Suicidality & Self-Harm

Guidance for primary care clinicians diagnosing and managing children with suicidality and self-harm

Suicidality refers to thoughts or actions related to suicide, including suicidal ideation (ranging from passive thoughts of death to active and/or specific thoughts of suicide with plans and intent), suicide attempts, and completed suicide. Self-harming behaviors are actions that result in intentional injury and are not considered the cultural norm. Self-harm behaviors do not always have suicidal intent. Suicide and self-harm are common but can be prevented through proper interventions. It’s important for health care providers to identify patients at risk and help ensure the patient’s safety.

Other Names

Non-suicidal self-injury (NSSI)
Self-injurious behavior
Suicide
Suicide attempt
Suicidal behavior
Suicidal events
Suicidal self-directed violence

Key Points

Reoccurrence risk - assess early
Children who attempt suicide are at high risk of attempting another suicide later. Therefore, early intervention is important.

Screen for mental health issues
It’s important for primary care clinicians to screen all children for suicide and self-harming behaviors. Many children feel guilt and shame and may not feel comfortable bringing up or discussing these topics. Primary care clinicians need to be open to having these discussions. Clinicians should also screen for other mental health disorders, including depression, anxiety, and substance use, as these conditions increase the patient's risk of self-harming behaviors and attempting suicide. Medical providers can help diagnose any underlying mental health disorder and provide and monitor treatment.

Evaluation of self-harm and/or suicidal behavior
A thorough clinical evaluation of self-harm and/or suicidal behavior is important. The clinician should explore the reasons, if known, why the patient engages in self-harming behavior and what function the behavior serves. The clinician should also conduct a suicide risk assessment, including current suicidal ideations, plans, intent, and access to means. This assessment informs the level of care that the patient will need in order to maintain safety. Inpatient hospitalization should be considered if the patient cannot maintain safety in a less restrictive environment, cannot engage in safety planning, refuses to disclose a suicide plan, or has medically significant effects from self-harm or a suicide attempt.

Interventions for self-harm and suicidality
Interventions need to be in place for individuals at risk for suicide and self-harm. Creating a safety plan which includes warning signs when an impending crisis is about to occur, coping strategies, a list of places or people who can provide distraction, and contact information for the crisis hotline. Other helpful interventions include increased parental supervision for children who are at risk and greater school involvement in children’s mental health and well-being.

Limit access to weapons or tools that can be used for self-harm
Firearms are one of the most common means of suicide and are associated with high morbidity and mortality. Firearm-associated injuries can be devastating and have high rates of morbidity with infections, fractures, neurological injury, compartment syndrome, and vascular injury. [Evans: 2020] It is important to limit access to weapons or tools which children can use to harm themselves. This includes counseling families to remove firearms from the home if possible and having secure locked storage of medications, sharp objects, and firearms. A helpful resource is Counseling on Access to Lethal Means (HHS & SAMHSA), an online course dedicated to reducing suicide and self-harm risk by helping medical professionals advise patients and families about ways to reduce access to firearms.

Counseling
Thoughts of guilt and shame often surround self-harming behaviors and thoughts of suicide. It can be difficult for children to reach out for support. Parents will often experience uncertainty in responding to their child’s self-harming behaviors. It’s important for parents to validate how their child is feeling and try to understand the reasons why their children engage in self-harming and suicidal thoughts in a non-judgmental environment with access to means restricted. Family therapy and counseling can help families communicate openly and help members understand the child’s perspective.

Understanding risk factors
Risk factors for suicide can be described as modifiable or non-modifiable. Modifiable risk factors are changeable behaviors or conditions that can either decrease or increase one’s risk of developing a disease. Common modifiable risk factors for suicide and self-harm include interpersonal conflict between family members, substance use, and firearms in the home. It is important for clinicians to know whether their patient has been exposed to these adverse social determinants of health, given that these exposures are significantly associated with increased suicide and self-harm. [Llamocca: 2022]

Social media as a risk factor
More research is needed to delineate how social media can impact rates of self-harm and suicidality; however, data suggest that increased social media use in youth increases the risk of cyber victimization and exposure to self-harm online. These, in turn, may be risk factors contributing to self-harm. [Biernesser: 2020] In addition, studies have shown that children who engage in online searches that include cyberbullying, drugs, sex, violence, hate speech, profanity, depression, and suicide/self-harm information are at higher risk of suicide-related behavior. Therefore, it is important for guardians and medical providers to be aware of a youth’s engagement in online activity as this can help identify at-risk youths and help improve preventative measures. [Sumner: 2021]

Assessment
Assessment may involve not only the patient but also a reliable collateral informant such as a parent or guardian. It is important to give the patient an opportunity to be interviewed alone. Confidentiality must be considered when talking to an adolescent about suicidal thoughts; however, when there is concern for acute or imminent safety risk, it is necessary to notify appropriate supports to maintain safety. Adolescents should be made aware of this obligation. Providers should be aware of and adhere to confidentiality laws in their state of practice.

