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 

As previously emphasized, screening tools for suicide risk factors in pediatrics are vital when assessing the potential for suicidal intentions or behavior (5). These tools are significant because incorporating them into routine assessments can assist in prompt identification and intervention. However, it is warranted that screening tools only account for a portion of the overall assessment pertaining to the risk of suicide in the youth population; thus, those tools must not be solely relied upon (5). 

One of the most popular screening tools for suicide risk factors in the pediatric population is the Ask Suicide-Screening Questions (ASQ) Toolkit (3). The ASQ is a free toolkit approved by the Joint Commission, and it has been validated for use in all populations receiving treatment in medical settings (3). Particularly, 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 

There are numerous risk factors that contribute to suicidal ideations and attempts. Among those suicide risk factors are age, gender, ethnicity, genetics/history, environmental factors, and psychological/physical health factors (4). Elementary and middle schoolers are 40% more likely to attempt suicide, though the risks of suicide-associated deaths are prominent in adolescents 16 years of age and older (4). Likewise, females are 2-3 times more likely to attempt suicide, whereas males are four times more likely to complete suicide acts (4). Even more so, there are more suicide attempts and completions in American Indian, Alaskan Native, Latina/Latino youths (4).  

However, genetics and history of suicide attempts are other factors to consider. One of the strongest predictors of completed suicides with 25-50% of youth victims correlates to previous attempts (4). Even more troubling is that risk significantly increases by at least three times when there is a family history of suicide (4). Those risk factors should not be overlooked.  

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 (4).  

Here are psychological/physical health factors highly linked to suicide (4):  

• depression or other mental illness 
• 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 & Symptoms of Associated with Suicide 

Oftentimes, suicide signs and symptoms are comparable to those noted in depressive situations.  

Some of the signs and symptoms linked to suicidal behavior include (4): 

• 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  

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; they must remain supervised in the clinical setting until safety is evaluated. At the same time, the environment is freed of harmful objects, and their 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 their 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 their 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 are 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 (2). Rest assured that detailed assessments and evaluations facilitate deriving the most appropriate plans of care. Therefore, the following ten steps are recommended when assessing for suicide risk in pediatric patients and managing patients who are suicidal: 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 mediation (i.e. antidepressants) and/or psychotherapy (i.e. cognitive behavior therapy aka CBT); document the risk assessment, interventions, and patient status); and arrange for review (2). 

As previously mentioned, safety is a priority; hence, composing a safety plan is a key component in providing effective and efficient care for the individual. The safety plan should encompass the following components: recognizing signs of patient status worsening; identifying and listing personal coping mechanisms; utilizing family and friends as distractions from suicidal ideations; involving the family in problem-solving during a crisis; contacting mental health clinicians and restricting access to lethal means (2). 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 child is brought to the ED via emergency transport after being found lethargic on the floor of their bathroom with an empty bottle of hydrocodone located close by their hand. It is assumed that they ingested an indefinite amount of hydrocodone tabs. Their 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, they gave their reason for the suicide attempt, which revolved around them being bullied by peers on almost a daily basis for the last couple of months. The patient excels academically and was a member of the middle school basketball team, which helped them cope until the season recently ended. Additionally, the patient lives with their grandparents, and 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 their head in their hands. You consider the appropriate next steps with the patient's safety of utmost importance.

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 their 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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