While suicide in children and adolescents is fortunately a relative rare occurrence, it is obviously a tragic outcome.  Efforts to intervene can have impact and screening is one intervention that can help reduce injury and deaths by leading to critically needed referral for supportive interventions and treatment for those at risk.

The prolonged disruptions to daily routine and social activity resulting from pandemic constraints are now a universal and significant stressor for all youth and their families and, in this context, the need to assess for suicidal risk is now more important even for those who, in other respects, do not have previously identified disorders or recognizable risk factors or precipitants.

It is of note that suicidal ideation is not uncommon, across all age groups, and one of the challenges in screening for suicidal risk is that of differentiating those who are at actual risk of acting on their ideation from those with minimal or no risk.  This said, it is also clear that not all suicides are predictable or preventable, yet screening and then assessing risk levels are key steps in defining acute interventions that can help in developing both immediate and a long term oversight or management strategies.

RISK LEVELS:

Higher Risk:    Individuals at higher risk for suicide and/or self-harm would typically be characterized as having both significant acute and/or chronic stressors, coupled with longstanding vulnerabilities, such as substantial underlying mental health problems and/or chronic interpersonal and psychosocial challenges.  Higher levels of concern should be aroused for those individuals with prior suicidal behaviors, issues with impulsivity, current substance abuse behaviors, and disturbances in affect regulation.   The absence of core social support systems is another risk concern.

Access to means of self-harm such as unsecured weapons or excess medications in the home are key environmental factors that need to be explored and addressed with the patient and the family.  Interventions for individuals deemed to be at high risk should entail referral to a crisis mental health service where either inpatient admission or high intensity outpatient engagement can be provided.  When making a referral to such services, arranging for safe transport to the facility should be considered with care.  Follow through efforts by the primary care provider to monitor the patient’s compliance with such referrals is also advisable and the primary care provider can be a valuable touchstone for the patient and family through follow up monitoring and triage into the future.

Moderate risk:   Individuals who report significant suicidal ideation and or pervasive depression without intent and without other risk features identified above, typically should be directed to seek consultation and treatment with mental health providers with support of their families and with follow up contacts in primary care until there is clear engagement in treatment or clear evidence of resolution of the presenting problem(s).   Whether provided through the primary care office or through engagement of an external agencies (such as the Access and Crisis Line or the SmartCare program) it is important to assure that linkage with the relevant treatment resource is achieved and that follow up care is monitored.

No or minimal risk:   Fortunately, most patient screening will result in negative findings, and no need for follow up interventions.   This said, screening for risk is typically well accepted by patients as an indication of concern and likely will prime both the youth and family to respond proactively to engage with their primary care provider should issues or problems arise in the future.

THE TALK:   Having a “scripted” phrase or two can make the screening process far easier on providers.   For example, “As part of our clinic’s efforts to help keep everyone safe during these difficult times, we are asking all patients if they having serious emotional distress or having thoughts of hurting themselves, so I’ wondering if that is or has been an issue for you.”  This normalizes the question as being one that all patients are being asked and opens a door for further dialogue about folks’ functioning and adaptation.

The following “scripts” are examples of how one might respond based on your assessment of the patient level of risk

NO RISK: “Hey, that is great—glad to hear it.  If things ever get rough, do let us know so we can help you with getting help.”

LOW RISK:   “Thanks for sharing, it sounds like it could help if we could give you a hand in finding some resources to deal with these concerns and keep your situation under better control.”  Providing a list of community resources such as 211, referencing relevant advocacy groups or websites, and offering linkage to other service facilitators such as SmartCare or other trusted service providers would be appropriate next steps.  Finally, arranging for a follow-up visit or other communication about how things have evolved would be warranted.