Practice Guidelines

Shain B.
Suicide and Suicide Attempts in Adolescents.
Pediatrics. 2016;138(1). PubMed abstract / Full Text

Walter HJ, Abright AR, Bukstein OG, Diamond J, Keable H, Ripperger-Suhler J, Rockhill C.
Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Major and Persistent Depressive Disorders.
J Am Acad Child Adolesc Psychiatry. 2023. PubMed abstract

Westers NJ, Plener PL.
Managing risk and self-harm: Keeping young people safe.
Clin Child Psychol Psychiatry. 2020;25(3):610-624. PubMed abstract

Sisler SM, Schapiro NA, Nakaishi M, Steinbuchel P.
Suicide assessment and treatment in pediatric primary care settings.
J Child Adolesc Psychiatr Nurs. 2020;33(4):187-200. PubMed abstract / Full Text

Diagnosis

Suicidality and self-harm behaviors are not specific diagnoses but can be associated with many different mental health issues, such as depression, anxiety, bipolar disorder, psychosis, and personality disorders. [Singhal: 2014] Risk of suicide and serious bodily harm can be increased by substance intoxication, impulsivity, and other factors. [Mars: 2019]

Presentations

Suicidality
Suicidality is a serious concern, and it is important for clinicians to identify youths who are at risk. Suicidality can range from passive thoughts without intent or plan to life-threatening suicide attempts. Death from suicide can be intentional, or it can result unintentionally from self-harming behavior. Suicidality can present as passive thoughts about death or expressing being better off dead, an active desire to kill themselves, helplessness and not wanting to live, using alcohol or drugs, changes in behavior including increased risk-taking activities, changes in sleep patterns, posting about death on social media, and actively seeking ways to die such as online searches about suicide. [Horowitz: 2020]
Methods of suicide can range in lethality and outcome. Although ingestion/poisoning is a common method of suicide, the effects tend to be less immediate and allow more time for intervention and treatment. Most completed suicides for children are by more immediately lethal means such as hanging, suffocation, and firearms. [Ruch: 2021] Patients may or may not tell others about suicidal thoughts, and the evidence of the behavior may be the presenting concern. Therefore, when children reach the clinician in an acute setting with injuries suggestive of ingestion of a substance, asphyxiation, ligature marks, or wounds, clinicians must consider suicidal intent as one of the possible underlying causes of the presenting concern.
Self-harm
Self-harming behaviors can take different forms such as cutting, hitting self, skin picking, burning, and ingesting or inserting foreign bodies. It can be difficult to identify as patients’ self-harm behaviors may be concealed in areas covered by clothing. Common locations may include arms, thighs, and chest. A change in dress, such as suddenly wearing long sleeves in warm weather, may indicate self-harm. Self-poisoning can also be considered self-harm, and an individual can present as an overdose of over-the-counter medications as well as illicit drugs or other substances. See NICE Guidelines: Self-Harm: Assessment, Management and Preventing Recurrence [London:: 2022].
Although it can be tempting in some situations to assume self-harm behavior as “attention seeking” in intent, it is important to validate the patient’s feelings and recognize that passive thoughts or behaviors without initial intent to die can go awry and inadvertently result in serious injury or death. Suicidal and self-harm behaviors often have a function, and it is important to think about the function of the behavior as it pertains to the individual without making assumptions that can be incorrect or harmful.

Diagnostic Criteria & Classifications

Suicidality
Suicide is when a person engages in a specific method with the intent to kill oneself. Suicidal injury is when injury from self-injurious behavior results from the intention of dying. [Gratz: 2015] Suicide is complex and difficult to predict. It can occur in the presence of any psychiatric diagnosis, including mood disorders, substance abuse, eating disorders, schizophrenia, and personality disorders. See Diagnosis, Traits, States, and Comorbidity in Suicide - The Neurobiological Basis of Suicide (nih.gov) [Fawcett: 2012].
Patients will often feel the need to escape from difficult situations, and that escape is impossible. As a result, death is the only way to resolve the conflict. [Fawcett: 2012] Patients may make impulsive decisions, including responding to transient suicidal thoughts by taking permanent and life-threatening actions that can complete suicide. This is especially true for adolescents who are still developing their higher-order control and, therefore, can struggle to thoroughly evaluate and make careful decisions. [Gvion: 2015] There can also be affective disturbance in which the patient is experiencing emotional dysregulation, where they can feel excessively overwhelmed and will rely on unhealthy coping mechanisms like self-harm. Patients may feel a loss of cognitive control that includes ruminations, cognitive rigidity, thought suppression, and ruminative flooding. [Schuck: 2019]
Nonsuicidal self-injury
Nonsuicidal self-injury (NSSI) is direct, self-inflicted destruction of the body without suicidal intent and is not socially appropriate. [Gratz: 2015] This includes self-mutilating acts such as cutting, burning, biting, and scratching self. The patient may feel unable to resist injuring themselves and may feel a sense of relief through engagement in the behavior. [Zetterqvist: 2015] Nonsuicidal self-injury usually has some recurrence; often, the patient will engage in the harmful behavior for at least 5 days in the past year. The function of nonsuicidal self-injurious behaviors is often to provide emotional relief or provide a positive emotional state; this is usually in the context of negative thoughts or interpersonal problems. [Gratz: 2015] Some patients also may express preoccupation with nonsuicidal self-injury.
Overall, nonsuicidal self-injury cannot occur in the setting of substance use, psychosis, or delirium. [Gratz: 2015] If the provider is concerned about substance use, psychosis, or delirium, then the provider must further investigate those possibilities. In those cases, nonsuicidal self-injury is not the primary diagnosis but rather secondary to another underlying cause, and treatment of substance use, psychosis, or delirium can mitigate the nonsuicidal self-injury.

