Pediatric Suicide Screening: A Review of the Evidence

Preteen Suicide Risk Screening in the Pediatric Outpatient Setting: A Clinical Pathway

We are in a youth mental health crisis with unprecedented and staggeringly high rates of suicidal ideations and suicide behaviors in preteens. In the United States 14.5% of children aged 9-10 have experienced suicidal thoughts and behaviors, including 1.3% with a suicide attempt. American Academy of Pediatrics guidelines call for universal suicide risk screening of youth aged 12+ years during preventative healthcare visits, and screening in preteens aged 8-11 years when clinically indicated. However, what constitutes a clinical indication at 8-11 years can be difficult to systematically detect and pediatric practitioners may not be equipped with necessary age-specific assessment tools. This is compounded by the lack of emphasis on preteen suicide risk screening (and focus on adolescents), which leaves practitioners without age-appropriate resources to make clinical determinations for at-risk preteens. The objective of this project was thus to develop an evidence-informed suicide risk screening pathway for pediatric practitioners to implement with preteen patients in outpatient settings. Suicide risk assessment in younger children (<8 years) is also briefly addressed. We convened a group of researchers and practitioners with expertise in preadolescent suicide, pediatric medicine, behavioral health screening integration with primary care, and child development. They reviewed the empirical literature and existing practice guidelines to iterate on a multi-informant clinical suicide risk screening pathway for preteens that includes both caregivers and preteens in the screening process. We also developed tools and accompanying guidelines for a preteen suicide risk screening workflow and risk determination to aid practitioners in deciding who, when, and how to screen. Finally, we provide scripts for introducing suicide risk screening to caregivers and preteens and to discuss screening findings.

Universal Suicidality Screening in a Pediatric Emergency Department to Improve Mental Health Safety Risk

INTRODUCTION

Suicide is the second leading cause of death for youth 12 to 18 years of age. Suicidal ideation can be predictive of suicide attempt, so screening for suicidal ideation by emergency nurses can help identify those at risk and facilitate timely intervention. This study evaluates the use of a universal suicide screening using the Patient Safety Screener 3 and the Columbia Suicide Severity Rating Scale to identify youth ages 12 to 18 years experiencing suicide risk and assess factors predictive of suicide risk level.

METHODS

We conducted a retrospective cohort study using data from patients presenting to the emergency department at an acute care hospital that uses a universal screening program for suicide risk. We determined the frequency of positive screens and performed multivariate analyses to identify predictive factors of scoring high on the Columbia Suicide Severity Rating Scale.

RESULTS

Notably, 9.1% of patients were experiencing some level of suicide risk; 10% of those with positive scores had no mental health history and were not presenting for a mental health reason. After controlling for other independent variables, insurance status, mental health presentation, and known mental health history were significantly associated with Columbia Suicide Severity Rating Scale score.

DISCUSSION

Universal screening for suicide risk in pediatric emergency departments by nurses is critical for all patients older than 12 years, given that we identified patients at risk of suicide who presented for non-mental health reasons. These patients may not have been identified or referred to treatment if they were not screened for suicidality increasing risk of future suicide attempt.

Integrated behavioral health services in pediatric primary care and emergency department utilization for suicide risk

Introduction

Universal screening for suicide risk in primary care settings is a promising avenue for preventing self-harm and improving health outcomes. Triaging youth to an appropriate level of care, including diverting lower-risk patients from the emergency department (ED) is a meaningful goal. Previous research indicates integrated behavioral health (IBH) may prevent unnecessary admission to the ED on the day of suicide risk screening. We hypothesized that youth who received an IBH consultation the same day as suicide risk screening would be less likely to be admitted to the ED, but more likely to contact IBH services and utilize primary care in the following month.

Methods

We conducted a retrospective chart review of 3,649 youth aged 10-18 years who were screened with the Ask Suicide-Screening Questions (ASQ) in two pediatric primary care practices. We collected demographic data, ASQ and Patient Health Questionnaire-9 (PHQ-9) scores, as well as patient contacts with IBH, the ED, and medical primary care the day of screening and the following 31 days. We conducted a series of logistic regressions and chi-square analyses to determine whether contact with IBH on the same day as positive suicide risk screenings predicted same-day admission to the ED, IBH contact, and medical primary care utilization.

