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16

Short Report

Suicide Ideation and Attempts in

Children With Psychiatric Disorders
and Typical Development
Susan Dickerson Mayes, Susan L. Calhoun, Raman Baweja, and Fauzia Mahr
Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
Abstract. Background: Children and adolescents with psychiatric disorders are at increased risk for suicide behavior. Aims: This is the first
study to compare frequencies of suicide ideation and attempts in children and adolescents with specific psychiatric disorders and typical children
while controlling for comorbidity and demographics. Method: Mothers rated the frequency of suicide ideation and attempts in 1,706 children
and adolescents with psychiatric disorders and typical development, 618 years of age. Results: For the typical group, 0.5% had suicide behavior
(ideation or attempts), versus 24% across the psychiatric groups (bulimia 48%, depression or anxiety disorder 34%, oppositional defiant disorder
33%, ADHD-combined type 22%, anorexia 22%, autism 18%, intellectual disability 17%, and ADHD-inattentive type 8%). Most alarming, 29%
of adolescents with bulimia often or very often had suicide attempts, compared with 04% of patients in the other psychiatric groups. Conclusion: It is important for professionals to routinely screen all children and adolescents who have psychiatric disorders for suicide ideation and
attempts and to treat the underlying psychiatric disorders that increase suicide risk.
Keywords: child psychiatric disorders, suicide behavior

Most psychiatric disorders in children and adolescents

are associated with an increased risk of suicide behavior, including depression (Goldston et al., 2009; Greening et al., 2008), attention deficit hyperactivity disorder
(ADHD; Hinshaw et al., 2012; Hurtig, Taanila, Moilanen,
Nordstrom, & Ebeling, 2012), eating disorders (Favaro &
Santonastaso, 1997; Franko & Keel, 2006; Mayes, Fernandez-Mendoza et al., 2014), anxiety disorders (Goldston et
al., 2009), autism (Mayes, Gorman, Hillwig-Garcia, &
Syed, 2013), oppositional defiant and conduct disorders
(Foley, Goldston, Costello, & Angold, 2006; Goldston et
al., 2009), and sleep disorders (Cukrowicz et al., 2006; Nadorff, Nazem, & Fiske, 2011, 2013). Ours is the first study
to compare frequencies of suicide ideation and attempts
between children and adolescents with specific psychiatric
disorders and typical children controlling for comorbidity
and demographics.

Method
Informed consent was obtained from participants in the
typical sample and was waived by the Institutional Review
Board for the psychiatric groups, because analyses were
conducted retrospectively on existing clinical data.

2014 Hogrefe Publishing

Sample
All children and adolescents in the psychiatric groups
were referred to our psychiatry outpatient clinics for diagnostic evaluations and were evaluated by licensed PhD
psychologists and/or board-certified child and adolescent
psychiatrists using the Diagnostic and Statistical Manual
of Mental Disorders (DSM) criteria. With the exception
of eating disorders, diagnoses using DSM-IV and DSM-5
criteria were the same. Evaluations included a diagnostic
interview with the parent and child or adolescent, a review
of records and early history data, scores on behavior rating
scales completed by parents and teachers, comprehensive
psychological testing, and observations of the child or adolescent during the evaluation. All children and adolescents,
with the exception of those in the intellectual disabilities
group, had an IQ of 80 or higher on the Wechsler scales
(WISC-IV or WASI) or were enrolled in regular education without academic problems. Patients on psychotropic medication were not excluded from the study to avoid
creating biased samples with spuriously lower levels of
psychopathology (including suicide behavior) not representative of patients with psychiatric disorders. The typical
and psychiatric samples were from the same geographic
region (Central Pennsylvania) and data for both groups
were collected during the past 15 years. Demographic data
are presented in Table 1.

