Among younger children, suicide attempts are often impulsive. They may be associated with feelings of sadness, confusion, anger, or problems with attention and hyperactivity.
Depression and suicidal feelings are treatable mental disorders. The child needs to have his or her illness recognized and diagnosed, and appropriately treated with a comprehensive treatment plan.
Risk factors include:
- Family history of suicide attempts
- Exposure to violence
- Aggressive or disruptive behavior
- Access to firearms
- Feelings of hopelessness or helplessness
- Acute loss or rejection
Children thinking about suicide may make openly suicidal statements or comments such as, "I wish I was dead," or "I won't be a problem for you much longer."
Other warning signs associated with suicide can include:
- changes in eating or sleeping habits
- frequent or pervasive sadness
- withdrawal from friends, family, and regular activities
- frequent complaints about physical symptoms often related to emotions, such as stomachaches,
- headaches, fatigue, etc.
- decline in the quality of schoolwork
- preoccupation with death and dying
Rather than putting thoughts in a child's head, the following questions can provide assurance that somebody cares, and your office is a safe place to talk about problems.
- Are you feeling sad or depressed?
- Are you thinking about hurting or killing yourself?
- Have you ever thought about hurting or killing yourself?
For adolescents 11-17, the PHQ 9 should be implemented and the 9th question, when at all positive. PCPs may use the SAFE-T or the Columbia Suicide Severity Rating Scale (CSSRS). for further investigation of suicidal ideation.
Managing Suicide Risk in Pediatric Primary Care:
Addressing suicide prevention and management as a team effort addresses several key issues. It makes it clear that awareness of suicide risk and prevention is part of the job of all staff, working within their role. The identification of concerns, assessment of risk and follow-up does not rest on one staff person.
Effective management rests on the development and of following a thoughtful and structured approach such as:
- Initial screening may be most effectively carried out by the medical assistant, or even the office staff as they check-in the patient for their appointment. Both screens are designed for the patient to fill out in their own, not as a question and response.
- Interpretation of screening results and assessment of risk will often fall to the medical practitioner who reaches level-of-care decisions in collaboration with the family and, perhaps, the behavioral health clinician.
- Development and tracking of a Collaborative Safety Plan fits easily into the role of a behavioral health clinician as they also may be involved in short-term follow-up pending a referral for therapy.
- Referrals, safety planning and assured follow-up may be best accomplished by the behavioral health clinician but may also involve a care manager if available.
Workflow for Addressing Suicidal Ideation in Pediatric Primary Care:
- The identification of suicide risk as a presenting problem in an office visit is unsettling to even the seasoned practitioner. However, 80% of adolescents who die from suicide have had contact with a medical professional in the 3 months before their death, most often their primary care provider.
- Normalizing a workflow to assess and manage suicide risk is key to pediatric practice.
- First step: Breathe deeply and stay calm. If the youth is sharing the concern with you, they are looking for help through this crisis. Even if potential risk was revealed through the PHQ-A, they have chosen to share their concerns with you. They trust you.
- Use an evidence-based tool such as the C-SSRS (Columbia - Suicide Severity Rating Scale to frame and document an assessment and guide your interventions. If the 9th question on the PHQ A is at all positive, the C-SSRS or a clinical interview about suicidal risk is always indicated.
- Using the clinical information, determine a level-of-care need based on assessed risk.
- If acute risk is present (often this means that a plan, means and intent indicated), facilitate emergent referrals needed to ensure safety.
- If assessed risk is low (thoughts of suicide with no plan and with adequate support in place) facilitate completion of Collaborative Safety Plan and refer to needed services to address drivers of risk and/or untreated mental health concerns.
- Consider an app such as MY3 to make it easier for the patient to connect with resources and support.
- Regardless of level of risk, ensure that a follow-up visit is scheduled with your practice and ensure that you reconnect with your patient in a timely manner.
- Within 72 hours post discharge from an inpatient unit,
- Within 1 week for sub-acute risk to ensure that safety plan is in place and risk remains low.
- Work with the patient and family to develop and implement a Collaborative Safety Plan to
- support coping skills and engagement with social, family and professional supports to address
- the next crisis before it happens.
- Safety Plan prepared with the patient, never for them. They must be part of the planning process.
- Transfer any paper plan to a phone app or have the patient take a picture of it with their phone.
- Safety plan is target for tracking improvement in follow-up sessions.
- Plan may be shared with parents or other support persons identified by the patient and forwarded to other engaged providers.
Visit the Primary Care pages of the SPRC website: www.sprc.org/for-providers/primary-care.
The Education Development Center's Suicide Prevention Resource Center (SPRC) Zero Suicide Initiative website: http://zerosuicide.sprc.org/.
Zero Suicide is a key concept of the 2012 National Strategy for Suicide Prevention, a priority of the National Action Alliance for Suicide Prevention (Action Alliance), a project of Education Development Center's Suicide Prevention Resource Center (SPRC), and supported by the Substance Abuse and Mental Health Services Administration (SAMHSA). The foundational belief of Zero Suicide is that suicide deaths for individuals under care within health and behavioral health systems are preventable. It presents both a bold goal and an aspirational challenge.
For health care systems, this approach represents a commitment:
- To patient safety, the most fundamental responsibility of health care
- To the safety and support of clinical staff, who do the demanding work of treating and supporting suicidal patients
The programmatic approach of Zero Suicide is based on the realization that suicidal individuals often fall through cracks in a fragmented, and sometimes distracted, health care system. A systematic approach to quality improvement in these settings is both available and necessary.
The challenge and implementation of a Zero Suicide approach cannot be borne solely by the practitioners providing clinical care. Zero Suicide requires a system-wide approach to improve outcomes and close gaps. For more information, visit: http://zerosuicide.sprc.org/.