Web Exclusive

Suicidality in Families: Number of Siblings or Birth Order?
By Brittany Stahnke Joy, DSW, LCSW, LMFT

Suicide rates in recent years have been on the rise, with suicide being the second-leading cause of death in age groups up to age 34, and two and a half times as many suicides as homicides occurring each year.1 Along with the number of completed suicides, the number of attempts is climbing. In 2022, while 1.6 million adults attempted suicide, 13.2 million adults considered suicide in this same year.2

Many suicide risk factors are known.3 While circumstances of childhood are not a listed risk factor here, across various cultures and both genders, the link between suicide and childhood neglect is strongly demonstrated in scholarship. Specifically, emotional neglect in childhood was associated with suicidal ideation and suicidal behavior; in Latvia, which has the highest suicide rates in the European Union, emotional neglect was even more strongly associated with suicide attempt than was emotional violence.4-6

Some studies demonstrate a more general association between childhood neglect and suicidal ideation or suicidal behavior;7-9 others show the association between neglect and both ideation and behavior.10,11 Suicide risk and physical neglect were associated in French adults,12 while first onset of suicidal ideation was associated with childhood emotional abuse and neglect.13 In Brazil, emotional neglect is more related to suicide risk than are sexual abuse, physical abuse, and physical neglect; the only thing more associated with risk is emotional abuse.4 As emotional mistreatment is a lot harder to quantify, it’s also easy to overlook. There’s also a positive association between ACEs (adverse childhood experiences) scores and suicidal behavior, which makes sense as six of the 10 ACE questions refer to childhood experiences of neglect, such as not feeling loved, having a family member with an addiction, and losing a parent.5,14,15

All states with the highest rates of suicide are in the western United States, including Wyoming, Colorado, and South Dakota.3 Research has found a positive association between higher altitudes in these areas and suicide,16 but there are other theories, such as an increased number of guns.17 Knowing the association between suicide rates and childhood neglect, lack of emotional resources in a family may also contribute. Western states also happen to have the highest rate of children per family, with Utah, New Mexico, Arizona, Nevada, Alaska, and Idaho having the most.18 Even in families that have well-intentioned parents, there may be far fewer resources such as emotional support, financial resources, and time spent with children that may contribute to aspects of neglect and thus suicidality in one’s life.

Further, in a qualitative interview study with 15 past-suicidal individuals in Colorado,19 it was found that almost all interviewees came from families of four or more children. As such a small sample does not necessarily demonstrate real associations, a literature review was conducted. Other studies have looked at birth order, finding that each increase in birth order was associated with a 46% (adjusted hazard ratio = 1.46, 95% confidence interval: 1.29, 1.66) increased risk of suicide in Norway,20 the United Kingdom,21 and an 18% higher risk of suicide in Sweden.22 In other words, the younger the child in the family, the higher the risk of suicide attempt. However, the total number of children in a family as related to suicidal ideation or behavior has not been explored explicitly in research, with the exception of one study finding that the size of sibling group was not a related factor in the birth order association, though data was not shown.22

In a preliminary survey of 43 adults, 76% of those who came from families of four or more children reported that they and/or a sibling had attempted or considered suicide. There’s also little research that covers suicidality in large families—a demographic that’s not generally looked at when collecting data on suicide. Research that does exist focuses on suicidality based on birth order—related to the concept of big families—but not assessing each child within that family equally.

Perhaps data collected needs to include further aspects of childhood, even for adult attempters of suicide. Only then could the relationship between family size—specifically, number of children in a home—and suicidality be causally demonstrated. Does the number of children in a family moderate the relationship between neglect and suicide? Are the factors that associate neglect and suicide also present in suicide in large families?

Why It Matters
While qualitative, exploratory studies can begin this journey, large-scale data analysis can carve the path to mediate this possible trend, potentially minimizing suicide within these families through policy and practice considerations. With knowledge, society could proactively prevent issues of emotional neglect and related factors that may exist. Further, tax cuts for people who have fewer children and for stay-at-home parents could be considered at the societal level. Having a large family may lead to factors of neglect that in most cases, cannot be prevented, but until these factors are better known, the potential to alleviate risk may remain unknown.

— Brittany Stahnke Joy, DSW, LCSW, LMFT, is a professor of social work and an academic at heart. When not teaching, mentoring, or conducting research, she can probably be found reading or writing. Her published book, The Doubting Disease, focuses on her specialty of mental health and experience with obsessive-compulsive disorder. She believes everyone should enjoy what they do. It’s a passion to guide students on their individual paths in this broad field.

References
1. Hedegaard H, Curtin SC, Warner M. Suicide mortality in the United States, 1999–2019. NCHS Data Brief. 2021;(398):1-8.