Results

Among the 7,982 ASQ scores, 1,380 (18%) were non-acute and 87 ASQs (1%) screened acutely positive. Over 90% of positive screens were diverted from the ED regardless of IBH contact. None of the patients died from suicide. Same-day IBH was associated with higher likelihood of general ED visits for all positive screens (acute and non-acute together). None of the positive screens that received an IBH consultation on the same day as screening were admitted to the ED in the subsequent month. Contact with IBH the same day as screening positively predicted utilization of IBH and medical primary care services in the subsequent month, especially for youth with minority race and ethnicity identities.

Discussion

In the context of clinics with IBH and systematic risk assessment processes, most youth who screen positive for suicide risk are diverted from the ED. However, contrary to our hypothesis, our study showed that youth who received same-day IBH consultations were more likely to be admitted to the ED compared to peers who did not receive IBH consultations. These findings suggest that systematic suicide screening combined with IBH consultations in pediatric primary care can effectively identify risk levels and triage patients to appropriate care.

Suicides among Children and Adolescents in Paraguay: An 18-year National Exploratory Study (2004-2022)

BACKGROUND

Suicide and suicide attempts are impacting events for patients and their relatives, and these behaviors are still taboo among adults and may be even more traumatic when involving children and adolescents.

AIM

In this study we aimed to describe suicide rates among children and adolescents in Paraguay over the last decades as well as associated factors such as sociodemographic characteristics and methods used for suicide.

METHODS

This was an observational and exploratory study describing the frequency and characteristics of suicide among children and adolescents in Paraguay between 2004 and 2022. Official records of all deaths by suicide were reviewed, and statistical analyses were performed. In addition, an attempt was made to predict the number of suicides in the next 5 years using a mathematical model based on simple linear regression.

RESULTS

In the 18-year period observed, 940 suicides among children and adolescents were recorded. The mean age was 15.05 ± 1.8 years old. Of these, 51.17% were male, 74.6% were from urban areas, and 22.2% were from the Greater Asunción and Central Department of Paraguay. The most frequently used method of suicide was intentional self-inflicted injury by hanging, strangulation, or suffocation, which all represented 75.3% of the cases. Our mathematical modeling based on simple linear regression determined that the expected yearly number of national suicides in the pediatric population for the following years, from 2023 to 2027, will range between 72 and 81.

CONCLUSION

This study is the first large national epidemiological report on the emerging issue of suicide among children and adolescents in Paraguay. It may be a relevant source of information for mental health professionals, health authorities, and decision makers to develop national prevention strategies and actions against suicide among youths.

Feasibility of a universal suicidality tool for adolescents

BACKGROUND

The suicide rate among adolescents has been increasing rapidly over the past several years.

LOCAL PROBLEM

Adequate screening for suicide risk in this population, particularly youth of color, is lacking.

METHODS

The Ask Suicide-Screening Questions (ASQ) tool was implemented at two adolescent-focused health clinics in a large U.S. city.

INTERVENTIONS

This project followed the Ottawa Model of Research Use. Participating clinicians were surveyed before and after receiving an educational module on suicide risk screening, the ASQ tool, and clinical pathways. Clinicians were also asked about the feasibility and acceptability of the ASQ tool in their practice. An electronic medical records software was used to gather data on patients newly screened for suicide risk using the ASQ tool.

RESULTS

Among eligible patients, 40.2% were screened using the ASQ tool during the 4-month duration of the project. Most clinicians reported that using the tool was feasible within their practice (66%) and 100% endorsed its acceptability (i.e., reporting that they were comfortable screening for suicide and that the ASQ was easy to use).

CONCLUSIONS

The ASQ may be a promising screening tool for clinicians to use to address the mental health needs of at-risk youth. This project supports the universal acceptability and feasibility of its use in inner-city primary care clinics.

Suicide in young people: screening, risk assessment, and intervention

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

Self-Harm Behaviors, Suicide Attempts, and Suicidal Ideation in a Clinical Sample of Children and Adolescents with Psychiatric Disorders

Suicidal ideation and self-harm behaviors have been found to be important risk factors for suicide. The aim of this study was to explore the rates of psychiatric disorders among different groups of patients with suicidal ideation, suicide attempts, and non-suicidal self-harm behaviors and to identify the associated socio-demographic and clinical variables. We conducted a cross-sectional study with emergency-admitted patients presenting with non-suicidal self-harm behaviors, suicide attempts, or suicidal ideation to the emergency room of the Child and Adolescent Psychiatry Clinic in Cluj-Napoca, Romania. Data were collected from the patients' charts using a questionnaire that contained socio-demographic and clinical variables. A total of 95 patients aged between 6 and 18 years were included in the study. Ingesting medication and cutting were the most frequently used methods to attempt suicide. Depression and mixed affective and conduct disorders were the diagnoses most commonly associated with suicidal behavior. Girls with depressive symptoms were more probable to have suicide attempts than boys, and girls with depressive symptoms and behavioral problems registered more self-harm behaviors. Further research should systematically examine the relationship between self-harm behaviors and suicide attempts and the profile of patients at risk of future suicide attempts.

