Learning Objectives

After the webinar, clinicians should:

1. Understand epidemiology of suicide in children and adolescents in the United States
2. Develop competency in suicide assessment in the pediatric population
3. Explain the role and importance of documentation in suicide assessment of children and adolescents
4. Summarize some of the current research findings in psychiatric treatment

Hello, my name is Sandra Hyams and I'm here to talk to you about suicide assessment and documentation in children and adolescents, part of a Carlat webinar. I am a psychiatric nurse practitioner and I work at John Peter Smith Hospital, part of Acclaim Multi-Specialty Group in Fort Worth, TX. I have no conflicts or disclosures.

After this webinar, clinicians should understand epidemiology of suicide in children and adolescents in the United States; develop competency in suicide assessment in the pediatric population; explain the role and importance of documentation in suicide assessment of children in adolescents; and summarize some of the current research findings in psychiatric treatment.

[Transcript edited for clarity]

Why are we talking about pediatric suicide now?

Overall, suicide rates have been increasing in children and adolescents over the last 20 years. Many children and adolescents have warning signs, and we'll talk about them a little later. Suicide is preventable. There are interventions, assessments that psychiatric providers and even non-psychiatric providers can do that can change the course.

This is a table from the Centers of Disease Control on the leading causes of death in United States for different age groups. On the left side, you can see the younger age groups, and that from 10 to 34 suicide is either the second or third leading cause of death. Interestingly, the data has changed from 2018 to 2020. In 2018, suicide was the second leading cause of death for this young age group. But in 2020, for that 15 to 24 age group, homicide has actually exceeded suicide.

On this slide, you can see a color-coded map of the United States based on the suicide rate per capita, and specifically we're looking at suicide deaths per 100,000 for ages 15 to 24. And what we can see is that the darker areas signify higher per capita suicide rates in this population, and the lighter areas signify fewer. What we can see is that the states of South Dakota, Montana, Wyoming, Colorado, New Mexico, and Alaska have the highest per capita suicide rate for this young population. This map does tend to follow the per capita rate of suicide in adults as well.

Who presents and who is at risk?

The largest factor or most important risk to look at with kids is whether they've had a previous suicide attempt. Even if the suicide attempt is superficial cutting, that didn't require stitches, didn't even require hospitalization, if the intent of the child or the person was to die, that still signifies a suicide attempt and they're still at higher risk of suicide attempts in the future. No matter what type of suicide attempt, it should always be taken as a risk factor. Additionally, some other risk factors include family history of suicide or other mental health, hopelessness, recent loss, depression, and other psychiatric illnesses including trauma, substance use, behavior problems, local epidemics of suicide, access to lethal means, bullying, and LGBTQ.

Risk factors and the amount of risk factors are very helpful and important for us to assess as clinicians, but they do not predict suicide. They are one aspect of a comprehensive assessment.

Suicide warning signs

The warning signs to look out for are changes in normal behavior, changes at school, changes in mood, preoccupation with death, and hopelessness. Some examples of these may be:

• a student who changes from a straight A student to a C or D student
• an adolescent who starts being late for school and then actually missing days of school
• a child who writes a suicide note that parents have found at home

Warning signs are very important and critical in your assessment because they're different than risk factors. Warning signs indicate or could indicate an imminent risk of suicide, whereas risk factors show an elevated risk for suicide, but do not necessarily give any information about timing.

How long for a suicidal crisis?

How long does it take a child to think about suicide to then go on to act on those suicidal thoughts? Numerous studies show that near lethal suicide often is impulsive, especially in the pediatric population. Simon et al did a study in Houston of 153 survivors of nearly lethal suicide attempts. They were young people, ages 13 to 34, and they asked them the question, “How much time passed between the time you decided to complete suicide and when you actually attempted suicide?”

And what you can see is that one in four deliberated less than five minutes. If you go to the bottom of the slide looking at the different durations, you can see that nearly 50% of these young people thought about suicide and then acted on it in less than 20 minutes. This is the reminder of how impulsive suicidal thoughts to actions can be in young people, and this is why warning signs and recent changes are very relevant for us to act on.

