Adolescent Suicide Risk Assessment and Precautions - CE - INACTIVE

ALERT

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

The Joint Commission identifies assessment of suicide risk as a Hospital National Patient Safety Goal.^{undefined#ref6">6}

The Food and Drug Administration issued a black box warning stating that an increased risk of suicide may exist for some children and adolescents who are treated with antidepressant medications. Closely monitor adolescents treated with selective serotonin reuptake inhibitors for worsening of symptoms or suicidal thinking.⁷

OVERVIEW

Suicide is a leading cause of death for persons between 10 and 24 years of age.² Although firearms are used to complete almost half of the suicides, young people also use methods such as suffocation and poisoning.² Those youths with a prior psychiatric diagnosis, often related to substance use and mood disorders, are at a higher risk for suicide.^2,8 Health risk behaviors associated with suicide among adolescents include injection drug use, forced sexual activity, purging and laxative use for weight loss, and methamphetamine use.¹

Suicide is a serious public health problem, and many persons between 10 and 24 years of age require medical care for self-inflicted injuries.² A national survey revealed that many high school students reported seriously considering suicide, although only half of those actually reported a suicide attempt.² A previous suicide attempt is the strongest predictor for a completed suicide.¹⁷ Of reported suicide deaths among 10- to 24-year-olds, the vast majority were males; however, females are more likely to report attempting suicide.²

Establishing therapeutic rapport is important when working with adolescents at risk for suicide.⁵ Rapport is enhanced with respect, honesty about the limits of confidentiality, reassurance of privacy, and acceptance conveyed through tone and posture.¹⁶ The lack of a therapeutic alliance with a patient may increase the risk of suicide.¹¹ The health care team member must also assess the adolescent’s safety and risk of harm and maintain communication with the health care team.

SUPPLIES

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EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Include the family in education and monitoring of treatment to help improve treatment of depression and decrease suicidal thinking.
• Use communication methods that offer support and encouragement.
• Keep in mind that stigma and shame may affect the patient’s and family’s disclosure and openness during the interview process.
• Explain to the patient and family the need for safety measures and a detailed assessment.
• Inform the patient and family that psychiatric disorders have biologic origins and are not personal weaknesses or deficits.
• Inform the patient and family of the patient’s rights and expectations during the inpatient stay.
• Educate the patient and family about the role of psychological stresses in triggering or exacerbating disturbed behavior or thoughts of suicide.
• Inform the patient and family that a family history of a completed suicide is a significant risk factor and that seeking treatment for suicidal thinking is vital.
• Provide activities that promote self-esteem, a sense of mastery, and self-worth.
• Collaborate with the patient and family in setting goals for inpatient treatment.
• Educate the patient and family about the use of restraints as a protective measure against imminent danger to the patient or others.
• Educate the patient and family about the visitor’s role in protection regarding items requested by the patient. Include the need for other health care team members to inspect items brought in for the patient.
• Inform the family that talking with the patient about suicide is important and will not induce the patient to attempt it.
• Educate the patient and family about signs of suicide risk, such as an abrupt change in mood, impulsivity, isolation, agitation, depressed mood, and hopelessness.
• Teach the patient and family that symptoms may recur and do not indicate personal failure.
• Teach the family that the patient’s ability to cope is affected by developmental level and not by age, income, or availability of family members.
• Teach the patient and family that self-mutilation is an unhealthy coping skill and not an expected developmental behavior. It may also be a precursor to suicidal behavior.¹³
• Educate the patient and family about the risks of substance abuse.
• Provide emergency contact numbers, including suicide hotline information and information about community resources for support.
• Determine whether the patient has access to weapons in the home and recommend that family members secure or remove weapons to prevent access. After discharge, the adolescent may become impulsive, and impulsivity can lead to death, particularly if violent means such as firearms are readily available.⁹
• Encourage questions and answer them as they arise.

ASSESSMENT

1. Perform hand hygiene before patient contact. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Before interacting with the patient, perform a self-assessment and self-inventory of personal values and beliefs regarding suicide and become familiar with the evidence indicating that young people do commit suicide.

