Youth Suicide

Mental health providers aiming to reduce the morbidity and mortality of suicidal thoughts and behaviors in individuals of any age group focus on understanding risk factors that are correlated with suicide. A risk factor may be a stable, nonmodifiable marker that designates an individual or group of individuals as one that will benefit from interventions or more close monitoring or a modifiable direct target of intervention to reduce death by suicide.

Younger children die by suicide at a much lower rate than adolescents and young adults (2). The transition from preadolescence to adolescence is generally understood to confer significantly increased risk of both suicidal thoughts and suicidal behavior (30). However, a nationally representative sample of 11,875 preadolescents found the rate of suicidal ideation in preadolescents to be 14.33% and the rate of suicide attempts to be 1.26%. Identifying as a sexual minority and having a psychiatric disorder—especially two or more psychiatric disorders—increased the risk of suicidal ideation. Male sex also increased the risk of suicidal ideation in preadolescents, which stands in contrast to adolescents and adults, where males have lower rates of suicidal ideation and suicide attempts but higher rates of death by suicide than females (31–33).

A study analyzing the circumstances of 134 younger children (ages 5–11) who died by suicide found that these children most commonly died by suffocation or hanging in their bedroom, with death by firearm being the second leading cause of death (34). Among those in the study who died by firearm, all obtained a gun that had been stored unsafely in the home.

Although the presence of a psychiatric disorder is a risk factor for death by suicide among age groups, research suggests that this risk factor is more important for older adolescents than for younger individuals (11). For instance, one study found that 60%, or 21 out of 35, of adolescents below age 16 who died by suicide had diagnosed psychiatric disorders in contrast to 82%, or 115 out of 140, of all youths who died by suicide (10, 11).

Characteristics in youths that are protective against suicide include a general sense of connectedness. Specifically, parent connectedness, connectedness to other adults, caring friends, participation in sports, academic achievement, and a fondness for school are associated with lower risk of suicidal behavior (35). Some youths are more likely to seek support from peers than adults, and when this peer support is strong and encourages healthy behaviors, this can be protective. Involvement with organized religion and private religious practices are associated with less suicidal ideation in youths (36).

Preventing suicide requires both the capacity to detect indicators of suicide risk through screening and a strategy to evaluate those at risk to determine acuity so that urgent action can be taken when it is needed. Clinical pathways for suicide risk screening in youths have been developed for emergency department and inpatient medical settings and have been adapted to outpatient medical settings (37, 38). To detect suicide risk in individuals who do not present with psychiatric chief complaints, the clinical pathway utilizes universal screening with the Ask Suicide-Screening Questions tool (ASQ), a set of four to five yes–no questions that can be administered in about 20 seconds (39). Patients who answer “no” to all four initial questions on the ASQ are considered to have a negative screen, and no further assessment is warranted. Patients answering “yes” to any of the first four items are asked a fifth “acuity” question: “Are you having thoughts of killing yourself right now?” Those answering “yes” to the fifth question are considered to have an acute positive screening and need an immediate safety assessment by a qualified individual. Those answering “no” to the fifth acuity item but “yes” to any of the first four items are determined to have a “nonacute positive” screening result and require further assessment, such as with a tool known as the “brief suicide safety assessment” or the Columbia-Suicide Severity Rating Scale (C-SSRS) (37). A toolkit from the National Institute of Mental Health for using the ASQ is available for free at www.nimh.nih.gov/ASQ.

A clinical assessment of suicide risk begins with detecting and characterizing suicidal thoughts. Questions can be drawn from the ASQ or the C-SSRS, or they can be paraphrased to inquire about whether an individual has had recent wishes to be dead and thoughts of killing oneself. Further assessment involves determining the frequency and duration of suicidal thoughts, the presence of a plan (and specificity of the plan), and the intensity of that plan (including the intent to act on a plan and perceived ease to avoid acting on thoughts).