Similarities and differences and risk factors by age

In a newer study in 2016 by Arielle Sheftall and colleagues at the Research Institute at Nationwide Children's Hospital, they looked for an answer to this question. They assess national data on children ages five to 11 and young adolescents ages 12 to 14, who died from suicide between the years 2003 and 2012. It compared the differences and the similarities of the two age groups, and as we go over that data, I want to remind you to take into account that these are young people who died from suicide and completed it.

When we look at the difference between the age groups, ages five to 11 (for the child) and 12 to 14 (for the adolescent), the child was more likely to be diagnosed with ADHD, whereas the adolescent was more likely to be diagnosed with depression. Children were more likely to be Black, whereas adolescence there was less correlation with ethnicity. For both children and adolescents, suffocation was the most common method of suicide; with children, 81% of them used that, whereas with adolescents, there was a much higher rate of firearms involved. In regards to the similarities matching national data, boys or the males were more likely to die by suicide, whereas girls were more likely to attempt. Most of the suicides occurred between noon and midnight and only one third of youth told anyone about their suicidal thoughts.

We need to ask about suicide. If we don't ask, we don't know. Going back to the previous study, one in three children who completed suicide didn't tell anyone, and numerous studies do not support the idea that youth get increased suicidal thoughts by asking questions about suicide. Developmentally, kids begin to understand the permanence of death with suicide at age 10, but with the exposure to violence and social media, kids are exposed to death and suicide at a very young age, even when they may not understand what it means.

When we're talking about different screening tools, they are a very effective way to screen for depression and potentially suicidality. But once we ask, once a screening tool becomes positive, what's the next step?

Keys to a good suicide assessment

Currently, the most evidence-based way to assess children and adolescents that have suicidal thoughts or have a history of suicidality for safety is through the clinical interview.

• Be Direct
1. When I have a patient that I'm concerned about because of their level of suicidality, I tell them that.
• Be Specific
1. When you're asking about whether they have thoughts to harm themselves, make sure that you differentiate between thoughts of self-injuring versus thoughts of dying.
• Be nonjudgmental
1. Kids will be way more likely to open up if they feel like they have a nonbiased hearing ear.
• Be transparent
1. Kids need to know before they open up that you have a duty as a practitioner and by law to inform the guardian and or emergency services if you are concerned for safety.
• Keep your cool!
1. It can be scary to have a really young child or any young person in your office that reports suicidal thinking, but really there isn't a perfect way to assess this patient. Making sure that you're comfortable and that you keep your calm can really help out the clinical interview.

SAFE-T

Let's talk about the SAFE-T, the suicide assessment, 5-step evaluation and triage (SAFE-T). This is available online for free from the US Department of Health and Human Services. They even have a pocket size guide that is printable and easy to have in your clinic. What I like about this guide is that it tells you what to think about, ask about, and to do with a suicide assessment. The bonus is that how it's laid out also helps you to know how to document. It may seem like a lot of information, but we're going to break it down so that it's easy to understand.

1. Risk factors

The first part of your suicide assessment with the safety is to assess risk factors. We talked a little bit about the risk factors earlier in this presentation, and this is a little bit of a different way of looking at risk factors and stratifying them. The section on Precipitants is similar to warning signs and as well as key symptoms. If possible, you can note factors that are fixed, but most importantly ones that are modifiable that you can help to modify in your clinic visit.

2. Protective factors

The second part of the SAFE-T is the assessment for protective factors. They differentiate protective factors by internal versus external. However, for myself, I typically tend not to separate them out that way. I think the most important thing as a provider is to know which protective factors you find the most pertinent that you want to ask the child and family about.

Additionally, I will harp on this throughout this presentation, more documentation is not necessarily better. Listing off generic protective factors is not as meaningful as one or two that are specific. For example, I would write, “Patient is connected to cat Mittens and states that she would never kill herself because no one would care for her cat.” Another example is I would write about a patient who is Catholic and states that based on his faith, he believes that suicide is immoral.

