: separations, death,
severe discipline, parental depression, alcohol
and drug abuse.
Similar to variables in 8 3 , except this docu-
ments period before 6 months preceding the
child’s evaluation.
Documents the child’s preoccupations and ex-
perience with death and his view of death as
pleasant, unpleasant, temporary, final.
Documents qualities of ego functioning. Ex-
amples: intelligence, affect regulation, im-
pulse control, reality testing.
Documents utilization of ego defenses. Exam-
ples: denial, reaction formation, repression.

.57. All but the reliability coefficient of the precipitating events

scale were significant at the .01 level or better.
The Population
Fifty-eight children, 6 to 12 years old, were sequentially admitted
to the Child Psychiatry Inpatient Service of the Bronx Municipal
Hospital Center from December 1976 to June 1978. They re-
mained in the hospital for a maximum of 3 months during which
time extensive diagnostic evaluations were made. These consisted
of individual interviews with the child and his family, milieu obser-
vation, group therapy observation, school evaluation, and a full
battery of psychological tests, including the WISC-R, WRAT,
Rorschach, TAT, Bender-Gestalt test, and Human Figure Draw-
ings. Each child had a therapist who was a child psychiatrist or a
child psychologist.
Suicidal Behavior in Latency-Age Children 683

Table 2
Child Suicide Potential Scale - Spectrum of Suicidal Behavior
1. Nonsuicidal: No evidence of any self-destructive or suicidal
thoughts or actions.
2. Suicidal Ideation: Thoughts or verbalization of suicidal intention.
Examples: (a) I want to kill myself.
(b) Auditory hallucination to commit suicide.
3. Suicidal Threat: Verbalization of impending suicidal action and/
or a precursor action which, if fully carried out,
could have led to harm.
Examples: (a) I am going to run in front of a car.
(b) Child puts a knife under his pillow.
(c) Child stands near a n open window and says
he will jump out.
4 . Mild Attempt: Actual self-destructive action which realistically
would not have endangered life and did not ne-
cessitate intensive medical attention.
Example: (a) Ingestion of a few pills and child’s stomach
pumped.
5 . Serious Attempt: Actual self-destructive action which realistically
could have led to the child’s death and may have
necessitated intensive medical care.
Example: (a) Child jumped out of fourth floor window.

T h e demographic characteristics of the population are presented

in table 3. There were no significant differences between the sui-
cidal and nonsuicidal children on any of these characteristics. Sui-
cidal children were defined as children with suicidal ideas, threats,
and attempts. DSM I1 criteria were utilized to assess diagnosis.
Worthy of note is the relatively high percentage of suicidal chil-
dren with learning disabilities, behavior disorders, and borderline
personality organization. T h e percentages for diagnostic categories
obviously do not add u p to 100% because many of the children had
more than one diagnosis.

RESULTS

Types of Suicidal Behavior

Forty-two (72%) of the 58 children had suicidal ideas, threats, o r
attempts. There were 37 (74%) boys who were suicidal out of a to-
tal of 50 boys and 5 (62%) girls who were suicidal out of a total of 8
girls. T h e spectrum of suicidal behavior and the suicidal methods
contemplated and enacted are shown in table 4.
684 Cynthia R.Pfeffer et al.

Table 3
Demographic Characteristics of the Hospitalized Children
Suicidal Nonsuicidal Total
N % N % N %
Number of children 42 72 16 28 58 100
Socioeconomic class Low Low Low
Race-ethnicity
White 5 12 1 6.2 6 10
Black 16 38 8 50 24 41
Hispanic 21 50 7 43.8 28 49
Sex
M 37 88 13 81 50 86
F 5 12 3 19 8 14
Mean age (years) 9.0 9.0 9.0
Diagnosis
Behavior disorder 14 33 8 50 22 39
Learning disabilities 15 36 8 50 22 40
Borderline personality 19 45 5 31 24 41
Depression 10 24 4 24 14 24
Psychosis 7 19 2 12 10 17
Organic brain syndrome 9 21 3 19 12 21
Adjustment reaction 5 12 2 12 7 12
Mental retardation 3 7 3 19 6 10
Language disturbance 3 7 1 6 4 7
Neurosis 1 2 1 6 2 3

