Primary and Secondary Prevention of Youth Suicide Lisa Horowitz, PhD, MPH, Mary V. Tipton, BA, Maryland Pao, MD

Youth suicide is a national and global public health crisis. Pediatricians can use primary and abstract secondary prevention strategies to intervene with youth before or after the onset of suicidal behaviors. Universal suicide risk screening programs can be used to identify youth in medical settings who may otherwise pass through the health care setting with undetected suicide risk. Pediatricians are uniquely positioned to help foster resilience in their young patients and equip families of at-risk youth with safety plans and lethal means safety counseling. Pediatricians on the frontlines of this critical public health crisis require education and training in detecting suicide risk, managing those who screen positive, and connecting their patients to much needed mental health interventions and treatments. Evidence-based suicide risk screening and assessment tools, paired with interventions, are feasible and potentially life-saving in the medical setting.

National Institute of Mental Health, Bethesda, Maryland

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2019-2056H Accepted for publication Jan 29, 2020 Address correspondence to Lisa Horowitz, PhD, MPH, Staff Scientist/Pediatric Psychologist, Director of Patient Safety and Quality, NIMH, Office of the Clinical Director, Intramural Research Program, National Institute of Mental Health, NIH, 10 CRC, Room 6-5362, 10 Center Dr, Bethesda, MD 20892-1276, E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Supported by the Intramural Research Program of the National Institute of Mental Health of the National Institutes of Health (ZIAMH002922-11). Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 145, number s2, May 2020:e20192056H SUPPLEMENT ARTICLE Youth suicide is a major global public time, with nearly half the increase psychopathology and suicide health crisis. In the United States, due to visits by preteens.12,13 attempts, making early detection suicide rates continue to rise, despite and intervention a public health many decades of prevention efforts. SUICIDE TERMINOLOGY imperative. Primary prevention In this article, we will describe the strategies aim to prevent the onset of “ ” increasing rates of youth suicide, Phrases like committing suicide or suicidal thoughts and behaviors by “ ” suicidal behavior, and ideation in the successful suicide are no longer mitigating the effects of internal and United States and discuss evidence- considered appropriate terms for external risk factors. Potential based strategies pediatricians can use pediatricians and researchers to use. prevention approaches include in primary and secondary prevention. Such phrases are discouraged as they fostering resilience in young patients, The gaps in our current knowledge carry negative, blaming connotations promoting peer and family and areas for future research will be and mislabel suicidal behavior as connectedness, and intervening on also be addressed. something that may be successfully parent psychopathology.30 accomplished. Instead phrases such “ ” “ as die by suicide or completed A young person’s ability to adapt to YOUTH SUICIDE: A BRIEF ” suicide are now more stress and adversity is essential for EPIDEMIOLOGIC OVERVIEW 14–16 acceptable. healthy development. Pediatricians, Suicide is the second leading cause of as de facto mental health providers, death for young people 10 to 24 years SUICIDE RISK AMONG PATIENTS IN can be trained to help youth navigate of age in the United States and MEDICAL SETTINGS 1 emotional distress by suggesting worldwide. In 2017, suicide individualized coping strategies to accounted for 25% of all injury- In many studies, researchers have identified medical illness as a risk tolerate frustrations and persevere related deaths for this age group, with 31 17–19 through failures, thus intervening a rate of 10.57 per 100 000.2 In factor for suicide in adults and 20–24 before the onset of psychiatric addition, more young people died by youth. Youth with chronic medical conditions have increased symptoms. Pediatricians can promote suicide than the top 17 leading resilience by highlighting the patient’s 3 contact with their pediatricians, medical causes of death combined. fi allowing opportunities for detection strengths, encouraging self-ef cacy, American Indians