Some other protective factors that I think are really important to assess for are restricted access to lethal means. This is one of the top protective factors that I always document about. We'll talk about it a little bit later about why it is so important to assess. Some other protected factors include:

• connectedness to family, community, job providers, or others
• having reasons for living, such as wanting to get into college
• hope for the future
• skills and problem solving
• conflict resolution
• a history of nonviolent ways of handling disputes
• support from ongoing medical and mental health care
• even coming into the office to see you is a protective factor
• responsibilities and or duties to others, such as a job
• engagement within the school and community
• strong self-worth, sobriety, stable housing, and physical safety
• good physical health

 Suicide inquiry

The third part of the SAFE-T is the assessment for suicide inquiry. This is where you as a provider ask specific questions about thoughts, plans, behaviors, and intent. This section is pretty similar to a suicide assessment of an adult, but I still think it's worthwhile to go through the different areas and discuss how they apply to children and adolescents.

• We need to assess ideation. What is the frequency, intensity, and duration of suicidal thoughts? Have they been occurring in the last 48 hours, the past month? Are the thoughts the worst they've ever been?
• We then go on to assess the plan. What is the timing, location, lethality, availability of the plan. And we want to make sure to assess for preparatory acts. For example, if I have a child that has a plan to overdose, I will ask him or her, “Have you decided on what pills you're going to take? Have you gathered the pills in your room?” These questions are very helpful because they help to identify the severity of the suicidality and the level of risk for suicidality.
• We go on to assess behaviors. Has the child had a past suicide attempt? We talked earlier that one of the greatest risk factors for suicide in the future is a past suicide attempt. This is a really important part when we're assessing for suicidality. We also want to ask about aborted attempts in the past; rehearsals, has a child tied a noose, loaded a gun? Has a child engaged in nonsuicidal self-injurious behaviors?
• We then go on to assess for intent. And for children and adolescents, this is a really important part of the suicide inquiry. So, for example, a child that has a thought about a plan of stabbing themselves with a knife in the heart but never intends to do so is less concerning than a child who persistently thinks of suicide and has a plan and intent to overdose. Even though overdosing is less violent and maybe less scary to us as providers, if the child has intent, that raises their level of suicidality and their level of risk for suicidality. In the SAFE-T, intent is assessed as the extent to which the patient expects to carry out the plan and believes the plan or act to be lethal versus self-injurious.

You should be exploring ambivalence. What are the child's thoughts about reasons to die versus reasons to live. When I'm asking these questions, I'm really trying to gauge what the tone of the child is at that point. Are they very negative during the interview? Are they not able to identify reasons to live because they're so focused on reasons to die? Are they crying during the interview? Are they not answering many of your questions because they're upset and angry? These are things that you want to take into account when you're assessing suicide inquiry. 

For youths. You need to ask the parent or guardian about their views of the child's suicidal thoughts, plans, or behaviors, and you need to ask the parent about changes in mood, behaviors, or disposition. Ask the guardian, ideally away from the child, what their views are. You'll find that some guardians are very in line with their child. They know what's going. And you'll also find that some guardians just don't have a clue about what's going on, and it will be your job as a provider to bridge that gap because that helps for the safety of the child, and that also is an intervention that you can document about that helps preserve the safety of the child.

Homicidal inquiry. With the suicide inquiry, there is a note that if the child, or if any person, has homicidal thoughts, when indicated, especially in a person with personality disorders or males with paranoia, dealing with loss or humiliation, you can go through this list of ideation plan behaviors and intent and just switch it from suicide inquiry to homicide inquiry, and that can be a really good way of framing an assessment for homicide as well.

4. Risk level/intervention. The fourth part of the SAFE-T is the assessment of risk level based on your clinical judgement. I like this table because it give you guidelines on what signifies low, moderate, or high risk. It is really important to document what you believe the patient;s risk is in your documentation, so I will put “the patient is moderate risk of suicidality because of xyz” and explain why I’ve chosen that risk level and what interventions I have done.

Key actions

Now that we've reviewed the SAFE-T, let's go over some key actions for a suicide assessment. Always offer to interview the child alone. It's vital to get their perspective without the guardian present. Of course, you want to do this only when it's developmentally appropriate. But also remember that when the child separates from the parent, it also can be an assessment tool to see how the child and parent connect and how that separation goes because that helps to tell you if this is a protective factor the relationship is, or if it may be a risk factor because there's a lot of discord.