Table 4
T h e Spectrum of Suicidal Behavior and Suicidal Methods
Undeter-
Children Jumping Stabbing Burning Ingestion Traffic mined
Nonsuicidal
N 16 0 0 0 0 0 0
% 28 0 0 0 0 0 0
Suicidal ideation
N 11 6 0 1 0 0 4
% 19 55 0 9 0 0 36
Threats
N 15 12 3 0 0 0 0
% 26 80 20 0 0 0 0
Mild attempts
N 8 3 0 2 2 1 0
% 13.5 38 0 25 25 12 0
Serious attempts
N 8 3 2 1 2 0 0
70 13.5 38 25 12 25 0 0
Total
N 58 24 5 4 4 1 4
70 100 57 11 10 10 2 10
Suicidal Behavior in Latency-Age Children 685

There was an even distribution of children along the spectrum

of suicidal behavior. T h e actual type of behavior was not the deter-
minant of hospitalization, which was based on a concern about the
potential dangerousness of the outcome of the behavior. Pfeffer
(1978) has stated that the first concern for intervention with sui-
cidal children is to protect the child from harm; and to insure this,
the hospital often becomes the treatment modality of choice. T h e
marked frequency of jumping from heights may indicate that this
suicidal technique is a characteristic method among latency-age
children. In contrast to what has been noted by Ackerly (1967),
Lourie (1966), and Mattsson et al. (1969), although boys in this
population of disturbed children outnumber girls, the percentage
of suicidal boys is not significantly different from the percentage
of suicidal girls in the spectrum of suicidal behavior.
Precipitating Stresses
There were no significant differences in recent types of stresses
for the suicidal and nonsuicidal children. T h e most common
stresses were preoccupations about school failure, disturbed friend-
ships, fears of parental punishment, and school and family
changes. Such stressful issues precipitated a crisis that might in-
clude suicidal behavior.
Affects and Behavior
There were no significant correlations between the degree of dan-
gerousness of suicidal behavior and recent or past states of anxiety
(r = .20 and r = .15, respectively). Similarly, there were no
significant correlations between the expression of recent or past
aggressive tendencies and the spectrum of suicidal behavior (r =
.07 and r = .06, respectively). Table 5 shows that a high percentage
of both suicidal and nonsuicidal children were intensely anxious
and displayed severe aggression that included defiance, fights,
restlessness, temper tantrums, tendency to hurt and tease others,
and destructiveness toward objects.
Although recent and past depressions were not significantly cor-
related with the spectrum of suicidal behavior (r = .20 and r = .15,
respectively), the variables of depression, hopelessness, worth-
lessness, and the wish to die significantly distinguished between
the suicidal and nonsuicidal children. Suicidal children were noted
to become significantly more depressed and hopeless during the
six months before evaluation. However, they were reported to feel
686 Cynthia R . Pfeffer et al.

Table 5
Affects and Behavior Shown by the Suicidal and Nonsuicidal Children
RECENT PAST
Non- Non-
Suicidal suicidal t, P Suicidal suicidal t, p
% % % 70
Affects
Anxiety 71 62 NS 75 56 NS
Depression or
sadness 60 19 2.79, p < .01 36 25 NS
Hopelessness 50 12 2.32, p < .05 38 12 NS
Worthlessness 56 12 2.63, p < .01 44 6 2.48, p < .01
Wish to die 62 0 3.82, p<.O1 44 0 3.00, p < .01
Aggression 90 75 NS 94 88 NS
Symptoms
Sleep disorder 52 38 NS 42 31 NS
Stealing 24 46 NS 24 53 NS
Firesetting 46 54 NS 42 23 NS
Running away 28 23 NS 24 15 NS

chronically worthless and had thoughts of wanting to die for a long

time preceding the evaluation. Such symptoms as stealing,
firesetting, and running away were prevalent among both the sui-
cidal and nonsuicidal children.

Family Issues
Several important variables in the family did not distinguish be-
tween the suicidal and nonsuicidal children: parental separations
existed in the families of 94%of the suicidal children and 75% of
the nonsuicidal children; 62% of the fathers of suicidal children
and 56% of the fathers of the nonsuicidal children were absent or
there were multiple father figures; abusive home atmospheres
including frequent violent parental arguments, and severe punish-
ment toward the child occurred in 75% of the suicidal and
nonsuicidal populations.
A significant finding is that the mothers of suicidal children
w e r e more frequently depressed (t = 2.11, p < .05) than the
mothers of the nonsuicidal children. In addition, there was a
significant correlation between parents who were depressed and
suicidal and the degree of dangerousness of suicidal behavior in
their children (t = 2.61, p < .01). In the entire population, 13
mothers (22%) had suicidal ideas, 10 mothers (17%) attempted sui-
cide, and 2 mothers (3%)committed suicide; there were 2 fathers
Suicidal Behavior in Latency-Age Children 687