MEDIUM RISK:  “I’m concerned that you are experiencing these difficulties, so let’s take a moment to set up some safety measures to keep you safe and get you support and assistance in resolving these problems.”   For patients deemed to have mid-level risk and vulnerability engagement of the family and/or trusted community support resources is warranted with a focus both on defining a Safety Plan (what to do and where to go if the stressors and the risks get further elevated) and on getting the youth and family engaged with formal service providers capable of working overtime to address the stressor or underlying conditions and problems.   Interactions with these patients should always include a closing note to the effect that “I want to hear from you next week or so to hear about how things are going.  Feel free to call me if you think you’re not making progress.”

HIGH RISK:  “We are going to arrange for you to get help now.”     Patients who report active suicidal and self-harm propensities with concurrent areas of vulnerability and/or active risk factors will need immediate attention and referral to appropriate resources for further evaluation and intervention.  If they are currently in treatment, contact with their current provider would be appropriate to assist in developing an action plan.  When risk concerns are acute, referral to a crisis evaluation service or hospital ER with attention paid to transport safety.  (See below for local resources.)

When immediate referral for ER/crisis services is deemed unnecessary, a Safety Plan identifying ways to reduce potential risk is warranted and should include the following:

• secure guns and other lethal items from accessibility
• identify a protocol for ongoing monitoring of the patient’s status
• scheduling follow up with the responsible behavioral health professional
• clarifying triggers for future contact with emergency resources, etc.

COMMUNITY RESOURCES

Emergency & Crisis Numbers

911
Emergency Response if you are experiencing a behavioral health emergency or in case of immediate threat of harm to self or others.

San Diego 24-Hour Access and Crisis Line
24/7 toll free availability for information on how to handle a behavioral health crisis.
1 (800) 479-3339

211 San Diego
2-1-1 San Diego connects people with community, health and disaster services through a free, 24/7 phone service and searchable online database.

HELPLINES

The National Suicide Prevention Lifeline
Available 24/7, toll-free 1-800-273-TALK

Crisis Text Line
Text BRAVE to 741-741  Anyone in the U.S. can receive free, 24/7 crisis support.

National Eating Disorders Association Helpline
1-800-931-2237; Toll-free, available Monday through Thursday, 9am-9pm, Friday 9am-5pm (EST)

National Runaway Safeline
1-800-RUNAWAY; Toll-free, available 24/7

National Sexual Assault Hotline
1-800-656-HOPE; Toll-free, available 24/7; Free instant messaging option available

Trevor Project
1-866-488-7386; Available 24/7; free texting and chat options available; for gay and questioning youth

HOSPITAL & CRISIS FACILITIES

Emergency Screening Unit (MediCal insured):   4309 Third Avenue; SD, CA 92103       619-876-450

Rady’s Behavioral Urgent Care 4305Unversity Avenue, Ste 150; SD, CA 92105             858-966-5484

Rady Children’s Hospital C&A Psychiatry; 8001 Frost St, Nelson Pavilion 92123       858-576-1000 x225800

Sharp Mesa Vista Hospital:    7850 Vista Hill Avenue SD, CA 92123                                  858-836-8434

Aurora Behavioral Healthcare SD Hospital   11878 Avenue of Industry SD, CA 92128    858-457-3200

 REFERENCES:

SmartCare E-Weekly Articles  http://www.smartcarebhcs.org/newsletters/

Developing & Implementing a Safety Plan 

https://www.vistahillccyp.org/developing-and-implementing-a-safety-plan-7-11-2019/

Suicidal Patients & COVID 19: Tips for Managing SI in a Telehealth World

http://www.smartcarebhcs.org/suicidal-patients-covid-19-tips-for-managing-si-in-a-telehealth-world-6-4-2020/

Adolescent Self-Harm & Suicide Risk: Management Strategies 9/10/2020

http://www.smartcarebhcs.org/adolescent-self-harm-suicide-risk-management-strategies-9-10-2020/

Non-Suicidal Self Injury

http://www.smartcarebhcs.org/non-suicidal-self-injury-11-2-2017/

Because of the prevalence of suicidal thoughts in adolescents (and other age groups), it is important for all medical and mental health providers to be comfortable asking questions related to suicide risk. The American Academy of Pediatrics 2016 guidelines on “Suicide and Suicide Attempts in Adolescents” urges pediatricians to screen patients for suicidal thoughts. The report identifies risk factors linked to teen suicide attempts, including:

1. Family history of completed suicide and suicide attempts
2. Personal history of suicide attempt and/or non-suicidal self-injury
3. History of physical, sexual or emotional abuse or neglect
4. Mood disorders and psychotic disorders
5. Drug and alcohol use
6. Sexual orientation
7. Firearms in the home
8. Strained parent-child relationship or living outside of the home
9. Poor school attendance and/or performance
10. Bullying, including cyber-bullying – highest risk in teens who are both bullies and victims of bullying
11. Internet exposure – particularly concerning if using more than 5 hours/day.
12. Male vs female: Girls more likely to make suicide attempts; boys more likely to have completed suicides.

Studies show that asking about suicide risk does not increase the risk of suicide attempts or “put the idea in the patient’s head” as some providers may be concerned about. It is helpful to talk with a teen patient privately to increase their comfort in disclosing sensitive information. With the stressors of the pandemic an ongoing concern for virtually everyone, it may be helpful to start a dialogue with a comment such as “The virus situation has really been a challenge for so many people and I’m checking in with all my patients to see how they are doing with all the changes and restrictions from normal activities. How are you doing?” If needed, following up on this general inquiry by asking about how things are going for the teen at home, with schoolwork, and with friends can help keep the dialogue going.   Clearly if the youth acknowledges any significant distress or depressive symptoms, a more specific inquiry such as “Have you ever thought about killing yourself or wished you were dead or never born?” would be appropriate, but given many teen’s reluctance to share emotionally sensitive concerns, it will always be appropriate to make the “ask”: “Have you ever done anything on purpose to hurt or kill yourself?”

Though for many this may feel like an emotionally charged inquiry, it is important to make the “ask” in a non-judgmental and matter of fact manner. If the answer to is yes, it is obviously important to obtain more details and it is particularly important to assess lethality and intent in determining the appropriate management. If the youth’s response is vague or otherwise unclear or seemingly uncomfortable, further dialogue is indicated.   If there is a concern about acute risk, a provider should err on the side of caution and seek out emergency mental health services.

In 2015, the US Preventive Task Force concluded that while they recommend relying on screening tools in the primary care setting to screen for depression in adolescents and adults, the evidence did not support using screening tools alone to screen for suicide risk in patients without a psychiatric disorder. When there is concern about depression, it is important to ask about suicide risk and there are questionnaires that can be useful: the PHQ9 has questions about thoughts of suicide and suicide attempts and the Columbia Suicide Severity Rating Scale is likewise a useful tool.

https://www.integration.samhsa.gov/clinical-practice/Columbia_Suicide_Severity_Rating_Scale.pdf

This report is relevant in that it highlights the importance for all providers to feel comfortable asking about suicide risk in patients. It is our hope that this article brings each of you closer to that goal.

References:

http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420

https://www.integration.samhsa.gov/clinical-practice/suicide-prevention#tools

https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/With-suicide-Now-Teens’-Second-Leading-Cause-of-Death-Pediatricians-Urged-to-Ask-About-its-Risks.aspx

Even in the best of times, the holidays are a time of heightened concern about mental health challenges and this year, with ongoing social constraints, family hardships, and individual and interpersonal stressors associated with the pandemic, sensitivity to the pressures and awareness of potential resources for those vulnerable and at-risk is of obvious importance.

While screening for vulnerability to emotional turmoil is a relevant primary care concern across all sectors of the population at all times of the year, awareness and inquiry about potential risks is particularly warranted for youth with unique sociocultural attributes in challenging times. Among the groups of concern are youth with mental illness and/or substance use disorders, those with prior suicidal behavior and those exposed to losses of friends and loved ones from suicide, youth with disabilities and chronic health conditions, those from institutionally and economically marginalized ethnic communities, and youth with non-mainstream sexual preference and identity issues.

