Dr. Whalen et al. reply.

T he recent article in the November 2015 issue of the Journal by Whalen et al. 1 reported that 11% of their sample of 3-through 7-year-old children manifested some form of suicidal cognition or behavior (SI). Because this study represented the first systematic examination of suicidal cognitions and behaviors in very young children , the authors are to be commended. However, an apparent inconsistency in the findings seems worthy of follow-up. Endorsement of SI during 3 to 7 years of age was the strongest predictor of SI during 7 to 12 years of age, yet endorsement of SI during 3 to 7 years was not associated with a diagnosis of depression during 3 to 7 years after controlling statistically for several covariates, which raises a question about the validity of the measurement of SI. The authors measured SI with questions from the Preschool Age Psychiatric Assessment (PAPA) 2 that covered 3 items: thoughts about death or suicide, suicidal plans, and suicidal attempts. In their sample of 306 young children, at least 1 of these items was endorsed 37 times, 76% of which was accounted for by thoughts about death or suicide. An important issue seems to be, what did thoughts of death or suicide sound like? The online supplement provided examples of 6 cases but appears to have provided only the most clearly suicidal statements. I have similar data from a group of 330 children 3 through 6 years of age, of whom 284 were exposed to trauma. 3 This letter reports the data on suicidal items for the first time. Using the same questions from the PAPA, I found that 42 met these SI criteria. Consistent with Whalen et al., the item " Thinking about death " was by far the most commonly endorsed. Of the 42 who met SI criteria in our sample, 83% were accounted for by those who endorsed only " Thinking about death. " We took it a step further and examined what parents reported as examples of these items. Although some examples seemed to reflect suicidal thoughts, such as " Says he wants to die and would cut himself, " the vast majority seemed to be more curious about death and/or normal developmental play, such as " Asks 'Am I going to die', " " Asks questions about what happens after death, " " Killing bugs and shooting games, " " People drown or …