LETTERS TO THE EDITOR What Happens to Children Whose Parents Commit Suicide? To the Editor: uicide remains one of the leading causes of death among 25- to 49-year-olds in the United States, and each year roughly 30,000 children are victims of parental suicide in the United States (Center for Disease Control and Prevention, 2005). 1 We report a case of a young child who lost both of his parents to suicide. CASE PRESENTATION S.T. is an 8-year-old boy with a history of posttraumatic stress disorder (PTSD) due to early childhood trauma that manifested with nightmares, flashbacks, bad memories, hypervigilance and hyperarousal, separation anxiety disorder (SAD), and attention-deficit/hyperactivity disorder (ADHD). S.T. was formally adopted when he was 4 years old, but he lived with his adoptive parents since he was 2.5 years old. When S.T. was 2 years old, his biological father committed suicide by hanging himself in the basement of their house. The biological father was found by S.T.’s biological mother, who had struggled with significant depression and chronic suicidality herself. S.T. and his biological mother lived by themselves for about 6 months. During that time, the biological mother was unable to function. At the age of 2.5 years, S.T. and his biological mother moved in with his adoptive parents. They were several generationsremoved family members. Between the ages of 2.5 and 4 years, S.T.’s biological mother attempted suicide on numerous occasions and eventually killed herself by overdosing on insulin. The adoptive parents reported that at the age of 2.5 years, S.T. was nonverbal. His bedtime routine was elaborate and consisted of setting up his blankets in a very meticulous way. He had severe nightmares every night. S.T. was inconsolable upon waking in the middle of the night, and he would not allow anyone to console him. To his consultation, S.T. presented with severe separation anxiety. When his adoptive parents would drop him at school, they had to reassure S.T. numerous times that they were going to pick him up. His medications included sertraline (50 mg daily) for anxiety, lisdexamfetamine dimesylate (50 mg daily) and guanfacine [(1 mg daily) for ADHD, and trazodone (25 mg at bedtime) with melatonin (dosage unknown) for insomnia. S.T. has also been attending therapy since the age of 5 years, which was initially all play therapy but recently transi- tioned into more trauma-focused narrative therapy. During the consultation, it became apparent that S.T. was very confused by his parents’ deaths. When asked directly about his parents’ deaths, he said they died because of their health issues, but he could not understand how a young person could have died so suddenly. Over the course of his childhood, he developed a significant fear that he was going to die and that his adoptive parents would die. When asked if he could have 3 wishes in his current life, he said that he was not going to ask to have his biological parents back because they were happy in heaven and he was happy with his adoptive parents. The consulting child psychiatrist discussed with the adoptive parents the need to talk to S.T. about his biological parents’ suicides. Together they concluded that the longer they waited, the more potential harm might be done to the patient. His adoptive parents seemed to be relieved when discussing recommendations, as they were uncomfortable with keeping secrets from S.T. It was emphasized that the conversation should take place in a safe and calm atmosphere and that the adoptive parents should be the ones to share the information with S.T. The patient’s therapist suggested that the adoptive parents tell S.T. that they would put the story of his biological parents into a “suitcase” and that they will “carry” it for him until he is ready to “open it.” They explained to him that biological parents made a choice to take their own lives because they were sad. S.T. was upset; he did not understand how his mother “chose to take her life if she went to the hospital.” At first, he did not want to explore it with his therapist for several sessions, but when he was ready, he created a story of a superhero who lost his parents but was able to overcome his sadness. There were no discernible behaviors at school, and in fact S.T. has continued to do well with his academics and friends. DISCUSSION We have described the case of an 8-year-old boy who survived the suicides of both of his parents. We fear that, with the opioid epidemic, there is a growing population of children who lose both of their parents to accidental or intentional overdose. To our knowledge, there are only a handful of studies that address bereavement in youth who lose one of their parents to suicide. 2 It is known that those children are at increased risk for developing depression and alcohol or substance abuse as compared with children who have lost their parents to cancer or sudden natural death. 3 Recently, Kuramoto et al. published findings from a population-based retrospective cohort study that showed that survivors of parental suicide in early childhood had the highest cumulative risk for being hospitalized for their own suicidal behavior. 4 We do believe that there are important research questions about our clinical work with such children of various ages. Should these children be closely followed up because of their own increased risk for suicide? When and what should be shared with the child? In the absence of research evidence, we believe that the truth, albeit difficult, is better than secrets or lies. However, the details of what is shared with children should be assessed on a case-by-case basis. Magdalena Romanowicz, MD Alastair J. McKean, MD Jennifer L. Vande Voort, MD Accepted March 8, 2018. Drs. Romanowicz, McKean, and Vande Voort are with the Mayo Clinic, Rochester, MN. The authors acknowledge and thank the patient and his family for allowing them to share their story. Disclosure: Dr. Vande Voort is a coinvestigator on an investigator-initiated study that has a grant-in-kind for supplies and genotyping from AssureRx Health, Inc. Drs. Romanowicz and McKean report no biomedical financial interests or potential conflicts of interest. Correspondence to Magdalena Romanowicz, MD: romanowicz.magdalena @mayo.edu 0890-8567/$36.00/ª2018 American Academy of Child and Adolescent Psychiatry https://doi.org/10.1016/j.jaac.2018.01.022 S Journal of the American Academy of Child & Adolescent Psychiatry www.jaacap.org 351 Volume 57 / Number 5 / May 2018