Suicidal Ideation in Pediatric Patients

Whether it's from research, media, clinical practice or day-to-day life, messages about youth suicide can be confusing. Messages warn of a potential public health crisis while simultaneously reminding us that suicide is statistically rare. However, scholarly sources agree that suicidal ideation is on the rise among children and adolescents ages 10 to 19, and new guidelines from the American Academy of Pediatrics recommend routine screenings start at age 12.

What is suicidal ideation?

Suicidal ideation is an umbrella term that describes a spectrum of thoughts and behaviors associated with suicide, including: thoughts, urges, 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

Suicide is commonly cited as the second leading cause of death among adolescents ages 15 to 19 and, more recently, children ages 10 to 14. According to the Centers for Disease Control's Youth Risk Behavior Survey, 31.5% of adolescents report feeling sad or hopeless with associated impact to their daily functioning in 2017, and about 17% have "seriously" considered suicide. In Colorado, approximately 7% of youth made at least one suicide attempt in the previous year and 13% made a plan. Nationally, girls are about twice as likely to make a suicide attempt, but their male counterparts are about three times as likely to die.

Suicide warning signs and risk factors

While assessing suicidal intent is challenging at best, a number of warning signs and social and emotional factors can help identify someone at risk:

• Past behavior: previous suicidal thinking or suicidal actions put someone at higher risk for future concern.
• Changes in behavior: look for changes in academic or athletic performance, social withdrawal and attitude or personality changes.
• Cries for help: most people will disclose to at least one person what they are thinking before they make an attempt. Take these comments seriously and follow up with direct questions.
• Acute stressors: Suicide is not caused by one event or stressor. However, break-ups, bullying and fights with parents can layer with other stressors, generate big emotions and put kids at an escalated risk.

Starting the discussion about suicide in pediatrics

Perhaps the most prevailing fear of asking someone about suicidal ideation is 'putting the idea into their head.' This notion has been widely disproven, 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.

Means restriction

It is a common misconception that a seriously suicidal person will inevitably find a way to die. In fact, most teen suicides are impulsive, with about 69% of attempts escalating from ideation to action in less than 30 minutes. When a lethal method is unavailable at the height of a crisis, the likelihood that the crisis will pass without a fatal outcome is significantly increased.

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

Over 90% of those who have previously attempted suicide will not go on to die by suicide. Connecting these youths with mental health resources greatly reduces their risk. And 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. Program the National Suicide Hotline (800-273-8255) and text line (741741) into your phone to have it ready.

If safety is an acute concern for your patient, the Partial Hospitalization Program at Children's Hospital Colorado can help. In this 30-hour per week intensive, collaborative treatment program, Children's Colorado's pediatric mental health experts stabilize suicidal thinking and behavior, develop a comprehensive treatment plan to address safety and help enhance coping resources to manage ongoing stressors. For more information, call the Partial Hospitalization Program intake coordinator at 720-777-7794.