Diagnostic Testing & Screening

There is no diagnostic testing for suicidality or self-harm, both of which are identified based on clinical evaluation, history, and physical examination. Research is underway to understand how certain biomarkers, including alpha 1-antitrypsin, high-density lipoprotein cholesterol, apolipoprotein A1, and transferrin, may have a close relationship with depression and suicide. [Bai: 2021] However, currently, there are no biomarkers to diagnose suicidality or predict suicide. There is also research into the utility of neuroimaging for suicidality is ongoing. Recent studies have shown that disturbances in the ventral prefrontal cortex (VPFC) and the dorsal prefrontal cortex (DPFC) of the brain are associated with suicidal thoughts and behaviors. [Schmaal: 2020] Further research is needed.
Suicidality screening
There has been limited research in terms of validity and challenges with universal implementation. [Cwik: 2020] Research has shown that many children who die from suicide contacted medical providers several months prior to their death (42%), while nearly all (88%) had at least 1 visit within the previous year. [Braciszewski: 2022] It is unclear if they were screened for suicide during those visits. [Cwik: 2020] Regardless of the lack of supporting research, screening in the pediatric population should still be considered beneficial. In particular, it could be beneficial for youths to be screened for common psychiatric issues, given that a psychiatric diagnosis can increase risk of suicide and self-harm, and these patients can greatly benefit from treatments. [Cwik: 2020] The United States Preventive Services Task Force (USPSTF) recommends universal screening for depression in adolescents 12-18 years old.[Walter: 2023] Insufficient evidence exists to recommend universal screening for children 11 years old and younger. [Siu: 2016]
Common screening tools for suicidality include:
Self-harm screening
Clinical assessment tools for self-harm include:
  • Self-Harm Screening Inventory (SHSI) is a self-report questionnaire with binary yes/no questions assessing engagement in self-harm behaviors within the past year. The total score is the sum of the “yes” responses. This questionnaire can be used to also screen borderline personality disorders (BPD) as well as past mental healthcare utilization. [Sansone: 2010]
  • Chronic Self-Destructiveness Scale (CSDS) is a 73-item self-report questionnaire that assesses a broad range of high-risk and impulsive behaviors, which can increase risk of self-harm and suicidal behavior. [Sansone: 2010]
  • Self-Harm Behavior Survey (SHBQ) is a questionnaire that delves into the patient’s background information, including family history of mental illness, different self-harm behaviors, as well as other potential psychiatric illness.
Ask directly
Assessing for depression and other psychiatric disorders may provide a natural transition into asking more probing questions about suicidal thoughts and behaviors. Asking directly about suicidality is likely to produce honest answers from adolescents. It is unlikely to increase the risk for suicide. [Gould: 2005] The American Academy of Child and Adolescent Psychiatry practice parameter suggests the relevant questions: [AACAP: 2001]
  • Have you ever wished you were not alive or wanted to die?
  • Have you ever hurt yourself or tried to hurt yourself?
  • Have you ever tried to kill yourself?
  • Have you ever thought about or tried to commit suicide?
  • Have you ever done something you knew was so dangerous that you could get hurt or killed by doing it?
Affirmative answers to any of the above warrant additional questioning, including:
  • Previous attempts or thoughts
    • How many times have you tried to hurt or kill yourself?
    • How did you attempt?
    • Did you tell anyone? Who?
    • How did [your parents] find out about what happened?
    • What happened? Did you have to go to a doctor, hospital, or Emergency Department?
    • Have you had any other plans or ways you’ve thought about ending your life?
    • What made you stop or want to live?
Current thoughts
  • Do you have thoughts of harming or killing yourself now?
  • How would you do it?
  • How do you feel about being alive now?
  • What do you have to live for right now?
Ask about firearms and other lethal means in the home
  • It is important to note that the purpose of asking these questions is not to judge firearm ownership. Explain to the patient the reason why you are asking about firearms in relation to the patient’s health and well-being in a respectful, non-confrontational manner.
  • Are there any firearms in your home?
  • Who has access to them?
  • Are all guns and ammunition stored safely so that they can’t be accessed by unauthorized users?
  • How are your firearms stored?
  • Follow up on firearm access at the next patient’s visit and ask again about firearms, given that the home situation and circumstances can always change.