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S. Dickerson Mayes et al.: Suicide Behavior in Child Psychiatric Disorders

Table 1. Demographic data (N = 1,706)

Group

Mean

Age

age

range

Male

White

Professionala

Autism

329

8.6

616

87.5

93.0

46.8

ADHD-C

566

8.9

616

74.6

91.9

36.7

ADHD-I

235

9.3

616

57.4

94.0

48.9

71

11.1

616

35.2

97.2

53.5

Depression/anxiety
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Eating disorder

90

13.8

718

3.3

95.6

57.8

Intellectual disability

229

8.6

618

72.9

87.3

19.2

Typical

186

8.7

612

43.5

78.5

51.1

Note. ADHD-C = attention deficit hyperactivity disorder-combined type; ADHD-I = attention deficit hyperactivity disorder-inattentive type.
a
One or both parents have a professional or managerial occupation.

Autism

Depression and Anxiety Disorder

All children and adolescents with autism had a DSM diagnosis of autism and a score in the autism range on the
Checklist for Autism Spectrum Disorder (CASD; Mayes,
2012). The CASD is standardized on 2,469 children and
adolescents and differentiates those with and without autism with 99.5% accuracy. Consistent with research findings (Mayes, Calhoun, Mayes, & Molitoris, 2012), almost
all patients in the autism group had ADHD symptoms.
Some patients with autism had comorbid oppositional defiant disorder (ODD), anxiety, or depression, which was
controlled for in the statistical analyses.

Children and adolescents in the depression group had

dysthymic disorder or major depressive disorder. Anxiety
disorders included generalized anxiety, obsessive-compulsive, panic, social anxiety, and separation anxiety disorders. Children and adolescents with ADHD, autism, and
eating disorder were not included. Comorbid ODD was
statistically controlled for.

ADHD
All children and adolescents with ADHD met the following criteria: (1) DSM diagnosis of ADHD by a licensed
PhD psychologist, (2) symptoms of ADHD observed during psychological testing, and (3) parent or teacher rating
of short attention span or distractible as often or very often a problem on the Pediatric Behavior Scale (Lindgren
& Koeppl, 1987). Patients with ADHD were classified as
having ADHD-combined type (ADHD-C) if the majority
of the mother, father, and teacher ratings on the impulsivehyperactive items were often or very often a problem. Patients were classified with ADHD-inattentive type
(ADHD-I) if the majority of impulsivehyperactive ratings
were less than often a problem. Patients with autism were
not included in the ADHD sample. Some children and adolescents with ADHD had ODD, anxiety, or depression, and
these comorbidities were statistically controlled for.

Eating Disorder
This group consisted of children and adolescents diagnosed with anorexia or bulimia by a board-certified child
and adolescent psychiatrist using DSM-5 criteria. Diagnoses were confirmed through a chart review by a licensed
PhD psychologist. Comorbid ODD, anxiety, and depression were controlled for in the analyses.
Crisis 2015; Vol. 36(1):5560

Intellectual Disability
These children and adolescents had IQs below 80 on the
Wechsler scales (M = 63.0, range = 1279) with or without
comorbid ADHD, autism, anxiety, depression, or ODD.

Typical
The typical sample comprised elementary school students
from a general population epidemiologic study of the prevalence of sleep disorders in children (Bixler et al., 2009).
All children from the epidemiologic study who were not
on psychotropic medication and did not have an identified
neurodevelopmental disorder (intellectual disability, autism, ADHD, learning disability, or acquired brain injury)
were included in the typical group. Children with possible ODD, anxiety, and depression were not excluded, and
these conditions were controlled for in the analyses.

ODD
All of the aforementioned subgroups potentially included
children and adolescents with ODD. Because of restrictions imposed by sample sizes, it was not possible to create mutually exclusive groups with and without ODD for
each diagnosis. Therefore, analyses were conducted on
children and adolescents with and without ODD extracted
from the total sample. Children and adolescents with ODD
were those whose mothers rated four or more of the eight
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S. Dickerson Mayes et al.: Suicide Behavior in Child Psychiatric Disorders

DSM-5 ODD symptoms on the PBS as often to very often

a problem, as specified by DSM-5 ODD criteria.

