Suicide and Suicide Risk in Adolescents

Publication Date: December 11, 2023
Last Updated: December 11, 2023

Summary of Guidance for Pediatricians and Pediatric Health Care Providers

  • Be mindful of individual, relationship, and community/societal factors, including history of trauma or other adversity, when assessing suicide risk in patients.
  • Screen for suicide risk as part of well-child visits starting at 12 years of age and during higher-risk situations, such as any presentation of a behavioral or mental health concern or for youth with additional risk factors. Be aware that screening only for depression is not sufficient to identify suicide risk.
  • Screen for suicide risk during ED visits and medical hospitalizations.
  • Screen for substance use disorders, because substance use is often associated with depression and self-treatment and is a risk factor for suicidal thoughts and behaviors.
  • If suicide screen is positive, conduct a BSSA and subsequent safety planning and/or referrals as appropriate.
  • For all adolescent health supervision visits, and especially visits with adolescents who have suicidal thoughts, assess for access to lethal means, with counseling on safe firearm and medication storage. Removal of firearms and medications from the home entirely should also be assessed, especially if an adolescent is having SI.
  • Include the family in suicide prevention and treatment efforts, when possible, because family-based interventions have been shown to be effective in preventing future suicide attempts in youth.
  • During health supervision visits and visits addressing mental health concerns, counsel families around sleep hygiene, community engagement, and connectedness, because these factors can help to promote emotional wellness and may be protective against suicidal thoughts.
  • Treat depression with a referral to a psychotherapist and with antidepressant medication, when indicated, because depression increases the risk of suicide. When indicated and available, refer to a child and adolescent psychiatrist or other mental health provider.
  • Be aware of use of language when speaking with youth and families about suicide. Attempt to replace questionable terminologies with sensitive terminologies as follows:
    • Use “die by suicide” instead of “commit suicide.”
    • Use “death by suicide” instead of “successful suicide.”
    • Use “suicide attempt” instead of “failed suicide attempt.”
  • Recognize the importance of setting aside one-on-one time during appointments with adolescents to discuss potential suicidal behavior, other mental health issues, and the teen’s history of trauma and adversity.
  • Advocate for increased research on prevention strategies for the high rates of suicide in youth in the child welfare and juvenile justice systems.
  • Advocate for suicide prevention research for other high-risk groups, such as LGBTQ youth, American Indian/Alaska Native and Black youth, other youth in minoritized racial and ethnic groups, and youth living in rural areas.
  • Advocate for increased access to youth mental and medical health care, including evidence-based, trauma-informed interventions and gender-affirming care, when indicated, and particularly for populations that have been historically discriminated against and underresourced.
  • Advocate for adequate payment for providing suicide risk screening and assessment services, as well as payment for additional time, training, and care coordination services for HCPs who manage mental health conditions.
  • Advocate for adequate payment for integrated behavioral/mental health care into primary care and for evidence-based trauma-informed mental health care when indicated.

Questions to Ask to Screen for Protective Factors/Strengths

Having trouble viewing table?
  • Do you feel connected to your family?
  • Do you feel supported by your family?
  • Do you have a supportive friend group?
  • How would your good friends describe you?
  • Are you religious or spiritual?
  • What do you think you’re good at?
  • What are you proud of?
  • Are you part of any school groups?
  • For parents: What are your child’s strengths?

ASQ Suicide Screening Tool

Having trouble viewing table?
  1. In the past few weeks, have you wished you were dead?
  2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
  3. In the past weeks, have you been having thoughts of killing yourself?
  4. Have you ever tried to kill yourself?
  5. Are you having thoughts of killing yourself now? (only ask question 5 if any answers to questions 1-4 are "yes")

Interpreting the ASQ: If the patient answers no to the first 4 questions, this is considered a negative screen, and no intervention is necessary. Any yes answer or refusals to answer are considered a positive screen. Any yes answer to any of the questions 1 to 4 requires a brief suicide assessment. If the answer to question #5 is yes, then that is considered an acute positive screen necessitating a safety/mental health evaluation immediately. N, no; Y, yes.