and Alaska teaching effective problem-solving Natives4; lesbian, gay, bisexual, of suicide risk. Medical settings are well positioned to screen for suicide skills, and identifying protective transgender, and queer or factors, such as strong social questioning youth5; individuals with risk. Death registry studies reveal that connections, engagement in neurodevelopmental disorders6; and the majority of young suicide mental health treatment, and children in the foster care system7 are decedents (80%) have visited a health care setting months, strong religious and spiritual at greater risk for suicidal ideation 32,33 25,26 beliefs. and behavior. sometimes weeks, before death, and only 20% had contact with 27 In some studies, researchers have Although underrepresented in a mental health professional. found that increased feelings of current research, preteens and Importantly, .1.5 million young school and peer connectedness are younger children think about, plan, people will have an ED visit as their and die by suicide. Among children 5 sole contact with the health care related to lower reports of suicidality fi 34,35 to 12 years of age, suicide is the fth system,28 which may be the only among students. In addition to 3 leading cause of death. Notably, opportunity to recognize their peer support, familial and community suicide rates in youth 10 to 14 years support are protective factors against distress and intervene. Despite these 33 of age are the fastest growing, with statistics, few pediatric health care suicidal behavior. Furthermore, rates of suicide now exceeding death settings screen for suicide risk, and research suggests a strong fi 3,8 9 by traf c accidents. Bridge et al fewer use evidence-based relationship between child and parent fi uncovered a signi cant racial methods.29 mental health, such that parents with disparity for children ,12 years of mental illness are more likely to age, with African American children have children with psychiatric dying by suicide at higher rates than PRIMARY PREVENTION STRATEGIES symptoms.36,37 Notably, intervening white children; this trend completely There is rarely a single cause of and mitigating parental depression reverses at 13 years of age,10 but a death by suicide but rather has been shown to reduce depressive limited data do not explain why.11 In a combination of genetic and and suicidal symptoms and promote recent trends, it is shown that visits environmental risk factors, as well as better health outcomes38 for their to emergency departments (EDs) for precipitating events. Suicidal thinking children, turning a risk factor into suicidal behavior have doubled over in childhood is the gateway to adult a protective factor.

Downloaded from www.aappublications.org/news by guest on September 30, 2021 S196 HOROWITZ et al SECONDARY PREVENTION STRATEGIES general medical settings. In 2016, TJC questions developed to assess broadened this alert by issuing suicidal ideation and behavior. A Risk Factors and Warning Signs of Sentinel Event Alert 56,41 positive screen result on the ASQ will Suicidality recommending that all patients in flag a patient who needs further risk Secondary suicide prevention efforts medical settings be screened for assessment. The ASQ was developed are aimed at detecting youth at risk suicide risk using standardized, in the pediatric ED with 96.9% for suicide and recognizing those evidence-based screening tools. The sensitivity, 87.6% specificity, and exhibiting warning signs. Known risk National Action Alliance for Suicide takes 20 seconds to administer. factors for suicidal ideation and Prevention44 and the American Current studies validating the ASQ behavior include previous suicide Academy of Pediatrics45 have also among youth in inpatient and attempt, mental illness or substance supported implementing suicide risk outpatient settings, and in adult use disorder, family history of suicide, screening procedures in medical medical patients, are showing childhood abuse, trauma or neglect, settings and increasing provider promising psychometrics. An online impulsive or aggressive tendencies, education about suicide risk among ASQ toolkit was created to assist isolation, hopelessness, interpersonal medical patients. medical settings with 32,33,39 loss, and medical illness. implementation, including scripts for The number one root cause of suicide However, most youth