Suicidal ideation and behavior in children and adolescents: Evaluation and disposition

INTRODUCTION — Suicide is the fourth leading cause of death worldwide among adolescents aged 15 to 19 years [1]. Across 45 countries, the United States has the seventh highest rate of suicide among youth aged 10 to 19 years. In the United States in 2020, suicide was the second leading cause of death among those aged 10 to 14 years (n = 581 deaths), and the third leading cause of death among those aged 15 to 19 years (n = 2216).

This topic reviews the evaluation and disposition of children and adolescents with suicidal ideation and behavior. The epidemiology, risk factors, prevention, and treatment of pediatric suicidality are discussed separately. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors" and "Suicidal ideation and behavior in children and adolescents: Prevention and treatment".)

WARNING SIGNS — Risk factors for suicide include the following [1-3]:

●Psychiatric disorders (eg, major depression, substance use disorders, or psychotic disorders)

●Talking about suicide or death

●Nonsuicidal self-injury such as cutting

●Previous suicide attempt

●Changes in behavior that include increased impulsivity, aggression, or interpersonal or legal conflicts

●Gay, lesbian, or bisexual orientation, or transgender or gender-nonconforming identity (see "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Mental health and self-harm')

●History of physical or sexual abuse

●Family history of suicidal behavior

Additional information about risk factors for adolescent suicide is discussed separately. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors", section on 'Risk factors'.)

The American Association of Suicidology developed a mnemonic ("is path warm?") to help identify key warning signs for suicide [4,5]:

●Ideation – Talking about or threatening to harm or kill oneself; looking for ways to kill oneself; talking or writing about death, dying, or suicide

●Substance abuse – Increased substance use

●Purposelessness

●Anxiety – Worry, fear, or agitation

●Trapped – Feeling like there is no way out of a bad situation

●Hopelessness

●Withdrawal or feeling isolated from friends, family, and society

●Anger

●Recklessness

●Mood changes

Protective factors — Factors that may protect youth against suicidal ideation and behavior include [1,6,7]:

●Family cohesion, including mutual involvement and emotional support

●Connectedness to other individuals and institutions

●Religiosity and moral objections to suicide

●Reduced access to lethal means of suicide

ASSESSMENT — It is impossible to accurately predict suicide for individual patients [2,8]. Nevertheless, clinicians can mitigate the risk of suicide by identifying at-risk children and adolescents and pursuing early treatment before suicidal behavior emerges.

Screening for suicidal ideation

Primary care — Screening for suicide risk in primary care is discussed separately. (See "Screening tests in children and adolescents", section on 'Depression and suicide risk screening'.)

Emergency department — For youth evaluated in the emergency department by non-mental health clinicians, we typically screen adolescents for suicidal ideation by directly asking about it in the context of screening for depression.

A reasonable alternative is to use a brief screening tool for suicidal behavior. The Ask Suicide-Screening Questions is a four-item instrument that clinicians can administer to screen for risk of suicide in patients who present to pediatric emergency departments with psychiatric or general medical complaints [9]. The four items are:

●In the past few weeks, have you wished you were dead?

●In the past few weeks, have you felt that you or your family would be better off if you were dead?

●In the past week, have you been having thoughts about killing yourself?

●Have you ever tried to kill yourself?

Answering yes to at least one question constitutes a positive screen that should trigger a more extensive evaluation of the patient’s risk for suicide. (See 'Risk assessment of suicidal ideation' below.)

A cross-sectional study in patients aged 10 to 21 years who presented to pediatric emergency departments with psychiatric (n = 180) or general medical (n = 344) problems found that the Ask Suicide-Screening Questions had good psychometric properties [9]. Sensitivity was 97 percent and specificity 88 percent. In psychiatric patients, the positive and negative predictive values were 71 and 97 percent; in general medical patients, positive and negative predictive values were 39 and 100 percent. A limitation of the study was that it was cross-sectional rather than assessing true predictive ability.

Asking about suicidal ideation — The basic means to identify youth at risk for suicide is to ask about risk factors, suicidal thoughts, and intent. The concern that talking or asking about suicide will provoke suicidal ideation or actions in a child or adolescent is not supported by evidence [1,2,10].

Clinicians should interview adolescents with their parents as well as separate from parents, because interviewing patients alone may facilitate a more open discussion about suicidal ideation and behavior [2]. However, confidentiality should not be promised because it cannot be maintained under these circumstances. (See "Confidentiality in adolescent health care", section on 'Suicidal ideation or attempt'.)