Beyond suicidal thoughts, risk factors as described earlier are assessed, including past history of suicidal behavior and nonsuicidal self-injurious behavior, presence of psychiatric disorders, substance use, family history of suicide and psychiatric disorders, a history of trauma, and acute stressors. Access to lethal means of suicide is part of the assessment, and the presence of firearms in the home should always be determined as part of a suicide risk assessment. Connectedness is an important dimension of suicide risk in youths, and signs and symptoms of struggling in youths that deserve further assessment include pulling back from extracurricular activities, isolating in one’s room or otherwise withdrawing from family and social interactions, and declining grades.

Because suicidal thoughts may precede suicide attempts and death by suicide in some individuals, it is important to identify individuals who are experiencing them. However, in terms of risk of death by suicide, suicidal thoughts themselves exist on a continuum, on which the risk is much higher when there is detailed planning and intent to carry out a suicide plan. One way to conceptualize this continuum is depicted in Figure 1.

The continuum proceeds from the left, corresponding to minimal risk of suicide, to the right, corresponding to extremely high and imminent risk. This helps explain why assessment of risk in individuals having suicidal thoughts includes asking about methods considered and the degree of detail. A nearly universal experience, not particularly associated with risk of suicide, is a wish to escape problems or stressors. Slightly further along the continuum is the experience of feeling so overwhelmed (by emotions or stressors) that the individual feels that death might be advantageous. This line of thought, without thoughts of actually taking action to end one’s own life, is sometimes called “passive” suicidal ideation. Next on the continuum is having thoughts about suicide without having seriously considered any methods to do it. Progressing along the continuum, individuals may have considered a plan to varying degrees of specificity. At some point, the individual may have considered the plan in enough detail to be prepared to carry it out (e.g., a plan of how and when to access a firearm to attempt suicide or to access the pills needed for a lethal ingestion). At the extreme end of the continuum, a patient might have a detailed plan with the intent to carry it out; these individuals are on the cusp of attempting suicide unless prevented from doing so.

Normally, movement along the continuum is expected to be gradual, giving opportunities for the patient to reach out for help and to utilize coping skills or take advantage of protective factors before they are on the extreme right side of the continuum. However, there are some factors that appear to make individuals at a higher risk for moving quickly to the extreme right side of the continuum. These “fast-track” factors include impulsivity from substance use, bipolar disorder, ADHD, or traumatic brain injury; a significant history of trauma; and young age (preadolescence) or intellectual disability (Figure 2).

Detection of suicide risk necessitates steps to prevent it. Treatment of co-occurring psychiatric disorders such as mood, anxiety, and eating and substance use disorders, and ensuring connection with mental health treatment and longitudinal follow-up, can help reduce risk.

A structured approach to crisis planning, called the safety planning intervention (SPI), results in a written and prioritized list of strategies to cope and sources of support for patients to use in a suicidal crisis (40). The six basic components of the SPI involve an understanding of the warning signs of a suicidal crisis; internal coping strategies that can be used; people and social settings that provide distraction; people (with name and contact information) whom the individual can ask for help; professionals, agencies, and hotlines that can be contacted in a crisis; and how the environment can be made safe (restriction of access to lethal means).

When the SPI is unable to provide a sufficient level of safety, a higher level of care and other interventions directly targeted at increasing safety may be necessary. This can include inpatient and partial hospitalizations, intensive outpatient treatment, and sometimes treatments specific to suicidal thoughts and behaviors.

Because connectedness and healthy relationships with family members and peers are protective against suicide, helping facilitate healthy engagement with activities and individuals is important, through both identifying existing possibilities with the SPI and improving these and fostering new ones through work with youths, their families, and their schools during longitudinal follow-up care.

With increasing rates of suicide in youths, making an impact relies on understanding key risk and protective factors. Identifying those at risk, assessing the acuity of this risk, and utilizing interventions to mitigate it are important skills for clinicians involved in youth mental health to prevent suicide.