Efficacy and safety of repetitive transcranial magnetic stimulation in children and adolescents with depression: A systematic review and preliminary meta-analysis

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) benefits adults with depression while its efficacy and safety in children and adolescents with major depressive disorder (MDD) remain unclear. We conducted a preliminary meta-analysis here to objectively appraise rTMS in the youth with MDD to inform future research and clinical practice.

METHODS

We searched Pubmed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials from their inception to December 1, 2021. Studies with a control group or self-controlled designs and evaluating the Hamilton Depression Scale (HAM-D) or the Children's Depression Rating Scale-Revised (CDRS-R) at baseline and post-rTMS treatment were included. Two reviewers independently selected eligible studies, retrieved data in a structured fashion and assessed studies' quality. Hedges'g with 95 % confidence intervals and withdrawal rate with 95 % confidential intervals were separately used to evaluate the efficacy and safety of rTMS.

RESULTS

Thirteen studies with six datasets (165 patients, 61.8 % female, age range from 10 to 25 years old) were included and our meta-analysis found children and adolescents with MDD benefited from rTMS treatment (Hedges'g 1.37, 95 % CI 0.85 to 1.90, P = 0.001). In addition, 4 % of patients (95 % CI 0.02 to 0.09) withdrew during rTMS treatment for reasons including fear, mood swings, suicide ideation and adverse events.

LIMITATIONS

This conclusion is tempered by a small number of studies included and a potentially existing placebo effect.

CONCLUSIONS

Our findings suggest rTMS could benefit children and adolescents with MDD in a relatively safe manner, and this result may help guide clinical practice.

A Pre-Adolescent and Adolescent Clinical Sample Study about Suicidal Ideation, Suicide Attempt, and Self-Harming

Suicide is the second cause of death among adolescents, and nonsuicidal self-injury (NSSI) is one of the main risk factors for suicidal behavior. However, the possible variables specifically associated with suicidal ideation and suicide attempt, as well as the psychopathological characteristics linked to the concomitant presence of suicidal ideation/attempt and NSSI are still under-investigated in youth. The current study aimed to address these issues in a sample of 174 young Italian inpatients (M_age = 14.3 years ± 1.93, 78.2% girls). Sociodemographic and clinical variables were assessed through psycho-diagnostic interviews and ad hoc questionnaires. A binomial logistic regression was performed to identify the predictors of suicidal ideation and suicide attempt. Then, Kruskal-Wallis tests were run to analyze the psychopathological differences between patients with suicidal ideation and suicide attempt considering the coexistence of NSSI. The results highlighted that previous access to child mental health services and general psychopathological problems significantly predicted suicidal ideation, while previous hospitalizations, borderline personality functioning, and affective disorders significantly predicted suicide attempt. In general, inpatients with also NSSI reported higher levels of internalizing, somatic and total problems, impulsiveness, alexithymia, and emotional dysregulation. The clinical implications of our findings in terms of primary and secondary preventive programs are discussed.

Child Sexual Abuse and Suicide: Essentials for the Forensic Nurse

Sexual abuse can result in significant negative sequelae for victims. One particularly harmful consequence is suicidal ideation, which can lead to suicide attempts and even death. It is essential to screen children and adolescents for suicidal ideation when providing medical forensic care after disclosure of acute or nonacute sexual abuse/assault. Forensic nurses must feel confident in their abilities to assess suicide risk and provide appropriate intervention and referrals. A thorough understanding of the relationship between sexual abuse and suicidal ideation and behaviors can assist the forensic nurse in the development of practice behaviors to better identify, intervene, and prevent suicidal ideation and behaviors among youth experiencing sexual abuse.

