Have a Conversation With Your Patient About Suicide Risk
After using an evidence-based tool to conduct the brief suicide safety assessment, pediatric health clinicians can ask subsequent questions that build an understanding of what suicidal thoughts are like for each individual person. For example, if a patient shares that they have had thoughts of suicide, consider these follow up questions:
- "Does that make you feel worried?"
- "Does that scare you?"
- "Have you talked with anyone about this before?"
Pediatric health clinicians can also consider connecting with family members to understand their experiences of their child’s suicidal thoughts. Consider follow-up questions such as:
- "What was it like for you to hear that?"
- "Does it feel overwhelming?"
- "Does that scare you?"
These types of questions can help build an understanding of the patient and family’s experiences, which may make it easier to communicate and work together on a safety plan and any necessary follow-up care.
Provide Trauma-Informed, Patient-Centered Care
Suicide is complex, with many different factors contributing to individual youths’ risk of suicide. Youth and families may respond differently to screening and risk-assessment questions, and pediatric health clinicians should work to center their efforts around the patient’s needs and experiences.
Pediatric health clinicians can consider the following when screening and assessing risk:
- Establish a trusting relationship and rapport with the patient
- Use a non-judgmental tone when asking questions
- Use active listening when a patient discloses information related to suicidal thoughts and behaviors
- Understand that follow-up questions about mental health may need to be adapted to a patient’s family or culture; language used in screening and assessment forms is often white-centric
Pediatric health clinicians can help youth and families understand and contextualize suicidal ideation:
- Many youth experience suicidal thoughts: however, it is not common to attempt or die by suicide
- Suicidal thoughts are an indicator of other mental health concerns (eg, a mental health condition, excessive stress, or a need for building more effective coping skills). These underlying concerns are treatable, and pediatric health clinicians can support the youth and parent/caregiver in addressing these concerns
- Pediatric health clinicians see the strengths in each patient and can be trusted adults that foster resilience. They can also help parents foster resilience by helping them shift from being “managers” of their child’s life to becoming “consultants” as their children grow, allowing for more developmentally appropriate independence
- Pediatric health clinicians can emphasize that they are on the youth’s team and can help manage the suicidal thoughts by working together.
- Example phrase: "You’re not stuck here, and these feelings can change. I’m here to help you get through this."
Pediatric health clinicians can utilize trauma-informed care principles when addressing mental health and suicide. This includes care that promotes:
- Trustworthiness and transparency
- Peer support
- Humility and responsiveness
Language, Stigma, and Myths
Language matters when speaking with youth and families about suicide. Avoid terms that have a negative connotation or perpetuate stigma or blame:
- Use “die by suicide” instead of “commit suicide”
- Use “death by suicide” instead of “successful suicide”
- Use “suicide attempt” instead of “failed suicide attempt”
- When talking about warning signs or concerning behaviors, name the behaviors explicitly instead of using euphemisms like “suicidal gesture,” or “parasuicidal behavior” and avoid referring to people as “suicidal”
Talk directly with patients and families about how to navigate stigma and myths around mental health. Challenge the myth that people who are talking about suicide are only trying to get attention, or someone who is thinking about suicide is “crazy” or the myth that talking about suicide puts the idea into someone’s head.
Confidentiality and Parental Engagement
Confidential care is a key tenet of adolescent health care. However, confidentiality has limits, and pediatric health clinicians are considered mandated state reporters when they discover that someone is a danger to themselves or others. This means that navigating confidentiality in the context of suicide risk can be challenging.
The AAP policy, ”Unique Needs of the Adolescent,” and Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents (4th Edition) highlight the need for confidential, one-on-one time between a pediatric health clinician and an adolescent during clinical visits, to discuss preventive services and individual health questions. This one-on-one time allows an opportunity for youth and clinicians to have an open, honest discussion and helps prepare the youth to be an active participant in their own health care. Pediatric health clinicians may choose to address mental health and suicide risk during these one-on-one discussions, when the parent is not in the room.
Pediatric health clinicians should set the expectation for this confidential, one-on-one time early in adolescence, and remind both youth and parents that this is a standard protocol at the beginning of the visit.
