Suicides in children and early adolescents: a retrospective review from a large metropolitan area

Suicide in individuals younger than 14 years remains an underrecognized and understudied phenomenon in forensic pathology, despite increasing incidence and substantial medicolegal implications. Although children are often presumed incapable of understanding death or engaging in intentional self-harm, psychiatric evidence indicates that by age 8 many possess a conceptual understanding of death and suicidal behavior. This retrospective study examines suicidal deaths in subjects under 14 years of age investigated at a large urban medical examiner's office, emphasizing autopsy findings and medicolegal interpretation. The digital database of the Cook County Medical Examiner's Office was searched for deaths certified as suicide between 2015 and 2023. Cases certified as 'undetermined,' in which suicide was a reasonable diagnostic consideration, were reviewed as well. Fifty-three suicides and 2 undetermined deaths met the inclusion criteria. Cases were stratified into childhood (6-11 years) and early adolescence (12-14 years). Autopsy, toxicology, investigative, and police reports were reviewed. For suicides, temporal and environmental variables were also evaluated. Hanging was the most frequent suicide method, followed by firearm injuries and drug toxicity. Identifiable ligature marks were present in most cases, commonly discontinuous and located at or above the thyroid cartilage, without associated cervical skeletal fractures. Firearm suicides were confined to young teens and predominantly involved contact wounds to the head. Drug-related deaths involved readily accessible prescription or over-the-counter medications. In undetermined cases, overlapping investigative and autopsy features precluded definitive certification, highlighting the evidentiary constraints of pediatric death investigations. This study highlights that pediatric suicides often demonstrate recognizable autopsy findings and injury patterns. Accurate manner of death determination requires careful integration of scene investigation, autopsy findings, and contextual information, while avoiding speculation.