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Instrument
Mothers rated their children on a 4-point scale (0 = not at
all, 1 = sometimes, 2 = often, and 3 = very often a problem)
on the 165-item Pediatric Behavior Scale (PBS; Lindgren
& Koeppl, 1987). Dependent variables were suicide ideation (talks about harming or killing self) and suicide
attempts (deliberately harms self or attempts suicide).
These two items have been used in other studies to assess
suicide ideation and attempts (Mayes et al., 2013; Mayes,
Baweja et al. 2014; Mayes, Fernandez-Mendoza et al.
2014). Scores on maternal PBS ratings of anxiety (fearful,
anxious, or worried), sadness (sad, unhappy, or depressed),
ODD (disobedient, argues, defiant, mean, explosive, irritable, angry, easily annoyed, and loses temper), and sleep
disturbance (sleeps less than most other children, trouble
falling asleep, wakes often during the night, and nightmares) were used in the analyses to control for these comorbid problems, which are known to be associated with
suicide behavior. Validity studies demonstrate that the PBS
differentiates diagnostic groups, and the PBS has been
used to diagnose and measure psychological problems in
several published studies (Mattison & Mayes, 2012; Max
et al., 1997; Mayes & Calhoun, 2007; Mayes, Calhoun,
Bixler & Vgontzas, 2009; Mayes, Calhoun, Murray, Ahuja, & Smith, 2011; Nichols et al., 2000; Wolraich et al.,
1994).

Data Analysis
Differences in the percentage of children and adolescents
with suicide ideation and attempts (rated as sometimes

or more by mothers on the PBS) between the diagnostic

groups were analyzed using 2 and Fishers exact test. Differences in suicide ideation and attempt scores (0 = not at
all, 1 = sometimes, 2 = often, and 3 = very often a problem
according to maternal ratings on the PBS) between the psychiatric groups were analyzed using ANCOVA controlling
for between-group differences (p < .0001) in age (F =
74.2), gender (2 = 327.2), parent occupation (2 = 83.0),
and race (2 = 48.2). Children and adolescents with and
without ODD could not be included in ANCOVA because
they were extracted from each of the diagnostic groups and
were not a mutually exclusive group. To determine the impact of comorbidity, ANCOVA was repeated controlling
for maternal PBS ratings of ODD, anxiety, sadness, and
sleep disturbance. Stepwise linear regression analysis was
used to determine which of the dependent variables (i.e.,
the six psychiatric diagnoses; comorbid anxiety, sadness,
ODD, and sleep disturbance; and demographics including
age, gender, race, and parent occupation), when considered together, were significant independent correlates of
suicide ideation and attempt scores.

Results
Patients with bulimia had higher suicide ideation and attempt scores than those with anorexia (t = 2.3 and 3.3,
p < .05), so these subtypes were separated in the analyses.
Differences in ideation and attempts were nonsignificant
between patients who had an anxiety disorder without depression, depression without an anxiety disorder, and both
anxiety disorder and depression (F = 2.5 and 2.6, p > .05),
so these groups were combined.
Percentages of children and adolescents with suicide
ideation and attempts for each diagnostic group are shown
in Table 2, and are reported for children and adolescents
separately in Table 3. Mean maternal ratings of suicide

Table 2. Suicide ideation and attempt percentages

Group

Percent of children and adolescents wih

Ideation

Attempts

Sometimes

Often
very often

Total

Sometimes

Often
very often

Total

Bulimia (n = 21)

23.8

19.1

42.9

14.3

28.6

42.9

ODDa (n = 596)

21.3

8.5

29.8

8.4

3.5

11.9

Depression/anxiety (n = 71)

15.5

14.1

29.6

11.3

4.2

15.5

ADHD-C (n = 566)

15.4

5.3

20.7

4.4

1.6

6.0

Anorexia (n = 69)

20.3

0.0

20.3

2.9

0.0

2.9

Autism (n = 329)

12.2

3.3

15.5

5.8

1.2

7.0

Intellectual disability (n = 229)

8.7

4.0

12.7

7.9

1.3

9.2

ADHD-I (n = 235)

4.3

3.0

7.3

1.7

0.9

2.6

Typical (n = 186)

0.5

0.0

0.5

0.0

0.0

0.0

Note. ADHD-C = attention deficit hyperactivity disorder-combined type; ADHD-I = attention deficit hyperactivity disorder-inattentive type; ODD =
oppositional defiant disorder.
a
Extracted from the total sample.
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S. Dickerson Mayes et al.: Suicide Behavior in Child Psychiatric Disorders