Resources

General Resources

  1. Blueprint for Youth Suicide Prevention
  2. 3-digit dialing code 988 (suicide prevention)
  3. 1-800-799-7233 (domestic violence)
  4. 1-866-488-7386 (Trevor Project: LGBTQ crisis support)
  5. 1-877-565-8860 (trans lifeline)
  6. Crisis Text Line: Text HOME to 741741
  7. Family Acceptance Project is an initiative to prevent health and mental health risks for LGBTQ youth and provides research-based resources for ethnically, racially, and religiously diverse families: https://familyproject.sfsu.edu/
  8. American Foundation for Suicide Prevention “Mental Health Resources for Underrepresented Communities” (https://afsp.org/mental-health-resources-for-underrepresented-communities)
  9. https://theactionalliance.org/communities/american-indian-alaska-native/hope-life-day-toolkit#:~:text=The%20National%20Action%20Alliance%20for,suicide%20in%20AI%2FAN%20communities
  10. https://www.samhsa.gov/native-connections
  11. http://www.npaihb.org/thrive/

Resources for Families

  1. AFSP: Teens and Suicide—What Parents Should Know: https://afsp.org/teens-and-suicide-what-parents-should-know
  2. Seize the Awkward: https://seizetheawkward.org/
  3. National Alliance on Mental Illness: Family Members and Caregivers: https://www.nami.org/Your-Journey/Family-Members-and-Caregivers
  4. AAP Healthy Children: 10 Things Parents Can Do to Prevent Suicide: https://www.healthychildren.org/English/health-issues/conditions/emotional-problems/Pages/Ten-Things-Parents-Can-Do-to-Prevent-Suicide.aspx
  5. Support after a suicide attempt: https://afsp.org/when-a-loved-one-has-made-an-attempt
  6. Support after a loss from suicide: https://afsp.org/ive-lost-someone

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Suicide and Suicide Risk in Adolescents

Authoring Organization

Publication Month/Year

December 11, 2023

Last Updated Month/Year

December 13, 2023

Document Type

Consensus

Country of Publication

US

Document Objectives

Suicide is the second leading cause of death for 10- to 24-year-olds in the United States and is a global public health issue, with a recent declaration of a National State of Emergency in Children’s Mental Health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association. This clinical report is an update to the previous American Academy of Pediatrics clinical report, “Suicide and Suicide Attempts in Adolescents.” Because pediatricians and pediatric health care providers are at the front line of care for adolescents amid a child and adolescent mental health crisis, and because of the chronic and severe shortage of mental health specialists, it is important that pediatric health care providers become facile with recognizing risk factors associated with suicidality and at-risk populations, screening and further assessment of suicidality as indicated, and evidence-based interventions for patients with suicidal ideation and associated behaviors. Suicide risk can be mitigated by appropriate screening, bolstering of protective factors, indicated treatment, community resources, and referrals to mental health providers when available.

Inclusion Criteria

Male, Female, Adolescent

Health Care Settings

Ambulatory, Childcare center, Hospital, Outpatient, School

Intended Users

Counselor, nurse, nurse practitioner, physician, physician assistant, psychologist, social worker

Scope

Counseling, Diagnosis, Assessment and screening, Management, Prevention, Rehabilitation

Diseases/Conditions (MeSH)

D013405 - Suicide, D000092864 - Suicide Prevention, D013406 - Suicide, Attempted

Keywords

children, depression, adolescents, Mental health, Suicide, childhood depression, suicide risk, suicide risk assessment, suicide precautions

Source Citation

Liwei L. Hua, Janet Lee, Maria H. Rahmandar, Eric J. Sigel; Suicide and Suicide Risk in Adolescents. Pediatrics 2023; e2023064800. 10.1542/peds.2023-064800