- Explain that anything discussed during that one-on-one time will remain confidential unless someone’s immediate safety is at risk
- AAP provides tips and resources about how to implement confidential discussions with adolescents
If suicide risk is detected on the screener or during a confidential discussion, pediatric clinicians will need to notify the parents/caregivers. Prior to doing so, talk with the youth about what will happen next:
- Explain that you need to have a conversation with the patient’s parents/caregivers to make sure they know about the risk
- Give the youth options for how they’d like their parent to be informed, to ensure they are an active participant in their care. For example, the patient can choose whether they’d prefer:
- Clinician to disclose to the parent privately
- Clinician to disclose to the parent with the adolescent in the room
- Patient to disclose to their parent privately
- Patient to disclose to their parent with the clinician in the room
- Some example phrases include:
- "Your safety is the most important thing, so I am going to tell your parents how you’re feeling."
- "I don’t want you to die. I’m going to tell your grandma what’s going on so we can all keep you safe."
- "I’m going to say something like, “Our screener indicated that Jaime is having thoughts of suicide, and that these thoughts scare him. He says they get worse at night, and he has trouble sleeping.” Does that sound right to you? Is there anything you want me to add?"
- If the youth expresses fear that they may get in trouble for expressing suicidal thoughts, talk with them about these concerns, and assure them that you will help keep them safe. In this case, have a separate discussion with the parent/caregiver to assess and address their reaction to the disclosure, to further assess safety of the young person, including the parent/caregiver’s ability to keep the young person safe
Then, engage parents:
- Ask the parent/caregiver if they know about the child’s suicidal ideation/behavior in a way that does not come across as blaming or judgmental. For example, you can say, “Your child spoke about having suicidal thoughts. Is this something they have shared with you?”
- Youth are often private about their suicidal thoughts
- It is common for parents/caregivers to be unaware of suicidal ideation or behaviors
- Ask the parent/caregiver if there is anything they want to tell you in private
- A private conversation with the parent/caregiver provides an opportunity to speak privately to gather relevant health information about family history or dynamics
Be aware there are variations in state laws related to adolescent confidentiality, minor consent, and documentation. For a listing of state laws related to adolescent confidentiality, visit the Center for Adolescent Health and the Law.
Talking to Families About Other Topics Related to Suicide
Social media and youth mental health
Pediatric clinicians may encounter questions from parents about the role of social media in mental health and suicide risk. Social media offers a potential platform for the critical developmental tasks of adolescence, including establishing peer relationships, building independence, and exploring identity.
Research on the impact of social media on youth mental health is a growing field, and studies have identified both harms (eg, cyberbullying, social exclusion, or anxiety around peer-comparisons) and benefits (eg, finding community, connecting with friends, reducing stigma around mental health treatment).
When addressing social media use, Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents (4th Edition) notes that pediatric health clinicians can encourage patients and families to communicate openly about social media, protect online safety and privacy, and set healthy limits on screen time.
Non-suicidal self-injury (NSSI) is defined as deliberately injuring oneself without suicidal intent for purposes not socially or culturally sanctioned. Common behaviors can include cutting, scratching, head-banging, hitting, burning, or intentionally preventing wounds from healing. Although the specific behavior is not linked to suicidal intent, youth who engage in NSSI have been found to have a higher risk of suicide over time.
Talking to Families About Treatment Options
Medications can be a useful tool in treating mental health conditions in youth. Research has found that the combination of medication and therapy customized to the patient’s condition can be especially helpful. The AAP-endorsed policy statement, Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Treatment and Ongoing Management, outlines considerations for use of medications to treat depression in adolescents. To learn more about specific risks and benefits of medication and how to maximize treatment for reducing suicide risk, consider these resources.
Evidence-based behavioral health treatments
There are evidence-based behavioral health treatments and psychotherapies that are approved for use with patients who attempt suicide or live with mental health conditions. These treatments include cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) and are designed to be provided by trained mental and behavioral health providers as part of an ongoing care plan. For more information on behavioral health treatments aimed at reducing suicide risk, visit the American Foundation for Suicide Prevention or the American Academy of Child and Adolescent Psychiatry (AACAP).
American Academy of Pediatrics