Screening Family Members

Self-harm and suicidal behavior are complex and involve both genetics and environmental factors. Past studies showed low levels of 5-HT and 5-HIAA in post-mortem brainstem tissues from patients who completed suicide along with an upregulation of 5-HT2 receptors in the prefrontal cortex; most notably, an upregulation of these receptors, most likely due to the deficiencies in serotonin. [Mann: 1989] However, these biomarkers are not measured in a clinical setting, and there are no current genetic tests to identify a patient’s suicide risk.

It is important for clinicians to understand the family history of completed suicides, self-harming behaviors, and psychiatric illness in relatives, as this history can be used in the overall assessment of a patient’s suicide risk. [Qin: 2002]

Risk Factors

Modifiable Risk Factors

Sexual and physical abuse/domestic violence
Studies have shown that childhood abuse is associated with an increased risk for self-harm, suicidal behavior, and impulsivity; children who had been exposed to sexual, physical, and emotional abuse had a 2.5-fold greater odds for suicidal ideation and a 4.0-fold increased odds for suicide plans compared to children who hadn’t had traumas. [Angelakis: 2020] Therefore, another important screening is child abuse and understanding the overall home environment.

Substance abuse
An assessment should always include questions about a patient’s substance use. Screening, brief intervention, and referral to treatment (SBRIT) model is recommended by the American Academy of Pediatricians as a universal screening for adolescent substance use. Follow-up on any of the screening questions that the patient endorses. Substance Use Disorders has details.

Bullying
Regardless of whether the patient identifies as the “bully” or the “victim,” “bullies" are at higher risk of using substances and engaging in possible legal issues, and victims can struggle with self-esteem and overall well-being, which can impact the development of depressive syndromes. [Dilillo: 2015]

Environment
A safe environment is a crucial modifiable risk factor to minimize access to suicide means. Counseling on Access to Lethal Means (HHS & SAMHSA) is an online course that was created with the support of the U.S Department of Health and Human Services and Substance Abuse and Mental Health Services Administration to reduce access to methods people could use to harm or kill themselves. This course can be beneficial for medical providers to engage with patients and their families about reducing access to lethal means.

Non-modifiable Risk Factors

Several important non-modifiable risk factors include: [Dilillo: 2015]

  • Presence of psychiatric illness
  • Previous suicide attempts
  • Sexual orientation and gender identity
  • Family history

Genetics

There has been much research evaluating the genetics and heritability of suicidality and self-harming behaviors. It has been shown that children of parents who died of suicide were at higher risk of suicidality and self-harm. [Mishara: 2021] However, less than 5% of people who died by suicide had a parent who died by suicide. [Mishara: 2021]
Despite extensive research, a single gene or a group of genes has yet to be directly linked to suicide. [Mishara: 2021] Rather, suicide and self-harm can be seen as complex conditions associated with different genetic variants and environmental factors, with heritability being unclear. [Mishara: 2021] There is extensive ongoing research evaluating the genetic component in mental disorders, substance abuse, and impulsivity, all of which are associated with increased suicide risk.

Prevalence

According to the 2019 Youth Risk Behavior Surveillance System (CDC), 18.8% of students had seriously thought about suicide in the previous 12 months, 8.9% of students had made at least 1 attempt, and 2.5% of students had made an attempt that required medical treatment. In 2019, suicide was the second leading cause of death in children 14-18 years of age. Females were more likely to have suicidal ideation, suicide plans, and suicide attempts, including attempts that required medical treatment, than males. Sexual minority youth (lesbian, gay, bisexual, transgender, or questioning) had the highest prevalence estimates of suicidal ideation, suicide plans, attempts, and attempts requiring medical treatment.

Differential Diagnosis

Suicidal and self-harm behaviors can be a feature of any psychiatric illness; however, psychiatric illness itself does not always predict suicidal behavior. About 10% of those who attempt suicide do not have an identifiable psychiatric illness. [Oquendo: 2008] Therefore, when evaluating a patient who has attempted suicide, it is important for clinicians to fully evaluate the patient’s psychosocial history, evaluating possible mental health disorders as well as social stressors that may be associated with suicidal and/or self-harm thoughts and behaviors.
Additionally, some behaviors that result in self-injury do not have any underlying suicidal or self-harm intent. The differential diagnosis for some such behaviors include:
  • Excoriation disorder (skin picking disorder): an obsessive-compulsive-related disorder in which a patient is unable to stop picking at their skin despite efforts to stop. The behavior can occupy a significant portion of the day. [Lochner: 2017] Skin-picking can occur anywhere on the body and is usually found in multiple sites. This recurrent picking of the skin may lead to skin lesions and a compromised skin barrier. [Lochner: 2017] Clinical evaluation and understanding the patient’s motives can help differentiate excoriation disorder and self-harm behavior. The injuries produced in self-harm are often intentional and may function to produce physical pain to release negative emotions. In excoriation disorder, patients may be unconsciously aware they are engaging in such behaviors. For these patients, the intent to pick their skin is not to harm themselves for pain, but rather because picking may be experienced as gratifying or alleviating anxiety.
  • Stereotypic movements (stereotypies) are commonly seen in children with neurodevelopmental disorders such as Autism Spectrum Disorder, Rett Syndrome, and Intellectual Disability & Global Developmental Delay. Stereotypies are repetitive and rhythmic bilateral movements with a fixed, regular pattern that can inadvertently result in self-injury. [Péter: 2017] Examples include head-banging, face-slapping, eye-poking, and biting of hands, lips, and other body parts. [Claes: 2007] Like above, differentiation between self-harm and stereotypies is through clinical evaluation and exploration of the motivation underlying the behavior. Motor stereotypies often occur when a child is experiencing high emotional states such as excitement, stress, boredom, or fatigue. The intent of the behavior is not to cause bodily harm. In some cases, children report feeling satisfied when performing the stereotypies. [Claes: 2007] It is important to note that there can also be secondary causes to stereotypic movements including use of psychomotor stimulants. Toxicology screening and other appropriate diagnostic testing may help in differentiating possible secondary causes of motor stereotypies.

