Suicidal Ideation in Children and Adolescents

Whether it's from research, media, clinical practice or day-to-day life, messages about youth suicide can be confusing. Messages warn of a public health crisis while simultaneously reminding us that suicide is statistically rare. However, scholarly sources agree that in recent decades suicidal ideation has risen among children and adolescents, and suicide is a leading cause of death in youth and young adults ages 10 to 24.  

Given that 80% of youth met with a healthcare provider within the year prior to death by suicide, clinicians have important opportunities to screen for suicide, identify risk and connect families with resources. Acknowledging this need, the American Academy of Pediatrics (AAP) and American Foundation for Suicide Prevention, along with experts from the National Institute of Mental Health (NIMH), created a Blueprint for Youth Suicide Prevention to provide health professionals guidance for identifying risk for and preventing youth suicide. Pediatric and adolescent psychologist Lauren Gallanis, PhD, explores these resources and offers guidance below.

What is suicidal ideation?

The suicidal ideation definition encompasses a spectrum of thoughts and behaviors associated with suicide, including: thoughts, plans, intent and attempts.

Term	Definition
Suicidal thoughts	Thoughts of wanting to die, no longer being alive or killing oneself
Suicide plan	A set of steps someone has identified to end their life, usually including identification of a method or means
Suicidal intent	Desire to act on thoughts of suicide
Suicide attempt	A self-directed, potentially injurious behavior with intent to die as a result of the behavior
Non suicidal self-injury	Purposefully hurting oneself without the direct intention of dying, often as a means of regulating intense or difficult emotions

According to the Centers for Disease Control's Youth Risk Behavior Survey, in 2023, 40% of high school students reported experiencing persistent feelings of sadness or hopelessness, up from 30% in 2013. Of these students, 20% reported seriously considering suicide, 16% reported making a suicide plan and 9% reported attempting suicide. While females are twice as likely as males to report attempting suicide, males are more likely to die by suicide; in Colorado in 2023, almost twice as many males as females between the ages of 10 and 18 died by suicide. In the national survey, LGBTQ+ students reported rates of attempted suicide over 3 times higher than those of cisgender and heterosexual students. Respondents to the 2023 Healthy Kids Colorado Survey reported a similar discrepancy. Racial and ethnic identity is also associated with varying risk, and youth identifying as American Indian or Alaska Native report the highest rates of suicidal thoughts.

Suicide warning signs and risk factors in kids

While assessing suicidal intent can be challenging and complex, various warning signs can help identify someone at increasing risk:

• Cries for help: Most people will disclose to at least one person what they are thinking before they attempt suicide. They may make statements ranging from having no reason to live or feeling hopeless about the future, to expressing thoughts about killing themselves. Take these comments seriously and follow up with direct questions.
• Changes in mood and behavior: Changes in mood, social isolation, withdrawal from activities or increased use of substances can sometimes signal escalating suicide risk. Ask youth and their caregivers whether they’ve observed changes.

Other factors may place youth at increased risk of suicide:

• Past behavior: Previous suicidal thinking or suicidal actions put someone at higher risk for future concern.
• Existing mental health concerns: Depression carries a strong link with suicidal thoughts and behaviors, and other mood, anxiety and trauma-related disorders can also increase risk.
• Acute stressors: Suicide is not caused by one event or stressor; however, break-ups, bullying and fights with caregivers can layer with other stressors, generate intense emotions and put kids and teens at an escalated risk.
• Community factors: Youth with marginalizing experiences based on factors such as race or ethnicity, gender identity, sexual identity, socioeconomic factors or stigma associated with help-seeking can be at increased risk of suicide.

Talking to youth and families about suicide

Perhaps the most prevailing fear of asking someone about suicidal ideation is 'putting the idea into their head.' Researchers have widely disproven this notion, with clear evidence that asking the question assures kids that someone cares and is willing to have tough conversations. But while youth may be ready for these questions, their parents are sometimes not. Parents should be notified, but not present, during suicide screenings.

Here are some tips for handling the discussion of suicidal thoughts in pediatric patients:

With youth:	With parents:
Be direct and open. Use appropriate language and avoid clinical, vague or confusing words. Manage your own reactions; be calm but responsive. Ask about both suicidal thoughts and previous attempts. Ask about plans and intent to die. Ask about coping resources and support.	Reassure them that asking questions will not put ideas in children's heads. Use AAP guidelines or previously identified concerns to help initiate conversation. Validate the parent's discomfort, worry or concern. Model an active approach and help get them connected to resources.

Providers should also consider exploring publicly available NIMH tools for suicide screening and brief safety assessments in primary care settings. These tools can help you feel comfortable and confident in asking youth about suicidal thoughts and behaviors and identifying appropriate next steps.

Lethal means counseling

It’s a common misconception that a seriously suicidal person will inevitably find a way to die. In fact, most teen suicides are impulsive, with many attempts escalating from ideation to action in less than 30 minutes. When youth don’t have access to a lethal method at the height of a crisis, they’re much more likely to pass the crisis without a fatal outcome.

The single best thing parents can do to reduce risk of suicide is to reduce access to lethal means in times of crisis. Lethal means counseling is most effective when individualized to each family, which is why it's critical to learn of potential suicide plans. Examples of restricting access to lethal means include:

• Removing or locking up all firearms and storing ammunition separately
• Locking up all prescription and over-the-counter medications
• Removing car keys from teenagers

Suicide prevention resources

More than 90% of youth who have previously attempted suicide will not go on to die by suicide. Connecting these youths with mental health resources reduces their risk. While not all who experience suicidal ideation will act on those thoughts, thoughts of suicide are a red flag that a person is in pain and may need treatment for suicidal ideation. Mental health resources not only address suicide directly, but also improve coping and resilience.

Providers should maintain a list of names and contact information for local mental health centers and mental health providers to quicken the referral process. Make patients and families aware of the Suicide & Crisis Lifeline, 988, where individuals can call or text for rapid support when in crisis. Encourage them to put the lifeline into their phone to have it ready. Phone applications like “My 3” can also be helpful tools for safety planning and suicide prevention.

If safety is an acute concern for your patient, consider sending them to an emergency department or crisis center, or using the 988 Suicide & Crisis Lifeline for rapid support. If your patient does not present with acute safety concerns but is reporting a high level of mental health symptoms that are impairing their typical functioning (e.g., school, social relationships), they may be a good fit for the Partial Hospitalization Program at Children's Hospital Colorado. Children’s Colorado has partial hospitalization programs at our Anschutz Medical Campus, Aurora, North Campus, Broomfield and Therapy Care on Telstar, Colorado Springs.

A summary of all our mental health programs and estimated wait times can be found here: https://www.childrenscolorado.org/health-professionals/refer/mental-health-capacity/

For more information, please call the Pediatric Mental Health Institute intake coordinators at 720-777-6200.