Suicide is one of the leading causes of death for adolescents.1,3 Much recent research has been focused on our understanding of risk and protective factors. Central to suicide prevention is recognizing those at the greatest risk and implementing targeted interventions. To help identify risk, we often rely on what parents tell us.4 How valid are these reports? That is the question that Jones et al5 address in their study “Parent-Adolescent Agreement About Adolescent’s Suicidal Thoughts” in this issue of Pediatrics.

Previous studies have identified a lack of parental awareness about youth suicidal ideation6,10 or knowledge of their overall psychopathology7,11; however, small sample numbers limit the generalizability of these earlier studies. In their study, Jones et al5 help expand these findings in a cohort of 5137 adolescents from 11 to 17 years of age recruited from the Philadelphia Neurodevelopmental Cohort nonclinical sample. Concordance among parent and adolescent responses to questions such as, “Have you ever thought about killing yourself?” and “Have you ever thought a lot about death or dying?” were analyzed.5 The authors acknowledged limitations of the brevity of suicide-related assessment, the cross-sectional design, and potential for recall bias.5 They found that half (49.9%) of the parents were unaware of their children’s thoughts of killing themselves, and most (75.6%) were unaware of the adolescent’s recurrent thoughts of death.5 These findings confirm previous reports6,10 highlighting the limitations of parent reports of adolescents’ thoughts of death and suicide.

The authors also found that when parents reported that their children had thoughts of suicide, nearly half (48.4%) of their children denied suicidal thoughts, and many (67.5%) denied thoughts of death.5 This is in keeping with several previous studies in which authors describe the presence of inconsistencies between self-report and clinical records or interviews for adolescents’ endorsements of self-harm, suicidal thoughts, and attempts.12,14 Increasing chance of incorrect recall of suicidality over time has been shown in the past.15 Variable interpretation of questions may be an additional consideration,16 especially when responding to “Have you ever thought a lot about death or dying?” Nevertheless, denial of symptoms by adolescents in self-reports should be considered. Parental awareness of symptoms that adolescents may deny is a noteworthy finding of this study. Including parents and other sources of information in assessments may help capture a larger percentage of adolescents who are at risk.

The overall emphasis of the authors on improving the reliability of information obtained is important. Accurate identification and intervention for suicidal ideation and underlying risk factors are paramount to reducing the risk of suicide. However, strong predictors of suicide ideation (ie, depression) do not always predict suicide attempts.17,22 A 2017 national survey of adolescents showed that 17.2% had thoughts of suicide, 13.6% had an active plan, and 7.4% attempted suicide.23 It is critical to recognize that as many as 40% of adolescents who think about suicide act on these thoughts.19,23 This makes it important to achieve more specificity in identifying those most at risk for attempting among those with suicidal ideation. Interventions that are aimed more broadly at everyone with suicidal ideation and/or underlying risk factors (eg, depression) may not suffice in moving the needle on completed suicides. This is reflected in a nationally representative cohort of 6483 adolescents with suicidal ideation and attempts, in which >80% of those with suicidal ideation received some form of mental health treatment, and these treatments, focused on ideation (versus risk for attempting), did not prevent conversion to attempts in >55% of the cohort studied.19 Risk factors such as impulsivity, substance abuse, family and/or peer suicide history, and externalizing disorders are associated with suicide attempts.17,19,21 Those with a plan are at a higher likelihood of acting on their ideation.19 These risk factors can be used to help identify those most likely to attempt suicide with greater precision and inform treatments that target attempts. Authors of intervention studies have reported group and family therapies as advantageous over individual therapies in reducing suicide attempts versus suicidal ideation,24 although further research is needed.

Authors of the current study did not report on the psychopathology subtype, the presence of a plan, previous attempts, or therapy modality.5 The authors suggest their findings have implications for screening in primary care settings, recommending multiple sources of information and increased training for providers in assessing suicidal ideation.5 We agree with the recommendation that multi-informant assessments should be used, and disagreements should be carefully explored. Further research to improve our understanding of factors driving the denial of symptoms by adolescents and its relation to the risk for suicide attempts is needed. It may help inform screening as well as interventions and ultimately enhance our ability to effectively address suicide in adolescents.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: Funded by the National Institutes of Health (NIH).

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-1771.

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. Leading causes of death reports, 1981–2016. 2016. Available at: https://webappa.cdc.gov/sasweb/ncipc/leadcause.html. Accessed October 19, 2018
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. QuickStats: death rates for motor vehicle traffic injury, suicide, and homicide among children and adolescents aged 10–14 years — United States, 1999–2014. 2016. Available at: https://www.cdc.gov/mmwr/volumes/65/wr/mm6543a8.htm?s_cid=mm6543a8_w. Accessed October 19, 2018
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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.