Co-occurring Conditions

Mental health disorders
Patients who struggle with mental disorders are, in general, are at increased risk for suicide and self-harm behaviors. [Harris: 1997] Therefore, it is important to identify and treat any underlying psychiatric disorder. This includes (links lead to screening and management information):
  • Depression - see for validated screens.
  • Bipolar spectrum disorders - substantial disease burden for bipolar disorders is associated with suicide. Between 25% to 60% of people with bipolar with attempt suicide, and around 4% to 19% will complete suicide. [Novick: 2010]
  • Psychotic disorders
  • Substance Use Disorders must be considered when assessing patients as they increase risk for suicide and self-harm. [Singhal: 2014] Substance abuse, which includes all drugs and alcohol, should be evaluated given that its use increases suicide, especially among young children; substance abuse can worsen impulsivity and aggression, which in turn increases the risk for suicidal behaviors. [Dawes: 2008] For example, children 13 years or younger who engaged in heavy episodic drinking, drinking at least 60g or more of alcohol in the past month, were 2.6 times more likely to report a suicide attempt compared to children who had not engaged in heavy episodic drinking; individuals who were 18 years old or older who were engaged in heavy episodic drinking were only 1.2 times more likely to attempt suicide compared to the general population. [Aseltine: 2009]
  • Anorexia nervosa is also another common comorbid condition. Patients who struggle with anorexia nervosa are more likely to die by suicide compared to the general population with almost an eight-fold risk of suicide attempts. [Suokas: 2014]
Traumatic brain injury
Children who have experienced traumatic brain injury (TBI) can have numerous psychosocial and psychiatric issues, including the development of mood disorders, irritability, impulsivity, and behavioral issues. As a result, youths who have sustained a TBI are at higher risk for suicide. [Richard: 2015] Children who have sustained a TBI should have access to mental health services in addition to appropriate neurological follow-up. See Traumatic Brain Injury
Mild traumatic brain injury and post-concussion syndrome
Children who experience concussions, or mild traumatic brain injury, may have transient emotional or behavioral disturbances that resolve without treatment, while others may experience problems that can last for months to years. [Izzy: 2021] This is also known as post-concussion syndrome, in which patients can experience symptoms such as depression, anxiety, memory problems, headaches, and fatigue beyond the expected duration of a typical concussion. Because of the high variability of symptoms, severity, and duration of post-concussion syndrome, there are currently no formal protocols for treatment. It is advised for patients to seek medical guidance from their primary care provider for further management. Medications are generally not used; however, antidepressants and antianxiety medications can be used in the acute phase. Patients should be reassured that this condition is temporary unless patient continues to have repeated concussions. [Renga: 2021] Please see Mild Traumatic Brain Injury (TBI) & Post-concussive Syndrome for detailed assessment and management information.
Epilepsy
Patients who have a history of epilepsy are at higher risk for engaging in self-harming behaviors and suicide. One possible theory is that seizures can cause changes in serotonergic activities, including lower levels of cerebrospinal fluid 5-HIAA (5-hydroxyindoleacetic acid), as well as lower levels of tryptophan. As a result, mental health screenings are recommended for patients with epilepsy. [Nickels: 2021]
Autism
Patients with autism spectrum disorder (ASD) are at increased risk for self-harming behaviors, suicidal ideation, and suicide. One of the primary reasons is that patients with ASD have co-occurring mental health conditions, including anxiety and depressive disorders. Clinicians should be aware of this risk. [Blanchard: 2021] Please see Autism Spectrum Disorder for detailed assessment and management information.