Quo vadis? Problems of prevention of suicidal behavior in adolescents (narrative review)

Among the existing problems related to the health and quality of life of Russian youth, the topic of suicidal behavior is the most biased, but at the same time the least solvable in a practical sense. This is due to the fact that suicide is an integrative phenomenon, and the suicidal act itself is interpreted in essence as the tip of the iceberg. Especially clearly manifested in adolescence is the fact that suicidal readiness is associated not so much with the level of severity of mental pathology and personality dysfunction, but with the general social context of total trouble. In this regard, suicide prevention cannot be based only on the timely identification of persons at risk for mental pathology. The purpose of this article is to provide a meaningful overview of modern integrated prevention programs that have shown to be effective in reducing the level of suicidal behavior among young people, compared with isolated approaches. The article discusses the problems associated with the implementation and evaluation of the effectiveness of such preventive programs, and also suggests approaches that allow them to be adapted in the public health system and, in particular, in the clinical practice of psychiatrists.

Suicidal ideation and executive functioning in pediatric cancer

OBJECTIVE

Neurocognitive impairments and psychological distress are among the most common difficulties experienced by children treated for cancer. Elevated rates of suicidal ideation (SI) are documented among cancer survivors, and a link between neurocognitive deficits and SI is evident, yet the relationship between SI and pediatric cancer-related neurocognitive effects has not yet been studied.

PARTICIPANTS AND METHODS

Participants were 166 pediatric cancer patients (57.8% Brain Tumor, 31.3% leukemia, 10.8% other cancers) aged 6-23 (M = 11.57, SD = 3.82; 45.8% female) referred for neuropsychological surveillance. SI prevalence was measured by parent, teacher, or patient endorsement of self-harm related items on informant-report measures (e.g., the Child Behavior Checklist). Executive functioning (Behavior Rating Inventory of Executive Function), ADHD symptoms (ADHD Rating Scale), and performance-based measures were compared between those with SI and those without.

RESULTS

17.5% of pediatric cancer patients experienced SI, of which 44.7% had self-endorsement only, 58.5% parent-endorsement only, 20.6% teacher-endorsement only, and 24.1% had two endorsements. Those with SI had significantly greater impairments in global executive composite scores by both parent- and teacher-report (ps < 0.05). Parents of children with SI endorsed significantly more inattention symptoms (M = 6.10, SD = 15.48) than those without SI (M = 50.56, SD = 8.70; p < 0.01), but hyperactivity symptoms did not differ. Intellectual and executive function performance did not differ between those with and without SI (ps > 0.1).

CONCLUSIONS

An elevated number of children treated for cancer experience SI and related neurocognitive problems. Screening for SI and further assessment of the connection between executive functioning and SI in pediatric cancer populations is needed.

Sexual Minority Status and Age of Onset of Adolescent Suicide Ideation and Behavior

OBJECTIVES

To determine if sexual minority adolescents have earlier onset of suicidality and faster progressions from ideation to plan and attempt than heterosexual adolescents.

METHODS

A population-based longitudinal cohort of 1771 adolescents participated in the NEXT Generation Health Study. Participants reported sexual minority status (defined by sexual attraction) in 2010-2011 and retrospectively reported age at onset of suicidality in 2015-2016.

RESULTS

Sexual minority adolescents (5.8% of weighted sample) had higher lifetime risk of suicide ideation (26.1% vs 13.0%), plan (16.6% vs 5.4%), and attempt (12.0% vs 5.4%) than heterosexual adolescents. Survival analyses adjusted for demographic characteristics and depressive symptoms revealed positive associations of sexual minority status with time to first onset of suicide ideation (hazard ratio [HR] = 1.77; 95% confidence interval [CI] 1.03-3.06) and plan (HR = 2.69; 95% CI 1.30-5.56). The association between sexual minority status and age at onset of suicide attempt was stronger at age <15 (HR = 3.26; 95% CI 1.25-8.47) than age ≥15 (HR = 0.59; 95% CI 0.21-1.66). The association between sexual minority status and progression from ideation to plan was stronger in the same year of first ideation (HR = 2.01; 95% CI 1.07-3.77) than ≥1 year after first ideation (HR = 1.33; 95% CI 0.26-6.77).

CONCLUSIONS

Sexual minority adolescents had earlier onset of suicidality and faster progression from suicide ideation to plan than heterosexual adolescents. The assessment of sexual minority status in routine pediatric care has the potential to inform suicide risk screening, management, and intervention efforts among early sexual minority adolescents.