Screening for Suicide Risk Factors in Pediatrics

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Pediatric patients can be impacted by mental health problems such as depression and stress, and their abilities to cope with those problems can be challenging. Unfortunately, the pediatric population is not exempt from detrimental situations such as suicide. In that regard, it is important to include screenings for suicide risk factors in pediatrics throughout clinical practices to assess suicide risk, and to implement strategies that can potentially prevent suicide attempts or successful acts from occurring. As clinicians, we must all assume responsibility for conducting screenings for suicide risk factors that can assist in recognizing behaviors of concern that indicate the need for interventions. 

Introduction

Our youth are our future, and their welfare (physical as well as psychological) is a public health concern. In the youth population, suicide is attributed as the 2nd leading cause of death (3). Moreover, suicidal ideations and attempts are even more common than suicidal deaths (3). Our youth's mental health must be addressed when conducting routine or urgent health screenings to deal with this global public health problem. Consequently, screenings for suicide risk factors in pediatrics have proven beneficial in suicide prevention, and most clinical practices have incorporated them into clinical pathways (3). Ultimately, screenings for suicide risk factors are vital tools that can be utilized to detect behaviors relevant to suicide. The results of those tools can serve as guides for warranted intervention. 

The Significance of Screening Tools for Suicide Risk Factors in Pediatrics

The importance of screening tools for suicide risk factors in the pediatric population is evident.  Screening is a fast and efficient method of identifying someone needing further evaluation (6).  Those with positive findings on a suicide risk screening tool should be followed up with an assessment for suicide (6).  

Screening for suicide in the pediatric population is essential. It is also necessary that the tools used are evidence-based for this specific population.  The Ask Suicide Screening Questions (ASQ) is an evidence-based suicide risk screening tool used for medical and behavioral health pediatric patients (5).  This is a frequently used tool that is approved by The Joint Commission (5).  

There is a youth version of the ASQ that is developmentally appropriate for assessing suicide risk in children eight years of age and older (3). More importantly, the ASQ is available in multiple languages. Unfortunately, there are no screening tools for children less than eight years of age; therefore, a full mental health evaluation is conducted (3). Regardless of the approach selected, children are screened without their parents or guardians present for accurate results (3). Additionally, policies or plans of action must be in place if screenings or evaluations indicate positive results (3). 

Suicide Risk Factors in Pediatric Populations

In the past two decades, the suicide rate for adolescents has increased (4).  Males continue to have a higher suicide death rate.  However this rate has doubled for females during this period (4).  The suicide death rate has tripled for those 12-14 years of age (4).  Compared to the adult population, suicidal ideation, self-harm, and suicide attempts are now more common among the younger population (4).  Contributing factors to this increase in suicide are (4). 

• Bullying 
• Social isolation 
• Increase in technology and social media 
• Increase in mental health disorders 
• Economic recession 

Statistics indicate that certain racial and ethnic minority youth experience higher rates of suicidal behaviors. American Indians and Alaska Natives have the highest reported rates of suicide attempts and ideation (4).  There has also been an increase in suicide attempts among the African American youth (4). Risk factors that contribute to this include (4). 

• Access to mental health services 
• Poverty 
• Historical trauma 
• Adverse childhood experiences 

In addition, the prevelance of suicidal thoughts and behaviors has significantly increased among the LGBTQ+ youth (4).  Risk factors unique to this population include(4). 

• Discrimination 
• Violence and trauma 
• Rejection 
• Increased mental health disorders 

While death by suicide is uncommon among children under eight years of age, factors such as anxiety, depression, or suicidal ideation can be present in this age group. (2) Research also indicates that racial disparities in children under 12 exist (2).  Black children are twice as likely to die by suicide than white children (2).  

There are specific warning signs of suicide risk for this age group that include (2). 

• Verbalizing wanting to die or kill oneself. 
• Displaying actions of hurting oneself. 
• Engaging in self-harming behavior. 
• Impulsive aggression. 
• Giving away toys or possessions. 
  

Genetics and history of suicide attempts are other factors to consider. One of the strongest predictors of completed suicides is a previous suicide attempt(4). Even more troubling is that risk significantly increases when there is family history of suicide (4).  

As clinicians, we must maintain accountability for screening and assessing for all indicators of suicide potential. In saying that, environmental factors such as dysfunctional family dynamics, domestic violence, abuse and neglect, bullying, stressors (i.e., life-changing events or losses), and socioeconomic strains should be considered notable suicide risk factors that are highly impactful (4). Also, it is important to inquire about an individual's access to lethal methods, especially if they imply that they have a plan (7).  

The psychological/physical health factors highly linked to suicide include (4,7).  

• Depression or other mental health disorders 
• Traumatic brain injury or concussion 
• Chronic physical condition 
• Alcohol or substance use/abuse 
• Lack of social interaction or support 
• Learning difficulties or disabilities 
• Aggressive or disruptive behavior 
• Excessive video game or internet use (more than five hours daily) 
• In foster care or adopted  
• Sexual orientation 
• Impulsivity  

Signs and Symptoms Associated with Suicide 

There is no doubt that suicide among youth is a serious problem. Often, suicide signs and symptoms are comparable to those noted in depressive situations, and it is a fact that the majority of adolescents and children who attempt suicide do have mental health disorders (8). Most frequently, this is depression (8). 