Demonstrating that one is comfortable discussing suicide is an important element of an effective inquiry. The questions that are posed should be short, to the point, and asked in a nonjudgmental manner in developmentally appropriate language [11]. Avoiding abrupt and intrusive questions may help establish rapport [2]. Questions about suicidal ideation are typically asked toward the end of questions about signs and symptoms of major depression (table 1). Sample questions about suicide include:

●Do you ever think about dying? How often?

●What do you think happens when you die?

●Have you ever wished you were dead?

●Do you ever think the world would be better off if you were dead? Do you think life would be easier for your family and friends if you were dead? Have you ever thought of what would have to happen for your life to end?

●Have you had thoughts about hurting yourself? Killing yourself?

●Have you ever tried to kill yourself?

If the child or adolescent begins talking about suicidal thoughts, the lines of communication must be kept open. This can be facilitated through active listening, patience, maintenance of a calm demeanor, and neither minimizing the patient's concerns nor reacting with disapproval. The natural tendency to be reassuring and optimistic must be restrained. Attempts to talk the child or adolescent out of suicide should be avoided, as should discussions of whether suicide is right or wrong.

Risk assessment of suicidal ideation — Once a child or adolescent has disclosed suicidal ideation, clinicians should promptly assess the risk of suicidal behavior. The assessment includes evaluation of multiple elements (table 2A-B):

●Content and chronicity of the suicidal thoughts

●Existence and details of a suicide plan

●Access to the means described in the plan

●The level of intent (eg, “I’m really gonna do it”)

●Stressors, emotional pain, behavioral regulation, and social support

Other factors to assess include substance abuse, functional impairment, and lack of developmental progress [2].

Risk assessment information should be obtained from the parents or guardians, as well as the child or adolescent [12]. Additional sources include medical records, school reports, therapists and behavioral staff, and other individuals who are close to the child or adolescent. Collateral information is necessary because the patient may intentionally provide inaccurate information (eg, to avoid hospitalization).

Risk for suicide should be considered high in patients who report active suicidal ideation (eg, “I want to kill myself”) with a specific plan or intent and have access to lethal means. The clearer the intent, the higher the risk, particularly in the context of disinhibition (eg, impulsivity or intoxication) and access to lethal means.

Nevertheless, passive suicidal ideation (eg, “I wish I would get run over by a car”) should not be ignored. Passive suicidal ideation can progress to active suicidal ideation with a plan (eg, jumping in front of a train).

As part of assessing suicidal ideation, as well as supporting the patient's ability to avoid suicidal behavior, clinicians may ask if the patient can "contract for safety" or agree to a "no harm contract." The phrases imply that patients can promise clinicians that they will try not to harm themselves when they have suicidal thoughts and will seek help if necessary. The terms are not defined or used consistently, and clinicians generally do not receive formal training in suicide prevention contracts. Best clinical practice avoids the terminology of no-suicide contracts (“contracting for safety”); despite their frequent use, there is little evidence that such contracts actually reduce suicide [13]. Contracting for safety may thus provide a false sense of security.

Instead, best clinical practice involves collaborating with patients to develop a safety plan that specifies how patients can cope with recurrent suicidal urges in the future (figure 1). The safety plan is a widely used therapeutic tool. In addition, how readily and the extent to which the adolescent can generate a safety plan provides additional information about the adolescent’s risk for suicidal behavior. (See "Suicidal ideation and behavior in children and adolescents: Prevention and treatment", section on 'Safety plan'.)

Referral — Although some pediatricians have the requisite training and experience to manage patients with suicidal ideation, most patients are referred to psychiatrists and other mental health clinicians if these specialists are available. In particular, patients at moderate to high risk (eg, active suicidal ideation with a plan, or any recent/current suicidal behavior) should be referred for a mental health evaluation [2]. Primary care clinicians who refer patients to specialists are encouraged to remain involved in management. Pediatricians can help educate patients and families about treatment and reinforce the need for adherence.

When children or adolescents are in an acute suicidal crisis due to thoughts of wanting to kill themselves, the focus of the intervention is to keep them safe until the suicidal state diminishes or abates. This usually involves working with the family or other supportive individuals who can address safety concerns (eg, remove access to means) and are willing to always stay with the patient.

Treatment options include hospitalization, medication for underlying psychiatric disorders such as major depression, more frequent psychologic intervention, mobilizing supports, and access to crisis intervention services [14]. The level of intervention depends upon the level of suicide risk (see 'Risk assessment of suicidal ideation' above), available support, and the ability of patients to join with those who seek to keep them safe:

●Immediate psychiatric evaluation (through the emergency department or psychiatry crisis clinic) and/or hospitalization is indicated when there is an imminent risk of suicide (eg, an active plan or intent without solid support or psychiatric intervention already in place to maintain safety) [2,11,15-17].