Table 3. Percent of children and adolescents who have suicide ideation and attempts at least sometimes
Ideation
< 12 years

12 years

< 12 years

12 years

NAa

42.9

NAa

42.9

ODD (n = 596)

27.9

37.4

10.8

16.3

Depression/anxiety (n = 71)

22.0

40.0

2.4

33.3

ADHD-C (n = 566)

20.2

23.3

5.3

10.0

Anorexia (n = 69)

50.0

15.3

10.0

1.7

Autism (n = 329)

13.4

31.6

6.5

10.5

Intellectual disability (n = 229)

Group
Bulimia (n = 21)
b

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Attempts

12.4

14.3

9.8

5.7

ADHD-I (n = 235)

7.1

7.8

2.2

3.9

Typical (n = 186)

0.7

0.0

0.0

0.0

Note. ADHD-C = attention deficit hyperactivity disorder-combined type; ADHD-I = attention deficit hyperactivity disorder-inattentive type; ODD =
oppositional defiant disorder.
a
All patients with bulimia are 12 years or older. bExtracted from the total sample.

Table 4. Mean maternal ratingsa on the Pediatric Behavior Scale

Group

Suicide ideation

Suicide attempts

Sadness

Anxiety

ODD

Sleep disturbance

M (SD)

M (SD)

M (SD)

M (SD)

M (SD)

M (SD)

Bulimia (n = 21)

0.7 (1.0)

0.9 (1.2)

2.0 (1.0)

1.9 (1.2)

1.2 (0.8)

0.9 (0.8)

ODDb (n = 596)

0.4 (0.7)

0.2 (0.5)

1.1 (1.0)

1.5 (1.0)

2.0 (0.5)

0.9 (0.8)

Depression/anxiety (n = 71)

0.5 (0.9)

0.2 (0.5)

1.3 (1.0)

1.9 (1.0)

1.0 (0.7)

0.7 (0.7)

ADHD-C (n = 566)

0.3 (0.6)

0.1 (0.3)

0.8 (0.9)

1.1 (1.0)

1.5 (0.8)

0.7 (0.7)

Anorexia (n = 69)

0.2 (0.4)

0.0 (0.2)

1.7 (0.9)

1.7 (0.9)

0.8 (0.7)

0.5 (0.6)

Autism (n = 329)

0.2 (0.5)

0.1 (0.4)

0.8 (0.9)

1.5 (1.0)

1.4 (0.7)

0.9 (0.8)

Intellectual disability (n = 229)

0.2 (0.5)

0.1 (0.3)

0.5 (0.7)

1.1 (1.0)

1.2 (0.7)

0.7 (0.7)

ADHD-I (n = 235)

0.1 (0.4)

0.0 (0.2)

0.6 (0.8)

0.9 (0.9)

0.7 (0.6)

0.4 (0.6)

Typical (n = 186)

0.0 (0.1)

0.0 (0.0)

0.2 (0.4)

0.5 (0.6)

0.4 (0.4)

0.4 (0.5)

Note. ADHD-C = attention deficit hyperactivity disorder-combined type; ADHD-I = attention deficit hyperactivity disorder-inattentive type; ODD =
oppositional defiant disorder.
a
0 = not at all, 1 = sometimes, 2 = often, and 3 = very often a problem. bExtracted from the total sample.

ideation and attempts, sadness, anxiety, ODD, and sleep

disturbance are presented in Table 4. Only one typical child
had suicide ideation (rated as sometimes), and none had attempts. The frequency of ideation or attempts occurring at
least sometimes was significantly greater in all psychiatric
groups than in typical children (2 > 13.1, p < .0001). In the
total sample, ideation and attempt scores were significantly
higher in children and adolescents who were often or very
often sad (t = 9.7 and 5.8, p < .0001) or anxious (t = 7.8
and 5.4, p < .0001) versus those who were only sometimes
sad or anxious. Similarly, children and adolescents who had
a sleep disturbance (t = 5.9 and 4.8, p < .0001) and ODD
(t = 10.0 and 5.9, p < .0001) had higher ideation and attempt
scores than did those without these problems.
Total suicide behavior scores (ideation plus attempt
scores) were higher in adolescents with bulimia than in
all other psychiatric groups, and children and adolescents
with depression or an anxiety disorder had higher suicide
behavior scores than all other groups except the bulimia group (F = 11.7, Bonferroni p < .05, controlling for
Crisis 2015; Vol. 36(1):5560