(3%)who thought of suicide, 3 fathers (5%)who attempted suicide,

and 1 father (2%)who committed suicide.
Concept of Death
T h e suicidal children were significantly more preoccupied with
thoughts about death than the nonsuicidal children (t = 1.2, p <
.O 1). In addition, preoccupation with death correlated significantly
with the degree of dangerousness of suicidal behavior (t = .40, p <
.01). T h e suicidal children more often worried about people in
their family dying (t = 2.38, p < .05). Furthermore, suicidal chil-
dren were more extremely upset by the death of someone they
considered important to them (t = 2.38, p < .05).
T h e belief that death is a pleasant state correlated significantly
with the degree of dangerousness of suicidal behavior (r = .32, p <
.05). Finally, suicidal children differed from nonsuicidal children
in their concept that death is temporary (t = 2.58, p < .Ol).
Ego Functioning
There were no specific characteristics of ego functioning that dis-
tinguished between the suicidal and nonsuicidal children. Notewor-
thy is the fact that the entire group of children demonstrated mul-
tiple deficits in ego functioning.
T h e mean full-scale IQ was within the dull-normal range for the
entire population (88.15 for suicidal children and 84.15 for
nonsuicidal children). Seventy-five percent of the suicidal and 82%
of the nonsuicidal children tested below grade level in school
achievement tests. In addition to learning disabilities resulting
from such deficits as perceptual-motor functioning, memory, and
language disabilities, school achievement was diminished by the in-
trusion of worries about peer relationships and school perfor-
mance. For example, 48% of the suicidal children and 19%of the
nonsuicidal children chronically worried about doing poorly in
school. This finding significantly discriminated between the sui-
cidal and nonsuicidal children (t = 2.01, p < .Ol).
T h e data indicated that both suicidal and nonsuicidal children
exhibited poor impulse control. They were unable to tolerate frus-
tration, unable to delay actions, unable to tolerate deprivation, and
unable to plan for the future. Characteristically, they were de-
manding and when their desires were not fulfilled, they displayed
intense rage. At other times, when satisfied, they related affection-
ately and clung to empathic adults. As a result, the children exhib-
688 Cynthia R . Pfefler et al.

ited frequent, sudden shifts in a variety of affects ranging from an-

ger, depression, anxiety, passivity, to cheerfulness. In addition,
there tended to be an association between less serious suicidal be-
havior and the ability to display appropriate affect. For example,
the children who could utilize their relationships with other people
who provided an external ego support manifested a diminished
tendency to acting-out behavior.
Denial, projection, introjection, repression, and displacement
were defenses commonly found in this population. However, in-
tellectualization, undoing, and reaction formation were infre-
quently utilized defense mechanisms. Defense profiles were not
significantly different for the suicidal and nonsuicidal children.
Under the stress of internal drive expression, traumatic memories,
and extreme environmental stimulation, the brittle ego functioning
of children in both groups was prone to decompensate easily. T h e
resulting direct expression of drives eventuated in acting-out be-
havior.

DISCUSSION

This study has systematically delineated multiple factors that are

associated with high risk for suicidal behavior in latency-age chil-
dren. Such risk variables may be thought of as belonging to two
categories. First, there are factors probably associated with severe
childhood psychopathology in general. Second, there are specific
variables that sign’ificantly distinguish between suicidal and
nonsuicidal children. T h e presence of these specific variables in-
creases a child’s potential for suicidal behavior. These two catego-
ries of risk variables are presented in table 6.
Among the factors associated with severe psychopathology
are extreme environmental stress involving underachievement at
school, disturbed peer relationships, markedly aggressive behavior,
inconsistent child-rearing patterns, and severe parental psycho-
pathology. Chronic environmental traumas of deprivation, family
disorganization, separations, displays of violence, and overt sexual
encounters influence the course of ego development of the child.
T h e resultant effects include multiple deficits in ego functioning
and the evolution of a fragile defense system that is vulnerable to
decompensation. T h e children experienced intense feelings of
frustration and their states of extreme rage were marginally main-
tained under control. They viewed the world as hostile, ungiving,
Suicidal Behavior in Latency-Age Children 689

Table 6
Risk Factors for Suicidal Behavior of Latency-Age Children

A. Specific Factors Significantly Correlating with Suicidal Behavior

Depression
Hopelessness
Worthlessness
Wish to die
Severe depression in mother
Depression and suicidal behavior in parents
Preoccupations with death
Concept that death is temporary
Concept that death is pleasant