Also, you need to inform the patient prior to your suicidal questions and inquiry what safety issues have to be reported to the guardian or others. It can be hard to tell an adolescent who has opened up to you and been honest and vulnerable that you have to “tattle” on him. However, not informing him may be damaging to the therapeutic relationship long term if he doesn't know that you're going to break that therapeutic alliance for safety. The ways I approach that with children is I try to be as calm and cool and collected as possible, and I'll say, “Hey, before we talk anymore, I’ve got to tell you that if you tell me something where I think you or someone make it really hurt, I'm going to have to tell Mom.” If the child pushes back, I tend to flip the role and say, “If you were the health professional, what would you do?” I do try to avoid that with oppositional kids because they may not engage in the healthcare role play. And then sometimes I even move forward and acknowledge I have to tell someone because you sound like you're in a really bad place right now, and when you join with a child and give them that understanding of how much they're struggling, it can be a lot easier to then tell the parent and tell the child that either the child or you are going to talk to the parent about the suicidal thoughts.

If the child is under 18, you need to contact the guardian to gain collateral information and you need to inform the guardian of safety concerns and you have to give the recommendations for care.

Keys to documentation

Have a template that helps prompt you. Like the SAFE-T, it can be really helpful to have the questions structured within your electronic health record so you know what to ask and then also easily are able to document.

Use quotes. If a child says, “I'm so excited to go to the Miley Cyrus concert,” for example, you can quote that. Why do you quote that? Well, that goes into the next key to documentation. You want to address future-oriented thinking. If the child has thoughts about the future, when you quote that, that really does support your suicide inquiry, your assessment, and what your interventions are.

You want to document anyone you contacted for collateral. The more collateral you get, the more support you get for your assessment and your interventions. Of course, you need to have a release of information (ROI) before you reach out to, for example, the school counselor. But if you spend that time, get that ROI, it can be really, really helpful for your suicide assessment.

And always include a safety plan. Go over the ways the child can reach out if they're feeling suicidal, what the emergency numbers are. You want to make sure that you have the guardian and the child fill out a safety plan, and that you also document that you included a safety plan and reviewed it.

We mentioned earlier the importance of always educating and documenting about restricting access to means, including firearms, sharps, and medications, and over-the-counter medication. We talked about how this is a protective factor that's high on the list as protective factors for children and adolescents.

And I talk about this and want to highlight it because you can see with this table that data from the CDC of suicide by method in 2020 shows that over 50% of all suicides were completed by firearm. What that shows us is that we don't know whether restricting the firearm would've prevented the suicide, but certainly if over 50% of suicides are from firearms, we should do our best to have patients with suicidality not have access to guns.

Conclusions

Suicide is a leading cause of death in young people and is steadily rising. Comprehensive assessment is key to evaluation of suicidality in children. No matter what documentation, template, or guidelines you use, if it's SAFE-T or something else, it should always include risk factors, protective factors, suicidal inquiry interventions, and restricting means. I want to remind you that interventions can be as simple as educated the guardian and child on crisis numbers to contact if the child's suicidality worsens. As long as your assessment and level of risk supports education as an intervention, that can be the most reasonable and the best action plan for a child with suicidality.

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REFERENCES:

https://ourworldindata.org/suicide#suicide-rates-by-age

https://www.mhanational.org/child-and-adolescent-suicide (warning signs)

CDC. Leading Cause of Death in the United States. 2020. https://www.nimh.nih.gov/health/statistics/suicide

http://statehealthcompare.shadac.org/map/216/suicide-deaths-per-100000-people-by-age#147/32/248

AFSP, 2020 https://afsp.org/risk-factors-protective-factors-and-warning-signs

Risk and protective factors for youth https://youth.gov/youth-topics/youth-mental-health/risk-and-protective-factors-youth

NIMH. Suicide https://www.nimh.nih.gov/health/statistics/suicide.shtml#part_154969

Rudd MD et al, Suicide Life Threat Behav 2006;36(3):255-262

Simon OR, Suicide Life Threat Behav 2001;32(1 Suppl):49-59

Sheftall AH et al, Pediatrics 2016;138(4):e20160436de

Dazzi T et al, Psychol Med 2014;44(16):3361-3363  

SAMHSA 2009: https://store.samhsa.gov/sites/default/files/d7/priv/sma09-4432.pdf

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