Following are resources distributed to the community by the San Diego County Office of Education.

Created by the SDCOE Student Wellness Positive School Climate Department-September 2020

Because of the prevalence of suicidal thoughts in adolescents, it is important for all medical and mental health providers to be comfortable asking questions related to suicide risk. With these new findings, the American Academy of Pediatrics revised their 2007 guidelines on “Suicide and Suicide Attempts in Adolescents” this month to urge pediatricians to screen patients for suicidal thoughts. The report identifies risk factors linked to teen suicide attempts, including:

1. Family history of completed suicide and suicide attempts
2. Personal history of suicide attempt and/or non-suicidal self injury
3. History of physical, sexual or emotional abuse or neglect
4. Mood disorders and psychotic disorders
5. Drug and alcohol use
6. Sexual orientation
7. Firearms in the home
8. Strained parent-child relationship or living outside of the home
9. Poor school attendance and/or performance
10. Bullying, including cyber-bullying – highest risk in teens who are both bullies and victims of bullying
11. Internet exposure – particularly concerning if using more than 5 hours/day

Screening for suicidal thoughts is important, and studies show that asking about suicide risk does not increase the risk of suicide attempts or “put the idea in the patient’s head” as some providers are concerned. It is helpful to talk with a teen patient privately to increase their comfort in disclosing sensitive information, but it is also important to review mandated reporting with the teen. An example of an appropriate screening question is: “Have you ever thought about killing yourself or wished you were dead or never born?” It is best to embed a question like this in the middle of other questions about depressive symptoms, after asking more general questions about how things are going for the teen at home, at school, with friends, etc. The follow up question could be “Have you ever done anything on purpose to hurt or kill yourself?” If the answer to either question is yes, it is important to obtain more details. It is particularly important to assess lethality and intent in determining the appropriate management. In most cases, if there is a concern about acute risk, a provider should err on the side of caution and seek out emergency mental health services.

This report is relevant in that it highlights the importance for all providers to feel comfortable asking about suicide risk in patients. It is our hope that this article brings each of you closer to that goal.

References:

http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420

http://www.usatoday.com/story/news/health/2016/06/27/pediatricians-urged-screen-suicide-risks-among-teens/86348186/

https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/With-suicide-Now-Teens’-Second-Leading-Cause-of-Death-Pediatricians-Urged-to-Ask-About-its-Risks.aspx

Multiple previous studies have shown a link between childhood bullying and the development of childhood mental health concerns, like low self-esteem, depression, poor academic performance and even an increased risk of suicidal thoughts and suicide. This is one of the first efforts to assess the longer-term effects of childhood bullying.

In the study, children were assessed for involvement with bullying (whether they were bullying others or being bullied by others or both) at age 8, then followed up with in their late teens and early adulthood. What was found was that the patients who were involved with bullying in childhood (whether they were being bullied by others or bullying others) were twice as likely to be receiving treatment for a psychiatric condition compared to the patients who were not involved with bullying in childhood. The group that was involved both in being bullied and being bullies themselves fared the worst – they were three times as likely to be receiving psychiatric treatment and were more likely to have more serious diagnoses like schizophrenia, substance abuse and mood disorders.

It is important to be aware of and address bullying with our pediatric patients. It is particularly important to be aware if a child is involved both as a bully and as a victim, because he is at a higher risk for serious problems both in childhood and adulthood.

Here are some additional resources that you may find helpful with regard to bullying.

https://www.sandiegounified.org/parents-and-guardians-bullying-and-intimidation-facts for information about San Diego Unified School District’s policy on bullying and their online bullying reporting system.

https://www.stopbullying.gov/index.html for information and support on bullying.

http://www.pacer.org/bullying/ for information and support on bullying.

References:

Association of Bullying Behavior at 8 Years of Age and Use of Specialized Services for Psychiatric Disorders by 29 Years of Age; JAMA Psychiatry, Online First, December 9, 2015.