B. Factors Associated with Severe Psychopathology

Severe anxiety
Severe aggression
Preoccupations about school failure
Learning disabilities
Fear of parental punishment
Parental separations
Abusive home atmosphere
Disturbed peer relationships
Multiple deficits in ego functioning

lacking in empathy, and obviously devoid of adequate perception

of their developmental needs. Such experiences excited both the
child’s feelings of being blamed for family turmoil and vivid
thoughts of not being wanted. Often, both suicidal and homicidal
impulses were expressed. T o defend against this rage, the children
denied, projected, and displaced hostile feelings onto others.
Splitting mechanisms protected the child’s image of the “good par-
ent” and promoted the realization of the wish for affection.
The children in this population were often involved in intense
symbioticlike relationships with their parents, who expected that
their children would be omnipotent caretakers who could provide
them with inappropriate libidinal gratification. The parents, lack-
ing objective understanding of the autonomy of their children,
projected their own feelings onto their children. For example, one
mother related that she often doubted her daughter’s intentions
“because of the way she looked or because of the sound of her
voice.” Another mother, unable to set appropriate limits for hei-
son and to discipline him, said, “I never hit him. I only allow him
to hit me when he is angry.” A third example is of a mother who
could not differentiate between her own needs and those of her
daughter. This mother, frequently sick with severe asthma attacks,
690 Cynthia R . Pfeffer et al.

kept her daughter out of school for 90 days in one year and forced
her daughter to stay in the house to care for her.
Such parental qualities may promote the development and repe-
tition of similar characteristics in the children. Intense outbursts of
impulses, rapid and frequent shifts in affects, low self-esteem, and
disturbed object relations were qualities commonly noted in this
population of children. They were constantly in search of empathic
relationships and responded hopefully to supportive adults. How-
ever, the children were sensitive to being easily rejected and aban-
doned, and they lacked a firm concept that people were predict-
able and trustworthy. Furthermore, believing that they had omni-
potent powers, the children sometimes attempted to control others
by means of suicidal behavior. However, because the children also
feared the consequences of their behavior, they sought to be
controlled by seemingly omnipotent but empathic adults.
Table 6 also lists specific high-risk variables for childhood sui-
cidal behavior, which include sadness or depression, hopelessness,
worthlessness, and statements of the wish to die. Suicidal behavior
and depression among the parents were specifically correlated
with childhood suicidal behavior. This finding lends support to
the value of further investigating the nature of the parent-child in-
teraction. A. Freud (1963) mentioned “that depressive moods of
the mother during the first two years after birth create in the child
a tendency to depression . . . such infants achieve their sense of
unity and harmony with the depressed mother not by means of
their developmental achievements but by producing the mother’s
mood in themselves” (p. 264). As a corollary, one may hypothesize
that the identification with the sadistic punitive parental feelings
may create the channeling of hostile impulses onto the self, with
one outcome being self-destructive behavior.
Perception and identification with other parental traits may also
be internalized as self-images. States of hopelessness and worth-
lessness may increase the vulnerability to suicidal behavior. In addi-
tion, the relatively frequent incidence of suicidal behavior in the
parents provides a cognitive awareness and experience with threats
of death, either real or fantasized. Identification with parent fan-
tasies of death may add to the potential for suicidal behavior.
Death viewed as pleasant and temporary serves as an immediate so-
lution to feelings of despair and deprivation. Chronic depression
and anxiety may be defended against by denial and the fantasy of
being somewhere else.
Suicidal Behavior in Latency-Age Children 69 1

Implications
Many of the risk variables described in this study are similar to
those commonly recognized for adolescents and adults. T h e assess-
ment of risk for suicidal behavior should therefore become a rou-
tine aspect of the psychiatric evaluation of children. Questions
about preoccupations with death and self-destructive behavior
should be included in the mental status of children.
Evaluation of learning disabilities, assessment of appropriate
school planning, and educational remediation are important as-
pects of the interventions for potentially suicidal children.
T h e high percentage of suicidal children in this hospitalized
population also implies that treatment should focus on an intensive
long-term intervention approach. Mattsson et al. (1969) remarked
that “the child with suicidal behavior was rather consistently judged
as more in need of inpatient and long term aftercare than the
nonsuicidal child” (p. 106).
Finally, this study has established that suicidal behavior is one of
the most common symptoms among severely disturbed latency-
age children. Although this investigation may lend support to
Ackerly’s ( 1967) assumption that children with suicidal behavior
have “severe emotional disturbances,” additional studies of popula-
tions of less disturbed children are needed to determine if suicidal
behavior is only associated with severe psychopathology.

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