Metabolic conditions
Certain metabolic disorders can be associated with nonsuicidal self-injurious behaviors. One example is Lesch Nyhan syndrome, an X-linked recessive error in the purine metabolism due to a deficiency in the hypoxanthine-guanine phosphoribosyl transferase (HPRT) enzyme. Children with this disorder have an urge to harm themselves, including destruction of the perioral tissues and fingers. Other injuries include biting the fingers, hands, lips, and cheeks, and banging the head or limbs. Possible ways to prevent self-mutilation include botulinum toxin A injections into the bilateral masseters as well as the use of gabapentin to help with neuropsychiatric symptoms. [Jathar: 2016] Overall, the prognosis is poor for these patients, and the underlying goal is to decrease the uric acid as elevated uric acid is the primary offender in this disease. Although decreasing the uric acid can reduce complications like gouty arthritis and urolithiasis, it cannot reverse the neurodevelopmental or cognitive outcomes.

Prognosis

Children who experience suicidal ideation are at increased risk for continued suicidal ideation and suicidal attempts and have an increased likelihood of developing mood disorders and anxiety disorders later in life. [Herba: 2007] Children who have attempted suicide are at increased risk for another attempt. The National Institute of Mental Health highlights that young children who attempt suicide are 6 times more likely than non-suicidal children to attempt suicide again in adolescence. [Brent: 1999] This emphasizes the importance of early interventions for children who are experiencing suicidal ideation as well as for those who have attempted suicide.

Children with untreated self-harm behaviors are at increased future risk of hospitalizations, suicide attempts, and development of mental health disorders. [Beckman: 2016] Data show that reductions in non-suicidal self-injury, as well as self-injury, impulsiveness, and anger, can be achieved through treatments that target the underlying disorder. Such treatments include psychotherapies and medications, including SSRIs. [Turner: 2014]

Treatment & Management

Treatment of suicidal and self-harm behaviors depends on multiple factors, including the intent, specificity, availability of plan, severity, ability to communicate feelings and thoughts and seek help from natural supports, and overall assessment of imminent risk of harm to self. These factors help the clinician, patient, and family determine the level of care currently needed to maintain safety, as well as address factors contributing to suicidality and self-harm.

Mental Health / Behavior

Levels of Care

Some patients with passive suicidal thoughts and no intent or access to means may be managed safely in an outpatient setting, whereas others with high imminent risk of self-harm may need inpatient psychiatric hospitalization to ensure safety. Inpatient psychiatric hospitalization is the standard of care for the acutely suicidal patient at high imminent risk of self-harm.

Inpatient care
If a child or adolescent being evaluated for suicidality expresses a persistent wish to die or is in an altered mental state, refer for inpatient hospitalization. Altered mental states include, but are not limited to, severe depression, mania/hypomania, severe anxiety, psychosis, or substance intoxication. Patients who are unable to participate in safety planning or are unable/unwilling to disclose self-harm and suicidal thoughts may need an inpatient level of care to maintain safety.

Safety planning is a brief intervention to help individuals manage suicidal thoughts and self-harm urges by developing written steps to reduce the likelihood of acting out on the thoughts. Usually, this is a collaborative process between the patient and medical provider and identifies a series of actions in order of increasing response intensity. [Moscardini: 2020] Several factors that are included in safety planning include:

  • Warning signs or triggers that exacerbate suicidal ideation for this person
  • Coping strategies or distraction techniques to use when experiencing suicidal ideation or self-harm urges
  • Names and contact information for supportive persons who can assist.
  • Emergency resource information including hotlines, local hospital emergency room locations
  • Environmental factors to limit access to lethal means It may be possible to manage adolescents with suicidal ideation or self-harm behavior in an outpatient setting, but this decision entails careful assessment.
In addition to ability to engage in the safety planning measures above, considerations should include the following:
  • The child or adolescent must not have a persistent wish to die or plans for self-harm.
  • Mental health treatment is in place (therapy, medication management as indicated).
  • Proper adult supervision.
  • The evaluator should initiate a discussion about removing lethal means (guns, medications) and expressly recommend their removal from the home.
  • It may also be valuable to provide education about other risk factors, such as substance abuse.
  • Provide community resources and hotlines and encourage the patient to use them.
The American Foundation for Suicide Prevention has useful resources, including the 988 Suicide & Crisis Lifeline where people can call or text 988 to access trained crisis counselors to help anyone experiencing suicidal, substance use, or mental health crisis.

Treatment of Underlying Psychiatric Illness

Therapy
Dialectical Behavior Therapy for Adolescents (DBT-A) is a well-established therapy for decreasing self-harming behaviors, including nonsuicidal and suicidal self-injury and suicidal ideations. [Glenn: 2019] There is also evidence that it may also be efficacious for reducing suicidal attempts. [McCauley: 2018]

Another therapy is Integrated Family Therapy. This therapy can be effective in reducing self-injurious thoughts and behaviors when incorporating skills training like emotional regulation for the entire family. [Glenn: 2019]

Since depression is a common risk factor for suicide and self-harm, there has been a focus on how psychosocial treatments can improve depression. For adolescents who struggle with depression, Cognitive Behavioral Therapy (CBT) and group-based CBT are considered efficacious treatments. A combination of CBT and medication may be particularly helpful for individuals with higher severity of depression or for youths with multiple and complex psychiatric problems. [Weersing: 2017] Data has also shown the potential for CBT to become a preventative intervention for at risk youths susceptible to depression, improving their overall functioning. [Weersing: 2017] Interpersonal therapy (IPT) and family-based IPT have also been shown to be efficacious for children struggling with depression, with families having high compliance with these treatments. [Weersing: 2017]

Depression has extensive management information.

