A 16-year-old presents to her pediatrician with a several week history of low mood, withdrawal from friends, isolation from family, decrease in grades and suicidal ideation. She has no history of suicide attempt but recently has been cutting herself during times of severe distress. She reports hopelessness and does not see how anything could get better. How can the pediatrician screen and assess for suicide risk factors, as well as provide interventions to decrease this patient’s risk of suicide?
An updated AAP clinical report provides guidance on the assessment and evaluation of adolescents for suicide risk, as well as evidence-based screening tools, safety assessments and treatment recommendations. It also describes factors contributing to increased risk of suicide, including individual, relationship, societal and structural factors, and encourages pediatricians to promote protective factors during well-child visits.
The report Suicide and Suicide Risk in Adolescents, from the Committee on Adolescence and Council on Injury, Violence and Poison Prevention, is available at https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2023-064800 and will be published in the January issue of Pediatrics.
Rising rates of suicide, attempts
The suicide rate in youths ages 10-24 years has been increasing since 2007. Suicide now is the second leading cause of death in this age group in the United States.
Suicide attempts also are rising. A large percentage of high school students have experienced suicidal ideation, with the highest prevalence among youths who are American Indian/Alaska Native (AI/AN); lesbian, gay or bisexual; or female. AI/AN youths have the highest rates of suicide in the U.S., and rates of suicide in Black youths are increasing faster than in other racial groups.
The clinical report explains the framework for the Blueprint for Youth Suicide Prevention, which recommends a three-tiered pathway for supporting youths at risk for suicide: 1) brief screen, 2) brief suicide safety assessment (BSSA) for those who screen positive and 3) decision on disposition based on the safety assessment.
Two evidence-based screeners are described: the Patient Health Questionnaire-9 (PHQ-9) and the Ask Suicide Screening Questions (ASQ). The PHQ-9 does not screen for suicide risk as the ASQ does, but in combination, they can screen for depression and suicide risk.
If an adolescent screens positive for suicidal ideation, a brief suicide safety assessment such as the ASQ-BSSA or the Columbia Suicide Severity Rating Scale can be used to assess risk. Following the safety assessment, plans for intervention and disposition can be made.
Interventions include safety planning, counseling to decrease access to lethal means and engaging adolescent patients and their families in treatment. Cognitive and dialectical behavioral therapeutic strategies are used in suicide prevention. Examples include the Family Intervention for Suicide Prevention, Safe Alternatives for Teens and Youth and attachment-based family therapy.
Other interventions may include referral to a mental health specialist (outpatient, inpatient, crisis team); use of integrated behavioral health care programs or access lines to aid in determining appropriate interventions; and psychopharmacotherapy.
The clinical report also gives guidance on the portrayal of suicide in the media, supporting families who experience a suicide attempt or death of a loved one and supporting health care providers who have lost a patient to suicide.
Recommendations for pediatricians
Key recommendations include the following:
- Screen for suicide risk as part of well-child visits starting at age 12 years, as well as during higher-risk situations between well visits. Screening for suicide risk also is recommended during emergency department visits and hospitalizations for physical health reasons.
- Be aware of factors that increase risk of suicide, including past attempts, substance abuse, history of trauma and minoritized status.
- Assess for protective factors such as patient strengths and family/community support to minimize risk factors and promote protective factors.
- Set aside one-on-one time to evaluate adolescents individually.
- Follow up a positive suicide risk screen with a brief suicide screening assessment.
- Engage in safety planning, assess for presence of lethal means in the home and educate on safe storage of firearms and medications. Recommend removal of firearms if the patient is suicidal.
- Include family in treatment and suicide prevention efforts.
- Refer to mental health specialists as necessary and make use of integrated behavioral health providers where available and child psychiatry access lines where access is low.
- Advocate for suicide prevention research in minoritized youth and those in the child welfare and juvenile justice systems, as well as increased access to care.
Dr. Hua is the liaison from the American Academy of Child and Adolescent Psychiatry to the AAP Committee on Adolescence. She is a lead author of the clinical report.
- Blueprint for Youth Suicide Prevention
- Information for parents from HealthyChildren.org on how to help prevent suicide
- To reach the 988 Suicide and Crisis Lifeline, dial 9-8-8 or text HOME to 741741.
- Additional resources can be found in the clinical report.