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CASE REPORT |
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| Ahead of print
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| An attempt of lethal self-harm in a 7-year-old child |
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Sharanya Vijayakumar1, Smitha Ramadas2
1 Former Senior Resident, Department of Psychiatry, Government Medical College, Thrissur, Kerala, India
2 Additional Professor, Department of Psychiatry, Government Medical College, Thrissur, Kerala, India
Click here for correspondence address and email
| Date of Submission | 02-May-2022 |
| Date of Acceptance | 15-Jun-2022 |
| Date of Web Publication | 20-Jul-2022 |
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Suicidal behavior in young children is inadequately studied due to methodological limitations, although there is an increasing trend of suicidal behavior among youngsters. Here, we report the case of a lethal act of self-harm by a 7-year-old child. On evaluation, the child was detected to have attention-deficit/hyperactivity disorder and oppositional defiant disorder. He attempted hanging after a trivial altercation with mother and was nearly strangulated. He had learned the method from visual media and did the act impulsively. There was history of suicides in the family. Pharmacological and psychosocial interventions were done and the child was followed up for almost 1 year. There was good resolution of the symptoms and the family interaction pattern improved. This case highlights that, suicide threats even in very young children need to be urgently and sensitively handled, from a biopsychosocial perspective. The media influence on suicide on young children needs to be addressed urgently.
Keywords: Attempt, child, suicide
| Introduction | |  |
Although deaths due to suicide are increasing among children and adolescents, there is little exploration into child suicidal behavior.[1] Research on acute suicidal behavior has many practical and ethical concerns.[2] The narrative of a child who has survived a lethal suicide attempt gives us insights into child suicidal behavior. Visual media influence on child suicidal behavior also needs due consideration. Here, we report the case of a lethal suicide attempt by a child.
| Case Report | | |
A 7-year-old boy, studying in class two, from middle socioeconomic status, was brought by parents for a consultation to the psychiatry outpatient services of a tertiary care teaching hospital in Kerala, after a suicide attempt 2 weeks ago. The history is as follows. One day following an altercation with his mother and sister, he suddenly went to the bedroom, climbed over a stool, wound around his neck a wire that was hanging from the ceiling, and jumped from the stool. He instantly got strangulated and cried for help. His sister rushed into the room, to find him hanging and unconscious. She rescued him and rushed him to the hospital. He regained full consciousness after about 15 min. On enquiring into the details, he told the doctor that he “attempted suicide” (in vernacular language) because he felt nobody wanted him or loved him. This alarmed his family, and they sought psychiatric consultation. He was the younger among two children, born of full-term delivery, and developmental milestones were normal. His sister was older than him by about 10 years. Since a toddler, he used to be unusually hyperactive for his age, would often lose temper, become aggressive, and was occasionally spiteful. He was also impulsive. He had a difficult temperament. On three occasions, following intense anger, he had walked out of home into the neighborhood. He would either be brought back by parents or would stand helplessly crying. The impulsive and defiant behavior continued, and recently after quarrels, he was expressing threats of self-harm; but the family ignored it and never sought professional help. There was no history of depressive, anxiety, or manic symptoms in the child. His scholastic performance was above average and he was reported to be hyperactive in school. He lived with his mother. His father was employed overseas and his sister was studying away from home. The mother's parenting was of permissive type. She yielded to most of the child's demands, with poor limit setting, to avoid conflicts at home. There was history of suicide with filicide in paternal grandmother and suicide in paternal grandmother's sister. Paternal grandfather was dependent on alcohol. The child's father reported that he also had several suicidal impulses following interpersonal issues, which he learned to overcome and therefore could empathize with the child.
