Evaluation and Management of Suicidal Ideation and Self-Harm in Children in the Emergency Department (Behavioral Health CME)

Table of Contents

 

About This Issue

Suicide and self-harm behavior among youth represent a major public health crisis. Use of the emergency department (ED) by children with mental health crises has increased over the past decade. The ED may be the first or only healthcare contact for many youths in mental health crisis. Therefore, it is crucial for ED clinicians to understand best practices for the evaluation of youth with suicidal ideation and self-harm behavior. This issue reviews key risk factors for youth suicide and discusses strategies for screening and assessment, ED-based interventions, and considerations for determining appropriate levels of care. In this issue, you will learn:

Risk factors for suicide

Medical conditions that can cause or exacerbate psychiatric symptoms

Relevant historical details and subtle physical examination findings that can help differentiate specific toxidromes or medical conditions from suicidal ideation and self-harm

Suicide risk screening tools, such as the Ask Suicide-Screening Questions (ASQ) and Columbia Suicide Severity Rating Scale (C-SSRS) screen version, that can facilitate identification of suicide risk

Specific circumstances in which laboratory testing is indicated

Recommendations for ensuring a safe environment in the ED

Guidance for management of self-inflicted injuries and intentional ingestions

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
   3. Suicide Risk Screening Tools
10. Diagnostic Studies
11. Treatment
    1. Ensuring a Safe Environment
    2. Medication Management
    3. Wound Care For Self-Inflicted Injuries
    4. Management of Intentional Ingestions
    5. Management of Specific Toxidromes and Acute Agitation
12. Special Populations
    1. Children With Intellectual Disabilities and Autism Spectrum Disorder
13. Controversies and Cutting Edge
    1. A “No-Suicide” Contract Is Not Recommended
    2. Suicide Screening Does Not Increase Risk of Suicide
    3. Provision of Safety Devices in the ED as Part of Lethal Means Counseling
    4. Novel Methods to Identify Suicide Risk
       1. Natural Language Processing
       2. Computerized Adaptive Testing
14. Disposition
    1. Determining an Appropriate Level of Care
    2. Preparing for Safe Discharge
    3. Care of Patients Awaiting Admission
15. Summary
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls for Suicidal Ideation and Self-Harm in Children
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. National Institute of Mental Health ASQ Emergency Department Suicide Risk Clinical Pathway for Youth
21. Tables and Figures
22. References

Abstract

Suicide is a leading cause of death among youth, and the emergency department (ED) serves as the primary point of healthcare contact for many with suicidal ideation. As suicide-related presentations to the ED continue to rise, the implementation of time- and cost-effective care pathways becomes ever more critical. Evidence-based tools for the identification and stratification of suicide risk can aid in clinical decision-making and care linkage. This issue reviews best practices for suicide risk assessment of youth to guide evaluation, management, and disposition planning within the ED setting.

Case Presentations

A 13-year-old girl presents with her father with the request for a medical evaluation after she ran away from home for 24 hours...

• The girl tells you she wanted to hang out with friends after recently getting into an argument with her father about her grades at school. She has a history of depression noted in the electronic medical record and no prior ED visits.
• During triage assessment, the patient avoids eye contact with the triage nurse and answers questions with few words.
• You wonder whether there is more to this patient’s story and what questions you should ask when interviewing the patient in a room.

A 16-year-old boy presents with his foster mother for concern for worsening mental health symptoms…

• The boy was recently started on an antidepressant medication and started to see a therapist last year but has not recently followed up. His foster mother discovered recent texts to a friend on his phone discussing suicidal ideation over the past several weeks. He has no prior history of suicide attempt or self-harm.
• In the ED, he is placed in a safe room. While conducting your history, he shares that he has been engaging in self-harm activities of cutting.
• What are your next steps to complete his ED assessment?

An 8-year-old boy with history of autism spectrum disorder presents with his parents for self-harm by head-banging...

• The parents tell you the head-banging is a new behavior that started 3 days ago and is increasing in frequency.
• In the ED, the patient appears upset and is trying to hit his head on the gurney.
• What underlying etiologies for his symptoms should you consider? What strategies can be used to help with your assessment of a child with autism spectrum disorder and concern for self-harm in the ED?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

National Institute of Mental Health ASQ Emergency Department Suicide Risk Clinical Pathway for Youth

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * American Academy of Pediatrics and American Foundation for Suicide Prevention. Suicide: blueprint for youth suicide prevention. Accessed February 1, 2024. (Report)

7. * King CA, Grupp-Phelan J, Brent D, et al. Predicting 3-month risk for adolescent suicide attempts among pediatric emergency department patients. J Child Psychol Psychiatry. 2019;60(10):1055-1064. (Prospective observational study; 2897 participants) DOI: 10.1111/jcpp.13087

13. * Doupnik SK, Rudd B, Schmutte T, et al. Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: a systematic review and meta-analysis. JAMA Psychiatry. 2020;77(10):1021-1030. (Systematic review and meta-analysis; 14 studies, 4270 patients) DOI: 10.1001/jamapsychiatry.2020.1586

34. * Hughes JL, Horowitz LM, Ackerman JP, et al. Suicide in young people: screening, risk assessment, and intervention. BMJ. 2023;381:e070630. (Review) DOI: 10.1136/bmj-2022-070630

64. * Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166(12):1170-1176. (Instrument validation study) DOI: 10.1001/archpediatrics.2012.1276

138. *King CA, Brent D, Grupp-Phelan J, et al. Prospective development and validation of the computerized adaptive screen for suicidal youth. JAMA Psychiatry. 2021;78(5):540-549. (Prospective multicenter study; 2075 adolescents) DOI: 10.1001/jamapsychiatry.2020.4576

150. *Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry. 2018;75(9):894-900. (Comparative study; 1640 patients) DOI: 10.1001/jamapsychiatry.2018.1776

160. *United States Department of Health and Human Services Health Resources and Services Administration, Maternal and Child Health Bureau. Critical crossroads pediatric mental health care in the emergency department: a care pathway resource toolkit. 2019. Accessed, February 1, 2024. (Toolkit)

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Keywords: suicide, suicidal ideation, suicidality, suicidal thoughts, suicidal behaviors, suicide attempt, self-harm, self-inflicted injuries, suicide screening, Ask Suicide-Screening Questions, ASQ, Columbia Suicide Severity Rating Scale, C-SSRS, suicide assessment, Brief Suicide Safety Assessment, BSSA, Suicide Assessment Five-Step Evaluation and Triage Risk Stratification, SAFE-T, intentional ingestion, safety planning, no-suicide contract, suicide-prevention contracting, lethal means counseling, Stanley-Brown Safety Plan, computerized adaptive testing, CAP, computerized adaptive screen for suicidal youth, CASSY