The suicides of under-16-year-olds in our study had many similarities with the suicides of older adolescents, as described in the research literature. External circumstances hardly differed, but the younger ones presented fewer risk factors and less known intent. The suicide index, constructed for this study to assess potential mislabeling of suicides as accidents, and vice versa, distinguished effectively between the two groups. The extent of mislabeling was small in our sample.
The suicides
The overrepresentation of boys (71%) in the suicide group is in accordance with studies in other Western countries[3, 19, 20] but in contrast to Turkey[21], where 71% of suicide victims 15 years and younger were female. Likewise, Chinese suicide victims have a female-to-male ratio close to 1.0[22]. The explanation as to why boys as well as men commit suicide more often than females is complex and poorly understood. The possible link to high testosterone levels, associated with a higher degree of aggression towards others or self, has been investigated by Perez-Rodriguez[23]. He found no support for the putative role of high testosterone levels as a biological marker of suicidal behavior among adult males. Like Perez-Rodriguez, we found no overrepresentation of aggressive or temperamental personality traits among the male suicide victims. Aggression, a risk factor to suicide, is associated with low CSF 5-HIAA in children and adolescents[24]. However, we had no information on level of testosterone or CSF-5-HIAA.
Like Beautrais and Shaw[10, 20], we found that a greater proportion of suicides (60%) took place in the family residence or in the garage used daily by the parents. This has also been found previously in adolescents under the age of 19[25].
The suicides in our study occurred most frequently during the work week, in the afternoon, after school and before the parents were expected home from work, a time of day children often will be on their own. This is in contrast to the findings of Beautrais[10], who found that suicides tended to take place while family members were present in the house or on the property. The time of day of committing suicide in our sample may reveal intentions to die because these children were likely alone and would not be disturbed. The time and location chosen would secure quick discovery by someone dear. On the other hand, the same circumstances could also be an expression of ambivalence, because it includes the possibility of being rescued.
There are few studies on the seasonality of youth suicides, and the findings are inconclusive. In our sample the suicides occurred more often in the dark season, in line with McCleary who found an unimodal seasonality peak in fall/winter for young males[26], whereas Goren found no seasonal differences[21], and Dervic found the greater number of suicides during April, May, October, and November[19].
The altered behavior observed prior to suicide in 67% of the suicide victims may indicate that the decision to commit suicide had been reached and presented some type of relief. In suicidology, this phenomenon is known among adult victims; however, it is rarely mentioned in the literature on children and adolescents[4].
Risk factors
Mental health
We found 20% of our suicide victims had diagnosable mental disorders, which is relatively low. Psychological autopsy studies in the United States of adolescents under 16 and 17 years of age[1, 7] showed a higher prevalence of psychiatric disorders, 60% and 83%, respectively, although lower prevalence than studies that included 15-20-year-olds[7, 27]. These studies of 15-20-year-olds showed more than a 90% prevalence rate of psychiatric disorders. The lower prevalence of psychiatric disorders in children compared to older adolescents is an important factor in explaining the lower rates of suicide in children under 16 years of age[1].
Depressive disorder, specifically, was found in only 10% of our sample, whereas Brent[1] found a mood disorder in 43% of his sample in an autopsy study of under-16-year-olds, and Grøholt[3] identified 29% in under-15-year-olds in her investigation of official records. We should note that there are studies that suggest Norwegian parents may tend to underreport emotional disorders in their children[28], which may be an explanation to the low numbers in this autopsy study. The time span between the child’s death and the interview period may also have increased the parents’ tendency not to report depression. International studies show that depression has a higher prevalence in older adolescents[20, 27, 29]. In his recent study, Gibbons[30] found that when clinical depression is present, the severity of the depression in youths is strongly related to suicide risk. However, while antidepressant medication can reduce depression severity, he found that it had no effect on suicide risk. Thus, an important task is to identify different types of psychopathology, aggressive impulsive traits and other factors contributing to suicide among children.
Conflicts
One third of our suicide victims had been bullied. Klomek found an association between frequent bullying at age eight and later suicide attempts and completed suicides up to age 25 and that the later suicidal behavior varied by sex[31]. Kaltiala-Heino found that suicidal ideation was more common among 14–16 –year-olds who were involved in bullying[32]. Still, the association between bullying and completed suicide is not yet fully understood.
A conflict with parents, school, peers or authorities is thought to be a stressor contributing to suicide, and this was indeed found in 60% of our sample. This is in line with the autopsy-findings of Brent[1], which identified 51% of suicide victims who had experienced parent–child conflict. In her review of coroners’ files of children less than 15 years old, Beautrais[10] estimated that 71% had been in trouble that was considered to be a precipitant to suicide. However, conflicts and stressors described in autopsy studies are often categorized differently, and the age groups included vary. Hence, the results are difficult to compare[1, 33, 34]. Conflict with parents is most often described in young victims, whereas boy/girlfriend conflicts and disruption of romantic relationships are more often cited in older adolescent suicide victims[1].
We found a brief conflict-suicide interval in our data, most often within hours. This is in accordance with Shaffer’s findings[35], although he did not define “brief”. Marttunen[34] found that in older adolescents, all conflicts considered precipitants had occurred within a week preceding the suicide. Greydanus[36] suggested that the mental immaturity of children may contribute to their fate. That is, when faced with a major life crisis, from their point of view, suicide may become an immediate option as a solution to their overwhelming problems. Our study supports this assumption.
Loss
Broken relationships and interpersonal losses leaving a marked emotional footprint were experienced by 50% of the suicide victims in our study. Likewise, Gould[33] found that 54% had an experience of loss in her autopsy of suicides in a sample of victims younger than 20 years of age. She defined loss as the death of a relative or friend, disruption of a relationship or a recent separation, much like our definition but without specifying whether pets were involved. Loss and conflict were experienced significantly less often by the accident victims than suicide victims, which gives us reason to believe that both factors might have contributed to suicide. Variability in labeling and in definitions of loss makes comparisons difficult, both across autopsy and non-autopsy studies[3, 10, 34].
History of suicide in the victim’s environment
Over 40% of our sample had experienced suicide previously, either in the family or in the local community. This finding is partially supported by Beautrais[10], who examined coronial files of 61 suicides of youths younger than 15 years of age and found that 15% had experienced a recent death in family, while 10% had a history of suicide in a parent, sibling or cousin. In our study, we included suicide in the local community, which may explain why our numbers are higher. Qin and Runeson, among others, found that suicide in family members are associated with suicide, and Brent and Wender found a familial link between suicide and impulsive aggression[37–40]. However, in our sample of suicide victims, only two had experienced suicide in the family, whereas 16 had experienced suicide in the local community, among peers or neighbors. Mercy[41] found no evidence of prior exposure to others’ suicidal behavior being a risk factor for nearly lethal suicide attempts among children and young adults. Knowledge about the suicide of a respected family member, a peer or neighbor, may induce an acceptance of suicide, and combined with a possible inadequate understanding of the meaning of suicide and death[9, 42–44] may give the youth fewer objections to such an action.
Possible mislabeling
One of the goals of this paper was to look for the possible mislabeling of suicides and accidents. In addition to the factors included in the suicide index, we examined suicide notes (diaries, essays) indicating some type of suicidal planning, school attendance on the day of the suicide, altered behavior prior to the suicide and probable grade of impulsiveness.
None of the accidents gave any indications of being actual suicides that had been mislabeled. In the one accidental strangulation, the parents did express some uncertainty, but after evaluating the case and using all available information, the labeling as accident seemed correct.
None of the 31 suicides having a high suicide index (above 3) showed any indication that they had been accidents that were mislabeled, although the parents were doubtful in five of these cases. In one of those five instances, the information was too incomplete for a sufficiently comprehensive evaluation. Of the 11 suicides with a low risk-load on the suicide index, there was one shooting incident that was ambiguous as to whether it was an accident or a true suicide. Most indications suggested that the four strangulations in which the victims were found fully suspended were suicides. Three of those appeared well planned, while the fourth was most likely an impulsive act. One of the strangulation victims who was sitting down had left an undated note that bequeathed his assets. The two who were in trouble with their parents at the time showed high degrees of impulsiveness, making their parents assume that their child had intended to scare rather than to die; consequently, a labeling of uncertain could have been considered. The fourth showed all the signs of being an accident, reflecting the conclusion of the police report: the boy strangulated himself while he was waiting for his friend. Thus, in three strangulation cases the labeling could be questioned, and the labeling of suicides in the age group 11–15 in the Norwegian statistics, as represented in our material, seems to be closer to an overestimation rather than an underestimation, whereas none of the accidents gave any suspicion of incorrect labeling.
We know asphyxiation games have been played by individuals for generations[11]. These games are defined as self-strangulation or strangulation by another person for the purpose of achieving a brief euphoric state caused by cerebral hypoxia[45], without using drugs and not necessarily in a sexual context. In our dataset, we had two similar cases of strangulation, one labeled an accident and the other a suicide by SSB. Both were boys, alone in their room, sitting and leaned forward on their knees, with a noose around the neck, suffocated. Katz[46] preferred to call it “strangulation activity”, to indicate the potential danger of the game. Another question is how well does a child or an adolescent understand that strangulation can be lethal even with feet on solid ground.
Assessing grade of intent involves the rating of many aspects of the suicide, including the method, the understanding of the method’s lethality, location of the suicide, the risk of being interrupted during the act, the behavior prior to suicide, suicide note and/or other preparations, suicidal preoccupation and suicide threats. In addition to one’s mental health status, prior suicide attempts, personality traits, and the ability to cope with daily life and its challenges are important factors. In our sample, a suicide note was found in 41% of cases. The presence of suicide notes varies according to the literature, ranging from 4%-37%[20]. Copeland[47] found that 52% of 13-19-year-olds in his study had left notes. The numbers may be higher, as we cannot be certain if notes had been removed prior to the arrival of authorities or if letters were found later and thus not registered.
Limitations
Psychological autopsies are always associated with recall bias. The respondent may tend to remember positive characteristics and forget the negative ones. Information may also be unreliable because the informant may be unaware of certain factors or may deliberately withhold information[48]. We achieved a low response rate of 45% in comparison with other autopsy studies that achieved closer to 70%[7, 49, 50]. This was a pervasive problem, making us cautious not to draw conclusions or generalize. In Table2, due to many comparisons, all results ≥0.03 must be interpreted with great caution, to avoid Type I errors.
There is also the question as to who chose to participate in this type of research, and do these people differ from those who chose not to participate. The answers to these questions could possibly reveal a skewed distribution of the participant parents. We investigated two groups of deceased 15-year-olds and younger, dead by very different causes, which most likely colored the parents’ information. Concerning the personality traits, the use of The Junior Temperament and Character Inventory[51] would have made comparison to other studies possible. The interviews should ideally have been conducted closer to the actual time of the deaths, and interviews with teachers and friends could have provided additional and richer information. We obtained significantly fewer police reports in the accident group, which may have influenced our findings. However, the police reports we did have, gave very little information beyond the information provided by the parents.
Ethical considerations
Asking parents to recall and talk about their deceased child, regardless of the cause of death, can be upsetting and can reactivate grief. We asked them to participate without being able to assure them that the data they provide will actually help prevent new deaths. However, we know from other similar studies that participation has commonly been perceived as a “positive” experience[52] and many of the interviewees seem to benefit from the interview[53].
