Childhood Maltreatment and Suicidality
Authors: Brett Burstein, Brian Greenfield
Journal: JAMA Network Open (2020)

JAMA Network Open, Angelakis et al 1 have conducted an important exploration of adverse childhood experiences (ACEs) and their association with suicide in the pediatric age group.The authors have undertaken a meta-analysis to quantify the association between ACEs and suicide ideation, attempts, and plans, offering odds ratios (ORs) to elucidate the relative contribution of several core ACEs to eventual suicidal phenomena.Core ACEs assessed include sexual, physical, and emotional abuse, emotional and physical neglect, and "combined abuse" (when the type of abuse and neglect were undefined).Their meta-analysis includes 79 studies with 337 185 participants and, compared with prior studies, offers the advantage of greater inclusiveness, and studied both community and clinical samples with documented psychopathology.The work of Angelakis et al 1 should be recognized as a landmark study; they have conducted a comprehensive, methodologically rigorous analysis providing some of the most robust evidence linking core forms of ACEs with suicidal behaviors in children.This study is the largest to date confirming long-held child-psychiatric observations, lending credence to a nonbiological basis of that distress. 2A critical challenge remains: translating these findings into effective suicide risk-reduction interventions for children who experience maltreatment.In the United States, suicide has been recognized as a major public health concern.Emergency departments (EDs) nationwide have witnessed a doubling in children presenting for suicidal behavior during just the 9-year period from 2007 to 2015, 3 corresponding to an increase in actual completed suicides during the same time. 4In fact, suicide is the second leading cause of death among young adolescents, and the incidence rose by 113% from 1999 to 2017, the largest relative increase in any age group. 5National suicide prevention campaigns have not succeeded in slowing the rising rates of suicidal behavior and suicide deaths among children and adolescents. 4 is conceptually interesting to consider the relative contributions of each type of core ACE in terms such as ORs, and several strong associations emerge from this analysis, such as between sexual or physical abuse and suicide attempts (relative ORs, 3.41 and 2.18, respectively).However, there remains a fundamental challenge applying these data clinically to guide suicide prevention interventions.It is more clinically meaningful that all forms of abuse studied significantly increased the odds of suicidal behaviors.Furthermore, these core types of experiences often coexist.More important than the differences in ORs among adverse experience types is the study's emphasis linking family dysfunction and suicidal distress among children and young adults.Identifying the presence of any of these core ACEs may be an opportunity not only to refer for social and psychiatric support but also to intervene early with targeted suicide risk reduction.As the authors appropriately highlight, 54 of 79 included studies were cross-sectional or retrospective in design (eTable in the article's Supplement), and most (63 of 79) were of low methodological quality.Accordingly, a direct causal relationship cannot be ascribed based on this analysis alone, although the association between ACEs and suicidality may seem intuitive.The phenomena of suicidality, as expressed by ideation, plans, and attempts, is far more complex.Which factors render some such patients vulnerable to suicidal thoughts, actions, and plans, whereas others possess protective factors conferring resilience to toxic environments and less vulnerability to distress?Some who experience abuse are paradoxically strengthened by adversities, later reporting no mental health psychopathology and succeeding in multiple life pursuits.