CME Author: Vicki Brower
Study Authors: Jason D. Jones, Rhonda C. Boyd, et al.
Target Audience and Goal Statement:
Child and adolescent psychiatrists and psychologists, social workers, pediatricians, family medicine specialists
The goal was to determine, using the largest sample to date, whether there was agreement or discrepancies between parent and adolescent reports of the latter’s suicidal thoughts in a community-based study, and to explore demographic and clinical factors associated with agreement.
- What is the level of agreement and discrepancy between parent and adolescent reports of adolescents’ suicidal thoughts?
- What are the demographic and clinical characteristics that may increase or decrease the risk of parental unawareness and adolescent denial of suicidal thoughts?
- Do the results of this study confirm findings in other similar, smaller studies? If not, to what might the discrepancies be attributed?
Study Synopsis and Perspective:
In order to determine agreement between parent and adolescent reports of adolescents’ suicidal ideation, researchers examined data from the Philadelphia Neurodevelopmental Cohort, a community-based sample of 5,137 adolescents, ages 11 to 17, with an average age of around 15. This adolescent population was “not enriched for individuals seeking psychiatric help,” the authors wrote.
Just over half of the adolescents were girls, and 57% were white, with 32% of child-parent pairs reporting being African American and 6% Hispanic or Latino. Individuals were excluded if they did not speak English, or had physical or cognitive conditions that interfered with participating in the study.
Jason Jones, PhD, of the Children’s Hospital of Philadelphia in Pennsylvania, and colleagues collected information about suicidal thoughts from both adolescents, and a “collateral informant” (mostly parents). Adolescents and parents who met study qualifications completed a GOASSESS interview designed to screen individuals for symptoms of major psychiatric disorders. Both were asked about lifetime suicidal ideation of the child, and a trained professional afterwards inquired about treatment histories regarding their psychopathology, family histories, and demographic information.
They found that the prevalence of adolescents who thought about killing themselves was 8% (413 adolescents), while about 15% (786 adolescents) had thoughts of death or dying. Three-quarters of their parents said that they were unaware of these thoughts in their children, Jones and colleagues reported in Pediatrics.
Researchers found moderate agreement for thoughts of suicide (k=0.466), and low agreement for thoughts of death or dying (k=0.171). Discrepancies stemmed from both parental unawareness of suicidal thoughts reported by adolescents, and adolescent denial of suicidal thoughts reported by parents. Fifty percent of parents were unaware of adolescents’ thoughts of suicide, and 65.6% of parents were unaware of adolescents’ recurring thoughts of death reported by parents. Certain demographic (age) and clinical characteristics (treatment history) tracked with agreement.
Older adolescents were associated with better agreement with their parents’ responses, but differences varied by sex. Parents of young girls were typically more unaware of their children’s suicidal or morbid thoughts than they were for older children, while the opposite was true for boys (parents became increasingly unaware of their sons’ thoughts of death the older the boys were). This is particularly important in light of recent evidence that deaths by suicide among younger adolescents have increased, the researchers wrote.
When parents said they believed their children had thoughts of suicide, about half of children said they didn’t, and two-thirds of those whose parents thought they were having thoughts of death denied it, Jones and colleagues reported.
The authors found that parents of minority children were more likely to be unaware of their children’s thoughts of death than parents of white children, although Hispanic or Latino ethnicity was associated with decreased odds of parental unawareness of thoughts of death, the authors wrote.
Adolescents who had a psychiatric history, and/or a family history of suicide had parents who were more aware of their childrens’ thoughts of suicide and thoughts of death. A history of psychiatric hospitalization was associated with decreased risk of adolescent denial of thoughts of suicide, the study found.
Fathers were more likely to be unaware that their children were having thoughts of killing themselves than mothers, the authors reported. If a child had previously undergone psychotherapy or had family histories of suicide, his or her parents were less likely to be unaware if their child considered suicide or had recurring thoughts of death, they wrote.
