Understanding of death and related constructs in children with suicidal thoughts and behaviors: A review and future directions

Abstract

Despite rising rates of suicidal thoughts and behaviors in children, little is known about best practices for conducting suicide risk assessments in this population. The acquisition of the concept of death occurs during childhood, and thoughts and preoccupation with death can be developmentally normative. This review highlights a critical gap in knowledge about how children with suicide ideation understand death—a foundational issue in assessing suicide risk. First, we provide an overview of studies that examined the concept of death and related constructs (e.g., preoccupation with death) among children who experienced suicidal ideation or attempted suicide, many of which date back to the 1970s and ’80s. We describe indirect methods of assessing death cognitions, such as the Death Implicit Association Test, representations of death/suicidal themes in play, and the role of exposure to these themes through screens (e.g., social media, videogames). Given the potential impact of sociocultural changes since the 1970s–1980s on how children understand death, gaining a contemporary perspective on how children think about death and its relationship to suicide risk is warranted. Guided by a developmental approach, we provide recommendations for future areas of research to advance this field and inform the design of developmentally appropriate risk assessments and interventions for children.

Plain language summary

The concept of death among children who experience suicide ideation or attempt suicide: The development of the concept of death takes place in childhood and entails the understanding of five dimensions: inevitability, universality, irreversibility or finality of death, cessation, and causality. Historically, some researchers and clinicians have argued that without understanding the concept of death, children could not think about or attempt suicide. This idea has been discarded, yet evidence to contradict this statement is lacking. We conducted a review of studies examining the concept of death and related constructs among children who experience suicide ideation or attempt suicide. Most studies on this topic were conducted in the 1970s and 1980s and suggested that children who think about or attempt suicide may have a distorted concept of death, often making more references to the afterlife and resurrection than children without these behaviors. They tend to describe death as more pleasant and less permanent, report a greater preoccupation with death, and endorse more violent ways of dying. Societal changes since these studies were conducted may have influenced how children now conceptualize death. Gaining an updated perspective on how children think about death and its relationship to suicide risk can help clinicians assess the severity of suicidal thoughts and behaviors and make recommendations for care. Guided by a developmental approach, we provide a critical review of prior studies, discuss alternative ways to assess death constructs (e.g., implicit identification with death, representations of death and suicidal themes in play), consider exposure to death-related themes through screens (e.g., social media, videogames), and propose new research directions to advance the field. We believe these contributions will aid in designing developmentally appropriate risk assessments and interventions for children.