Rationale: Self-assessment is part of reflective practice that allows the health care team member to gain a better understanding of personal feelings when encountering difficulty with establishing a rapport with a suicidal adolescent.⁵ The team member should review personal feelings related to the patient’s suicidal thoughts and death wish.

5. Stay with and continuously observe the patient throughout the assessment process until suicide risk has been ruled out or observation has been delegated to appropriate personnel.
6. Obtain necessary written and verbal consents for assessment and treatment.

Rationale: Depending on the patient's age and legal status, parental consent or consent by a guardian may be required in certain jurisdictions.

7. Gather assessment data from the patient and family. There are a number of standardized suicide assessment tools that can be used with adolescent patients, including the Columbia Suicide Severity Rating Scale for adolescents.¹⁵

Rationale: Collateral information from the family is helpful to determine suicide risk; it can be gathered without revealing confidential information about the patient.

8. Explain to the family the need to interview the patient in private. (Check state confidentiality laws for adolescents younger than the age of majority or those who are emancipated.)

Rationale: The patient may be uncomfortable or embarrassed sharing certain information with family. Adolescents tend to cooperate when confidentiality and privacy are assured.

9. Assess the immediate environment for safety.
   1. Identify any objects or hazards in the environment that may be used for self-harm, such as plastic bags, wire hangers, curtain rods, chemicals, lighters, glass objects, IV tubing, call light cables, and belts.
   2. Assess the patient and the patient's belongings for potentially harmful objects and weapons.
10. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.⁶
    1. Determine the immediate safety risk by assessing the patient’s current suicidality.
    2. Assess the patient for current suicidal thoughts, ideations, and intentions.
    3. If the patient has an active plan for suicide, assess the details of the plan and the patient’s ability to carry it out.
    4. Consider consultation with a psychiatric practitioner. Involve the practitioner in the suicide risk assessment.

    Rationale: A detailed and thorough psychiatric interview is crucial. Monitoring risk within a safe and least-restrictive environment should be balanced with fostering autonomy and respecting the patient’s rights.

11. Assess the patient for potential communication barriers, such as language differences, sensory impairments, or cognitive impairments and provide for required interpretation or aids per the organization’s practice.
12. Assess the patient’s current situation.
    1. Assess strengths and coping skills, including ability to handle confinement in the health care setting.
    1. Ask how the patient has dealt with stressful situations in the past.
    2. Ask whether the patient has ever been forced to stay in a place involuntarily before, and if so, how the patient handled it.
    2. Assess the patient for any alterations related to substance use, including toxicology reports.
    3. Obtain physical assessment data and look for other indicators of suicide risk, such as self-mutilation or self-injury, chronic illness, disfigurement, or terminal illness.
    4. Assess precipitating events of the patient’s current situation and current life stressors, including recent significant actual or perceived losses, such as loss of a family member, friend, or pet.
    5. Assess the patient’s cognitive and emotional response to the current situation and determine the patient’s ability to problem solve, understand consequences and actions, and delay gratification.
    6. Assess for changes to the patient’s family system or support system, such as relocation, divorce or separation, family discord, financial stress, or military deployment.
    7. Assess the patient for indirect statements or nonverbal cues indicating suicidality, such as giving away possessions.
    8. Assess the patient’s supports and resources.
13. Assess the patient’s history.
    1. Obtain a psychosocial history, including a careful history of substance use, impulsivity, and aggression—all indicators of suicide risk.¹
    2. Ask the patient directly about use of drugs or alcohol, including prescription drugs.
    3. Discuss the patient’s patterns of interaction. Determine whether the patient has done things spontaneously without considering the consequences, has engaged in high-risk behaviors, angers easily, or ever becomes violent or self-injurious.
    4. Review any past events that may be affecting the current situation.
    5. Obtain a medical history, including use of both prescription and over-the-counter medications.
    6. Obtain a family medical and psychosocial history, especially of mood disorders, suicide attempts, and completed suicides.
    7. Obtain the patient’s history of previous inpatient stays, including psychiatric admissions, and history of being away from home and family.
    8. Assess the patient for previous suicide attempts, reported or unreported, and history of self-injurious behaviors.
    9. Assess the patient’s adherence to and cooperation with previous medical and psychiatric treatment.
    10. Assess the patient’s history of victimization, such as child abuse, bullying, dating violence, or trauma. Ask whether anyone has ever hurt the patient, either physically or emotionally and whether the patient has ever witnessed violence within the family.