“Given the high prevalence of parental unawareness and adolescent denial of suicidal thoughts found in this study, it is possible that a large number of adolescents with suicide risk may not be detected by brief screens at routine check-ups,” the authors stated.
Source References: Pediatrics, Jan. 14, 2019; DOI: 10.1542/peds.2018-1771
Editorial: Pediatrics, Jan. 14, 2019; DOI: 10.1542/peds.2018-3071
Study Highlights: Explanation of Findings
Effective early identification of and intervention to prevent adolescent suicide depends on accurate assessment of suicide risk. The current study indicates that “there is a high prevalence of parental unawareness and adolescent denial of suicidal thoughts,” which means that there is a large number of adolescents at risk for suicide going undetected.
“These findings have important clinical implications for pediatric settings, including the need for a multi-informant approach to suicide screening and a personalized approach to assessment based on empirically derived risk factors for unawareness and denial,” the researchers wrote.
For the study, adolescents and parents who met study qualifications completed a GOASSESS interview designed to screen individuals for symptoms of major psychiatric disorders. Both were asked about lifetime suicidal ideation of the child, and a trained professional afterwards inquired about treatment histories regarding their psychopathology, family histories, and demographic information.
Trained interviewers asked adolescents the following two questions, which were also asked of the parents with regard to their children:
- “Have you ever thought about killing yourself?”
- “Have you ever thought a lot about death or dying?”
Researchers found moderate agreement for thoughts of suicide (k=0.466), and low agreement for thoughts of death or dying (k=0.171). Discrepancies stemmed from both parental unawareness of suicidal thoughts reported by adolescents, and adolescent denial of suicidal thoughts reported by parents. Fifty percent of parents were unaware of adolescents’ thoughts of suicide, and 65.6% of parents were unaware of adolescents’ recurring thoughts of death reported by parents.
In an accompanying editorial, Khyati Brahmbhatt, MD, and Jacqueline Grupp-Phelan, MPH, MD, both of the University of California San Francisco, noted that there could be multiple interpretations of the questions researchers asked participants, particularly, “Have you ever thought a lot about death or dying?” which may have affected the data published in this study, particularly for young children. They cited a 1998 study that found a “typology of adolescents’ most common explanations for discrepant reporting of suicidal behavior.”
Study researchers concluded that “evidence suggests that agreement between parent and adolescent reports of adolescents’ suicidal thoughts are poor and that this lack of agreements stems largely from parental unawareness of adolescents’ suicidal thoughts.
In a previous study, more than two-thirds of young people considering suicide reported not receiving mental healthcare, which may partially be due to the fact that their parents — who serve as “gatekeepers” for these services — are not aware that their child is having these thoughts, the authors wrote.
Researchers noted that this study found lower rates of suicidal ideation than in a national survey of youth (18%), possibly because the study included younger adolescents, whereas the national study was focused on high school students.
Providing access to mental health services is increasingly important since up to 40% of adolescents who consider suicide act on these thoughts, according to Brahmbhatt and Grupp-Phelan.
As a result, broad intervention methods “may not suffice in moving the needle on completed suicides.” Instead, preventative measures should be designed with risk factors such as impulsivity, substance use, or whether an individual has a plan for suicide in mind, the editorialists added.
The study authors wrote that their study “highlights the urgent need for continued training of pediatric primary care physicians in the evaluation and management of suicidal ideation and the importance of collecting information from multiple informants and rectifying discrepant reports.” They added that increased awareness should be paid to the demographic and clinical characteristics they found, which may increase or decrease the risk of parental unawareness and adolescent denial of suicidal thoughts.
Regarding possible study weaknesses, the authors noted that because this study focuses on a single center in one geographic area, the data may not be generalizable to larger populations. It could also be limited because the interviews conducted were relatively brief and the questions that were asked could be susceptible to recall bias, as well as misunderstanding, researchers reported. In addition, prevalence of suicidal ideation was lower than in a national survey of high school students, which the authors potentially attributed to the inclusion of younger adolescents in the study.
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco