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ASKING ABOUT SUICIDE IN CHILD ABUSE CASES
LETTERS TO THE EDITOR
ASKING ABOUT SUICIDE IN CHILD ABUSE CASES To the Editor:
The response of Jacobsen et al. to my previous letter [about maltreatment and prepubertal suicide] (Krugman, 1994) magnifies the problem and does little to contribute to the solution. In my opinion, their response illustrates the relative professional vacuum that exists in the field of psychiatry with regard to the problem of child abuse and neglect. They state that their review (jacobsen et aI., 1994) was "illustrative, not exhaustive" and, in their letter, but not in the article, cite recently published reviews in the pediatric and child abuse literature that would be helpful. Most of use who work in the field are familiar with these reviews-the point is that trainees and practitioners in child psychiatry probably are not and should at least be helped to incorporate maltreatment into a differential diagnosis. Of greater concern, Jacobsen et al. argue that one reason they did not discuss the relationship between child maltreatment and prepubertal suicide is that, in contrast to the situation with adolescents and adults, there are not enough data on prepubertal children to be able to know whether the link exists in this age group as well. How tautological can one get? If the leading researchers in the field of suicide in prepubertal children don't ask the questions-directly or indirectly-how will we ever have data? Richard D. Krugman, M.D. University of Colorado Health Sciences Center Denver, CO Jacobsen LK, Rabinowitz I, Popper MS, Solomon RJ, Sokol MS, Pfeffer CR (1994), Interviewing prepubertal children about suicidal ideation and behavior. JAm Acad Child Adolesc Psychiatry 33:439--452 Krugman RD (1994) , Is abuse a risk factor for suicide? (letter). JAm Acad Child Adolesc Psychiatry 33:1208-1209
To the Editor:
The article by Jacobsen et aI. (1994) refers in the literature to the role of parents in evaluating suicidal ideation and behavior in children. The studies report, "The failure of parents to report suicidal ideation or behavior reported by their children was interpreted as a lack of awareness of these symptoms on the part of the parents." My clinical experience suggests that, in many cases, another factor is operative here. On one level or another of awareness, parents of suicidal children are often desirous of the suicide of the children. The lower the level of functioning of the child, the greater the likelihood exists that the child
700
is acting out a relatively overtly expressed death wish on the part of the parents toward the child. Such death wishes may be expressed as, "I wish you were dead," or "I am sorry you were ever born." At a higher age level, one of the rarer phenomena in outpatient child psychotherapy is for a child referred after a suicide attempt to remain in treatment until agreed-upon goals are achieved. This is in contrast to the 15% who usually stay in treatment until agreed-upon goals are reached. At a somewhat older age, that is, among hospitalized adolescents, the percept of a suicide attempt, carrying out (in the child's mind) the death wishes of the parents, appears with a high degree of consistency. Any end behavior such as suicide has a variety of complex causes such as manipulative attempts, accidental overdoses, reunion with dead loved ones, severe depression, idiosyncratic psychotic ideation ofpunishing those left behind, etc. Among the many causes of actual suicide attempts in children, some of which are ultimately successful, my experience has been that the percept that the parent wishes the child dead (in the child's mind) is the most common. Thus, the child separates and attaches simultaneously. The implications for this are clear. Without threatening the parents by presenting this percept to them directly, work must be done with the parents separately from the child to address such feelings within the parent, should such feelings exist. During the initial interviewing of the parents, the therapist must always keep in mind that this possibiliry exists as a motivation for child and adolescent suicide attempters. With such confirmed, the ongoing treatment of the parent concurrently with the child becomes essential for reasonable resolution of those cases that can be successfully addressed psychotherapeutically. Potential environmental triggers often can be elicited during an interview, whether verbally or through projective psychological testing, to determine what environmental events are likely to trigger suicidal behavior within the child or adolescent. Awareness of these triggers in those nonpsychotic children, where such a response is usually predictable, can then allow the therapist to feelmore comfortable in cueing both professionals and parents when to be aware of the periods of greatest danger. With such awareness, the comfort of the therapist increases, and treatment is likely to proceed more successfully. Richard S. Greenbaum, Ph.D. University of Miami School of Medicine Miami , FL Jacobsen LK, Rabinowitz I, Popper MS, Solomon R], Sokol MS, Pfeffer CR (1994), Interviewing prepubertal children about suicidal ideation and behavior. JAm Acad Child Ado/esc Psychiatry 33:439-452