    Comply with mandated reporting of suspected abuse or neglect.

    11. Assess the patient’s social history, such as school attendance and performance, running away, incarceration, or legal problems.
    12. Ask the patient about relationships with peers, including any friendships, any bullying by others, and any suicide attempts by someone the patient has known.
    13. Evaluate the patient’s living situation and ask whether the patient has ever been homeless.
14. Perform a cultural assessment, assessing the patient’s beliefs about illness, suicide, and death.
15. Assess the patient’s spirituality: meaning of suicide, meaning of life and death, life satisfaction, attachments, and feelings of hopelessness.
16. Assess the patient’s short-term goals for treatment.
17. Assess the need for a psychiatric practitioner consult and seek a consult as appropriate.

STRATEGIES

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the strategies and ensure that the patient agrees to treatment.
4. Develop rapport with the patient and family and establish a therapeutic alliance to encourage openness in the patient–team member relationship.
1. Approach the patient and family in a calm and unhurried manner.
2. Actively listen to what is being said and respect the family's communication style. Parents will be able to provide more effective support if they are engaged in the patient’s treatment.¹⁴
3. Convey caring, empathy, respect, and acceptance.
4. To prevent the patient and family from feeling intimidated by the health care team member’s power, create a sense of welcome, comfort, privacy, and safety.

Rationale: Establishing rapport with the patient and family is important because parental attitudes may influence the adolescent’s attitude toward the current health care. Privacy is important because adolescents undergo developmental changes that may cause self-consciousness or embarrassment. When efforts are made to help the patient feel normal and connected, the patient is more likely to accept treatment.

5. Review risk factors with the patient and clarify the perception of stressors.

Rationale: Most suicidal youths attribute suicidal behavior to life stressors, not depression or mental illness.⁴

Do not assume that a patient who denies suicidal ideation will not commit suicide.

6. If the patient focuses discussions on suicidal thoughts and urges for self-harm or destructive behaviors, consult the mental health practitioner, who may encourage the patient to keep a journal of thoughts and feelings that the patient may want to share with the health care team.

Rationale: Suicidal thought processes change. Adolescents may be particularly anxious, or they may have difficulty processing thoughts or feelings like adults.

7. Inform the patient and family of the organization’s procedures to protect patients at risk for suicide. Include the family in the discussion of unit rules to ensure an understanding that the patient is to remain on the unit.
8. Take measures to ensure the patient’s safety.
1. Remove and secure the patient's belongings.
2. Search the patient for potentially harmful items, including medications, weapons, belts, mirrors, razors, lighters, nail files, glass, cords, and so on.
3. Search any items visitors bring to the patient and remove restricted items.
4. Inform the patient's family that potentially harmful items are not to be given to the patient.
5. Secure medications.

Rationale: The patient’s person and environment are to be free of anything that may be used for self-harm. The means to commit suicide are commonly found in the patient’s physical environment.⁶ Access to drugs that can be used for overdose must be restricted.

Consider that patients may hide items with their clothing.

9. Place the patient in a room close to the nurses’ station so that the patient is visible to health care team members. Arrange for a semi-private rather than a private room, if possible.

Rationale: A room close to the nurses’ station makes observation of the patient easier. Having a roommate also enhances safety.

10. Obtain a practitioner’s order to place the patient on an appropriate observation plan.¹⁰
1. Depending on the level of risk, arrange for constant direct observation by a dedicated, trained observer (1:1 staffing ratio) or frequent monitoring.
2. Implement variable random checks and body checks for self-mutilation.

Rationale: Variable random checks impede the patient's ability to plan self-harm.

11. Communicate the initiation of protective measures and level of observation to health care team members and other service providers.
12. Ensure that the health care team member assigned to observe the patient continuously and directly is not assigned to other duties and is relieved or replaced periodically.

Rationale: The health care team member should not have other duties to distract from observation of the patient. The team member should be relieved or replaced periodically to ensure that maximum attention is paid to the patient.

13. Ensure that the team member assigned to observe the patient understands safety risks and monitoring priorities (including bathroom observation)¹⁰ and is informed about the patient’s behaviors, emotions, thought processes, and coping mechanisms.

Rationale: The assigned health care team member must be able to assess changes in the level of safety or risk and communicate such changes to other team members.

Ensure that other health care team members know that labile, irritable, and impulsive behavior is an indicator of serious risk.¹²

14. Conduct environmental assessments for areas that pose a potential risk for use by a patient who may attempt suicide by hanging.
1. Remove or restrict items that may be dangerous, including call light cords and IV tubing.
2. Note any ceiling fixtures such as pipes, lighting, fire sprinklers, curtain rods, sturdy shower rods, and clothing or towel hooks. Adjust fixtures of any height as much as possible to minimize their ability to support a strangulation device.

Rationale: Access to ceiling fixtures is particularly dangerous to the patient who may attempt hanging. Providing a safe environment is an essential component of nursing care for the potentially suicidal patient.³

15. Restrict the use of sharp objects, such as razors, as well as the use of curling irons, glass bottles and jars, and potentially hazardous hygiene products.
16. Order meal trays with plastic containers and plastic utensils to minimize opportunities for self-harm. Consider having the health care team track distribution and collection of utensils to prevent use for injury.
17. Provide support to the adolescent who may be unaccustomed to being away from home or being an inpatient.
1. Provide the patient with information about the unit and daily routine.
2. Inform the team members of any fears or concerns the patient may have.

Rationale: The adolescent unaccustomed to being away from home or being an inpatient may require additional contact from the team members. Team members who are aware of the patient’s fears and concerns can provide support, reassurance, and clarification as necessary.

18. If a risk of danger to the patient or others exists and the patient requires restraint, obtain assistance from health care team members trained in crisis interventions. Ensure that an adequate number of team members are present if the patient is to be restrained.
19. Remove PPE and perform hand hygiene.
20. Document the strategies in the patient’s record.

REASSESSMENT

1. Perform regular, repeated evaluations throughout the patient’s inpatient stay to determine the suicide risk.

   Rationale: Variables contributing to suicide are dynamic and may change. Reassessment helps maintain safety and vigilance.¹⁰

2. Reassess the amount of observation required by assessing risk throughout each shift. Notify the practitioner of any change in patient status and the need for more or less observation.

   Rationale: The amount of observation should appropriately respond to the patient's risk and respect the minimal level of restriction needed to ensure safety.

3. Assess the family's commitment to providing a safe and healthy environment for the adolescent.

   Rationale: Family is an important support system to contribute to the adolescent's safety and well-being.¹⁸

4. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

• Safety and freedom from harm for patient and health care team members
• Creation of an environment that is safe for the adolescent
• Discussion of suicidal ideation, intentions, or plan to assign appropriate intervention and treatment
• Patient and family involvement in care and awareness of signs of suicide risk and appropriate actions to take

UNEXPECTED OUTCOMES

• Self-injurious patient behavior
• Suicide attempt
• Suicide completion
• Restraint needed to prevent self-harm
• Injury of health care team member

DOCUMENTATION

• Self-injurious thinking or behavior
• Physical findings of self-mutilation
• Suicide risk assessment at admission, during any change in patient’s condition or treatment, and before discharge
• Suicidal ideation, intent, and plan at admission and at each shift
• Implementation of treatment plans or changes in plans
• Review of observation levels
• Evaluation of effectiveness of observation
• Patient consent to contact family or, if no consent documented, documentation of organization-approved process followed to obtain critical information to protect patient
• Inquiry into the presence and location of firearms and related instructions given to patient and family
• Treatment plan for reducing risk, including observations and restrictions
• Use of restraints
• Contact made with regulatory agencies
• Support provided to reduce patient’s level of distress
• Patient’s strengths that promote effective coping and recovery
• Medications given
• Outcomes and responses to medications and other interventions
• Education
• Provision of emergency contact numbers, hotlines, and community resources
• Unexpected outcomes and related interventions

SPECIAL CONSIDERATIONS

• Offer health care team member education on developmental needs of adolescents and their families.
• Develop and implement health care team member education on assessing and monitoring suicide risk and threats and implementing techniques for intervention.
• Implement support for health care team members to promote self-care behaviors and stress reduction.
• Generate a list of available community resources to plan for a system of care after discharge.

