Casenotes

Understanding the Relationship between Childhood Maltreatment and Suicidal Behaviors

Research aimed at identifying mechanisms that contribute to suicidal behavior among maltreated youth can inform the development of treatments targeting those mechanisms.

By Christine Cha

Suicide death accounts for 8.5 percent of all deaths among adolescents and young adults around the world (15-29 years) and is a leading cause of death among youth worldwide (WHO, 2017).  Existing research has found that approximately 19.8 percent and 24.0 percent of youth in the U.S. experience suicidal ideation (Nock, Borges, Bromet, Cha et al., 2008), and similar rates are found in other nations (e.g., Kokkevi, Rotsika, Arapaki, & Richardson, 2012).  These rates are concerning, especially since suicide is preventable.  Yet the understanding of factors associated with suicide risk is still limited in youth, with even less knowledge on how the risk may be similar or different for youth who experience maltreatment or abuse.    

In a recent review paper published in the Journal of Child Psychology and Psychiatry, we identified the patterns and gaps of existing knowledge on the literature on suicidal thoughts and behaviors among youth.  We found that the literature provides strong evidence indicating various forms of childhood maltreatment (i.e., sexual, physical, and emotional abuse) predict future suicidal ideation and suicide attempt among youth.  Childhood sexual abuse in particular has been identified as a strong risk factor for suicidal behaviors compared to other forms of childhood maltreatment and adversities (e.g., loss of a caregiver, family violence, parental psychopathology; Fergusson, Horwood, & Lynskey, 1996; Joiner et al., 2007; Molnar, Berkman, & Buka, 2001).  A history of childhood sexual abuse also affects the transmission of suicide risk from parents to offspring (Brent et al., 2002; Melham et al., 2007).

Additionally, prospective cohort studies and twin studies have demonstrated the unique impact of sexual abuse on suicide attempt and death among adolescents and young adults, independent of contextual factors such as parent and child characteristics and quality of family environment (e.g. Brown, Cohen, Johnson, & Smailes, 1999; Castellvı et al., 2017; Fergusson, Boden, & Horwood, 2008; Fergusson, Horwood, & Lynskey, 1996; Nelson et al., 2002). Sexual abuse has been shown to have longer term effects than physical abuse (Fergusson et al., 2008), another potent risk factor for suicidal ideation and attempt (Dunn, McLaughlin, Slopen, Rosand, & Smoller, 2013; Gomez et al., 2017). Although less frequently studied, emotional abuse also has been shown to increase likelihood of suicidal ideation in older children and adolescents controlling for covariates such as history of suicidal ideation, depressive symptoms, and in some cases controlling for sexual and physical abuse (Gibb et al., 2001; Miller et al., 2016).

While the literature clearly shows childhood maltreatment to be a risk factor for suicidal thoughts and behaviors, it is important to remember that not all youth who experienced abuse develop suicidal ideation or engage in self-harmful or suicidal behaviors.  In fact, our previous findings suggest that certain psychological traits, such as emotional intelligence, may protect against effects of childhood sexual abuse on suicidal ideation and attempts (Cha & Nock, 2009).  This association was weaker among those with moderate levels of emotional intelligence, and most notably, was completely buffered and nonsignificant among those with high levels of emotional intelligence.

Our review also highlighted some of the trends found in this field of research, particularly in the attempts to better understand the characteristics of maltreatment and how it may impact suicidal thoughts and behaviors.  Recent studies have shifted toward identifying the temporal characteristics of maltreatment (i.e. onset of first exposure, occurrence of exposure during a specific developmental period) and determining their relationship to suicidal thoughts and behaviors.  We found mixed findings regarding sensitive periods of maltreatment exposure, with some highlighting the impact of exposure during mid-adolescence (Khan et al., 2015), others underscoring exposure during preschool years and early childhood (Dunn et al., 2013; Khan et al., 2015), and finally some reporting no association at all (Gomez et al., 2017).  Some of these factors may depend on sex or type of maltreatment (Khan et al., 2015). Most of these studies relied primarily on epidemiology, etiology, treatment cross-sectional designs and/or retrospective recall of maltreatment.

In conclusion, there is much more to learn about the effects of childhood maltreatment on suicidal behaviors.  Both suicide death and childhood maltreatment are preventable - improved understanding of these two areas of research allow for an unique, intersectional, multidisciplinary approach to working with youth whose adverse experiences have contributed to their suicidal ideation and attempts. By focusing our research on the identification of individual, malleable mechanisms, we can better inform the development of treatments targeting these mechanisms as a way of preventing suicide deaths for these at-risk youth.

References

Cha, C.B., & Nock, M.K. (2009). Emotional intelligence is a protective factor for suicidal behaviors. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 422-430.

Brent, D.A., Oquendo, M., Birmaher, B., et al. (2002). Familial pathways to early-onset suicide attempt: risk for suicidal behavior in offspring of mood-disordered suicide attempters. Arch Gen Psychiatry, 59, 801-807.

Fergusson, D.M., Horwood, L.J., Lynskey, M.T. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood: II. Psychiatric outcomes of childhood sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1365-1374.

Joiner, T.E. Jr., Sachs-Ericsson, N.J., Wingate, L.R., Brown, J.S., Anestis, M.D., Selby, E.A. (2007). Childhood physical and sexual abuse and lifetime number of suicide attempts: A persistent and theoretically important relationship. Behaviour Research and Therapy, 45, 539-547. 25.

Melhem, N.M., Brent, D.A., Ziegler, M., et al. (2007). Familial pathways to early-onset suicidal behavior: Familial and individual antecedents of suicidal behavior. American Journal of Psychiatry, 164, 1364-1370.

Molnar, B.E., Berkman, L.F., Buka, S.L. (2001). Psychopathology, childhood sexual abuse and other childhood adversities: Relative links to Subsequent suicidal behavior in the US. Psychological Medicine, 31, 965-977.