1. Introduction
Suicide attempt in children under 10 years of age is a warning and a matter of concern. It can be an important indicator for evaluating the mental health of individuals in the community. Although all age groups are affected by this phenomenon, the highest incidence is related to 15-30 years age group. Studies on suicidal behavior in children are limited and with small sample sizes. Therefore, its global epidemiology and risk factors in the age group <10 years are unknown and there is need for identifying the risk factors contributed to suicidal behavior in children. The Centers for Disease Control and Prevention reported a suicide rate of 0.17 per 100 000 people in youth between the ages of 5 and 11 years. Between 2008 and 2015, a total of 14,852 children aged 5-11 years with suicidal ideation or suicide attempt were hospitalized in the United States, mostly due to mood disorders including suicide. During 1993-2001 in Iran, there was a total of 3225 suicides among children and adolescents in Iran where the ratio of boys to girls was 3.7:1. 

2. Case Report
The case was an 8-year-old boy with three suicide attempts by hanging referred to the psychiatric clinic of Shahid Mostafa Khomeini Hospital in Ilam, Iran by his parents. They were living in one of the villages of Ilam city. This family had five children; the case was the fourth child of this family studying in the grade-2 elementary school. He had average grades with no hyperactivity or aggressive behaviors at school. His parents stated that he hanged himself in a barn three times during 2018-2019, but he had been saved by his older sister. His parents had elementary education with a monthly family income of 1-1.5 million Tomans. They had no family history of suicide or mental illness. Rural life and large family size, cause young children not receive much psychological and emotional support. Psychiatric assessment was performed in a clinic. The results revealed that he had a major depressive disorder (undiagnosed). Hence, he treated with 12.5 mg sertraline daily for one week and then the dosage increased to 25 mg daily. During this period, psychotherapy based on emotional release was carried out. Throughout this period, which lasted several weeks, his responds to treatment somewhat improved such that in the fifth session, he began to cry. Then, his behavior was assessed by parents using the Child Behavior Checklist (CBCL). He is currently under treatment by a psychiatrist and is visited monthly, and has not attempted suicide again. 

3. Discussion and Conclusion
This study aimed to report behavioral-emotional disorders in an 8-year-old boy with attempted suicide by using the CBCL and psychiatric diagnosis. The CBCL was completed by one of his parents. It can be completed as a self-report or through interview. It measures 8 emotional-behavioral problems under three categories of internalized problems, externalized problems, and general problems. The CBCL scores showed that the boy had higher scores in aggressive behavior, attention problems, rule-breaking behavior, and anxious/depressed subscales. The externalized problems were predominant. His psychiatric assessment revealed that he had major depressive disorder. Suicide attempt among children aged <10 years compared to other age groups is rare, and are commonly had specific behavioral disorders. A stressful event may trigger suicide in children who have mental problem such as depression. These children are usually anxious and inactive, and change their behaviors quickly. Untreated depression is an important factor in suicide attempts in children. In the study boy, undiagnosed depression and lack of support by parents led to suicide attempts. Parent-child conflict is a hidden factor that accelerates suicide attempts among children, and hanging is one of the most common method of suicide in these children. 
The boy had reasonable demands such as being loved, and buying him toys and clothes but his parents could not provide them due to high number of children in the family and the parents’ financial inability. These factors cause the inability of parents to meet the various needs of children and creates child neglect in the family. Children with depression have a high tendency to commit suicide. Exposure to acute stressors can exacerbate this condition. Therefore, improving the parent-child relationship and eliminating the children’s emotional deprivation can be effective in reducing the incidence of suicide in children. Emotional-behavioral problems in childhood are associated with many functional impairments in various areas of life. Therefore, preventive services in the health care system such as a safe care program as in-home training program with an emphasis on child-parent conflicts, safe family environment, and child health can effectively reduce these disorders. Moreover, teachers need to be educated on the mental health to detect students’ behavioral disorders. 

Ethical Considerations
Compliance with ethical guidelines
This article is taken from the registered cases of suicide attempts in Ilam province approved by Ilam University of Medical Sciences (Ethics Code: IR.MEDILAM.REC.1398.056).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors contributions
Conceptualization and supervision: Amir Adibi; Research and data collection: Ali‌ Ashraf Mozafari and Ali Sahebi; Writing – original draft, and writing – review & editing: Elham Shafiei; Review and editing: Ali Sahebi and Ali‌ Ashraf Mozafari. 

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We would like to thanks the Clinical Research Development Unit, Shahid Mostafa Khomeini Hospital, Ilam University of Medical Sciences.

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