Some of the signs and symptoms linked to suicidal behavior include (4,7). 

• Isolation from others 
• Hopelessness 
• Ridding self of cherished possessions 
• Discussions of death 
• Irritability or agitation 
• Defiance 
• Expressions of guilt or shame 
• Violent behavior 
• Personality changes 
• Neglecting personal appearance 
• Physical complaints 
• Loss of pleasure in usual activities 
• Low self-esteem 
• Psychosis  
• Changes in eating habits 
• Changes in sleeping habits 
• Feelings of sadness 

Interventions for Concerns Related to Suicide Risk Factors

The ASQ outlines "Next Steps" to take in circumstances of positive results (3). This is based on a "Yes" response to any of the four questions, which would then prompt asking the fifth question. If the answer to question #5 is "Yes," the screening is marked as an acute positive screening, and the patient is considered at imminent risk. In that regard, the patient requires an immediate safety/full mental health evaluation; he/she must remain supervised in the clinical setting until safety is evaluated. At the same time, the environment is freed of harmful objects, and his/her physician or responsible clinician is notified (3).  

Contrarily, if the answer to question #5 is "No," the screening is noted as a non-acute positive screen that insinuates a potential risk identified. The patient must remain in the clinical setting until his/her safety is evaluated. For that matter, there is a brief suicide safety assessment conducted to establish whether a full mental health evaluation is necessary (3). The clinician responsible for the patient's care or his/her assigned physician is also notified in this case (3). Essentially, the patient's safety is a priority. 

Management of the Suicidal Patient

Assessment and management of a suicidal patient is pertinent to prognosis. Although no intervention is 100% guaranteed to stop an individual from carrying out an act, interventions have proven to be positively impactful in many cases. It has been proven that asking questions pertaining to suicide risk does not increase an individual's likelihood of committing suicide (6). Rest assured that detailed assessments and evaluations facilitate deriving the most appropriate plans of care and should be included in the treatment approach.  

Therefore, the following should be considered when managing suicidal  behavior in pediatric patients (4). 

•  Assess for suicidal risk factors.;  
• Assess mental status.  
• Involve parents or guardians, if possible.  
• Offer psychological education.  
• Consider the need to hospitalize the patient.  
• Interprofessional collaboration or involvement of other services (e.g., psychologist or psychiatrist, counselor, or crisis assessment team/public mental health service).  
• Create a youth safety plan or make a referral to a mental health clinician with this expertise.  
• Focus on treating underlying mental health problems with psychotropic medication (i.e. antidepressants). 
• Psychotherapy.  
• Cognitive Behavior Therapy (CBT). 
• Dialectical Behavior Therapy (DBT). 
• Document the risk assessment, interventions, and patient status. 
• Promotion of continuity of care.  
• Connect to resources. (2). 

As previously mentioned, safety is a priority; hence, safety planning is an important evidence-based treatment approach. Research supports that those who participate in safety planning are less likely to experience suicidal behavior and more likely to seek mental health services (4).  The safety plan consists of a list of coping strategie and sources of support and should encompass the following components (9). 

•  Recognizing signs of patient status worsening.  
• Iidentifying and listing personal coping mechanisms.;  
• Uutilizing family and friends as distractions from suicidal ideations.  
• Iinvolving the family in problem-solving during a crisis.  
• Ccontacting mental health clinicians and restricting access to lethal means.  

Likewise, providing access to a resource such as the National Suicide Prevention Lifeline to patients and families is also a means for them to receive counseling, suicide educational materials, and referrals (1). 

Case Study

A 12-year-old boy is brought to the ED via emergency transport after being found lethargic on the floor of his bathroom with an empty bottle of hydrocodone located close by his hand. It is assumed that he ingested an indefinite amount of hydrocodone tabs. His initial vital signs are temperature, 97.9 F; heart rate, 50 beats/min; blood pressure, 85/57 mm Hg; respiratory rate, 8 breaths/min; and oxygen saturation 95% on room air.  

The patient is difficult to arouse, and Narcan is administered per protocol. Once the patient's condition is stabilized, he voiced his reason for the suicide attempt, which revolved around him being bullied by peers on almost a daily basis for the last couple of months. The patient excels academically and was a member of his middle school basketball team, which helped him cope until the season recently ended.

Additionally, the patient lives with his grandparents, and he stated, "Everyone is always making fun of how I dress and the car that my granddad drives. I'm just tired of people bothering me, and I wanted it to be all over." This was the patient's first suicidal attempt. During the one-on-one evaluation, it is noted that the patient made minimal eye contact and intermittently placed his head in his hands. You consider the appropriate next steps with the patient's safety of utmost importance. What next steps would you implement for managing this patient's care? 

Recommendations

Conduct suicide assessments and evaluations on every visit because each visit affords the opportunity to identify, educate, and intervene. Research best practices and stay cognizant regarding recommendations for effective approaches associated with suicidal patients. Involve family members, other health care providers, and support personnel for a collaborative approach to meeting the patient's needs. Remember, inquiring about a patient's suicide risk does not increase his/her likelihood of engaging in suicidal behavior but rather serves as a vital means for intervening as opposed to neglecting to address the situation. 

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