2. Suicide. National Institute of Mental Health website. https://www.nimh.nih.gov/health/statistics/suicide. Updated February 2024.

3. Risk and protective factors for suicide. Centers for Disease Control and Prevention website. https://www.cdc.gov/suicide/risk-factors/index.html

4. Barbosa LP, Quevedo L, da Silva GD, et al. Childhood trauma and suicide risk in a sample of young individuals aged 14–35 years in southern Brazil. Child Abuse Negl. 2014;38(7):1191-1196.

5. Springe L, Pulmanis T, Velika B, Pudule I, Grīnberga D, Villeruša A. Self-reported suicide attempts and exposure to different types of violence and neglect during childhood: findings from a young adult population survey in Latvia. Scand J Public Health. 2016;44(4):411-417.

6. Xiao Z, Baldwin MM, Meinck F, Obsuth I, Murray AL. The impact of childhood psychological maltreatment on mental health outcomes in adulthood: a protocol for a systematic review and meta-analysis. Syst Rev. 2021;10(1):224. 

7. Vanderminden J, Hamby S, David-Ferdon C, et al. Rates of neglect in a national sample: child and family characteristics and psychological impact. Child Abuse Negl. 2019;88:256-265.

8. Kwok SYCL, Gu M. Childhood neglect and adolescent suicidal ideation: A moderated mediation model of hope and depression. Prev Sci. 2018;20(5):632-642.

9. Liu P, Huang W, Chen S, et al. The association among childhood maltreatment, sleep duration and suicide behaviors in Chinese young people. J Affect Disord. 2023;327:190-196.

10. Enns MW, Cox BJ, Afifi TO, de Graaf R, Have MT, Sareen J. Childhood adversities and risk for suicidal ideation and attempts: a longitudinal population-based study. Psychol Med. 2006;36(12):1769-1778.

11. Stickley A, Waldman K, Ueda M, et al. Childhood neglect and suicidal behavior: findings from the National Comorbidity Survey Replication. Child Abuse Negl. 2020;103:104400.

12. Yrondi A, Aouizerate B, Bennabi D, et al. Childhood maltreatment and clinical severity of treatment‐resistant depression in a French cohort of outpatients (Face‐DR): one‐year follow‐up. Depress Anxiety. 2020;37(4):365-374.

13. Blasco MJ, Vilagut G, Alayo I, et al. First-onset and persistence of suicidal ideation in university students: a one-year follow-up study. J Affect Disord. 2019;256:192-204.

14. Thompson R, Litrownik AJ, Isbell P, et al. Adverse experiences and suicidal ideation in adolescence: exploring the link using the LONGSCAN samples. Psychol Violence. 2012;2(2):211-225.

15. Bunting L, McCartan C, Davidson G, et al. The influence of adverse and positive childhood experiences on young people’s mental health and experiences of self-harm and suicidal ideation. Child Abuse Negl. 2023;140:106159.

16. Brenner B, Cheng D, Clark S, Camargo CA Jr. Positive association between altitude and suicide in 2584 U.S. counties. High Alt Med Biol. 2011;12(1):31-35.

17. Siegler K. How one Colorado town is tackling suicide prevention — starting with the kids. NPR. October 23, 2018. https://www.npr.org/sections/health-shots/2018/10/23/658834805/how-one-colorado-town-is-tackling-suicide-prevention-starting-with-the-kids#:~:text=It’s%20not%20clear%20why
%20mountain,the%20bootstraps%22%20mentality%20runs%20deep

18. Olito F. Utah has the highest number of children in their families. here’s the average number of kids per family in every state. Business Insider. February 22, 2019. https://www.businessinsider.com/the-average-number-of-kids-per-family-in-every-state-2019-2

19. Stahnke B, Gaumond C, Davis R. Experienced causes of suicidal intent: a grounded theory analysis. Crisis, Stress, and Human Resilience: An International Journal. 2022;4(1):32-52.

20. Bjørngaard JH, Bjerkeset O, Vatten L, Janszky I, Gunnell D, Romundstad P. Maternal age at child birth, birth order, and suicide at a young age: a sibling comparison. Am J Epidemiol. 2013;177(7):638-644.

21. Easey KE, Mars B, Pearson R, Heron J, Gunnell D. Association of birth order with adolescent mental health and suicide attempts: a population-based longitudinal study. Eur Child Adolesc Psychiatry. 2019;28(8):1079-1086.

22. Rostila M, Saarela J, Kawachi I. Birth order and suicide in adulthood: evidence from Swedish population data. Am J Epidemiol. 2014;179(12):1450-1457.