AAP Updates Advice on Adolescent Suicide Prevention

Ricki Lewis, PhD

June 27, 2016

Suicide has replaced murder as the second leading cause of death for individuals aged 15 to 19 years. In response, the American Academy of Pediatrics (AAP) has updated guidelines for screening patients for suicidal thoughts, identifying risk factors for suicide, and assisting at-risk young people.

The new report, authored by Benjamin Shain, MD, PhD, a child psychiatrist at NorthShore University HealthSystem in Illinois, replaces AAP's 2007 report on suicide and suicide attempts in adolescents. The updated document, which highlights stress from bullying and "pathological" use of the Internet, appeared online June 27 in Pediatrics.

The AAP recommends that pediatricians routinely ask patients if they think about self-harm, screen for other risk factors, and refer at-risk patients for mental health evaluation and possible treatment, including use of antidepressants.

Attempted suicides outnumber completed suicides among adolescents 50 to 100:1, previous data show. The top four methods are suffocation, guns, poisoning, and falling.

Risk factors for attempting suicide among adolescents are many and varied. They include previous suicide attempt, family history of suicide, drug and alcohol use, male sex, sexual identity issues, mood disorders, stressful relationship with parents, problems in school or not attending school or working, and personal history of physical or sexual abuse.

An increasingly recognized risk factor for adolescent suicide is bullying, including cyberbullying. Another risk factor on the rise is imitating suicidal behavior or thinking about suicide after news reports of a suicide or suicide attempt, especially in another teen.

Other factors that increase risk for suicidal behavior are depression, bipolar disorder, substance use disorders, disturbed sleep, psychosis, posttraumatic stress disorder, panic attacks, impulsivity, history of aggression, and Internet use exceeding 5 hours a day.

Adolescents who practice a religion and get along well with parents, peers, and people at school are at lower risk for suicidal thoughts, according to the report.

Although twice as many females attempt suicide as males, the males are three times as likely to succeed because they choose more reliable methods, such as guns. The AAP has found that adolescent suicide risk is elevated in homes that have firearms.

The updated report cautions that although risk factors are common, suicide is not, and conversely, absence of risk factors does not mean suicide is not possible. However, intent is a red flag for elevated risk, including evidence of a plan, a prior suicide attempt using a likely lethal method, clear suicidal ideation or behavior with hopelessness or agitation, and severe symptoms of a mood disorder.

In addition, practitioners should recognize that risk factors provide only guidance, and that risk for suicide attempt may be reduced but not eliminated.

The report concludes with specific advice for pediatricians:

  1. Include questions about risk factors for suicide in routine history taking, perhaps including a depression scale. The report suggests specific questions to start conversations, sensitively inquire about suicide ideation, and how to follow up on the answers. The AAP advises conducting interviews without the parents present, but informing patients that parents will be notified if suicide risk is found.

  2. Be familiar with and educate appropriate patients about possible benefits and risks of antidepressants. Recognize that adolescents with mood disorders present in several ways.

  3. Work closely with family members, other healthcare professionals, and emergency departments to best assist adolescents at risk for suicide.

  4. Provide information on local resources for preventing suicide.

  5. Obtain additional training in diagnosing and treating mood disorders in adolescents, if necessary.

  6. Identify homes that have firearms, inquire about how the weapons are stored, and inform parents about the increased risk for adolescent suicide in homes that have guns.

The author has disclosed no relevant financial relationships.

Pediatrics. Published online June 27, 2016. Full text

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