who experience nurses and medical assistants, flyers Sentinel Events is lack of assessment one or more of these risk factors will for parents, and brief suicide safety for suicide risk.41 Most often, patients not die by suicide, as is true of most assessments (BSSAs) (www.nimh.nih. present with somatic chief complaints risk factors for any serious medical gov/ASQ). condition. Yet, being aware of and will rarely initiate conversations warning signs can be invaluable and about their suicidal thoughts if not Recently, youth suicide risk screening “ can help pediatricians intervene with asked directly, Are you having clinical pathways,46 sponsored by the ” youth who are displaying signs of thoughts about killing yourself? American Academy of Child and imminent risk. Possible warning Pediatricians should not rely solely on Adolescent Psychiatry, were signs40 include talking about wanting clinical intuition or evidence of published to provide physicians with to die or killing oneself, which, no warning signs of suicidality to screen step-by-step implementation matter what age, should always be a patient; such screening should be instructions. These pathways were taken seriously; looking to obtain universally systematic with young designed to allow each medical 46 lethal means to kill oneself; talking patients 10 years of age and older. setting the flexibility needed to adapt about feeling hopeless, helpless, or Pediatricians will need clinical their screening programs depending having no reasons to live; feeling like pathways that include both screening on available staff and resources. The 46 a burden to others; experiencing and assessment tools, which each pathways outline a 3-tiered system: insurmountable pain; increased use serve different functions. Screening (1) nurses and medical assistants of alcohol or drugs; increased tools are used to rapidly identify administering the ASQ as a brief agitation, anxiety, or recklessness; patients who require further screen; (2) mental health clinicians, and sleeping too much or too little or assessment. Subsequently, nurse practitioners, physician not wanting to get out of bed in the assessment tools guide pediatricians assistants, or physicians conducting morning. in a more comprehensive evaluation a BSSA using the Columbia-Suicide of risk to determine the next steps Severity Rating Scale48 or the ASQ Detecting Suicide Risk in the Medical of care. BSSA47; and, if necessary, (3) a full Setting mental health evaluation. The critical Suicide is one of the most frequently Screening Tools and the Youth second step of the BSSA allows reported Sentinel Events to The Joint Suicide Risk Screening Clinical physicians to choose next steps for Commission (TJC) among behavioral Pathway patients who are at varying health and medical patients. A It is important to use tools that are intermediate levels of risk for suicide. significant percentage of Sentinel evidence-based for the population in An ASQ BSSA has been developed Event suicides reported to TJC occur which they are intended to be used. specifically for pediatricians for in nonbehavioral health units (eg, ED, The Ask Suicide-Screening Questions specific venues. The pathways are ICU, inpatient medical or surgical (ASQ; see Fig 1) is an example of meant to be individualized according units).41,42 In 2007, TJC issued an evidenced-based suicide risk to each institution’s culture and, if National Patient Safety Goal 15,43 screening tool for medical and implemented thoughtfully, can stating that all behavioral health behavioral health pediatric patients make screening more feasible and patients are required to be screened approved by TJC.47 The ASQ is a brief spare strapped mental health for suicide risk in psychiatric and screening tool containing 4 yes or no resources.

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 145, number s2, May 2020 S197 for suicide missed 28% of pediatric patients at risk.57 In addition, there is also no empirical evidence to support the all too common and tedious practice of sequentially screening a patient first with the Patient Health Questionnaire–2; then, if positive, administering a Patient Health Questionnaire–9; and then, if still positive, administering a suicide risk screen. Asking directly about suicide with validated suicide-specific screening instruments is the best way to accurately identify patients at risk.