●Prompt referral to a mental health professional who is readily available (eg, within a few days) is warranted if the risk is not imminent.

The confidentiality of adolescents who are at risk to harm themselves must be breached in deference to patient safety; safety trumps confidentiality [2].

EMERGENCY EVALUATION OF SUICIDAL BEHAVIOR

Emergency department referral and stabilization — Children and adolescents with suicidal behavior are typically evaluated in an emergency department. The manner in which patients with suicidal behavior and their families are treated by the emergency department staff may affect adherence with follow-up care [18]. Emergency department clinicians should stress the importance of treatment [12,19]. (See 'Disposition' below and "Suicidal ideation and behavior in children and adolescents: Prevention and treatment", section on 'Choosing treatment'.)

The first priority for patients who have attempted suicide is medical stabilization. The appropriate surgical service should be contacted for management of trauma. Patients whose attempt involved drug ingestion should undergo decontamination and receive antidotes as indicated. (See "Classification of trauma in children" and "Gastrointestinal decontamination of the poisoned patient" and "Approach to the child with occult toxic exposure" and "Anticoagulant rodenticide poisoning: Management" and "Society guideline links: General measures for acute poisoning treatment" and "Acetaminophen (paracetamol) poisoning: Management in adults and children".)

Ensuring safety — Youth with suicidal behavior should have one-to-one attention until the seriousness of their intent is evaluated. Potentially harmful medical supplies and equipment should be removed from the examination room where patients are evaluated [11,19]. To discourage elopement, hospital gowns should be provided to patients and their clothing and belongings should be stored separately [19,20].

Restraints should be used only if the patient is actively seeking ways to harm self or others and does not respond to verbal redirection (the proper use of restraints should be part of the educational curriculum for emergency department clinicians) [19,21]. Aggression or behavioral dyscontrol that does not respond to verbal interventions can be managed with pharmacotherapy, bearing in mind potential side effects [19]. Additional information about restraints and chemical sedation is discussed in a separate topic on the emergency management of acutely agitated or violent adults; drug doses and other aspects may not apply to pediatric patients. (See "Assessment and emergency management of the acutely agitated or violent adult".)

Caring for children and adolescents with suicidal behavior requires deliberation and planning for emergency department staff. Emergency departments may need to review their care system and modify their physical structure to provide a safe and contained environment for these patients [22]. Potential areas of modification include more mental health training, better access to mental health records, the development of crisis plans for adolescents at risk, and provision of additional staff (eg, security guards and other personnel who play a role in observation of at-risk patients).

History and physical examination — The important aspects of the history that should be included in evaluation of children or adolescents with suicidal behavior are discussed in the psychiatric evaluation. (See 'Psychiatric evaluation' below.)

The physical examination should be performed with attention to vital signs, level of consciousness and orientation, and manifestations of toxidromes [20]. In addition, clinicians should look for signs of recent or remote suicide attempts (eg, scars from cutting or bruises from hanging), physical or sexual abuse (eg, characteristic bruising patterns or genital trauma) (table 3), substance abuse (eg, track marks from intravenous drug use, or nosebleeds or perioral blisters from inhalant use), and general medical disease (eg, thyroid disease) [20]. (See "Approach to the child with occult toxic exposure" and "Physical child abuse: Recognition" and "Evaluation of sexual abuse in children and adolescents".)

Laboratory evaluation — The laboratory evaluation of the child or adolescent with suicidal behavior should be individualized according to the circumstances of the attempt and the clinical risk of illicit drug use and confounding medical problems, such as pregnancy and presence of sexually transmitted infections. Commonly performed screening laboratory tests, which are generally required by hospitals before they accept patients for admission, include complete blood count, serum chemistry panels, urinalysis, thyroid stimulating hormone, human chorionic gonadotropin (pregnancy) in girls, and urine toxicology screen for drugs of abuse, aspirin, and acetaminophen [23].

Psychiatric evaluation — The psychiatric evaluation is conducted after the patient is medically stable. The goals of the evaluation include [12]:

●Determining the risk of subsequent suicide attempt or suicide completion

●Identifying any predisposing and precipitating factors that can be treated or modified

●Recommending the level of care (ie, inpatient, partial hospital, or outpatient care)

The psychiatric assessment should be performed by clinicians with specialized training and experience in the psychiatric problems of children and adolescents. In some situations (eg, if a clinician with such training is not available), it may be necessary for general medical emergency department clinicians to perform the initial evaluation to determine whether the patient should be transferred to another facility for a formal psychiatric evaluation.

