Abstract
This cross-sectional study examines the rates of intentional misuse of substances in US children aged 6 to 18 years in the past 20 years.
Pediatric emergency department visits for suicidality account for more than 1.1 million encounters per year, and this number has doubled in the past decade. Although attention has focused on suicidality among adolescents, another important group to consider is preadolescent children.1 A recent study of suicide risk screening in the emergency department for children aged 10 to 12 years found that more than half of these children with psychiatric complaints and almost 1 in 10 children with medical complaints received a positive screen.2 Approximately 1 in 5 preadolescent children in the study reported previous suicidal behavior.2 The objective of the present study was to examine age-specific patterns in suicidal ingestions using a nationally representative database. We hypothesized that calls for suicidal ingestions have increased.
Methods
Data for this cross-sectional study were obtained for January 1, 2000, through December 31, 2020, from the National Poison Data System (NPDS), which is maintained by the American Association of Poison Control Centers. The NPDS data are collected from each certified regional poison center in the US. This study was deemed to be exempt from review by the Oregon Health and Science University Institutional Review Board, which waived the requirement for informed consent. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
The study population included all cases of ingestion among patients aged 6 to 18 years. Data on race and ethnicity were not available from the NPDS. Cases were coded by trained poison center staff for 1 of 3 reasons: intentional-suspected suicide, intentional misuse, and intentional abuse. Clinical outcome was coded as follows, using a priori definitions from the NPDS coding manual: no effect, minor effect, moderate effect, major effect, or death.3 Both reason for ingestion and outcome determination are defined in the coding manual.
Results
There were a total of 1 256 963 unique cases recorded during the study period, involving 854 411 female (68.0%) and 401 621 male (32.0%) children with a mean (SD) age of 15.3 (2.2) years (Table). There were 1005 deaths, and 28.7% of ingestions resulted in worse than minor clinical outcomes. Misuse or abuse ingestions remained relatively constant over the 20-year study period, although there was a dramatic increase in suicidal ingestions (Figure). All groups older than 9 years of age showed an increase in suicidal ingestions, but the change in those aged 10 to 12 years was the most significant: a 4.5-fold increase during the study period compared to a 2.4-fold increase in adolescents.
Table. Population Characteristics.
| Characteristic | No. (%) |
|---|---|
| No. of patients | 1 256 963 |
| Age group, y | |
| 6-9 | 30 954 (2.5) |
| 10-12 | 72 055 (5.7) |
| 13-15 | 502 287 (40.0) |
| 16-18 | 651 667 (51.8) |
| Sex | |
| Female | 854 411 (68.0) |
| Male | 401 621 (32.0) |
| Unknown | 931 (0.1) |
| Reason | |
| Intentional | |
| Abuse | 185 307 (14.7) |
| Misuse | 143 414 (11.4) |
| Suspected suicide | 928 242 (73.8) |
| Single substance use | 878 266 (69.9) |
| Ethanol beverage coingestion | 39 950 (3.2) |
| Outcomes | |
| No effect | 394 683 (31.4) |
| Minor effect | 501 832 (39.9) |
| Moderate effect | 323 208 (25.7) |
| Major effect | 36 235 (2.9) |
| Death | 1005 (0.1) |
Figure. Ingestion Type by Age Group.
Discussion
This cross-sectional study found a dramatic increase in suicidal ingestions among preadolescent children over the past 20 years. The Figure details a relatively constant number of misuse or abuse ingestions but a steady increase in suicidal ingestions in preadolescent children that was not seen at similar rates in other age groups.
The reasons for increased suicidal ingestions among younger age groups are unclear. Suicidality is multifactorial, complex, and not well understood, particularly in the preadolescent population. It is notable, however, that a number of social media platforms were launched around 2013, at the same time that increases in ingestions in this population were observed (Figure). The association between youth mental health and social media has been highlighted in recent research, including a study that used time-varying effects analysis, which found associations between social media, television, and depression in the adolescent age range.4,5 Further research is needed to better understand factors associated with this concerning pattern.
This study has limitations. First, because the NPDS relies on reporting of cases from poison centers, the true number of cases is likely to be underrepresented. Second, the calls to the poison centers must be coded correctly as suicidal ingestions. The professionals at the poison centers are trained for such coding; therefore, we expect the risk of misclassification to be low.
We believe this study highlights a need for better early identification of youth with mental health needs. The findings may inform future screening guideline recommendations that extend to the preadolescent population.6
References
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