Caroline Helwick

November 07, 2012

NEW ORLEANS — Children and adolescents may be "overlabeled" as being suicidal by school authorities, new research suggests.

Investigators at the Lincoln Medical and Mental Health Center in New York City came to this conclusion after they found that fewer than one half of children referred by schools to the emergency department (ED) for suicidal behavior received psychiatric treatment.

"This finding calls into question whether we are overlabeling children," said study investigator Mark Weems, MD, of Lincoln Medical and Mental Health Center.

The findings were presented here at the American Academy of Pediatrics (AAP) 2012 National Conference and Exhibition.

"Schools have a zero tolerance policy for children who say they want to kill themselves. They get a psychiatric evaluation of these children," said Dr. Weems.

He added that most physicians consider any hint of suicidality to be serious enough to warrant intensive evaluation and treatment.

"We evaluated this hypothesis by first defining what constitutes an intensive psychiatric evaluation and then determining what percentage of suicidal children received this," he said.

No New Prescriptions

The study evaluated children referred by their schools to the ED at an inner-city teaching hospital because they had expressed suicidal ideation verbally or through drawings or actions between 2004 and 2008.

The control group consisted of children who presented with behavioral symptoms but who were not thought to be suicidal.

A "significant psychiatric intervention" was defined as any of the following:

  • Hospitalization in a psychiatric facility

  • Period of observation in the ED > 12 hours

  • Use of restraints

  • Receipt of a new psychiatric medication

Suicidal labeling was considered "appropriate" if 1 or more of these interventions were recommended by a psychiatrist.

Of 581 records, 160 (27.1%) children were labeled suicidal and 421 (72.9%) were considered to have behavioral problems.

Of the 160 children believed to be suicidal, only 49.4% received a significant intervention, which was not significantly higher than in the nonsuicidal group, of whom 56.6% received an intervention (P = .1163), Dr. Weems reported.

The number of interventions by suicide status was not significantly higher for the suicidal ideation group than for the control group. About 15% of each group received 2 or 3 interventions, and the rest received 1 or none. Psychiatric interventions occurred equally for boys (73.7%) and girls (67.6%).

Hospital admissions occurred in 29.4% of the suicidal group, and 70.6% were discharged, compared with 10.4% and 89.6%, respectively, of the nonsuicidal group (P < .0001).

Observation for at least 12 hours was noted for 68.1% of the suicidal group and 81.2% of the nonsuicidal group (P = .0005). Restraints were used on 6.3% and 6.0%, respectively (P = .9217).

None of the suicidal group received a new prescription, whereas 61.1% of the nonsuicidal group did (P < .0001), said Dr. Weems.

He suggested that this may be due to the idea that "psychiatrists are hesitant to jump at giving a prescription on the first encounter."

Altogether, a significant intervention was conducted on 49.4% of the suicidal group and 56.6% of the nonsuicidal group (P = .1163).

"This is significantly different from our a priori assumption that 100% of children labeled with suicidal ideation would have a significant psychiatric intervention," he noted.

Overestimated or Undertreated?

Jeffrey Okamoto, MD, director of the Developmental-Behavioral Pediatrics Fellowship Program at the University of Hawaii at Monoa, had concerns that the study did not capture the use of behavior contracts as an intervention.

He said that many physicians would ask these patients to sign a contract, which can be an appropriate intervention.

"Without this, I don't think we can say we are overlabeling suicidality," he told Medscape Medical News.

He said it is also possible that these children are simply being undertreated, not overlabeled.

"We haven't really answered the question of overlabeling, and I would like to see a study that included contracts," he said. "But it's an interesting study, and it's something we should be looking at."

Dr. Weems and Dr. Okamoto have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2012 National Conference and Exhibition. Abstract 16792. Presented October 20, 2012.