Evidence-Based Suicide Prevention Programs for Medical Settings and Schools There are several evidence-based treatments that have been touchstones for treating adult individuals at risk for suicide. Cognitive behavior therapy intervention for those attempting suicide was shown to reduce reattempts by 50% over an 18-month period when compared with treatment as usual.58 Dialectical behavior therapy intervention reduced suicide attempts by 50% over 24 months, compared with community treatment.59 More recently, in a landmark Emergency Department Safety Assessment and Follow-up Evaluation study in adults, it was demonstrated that universal FIGURE 1 suicide risk screening paired with The ASQ tool was developed through a multisite study led by the National Institute of Mental Health. a simple, brief intervention of safety The Ask Suicide-Screening Questions (ASQ) Toolkit. Available at: https://www.nimh.nih.gov/ASQ. planning and postdischarge Accessed October 15, 2019. telephone check-ins was shown to decrease suicide attempts by 30% 60 Depression Screening Versus suicide risk. In studies, researchers over 12 months. Suicide Risk Screening have found that depression screens Several suicide prevention programs Some medical settings use depression underdetect patients who die by 52,53 are available to intervene with youth screening tools to screen for suicide. Not all youth who die by at risk for suicide in the medical fi suicide risk, such as the Patient suicide have clinically signi cant setting. The Family-Based Crisis 49 54 Health Questionnaire–9, depression, suggesting that Intervention61 was created in the modified Patient Health screening for depression may not be a pediatric ED to stabilize a suicidal 55,56 Questionnaire–Adolescents,50 or the sufficient to detect suicide risk. In adolescent within a single ED visit, PHQ–M51 for adolescents. Although similar data in pediatric medical with adaptations for primary care validated to screen for depression, inpatients, it was found that using currently in progress. The Family the questions on these tools have not only the Patient Health Intervention for Suicide Prevention62 been validated to specifically identify Questionnaire–Adolescents to screen intervenes with teens who present to

Downloaded from www.aappublications.org/news by guest on September 30, 2021 S198 HOROWITZ et al the ED with suicidal ideation or after having thoughts of suicide? Who will Another example of a screening a suicide attempt. This and similar you tell? How will you cope?”). Safety quality improvement project took prevention programs have been planning70 includes developing place in a large pediatric practice adapted for other medical, school, and coping strategies for times of crisis; in Richmond, Virginia, which community settings.63 Pediatricians recognizing one’s own warning signs; implemented the ASQ among should also be aware of and partner identifying family members, peers, or pediatric medical outpatients seen for 72 with school systems that have begun professionals who can be contacted routine physicals. All staff, including to use effective school-based for help; and providing contact physicians, nurses, nurse 64,65 interventions (eg, Signs of Suicide information for the National Suicide practitioners, and front desk staff, 66 and Sources of Strength ). Lifeline (1-800-273-8255) and the attended trainings on suicide risk detection and prevention. An example Pediatricians have a renewed interest Crisis Text Line (text “start” to of a revision to the program, after the in collaborative care models of 741741). pilot phase of screening all well visits integrated mental health care within for patients 12 years of age and older, primary care settings. Currently, Scaling Up Implementation of was responding to parent concerns mental health care is not well Suicide Risk Screening With Quality about asking children about suicide. integrated into primary care, but Improvement Projects Parents of the pediatric patients had creative solutions are being more questions about the screening developed to provide increased Turning suicide prevention research than anticipated, so the process was resources to those with more into real-world implementations is revised to include a flyer given out complex conditions. Telehealth is also challenging but has been done preemptively to parents during front an emerging method of managing successfully. In general, screening fl desk registration. The flyer mental health problems in areas programs need to be exible so that announced the new addition of where there are limited or no mental each institution can adopt validated suicide risk screening to standard health resources. tools and adapt processes to fit harmoniously within the workflows practice, the reasons for universal Safety Planning and Lethal Means and culture of each site and the screening, and referenced several Safety Counseling populations it serves. Screening research articles about the safety of screening young people for suicide Before discharging a patient that programs are best implemented risk. After the staff became more screens positive for suicide risk, the within a quality improvement “Plan- 70 comfortable screening, they expanded pediatrician, patient, and parent or Do-Study-Act” iterative model, the pilot to include all patient visits, guardian (if available) should create beginning with training and sick or well, for patients 10 years of an individualized safety plan and education of all involved, followed by age and older. The iterative, “Plan-Do- review