Suicide Risk in Children and Adolescents

Suicide risk assessment in youth should distinguish chronic vulnerability from acute danger. Prior suicide attempt or self-harm is a major distal marker of chronic risk, whereas current suicidal ideation, method or plan, intent, and preparatory behavior identify acute escalation. Document the risk designation, its rationale, actions taken, and the next reassessment or treatment step. ScienceDirectScienceDirectAssessment and Management of Suicide Risk in Children and Adolescents

Do not infer low risk from age, apparent developmental immaturity, parental lack of awareness, or a negative depression screen. In a nationally representative U.S. sample of 9- and 10-year-olds, lifetime suicidal ideation was reported by 14.33% and attempts by 1.26%; parent-child agreement for ideation and attempts was low. NatureNaturePrevalence and correlates of suicidal ideation and suicide attempts in preadolescent children: A US population-based study | Translational Psychiatry

The USPSTF recommends depression screening for adolescents aged 12 to 18 years when systems are available for diagnosis, treatment, and follow-up, but found insufficient evidence to determine benefits and harms of screening specifically for suicide risk in children and adolescents. JAMAJAMAScreening for Depression and Suicide Risk in Children and ... In behavioral health settings, structured assessment can improve consistent detection and documentation, but it does not substitute for formulation and management. Wolters KluwerWolters KluwerAssessing Suicide Risk in a Pediatric Outpatient... : Pediatric Quality & Safety

The pediatric Columbia-Suicide Severity Rating Scale (C-SSRS) is a semistructured clinician-administered instrument that captures lifetime and recent ideation and behavior from youth and caregiver report. In a pediatric outpatient behavioral health quality-improvement program, EHR-supported implementation achieved mean completion of 97.7% and increased documentation of suicide-related problem-list items from 1.47% to 5.66% monthly. Wolters KluwerWolters KluwerAssessing Suicide Risk in a Pediatric Outpatient... : Pediatric Quality & Safety

A youth under evaluation for suicidal thoughts or behavior should not leave before assessment is complete. Use an environment that reduces access to dangerous objects and apply observation according to local policy and the patient’s acuity. Obtain collateral information from caregivers, emergency medical services, school personnel, and outpatient clinicians when relevant; information may be obtained without consent when necessary to address an imminent and serious safety threat. acepacepManaging Suicidal Patients in the Emergency Department

Perform a focused medical assessment directed by history and examination, including ingestion, trauma, intoxication, delirium, medication effects, and medical illness affecting cognition or behavior. Routine nontargeted laboratory or radiographic testing has not demonstrated clinical benefit in emergency psychiatric assessment. acepacepManaging Suicidal Patients in the Emergency Department

If intoxication or impaired cognition prevents meaningful assessment, observe and reassess after cognitive capacity returns. Do not use a specific blood alcohol threshold as a proxy for assessment readiness. acepacepManaging Suicidal Patients in the Emergency Department

Psychiatric hospitalization is generally indicated for youth with a potentially lethal attempt, persistent suicidal ideation with strong intent, suicide rehearsal, or inability to maintain safety in a supervised environment. Voluntary hospitalization is preferred when feasible; involuntary evaluation or treatment must follow state-specific law. acepacepManaging Suicidal Patients in the Emergency Department

Outpatient management may be possible only after a complete assessment when imminent risk is judged acceptably low, the youth can engage in a safety plan, caregivers can provide supervision, lethal means can be restricted, and rapid follow-up is secured. Do not discharge solely because the patient denies current ideation after an attempt, intoxication resolves, or a caregiver promises monitoring. ScienceDirect+1ScienceDirectAssessment and Management of Suicide Risk in Children and AdolescentsacepManaging Suicidal Patients in the Emergency Department

A safety plan is a personalized, written sequence for recognizing escalating risk and using coping and help-seeking strategies. It should identify warning signs, internal coping strategies, distracting social settings or contacts, persons to ask for help, professional and crisis resources, and actions to make the environment safer. It differs from a no-suicide contract, which is insufficient and ineffective for risk management. ScienceDirect+1ScienceDirectAssessment and Management of Suicide Risk in Children and AdolescentsacepManaging Suicidal Patients in the Emergency Department

Include the caregiver in the safety plan whenever appropriate, with explicit roles for supervision, help-seeking, medication control, and means restriction. Protective reasons or social supports may guide intervention targets, but they should not be converted into a simplistic formula that negates acute risk. NatureNatureDevelopment and validation of the SuPr-10 questionnaire ...

Lethal-means counseling should specifically address firearms and toxic medications. During a suicidal crisis, recommend off-site firearm storage when legally feasible; if firearms remain in the home, they should be locked, unloaded, and separated from ammunition, with the youth unable to access them. Restrict and supervise access to potentially toxic medications. acepacepManaging Suicidal Patients in the Emergency Department

Address depressive, anxiety, trauma-related, disruptive behavior, substance use, psychotic, and other psychiatric syndromes as part of the longitudinal plan. In preadolescent youth, major depressive disorder, generalized anxiety disorder, conduct disorder, oppositional defiant disorder, and ADHD were associated with suicidal ideation; psychiatric comorbidity was associated with higher odds of both ideation and attempts. NatureNaturePrevalence and correlates of suicidal ideation and suicide attempts in preadolescent children: A US population-based study | Translational Psychiatry

For adolescents with recurrent suicidal behavior or self-harm, dialectical behavior therapy for adolescents has the strongest evidence among psychological interventions. In a randomized trial of high-risk adolescents, DBT reduced suicide attempts after treatment versus individual and group supportive therapy (odds ratio 0.30, 95% CI 0.10-0.91), although between-group differences were not significant at 12 months. NatureNaturePsychological interventions for suicidal behavior in adolescents: a comprehensive systematic review | Translational Psychiatry A systematic review concluded that DBT was the only intervention with replicated evidence across independent adolescent trials; evidence for CBT, family therapies, mentalization-based therapy, and brief interventions remains less conclusive. NatureNaturePsychological interventions for suicidal behavior in adolescents: a comprehensive systematic review | Translational Psychiatry

Medication may be indicated for a co-occurring psychiatric disorder, but pharmacotherapy should not replace direct suicide-focused assessment, safety planning, means safety, and psychotherapy. Antidepressants may be associated with increased suicidality risk in children, adolescents, and young adults, requiring appropriate monitoring when prescribed. acpjournals+1acpjournalsComparative Benefits and Harms of Second-Generation ...acpjournalsDepression | Annals of Internal Medicine

Document the nature, frequency, duration, and trajectory of suicidal thoughts; plan, intent, access, preparations, and past behavior; collateral information; acute and chronic risk formulation; protective and environmental factors; disposition rationale; safety plan; lethal-means counseling; caregiver participation; and exact follow-up arrangements. ScienceDirect+1ScienceDirectAssessment and Management of Suicide Risk in Children and AdolescentsacepManaging Suicidal Patients in the Emergency Department

Standardized workflows, clinician training, and EHR integration can improve reliability. In pediatric outpatient behavioral health care, structured C-SSRS use with EHR prompts improved documented identification of suicide-related risk without delaying encounter closure. Wolters KluwerWolters KluwerAssessing Suicide Risk in a Pediatric Outpatient... : Pediatric Quality & Safety