between-group differences in age, gender, race, and parent occupation). These differences remained significant
when ODD, anxiety, sadness, and sleep disturbance were
also covaried (F = 9.8, Bonferroni p < .05). All other
comparisons between groups were nonsignificant, except
that suicide behavior scores were higher in ADHD-C than
in ADHD-I (Bonferroni p < .05). This was still significant when sadness, anxiety, and sleep disturbance were
covaried, but not when ODD was covaried (Bonferroni
p = .28).
In regression analysis, diagnoses of bulimia and depression/anxiety and maternal PBS ratings of sadness and
ODD were significant and independent correlates of PBS
suicide ideation plus attempts scores (R = 45.3, explained
variance = 20.5%, F = 97.4, p < .0001). The remaining variables (diagnoses of anorexia, ADHD-C, ADHD-I, autism,
and intellectual disability; maternal PBS ratings of anxiety and sleep disturbance; age; gender; race; and parent
occupation) were not significant and increased explained
variance by less than 0.3%.
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S. Dickerson Mayes et al.: Suicide Behavior in Child Psychiatric Disorders

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Discussion
All psychiatric groups in our study had far more suicide
behavior than typical children. None of the typical children had attempts and only one had occasional ideation.
Across psychiatric diagnoses, frequencies for ideation or
attempts were 48 times higher than in the typical group,
ranging from 16 times more frequent in ADHD-I to 95
times more common in bulimia. Suicide behavior was
most common in bulimia, depression or anxiety disorder, and ODD. Most alarming, 29% of adolescents with
bulimia often or very often had attempts, versus 04% in
the other psychiatric groups. All children and adolescents
with psychiatric disorders should be screened for suicide
ideation and attempts at every appointment with their primary care physician and mental health professional. The
presence of suicide behavior is a marker for psychiatric
disorders, and this underlying psychopathology needs to
be treated to prevent suicide.
Future research should focus on replicating this study
in larger samples in other settings, supplementing maternal
report of behaviors with self-report, and evaluating suicide
behavior using more comprehensive measures.
Acknowledgments
This study was supported by National Institutes of Health
grants RO1 HL063772, MO1 RR010732, and CO6
RR016499.

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houns expertise is in the assessment of child mental health and

learning disorders and treatment of sleep disorders. She has over
50 scientific publications.

Received February 10, 2014

Revision received June 26, 2014
Accepted July 7, 2014
Published online November 18, 2014

Dr. Fauzia Mahr, MD, is an associate professor of psychiatry and

pediatrics, Vice Chief Division of Child and Adolescent Psychiatry and Director ofthe Child and Adolescent Psychiatry Fellowship Program at Penn State Hershey Medical Center, USA.
She is Medical Director of the Eating Disorder Child Partial and
Outpatient Program and has published research in psychiatric
disorders.

Dr. Raman Baweja, MD, is an assistant professor in the Department of Psychiatry at Penn State College of Medicine, PA, USA.
Dr. Baweja completed a fellowship in Child and Adolescent Psychiatry and has a graduate degree in Public Health Sciences. He
has published more than 10 articles on clinical psychiatry.

About the authors

Dr. Susan Mayes, PhD, is a senior clinical psychologist and professor of psychiatry in the Division of Child Psychiatry at Penn
State College of Medicine, PA, USA. She is a licensed psychologist and certified school psychologist. She has over 90 publications and 40 years of experience with children who have psychiatric and neurodevelopmental disorders.
Dr. Susan L. Calhoun, PhD, is a diplomate, licensed psychologist, certified school psychologist, and associate professor of
psychiatry at Penn State College of Medicine, PA, USA. Dr. Cal-

Crisis 2015; Vol. 36(1):5560

Susan D. Mayes
Department of Psychiatry H073
Hershey Medical Center
500 University Dr.
Hershey, PA 17033
USA
Tel. +1 717 531-6201
Fax +1 717 531-1578
E-mail: smayes@psu.edu

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