There are several brief interventions that pediatric health clinicians can use to support youth at risk for suicide. The strategies outlined below can help patients and families identify effective coping techniques to use in a crisis, limit access to dangerous items, and identify community supports and resources to promote mental health.
Safety planning is an evidence-based and effective technique to reduce suicide risk. Working with the patient and the family, clinicians can guide patients to identify effective coping techniques to use during crisis events.
Safety planning helps your patient think about what they will do when they have suicidal thoughts after they leave your office and includes identifying:
- Patient’s own warning signs or triggers for suicidal thoughts
- Coping strategies
- Social contacts/supports
- Emergency contacts
- Reducing access to lethal means
For example, the clinician can ask: “What will you do if it is 2:00am and you are thinking of killing yourself?” and then help the patient plan out coping strategies and write them down. Sample solutions may include: “I will call my aunt, or listen to music, or write in my journal, or exercise, or watch a TV series.”
Safety plans should:
- Be personalized to each patient
- Be developed collaboratively with each patient and family
- Be developmentally, culturally, and linguistically appropriate to the patient and family
- Include specific activities and people to call in the event of intense suicidal feelings
- Include strategies that can be used at all times of day or night
- Include a back-up plan, such as calling the National Suicide Prevention Lifeline or texting the Crisis Text Line
Thinking about safety plans in advance can help patients prepare to get through intense suicidal feelings.
When introducing safety planning to a patient at risk and their family, consider the “fire drill” analogy:
“A safety plan is a bit like a fire drill. Schools plan for emergencies by holding fire drills. These drills ensure that everyone knows what to do and where to go if they smell smoke. Having that plan of action in place helps people act quickly in an emergency. In the same way, a safety plan can help you plan for a future time that you’re having suicidal thoughts. We’ll come up with a plan now, and you can keep it with you. That way, if you start having thoughts of suicide, you’ll know what to do to help get you through the situation safely.”
Developing a safety plan with a patient and their parent/caregiver can be time-consuming. This process can be led by anyone in the office who has been trained in safety planning, including the pediatric health clinician, nursing staff, physician assistants, or social workers.
Safety plans can be developed via a smartphone app or on a paper template. If you use a paper template, consider encouraging the patient to take a picture of the plan on their phone, so that they don’t lose it.
Commonly used safety planning tools include:
Lethal Means Safety Counseling
Pediatric health clinicians can speak with parents/caregivers about keeping dangerous items away from their children during a suicidal crisis.
It is important that families know that suicidal crises can escalate quickly, and that suicide among youth is often impulsive and hard to predict. It is not always possible to stop someone from attempting suicide. However, reducing access to lethal means can help prevent youth from dying from a suicide attempt.
The goal is to protect the child in a "moment of crisis" which requires actively making the child's environment safe before the crisis ensues. Because of this, families should work to reduce their child’s access to dangerous items to help protect their safety.
Most people are not familiar with the term “lethal means.” Because of this, pediatric health clinicians can talk plainly with parents/caregivers about dangerous items in their home, which may include pills, poisons, chemicals, firearms, ropes, belts, knives, and other objects.
An example phrase is:
- “I want to help you keep your home as safe as possible for Andre while he’s feeling this way. Because a moment of crisis can escalate very quickly, it’s important that we make sure that he doesn’t have access to guns, medications, or other household items that he could use to harm himself in a crisis.”
- Most youth suicides using firearms occur with a firearm stored unsafely in the home
- Locking all guns reduces firearm suicide risk substantially compared with having any unlocked guns
- Unloading all guns also substantially reduces firearm suicide risk, and that locking the ammunition separately also reduces risk, but only if the youth doesn't know the combination to the lock or where the key is hidden
AAP policy, “Firearm-Related Injuries Affecting the Pediatric Population,” recommends that pediatricians and other pediatric health clinicians counsel parents/caregivers about the dangers of allowing children and youth to have access to guns inside and outside their home:
- Counsel families that the safest option is to temporarily remove guns from the home while their child is experiencing thoughts of suicide could save their life
- Consider an approach like, “What some families do is store their guns away from home until their child is feeling better: for example, with a relative or at a gun shop. Is this a good option for you?”
- Safe storage is the second-safest option, if the family is unable to remove the firearm from the home:
- Firearms should be stored unloaded and locked
- Ammunition should be locked and stored separately
- When possible, firearms can be disassembled, and essential pieces can be locked and stored separately
- Families should ensure that the child does not know the codes to the locks or locations of keys
- Most families have medicine cabinets in their bathrooms where medications are stored
- Many medications (eg, insulin, prescription medications, over-the-counter pills) can become a hazard during a suicidal crisis
- Talk with parents/caregivers about locking up both prescription and over-the-counter medications, reducing the quantity of medications in the home, and removing unneeded or expired medications from their home
- Suggest that families purchase necessary medications in blister-packs which can help to slow down access to larger quantities of medication in a crisis
Other Household Items
Common items found in the home can be lethal in a suicide attempt. Counsel families about temporarily removing these products from the home or storing them safely where youth cannot access them. This includes but is not limited to:
- Illicit drugs
- Carbon monoxide/car exhaust
- Household cleaners and other poisonous products
- Canned dusting products
- Knives, razors, or other weapons
- Ropes, belts, or plastic bags
Pediatric health clinicians can counsel parents/caregivers on these important practices. Clinicians should be aware that lethal means safety counseling may involve variations based on culture, family circumstances, or parent/caregivers’ profession (for example, families may need medication on hand to care for a relative or may have firearms in the house because a parent serves in the military or law enforcement). Counseling should always be specific to the family.
When addressing lethal means safety with families, utilize trauma-informed care principles. Choose your words carefully and avoid making the family feel judged or shamed if they own guns, or if they cannot remove all lethal means from the home. Emphasize to the family that these safety measures are temporary, and you are not singling them out, but rather this is common practice when someone is found to be at risk for suicide.
Commonly used courses for lethal means counseling include:
Connect All Patients and Families with Ongoing Support and Resources
Refer the patient to an outpatient mental health provider when clinically indicated by the brief suicide safety assessment:
- When possible, make a warm hand-off by connecting the family to a mental health provider while they are still in in your office for the appointment
- Follow up by phone over the next few days with families to see if they were able to see the mental health provider
- Families can be frustrated by trying to make appointments and hearing about long waiting lists or appointments too far into the future. If there no available mental health appointments, schedule a follow-up visit with the patient (either in person or via telehealth) in a few days to “check in”
Build Community Connections to Support the Patient and Family When They Leave Your Office
- AAP policy, “Guiding Principles for Team-Based Pediatric Care” recommends using a team-based care model to ensure youth are supported at home, at school, and in all settings where they spend time. Team-based care involves building connections between medical providers and community partners (eg, educators, pharmacists, state agencies, and families) and engaging these partners in supporting the youth’s overall health
- With permission, connect with the school nurse, school-based/college health center, and/or behavioral health professionals at the patient’s school to ensure they are aware of the situation and can provide supportive care at school
- Connect parents/caregivers to a Family Support Group from the National Alliance on Mental Illness (NAMI) or other additional resources as they support their child’s mental health
- Pediatric health clinicians can also engage other members of the patient’s community, such as community organizations (eg, Boys and Girls Club, 4H), clergy or religious leaders, or community or tribal elders
- To learn more about how to support a patient who is struggling, or about general suicide prevention efforts in the community, providers and families can establish connections with a local AFSP chapter
Connect All Patients with Free National Resources that are Available 24 Hours/Day, 7 Days/Week
Provide Patients and Families with Educational Information
Consider connecting patients, parents/caregivers, and families to information to help them cope with suicide risk, a suicide attempt, or a suicide loss.
- Suicide Prevention: What to do when someone is at risk
- After a Suicide Attempt:
- After a Suicide Loss:
Follow-Up with a “Caring Contact”
Follow-up care is a critical way to support patients and their families. Schedule a follow-up phone call, virtual visit or brief in-person visit within 24-48 hours to see how the patient is doing. Anyone in the practice or health system can provide these “caring contacts” – find the workflow that works best for your team.
During this follow-up, you can check in on whether lethal means have been removed/stored safely and ensure the family has connected with a mental health provider, if applicable. Most importantly, you can assure youth and families that you care about their mental health and are here to help them as they navigate this challenge.
You can access examples of “caring contact” postcards here, provided by Zero Suicide:
American Academy of Pediatrics