J. AM. ACAD . CHILD ADOLESC. PSYCHIATRY, 34 :6. JUNE 1995
ASKING ABOUT SUICIDE IN CHILD ABUSE CASES To the Editor:
The response of Jacobsen et al. to my previous letter [about maltreatment and prepubertal suicide] (Krugman, 1994) magnifies the problem and does little to contribute to the solution. In my opinion, their response illustrates the relative professional vacuum that exists in the field of psychiatry with regard to the problem of child abuse and neglect. They state that their review (jacobsen et aI., 1994) was "illustrative, not exhaustive" and, in their letter, but not in the article, cite recently published reviews in the pediatric and child abuse literature that would be helpful. Most of use who work in the field are familiar with these reviews-the point is that trainees and practitioners in child psychiatry probably are not and should at least be helped to incorporate maltreatment into a differential diagnosis. Of greater concern, Jacobsen et al. argue that one reason they did not discuss the relationship between child maltreatment and prepubertal suicide is that, in contrast to the situation with adolescents and adults, there are not enough data on prepubertal children to be able to know whether the link exists in this age group as well. How tautological can one get? If the leading researchers in the field of suicide in prepubertal children don't ask the questions-directly or indirectly-how will we ever have data? Richard D. Krugman, M.D. University of Colorado Health Sciences Center Denver, CO Jacobsen LK, Rabinowitz I, Popper MS, Solomon RJ, Sokol MS, Pfeffer CR (1994), Interviewing prepubertal children about suicidal ideation and behavior. JAm Acad Child Adolesc Psychiatry 33:439--452 Krugman RD (1994) , Is abuse a risk factor for suicide? (letter). JAm Acad Child Adolesc Psychiatry 33:1208-1209
To the Editor:
The article by Jacobsen et aI. (1994) refers in the literature to the role of parents in evaluating suicidal ideation and behavior in children. The studies report, "The failure of parents to report suicidal ideation or behavior reported by their children was interpreted as a lack of awareness of these symptoms on the part of the parents." My clinical experience suggests that, in many cases, another factor is operative here. On one level or another of awareness, parents of suicidal children are often desirous of the suicide of the children. The lower the level of functioning of the child, the greater the likelihood exists that the child
700
is acting out a relatively overtly expressed death wish on the part of the parents toward the child. Such death wishes may be expressed as, "I wish you were dead," or "I am sorry you were ever born." At a higher age level, one of the rarer phenomena in outpatient child psychotherapy is for a child referred after a suicide attempt to remain in treatment until agreed-upon goals are achieved. This is in contrast to the 15% who usually stay in treatment until agreed-upon goals are reached. At a somewhat older age, that is, among hospitalized adolescents, the percept of a suicide attempt, carrying out (in the child's mind) the death wishes of the parents, appears with a high degree of consistency. Any end behavior such as suicide has a variety of complex causes such as manipulative attempts, accidental overdoses, reunion with dead loved ones, severe depression, idiosyncratic psychotic ideation ofpunishing those left behind, etc. Among the many causes of actual suicide attempts in children, some of which are ultimately successful, my experience has been that the percept that the parent wishes the child dead (in the child's mind) is the most common. Thus, the child separates and attaches simultaneously. The implications for this are clear. Without threatening the parents by presenting this percept to them directly, work must be done with the parents separately from the child to address such feelings within the parent, should such feelings exist. During the initial interviewing of the parents, the therapist must always keep in mind that this possibiliry exists as a motivation for child and adolescent suicide attempters. With such confirmed, the ongoing treatment of the parent concurrently with the child becomes essential for reasonable resolution of those cases that can be successfully addressed psychotherapeutically. Potential environmental triggers often can be elicited during an interview, whether verbally or through projective psychological testing, to determine what environmental events are likely to trigger suicidal behavior within the child or adolescent. Awareness of these triggers in those nonpsychotic children, where such a response is usually predictable, can then allow the therapist to feelmore comfortable in cueing both professionals and parents when to be aware of the periods of greatest danger. With such awareness, the comfort of the therapist increases, and treatment is likely to proceed more successfully. Richard S. Greenbaum, Ph.D. University of Miami School of Medicine Miami , FL Jacobsen LK, Rabinowitz I, Popper MS, Solomon R], Sokol MS, Pfeffer CR (1994), Interviewing prepubertal children about suicidal ideation and behavior. JAm Acad Child Ado/esc Psychiatry 33:439-452
J. AM. ACAD . CHILD ADOLESC. PSYCHIATRY, 34 :6. JUNE 1995