Child and Adolescent Suicide Attempts, Suicidal Behavior, and Adverse Childhood Experiences in South Africa: A Prospective Study.
OBJECTIVE
This is the first known prospective study of child suicidal behavior in sub-Saharan Africa. Aims were to determine whether (1) cumulative exposure to adverse childhood experiences (ACEs) predicts later suicidality and (2) heightened risks are mediated by mental health disorder and drug/alcohol misuse.


METHODS
Longitudinal repeated interviews were conducted 1 year apart (97% retention) with 3,515 adolescents aged 10-18 years in South Africa (56% female; <2.5% refusal). Random selection of census enumeration areas from urban/rural sites within two provinces and door-to-door sampling included all homes with a resident adolescent. Measures included past-month suicide attempts, planning, and ideation, mental health disorders, drug/alcohol use, and ACE, for example, parental death by AIDS or homicide, abuse, and exposure to community violence. Analyses included multivariate logistic regression and multiple mediation tests.


RESULTS
Past-month suicidality rates were 3.2% of adolescents attempting, 5.8% planning, and 7.2% reporting ideation. After controlling for baseline suicidality and sociodemographics, a strong, graded relationship was shown between cumulative ACE and all suicide behaviors 1 year later. Baseline mental health, but not drug/alcohol misuse, mediated relationships between ACE and subsequent suicidality. Suicide attempts rose from 1.9% among adolescents with no ACE to 6.3% among adolescents with >5 ACEs (cumulative odds ratio [OR], 2.46; confidence interval [CI], 1.00-6.05); for suicide planning, from 2.4% to 12.5% (cumulative OR, 4.40; CI, 2.08-9.29); and for suicide ideation, from 4.2% to 15.6% (cumulative OR, 2.99; CI, 1.68-5.53).


CONCLUSIONS
Preventing and mitigating childhood adversities have the potential to reduce suicidality. Among adolescents already exposed to adversities, effective mental health services may buffer against future suicidality.
Department of Social Policy and Intervention, Center for Evidence-Based Intervention, University of Oxford, Oxford, United Kingdom; Department of Psychiatry and Mental Health, University of Cape Town, South Africa. Electronic address: lucie.cluver@spi.ox.ac.uk.
Lucie
L
Cluver
DST-NRF Centre of Excellence in Human Development, University of Witwatersrand, Braamfontein, Johannesburg, South Africa.
Mark
M
Orkin
School of Psychology and Speech Pathology, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia.
Mark E
ME
Boyes
Department of Infection and Population Health, University College London, London, United Kingdom.
Lorraine
L
Sherr
D000293:Adolescent; D000294:Adolescent Behavior / Q000523:psychology*; D002648:Child; D002649:Child Abuse / Q000523:psychology; D002652:Child Behavior / Q000523:psychology*; D000069581:Exposure to Violence / Q000523:psychology; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008137:Longitudinal Studies; D008297:Male; D063129:Parental Death / Q000523:psychology; D011446:Prospective Studies; D000067073:Psychological Trauma / Q000523:psychology*; D013019:South Africa; D059020:Suicidal Ideation; D013406:Suicide, Attempted / Q000517:prevention & control / Q000523:psychology*
Adverse childhood experiences; Mental health; South Africa; Substance abuse; Suicide