On examination, the child appeared small for his age. He was cooperative and rapport could be established, effortlessly. He was hyperactive, and mood was cheerful. On interviewing, the child revealed that he attempted the act with the “wish to die,” to “scare his family.” He said that he learned about the method from cinemas on television. On exploring, he did not have a deep concept of death and suicide. He now regretted the act which he said had been done in a sudden fit of rage. Serum thyroid profile and blood hemoglobin levels were normal. He was diagnosed with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), as per DSM 5 diagnostic criteria. Vanderbilt ADHD Diagnostic Parent Rating Scale was administered, which indicated a predominately hyperactive/impulsive subtype of ADHD. Psychosocial interventions were planned. The parents were psychoeducated and parent management training was given to the mother. Therapeutic alliance was established with the child and anger management skills were imparted to him. The child was also started on tablet methylphenidate (5 mg/day). On follow up, there was considerable improvement in his functioning. His impulsivity and anger outbursts decreased, and mother's parenting skills also improved. He was followed up for almost a year and no suicidal ideas were expressed subsequently.
| Discussion | | |
The case highlights the importance of handling sensitively and seriously threats of self-harm expressed even by a young child who may not have developed an abstract concept of death and its meaning, being in the “stage of concrete operations.”[3] Nevertheless, contrary to popular notions, suicidal cognitions and behaviors are expressed by very young children and they act as a significant risk factor for subsequent suicidal behaviors.[4],[5] This narrative points to the need for considering a multidimensional view of suicide - the genetics, biomedical diagnoses (ADHD and ODD), and social and environmental factors (maladaptive parenting, ignorance to seek timely professional help, and media influence). The media influence of suicide on vulnerable individuals and suicide capability[6] are also factors which result in the culmination of even a vague suicidal ideation into an act, by copycat effect.[7] This is especially relevant in a state like Kerala where the suicide rates are consistently high. Even young children without a clear concept of death and suicide are affected by the visual media portrayal of suicide. Often media and society exaggerate the proximal triggers and ignore the distal factors which lead to suicide. Such an oversimplification may prevent the public from considering that a person expressing suicidal ideas needs comprehensive professional evaluation and intervention. Psychological autopsy studies may also be biased by such prevailing beliefs.
We need to routinely assess suicide risk sensitively even in young children with externalizing disorders. Visual and mass media need to follow suicide reporting guidelines stringently to prevent influencing a vulnerable population. Parents and teachers need to be educated regarding the role of timely mental health interventions in children who express suicidal ideas, rather than dismissing them as age inappropriate. Death by suicide may happen in children who may not have the intent and who do not understand the lethality, by copycat effect.[5] The child was saved from a lethal attempt fortuitously, and the narrative of the child and exploration of the interplay of the proximal and distal factors provide some insight into childhood suicidal behavior. This can inform culturally relevant suicide prevention research and practice in children. Assent from the child and informed consent from the father were taken.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for patient clinical information to be reported in the journal. The guardian understands that patient names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Ayer L, Colpe L, Pearson J, Rooney M, Murphy E. Advancing research in child suicide: A call to action. J Am Acad Child Adolesc Psychiatry 2020;59:1028-35.  |
| 2. | Nugent AC, Ballard ED, Park LT, Zarate CA Jr. Research on the pathophysiology, treatment, and prevention of suicide: Practical and ethical issues. BMC Psychiatry 2019;19:332. |
| 3. | Koocher GP. Childhood, death, and cognitive development. Dev Psychol 1973;9:369. |
| 4. | Zeanah CH, Gleason MM. Suicidality in very young children. J Am Acad Child Adolesc Psychiatry 2015;54:884-5. |
| 5. | Whalen DJ, Dixon-Gordon K, Belden AC, Barch D, Luby JL. Correlates and consequences of suicidal cognitions and behaviors in children ages 3 to 7 years. J Am Acad Child Adolesc Psychiatry 2015;54:926-37.e2. |
| 6. | May AM, Victor SE. From ideation to action: Recent advances in understanding suicide capability. Curr Opin Psychol 2018;22:1-6. |
| 7. | Ramadas S, Kuttichira P, John CJ, Isaac M, Kallivayalil RA, Sharma I, et al. Position statement and guideline on media coverage of suicide. Indian J Psychiatry 2014;56:107-10. [ PUBMED] [Full text] |
Correspondence Address:
Smitha Ramadas,
Sayujyam, Kottekad Road, Viyyur P. O., Thrissur - 680 010, Kerala
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_71_22
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