Suicidality in Youth 14 Years Old and Younger
Impulsivity as a Risk Factor
Impulsivity is an important aspect that deserves attention, especially when considering youths aged 14 and younger. While trait impulsivity is recognized as a risk factor for suicidal behaviors, it does not consistently correlate with the impulsivity observed during a suicide attempt (Anestis, Soberay, Gutierrez, Hernandez, & Joiner, 2014). Additionally, it may not effectively differentiate between individuals who contemplate suicide and those who actually attempt it, specifically in the context of young people (Klonsky & May, 2010; May & Klonsky, 2016).
As a result, relying on trait impulsivity alone has limited utility in determining the immediate risk of suicide among this age group. Ongoing empirical studies are being conducted to examine the percentage of impulsive suicide attempts, along with debates surrounding the definition of an "impulsive" suicide attempt. Despite these definitional challenges, it is crucial to recognize that crises leading to suicide can escalate rapidly in youths, and attempts may occur with minimal planning (e.g., Simon et al., 2001).
Unfortunately, the field currently struggles to accurately assess and predict the likelihood of such rapid escalation, particularly in youths aged 14 and younger. This underscores the significance of implementing appropriate planning and prevention strategies for individuals in this age group, regardless of their level of risk.
Why Talk About Suicide With Children
Clinicians may sometimes feel hesitant to broach the subject of suicide with children aged 14 and younger, out of concern that discussing it might inadvertently increase the risk or harm the therapeutic relationship. However, compelling data demonstrates that screening or assessing suicide risk does not elevate the risk among children, and in fact, it may alleviate distress in those experiencing suicidal thoughts (e.g., Gould et al., 2005). In our experience, clinicians can maintain and even enhance rapport through skillful assessment of suicidal thoughts and behaviors in this age group. Skillful assessment reassures children that clinicians genuinely care about their well-being, respect their autonomy, and are willing to engage in open and empathetic dialogue about sensitive topics.
A proficient suicide risk assessment begins with explaining the importance of the topic and seeking permission to proceed (Brent et al., 2011). By normalizing the experience of suicidal thoughts and behaviors and discussing them in a straightforward manner, defenses can be lowered, fostering more open disclosure. Requesting permission further reduces defenses and demonstrates respect for the autonomy of children. For instance, when initiating the suicide risk assessment, clinicians can use a statement like the following:
"Your well-being and safety are my top priorities. Sometimes, when children feel upset or are going through difficult times, they may have thoughts of hurting themselves or wanting to die. Is it okay if I ask you some questions about those types of thoughts?"
If permission is granted, the clinician can proceed to inquire about suicidal thoughts and behaviors. If permission is not granted, the clinician should explore the child's concerns regarding discussing the topic (e.g., fears of negative consequences) and then reiterate the importance of addressing the issue. Engaging in an open and empathetic dialogue about the child's concerns often leads to a greater willingness to disclose suicidal thoughts and behaviors. Nevertheless, suicide risk assessment is not optional. If a child continues to refuse to answer questions about suicidal thoughts and behaviors, the clinician should convey that assessing risk is their ethical and professional responsibility and that they may need to take steps to ensure the child's safety, such as involving parents or considering hospitalization.
Confidentiality
Confidentiality limits are a common concern for both clinicians and children. Whether or not children express concerns about confidentiality, clinicians must discuss it prior to inquiring about suicidal thoughts and behaviors. Clinicians often worry that explicitly discussing limits to confidentiality before suicide risk assessment might make children less willing to disclose such thoughts and behaviors. While this concern is valid, it is important, both ethically and therapeutically, to ensure that children understand the limits to confidentiality before assessing suicide risk. The potential consequences of breached trust and rapport, particularly within an ongoing therapeutic relationship, outweigh the potential benefits of obtaining information from children who do not comprehend the limits of confidentiality. Children should not be caught off guard or feel deceived if clinicians breach confidentiality. We broach the subject of confidentiality limits with a statement like the following:
"Before we continue, I want to let you know that what we talk about today will remain private and confidential. However, if I have concerns about your safety, I may need to involve your parents or take necessary steps to keep you safe. I will only share information that is essential for your well-being and safety, and I will not discuss other things we talk about without your permission."
Once permission is granted and confidentiality limits are discussed, the clinician can proceed to inquire about suicidal thoughts and behaviors. Clinicians should gather relevant information concerning suicide risk from multiple sources, at a minimum from the children themselves and their primary caregivers. Whenever possible, clinicians should create opportunities to speak with the child and caregivers independently, as children may be more comfortable discussing sensitive topics like suicidal thoughts and behaviors without their caregivers present.
Safety Planning
When working with children, it is frequently beneficial to facilitate the entire safety plan in the presence of both the child and their caregivers. This approach allows for additional support and assistance to be provided to the child, as they may require guidance in the development and implementation of the safety plan. Conducting the safety plan collaboratively ensures that the child receives the necessary support and resources to effectively develop and utilize the safety plan. If the safety plan is conducted with only the child, it is critical to contact the legal guardian or caregiver to disclose the risk assessment and safety plan. Help the caregiver strategize ways to make the family home, and child’s room, safer and follow-up to confirm action steps were completed.
Documentation
After conducting a thorough risk assessment and implementing appropriate risk management strategies, it is essential for clinicians to carefully document their actions. At the very least, we advise clinicians to document the following information:
(a) The assigned risk designation, indicating the level of risk associated with the individual. (b) The reasoning behind the risk designation, including a detailed account of the nature and frequency of the individual's suicidal thoughts or ideation. (c) The specific actions taken by the clinician to address and mitigate the identified risk, outlining the interventions, therapies, or treatments implemented. (d) Future steps or recommendations for ongoing care and risk management, outlining the planned course of action to ensure the individual's well-being moving forward.
By diligently documenting these key elements, clinicians can maintain a comprehensive record of their risk assessment, management strategies, and plans for future care, which is crucial for providing effective and coordinated support to individuals in need.
Importance of Transperancy
The child may ask, “What happens when I tell a teacher about suicide?”
Let them know what happens:
Report concern to a trained screener:
Counselor, psychologist, nurses, athletic trainer (HS), school administrators, or prevention services care and advocacy team
Trained screener conducts a Columbia Suicide Severity Rating Scale (C-SSRS) triage assessment
Parent/guardian contact
Referral to outside care and potential safety planning
Trained screener completes district documentation
Recommendations for Screening Youth 14 Years Old or Younger for Suicidality
Research shows that child suicide deaths predominantly occur in the family home, particularly in the child’s bedroom. Additionally, the most common methods used are hanging and firearm use. When conducting safety planning, ensure that caregivers temporarily remove/relocate all objects that could be used for hanging (e.g. rope, belts, long pants, bed sheets). Confirm the use of safe firearm storage, or temporary relocating of the firearm outside the family home.
Students with mental health concerns, often involving depression or ADHD, should be given additional assessment and safety planning. This is also true for students with experiences of trauma.
When conducting the risk assessment, ask about family issues and school problems, as these are reported as common contributing factors to suicidality in children.