The information used in the evaluation should be gathered from several sources, including the child or adolescent, parents or guardians, previous psychiatric evaluation or assessments, school reports, and any other individuals who are close to the child [12]. This is because the child or adolescent may minimize what occurred or intentionally provide inaccurate information (eg, to avoid hospitalization). We suggest interviewing patients and caregivers both separately and together [19]. Family meetings may perhaps facilitate disposition to outpatient treatment instead of hospitalization. (See 'Outpatient treatment' below.)

Suicidal ideation, suicide plan, and intent must be addressed when evaluating the seriousness of suicidality and the risk for future attempts or completion. These areas are discussed in detail elsewhere in this topic (see 'Risk assessment of suicidal ideation' above). Information regarding underlying psychiatric or medical diagnoses and the inciting event is also important when assessing suicide risk [2,12]. The mnemonic "MALPRACTICE" (table 4) can help ensure that these areas are addressed [16].

Clinicians should not equate the lethality of suicide attempts with suicidal intent [24]. Because children may not be able to accurately assess lethality, suicide risk assessment in children should be based upon the child's perception of lethality rather than the objective lethality of the suicidal act [2,11,24,25].

Following a suicide attempt, the absence of current suicidal ideation can be misleading if none of the factors that precipitated the attempt have changed or the patient cannot identify reasons for the attempt [2].

In addition to the history, the psychiatric evaluation includes a mental status examination. Specific elements include [26]:

●Appearance

●Attitude

●Behavior

●Motor functioning

●Attention

●Concentration

●Orientation

●Memory

●Affect

●Speech

●Language

●Suicidal and homicidal ideation, plan, and intent

●Thought content

●Thought process

●Perception

●Intellectual functioning

●Judgement

●Insight

Distinguishing suicidal behavior from nonsuicidal self-injury — Clinicians should distinguish suicidal behavior from nonsuicidal self-injury. Suicidal behavior is characterized by self-harm intended to kill oneself, whereas nonsuicidal self-injury is a behavior characterized by the deliberate destruction of body tissue in the absence of any intent to die and for purposes that are not socially sanctioned [27-29]. Nonsuicidal self-injury is differentiated from socially accepted practices such as tattoos, piercings, and religious rituals; accidental self-harm; and indirect self-injury through behaviors such as disordered eating or substance abuse. Although nonsuicidal self-injury is distinct from suicidal behavior, nonsuicidal self-injury is a risk factor for suicide attempts and suicide.

Self-injurious behavior that is accompanied by any intent to die is classified as a suicide attempt, which is consistent with the practice of most clinicians and researchers [28,30], as well as recommendations from the United States Centers for Disease Control and Prevention [7,31]. This approach deliberately errs on the side of safety by categorizing ambivalent behaviors as suicidal [28].

Additional information about nonsuicidal self-injury is discussed separately. (See "Nonsuicidal self-injury in children and adolescents: Clinical features and proposed diagnostic criteria" and "Nonsuicidal self-injury in children and adolescents: Assessment".)

DISPOSITION — The disposition of suicidal children or adolescents from the emergency department or medical care depends upon the immediate risk of suicide [11]. Patients should not be discharged from medical care until their account of events has been verified by their caregiver(s) [12,19].

Hospitalization — Psychiatric hospitalization (inpatient or partial) for evaluation and initiation of therapy is nearly always indicated for children and adolescents with suicidal behavior or immediate high risk of suicide (algorithm 1) [2,12]. Factors that can place patients at high risk of suicide include [2,19,20]:

●Suicide attempt with a highly lethal method (eg, firearm or hanging)

●Suicide attempt that included steps to avoid detection

●Ongoing suicidal ideation or disappointment that the suicide attempt was not successful

●Inability to discuss the suicide attempt openly and honestly and what precipitated it

●Inability to discuss safety planning

●Adequate monitoring and treatment are not assured, which may be due to insufficient family support

●Psychiatric disorders underlying suicidal ideation and behavior (eg, unipolar major depression, bipolar disorder, psychotic disorders, or substance use disorders)

●Agitation

●Impulsivity

●Severe hopelessness

●Poor social support

Although the standard of care for youth at high risk of suicide is hospitalization, no high-quality studies have demonstrated that it prevents subsequent suicide [12].

While awaiting hospitalization, patients should be kept in a room with all sources of potential harm removed. A staff member should be assigned to provide constant observation. In addition, family may be present if the patient desires. Transfer of the patient should take place by ambulance, and the paramedics must be aware of the suicide risk. Inpatient treatment should continue until the patient’s safety has stabilized [12].