which lethal means are a brief pilot screening phase. A few Study-Act” process helped the available to determine how to safely weeks after initial implementation, pediatric practice gradually store or remove them from the stakeholder feedback should be used incorporate changes to their program home.67 Firearms are the leading and to revise the screening program as informed by their own patient data. most lethal method of suicide death necessary. Using a continuous Through this participatory, in youth 10 to 24 years of age in the improvement model that is able to experiential, monitoring, and results- United States (46% of all suicide incorporate advances in research, oriented progression, staff are now deaths), followed by suffocation or improve tools over time, and make comfortable with screening. They hanging (38%) and poisoning or revisions to the screening program is 3 have created a highly functioning and overdose (7%). Educating families important. Parkland Health and potentially life-saving screening about the importance of keeping Hospital Systems in Dallas, Texas, program that the practice, patients, firearms and medications locked serves as a universal suicide risk ’ and their families value. away from their child s access screening model program for the is critical and could be country; it has screened .2 million Lessons learned from life-saving.67,68 adult and pediatric patients for implementations teach us that Pediatricians should not ask patients suicide risk without major overresponding to positive screen to sign “safety contracts” to “promise” disruptions to their inpatient and results can make screening programs not to hurt themselves because these outpatient hospital workflows.71 untenable. It is unnecessary and are not valid.69 Rather, pediatricians They began with a pilot phase and burdensome to patients and staff to and patients together should create adjusted as needed on the basis of reflexively treat every patient who concrete, personalized safety plans feedback from patients, families, staff, screens positive as an “emergency” (eg, “What will you do when you are and physicians. (eg, a trip to the ED, automatic

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 145, number s2, May 2020 S199 one-to-one observer, and/or a full behaviors. New research has 3. Centers for Disease Control and psychiatric evaluation). Each positive identified implicit association tasks Prevention. Leading causes of death screen should be followed by as helpful in identifying patients’ reports, 1981–2018. Available at: a BSSA in which next steps can be implicit beliefs about suicidality.76 In https://webappa.cdc.gov/sasweb/ncipc/ determined for feasible and rational recent studies, it has been suggested leadcause.html. Accessed May 10, 2019 patient safety. that a computerized adaptive testing 4. Great Lakes Inter-Tribal Council, Inc. approach to screening may be able to Suicidal Behaviors Among American Challenges to implementing screening capture a more-complete spectrum of Indian/Alaska Native Populations: programs in medical settings include suicidality.77 Ecological momentary Indian Health Service Resource Patient time constraints, managing patients assessment research has started to Management System Suicide Reporting who screen positive, discomfort with Form Aggregate Database Analysis, use smartphones to track unique asking questions about suicide, and 2003-2012. Lac du Flambeau, WI: Great warning signs in real time that may stigma.29,73 Pediatricians have Lakes Inter-Tribal Epidemiology Center, precede or predict suicidal ideation concerns about adding to their Great Lakes Inter-Tribal Council, Inc; and behavior.78 already overburdened systems of 2013 referring for mental health care. 5. Centers for Disease Control and Although accessing mental health CONCLUSIONS Prevention. Sexual Identity, Sex of care is a public health problem Pediatricians are on the frontlines of Sexual Contacts, and Health-Risk nationwide, data from large screening this critical public health crisis of Behaviors Among Students in Grades 9- 12: Youth Risk Behavior Surveillance, programs reveal that screening youth suicide. Universal screening is medical patients for suicide risk has Selected Sites, United States, no longer theoretical; medical – not added volume to the ED boarding 2001 2009. Atlanta, GA: U.S. Department settings throughout the country are of Health and Human Services; 2017 crisis or overburdened systems of pioneering ways to successfully 74,75 care. Sadly, youth are struggling identify and manage suicide risk. 6. Horowitz LM, Thurm A, Farmer C, et al; with suicidal thoughts whether With evidence-based guidelines in Autism and Developmental Disorders Inpatient Research Collaborative. pediatricians screen them. For most place to manage patients who screen young people, screening itself can be Talking about death or suicide: positive, suicide risk screening paired prevalence and clinical correlates in an intervention because this could be with interventions is feasible and youth with autism spectrum disorder in the first encounter in which they are potentially life-saving. Every the psychiatric inpatient setting. verbalizing their troubling thoughts pediatrician can make a difference J Autism Dev Disord. 2018;48(11): to a trusted adult. In addition, much and move us closer to the goal of 3702–3710 of the time a parent is unaware that reducing youth suicide. their child is thinking about suicide.10 7. Pilowsky DJ, Wu LT. 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