Medications
Medications are often used to treat an underlying psychiatric disorder if present. For details about medication treatment of depression, see the Management section of Depression.

With particular respect to suicidality:

  • All medications with approval for use in treatment of depression in children, adolescents, and young adults up to age 25 have an FDA Black Box warning for the risk of increasing suicidal thoughts and behaviors. This risk should be disclosed to patients and families, and risks of suicide associated with ongoing untreated or undertreated depression should be weighed with risk of treatment. [Hetrick: 2012] If a youth or young adult recently started on antidepressant medication presents with worsening suicidal ideation, they should be promptly evaluated and the medication stopped if indicated. It is worth noting, however, antidepressants also can take several weeks to take effect, and suicidal thoughts due to underlying depression can also worsen during this time, which can complicate assessment. For additional information and discussion, please see Antidepressant Medications and Suicide Section of Suicide and Suicide Attempts in Adolescents (AAP) at [Shain: 2016].
  • Tricyclic antidepressants (TCAs) should not be used as first-line medication for depression in suicidal children and adolescents due to their lethality in overdose and significant side effect profile. [Dwyer: 2019]

Skin

Common sites of self-injury include areas that are easier to reach, such as the wrists, lower legs, arms, and ankles. Other sites that are easier to conceal include the abdomen, inner thighs, under the breasts, and genitals. Providers should look for evidence of scratching, self-cutting, burning, pinching, rubbing, or biting. Common skin findings include eroded or purpuric lesions that are usually sharply circumscribed, geometric, or evenly spaced. [Skaggs: 2022] Bruising around the head could also be suggestive of head-banging. Most of these skin conditions are self-limiting and will resolve with the cessation of the causal behavior.

Musculoskeletal

Self-injurious behaviors may lead to sequelae that involve the musculoskeletal system. While most minor self-injuries will heal with local wound care, some can lead to serious complications such as osteomyelitis, septic arthritis, and abscesses. [Skaggs: 2022] Persistent skin and musculoskeletal infections may be a signal of recurrent self-harm behavior. Clinicians should consider self-harm behavior in the differential diagnoses of persistent skin and musculoskeletal issues, and refer for interventions as appropriate to decrease long-term risks associated with ongoing self-injury. [Mosek: 2020]

Respiratory

Suicide attempt by hanging is associated with high morbidity and mortality. Hanging is associated with asphyxia, petechial hemorrhages, strangulation marks, and laryngeal or hyoid bone fractures. [Davies: 2011] Asphyxiation can lead to cardiac arrest, severe neurological dysfunction due to anoxic brain injury, or death. [Davies: 2011] Anoxic brain injury is global cerebral ischemia due to cardiac arrest. Early interventions are crucial and include pharmacologic treatment of the dysautonomia associated with the brain injury. Amantadine has been shown to improve the level of consciousness in these patients. [Irzan: 2022] In addition, early rehabilitation can contribute to better outcomes. This includes utilizing physical therapy, speech therapy, and neuropsychology, evaluating cognitive and behavioral problems, as well as intellectual function. See Pediatric Anoxic Brain Injury | PM&R KnowledgeNow (AAPM).

Physical Activity

Associations have been found between physical activity and lower rates of depression in adolescents. [Rodriguez-Ayllon: 2019] [Korczak: 2017] Clinical guidance for exercise in this population includes group-based and supervised light-to-moderate-intensity activities 3 times a week for 6-12 weeks. Studies showed that exercise is effective in both inpatient and outpatient settings for children and adolescents with moderate and severe depression. [Carter: 2016]

Services & Referrals

988 Suicide & Crisis Lifeline
24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States.

Self-Harm Crisis Text Line
Text HOME to 741741 to reach a volunteer Crisis Counselor. Chat or messaging on WhatsApp is also an option.

General Counseling Services (see NV providers [209])
This category includes all types of counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.

Psychiatry/Medication Management (see NV providers [37])
Can be very helpful in guiding and/or managing pharmacologic therapy, particularly for patients who do not respond promptly or well to standard medications.

Social Workers (see NV providers [7])
Social workers can help families identify family issues and improve communication skills and relationships. Social workers can help with crisis intervention and utilizing resources.

ICD-10 Coding

Resources

Information & Support

For Professionals

Suicide: Blueprint for Youth Suicide Prevention (AAP)
Educational resource to support pediatric health clinicians and other health professionals in identifying strategies and key partnerships to support youth at risk for suicide; American Academy of Pediatrics and American Foundation for Suicide Prevention, in collaboration with experts from the National Institute of Mental Health.

Suicide: Pediatric Mental Health Minute Series (AAP)
Assess risk, build hope and reasons for living. connect, strengthen connections with protective adults, develop safety plan; American Academy of Pediatrics.