REFERENCES

1. Carballo, J.J. and others. (2020). Psychosocial risk factors for suicidality in children and adolescents. European Child & Adolescent Psychiatry, 29(6), 759-776. doi:10.1007/s00787-018-01270-9 (Level I)
2. Centers for Disease Control and Prevention (CDC). (2017). Preventing suicide: A technical package of policy, programs, and practices. Retrieved April 25, 2022, from https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf (Level VII)
3. Frost, D.A. and others. (2020). Development and implementation of a suicide prevention checklist to create a safe environment. Psychosomatics, 61(2), 154-160. doi:10.1016/j.psym.2019.10.008
4. Gauvin, G. and others. (2019). Coping, social support, and suicide attempts among homeless adolescents. Crisis, 40(6), 390-399. doi:10.1027/0227-5910/a000579 (Level VI)
5. Gvion, Y., Fachler, A. (2017). When suicide is at stake: Some thoughts on the therapeutic space between therapists and adolescents. Journal of Infant, Child, and Adolescent Psychotherapy, 16(4), 267-278. doi:10.1080/15289168.2017.1377579
6. Joint Commission, The. (2022). National Patient Safety Goals^® for the hospital program. Retrieved April 25, 2022, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf (Level VII) (Level D)
7. Locher, C. and others. (2017). Efficacy and safety of selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents: A systematic review and meta-analysis. JAMA Psychiatry, 74(10), 1011-1020. doi:10.1001/jamapsychiatry.2017.2432 (Level I)
8. Paul, E. (2018). Proximally-occurring life events and the first transition from suicidal ideation to suicide attempt in adolescents. Journal of Affective Disorders, 241, 499-504. doi:10.1016/j.jad.2018.08.059 (Level VI)
9. Price, J.H., Khubchandani, J. (2017). Adolescent homicides, suicides, and the role of firearms: A narrative review. American Journal of Health Education, 48(2), 67-79. doi:10.1080/19325037.2016.1272507
10. Ray, R. and others. (2017). The impact of nursing protocols on continuous special observation. Journal of the American Psychiatric Nurses Association, 23(1), 19-27. doi:10.1177/1078390316668993 (Level VI)
11. Ring, M., Gysin-Maillart, A. (2020). Patients’ satisfaction with the therapeutic relationship and therapeutic outcome is related to suicidal ideation in the Attempted Suicide Short Intervention Program (ASSIP). Crisis, 41(5), 337-343. doi:10.1027/0227-5910/a000644 (Level VI)
12. Sellers, C.M. and others. (2019). Alcohol and marijuana use as daily predictors of suicide ideation and attempts among adolescents prior to psychiatric hospitalization. Psychiatry Research, 273, 672-677. doi:10.1016/j.psychres.2019.02.006 (Level VI)
13. Stockburger, S. (2017). Nonsuicidal self-injury related to suicide. International Journal of Child Health & Human Development, 10(4), 383-390.
14. Torok, M. and others. (2019). Preventing adolescent suicide: A systematic review of the effectiveness and change mechanisms of suicide prevention gatekeeping training programs for teachers and parents. Journal of Adolescence, 73, 100-112. doi:10.1016/j.adolescence.2019.04.005 (Level I)
15. Udoetuk, S. and others. (2019). Suicide in adolescents. Psychiatric Annals, 49(6), 269-272. doi:10.3928/00485713-20190509-01
16. Wilmots, E. and others. (2020). The therapeutic relationship in cognitive behaviour therapy with depressed adolescents: A qualitative study of good-outcome cases. Psychology and Psychotherapy, 93(2), 276-291. doi:10.1111/papt.12232 (Level VI)
17. Zheng, L. and others. (2020). Development of an early-warning system for high-risk patients for suicide attempt using deep learning and electronic health records. Translational Psychiatry, 10(1), 72. doi:10.1038/s41398-020-0684-2 (Level VI)
18. Zisk, A. and others. (2019). Parent–teen communication predicts treatment benefit for depressed and suicidal adolescents. Journal of Consulting and Clinical Psychology, 87(12), 1137–148. https://doi.org/10.1037/ccp0000457 (Level VI)

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports