Suicide is a term that is hard for people to acknowledge, let alone say out loud. Even in media, when someone dies by suicide, the headlines will often omit that scary word: suicide. However, our fear of acknowledging suicidal thoughts, behaviors and deaths further stigmatizes an issue we cannot afford to continue to ignore. That is why is is so important that mental health professionals have a knowledge of the signs of suicide in children from all backgrounds, as well as developing a skill in creating safety plans and interventions to help children experiencing suicidal thoughts and/or behavior.
Risk Factors
Next it's important to be mindful of risk factors that may increase a child's probability of experiencing suicidal thoughts and/or behaviors. They include:
Higher risk populations- There are some children who come from "high risk" populations such as younger children with ADHD, adolescents with depression, children with a trauma or grief event, sexual abuse survivors, survivors of suicide, history of suicide attempts or previously admitted to inpatient care for mental health concerns, children struggling with chronic pain, children experiencing command hallucinations and children who identify as LGBTQ+
Family dynamics & genetics- Children who have families members with a history of mental illness and death by suicide at are a higher risk than those children who do not
Precipitating events- Children are more likely to die by suicide or attempt suicide after dealing with an interpersonal conflict with a peer, partner or family member and/or experiencing bullying. This can include a cyberbullying incident
Access to lethal means- Children with access to a means to harm themselves (e.g. firearms) are at an increased risk of suicidal thoughts and/or behaviors
Concerning behaviors- Mental health professionals should be mindful of children who struggle with impulsivity, withdrawal from friends, family & activities, exhibit isolating behaviors, rehearse or have a preoccupation with dying, anxiety, sleeplessness, making suicidal statements and giving away personal possessions, as these are often contributing factors or signs of suicidal thoughts/behaviors
Play Themes of Suicide in the Playroom
Play themes are ways that play therapists can use Psychoanalytic Play Therapy to interpret the play of children and adolescents. These play themes may develop over several sessions, or within one session when a child shows the same theme using different activities. For example, the grief theme may be shown by a child playing with puppets where people die at the scene, then they play in the dollhouse and role play a funeral.
There are several play themes that can serve as signs of suicide in the playroom. They include:
Chaos: Shown when a child plays with a lot of toys and leaves the room messy. Can also include "dumping and flooding" (e.g. dumping the whole bin of Legos on the ground)
Perfectionism: Shown when a child takes a lot of time making sure things are "perfect" The play themes of chaos and perfectionism may be present, as they are related to feelings of anxiety. Mental health professionals should focus treatment on decreasing anxiety symptoms, increasing self-regulation skills and addressing the root of the anxiety.
Grief: Shown when the child role plays scenes of death/dying. As noted earlier, there are different precipitating events to suicidal acts in children, such as conflict with peers, family members or romantic partners, so the child may also be exhibiting the grief theme in play sessions. Interventions focused on addressing grief symptoms and assisting the student through the grief cycle
Connection: Shown when a child is always saying "watch this!" or "look!", which may lack strong attachments. Play therapy interventions focused on increasing attachments would be important treatment goals for these students.
Protection & safety theme: Shown through toys/activities where child expresses the need for protection and/or safety. Can include wearing helmets or role-playing scenes with superheroes where they are saving people. Children with feelings of helplessness and hopelessness may show signs of the protection & safety theme. The use of safety language, exploring safe places and people for that student, and building a strong therapeutic relationship will be key for these children.
Key Items for the Playroom
There are some suggested toys/activities to have in the playroom to support children experiencing suicidal thoughts and/or behaviors.
Aggressive release toys- toy guns, toy swords, punching bag
Grief miniatures- coffins, headstones, hearse, ghosts, skeletons
Doctor's kit
Costumes- community helpers (e.g. doctors, police officers, fire fighters), superheroes, helmets
Army men
Superheroes
Play Therapy Seminal Theories to Address Suicide
Many mental health professionals struggle with knowing how to reduce suicide risk in children & adolescents. First, it is important to identify the source of the suicidal thoughts. Then the therapist can use one of the play therapy seminal theories to help address the identified source. For example, if the trigger to the suicidal act was an attachment trauma like parents divorcing, the therapist could benefit from using an attachment based model like Theraplay to enhance the parent-child relationship. Below are some suggested play therapy seminal theories to address suicide in children & adolescents:
Important Resources
It will be important to provide the client and their caregivers with resources to provide the child with additional support outside of the playroom. Below are some suggested resources to share:
National Suicide Intervention Hotline- 988
Suicide Prevention Lifeline- www.suicidepreventionlifeline.org
Crisis Text Line- Text HOME to 741741
Trevor Project (great resource for LGBTQ+ youth)- www.trevorproject.org
Suicide Prevention Resource Center (great resource for additional psychoeducation for clients, caregivers and mental health professionals)- www.suicidepreventionlifeline.org
Looking to learn more ways to use play therapy to support children experiencing suicidal thoughts and/or behaviors? Check out our training calendar for a live webinar or contact workshop near you!