Suicide Resource Center (AACAP)
FAQs, research and training, video, and facts for families; American Academy of Child & Adolescent Psychiatry.

Understanding the Characteristics of Suicide in Young Children (NIH)
The characteristics of suicide in young children and the factors that sometimes precede these tragic events; National Institutes of Health.

NICE Guidelines: Self-Harm: Assessment, Management and Preventing Recurrence
Covers assessment, management, and preventing recurrence for children, young people and adults who have self-harmed. It includes those with a mental health problem, neurodevelopmental disorder or learning disability and applies to all sectors that work with people who have self-harmed; London: National Institute for Health and Care Excellence (NICE).

Diagnosis, Traits, States, and Comorbidity in Suicide - The Neurobiological Basis of Suicide (nih.gov)

Counseling on Access to Lethal Means (HHS & SAMHSA)
A free, self-paced, online course for health care and social services providers; U.S Department of Health and Human Services and Substance Abuse and Mental Health Services Administration

Patient Education

Suicide in Children and Teens (AACAP)
Education about suicide from the patient education Facts for Families series; American Academy of Child & Adolescent Psychiatry.

What You Need to Know About Self-Injury (Cornell Research Program) (PDF Document 1.4 MB)
Information for parents about how to know if their child is self-harming, how to talk to their child, what to avoid saying, and how to cope with their feelings about the discovery.

Tools

Patient Safety Plan Template (ZeroSuicide)
A fill-in-the-blank template for developing a safety plan with a patient who is at increased risk for a suicide attempt.

My Safety Plan (Vibrant)
A prioritized list of coping strategies and sources of support. It can help identify what leads to thoughts of suicide and how to feel better when having those thoughts.

Patient Health Questionnaire (PHQ) Screeners
Free screening tools in many languages with scoring instructions to be used by clinicians to help detect mental health disorders. Select from right menu: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4, PHQ-8.

Suicide Risk Curve (Stanley-Brown) (PDF Document 80 KB)
Risk vs. time mapped on a curve.

Columbia Suicide Severity Rating Scale (C-SSRS)
A free, validated screening tool to measure suicidal ideation over several months and rates suicide risk as low, moderate, or high based on the responses. This questionnaire uses yes/no questions.

Ask Suicide-Screening Questions (ASQ): (PDF Document 215 KB)
A free, 4-item questionnaire screening tool for youth and young adults ages 10-24. If a patient answers yes to any of the questions, the clinician is prompted to ask about current suicidal thoughts.

Self-Harm Screening Inventory (SHSI)
A self-report questionnaire with binary yes/no questions assessing engagement in self-harm behaviors within the past year. The total score is the sum of the “yes” responses. This questionnaire can be used to also screen borderline personality disorders (BPD) as well as past mental healthcare utilization.

Chronic Self-Destructiveness Scale (CSDS)
A 73-item self-report questionnaire that assesses a broad range of high-risk and impulsive behaviors, which can increase risk of self-harm and suicidal behavior.

Self-Harm Behavior Survey (SHBQ)
A questionnaire that delves into the patient’s background information, including family history of mental illness, different self-harm behaviors, as well as other potential psychiatric illness.

Services for Patients & Families in Nevada (NV)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

PubMed search for depression in children and adolescents, last two years

Uh S, Dalmaijer ES, Siugzdaite R, Ford TJ, Astle DE.
Two Pathways to Self-Harm in Adolescence.
J Am Acad Child Adolesc Psychiatry. 2021;60(12):1491-1500. PubMed abstract / Full Text

Bilsen J.
Suicide and Youth: Risk Factors.
Front Psychiatry. 2018;9:540. PubMed abstract / Full Text

LeMoult J, Humphreys KL, Tracy A, Hoffmeister JA, Ip E, Gotlib IH.
Meta-analysis: Exposure to Early Life Stress and Risk for Depression in Childhood and Adolescence.
J Am Acad Child Adolesc Psychiatry. 2020;59(7):842-855. PubMed abstract

Blanchard A, Chihuri S, DiGuiseppi CG, Li G.
Risk of Self-harm in Children and Adults With Autism Spectrum Disorder: A Systematic Review and Meta-analysis.
JAMA Netw Open. 2021;4(10):e2130272. PubMed abstract / Full Text

Korczak DJ, Finkelstein Y, Barwick M, Chaim G, Cleverley K, Henderson J, Monga S, Moretti ME, Willan A, Szatmari P.
A suicide prevention strategy for youth presenting to the emergency department with suicide related behaviour: protocol for a randomized controlled trial.
BMC Psychiatry. 2020;20(1):20. PubMed abstract / Full Text

Authors & Reviewers

Initial publication: April 2023; last update/revision: November 2023
Current Authors and Reviewers:
Author: Allison Chang
Senior Author: Mary Steinmann, MD, FAAP, FAPA
Reviewer: Jessica Lu, MD, MPH
Authoring history
2023: first version: Allison ChangA; Mary Steinmann, MD, FAAP, FAPASA
AAuthor; CAContributing Author; SASenior Author; RReviewer

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