Involuntary hospitalization — Involuntary hospitalization may be necessary if the parents or legal guardian of the child are not present and/or do not agree with the clinician's plans for hospitalization [19]. The process for admitting patients who will not or cannot sign themselves into a hospital vary among countries and from state to state in the United States. Most states require clinicians to certify that the patient is a danger to self or others, or is at imminent risk to come to harm because of an inability to adequately care for oneself.

Patients who are admitted against their will, or the will of their guardians, maintain the autonomy to consent for treatment [16]. The only medications that can be administered without their consent, or the consent of their guardians, are those that are necessary for stabilization during a crisis. If patients refuse daily medications that are deemed necessary for treatment of underlying psychiatric disorders, clinicians need to petition a court to order treatment.

Outpatient treatment — Outpatient therapy is usually the best option for lower-risk individuals, such as patients who are medically stable, are glad to be alive, and do not have a specific plan and intent to kill themselves [20,32]. Outpatient therapy is contingent upon a safety plan (figure 1). (See "Suicidal ideation and behavior in children and adolescents: Prevention and treatment", section on 'Safety plan'.)

For adolescents with suicidality who are evaluated in an emergency department, a family meeting may enable clinicians to avert hospitalization and discharge patients to their homes with outpatient follow-up. An open label randomized trial compared usual care plus a family meeting with usual care alone in adolescents who presented to the emergency department with suicidal ideation or suicidal behavior [33]. As part of usual care, patients underwent a standard psychiatric evaluation that included discharge recommendations. The family meeting lasted 60 to 90 minutes, during which the patient and parents formulated a description of the suicidal crisis, received psychoeducation, learned cognitive-behavioral skills, and developed a safety plan. Discharge home occurred in more patients who received the family intervention than controls (62 versus 32 percent).

Intensive home therapy — Intensive home therapy may possibly be an option for some patients who need crisis stabilization, but the benefit is not clear [19,32]. A 12-year registry study examined suicide deaths among individuals aged 15 years or more, and found that as the number of psychiatric inpatient suicides declined, the number of suicides in intensive home therapy and crisis stabilization increased [34]. In the final year of the study, nearly half as many suicides occurred in hospitalized patients, compared with patients receiving intensive home therapy/crisis stabilization. This suggests the possibility that home therapy may not protect patients against suicide as well as inpatient care.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Depressive disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Depression in children and adolescents (Beyond the Basics)" and "Patient education: Depression treatment options for children and adolescents (Beyond the Basics)")

OTHER RESOURCES FOR PATIENTS AND FAMILIES — Other resources for patients and families are listed in the two tables (table 5A-B).

SUMMARY

●Risk factors for suicide – Warning signs for suicide include psychiatric disorders, nonsuicidal self-injury, and previous suicide attempt. (See 'Warning signs' above and "Suicidal behavior in children and adolescents: Epidemiology and risk factors".)

●Screening for suicidal ideation – We typically screen adolescent primary care patients for suicidal ideation by directly asking about it in the context of screening for depression. For youth who present to pediatric emergency departments with psychiatric or general medical complaints, the Ask Suicide-Screening Questions is a four-item instrument that may identify risk for suicidal behavior. (See 'Screening for suicidal ideation' above.)

●Assessing youth with suicidal ideation – Assessing the risk of suicide in youth with suicidal ideation includes evaluation of multiple elements (table 2A-B), including the content and chronicity of the suicidal thoughts, existence and details of a suicide plan, access to the means described in the plan, and level of intent to commit suicide. Clinicians should also obtain collateral information from the parents. Risk for suicide is high in patients who report active suicidal ideation (eg, “I want to kill myself”) with a specific plan or intent and have access to lethal means. (See 'Risk assessment of suicidal ideation' above and 'Psychiatric evaluation' above.)

●Evaluating youth with suicidal behavior – Pediatric patients who present with suicidal behavior are typically evaluated in an emergency department. The first priority for these patients is medical stabilization. Patients should be under constant observation until the seriousness of their intent is assessed, and potentially harmful medical supplies and equipment should be removed from the examination room where patients are evaluated. To discourage elopement, hospital gowns should be provided to patients and their clothing and belongings should be stored separately. (See 'Emergency evaluation of suicidal behavior' above.)

●Disposition of youth with suicidality – The disposition of children or adolescents with suicidal ideation or behavior from the emergency department or medical care depends upon the immediate risk of suicide. Patients should not be discharged from medical care until their account of events has been verified by their caregiver(s). Psychiatric hospitalization for evaluation and initiation of therapy is nearly always indicated for children and adolescents with suicidal behavior or immediate high risk of suicide (algorithm 1). (See 'Disposition' above.)